home Audience 1 Resuscitation of premature babies. Primary resuscitation care for newborns

Resuscitation of premature babies. Primary resuscitation care for newborns

Resuscitation of newborns in the delivery room is based on a strictly defined sequence of actions, including predicting the occurrence of critical situations, assessing the condition of the child immediately after birth, and carrying out resuscitation measures aimed at restoring and maintaining respiratory and circulatory functions.

Predicting the likelihood of a child being born with asphyxia or drug-induced depression is based on an analysis of antenatal and intrapartum anamnesis.

Risk factors

Antenatal risk factors include maternal diseases such as diabetes, hypertension syndromes, infections, and maternal drug and alcohol use. Of the pathology of pregnancy, it should be noted that there is a lot or oligohydramnios, overmaturity, intrauterine growth retardation, and the presence of multiple pregnancies.

Intranatal risk factors include: preterm or delayed labor, abnormal presentation or position of the fetus, placental abruption, prolapsed umbilical cord, use general anesthesia, anomalies labor activity, the presence of meconium in amniotic fluid, etc.

Before the start of resuscitation, the child's condition is assessed according to the signs of live birth:

the presence of spontaneous breathing,
heartbeat,
umbilical cord pulsations,
voluntary muscle movements.

In the absence of all 4 signs, the child is considered stillborn and is not subject to resuscitation. The presence of at least one sign of live birth is an indication for the immediate start of resuscitation.

Resuscitation algorithm

The resuscitation algorithm is determined by three main features:

the presence of independent breathing;
heart rate;
color skin.

The Apgar score is assessed, as was customary, at the 1st and 5th minutes to determine the severity of asphyxia, but its indicators do not have any effect on the volume and sequence of resuscitation measures.

Primary care newborns in the maternity hospital

Initial activities(duration 20-40 s).

In the absence of risk factors and clear amniotic fluid, the umbilical cord is cut immediately after birth, the baby is wiped dry with a warm diaper and placed under a radiant heat source. If available a large number of mucus in the upper respiratory tract, then it is suctioned from oral cavity and nasal passages using a balloon or catheter connected to an electric suction device. In the absence of breathing, light tactile stimulation is carried out by patting the feet 1-2 times.

In the presence of asphyxia factors and pathological impurities in the amniotic fluid (meconium, blood), aspiration of the contents of the oral cavity and nasal passages is performed immediately after the birth of the head (before the birth of the shoulders). After birth, pathological impurities are aspirated from the stomach and trachea.

I. First assessment of condition and action:

A. Breathing.

Absent (primary or secondary epnea) - start mechanical ventilation;

Independent, but inadequate (convulsive, superficial, irregular) - start mechanical ventilation;

Independent regular - assess heart rate (HR).

B. Heart rate.

Heart rate less than 100 beats per minute. - carry out mask ventilation with 100% oxygen until heart rate normalizes;

B. Skin color.

Completely pink or pink with cyanosis of the hands and feet - observe;

Cyanotic - inhale 100% oxygen through a face mask until cyanosis disappears.

Mechanical ventilation technique

Artificial ventilation is carried out with a self-expanding bag (Ambu, Penlon, Laerdal, etc.) through a face mask or endotracheal tube. Before starting mechanical ventilation, the bag is connected to an oxygen source, preferably through a gas mixture humidifier. Place a cushion under the child's shoulders and tilt his head slightly back. The mask is placed on the face so that it top part The obturator lay on the bridge of the nose, and the lower one on the chin. When pressing on the bag, an excursion should be clearly visible. chest.

Indications for the use of an oral airway during mask ventilation are: bilateral choanal atresia, Pierre-Robin syndrome and the inability to ensure free patency of the airways when the child is positioned correctly.

Tracheal intubation and switching to mechanical ventilation through an endotracheal tube are indicated for suspected diaphragmatic hernia, ineffectiveness of mask ventilation within 1 minute, as well as apnea or inadequate breathing in a child with a gestational age of less than 28 weeks.

Artificial ventilation is carried out with a 90-100% oxygen-air mixture with a frequency of 40 breaths per minute and an inhalation to exhalation time ratio of 1:1.

After ventilation of the lungs for 15-30 seconds, the heart rate is again monitored.

If the heart rate is above 80 per minute, continue mechanical ventilation until adequate spontaneous breathing is restored.

If the heart rate is less than 80 beats per minute - while continuing mechanical ventilation, start indirect massage hearts.

Indirect cardiac massage technique

The child is placed on a hard surface. Two fingers (middle and index) of one hand or two thumbs Both hands apply pressure on the border of the lower and middle third of the sternum with a frequency of 120 per minute. The displacement of the sternum towards the spine should be 1.5-2 cm. Ventilation of the lungs and cardiac massage are not synchronized, i.e. Each manipulation is carried out in its own rhythm.

30 seconds after start closed massage hearts control heart rate again.

If the heart rate is above 80 beats per minute, stop cardiac massage and continue mechanical ventilation until adequate spontaneous breathing is restored.

If the heart rate is below 80 per minute, continue chest compressions, mechanical ventilation and begin drug therapy.

Drug therapy

If asystole or heart rate is below 80 beats per minute, adrenaline is immediately administered at a concentration of 1:10,000. To do this, 1 ml of ampoule solution of adrenaline is diluted in 10 ml of physiological solution. The solution prepared in this way is taken in an amount of 1 ml into a separate syringe and injected intravenously or endotracheally at a dose of 0.1-0.3 ml/kg body weight.

Heart rate is re-monitored every 30 seconds.

If heart rate recovers and exceeds 80 beats per minute, stop cardiac massage and other injections. medicines.

If there is asystole or heart rate below 80 beats per minute, continue chest compressions, mechanical ventilation and drug therapy.

Repeat the administration of adrenaline at the same dose (if necessary, this can be done every 5 minutes).

If the patient has signs of acute hypovolemia, which is manifested by pallor, weak thread-like pulse, low blood pressure, then the child is advised to administer a 5% albumin solution or saline solution at a dose of 10-15 ml/kg body weight. Solutions are administered intravenously over 5-10 minutes. If signs of hypovolemia persist, repeated administration of these solutions in the same dose is permissible.

Administration of sodium bicarbonate is indicated for confirmed decompensated metabolic acidosis (pH 7.0; BE -12), as well as in the absence of effect from mechanical ventilation, cardiac massage and drug therapy(suspected severe acidosis preventing cardiac recovery). Sodium bicarbonate solution (4%) is injected into the umbilical cord vein at the rate of 4 ml/kg body weight (2 mEq/kg). The rate of drug administration is 1 mEq/kg/min.

If within 20 minutes after birth, despite full resuscitation measures, the child’s cardiac activity is not restored (no heartbeats), resuscitation in the delivery room is stopped.

At positive effect from resuscitation measures, the child must be transferred to the department (ward) intensive care where it will continue specialized treatment.

Primary neonatal resuscitation

Death is the death of body cells due to the cessation of their supply of blood, which carries oxygen and nutrients. Cells die after sudden stop heart and breathing, although quickly, are not instantaneous. The cells of the brain, especially the cortex, that is, the department on the functioning of which consciousness, spiritual life, and human activity as an individual depend, suffer most from the cessation of oxygen supply.

If oxygen does not enter the cells of the cerebral cortex within 4–5 minutes, they are irreversibly damaged and die. Cells of other organs, including the heart, are more viable. Therefore, if breathing and blood circulation are quickly restored, the vital activity of these cells will resume. However, this will only be the biological existence of the organism, consciousness, mental activity either they will not be restored at all, or they will be profoundly changed. Therefore, the revival of a person must begin as early as possible.

