Réanimation du nouveau né

NEWBORN RESUSCITATION IN RESOURCE LIMITED OR PRECARIOUS SETTINGS Daniel Martinez Garcia, MD, MPH Medical Advisor - Pediatrics Medical Department Daniel.martinez@barcelona.msf.org pediatrics@barcelona.msf.org

OUTLINE • • • • • •

Overview of problem Epidemiology Basic NB resuscitation and equipment Advanced NB resuscitation Current limits of evidence in NB resuscitation Gaps and challenges in resource-limited settings

OVERVIEW OF PROBLEM • Globally, about one quarter of all neonatal deaths are caused by birth asphyxia.

• 40% of all under five deaths occurred in the neonatal period in 2008; • Asphyxia caused 9% of all under five deaths (2008).

• 10% of newborns require some assistance to begin breathing at birth / 1% require extensive resuscitation • Basic training in newborn resuscitation is scarce in resource limited settings/regions/countries.

• Heterogeneity in training from expatriate professionals going to the field with different medical organisations.

WHO. World health statistics. Geneva, WHO, 2011 Perlman JM et al. Circulation. 2010;122[suppl 2]:S516 –S538.)

Int J Gynaecol Obstet. Oct 2009; 107(Suppl 1): S47–S64.

Annual number of newborns who require assistance to breath at birth or any level of neonatal resuscitation

THESE ESTIMATES DID NOT INCLUDED SUB-SAHARIAN AFRICA

How many deaths in 2013? 2.9 million newborn babies die 2.6 million babies are stillborn every year

TIMING OF NEWBORN DEATH

Strategies for prevention of adverse perinatal • (i) primary prevention of the insult by adequate fetal monitoring and correct use of the partogram coupled with timely obstetric interventions • (ii) secondary prevention after the insult by immediate basic stabilization/resuscitation of the non-breathing baby • (iii) tertiary prevention of complications in the baby by adequate postnatal treatment.

WHERE TO PUT OUR EFFORTS? • The ability to detect the fetus at risk of hypoxia during labor is a key catalyst for subsequent interventions to reduce deaths and improve child health.

• The presence of skilled care at birth linked with emergency obstetric care were identified as two major components to reduce the number of stillbirths.

• Abnormal fetal heart rate (<120 or >160 beats/min), routinely detected using a fetal stethoscope, is strongly associated with fresh stillbirths, birth asphyxia, increased need for neonatal bag mask ventilation (BMV), and early neonatal death.

• Primary prevention is likely to have the greatest impact on intrapartum-related adverse outcome, but is probably the most complex, time-consuming and expensive concern to address.

Pathway of intrapartum-related hypoxia and appropriate interventions to avoid fetal injury and prevent perinatal morbidity and mortality

Help Babies breathe Only intervenes from here

H.L. Ersdal, N. Singhal / Seminars in Fetal & Neonatal Medicine 18 (2013) 373e378

RESOURCE-LIMITED ALGORITHM

1 MINUTE

ASSISTED VENTILATION is the most important and effective action during the neonatal

BASIC ESSENTIAL FIRST 6 STEPS IN FIRST MINUTE OF LIFE 1 Check for meconium Amniotic fluid meconium-stained but infant breathing spontaneously and tonic: suction not indicated; wipe face.

Amniotic fluid meconium-stained and infant is not breathing well or is hypotonic: quickly-gently suction the mouth 2 Stimulate the infant by drying Tactile stimulation can trigger spontaneous breathing. Drying the infant vigorously, not roughly. Effective respiratory effort should begin within 5 seconds. If not, stop the stimulation; the infant requires additional care.

3 Clamp and cut the cord: Delay cord clamping for at least 1 minute 4 Position the infant’s head: Lay the infant on back with head in neutral position; avoid neck flexion/hyperextension: this can obstruct the airway.

5 Clear the airway (with bulb syringe, only in the rare cases where there are copious secretions) Suction the mouth gently – i.e., not too deeply (max depth 2 cm from the lips) – and quickly (max duration 5 seconds) 6 Stimulate the infant Rub back and feet soles (do not shake, slap or hang the infant by the feet).

If effective respiratory effort has not begun after 5 seconds: stop the stimulation; the infant requires ventilation.