That's why everyone needs to know the methods primary resuscitation children, that is, to learn a set of measures to provide assistance at the scene of an incident, prevent fatal outcome and revitalization of the body. It is everyone’s duty to be able to do this. Inactivity while waiting for medical workers, no matter what its motivation - confusion, fear, inability - should be considered as a failure to fulfill a moral and civic duty towards a dying person. If this concerns your beloved baby, it is simply necessary to know the basics of resuscitation care!

Carrying out resuscitation for a newborn

How is primary resuscitation of children performed?

Cardiopulmonary and cerebral resuscitation (CPCR) is a set of measures aimed at restoring the basic vital functions impaired in terminal conditions. important functions body (heart and breathing) in order to prevent brain death. This resuscitation is aimed at reviving a person after breathing has stopped.

Leading reasons terminal states, developed outside medical institutions, V childhood are a syndrome sudden death newborns, car trauma, drowning, obstruction of the upper respiratory tract. Maximum number deaths in children it occurs before the age of 2 years.

Periods of cardiopulmonary and cerebral resuscitation:

The period of basic life support. In our country it is called the immediate stage;
Period further maintenance life. It is often referred to as a specialized stage;
The period of prolonged and long-term life support, or post-resuscitation.

At the stage of basic life support, techniques are performed to replace (“prosthetics”) the vital functions of the body - the heart and breathing. In this case, the events and their sequence are conventionally designated by a well-remembered abbreviation of three English letters ABS:

- from English. airway, literally opening the airways, restoring airway patency;

– breath for victim, literally – breathing for the victim, mechanical ventilation;

– circulation his blood, literally – ensuring his blood flow, external massage hearts.

Transportation of victims

Functionally justified for transporting children is:

with severe hypotension - horizontal position with the head end lowered by 15°;
in case of chest injury, acute respiratory failure of various etiologies– semi-sitting;
in case of spinal injury – horizontal on the backboard;
for fractures pelvic bones, organ damage abdominal cavity– legs bent at the knees and hips; joints and spread to the sides (“frog position”);
for injuries of the skull and brain with lack of consciousness - horizontal on the side or on the back with the head end raised by 15°, fixation of the head and cervical region spine.

Methodical letter

Primary and resuscitation care for newborns

Chief editors: Academician of the Russian Academy of Medical Sciences N.N.Volodin1, Professor E.N.Baibarina2, Academician of the Russian Academy of Medical Sciences G.T.Sukhikh2.

Team of authors: Professor A.G. Antonov2, Professor D.N. Degtyarev2, Ph.D. O.V.Ionov2, Ph.D. D.S.Kryuchko2, Ph.D. A.A. Lenyushkina2, Ph.D. A.V. Mostovoy3, M.E. Prutkin,4 Terekhova Yu.E.5,

Professor O.S. Filippov5, Professor O.V. Chumakova5.

The authors thank the members of the Russian Association of Perinatal Medicine Specialists who took an active part in finalizing these recommendations - A.P. Averina (Chelyabinsk), A.P. Galunin (Moscow), A.L. Karpov (Yaroslavl), A.R. Kirtbaya (Moscow), F.G. Mukhametshina (Ekaterinburg), V.A.Romanenko (Chelyabinsk), K.V.Romanenko (Chelyabinsk).

An updated approach to primary neonatal resuscitation outlined in methodological recommendations, heard and approved for IV

them. N.I. Pirogova."

2. Leading institution: Federal State Institution " Science Center obstetrics, gynecology and perinatology named after. Academician V.I. Kulakov."

3. State Educational Institution of Higher Professional Education St. Petersburg State Pediatric Medical Academy.

4. GUZ Regional Children's clinical Hospital No. 1 Ekaterinburg.

5. Ministry of Health and Social Development Russian Federation.

List of abbreviations:

HR – heart rate of ventilation – artificial ventilation lungs BCC - circulating blood volume

CPAP - continuous positive airway pressure PEEP positive end expiratory pressure

PIP - peak inspiratory pressure ETT - endotracheal tube

SpO2 – saturation (saturation) of hemoglobin with oxygen

Introduction

Severe ante- and intrapartum fetal hypoxia is one of the main causes of high perinatal morbidity and mortality in the Russian Federation. Effective primary resuscitation of newborns in the delivery room can significantly reduce the adverse consequences of perinatal hypoxia.

By different estimates, from 0.5 to 2% of full-term children and from 10 to 20% of premature and post-term children need to carry out primary resuscitation measures in the delivery room. At the same time, the need for primary resuscitation measures in children born with a body weight of 1000-1500 g ranges from 25 to 50% of children, and in children weighing less than 1000 g - from 50 to 80% or more.

Basic principles of organization and algorithm for providing primary and resuscitation care to newborns, used to date in the activities of maternity hospitals and obstetric departments, were developed and approved by order of the Ministry of Health and Medical Industry of Russia 15 years ago (order of the Ministry of Health and Medical Industry of the Russian Federation dated December 28, 1995 No. 372). Over the past time, both in our country and abroad, a large clinical experience on primary resuscitation of newborns of various gestational ages, a generalization of which made it possible to identify reserves for increasing the effectiveness of both individual medical measures and the entire complex of primary resuscitation as a whole.

The approaches to primary resuscitation of extremely premature infants have changed most significantly. At the same time, in the previously approved algorithm of actions medical personnel in the maternity room were found unjustified from the point of view evidence-based medicine and even potentially dangerous medical appointments. All this served as the basis for clarifying the principles of organizing primary care approved by order of the Ministry of Health and Medical Industry of Russia dated December 28, 1995 No.

resuscitation care for newborns in the delivery room, revision and differentiated approach to the algorithm for primary resuscitation of full-term and very premature infants.

Thus, these recommendations outline modern, internationally recognized and practice-tested principles and algorithms for primary neonatal resuscitation. But for their full-scale implementation in medical practice and maintaining high level quality medical care for newborns, it is necessary to organize on an ongoing basis the training of medical workers in every obstetric hospital. It is preferable that classes are conducted using special mannequins, with video recording of training sessions and subsequent analysis of training results.

The rapid introduction into practice of updated approaches to primary

And intensive care for newborns will reduce neonatal

And infant mortality and disability from childhood, improve the quality of medical care for newborn children.

Principles of organizing primary resuscitation care for newborns

The basic principles of providing primary resuscitation care are: the readiness of medical personnel of any medical institution functional level to the immediate provision of resuscitation measures to a newborn child and a clear algorithm of actions in the delivery room.

Primary and postnatal resuscitation care for newborns should be provided in all settings where birth may potentially occur, including the pre-hospital stage.

At every birth taking place in any unit of any medical institution licensed to provide obstetrics and gynecology care must always be present medical worker, having the special knowledge and skills necessary to provide the full scope of primary resuscitation care to a newborn child.

To provide effective primary resuscitation care, obstetric institutions must be equipped with appropriate medical equipment.

Work in the maternity ward should be organized in such a way that in cases of cardiopulmonary resuscitation, the employee who carries it out can be assisted from the first minute by at least two other medical workers (obstetrician-gynecologist, anesthesiologist, resuscitator, nurse- anesthetist, midwife, children's nurse).

The following must have skills in primary neonatal resuscitation:

Doctors and paramedics of ambulance and emergency medical care who transport women in labor;

- all medical personnel present in the delivery room during childbirth (doctor obstetrician-gynecologist, anesthesiologist-resuscitator, nurse anesthetist, nurse, midwife);

- staff of neonatal departments (neonatologists, anesthesiologists and resuscitators, pediatricians, pediatric nurses).

The obstetrician-gynecologist notifies in advance of the birth of the child a neonatologist or other medical worker who is fully proficient in the methods of primary neonatal resuscitation in order to prepare equipment. The specialist providing primary resuscitation care to newborns must be informed in advance by the obstetrician-gynecologist about the risk factors for the birth of a child with asphyxia.

Antenatal risk factors for the development of newborn asphyxia:

- diabetes;

- gestosis (preeclampsia);

- hypertensive syndromes;

- Rh sensitization;

- history of stillbirth;

- clinical signs of infection in the mother;

- bleeding in the second or third trimesters of pregnancy;

Polyhydramnios;

Low water;

- multiple pregnancy;

- intrauterine growth retardation;

- maternal drug and alcohol use;

- maternal use of medications that depress the newborn's breathing;

- the presence of developmental anomalies identified during antenatal diagnosis;

- abnormal cardiotocography indicators on the eve of childbirth.

Intrapartum risk factors:

- premature birth (less than 37 weeks);

- late birth (more than 42 weeks);

- Caesarean section operation;

- placental abruption;

- placenta previa;

- loss of umbilical cord loops;

- pathological position of the fetus;

- use of general anesthesia;

- anomalies of labor;

- presence of meconium in amniotic fluid;

- fetal heart rhythm disturbances;

- shoulder dystocia;

- instrumental childbirth ( obstetric forceps, vacuum extraction). The neonatologist should also be notified of the indications for surgery

caesarean section and features of anesthesia. When preparing for any childbirth you should:

- provide optimal temperature regime for a newborn (the air temperature in the delivery room is not lower than + 24º C, no draft, radiant heat source turned on, a warm set of diapers);

- check the availability and readiness for operation of the necessary resuscitation equipment;

- invite to the birth a doctor who is fully proficient in newborn resuscitation techniques. In case of multiple pregnancies, a sufficient number of specialists and equipment should be provided in advance to provide care to all newborns;

- when the birth of a child in asphyxia is predicted, the birth of a premature baby at 32 weeks of gestation or less, an intensive care team consisting of

of two people trained in all neonatal resuscitation techniques (preferably a neonatologist and a trained nurse). Care of the newborn should be the sole responsibility of the members of this team during the initial resuscitation.

After the birth of the child, it is necessary to record the time of his birth and, if indicated, proceed with resuscitation in accordance with the protocol outlined below. (The sequence of primary resuscitation measures is presented in the form of diagrams in Appendices No. 1-4).

Regardless of the initial state, the nature and extent of resuscitation, 1 and 5 minutes after birth, the child's condition should be assessed according to Apgar (Table 1). If resuscitation continues beyond 5 minutes of life, a third Apgar assessment should be performed 10 minutes after birth. When assessing the Apgar on the background of mechanical ventilation, only the presence of spontaneous respiratory efforts of the child is taken into account: if they are present, 1 point is set for breathing, if they are absent, 0, regardless of chest excursion in response to forced ventilation of the lungs.

Table 1.

Criteria for assessing a newborn according to V. Apgar



		Less than 100/min	More than 100/min
	Absent	Faint scream	Strong scream
		(hypoventilation)	(adequate breathing)
Muscle tone	Low (child	Moderately reduced	High (active
		(weak movements)	movement)
Reflexes	Not defined		Screaming or active
			movement
Color of the skin	Blue or white	Expressed	Fully pink
		acrocyanosis

Interpretation of the Apgar score.

The sum of 8 points or more 1 min after birth indicates the absence of asphyxia of the newborn, 4-7 points - about mild and moderate asphyxia, 1-3 points - about severe asphyxia. The Apgar score 5 minutes after birth is not so much diagnostic as prognostic value, and reflects the effectiveness (or ineffectiveness) of resuscitation measures. There is a strong Feedback between the second Apgar score and the incidence of adverse neurological outcomes. A score of 0 10 minutes after birth is one of the reasons for terminating primary resuscitation.

In all cases of live birth, the first and second Apgar scores are entered in the appropriate columns of the neonatal history.

In cases of primary resuscitation, a completed insert card for primary resuscitation of newborns (Appendix No. 5) is additionally pasted into the history of the development of the newborn.

The equipment sheet for primary resuscitation is presented in Appendix No. 6.

Protocol for primary resuscitation of newborns Algorithm for making a decision on the start of primary resuscitation measures:

1.1.Record the time of birth of the child.

1.2. Assess the need to move the child to the resuscitation table by answering 4 questions:

1.) Is the baby full term?

2.) Amniotic fluid clean, obvious signs are there any infections?

3.) Is the newborn breathing and crying?

4.) Does the child have good muscle tone?

1.3. If the health worker caring for the newborn can answer “YES” to all 4 questions, the baby should be covered with a dry, warm diaper and placed on the mother's chest. However, it should be remembered that during the entire period of stay in the delivery room, the child must remain under the close supervision of medical personnel. If the specialist answers “NO” to at least one of the above questions, he must transfer the child to a heated table (to an open resuscitation system) for an in-depth assessment of the child’s condition and, if necessary, for primary resuscitation.

1.4. Primary resuscitation measures are carried out if the child has indications, subject to at least one sign of a live birth:

Spontaneous breathing; - heartbeat (heart rate); - pulsation of the umbilical cord;

Voluntary muscle movements.

1.5. In the absence of all signs of a live birth, the child is considered stillborn.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols Ministry of Health of the Republic of Kazakhstan - 2015

Unspecified birth asphyxia (P21.9), Moderate to moderate birth asphyxia (P21.1), Severe birth asphyxia (P21.0)

Neonatology, Pediatrics

general information

Short description

Expert advice

RSE on REM "Republican Center for Health Development"

Ministry of Health and Social Development of the Republic of Kazakhstan

Protocol No. 10

I. INTRODUCTION PART

Protocol name: Resuscitation of premature babies.

Protocol code:

ICD-10 code(s):

P21.0 Severe asphyxia at birth

P21.1 Moderate and moderate asphyxia at birth

P21.9 Unspecified asphyxia at birth

Abbreviations used in the protocol:

HELL arterial pressure

IV IV

IVL artificial ventilation of the lungs

MTR birth weight

NMS indirect cardiac massage;

BCC volume of circulating blood

FOE functional residual lung capacity

RR respiratory rate

Heart rate heart rate

ETT endotracheal tube

FiO2 concentration of oxygen in the inhaled gas mixture

ILCOR International Liaison Committee on Resuscitation

PIP positive inspiratory pressure

PEEP positive end expiratory pressure (positive end expiratory pressure)

SpO2 blood oxygen saturation

CPAP continuous positive airway pressure (continuous positive airway pressure)

Date of development of the protocol: 2015

Protocol users: neonatologists, resuscitators and obstetricians and gynecologists of obstetric organizations.

Assessing the level of evidence of the recommendations provided (Consensus European recommendations on treatment respiratory distress syndrome in premature newborns - updated version 2013).

Level of evidence scale:

Level I:	Evidence obtained from a systematic review of all eligible randomized controlled trials.
Level II:	Evidence from at least one well-designed randomized controlled trial.
Level III-1:	Evidence obtained from a well-designed pseudo-randomized controlled trial (spare allocation or other method).
Level III-2:	Evidence obtained from comparative non-randomized studies with parallel controls and allocation (cohort studies), case-control studies, or interrupted time series with a control group.
Level III-3:	Evidence obtained from comparative studies with historical controls, two or more uncontrolled studies, or interrupted time series without a parallel control group.
Level IV:	Evidence obtained from a case series, either a post-test or pre-test and post-test.
Gradation of recommendation	Description
	Class A: recommended Class A treatment recommendations are given to those guidelines that are considered useful and should be used.
	Class B: acceptable

Diagnostics

Diagnostic measures: are carried out in the post-resuscitation period to identify the causes of pulmonary-cardiac disorders at birth, i.e. to establish a clinical diagnosis.