Equipment for Neonatal Resuscitation Standard Equipment (all care providers) Infant stethoscope (EMEQSTET4-- STETHOSCOPE, double cup, infant) Bulb syringe / Pump suction mechanical + tubing / Electrical suction Pump + tubing Self-inflating bag (Ambu), child/neonate + masks 0 (premature) & 1 (newborn) Mobile radiant infant warmer (when possible) / If not at least a bulb lamp Equipment for Oxygen therapy (when possible) Oxygen concentrator (5 L/min) Neonatal & Premature nasal prongs for oxygen (flow limited to 2 L/min maximum) Pulse oxymeter (not accurate in first minutes of life)

Tubes and Catheters (all care providers) Suction catheters (8CH, 10CH, 12 CH, 14CH) Oro/Nasogastric tubes (6CH, 8CH, 10CH) with caps IV line Butterfly set (22-25G) / Cannulas (22-25G) Microdropper / Stopcocks (two way or three way) IV tubing and IV poles / Intra-osseous needles 18G + IV 19G

Drugs & Supplies Dextrose 10%, Dextrose 50% Needles 16 or 18G to prepare injections / Syringes 2, 5, 10 ml Normal saline / Epinephrine (1:10 000) solution Rapide Diagnostic Tests (when possible) Glucometer / Hemoglobin test / Heel lancets

Others Clock & Examination mobile lamp & Examination neonatal table / Gloves Warm dry blankets, warm, dry and sterile sheets, baby clothes (hats and napkins) Chorhexidine 4% (or dermal povidone iodine 10%) Infant electronic scale (EANTSCAL6) Specialized Equipment: only to be used by trained pediatric or anesthesia doctor Neonatal laryngoscope: only to be used for meconium aspiration Endotracheal tubes (2.5, 3.0, 3.5, and 4.0 mm) (only to be used for meconium aspiration) PS: Items in italics are recommended but parts of the comprehensive levels of care and so, they are not mandatory at the basic level of neonatal care. They should be considered depending on each setting and operational level of neonatal care.

Which newborns should be resuscitated?

YES

All babies who do not cry, do not breathe at all, or who are gasping 30 seconds after birth should be resuscitated with bag-and-mask ventilation (WHO)

NO

 Still-births that are not fresh Newborn with a “severe malformation”: hydrocephaly, anencephaly, trisomy 13 or 18, short-limbed dwarfism, multiple defects);  “Extremely low gestational age” to be determined by local policy and probability of survival and capacity to give appropriate medical care In MSF this last point changes according to country and project and should be clearly establish and communicate to all medical staff

WHO RESUSCITATION ALGORITHM

Neonatal Resuscitation Algorithm based on WHO Pocketbook of Hospital Care for Children, updated with ILCOR 2005 Recommendations

MSF “ADVANCE” ALGORITHM IF HBB NOT ENOUGH

HIGH RESOURCES NEWBORN RESUSCITATION ALGORITHM

Kattwinkel J et al. Circulation. 2010;122:S909-S919

BIRTH DRY THOROUGHLY BREATHING/CRYING

ASSESS BREATHING

NOT BREATHING/CRYING

ROUTINE CARE SKIN TO SKIN CONTACT BREASTFEEDING

STIMULATE CLEAN AIRWAYS (SUCTION MOUTH/NOSE) BREATHING WELL CRYING

ASSESS BREATHING NOT BREATHING/CRYING CUT THE CORD START VENTILATION USING ROOM AIR

 

STOP VENTILATION ONGOING MONITORING

CONTINUE VENTILATION UNTIL HR > 100/MIN plus SPONTANEOUS BREATHING

  

ASSESS BREATHING AFTER 60 SECONDS

BREATHING WELL

NOT BREATHING/CRYING CALL FOR HELP HR > 60/MIN

RATIO CHEST COMPRESSION/VENTILATION 3:1 EPINEPHRINE 0.1-0.3 ml/kg (1:10.000) VOLUME EXPANSION NaCl 0.9%: 10 ml/kg

MARCO OLLA PEDIATRIC IMPLEMENTER – MSF NEONATAL GUIDELINES NOVEMBER 2014

CHECK HEART RATE HR ≤ 60/MIN   

CHEST COMPRESSIONS EPINEPHRINE CONSIDER VOLUME EXPANSION

THE BABY IS NOT BREATHING

PLACE BABY IN RESUSCITATION TABLE OPEN AIRWAYS CLEAN AIRWAYS START VENTILATION WITH O2 CHECK HEART RATE HR > 60/MIN

HR ≤ 60/MIN

CONTINUE VENTILATION UNTIL HR > 100/MIN PLUS SPONTANEOUS BREATHING

START CHEST COMPRESSIONS 3:1 AFTER 60 SEC EPINEPHRINE 0.1-0.3 ML/KG (1:10.000)