Main events
To determine the severity of birth asphyxia, immediately after the birth of the child, blood is taken from the artery of the clamped umbilical cord to determine its gas composition.
. Markers of severe perinatal asphyxia (hypoxia) are:
- pronounced metabolic acidosis(V arterial blood umbilical cord pH<7,0 и дефицит оснований ВЕ ≥ 12 ммоль/л);
- Apgar score 0-3 points at 5 minutes;
- clinical neurological disorders that manifest themselves in the early stages after birth (convulsions, hypotension, coma ─ hypoxic-ischemic encephalopathy);
- signs of multiple organ damage in the early stages after birth [UD - A].

Additional Research:
. monitoring of WWTP to maintain normal values within the range: pH 7.3-7.45; Ra O2 60-80 mmHg; SpO2 90-95%)); PaCO2 35-50 mm Hg;

. clinical blood test, platelet count to exclude or confirm the presence of a severe bacterial infection in the newborn (sepsis, pneumonia);

Heart rate, respiratory rate, body temperature, pulse oximetry, blood pressure monitoring to identify cardiopulmonary pathology, characterized by the development of hypotension, systemic secondary arterial hypoxemia against the background of increased pulmonary vascular resistance, leading to pathological shunting of blood through fetal communications (PDA, LLC);

Monitoring diuresis, taking into account fluid balance and electrolyte levels in the blood serum (pronounced low levels of sodium, potassium and chlorides in the blood serum with decreased diuresis and excessive weight gain together may indicate acute renal tubular necrosis or syndrome of inappropriate secretion of antidiuretic hormone, especially for the first time 2-3 days of life; increased urine output may indicate ongoing tubular damage and excess sodium excretion relative to water excretion);

The concentration of glucose in the blood serum (glucose is the main energy substrate necessary for postnatal adaptation and brain nutrition; hypoglycemia can lead to apnea and seizures).

Instrumental studies(preferably in the first days):
. Neurosonography to exclude/confirm IVH, ICH and other CNS pathologies;
. Ultrasound of the heart to exclude/confirm congenital heart disease, myocarditis;
. Echo CG to exclude/confirm congenital heart disease, PDA, LLC, etc.;
. Survey radiography to exclude/confirm respiratory pathology, UVB, NEC;
. Other studies according to indications.

Specialist consultations: are carried out as necessary in the post-resuscitation period to confirm the identified pathology (neurologist, cardiologist, ophthalmologist, neonatal surgeon, neurosurgeon, etc.).

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Treatment

II. MEDICAL REHABILITATION EVENTS

Purpose of resuscitation:
The goal of resuscitation is the complete restoration of vital body functions, the disruption of which is caused by perinatal hypoxia and asphyxia during childbirth.

Indications for medical rehabilitation: in accordance with international criteria in accordance with the Standard for organizing the provision of medical rehabilitation to the population of the Republic of Kazakhstan, approved by order of the Minister of Health of the Republic of Kazakhstan dated December 27, 2014 No. 759.

Indications for resuscitation:
. Premature newborns weighing 1000 - 1500 g require respiratory support immediately after birth in 25-50% of cases and those weighing less than 1000 g in 50-80% of cases (Class A).
. Such a frequent need for respiratory support is due to insufficient independent respiratory efforts in premature newborns and the inability to create and maintain functional residual capacity (FRC) of the lungs due to:
− immaturity of the lungs, surfactant deficiency;
− weakness of the chest muscles; −immaturity of the central nervous system, which does not provide adequate stimulation of breathing.
. Within the framework of the Newborn Resuscitation Program, a “Primary Assessment Block” has been allocated, which contains 3 questions that allow you to assess the condition of the child at the time of birth and identify the priority of actions:
− Is the baby full-term?
− Is he breathing or screaming?
− Is your muscle tone good?
. If the answer to at least one of the above questions is “no,” the child should be transferred to a heated table (open resuscitation system) for resuscitation measures.

Contraindications to medical rehabilitation:
Contraindications for resuscitation:
In Kazakhstan there is no law regulating the scope of provision

Resuscitation care for newborns in the delivery room. However, recommendations published by the International Consensus Committee on Resuscitation, based on the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 15: Neonatal Resuscitation: 2010, and the 6th edition of the textbook Neonatal Resuscitation, indicate conditions under which resuscitation is not indicated:
. If gestational age, birth weight, or congenital anomalies are associated with virtually certain death or unacceptably severe disability in surviving children, or:
. confirmed gestational age less than 23 weeks or birth weight less than 400 g;
. anencephaly;
. confirmed incompatible congenital malformations or genetic disease;
. the presence of data indicating an unacceptably high risk of death and disability.

Scope of medical rehabilitation

Main stages of resuscitation:
Resuscitation measures for premature newborns are carried out in the sequence recommended by the ILCOR (International Consensus Committee on Resuscitation) 2010 for all newborns [LE - A]:
A. Primary resuscitation measures (warming, clearing the airways, drying, tactile stimulation).
B. Positive pressure ventilation.
C. Indirect cardiac massage.
D. Administration of adrenaline and/or solution to replenish the volume of circulating blood (volume expander therapy).

After each step of resuscitation, its effectiveness is assessed, which is based on the child's heart rate, respiratory rate and oxygenation (which is preferably assessed using a pulse oximeter).
. If heart rate, respiration and oxygenation do not improve, proceed to the next step (block) of action.

Preparing for resuscitation
Assessment and intervention are simultaneous processes facilitated by the critical care team.
. The success and quality of resuscitation depends on the experience, readiness and skills of the staff, the availability of a full set of resuscitation equipment and medications, which should always be available in the delivery room. [UD -A]
. In case of premature birth, a team of doctors with experience in the neonatal intensive care unit is called to the delivery room, including employees who are well-versed in tracheal intubation and emergency umbilical vein catheterization. [UD A]
. If preterm birth is expected, the temperature in the delivery room should be increased to ≥26°C and a radiant heat source should be turned on first to ensure a comfortable ambient temperature for the preterm neonate. [UD -A]

Place an exothermic mattress under several layers of diapers located on the resuscitation table.
. If a baby is expected to be born with a gestational age of less than 28 weeks, it is necessary to prepare a heat-resistant plastic bag or plastic film for food or medical purposes and an exothermic mattress (warming mat). [UD - A]
. Warming and humidifying gases used to stabilize the condition may also help maintain the newborn's body temperature. [UD - V]
. A pulse oximeter and a mixer connected to a source of oxygen and compressed air should always be available. [UD - S]
. It is important to have a prepared, prewarmed transport incubator to maintain the neonate's body temperature when transported to the NICU after stabilization in the delivery room. [UD - A]

Block A.
Primary resuscitation measures ─ providing initial care to a newborn boils down to ensuring minimal heat loss, sanitation of the respiratory tract (if indicated), giving the child the correct position to ensure airway patency, tactile stimulation of breathing and re-positioning the newborn in the correct position, after which breathing and heart rate (HR) are assessed. [UD - V]

Prevention of heat loss:
. Preterm infants are particularly at risk for hypothermia, which can increase oxygen consumption and prevent effective resuscitation. This situation is most dangerous for newborns with extremely low (˂ 1000 g) and very low birth weight (˂ 1500 g). In order to prevent hypothermia, additional actions should be taken, which are not limited, as described above, to raising the air temperature in the delivery room to ≥26 ° C and in the area where resuscitation will be carried out, placing an exothermic mattress under several layers of diapers located on the resuscitation table. [LE C] When using an exothermic mattress, the manufacturer's instructions for activation should be strictly followed and the child placed on the appropriate side of the exothermic mattress.

Premature newborns with a gestational age of 29 weeks or less are placed immediately after birth (without drying) in a plastic bag or under a plastic diaper up to the neck on pre-heated diapers on the resuscitation table under a source of radiant heat (Fig. 1). The surface of the child's head is additionally covered with film or a cap. The pulse oximeter sensor is attached to the child's right wrist before being placed in the bag. The bag or diaper should not be removed during resuscitation efforts. [UD - A]

Picture 1

The child's temperature should be carefully monitored because sometimes, the use of methods aimed at preventing heat loss can lead to hyperthermia. [UD - V]

All resuscitation measures, including tracheal intubation, chest compressions, venous access, should be carried out while ensuring thermoregulation. [UD - S]

Sanitation of the respiratory tract:

Airway clearance has been shown to induce bradycardia during resuscitation, and tracheal evacuation in the absence of obvious nasal discharge in ventilated intubated neonates may reduce lung tissue plasticity and oxygenation, as well as reduced cerebral blood flow.

Therefore, airway debridement should be carried out only in those newborns who, during the first seconds of life, did not develop adequate spontaneous breathing due to obstruction by mucus and blood, and also, if mandatory positive pressure ventilation is required. [UD - S]

Giving the newborn's head the correct position

A newborn requiring resuscitation should be gently placed on his back with his head slightly tilted back (correct position, Fig. 2). This position will allow the back of the pharynx, larynx and trachea to be positioned in one line, ensuring maximum opening of the airways and unlimited air flow. [UD - V]

Figure 2:

If the back of the head is very prominent, a 2cm thick blanket or towel placed under the shoulders can help maintain the correct position. [UD - A]

Tactile stimulation
. In many cases, giving the head the correct position and sanitizing the airways (if indicated) are a sufficient stimulus to start breathing. Drying the newborn's body and head also stimulates breathing while keeping the head in the correct position.
. If the child does not have adequate respiratory movements, then additional tactile stimulation can be performed to stimulate breathing:
- gentle stroking along the back, torso or limbs (1-2 times), after which assess the effectiveness of primary resuscitation measures. [UD - A]

Evaluating the effectiveness of Block A
. If a premature newborn is not breathing after initial care, or has gasping breathing, or a heart rate of less than 100 per minute, this is considered indication for starting positive pressure ventilation (go to Block B) .

Block B. Positive pressure ventilation

Providing ventilation
. Uncontrolled inspiratory volumes, either too much or too little, have a damaging effect on the immature lungs of premature newborns. That's why routine use of ventilation with a self-expanding Ambu bag and mask is inappropriate . [UD - A]
. Most premature newborns do not have apnea, because... due to the immaturity of the lungs and surfactant deficiency, natural ventilation of the lungs and the formation of functional residual lung capacity are difficult. Use of early CPAP in the presence of spontaneous breathing(including groaning accompanied by chest retraction) with the ability to provide controlled inflation, is now the main way to safely stabilize preterm infants immediately after birth, reducing the need for mechanical ventilation. [UD - A]
. To provide CPAP (constant positive pressure in the airways throughout the entire respiratory cycle, created by a continuous flow of the gas mixture), a resuscitation device with a T-connector (Fig. 3) or a flow-filling bag with a resuscitation mask (Fig. 4) is used. as well as special equipment (CPAP machine, or neonatal ventilator with nasal cannulas or mask). CPAP cannot be provided with a self-inflating bag. [UD - S].

Figure 3

Figure 4. Flow-fill bag:

Continuous positive airway pressure (CPAP) is created by sealing a resuscitation mask attached to a T-system or flow-fill bag with the child's face. [UD - A].

Before applying the mask to the child’s face, it is necessary to adjust the CPAP value by firmly pressing the mask to the resuscitator’s hand (Fig. 3). Check the pressure gauge and adjust using the T-System PEEP valve or Flow Control Valve until the gauge reading corresponds to the required initial pressure of 5 cmH2O [LE - A]

Then you should place the mask tightly on the child's face and make sure that the pressure remains at the selected level. If the pressure decreases, the mask may not fit tightly to the child's face.

While CPAP is provided, the newborn's lungs are kept slightly inflated at all times, and he or she does not have to exert much effort to refill the lungs with air during each exhalation. [UD - A]

Sealed contact between the mask and the child's face is the most important prerequisite for creating positive pressure in the airways. . [AD A]

When using the T-system, signs of adequate mask position will be an audible exhalation sound and positive pressure as indicated by the pressure gauge (Fig. 5). [UD - A]

Figure 5.

If CPAP must be provided for a long time, then instead of a mask it is more convenient to use special nasal cannulas, since they are easier to secure in the desired position. [UD - A]

While CPAP is being provided, the child must breathe independently, without additional mandatory breaths provided by a resuscitation bag or T-piece resuscitation device (that is, this is not mandatory positive pressure ventilation!). [UD - A]

What concentration of oxygen in the breathing mixture should be used?

Tissue damage during childbirth and the early neonatal adjustment period can be caused by inadequate blood circulation and limited oxygen delivery to body tissues. Restoring these processes is an important task of resuscitation.

To start stabilizing the condition of a premature newborn, an oxygen concentration of 21-30% is appropriate, and its increase or decrease is carried out based on the readings of a pulse oximeter attached to the wrist of the right hand from the moment of birth to obtain information on heart rate and saturation (SpO2). [UD - A]

After birth, saturation should increase gradually from about 60% to 80% over 5 minutes, reaching 85% and above by about 10 minutes. [UD - A]

Oximetry can identify newborns that are outside the specified range and help control the oxygen concentration in the mixture. The recommended preductal saturation targets after birth are as follows:

Target SpO2 norms after birth:

1 minute	60-65%	4 minute	75-80%
2 minutes	65—70%	5 minute	80-85%
3 minute	70-75%	10 minute	85-95%

Initial CPAP settings[UD - A]:
. It is advisable to start CPAP with a pressure of 5 cmH2O. Art. at FiO2 = 0.21-0.30 under saturation control. In the absence of improvement in oxygenation, gradually increase the pressure to 6 cm aq. Art.
. The optimal recommended pressure is 6 cmH2O. Art. Using higher pressures with CPAP can cause serious complications (pneumothorax).
. FiO2 should be increased only after the pressure has increased.
. The pressure is provided by the flow rate (Flow), which is regulated by the device. The flow-pressure nomogram shows the relationship between flow rate and generated pressure (Fig. 6).

Figure 6. Flow-pressure nomogram (CPAP).

Indications for stopping CPAP:
. First of all, FiO2 is reduced, gradually to the level of 0.21 under the control of SaO2 88%. Then, slowly, 1-2 cm aq. Art. reduce pressure in the respiratory tract. When it is possible to bring the pressure to 4 cm aq. Art. at Flow-7 l/min, FiO2-0.21, SpO2 -88% CPAP is stopped [UD - C]
. If spontaneous breathing is ineffective in a child, mandatory ventilation should be performed instead of CPAP.
. In this case, the optimal inspiratory pressure (PIP) during the first forced breaths is selected individually for a particular newborn until the heart rhythm is restored and chest excursion occurs.
. An initial inspiratory pressure (PIP) of 20 cm H2O is adequate for most preterm infants.
. Forced ventilation should be carried out at a frequency of 40-60 breaths per minute to restore and maintain heart rate ˃ 100 beats/min:
‒ monitor blood oxygen saturation and adjust oxygen concentration to achieve the target SpO2 value in the ranges specified in the table “Target Preductal SpO2 Values after Birth”;
- insert an orogastric tube while ventilation continues;
- reduce inhalation pressure if filling the lungs with air seems excessive;
- during the entire period of forced ventilation, evaluate attempts at spontaneous breathing, heart rate and blood oxygen saturation continuously or every 30 seconds.