ALWAYS CHECK GLYCAEMIA AND TEMPERATURE STOP RESUSCITATION AFTER 10 MINUTES IF BABY HAS NOT HEART RATE AND IS NOT BREATHING AFTER 20 MINUTES IF HR < 60/MIN AND IS NOT BREATHING AFTER 30 MINUTES IF HR > 60/MIN AND IS NOT BREATHING MARCO OLLA PEDIATRIC IMPLEMENTER – MSF NEONATAL GUIDELINES NOVEMBER 2014

2012 WHO Recommendations on Basic Newborn Resuscitation

RECOMMENDATIONS: IMMEDIATE CARE AFTER BIRTH Strength

Evidence /quality

1 In newly-born term or preterm babies who do not require positive-pressure ventilation (PPV), the cord should not be clamped earlier than one minute after birth (1).

Strong

High to moderate

Weak

Development Group (GDG) consensus absence evidence GDG consensus absence evidence

When newly-born term or preterm babies require PPV, the cord should be clamped and cut to allow effective ventilation to be performed.

2 Newly-born babies who do not breathe spontaneously after Weak thorough drying should be stimulated by rubbing the back 2-3 times before clamping the cord and initiating PPV. 3 In neonates born through clear amniotic fluid who start breathing on their own after birth, suctioning of the mouth and nose should not be performed.

Strong

High

Weak

GDG consensus absence evidence

In neonates born through clear amniotic fluid who do not start breathing after thorough drying and rubbing the back 2-3 times, suctioning of the mouth and nose should not be done routinely before initiating PPV. Suctioning should be done only if the mouth or nose is full of secretions.

2012 WHO Recommendations on Basic Newborn Resuscitation

RECOMMENDATIONS: IMMEDIATE CARE AFTER BIRTH Strength

Evidence quality

4

In the presence of meconium-stained amniotic fluid, intrapartum suctioning of the mouth and nose at the delivery of the head is not recommended.

Strong

Low

5

• In neonates born through meconium-stained amniotic fluid who start breathing on their own, tracheal/mouth/nose suctioning should not be performed.

• In neonates born through meconium-stained amniotic fluid who do not start breathing on their own, tracheal & mouth & nose suctioning should be done BEFORE initiating PPV.

Strong

Moderate to low

6

• In settings where mechanical equipment to generate negative pressure for suctioning is not available and a newly-born baby requires suctioning, a bulb syringe (single-use or easy to clean) is preferable to a mucous extractor with a trap in which the provider generates suction by aspiration.

Weak

Very Low

2012 WHO Recommendations on Basic Newborn Resuscitation

POSITIVE-PRESSURE VENTILATION 7

In newly-born babies who do not start breathing despite thorough drying and additional stimulation, PPV should be initiated within one minute after birth.

Strong

Very low

8

In newly-born term or preterm (>32 weeks gestation) babies requiring PPV, ventilation should be initiated with air.

Strong

Moderate

9

In newly-born babies requiring positive-pressure ventilation, ventilation should be provided using a self inflating bag and mask.

Weak

Very low

10

In newly-born babies requiring PPV, ventilation should be initiated using a facemask interface.

Strong

Low

11

In newly-born babies requiring PPV, adequacy of ventilation should be assessed by measurement of the heart rate after 60 seconds of ventilation with visible chest movements.

Strong

Very low

12

In newly-born babies who do not start breathing within one minute Strong after birth, priority should be given to providing adequate ventilation rather than to chest compressions.

Very low

2012 WHO Recommendations on Basic Newborn Resuscitation

RECOMMENDATIONS: IMMEDIATE CARE AFTER BIRTH

Strength

Evidence quality

Strong

Low

STOPPING RESUSCITATION 13

• In newly-born babies with no detectable heart rate after 10 minutes of effective ventilation, resuscitation should be stopped.