If there is no rapid increase in heart rate, you should check to see if there is visible chest excursion. If there is no chest excursion, you should check the tightness of the mask on the child’s face and the patency of the airway. If after these measures there is still no chest excursion, it is necessary to carefully increase the inspiratory pressure (every few forced breaths) until breath sounds begin to be heard over both lung fields and chest excursions appear with each forced breath. With the advent of chest excursion, heart rate and blood oxygen saturation will begin to increase. [UD - V]

Tracheal intubation in premature newborns
. Only a small number of preterm neonates require tracheal intubation in the delivery room. It is used in infants who have not responded to positive pressure ventilation through a face mask, during chest compressions, as well as in preterm infants less than 26 weeks gestational age for the administration of surfactant for replacement purposes, and in children with congenital diaphragmatic hernia. [UD - V]
. If intubation is necessary, proper endotracheal tube (ETT) placement can be quickly verified using a CO2 colorimetric device (capnograph) before surfactant is administered and mechanical ventilation is initiated. If the ETT is inserted into the trachea, the capnograph indicator will show the presence of CO2 in the exhaled air. However, it should be noted that with a sharp decrease or absence of blood flow in the vessels of the lungs, the test results may be false negative, that is, CO2 is not detected, despite the correct administration of the ETT. [UD - V]

Therefore, along with the CO2 detector, clinical methods for correct ETT placement should be used: tube fogging, presence of chest excursions, listening to breath sounds on both sides of the chest, an increase in heart rate in response to positive pressure ventilation. [UD - S]

Surfactant therapy:
. Surfactant replacement administration directly in the delivery room is recommended for preterm infants up to 26 weeks' gestational age, as well as in cases where the mother did not receive antenatal steroids to prevent RDS in her newborn, or when intubation is necessary to stabilize the condition of the preterm infant. [UD - A]

In most clinical studies, the INSURE technique (INtubate-SURfactant-Extubate to CPAP) is recommended as the standard technique for administering surfactant. This technique has been shown in randomized trials to reduce the need for mechanical ventilation and the subsequent development of bronchopulmonary dysplasia (BPD) [LE-A]

Early therapeutic administration of a surfactant is recommended when CPAP is ineffective, with an increase in oxygen demand in newborns with a gestational age of less than 26 weeks, when FiO2 is ˃ 0.30, and for preterm infants with a gestational age of more than 26 weeks, when FiO2 is ˃ 0.40. [UD - A]

Evaluation of the effectiveness of block “B”:
. The most important sign of effective positive pressure mandatory ventilation and an indication for its termination is an increase in heart rate to 100 beats/min or more, an increase in blood oxygen saturation (SpO2 corresponds to the target indicator in minutes) and the appearance of spontaneous breathing. [UD - A]
. If after 30 seconds of mandatory positive pressure ventilation:
- heart rate less than 100 beats/min in the absence of spontaneous breathing, continue mechanical ventilation until it appears and provide for the need for tracheal intubation;
- heart rate is 60-99 per 1 min, continue mechanical ventilation and provide for the need for tracheal intubation; [UD - A]
− HR ˂60 in 1 min, begin chest compressions, continue mechanical ventilation and provide for the need for tracheal intubation. [UD -A]

Block “C” Supporting blood circulation using chest compressions

Indications for starting chest compressions(HMS) is a heart rate of less than 60 bpm despite adequate mandatory ventilation using supplemental oxygen for 30 seconds. [UD - A]
. NMS should be performed only against the background of adequate ventilation with 100% oxygen. [UD - A]

Indirect cardiac massage is performed by pressing on the lower third of the sternum. It is located under the conditional line connecting the nipples. It is important not to put pressure on the xiphoid process to prevent liver rupture. Two indirect massage techniques are used, according to which compression of the sternum is performed:
1) with the pads of two thumbs - while the remaining fingers of both hands support the back (thumb method);
2) with the tips of two fingers of one hand (second and third or third and fourth) - while the second hand supports the back (two-finger method)

The depth of compressions should be one third of the anteroposterior diameter of the chest, and the frequency should be 90 per minute. After every three pressures on the sternum, ventilation is carried out, after which the pressures are repeated. In 2 sec. it is necessary to perform 3 compressions on the sternum (90 per 1 min) and one ventilation (30 per 1 min). [UD - S]

Well-coordinated chest compressions and forced ventilation are performed for at least 45-60 seconds. A pulse oximeter and heart rate monitor will help determine heart rate without interrupting NMS [LE - C]

Evaluation of the effectiveness of block C:
− When heart rate reaches more than 60 beats/min. NMS should be stopped, but forced positive pressure ventilation should be continued at a rate of 40-60 forced breaths per minute.
− As soon as the heart rate becomes more than 100 beats/min. and the child begins to breathe independently, you should gradually reduce the frequency of forced breaths and reduce the ventilation pressure, and then transfer the child to the intensive care unit for post-resuscitation measures.
- If the heart rate remains less than 60 beats/min, despite ongoing chest compressions, coordinated with positive pressure ventilation for 45-60 seconds, proceed to block D. [EL - C].

Block “D” Administration of adrenaline and/or solution to replenish circulating blood volume

Adrenaline administration while continuing positive pressure ventilation and chest compressions
. The recommended dose of adrenaline for intravenous (preferably) administration to newborns is 0.01-0.03 mg / kg. The intravenous dose should not be increased as this may lead to hypertension, myocardial dysfunction and neurological impairment.

. For endotracheal administration of the 1st dose of epinephrine, while the venous access is being prepared, it is recommended to always use a higher dose of 0.05 to 0.1 mg/kg. However, the effectiveness and safety of this practice have not been determined. Regardless of the method of administration, the concentration of adrenaline should be 1:10,000 (0.1 mg / ml). [UD - S]

Immediately after endotracheal injection of epinephrine, forced ventilation of the lungs with 100% oxygen should be continued for better distribution and absorption of the drug in the lungs. If adrenaline is administered intravenously through a catheter, then it must be followed by a bolus of 0.5-1.0 ml of saline to ensure that the entire volume of the drug enters the bloodstream. [UD - V]

60 seconds after the administration of adrenaline (with endotracheal administration - after a longer period of time), the child’s heart rate should be assessed:
─ If after the administration of the 1st dose of adrenaline the heart rate remains less than 60 beats/min, you can repeat the administration of the drug at the same dose after 3-5 minutes, but only if the minimum permissible dose was administered during the first administration of the drug, then when subsequent administrations should increase the dose to the maximum allowable. Any repeated administration of epinephrine should be administered intravenously. [UD - V]

You must additionally ensure that:
- there is good air exchange, as evidenced by adequate chest excursion and listening to breath sounds over both lung fields; if tracheal intubation has not yet been performed, it should be performed;
- the ETT did not move during resuscitation;
- compressions are carried out to a depth of 1/3 of the anteroposterior diameter of the chest; they are well coordinated with forced ventilation.

Replenishment of circulating blood volume
. If the child does not respond to resuscitation measures and has signs of hypovolemic shock (pallor, weak pulse, dull heart sounds, positive white spot sign), or there are indications of placenta previa, vaginal bleeding or blood loss from the umbilical cord vessels, you should consider about replenishment of circulating blood volume (CBV). [UD - C] ●The drugs of choice that normalize blood volume are 0.9% sodium chloride solution or lactated Ringer's solution. To urgently replace significant blood loss, emergency blood transfusion may be necessary.

In premature infants with a gestational age of less than 32 weeks, one should remember the structural features of the capillary network of the germinal matrix of the immature brain. Rapid administration of large volumes of fluid can lead to intraventricular hemorrhage. Therefore, the primary volume of fluid required to replenish the bcc is injected into the umbilical vein at a dose of 10 ml/kg in a slow stream over ≥10 minutes. If, after the first dose, the child’s condition does not improve, a second dose of the solution may be required in the same volume (10 ml/kg). [UD - S]

After replenishing the blood volume, it is necessary to evaluate the resulting clinical effect. The disappearance of pallor, normalization of capillary refill time (the “white spot” symptom is less than 2 seconds), an increase in heart rate of more than 60 beats/min, and normalization of the pulse may indicate sufficient replenishment of blood volume. In this case, the administration of drugs and NMS should be stopped, while mandatory positive pressure ventilation is continued. [UD - S]
. As soon as the heart rate becomes more than 100 beats/min. and the child begins to breathe independently, the frequency of forced breaths should be gradually reduced and the ventilation pressure should be reduced, and then the child should be transferred to the intensive care unit for post-resuscitation care. [UD - S]
. If the measures taken are ineffective and there is confidence that effective ventilation, chest compressions and drug therapy are adequate, mechanical reasons for the failure of resuscitation, such as airway abnormalities, pneumothorax, diaphragmatic hernia or congenital heart disease, should be considered.

Termination of resuscitation measures
Resuscitation measures should be stopped if heartbeats are not detected within 10 minutes.
The decision to continue resuscitation after 10 minutes of absence of a heartbeat should be based on the etiological factors of cardiac arrest, gestational age, presence or absence of complications and parental decision.
Available evidence suggests that resuscitation of a newborn after 10 minutes of complete asystole usually results in the child's death or survival with severe disability. [UD - S].

Post-resuscitation period:
. After adequate ventilation has been established and the heart rate has been restored, the newborn should be transferred in a pre-warmed transport incubator to the intensive care unit, where he will be examined and treated.

A premature baby has very little glycogen stores. During resuscitation, his energy reserves are depleted, which can result in hypoglycemia. Hypoglycemia is a risk factor for brain damage and adverse outcomes in the presence of hypoxia or ischemia.

The level of glucose at which the risk of an adverse outcome increases is not defined, nor is its normal level. Therefore, to prevent the development of hypoglycemia, intravenous glucose should be administered in the first 12 hours of the post-resuscitation period with monitoring of its level every 3 hours. [UD - S].

. Premature babies may have short pauses between breaths. Prolonged apnea and severe bradycardia in the post-resuscitation period may be the first clinical signs of disturbances in temperature balance, blood oxygen saturation, decreased levels of electrolytes and blood glucose, the presence of acidosis, and infection.

To prevent metabolic disorders, it is necessary to monitor and maintain within the following limits: − glucose level 2.6 - 5.5 mmol/l; − total calcium 1.75 - 2.73 mmol/l; − sodium 134 - 146 mEq/l; − potassium 3.0 - 7.0 mEq/l.

To ensure adequate ventilation of the lungs and adequate oxygen concentration, SpO2 should be monitored until the child's body can maintain normal oxygenation when breathing air.

If the child continues to require positive pressure ventilation or supplemental oxygen, blood gases should be measured regularly at intervals that optimize the amount of care required.

If the medical organization where the child was born does not specialize in providing care to premature newborns requiring long-term forced ventilation, the child should be transferred to a medical institution of the appropriate profile (3rd level of perinatal care).

Caffeine should be used in infants with apnea and to facilitate cessation of mechanical ventilation (MV). [LE A] Caffeine should also be considered in all infants at high risk of requiring CF, such as those weighing less than 1250 g, who are receiving non-invasive mechanical ventilation [LE B].

To facilitate extubation in infants who remain on CF after 1–2 weeks, a short course of low or very low dose dexamethasone therapy should be considered, with a gradual dose reduction [LEA]

Parenteral nutrition should be started on the first day to avoid growth retardation and increased rapidly, starting at 3.5 g/kg/day protein and 3.0 g/kg/day lipids as tolerated [LE - C].

Minimal enteral nutrition should also be started on the first day [LOE -B].

Low systemic blood flow and treatment of hypotension are important predictors of poor long-term outcome.

Decreased systemic blood flow and hypotension may be associated with hypovolemia, left-to-right shunting through the ductus arteriosus or foramen ovale, or myocardial dysfunction. Establishing the cause will help you choose the most appropriate treatment tactics. Early hypovolemia can be minimized by delaying cord ligation. [UD - S].

If hypovolemia is confirmed by echocardiogram, and also if the cause is not clearly established, the possibility of increasing blood volume by administering 10-20 ml/kg of saline, but not colloid, should be considered.

In the treatment of hypotension in preterm infants, dopamine is superior to dobutamine in influencing short-term outcomes, but dobutamine may be a better choice for myocardial dysfunction and low systemic blood flow. In case of ineffectiveness of traditional treatment of arterial hypotension, hydrocortisone can also be used.
Drugs used to treat arterial hypotension in premature infants

A drug

Dose

During labor, the need for resuscitation may arise suddenly, so each birth should have at least one physician present who is trained in neonatal resuscitation and will be responsible for caring for the newborn. Additional staff (two health workers) are needed for high-risk deliveries.

The developed principles of ABC resuscitation make it possible to competently and consistently carry out all the required stages of intensive care and resuscitation for a newborn born with asphyxia.

Stage A includes:

Warming the baby;

Ensuring correct head position and clearing the airway if necessary (provide for the possibility of tracheal intubation at this moment);

Drying the skin and stimulating the baby's breathing;

Assessment of breathing, heart rate and skin color;

Supply oxygen if necessary.

Stage B consists of providing assisted ventilation under positive pressure using a resuscitation bag and 100% oxygen (provide for the possibility of tracheal intubation at this moment).

On stage C perform chest compressions while continuing auxiliary ventilation (provide for the possibility of tracheal intubation at this point).

On stage D administer adrenaline while continuing auxiliary ventilation and chest compressions (provide for the possibility of tracheal intubation at this point).

In order for primary resuscitation to be timely, effective and non-redundant, the neonatologist-resuscitator needs to assess:

Child's breathing (crying, breathing or not breathing);

Skin color (pink or cyanotic).

The presence of spontaneous breathing can be detected by observing the movements of the chest. A loud cry indicates the presence of breathing. However, sometimes an inexperienced neonatologist may mistakenly mistake gasping breathing for effective respiratory efforts. Gaspings are a series of deep individual or serial convulsive breaths that appear during hypoxia and/or ischemia. This type of breathing indicates severe neurological or respiratory depression.

Gasping in a newborn usually indicates a serious problem and requires the same intervention as a complete absence of breathing (apnea).

Skin color, which changes from blue to pink in the first few seconds after birth, can be a quick visual indicator of efficient breathing and circulation. It is best to determine the color of a child's skin by examining the central parts of the body. If there is a significant lack of oxygen in the blood, a blue tint to the lips, tongue and torso will be observed (cyanosis).

Sometimes central cyanosis can be detected in healthy newborns. However, their color should quickly change to pink within a few seconds after birth. Acrocyanosis, which refers to the blue tint of only the hands and feet, can last longer. Acrocyanosis without central cyanosis usually does not indicate a low level of oxygen in the child's blood. Only central cyanosis requires intervention.