Weak • In newly-born babies who continue to have a heart rate below 60/minute and no spontaneous breathing after 20 minutes of resuscitation, resuscitation should be stopped.

2012 WHO Recommendations on Basic Newborn Resuscitation

Very low

The Utstein formula of survival

CastrĂŠn M. Pre-hospital airway management e time to provide the same standard of care as in the hospital. Editorial. Acta Anaesthesiol Scand 2008;52: 877e8.

EXISTING GAPS IN NEWBORN RESUSCITATION IN RESOURCE-LIMITED SETTINGS CORD CLAMPING

• • • STIMULATION • • • SUCTION • • • • POSITIVE• PRESSURE • VENTILATION • •

Timing of cord clamping (1-2-3-4-5 min? Flat cord?)

Resuscitation with intact cord ?

Hyperbilirrubinemia risk with delayed cord clamping Effect of stimulation on avoiding PPV? Best way to stimulate?

Additional stimulation before PPV? Suction before PPV or intrapartum?

Meconium management?

Suctioning when chest not rising ?

Devices for suctioning?

Best interface for PPV ? (nasal cannula/mask, nasopharyngeal prongs) Optimal ventilation parameters?

Outcome of non-breathing infants?

Best way to measure Heart Rate during PPV? 2012 WHO Recommendations on Basic Newborn Resuscitation

EDUCATION

• Frequency of training?

• Retention of skills when used frequently and infrequently?

• Training of different levels of health workers?

• Role of video recording for training-evaluation ?

• Training methodologies?

OPERATIONAL • Effects of guidelines?

RESEARCH • How to scale up?

OTHERS

• Simple ways to administer blended oxygen?

• Thermal management of asphyxiated infant (warmer/hypothermia)?

• Burden of resuscitation?

2012 WHO Recommendations on Basic Newborn Resuscitation

THE NEAR FUTURE FOR NEWBORN RESUSCITATION IN MSF PROJECTS • FINAL BASIC ALGORITHM TAKING INTO ACCOUNT CURRENT EVIDENCE FOR TRAINED STAFF IN RESOURCE-LIMITED SITES AND CONSIDERS NEWBORN ASSESSMENT DURING LABOR: > HBB PLUS / HBB +

REFERENCES • • • • • • • • • • • • • • • •

WHO. Basic newborn resuscitation. Geneva, WHO, 2012.

2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science.

Baenziger O et al. The influence of the timing of cord clamping on postnatal cerebral oxygenation in preterm neonates: a randomized, controlled trial. Pediatrics, 2007, 119:455-459.

Carrasco M, Martell M, Estol PC. Oronasopharyngeal suction at birth: effects on arterial oxygen saturation. Journal of Pediatrics, 1997, 130:832-834.

2000 Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care: international consensus on science, Part 11: Neonatal resuscitation. Circulation, 2000, 102(Suppl. I):I343–I358.

2005 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 7: Neonatal resuscitation. Circulation, 2005, 112:III-91–III-99.

2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 11: Neonatal resuscitation: Circulation, 2010, 122(Suppl. 2):S516 –S538.

WHO et al. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Geneva, WHO, 2006; WHO. Essential newborn care course. Geneva, WHO, 2010.

WHO. Managing newborn problems: a guide for doctors, nurses and midwives. Geneva, WHO, 2003.

WHO. Pocket book of hospital care for children: guidelines for the management of common illnesses with limited resources. Geneva, WHO, 2005.

WHO. Handbook for guideline development. Geneva, WHO, 2010.

Wall SN, Lee ACC, Niermeyer S, English M, Keenan WJ, Carlo W, et al. Neonatal resuscitation in low-resource settings: what, who, and how to overcome challenges to scale up. Int J Gynaecol Obstet. 2009;107(Suppl 1):S47–62. S63-4.

Kattwinkel J. Textbook of Neonatal Resuscitation. 5th ed. American Academy of Pediatrics; Elk Grove Village, IL: 2005.

Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, et al. Two million intrapartum stillbirths and neonatal deaths: Where, why, and what can be done? Int J Gynecol Obstet. 2009;107:S5–S19.

Newton O, English M. Newborn resuscitation: defining best practice for low-income settings. Trans R Soc Trop Med Hyg. 2006 Oct;100(10):899–908.