Resuscitation principle A

The principle of resuscitation A (airway) - ensuring the patency of the respiratory tract - consists of the following steps:

1. Ensuring the correct position of the child.

2. Clearing the airways.

3. Tactile stimulation of breathing.

Ensuring the correct position of the child. The newborn should be placed on his back, with his neck moderately stretched and his head thrown back, in a position that will bring the back wall of the pharynx, larynx and trachea into one line and will facilitate free access of air (Fig. 3, A).

This alignment is also best for efficient bag and mask ventilation and/or insertion of an endotracheal tube. To maintain the correct position of the head, you need to put a diaper folded in the form of a roller under the shoulders of the child (Fig. 3, b). Care should be taken to avoid excessive stretching (Fig. 3, V) or neck flexion (Fig. 3, G), which limits the flow of air into the respiratory tract.

Wrong

Rice. 3. Correct and incorrect positions of the child for ventilation:

A- the neck is moderately extended; b- a diaper is placed under the shoulders; V- the neck is overextended; G- neck is bent excessively

Clearing the airways. If the amniotic fluid was stained with meconium, then after the birth of the baby's shoulders, it is necessary to suck out the contents of the oropharynx and nose using a catheter or rubber bulb.

The method of further debridement after birth will depend on the presence of meconium and the baby's activity level.

Secretions and mucus can be removed from the airways by cleansing the nose and mouth with a diaper or by suctioning the contents with a pear or catheter. If a newborn has a lot of secretion from his mouth, turn his head to one side.

To remove fluid that blocks the airways, you need to use a pear or a catheter that is associated with mechanical suction. First, the oral cavity is sanitized, then the nose, so that the newborn does not aspirate the contents if he takes a convulsive breath during suction from the nose.

Tactile stimulation of breathing. The correct position of the child, the suction of mucus often stimulate spontaneous breathing. Wiping, drying the body and head partly perform the same function (first, the child can be put on one hygroscopic diaper prepared before resuscitation, which will absorb most of the liquid, then other warm diapers should be used to continue drying and stimulation).

For most children, following these steps is sufficient for spontaneous breathing to occur. If the newborn is still not breathing effectively, short-term additional tactile stimulation of breathing can be performed.

Safe and appropriate tactile stimulation methods include:

Patting or tapping the soles;

Lightly rubbing the newborn's back, torso, or limbs (Fig. 4).

Rice. 4. Methods of tactile stimulation of breathing

Resuscitation principle B

Principle B - ensuring adequate breathing using oxygenation.

Oxygen starvation of vital tissues is one of the main causes of long-term clinical consequences associated with perinatal pathology, therefore it is necessary to ensure adequate breathing in a timely manner. Ventilation is the most important and effective method of cardiopulmonary resuscitation of a newborn.

For ventilation are used:

Resuscitation bag;

Oxygen tube;

Oxygen mask.

To achieve the highest possible oxygen concentration, it is necessary to apply a mask or hold the tube as close to the child's nose as possible (Figure 5).

Rice. 5. Ventilation support

For ventilating the lungs of newborns, the following are available:
types of resuscitation bags:

A bag that is filled with a flow (fills only when oxygen from an additional source of compressed gas approaches it) is an anesthesia bag;

A bag that fills itself (after each compression it fills spontaneously, sucking in oxygen or air).

It is very important that the size of the mask is selected correctly (Fig. 6).

Right wrong

A B C

Rice. 6. Correct and incorrect application of a ventilation mask:

A- the mask covers the mouth, nose and chin, but not the eyes; b- the mask covers the bridge of the nose and protrudes beyond the chin (very large); V- the mask does not cover enough

nose and mouth (too small)

Visible rise and fall of the chest is the best indication that the mask is sealing tightly and the lungs are being oxygenated.

Although the lungs must be ventilated at minimal pressure to ensure adequate chest excursions, the newborn baby's first few breaths often require high pressure (more than 30 cm H2O) to expel fluid from the fetal lungs and fill them with air. Subsequent ventilations require lower pressure.

The ventilation rate in the initial stages of resuscitation is 40–60 per minute, i.e. approximately 1 time per second.

Improvement in the condition of the newborn is characterized by the following signs:

Increase in heart rate;

Improving skin color;

Restoring spontaneous breathing.

The duration of mask ventilation is determined by the specific clinical situation. If the child is breathing spontaneously and the heart rate is adequate, assisted ventilation can be discontinued as soon as the rate and depth of spontaneous breathing are adequate. If cyanosis occurs after ventilation is stopped, oxygen therapy should be continued.

If ventilation with a bag and mask lasts longer than a few minutes, an additional gastric tube must be introduced into the stomach and left in it. This is a mandatory requirement, because during ventilation with a bag and a mask, the gas enters the oropharynx, from where it freely reaches not only the trachea and lungs, but also the esophagus. Even with the correct position of the head, part of the gas can enter the esophagus and stomach. And the stomach, distended with gas, presses on the diaphragm, preventing the full expansion of the lungs. Also, gas in the stomach can cause regurgitation of gastric contents, which the child can later aspirate during bag and mask ventilation.

Insertion of a gastric tube requires an 8 F feeding tube and a 20 ml syringe. The length of the inserted probe should be equal to the distance from the bridge of the nose to the earlobe and from the earlobe to the xiphoid process. This length should be marked on the probe.

It is better to insert the probe through the mouth rather than through the nose. The nose should be free for ventilation (Fig. 7).

In general, bag-and-mask ventilation is less effective than endotracheal tube ventilation because, when a mask is used, part of the air passes through the esophagus into the stomach.

If mask ventilation is ineffective, tracheal intubation may be appropriate.

Rice. 7. Correct placement of the gastric tube

Indications intubation:

Birth of a child with asphyxia;

Deep prematurity;

Surfactant administration is intratracheal;

Suspicion of diaphragmatic hernia;

Ineffective mask ventilation.

The equipment and materials required for tracheal intubation are as follows:

1. Laryngoscope (Fig. 8, A).

2. Blades (Fig. 8, b): No. 1 (for full-term newborns), No. 0 (for premature newborns), No. 00 (preferably for extremely premature newborns).

3. Endotracheal tubes with an internal diameter of 2.5; 3; 3.5 and 4 mm (Fig. 8, V).

4. Stiletto (conductor) - preferably (Fig. 8, G).

5. CO 2 monitor or detector - optional (Fig. 8, d).

6. Suction with a 10 F or large bore catheter and 5 F or 6 F catheters for suctioning the endotracheal tube (Fig. 8, e).

7. Adhesive plaster or endotracheal tube fixation (Fig. 8, and).

8. Scissors (Fig. 8, h).

9. Air duct (Fig. 8, And).

10. Meconium aspirator (Fig. 8, To).

11. Stethoscope (Fig. 8, l).

Rice. 8. Necessary equipment for tracheal intubation

Sterile disposable endotracheal tubes must be used. They should have the same diameter along their entire length and not taper at the end (Fig. 9).

Rice. 9. Endotracheal tube

Most neonatal endotracheal tubes have a line nigra near their endotracheal end, called the glottis mark. After inserting the tube, the mark should be at the level of the vocal cords. This usually allows the end of the tube to be placed over the tracheal bifurcation.

The size of the endotracheal tube is determined according to the child’s body weight (Table 1).

Table 1

Related information.

Any birth, including planned ones, must take place under the supervision of a resuscitator. There are cases when emergency resuscitation of a newborn is required. There are special indications for its implementation.

During childbirth, serious changes occur in the baby's body: the cardiac and pulmonary systems, as well as the central nervous system, begin to work differently. Therefore, one wrong move by the obstetricians and the mother in labor can cost the baby her health and even her life. In emergency situations, resuscitation of the baby may be required to restore his vital functions. The indications for it are: