Relevance of the topic. According to WHO, approximately 5–10% of all newborns require medical care in the delivery room, and about 1% require full resuscitation. Providing adequate care to newborns in the first minutes of life can reduce their mortality and/or morbidity by 6–42%. The degree of proficiency of medical personnel present at birth in methods of primary resuscitation of newborns has a positive effect not only on their survival, but also on their further development and level of health in subsequent age periods.

General goal: to improve knowledge on assessing the condition of a newborn, to determine the indications for resuscitation measures and their volume. Be able to temporarily begin resuscitation, master the skills of resuscitation of a newborn.

Specific goal: based on perinatal history, data objective examination determine the main signs of an emergency condition, conduct differential diagnostics, and provide the necessary assistance.

Theoretical issues

1. Preparation for providing resuscitation care to a newborn in the delivery room or operating room.

2. Assessing the condition of the newborn child, determining the need for intervention.

3. Activities after the birth of a child. Ensuring airway patency, oxygen therapy, artificial ventilation with a bag and mask, tracheal intubation, chest compressions, etc.

4. Delivery algorithm emergency care newborns with clean amniotic fluid.

5. Algorithm for providing emergency care to newborns in case of contamination of amniotic fluid with meconium.

6. Medicines for primary resuscitation of newborns.

7. Indications for stopping resuscitation.

Indicative basis of activity

During preparation for the lesson, it is necessary to familiarize yourself with the main theoretical issues through the treatment algorithm (Fig. 1) and literature sources.

Preparing to provide resuscitation care to a newborn in the delivery room

Staffing: 1 person who can provide resuscitation assistance; 2 people with these skills for high-risk deliveries where full life support may be required. In case of multiple pregnancy, the presence of several resuscitation teams is necessary. Before each birth, you need to assess the temperature in the room (not lower than 25 ° C), the absence of drafts, select, install and check the functioning of resuscitation equipment:

1. Before birth, turn on the radiant heat source, warm the surface of the resuscitation table to 36–37 °C and prepare warmed diapers.

2. Check the oxygen supply system: presence of oxygen, pressure, flow rate, presence of connecting tubes.

3. Roll the diaper into a roll under the shoulders.

4. Prepare equipment for suctioning the contents of the upper respiratory tract (rubber balloon, adapter for connecting the endotracheal tube directly to the suction tube).

5. Prepare a gastric tube size 8F, a 20 ml syringe for aspiration of gastric contents, an adhesive plaster, scissors.

6. Prepare equipment for artificial pulmonary ventilation (ALV): resuscitation bag (volume no more than 75 ml) and mask. The oxygen flow rate must be at least 5 l/min. Check the functioning of the control valve, the integrity of the bag, the presence of oxygen in the tank, it is advisable to have a pressure gauge.

7. Prepare an intubation kit.

Urgent Care

Activities after the birth of a child

Immediately determine the need for resuscitation. Estimate:

Presence of meconium contamination;

Breath;

Muscle tone;

Color of the skin;

Determine gestational age (term, premature).

Full-term, active infants with adequate breathing, a loud cry and normal motor activity do not require resuscitation. They are placed on the mother's stomach, dried and covered with a dry diaper. Sanitation of the upper respiratory tract is carried out by wiping the mucous membranes of the child’s mouth and nose.

Indications for further assessment of the newborn's condition and determination of the need for intervention:

1. Contamination of amniotic fluid or skin of a newborn with meconium.

2. Absence or decrease in the child’s response to stimulation.

3. Persistent central (diffuse) cyanosis.

4. Premature birth.

If any of these signs are present, newborns require standard initial resuscitation steps and require constant monitoring.

If a newborn needs emergency care, and the amniotic fluid is clear and there is no meconium on the baby’s skin, you must:

1. Place the baby under a radiant heat source on a warm swaddle.

2. Ensure airway patency: position on the back with the head moderately tilted back (roll under the shoulders).

3. Suck out the contents from the mouth, then from the nasal passages. If there is a significant amount of secretion, turn the child's head to the side.

4. Dry your skin and hair with a diaper using quick blotting movements.

5. Remove the wet diaper.

6. Again ensure the correct position of the child.

7. If there is no effective spontaneous breathing, perform one of the tactile stimulation techniques, which is repeated no more than two times (patting the soles, light blows on the heels, rubbing the skin along the spine)1.

8. If the skin of the body and mucous membranes remain cyanotic in the presence of spontaneous breathing, administer oxygen therapy. A free flow of 100% oxygen directed to the child's nose is provided through an anesthetic bag and mask, or through an oxygen tube and the palm of the hand, placed in the form of a funnel, or using an oxygen mask.

Once cyanosis has resolved, oxygen support should be gradually withdrawn so that the child remains pink when breathing room air. The preservation of the pink color of the skin when the end of the tube is removed by 5 cm indicates that the child does not need high concentrations of oxygen.

In case of any contamination of amniotic fluid with meconium:

It is necessary to assess the activity of the newborn, clamp and cut the umbilical cord, inform the mother about the child’s breathing problems, without taking away the diaper and avoiding tactile stimulation;

If the child is active - screaming or breathing adequately, has satisfactory muscle tone and a heart rate (HR) of more than 100 beats per minute, he is placed on the mother's stomach and observed for 15 minutes. A baby at risk of meconium aspiration may require subsequent tracheal intubation, even if active after birth;

In the absence of respiratory distress, provide standard medical care in accordance with clinical protocol medical supervision of a healthy newborn child (Order No. 152 of the Ministry of Health of Ukraine dated April 4, 2005);

If the newborn has depressed breathing, decreased muscle tone, and a heart rate less than 100 beats per minute, immediately suck out the meconium from the trachea through the endotracheal tube. Aspiration of meconium should be carried out under heart rate control. If bradycardia increases, stop repeated aspiration of meconium and begin mechanical ventilation with a resuscitation bag through an endotracheal tube.

All measures for the initial treatment of a newborn are completed in 30 seconds. The child's condition (breathing, heart rate and skin color) is then assessed to determine whether further resuscitation is necessary2.

Breathing assessment. Normally, the child has active chest excursions, and the frequency and depth of respiratory movements increases a few seconds after tactile stimulation. Convulsive respiratory movements are ineffective, and their presence in a newborn requires a complex of resuscitation measures, as in the complete absence of breathing.

Heart rate assessment. The heart rate should exceed 100 beats per minute. Heart rate is calculated at the base of the umbilical cord, directly at the site of its attachment to the anterior abdominal wall. If the pulse on the umbilical cord is not detected, you need to listen with a stethoscope to the heartbeat over the left side of the chest. Heart rate is calculated for 6 seconds and the result is multiplied by 10.

Skin color assessment. The baby's lips and body should be pink. After normalization of heart rate and ventilation, the child should not have diffuse cyanosis. Acrocyanosis does not usually indicate low oxygen levels in the blood. Only diffuse cyanosis requires intervention.

Once heat loss has been eliminated, the airway has been maintained, and spontaneous breathing has been stimulated, the next step in resuscitation should be to support ventilation.

Artificial ventilation with a bag and mask

Indications for mechanical ventilation:

Lack of breathing or its ineffectiveness (convulsive breathing movements, etc.);

Bradycardia (less than 100 beats per minute) regardless of the presence of spontaneous breathing;

Persistent central cyanosis on free-flow 100% oxygen in a child who is breathing spontaneously and has a heart rate greater than 100 beats per minute.

The effectiveness of ventilation is determined: by chest excursion; auscultation data; increase in heart rate; color improvement skin.

The first 2–3 breaths are performed, creating an inhalation pressure of 30–40 cm of water column, after which ventilation is continued with an inhalation pressure of 15–20 cm of water column and a frequency of 40–60 per minute. In the presence of pulmonary pathology, ventilation is carried out with an inspiratory pressure of 20–40 cm of water column. Ventilation of newborns is carried out with 100% humidified and warmed oxygen.

After 30 s of positive pressure ventilation, the heart rate and the presence of spontaneous breathing are again determined. Further actions depend on the result obtained.

1. If heart rate is more than 100 beats per minute:

If spontaneous breathing is present, mechanical ventilation is gradually stopped, reducing its pressure and frequency, a free flow of oxygen is supplied, and the skin color is assessed;

In the absence of spontaneous breathing, mechanical ventilation is continued until it appears.

2. If heart rate is from 60 to 100 beats per minute:

Continue mechanical ventilation;

If mechanical ventilation was carried out with room air, anticipate the transition to the use of 100% oxygen and the need for tracheal intubation.

3. Heart rate is less than 60 beats per minute:

Indirect cardiac massage is started at a rate of 90 compressions per minute, mechanical ventilation with 100% oxygen is continued at a rate of 30 breaths per minute, and the need for tracheal intubation is determined.

Heart rate is monitored every 30 s until it exceeds 100 beats per minute and spontaneous breathing is established.

Carrying out mechanical ventilation for several minutes requires the introduction of an orogastric tube (8F) in order to prevent inflation of the stomach with air and subsequent regurgitation of gastric contents.

Indirect cardiac massage is indicated if the heart rate is less than 60 beats per minute after 30 seconds of effective ventilation with 100% oxygen.

Perform indirect cardiac massage by pressing on the lower third of the sternum. It is located below the conditional line that connects the nipples. It is important not to press on the xiphoid process to avoid rupture of the liver.

Two indirect massage techniques are used, according to which pressure is applied to the sternum:

the first - with two thumbs, while the remaining fingers of both hands support the back;

the second - with the tips of two fingers of one hand: II and III or III and IV; while the second hand supports the back.

The depth of compression should be one third of the anteroposterior diameter of the chest.

The frequency of pressure is 90 per minute.

It is important to coordinate chest compressions with mechanical ventilation, avoiding performing both procedures simultaneously, and not removing your fingers from the surface of the chest during the pause between pressures. After every three pressures on the sternum, a pause is made for ventilation, after which the pressures are repeated, etc. In 2 seconds you need to make 3 pressures on the sternum (90 per 1 minute) and one ventilation (30 per 1 minute). Stop chest compressions if the heart rate is more than 60 beats per minute.

Tracheal intubation can be performed at all stages of resuscitation, in particular:

If necessary, suck out meconium from the trachea;

If prolonged ventilation is necessary to increase its effectiveness;

To facilitate the coordination of chest compressions and ventilation;

To administer adrenaline;

If you suspect a diaphragmatic hernia;

With deep prematurity.

Use of medications. Administration of drugs is indicated if, despite adequate ventilation of the lungs with 100% oxygen and chest compressions for 30 seconds, the heart rate remains less than 60 beats per minute.

During primary resuscitation of newborns, medications are used: adrenaline; means that normalize bcc; sodium bicarbonate, antagonists of narcotic drugs.

Adrenalin. Indications for use:

Heart rate less than 60 beats per minute after at least 30 seconds of mechanical ventilation with 100% oxygen and chest compressions;

Absence of heartbeats (asystole) at any time during resuscitation.

Adrenaline is administered as quickly as possible intravenously or endotracheally at a dose of 0.1–0.3 ml/kg solution at a concentration of 1: 10,000. The concentration of the solution is 1: 10,000 (to 0.1 ml of 0.1% solution of adrenaline hydrochloride or add 0.9 ml of isotonic sodium chloride solution to 0.1 ml of 0.18% adrenaline hydrogen tartrate solution).

Endotracheally, adrenaline is injected from a syringe directly into the tube or through a probe inserted into the tube. In this case, a solution of adrenaline at a concentration of 1: 10,000 can be further diluted with isotonic solution to a final volume of 1 ml or the endotracheal tube (probe) can be washed with isotonic sodium chloride solution (0.5–1.0 ml) after administering the undiluted dose. In case of endotracheal administration, it is recommended to always use a dose of 0.3–1.0 ml/kg. After injecting epinephrine into the trachea, it is important to immediately perform several effective positive pressure ventilations.

If there is no effect, the injection of adrenaline is repeated every 3-5 minutes, repeated injections only intravenously.

Large doses of intravenous epinephrine are not recommended for resuscitation of newborns, since their administration can cause damage to the baby's brain and heart.

Agents that normalize bcc: 0.9% sodium chloride solution; lactated Ringer's solution; in order to correct significant blood loss (with clinical signs of hemorrhagic shock) - transfusion of O(I) Rh(–) red blood cells. Indications for use:

Lack of response of the child to resuscitation measures;

Signs of blood loss (pallor, weak pulse, persistent tachycardia or bradycardia, no signs of improvement in blood circulation, despite all resuscitation measures).

With the development of hypovolemia, children whose condition does not improve during resuscitation are administered intravenously slowly, over 5–10 minutes, up to 10 ml/kg of one of the indicated solutions (isotonic sodium chloride solution is recommended).3

Sodium bicarbonate is indicated for the development of severe metabolic acidosis during prolonged and ineffective resuscitation against the background of adequate mechanical ventilation. A 4.2% solution at a dose of 4 ml/kg or 2 mEq/kg is injected into the umbilical cord vein slowly, no faster than 2 ml/kg/min. The drug should not be administered until the newborn's lungs are ventilated.

Antagonists of narcotic drugs (naloxone hydrochloride)

Indications for use: persistent severe respiratory depression during positive pressure ventilation, with normal heart rate and skin color in a child whose mother was administered narcotic drugs during the last 4 hours before birth. Naloxone hydrochloride is administered at a concentration of 1.0 mg/ml solution, at a dose of 0.1 mg/kg IV. When administered intramuscularly, the effect of naloxone is delayed; when administered endotracheally, it is ineffective.

Naloxone should not be prescribed to a child from a mother suspected of drug addiction or from a mother who is on drug addiction. long-term treatment narcotic drugs. This may cause severe cramping. The child's breathing can also be suppressed by other drugs administered to the mother (magnesium sulfate, non-narcotic analgesics, anesthetics), but their effect will not be blocked by the administration of naloxone.

If the child’s condition does not improve, despite effective mechanical ventilation and chest compressions, administration of drugs, rule out abnormalities in the development of the respiratory tract, pneumothorax, diaphragmatic hernia, congenital heart defects.

Resuscitation of the newborn is stopped if, despite the correct and complete implementation of all resuscitation measures, there is no cardiac activity for 10 minutes.

1 It is prohibited to pour cold or hot water, direct a stream of oxygen into the face, squeeze the chest, hit the buttocks and carry out any other measures whose safety for a newborn has not been proven.

2 The Apgar score characterizes the general condition of the newborn and the effectiveness of resuscitation measures and is not used to determine the need for resuscitation, its volume or the timing of resuscitation measures. The Apgar score should be assessed at 1 and 5 minutes after the baby is born. If the assessment result at the 5th minute is less than 7 points, it should be additionally carried out every 5 minutes until the 20th minute of life.

Literature

1. Order of the Ministry of Health of Ukraine No. 437 dated 08/31/04 “On the approval of clinical protocols for the provision of medical assistance for difficult conditions in children at the hospital and pre-hospital stages.” 2. Order of the Ministry of Health of Ukraine No. 152 dated 04/04/2005 “On the approval of the clinical protocol for medical supervision of a healthy newborn baby.” 3. Order of the Ministry of Health of Ukraine No. 312 dated 06/08/2007 “On the approval of the clinical protocol for initial resuscitation and post-resuscitation care for newborns.” 4. Uncomplicated topics in pediatrics: Beg. pos_b. / Volosovets O.P., Marushko Yu.V., Tyazhka O.V. ta inshi / Ed. O.P. Volosovtsia and Yu.V. Marushko. - Kh.: Prapor, 2008. - 200 p. 5. Emergency conditions in children / Petrushina A.D., Malchenko L.A., Kretinina L.N. and others / Ed. HELL. Petrushina. - M.: Medical Information Agency LLC, 2007. - 216 p. 6. Peshiy M.M., Kryuchko T.O., Smiyan O.I. Uncomplicated assistance in pediatric practice. - Poltava; Sumi, 2004. - 234 p. 7. Emergency medical care for children at the prehospital stage / G.I. Posternak, M.Yu. Tkacheva, L.M. Beletskaya, I.F. Volny / Ed. G.I. Belebezeva. - Lvov: Medicine for the World, 2004. - 186 p.

Additional

1. Aryaev M.L. Neonatology. - K.: ADEF - Ukraine, 2006. - 754 p. 2. Handbook of neonatology: Trans. from English / For ed. Jonah Cleorti, Anne Stark. - K.: Fund for Helping Children of Chornobyl, 2002. - 722 p. 3. Shabalov N.P. Neonatology: Textbook for students and residents of pediatric faculties of medical institutes. - Second edition, corrected and expanded. - St. Petersburg: Special literature, 1997. - T. 1. - 496 p.

4. Reanimation of newborns: Pidruchnik / Ed. J. Cavintela: Translation from English. - Lviv: Spolom, 2004. - 268 p.

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Neonatal resuscitation

Unfortunately, not all births take place and end successfully. It happens that the baby needs special help. The presence of a neonatal intensive care unit in a maternity hospital is a chance for a large number of children to survive and grow up healthy.

Resuscitation is a set of measures designed to restore the vital functions of the body - primarily blood circulation and breathing. Neonatal resuscitation refers to medical measures that are carried out immediately at birth and in the next day of a child’s life to bring the child out of a critical condition. Resuscitation is carried out in cases where there is no breathing or cardiac activity stops, or in the absence of both of these functions. Resuscitation is also necessary when low heart rate baby - less than 100 beats per minute, shortness of breath, apnea, hypotension - that is, with the so-called cardiopulmonary depression. According to WHO in specialized assistance up to 10% of newborns need it at birth.

Primary neonatal resuscitation

After birth in the delivery room, the baby must be examined by a neonatologist. According to the state of breathing, heartbeat, skin, muscle tone a so-called Apgar score is given. Resuscitation assistance will be required if, upon examination of the newborn, it is discovered:

• lack of heartbeat;
• diaphragmatic hernia;
• lack of spontaneous breathing;
• decreased heart rate;
• meconium aspiration.

The first resuscitation measures for newborns in the delivery room are carried out by a neonatologist, an anastasiologist-resuscitator and two nurses, each of whom performs strictly defined tasks. When the newly born baby is cleared of amniotic fluid and placed on a heated neonatal resuscitation table, the neonatologist measures the baby's body temperature and clears the baby's airways of mucus. The resuscitator calculates the heart rate, performs chest compressions, and listens to the lungs. If necessary, artificial ventilation of the lungs is prescribed using a special mask and bag until the skin turns pink. If after this resuscitation measure the newborn does not begin to breathe on his own, tracheal intubation is performed. Methods of resuscitation of newborns include the administration of substances (adrenaline, cocarboxylase) that help restore vascular tone.

If the child does not inhale on his own, resuscitation measures are completed after 15-20 minutes.

Stage two - neonatal intensive care unit

If the initial measures resulted in the improvement of breathing and heartbeat functions, the child is transferred to the neonatal intensive care unit. There, all the doctors’ actions will be aimed at preventing or eliminating cerebral edema, restoring blood circulation, and renal function. The baby is subjected to so-called hypothermia - local cooling of the baby's head. In addition, a newborn baby in intensive care is given dehydration therapy, the essence of which is to remove excess fluid from the body. The baby's blood parameters are monitored: coagulability, protein content, calcium, magnesium, etc. Depending on the severity of the baby's condition, he is placed in an oxygen tent or in an incubator with oxygen supply and his body temperature and intestinal function are monitored. Feeding the baby is possible no earlier than 12 hours after birth with expressed milk through a bottle or tube, depending on the severity of the lesion.

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Neonatal resuscitation: indications, treatment, prognosis

Profound changes occur in the cardiovascular and respiratory systems at birth. Disturbance of these changes can lead to death or damage to the central nervous system. Accordingly, a physician trained in neonatal resuscitation must be present at all births. Wasting time searching for someone who can resuscitate a newborn can have disastrous consequences for the baby. This article discusses the causes and consequences of cardiorespiratory failure at birth and resuscitation techniques. Whenever possible, American Academy of Pediatrics guidelines were followed.

Guidelines for neonatal resuscitation have been issued by many organizations, including the American Heart Association and the American Academy of Pediatrics. Recommendations are useful for remembering the sequence of resuscitation measures. Failure to follow the principles leads to poor results. However, mindlessly following recommendations can also lead to poor results. Understanding the physiology of labor and birth is the key to success.

Neonatal resuscitation requires training and practical experience. Unfortunately, most anesthesiologists have little opportunity to acquire and maintain neonatal resuscitation skills because few of their patients require resuscitation. Simulations can solve this problem. In the near future, those who perform neonatal resuscitation will be required to train in a simulator and repeat this training several times a year to maintain certification.

Identifying potential problems and preparing to address them before birth increases the likelihood of successful resuscitation of patients. Fetal monitoring heart rate is a completely reliable and widely used method for the early detection of serious fetal problems. Analysis of blood gases and fetal pH can be used to identify hypoxia and determine the need for urgent premature delivery of the fetus.

Asphyxia (i.e. decreased PaO2 and pHa and increased PaCO2) occurs when gas exchange through the placenta (fetus) and lungs (newborn) is inadequate or when there is a right-to-left shunt of blood in the heart or lungs after birth. This also occurs with myocardial dysfunction.

With fetal asphyxia, PaO2 decreases from normal 25-40 mm Hg. Art. to less than 5 mm Hg. Art. for approximately 2 min, followed by anaerobic metabolism. After five minutes of asphyxia, the pH decreases to 6.90 or less, PaCO2 increases to more than 100 mm Hg, and PaO2 decreases to a level where it is undetectable. Blood flow to the liver, kidneys, intestines, skin and muscles is reduced, but blood flow to the heart, brain, adrenal glands and placenta is unchanged or increased. The consumption of oxygen from the blood increases significantly. Myocardial function is supported by myocardial glycogen and lactic acid metabolism. A heart rate of less than 100 beats/min significantly reduces cardiac output. Catecholamines are also important for survival after asphyxia. Asphyxia during childbirth can lead to hypervolemia or hypovolemia.

Fetal assessment at birth

The Apgar score, done properly, is a simple, useful guide to the condition and need for resuscitation of the newborn, but it is only a guide. The 1 minute score correlates well with acidosis and survival. The 5-minute assessment predicts neurological outcome, but not always. To obtain an overall score, each parameter must be assessed at 1 and 5 minutes. However, neonates with severe acidosis may have relatively normal Apgar scores at 1 and 5 minutes due to peripheral vasoconstriction, which is manifested by pale skin with normal heart rate and blood pressure.

In healthy fetuses and newborns, heart rate ranges from 120 to 160 beats/min. When the heart rate is less than 100 beats/min, cardiac output and tissue perfusion are reduced.

Breathing usually begins 30 seconds after birth and is maintained for 90 seconds. A few minutes after birth, the respiratory rate of healthy newborns is 30-60 per minute.

The absence of a pause between inhalation and exhalation helps develop and maintain FRC. Apnea and bradypnea prolong expiration, reduce FRC and cause hypoxia. The causes of apnea and bradypnea can be severe acidosis, asphyxia, drugs used by the mother, infections and damage to the central nervous system. Tachypnea (>60 breaths/min) occurs due to:

hypoxemia;

hypovolemia;

metabolic and respiratory acidosis;

hemorrhage of the central nervous system;

air leak syndrome;

pulmonary disease (eg, hyaline membrane disease, aspiration syndromes, infections);

pulmonary edema;

drugs used by the mother (eg, drugs, alcohol, magnesium, barbiturates).

Resuscitation with 100% oxygen can have detrimental effects. Resuscitation of newborns with room air is as successful as resuscitation with oxygen. Animals resuscitated with air had less hydrogen peroxide in their brain tissue than those resuscitated with oxygen. Polymorphonuclear cells were less activated by room air. Supplying oxygen in excess of what is contained in room air increases the likelihood inflammatory reaction. Whenever possible, room air rather than oxygen should be used for neonatal resuscitation.

Muscle tone

Most newborns, including those born prematurely, are active immediately after birth and move their limbs in response to stimulation. Previous asphyxia, damage to the central nervous system, congenital amyotonia and myasthenia, as well as the prescription of maternal medications can contribute to a decrease in muscle tone in the newborn. Flexion contractures and the absence of skin folds in the joint area are signs of intrauterine damage to the central nervous system.

Reflex activity

Newborn baby in in good condition reacts with motor activity in response to stimulation, and when a catheter is inserted into the nasal passage, he cries or shows a crying grimace on his face. The newborn may not move in case of hypoxia and acidosis, as well as in the presence of damage to the central nervous system, congenital muscle diseases and when the mother is prescribed sedatives.

Color of the skin

In the first minutes after birth, all newborns have a bluish skin color. After 60 s, most children's skin becomes pink, with the exception of the hands and feet, which are still cyanotic. If central cyanosis persists for more than 90 seconds, especially against the background of oxygen therapy and controlled ventilation, then asphyxia, low cardiac output syndrome, pulmonary edema, methemoglobinemia, polycythemia, congenital diseases should be suspected. of cardio-vascular system, arrhythmia and lung diseases (for example, respiratory distress syndrome, airway obstruction, pulmonary hypoplasia, diaphragmatic hernia).

Pale skin at birth is often observed in children in cases of asphyxia, hypovolemia, acidosis, or in the presence of a congenital malformation of the cardiovascular system. If a newborn's pale skin color persists for more than 2 minutes, alcohol intoxication, hypermagnesemia, or alkalosis (pH>7.50) should be suspected. Rubeosis of the skin is observed in polycythemia.

Resuscitation equipment

The resuscitation bed should be positioned so that the child's head is below the level of the lungs. This is necessary to ensure drainage of lung fluid and prevent aspiration of gastric contents. In the absence of asphyxia, it is necessary to maintain the newborn’s body temperature at 36-37°C. To do this, use an infrared heater with servo control. In case of asphyxia, to ensure protection of the brain, the child’s body temperature must be reduced to 34-35°C. The resuscitation area must be equipped with a suction device with adjustable suction pressure; It is unacceptable to use pressure less than 100 mmHg. Art.

To perform tracheal intubation, straight laryngoscope blades of sizes 00 and 0 are required; pencil type laryngoscope; endotracheal tubes with an internal diameter of 2.5, 3.0 and 3.5 mm; suction catheters of appropriate diameter.

The ventilator must provide ventilation at a rate of up to 150 breaths/min and maintain PEEP. Be aware of the potential for sticking of the breathing circuit valves, especially when performing high-frequency ventilation with high gas flow. If the specialist has the appropriate training, modified Jackon-Rees or Eyre circuits can be used for ventilation. Overinflation of the lungs during high tidal volume ventilation causes lung damage and activation of a systemic inflammatory response, which can lead to the development of chronic lung disease. Gentle ventilation of the lungs has less damaging effects. When providing assisted or controlled ventilation in the delivery room, peak inspiratory pressure should be monitored continuously and overpressure and high tidal volume ventilation should be avoided.

As in any critical situation, decision-making must be based on the information received. In this regard, monitoring of blood gas composition and pH level is mandatory, and test results must be obtained within 10 minutes from the moment of blood collection. It is convenient to use an umbilical arterial catheter to monitor blood pressure and collect blood for research. In case of emergency, an infusion can be performed through it.

Arterial blood saturation (SaO2) in the first minutes after birth can be determined by attaching a pulse oximeter sensor to the palm or foot of the newborn. A pulse oximeter allows you to quickly detect changes in oxygenation or FiO. Normally, in newborns, SaO2 is 87-95%, which corresponds to PaO2 55-70 mmHg. Art.

Pulmonary resuscitation

If the heart rate is less than 80 beats/min and SaO2 is less than 85%, the need for tracheal intubation should be considered and mechanical ventilation should be started at a rate of 30-60 breaths/min. During the first minutes, the duration of every fifth breath should be 2 seconds. This increase in inspiratory time allows the atelectatic lungs to open and lung fluid to be removed. PEEP is maintained at 3-5 cm h3O. Excessive peak inspiratory pressure should be avoided. In an experiment on premature lambs, it was shown that giving just six artificial breaths with excess pressure significantly increases the damage to lung tissue and interferes with the response to surfactant. Excessive tidal volume is also associated with inflammation and chronic lung disease. Determination of airway pressure helps prevent ventilation with excessive pressure and tidal volume.

Tracheal intubation

When performing mask ventilation and tracheal intubation, the child’s head should be in the “sniffing” position. After visualizing the glottis, an endotracheal tube is inserted into the trachea to a depth of 1-2 cm below the level of the glottis, depending on the size of the child. Typically this corresponds to a depth of 7, 8, 9, 10 cm from the anterior margin of the gums in a newborn weighing 1, 2, 3 and 4 kg, respectively. When performing ventilation with a peak pressure of 15-25 cm h3O, a small air leak should be heard when auscultating the child's mouth. This is typically seen with 2.5 mm ID tubes in children weighing less than 1.5 kg, 3.0 mm ID tubes in children weighing 1.5-2.5 kg, and 3.0 mm ID tubes. 5 mm in children weighing more than 2.5 kg. Confirmation of successful tracheal intubation is visualization of the passage of the endotracheal tube beyond the vocal cords, the movement of both halves of the chest with each artificial inspiration, and the appearance of perspiration on the inner surface of the tube during each exhalation. Breath sounds should be louder when auscultating the lungs than when auscultating the abdomen. Once positive pressure ventilation is started, skin color should improve, as should heart rate and SaO2. At the moment of exhalation, carbon dioxide should be determined (capnometry).

However, the small tidal volume and low pulmonary blood flow velocity that characterize some infants at birth may make capnography difficult to use effectively.

Adequacy of ventilation

During inhalation, both halves of the chest should move simultaneously and symmetrically, however, the excursion of the chest during artificial ventilation should not exceed the excursion during normal spontaneous breathing of the newborn. Availability breath sounds upon auscultation it is not reliable sign adequacy of ventilation, due to the possibility of conducting breath sounds from the other lung in newborns with a small chest. Asymmetry of breath sounds during auscultation of the lungs on both sides may indicate endobronchial intubation, pneumothorax, atelectasis, or congenital lung anomaly. The presence of loud respiratory sounds during auscultation in the epigastric region allows one to suspect esophageal intubation or tracheoesophageal fistula. If there is adequate ventilation, the child turns pink, begins to breathe spontaneously, and the heart rate normalizes.

Since most asphyxiated newborns do not have lung disease, they can be effectively ventilated with a peak pressure of less than 25 mmHg. Art., including during the first breaths. Neonates with hard lungs (eg, erythroblastosis fetalis, congenital pulmonary anomalies, pulmonary edema, severe meconium aspiration, diaphragmatic hernia) may require high peak inspiratory pressure ventilation, increasing the likelihood of air leak syndrome. It can be prevented by ventilation with a peak pressure of 15-20 cmH2O and a frequency of 150-200 breaths/min. If low-pressure (low-volume) high-frequency ventilation does not improve oxygenation, ventilatory support may be required. high pressure and high tidal volume. Failure to effectively ventilate at birth can worsen hypoxemia and lead to central nervous system damage and even death. When PaO2 increases more than 70-80 mm Hg. Art. or SaO2 more than 94%, the concentration of inhaled oxygen (if a breathing mixture with a high oxygen content was previously used) should be brought to a level at which SaO2 and PaO2 will be maintained at normal age levels. In infants less than 34 weeks of gestation, oxygenation is maintained at the lower limit of normal to prevent the development of neonatal retinopathy. During tracheal intubation in a hypoxic newborn, there is a risk of arrhythmia, and therefore the heart rate should be constantly monitored.

Routine tracheal debridement

If there is an admixture of dense meconium in the amniotic fluid, as well as in the case of massive vaginal bleeding, ventilation of the lungs is started only after aspiration of the tracheal contents. Descriptions of meconium aspirators are widely available in the literature.

Particulate meconium must be removed from the lungs before ventilation is started. The mouth and throat must be sanitized immediately after the baby's head is born. After tracheal intubation, the endotracheal tube is connected to a special suction device and, at the time of aspiration, is removed from the trachea. The laryngoscope is not removed. After aspiration of meconium, the endotracheal tube is inserted into the trachea, after which repeated aspiration is performed. Gentle ventilation is then carried out. During laryngoscopy and aspiration, it is necessary to constantly monitor the heart rate and insufflate 100% oxygen near the newborn's face. Meconium should also be aspirated from the stomach to avoid regurgitation and aspiration. Newborns with an Apgar score of 9-10 do not require tracheal sanitation. Removing liquid meconium from a newborn's trachea at the time of birth has no beneficial effect, whereas removing solid meconium particles is effective.

Other causes of respiratory failure

Pneumothorax

Pneumothorax occurs in 1% of cases during vaginal delivery, in 10% of cases in the presence of meconium in the amniotic fluid and in 2-3% of newborns who require artificial ventilation in the delivery room. In the presence of unilateral pneumothorax, overinflation of one half of the chest and limitation of its respiratory excursion are observed. The heartbeat is shifted to the healthy side. Heart sounds may be muffled.

In the presence of pneumothorax, the affected part of the chest glows when illuminated with a narrow beam of highly intense cold light. Elimination of pneumothorax is carried out by puncture or drainage of the pleural cavity.

Surfactant administration

Surfactant administration resulted in a significant reduction in the incidence of air leak syndrome, including interstitial emphysema, hyaline membrane disease, bronchopulmonary dysplasia (BPD), and mortality. Surfactant is administered intratracheally at a dose of 5 ml of solution per kilogram of body weight immediately at birth or within a short period of time after it. The administration of surfactant is accompanied by a short episode of desaturation. In most cases, SaO2 subsequently increases rapidly due to increased pulmonary compliance, which, in turn, can lead to hyperinflation of the lungs with subsequent damage to the lung tissue or the occurrence of air leak syndrome if inspiratory pressure is not reduced in a timely manner.

Premature infants often require nasal CPAP after birth, which reduces the likelihood of tracheal intubation and mechanical ventilation. However, this does not reduce the incidence of hemorrhage in the central nervous system and chronic lung disease. The duration of oxygen dependence and chronic lung disease does not change.

Vascular resuscitation

Vascular resuscitation is not a core aspect of neonatal resuscitation. If the newborn's condition does not improve with ventilation, oxygenation (if necessary), and tactile stimulation, it is necessary to catheterize the umbilical artery to collect blood for gas and pH testing, as well as to administer fluid therapy if necessary.

Correction of acidosis

Correction of respiratory acidosis is carried out using artificial ventilation. To correct metabolic acidosis, a sodium bicarbonate solution is administered. Its osmolarity is 1800 mOsmol/L, so rapid administration of this solution (>1 mmol/kg/min) in premature infants can lead to intracranial bleeding. The interaction of hydrogen ions with 50 mmol of bicarbonate leads to the formation of 1250 ml of CO. If pulmonary ventilation is adequate, this does not lead to an increase in PaCO2; with inadequate ventilation, a significant increase in PaCO2 occurs, which can cause cardiac arrest and/or intracranial hemorrhage. Therefore, sodium bicarbonate solution can only be administered to newborns with metabolic acidosis, provided there is adequate pulmonary ventilation. In hypovolemic neonates, administration of sodium bicarbonate may cause hypotension by reversing peripheral vasoconstriction caused by acidosis. Trisamine (THAM) is an alternative drug. Its administration leads to a decrease in PaCO levels.

If, despite tactile stimulation and ventilation, the Apgar score is 2 or less at 2 minutes or 5 or less at 5 minutes, it may be necessary to administer sodium bicarbonate at a dose of 2 mmol/kg during ventilation. If the pH is less than 7.0, PaCO2 is less than 35 mmHg. Art., and the blood volume is adequate, one-fourth of the base deficiency should be corrected. If the pH is more than 7.1, sodium bicarbonate is not administered, but pulmonary ventilation is continued. If the pH is more than 7.15, then only ventilation is performed. If, against this background, the pH decreases or remains at the same level, continue ventilation and correct one-fourth of the deficiency of buffer bases by administering sodium bicarbonate or trisamine. A significant increase in PaO2 was not observed until the pH increased from 7.1 to 7.2, when Rudolph and Yuen found the most significant decrease PVR.

Typically, metabolic acidosis develops as a result of decreased tissue perfusion as a consequence of hypovolemia or heart failure. Acidosis-induced heart failure usually occurs when the pH decreases less. When pH increases above 7.15, cardiac output improves. In case of heart failure due to congenital bradycardia, isoproterenol is prescribed (in an initial dose of 0.05 mcg/kg/min with a further increase if necessary) or a transvenous pacemaker is installed. Hypoglycemia may be the cause of heart failure. Therefore, when resuscitating a newborn, it is necessary to monitor blood glucose levels.

Intravascular volume expansion

If the umbilical cord is clamped early or if the umbilical cord is tightly wrapped around the fetus's neck and the umbilical cord must be cut to deliver the baby, the fetus may become hypovolemic. It is also observed with asphyxia during childbirth, abruption and placenta previa.

Diagnosis of hypovolemia

Hypovolemia is determined by measuring blood pressure and physical examination (ie, skin color, perfusion, capillary refill time, pulse refill, and extremity temperature). CVP measurements are useful in diagnosing hypovolemia and in determining the adequacy of fluid replacement. Venous pressure in healthy newborns is 2-8 cm h3O. If the CVP is less than 2 cm h3O, hypovolemia should be suspected.

Therapy for hypovolemia

Treatment of hypovolemia requires intravascular volume replacement with blood and crystalloids. Albumin can also be used, but evidence of its effectiveness is limited. If it is suspected that the newborn will be hypovolemic at birth, then a bag of Rh negative type 0 blood should be available in the delivery room before the baby is born.

Sometimes, in order to raise blood pressure to normal, huge amounts of blood and solutions are required. At times, it is necessary to replace more than 50% of the blood volume (85 ml/kg in full-term newborns and 100 ml/kg in premature newborns), especially if abruption or placental injury occurs during childbirth. In most cases, up to 10-20 ml/kg of solutions are required to restore mean arterial pressure to normal.

Excessive increase in intravascular volume should be avoided because sudden systemic hypertension may rupture cerebral vessels, leading to intracranial hemorrhage, especially in premature infants.

Other causes of hypotension

Hypoglycemia, hypocalcemia, and hypermagnesemia cause hypotension in newborns. Hypotension caused by alcohol or magnesium intoxication usually responds well to blood volume replacement or dopamine, or both. Hypermagnesemia in newborns is usually treated with 100-200 mg/kg calcium gluconate administered over 5 minutes.

Heart massage

If, despite stimulation and ventilation, the heart rate in the 1st minute of life or earlier is less than 80 beats/min, it is necessary to intubate the trachea, perform mechanical ventilation with oxygen and begin closed cardiac massage. Place both thumbs on the sternum and use your other fingers to support the baby's back. Compress the sternum 2-2.5 cm with a frequency of 100-120 per minute. There is no need to interrupt ventilation during cardiac massage. The effectiveness of cardiac massage is assessed by measuring blood gases and pH created by blood pressure m and examination of the pupils, which should be in the middle position or constricted. If the pupils are dilated and no atropine has been used, cerebral blood flow and oxygenation are inadequate.

Drugs for resuscitation

In severe acidosis (pH

When to stop resuscitation

Allergies in newborns

The goal of resuscitation and intensive treatment is to prevent or eliminate the danger of long-term cell damage from asphyxia.

Preliminary training of the personnel involved in resuscitation and the serviceability of instruments and equipment checked daily are necessary. Delay or prematureness and unnecessary actions are equally dangerous for the child. The actions of the resuscitator must be thoughtful and careful, sparing the newborn from injury, infection and cooling. At room temperature, the newborn loses about 837.4 J (200 cal) per kg of body weight in 1 minute and in 10-15 minutes the rectal temperature can drop by 2-3 ° C.

Resuscitation of a newborn baby has two phases:

1. Primary resuscitation or emergency measures mandatory for the doctor or team leading the birth.

2. Secondary or prolonged resuscitation carried out by a neonatologist or team in close collaboration with an anesthesiologist. It is a set of care and treatment measures and is carried out in the sector (department) for intensive treatment of a newborn.

Primary resuscitation. It is advisable that primary resuscitation be provided by a team consisting of a neonatologist, an anesthesiologist and an obstetrician. During high-risk births, the presence of at least one physician competent in neonatal resuscitation is required. Intensive observation, care and treatment can be temporarily (from 2 to 6 hours) carried out in the appropriate sector (box) in the delivery room under the guidance of a neonatologist.

Primary resuscitation has the following tasks: a) respiratory resuscitation, b) maintaining blood circulation, c) biochemical resuscitation and elimination of acidosis, d) prescribing vasodilators and other therapeutic, pathogenetically based agents.

The following aids and medications are used in the delivery room:

Benefits: radiant heating body above the child; endotracheal tubes with a diameter of 3.0, 2.5 and 2.0 mm such as Portex or Vygon; children's laryngoscope with spatula for newborns No. 0 and 1; devices and aids for aspiration, including aspirators for single use; source of oxygen and condensed air; masks for newborns of various sizes; Ambu or Penlon balloon; apparatus for changing (intermittent) positive pressure; set for catheterization of umbilical vessels; apparatus or aids for measuring blood pressure; set for blood transfusion and venesection; a modern device for monitoring cardiac activity and respiration; thoracentesis kit; incubator with free access for manipulations and intravenous infusions; resuscitation table; clock with sound signal; umbilical catheters for single use: a transportable incubator with the ability to heat, equipped with an oxygen bottle and a humidifier.

Medicines.

Before giving birth, it is necessary to check the condition of benefits, materials and ensure the presence of those involved in resuscitation.

Caring for a newborn with an Apgar score of 9 and 10. Immediately after the head is released from the birth canal, secretions can be evacuated from oral cavity and pharynx, thus preventing their aspiration during the first inhalation. After birth, the baby is left under the entrance to the birth canal, the umbilical cord is tied and placed in a draining position. Approximately 90% of children begin breathing spontaneously. The Apgar score is noted at the 1st and 5th min. The presence of mild acrocyanosis is considered normal in the first 4 minutes. The child's body is dried with a warm, sterile blanket. The amniotic fluid is removed, but in such a way as to avoid cooling. It has been established that cold stress increases metabolic acidosis and oxygen consumption. The resuscitation table must be sufficiently provided with a heat source and adequate lighting. If these conditions are not present, the child can be wrapped in a sheet of staniol and warmed diapers. The umbilical cord is ligated (pinched), mandatory prophylaxis against blenorrhea is carried out, the newborn is identified with the mother's name or number, documentation is filled out and no later than 2 hours later, transferred to the sector for healthy newborns.

Mild depression- 7-8 points on the Apgar scale. The child is placed in a draining position - moderate Trendelenburg, with the head turned to the side (15-30°), which ensures the outflow of fluids and reduces the risk of aspiration of secretions. Again, using an aspirator, the upper respiratory tract is emptied, and then the gastric contents are aspirated. Thus, the presence of esophageal atresia is excluded, vomiting and additional aspiration, often observed after cesarean section, are prevented. The child’s tilt should not be very large, otherwise breathing will be difficult, as the diaphragm and lungs are compressed. Light tapping, tangential irritation of the skin of the feet or insertion of a catheter into the nostrils causes reflex irritation, evaluates the child’s reaction (on the Apgar scale at the end of the first minute) and at the same time checks for atresia of the nasal passages (with a thin polyethylene catheter for single use).

Reflex irritation is also caused by light massages in the precordial area and the liver area, along the spine. The action of the diaphragm can also be used by applying gentle pressure and release at the base of the chest. Gentle rubbing, spraying with alcohol or directing a stream of oxygen from a distance, which has a mechanical effect, is allowed. These simple methods often give good results. After several uneven breathing movements, breathing begins, which gradually acquires a normal rhythm and frequency. The Apgar score increases. The skin gradually turns pink, heart rate, frequency and tone improve. The child remains under constant observation - the onset of secondary apnea is possible. A short-term supply of oxygen through a loosely applied mask or the child is placed in a tent has a beneficial effect.

Resuscitation of a newborn with moderate depression- 4-6 Apgar points. As already mentioned, it is necessary to quickly and gently ensure airway patency. Prolonged aspiration can cause reflex bradycardia and apnea due to vagal irritation in the pharyngeal region. Adequate ventilation is initiated by supplying oxygen through the mask of an automatic or manual intermittent positive pressure device or an Ambu device. Respiration rate 40 times per minute, volume - 10-15 cm3, pressure in the expansion phase 2.45-2.94-3.92 kPa (25-30-40 cm water column) and in the breathing phase 1.47- 1.96 kPa (15-20 cm water column).

Short-term enrichment of the air with oxygen and periodic use of a mask improve gas exchange in the lungs. Within a few minutes, the oxygen supply and CO2 release are restored. In rare cases with mild adaptation disorder, buffering blindly or after gas analysis is necessary. If the vital functions of a newborn are not restored within 2-3 minutes, further behavior should be the same as in severe states of depression.

Resuscitation of children with severe depression- 0-3 Apgar points. During resuscitation, the heart rate is constantly monitored - most conveniently using an electronic device with a screen. If the heart rate is below 80, immediate tracheal intubation is necessary. The most important technical rules are as follows:

1. The child's head should be at shoulder level. Excessive extension or adduction of the head to the chest makes intubation difficult due to flexion of the neck.

2. When intubating premature infants, small laryngoscope spatulas should be used. The spatula is inserted into the oral cavity so that the tongue moves to the left. The laryngoscope is carefully straightened and the spatula is slightly moved upward so that the epiglottis is visible. Using careful movements at the base of the epiglottis, the latter is lifted with a spatula so that the vocal cords are visible. If the epiglottis is not visible, then the spatula has penetrated deeper.

3. Maintain visibility vocal cords and a tube of appropriate size is inserted into the trachea on the right. If visibility is good, preliminary aspiration of mucus from the nasopharynx is recommended. The passage of the tube into the trachea is facilitated by light pressure on the trachea from the outside with the fifth finger of the left hand holding the laryngoscope.

4. After intubation and careful aspiration through the tube, the latter is connected to the Ambu apparatus or another device and ventilation begins. Movement of the chest wall, improvement in skin color, and normalization of heart rate indicate the effectiveness of ventilation. The advantage of the Ambu balloon is that the pressure is limited to 2.94 kPa (30 cm of water column) and there is less danger of overstretching the alveoli; The disadvantage is the impossibility of receiving a higher concentration of oxygen.

5. Once the newborn's condition has stabilized, the position of the tube is checked again. It needs to be located approximately 2 cm below the vocal cords.

Simultaneously with respiratory resuscitation, drug correction acidosis blindly or accordingly BE.

Cardiac massage is necessary when the heart rate drops below 100 beats/min. It is performed by successive pressure on the chest bone between the middle and lower third with two fingers at a frequency of about 90-100 per minute. The chest bone moves towards the spine by approximately 1.5-1.8 cm. Massage can also be performed by covering the chest on both sides and pressing with the thumbs (with the same frequency) on the middle of the chest bone. Three (up to five) pressures on the chest bone should correspond to one breathing movement. The effectiveness of cardiac massage is monitored by an assistant based on the pulse in the carotid or femoral arteries or the reaction and size of the pupils, without stopping cardiopulmonary resuscitation.

Variable positive pressure can also be achieved using the old method - artificial respiration"mouth to mouth and nose" With the head in the correct position (weak dorsal flexion), air is blown through the gauze only from the resuscitator’s mouth - about 15-20 ml, which can be enriched with oxygen through a tube connected to an oxygen source and inserted into the resuscitator’s oral cavity. Frequency - 30-40 breaths per minute. The method can be carried out after intubation as “mouth-tube” breathing and be accompanied by chest compressions.

Medications and infusions. Anti-acidotic treatment during primary resuscitation is carried out by administering an 8.4% sodium bicarbonate solution in a dose of 2 to 5 ml per body weight, which corresponds to 2 to 5 mmol/kg body weight. Accordingly - BE (base deficiency) is dosed according to the formula - BE kg weight X 0.3 = ml 8.4% sodium bicarbonate. The coefficient of 0.3 in the smallest preterm infants increases to 0.6, since their extracellular space is relatively larger.

A good anti-acidotic effect is also achieved with the help of trisbuffer, which also has an intracellular effect. Dosed with a 0.3 molar solution according to the formula: - BE x kg weight = ml 0.3 molar trisbuffer.

Rapid infusion of antiacidotic agents should be avoided due to the risk of apnea, hyperosmolarity, and cerebral hemorrhage. Infusion rate 2 ml/min/kg body weight = better with an infusion pump. Antiacidotic treatment cannot replace respiratory resuscitation, but is used in parallel with it in order to prevent cell damage. It can be used without prior examination in the following conditions that threaten the life of the child: a) established intrauterine disorders in the fetus - deterioration of heart sounds, changes in amniotic fluid or acidosis determined by microanalysis of blood during childbirth; b) in cases where spontaneous breathing does not begin until 90 s after birth despite artificial respiration; c) changes in general condition child due to placental insufficiency; d) severe pallor - peripheral vasoconstriction; e) breathing disorder; f) Apgar score of 6 or lower at 5 minutes or 0 to 3 at the end of the first minute (see Continuous Neonatal Resuscitation).

Adrenalin. Prescribed when the heart rate is less than 50 beats/min in a solution: 1: 10,000 from 1 to 3 ml into the umbilical vein. When heart rate is less than 10 beats/min (or asystole), it is administered immediately intracardially.

Glucose. To eliminate hypoglycemia in a severe depressive state, a 25% glucose solution is prescribed at 3-4 ml/kg body weight, slowly intravenously. They prefer less concentrated solutions - 5 and 10%, in the form of a drip infusion as a calorie source at the beginning of parenteral feeding.

Calcium gluconate. Increases myocardial contractility. Its rapid administration causes arrhythmias. Used in a 10% solution, 1.5-2.0 ml per kg of weight.

Antishock agents and volumetric substitutes. In case of low blood pressure or danger of shock, albumin is prescribed through the umbilical vein at 1 g/kg body weight or 4 ml/kg body weight of a 25% solution, respectively, 5% humanalbumin at 10-20 ml/kg body weight. A transfusion of plasma 10-20 ml/kg body weight or blood 10-15 ml/kg body weight is prescribed when the child is in a state of shock or severe anemia.

Depression caused by analgesic or anesthetic substances prescribed to the mother is manifested by sluggish breathing with a normal heart rate. Alylnormorphine 0.1 mg intravenously or 0.25 mg intramuscularly is used as an antidote for morphine and its derivatives. According to indications, repeat doses after a few minutes up to 0.8 mg.

Catheterization of umbilical vessels. It is carried out under sterile conditions and is rarely difficult. The correct position of the catheter in the inferior vena cava is recognized by the height of the blood column and pressure fluctuations. In children weighing less than 1000 g, umbilical vein catheterization is carried out at a depth of 6 cm, in children weighing from 1000 to 1500 g - 7 cm, from 1500 to 2000 g - 8 cm, from 2000 to 2500 g - 9 cm, and in children with a weight of more than 2500 g at a depth of 10 to 12 cm. Deflection of the catheter towards the portal vessels is dangerous during infusion hypertonic solutions. To avoid gas embolism, the polyethylene catheter should always be filled with fluid and sealed or closed with a syringe inserted into it. Immediately after birth, the umbilical vessels bleed at the time of ligation. It is necessary to grab the cordon with tweezers and, squeezing it slightly, insert the catheter. It is convenient to find the umbilical vessels on a half-cut cordon, sandwiched between the fingers of the operator’s left hand. Catheterization of the umbilical artery is easy in the first hours, and then becomes difficult due to vasospasm. After the first day and for 4-5 days it is still possible. The depth of catheter insertion is from 6 to 14 cm, depending on the weight of the child. The catheter is fixed to the skin of the abdomen with an adhesive tape, and a sterile gauze swab is applied to the umbilical wound. When removing the catheter, a compressive bandage with a gauze pad is sufficient. For conditions requiring urgent action, this method provides optimal therapy. For prolonged resuscitation, another vein is also used. Preference is given to central catheterization with a gentle catheter inserted through the skin and a peripheral vein.

Side effects and adverse events during resuscitation. During intubation, the spatula is sometimes mistakenly inserted deeper than it should be. Hyperextension of the neck makes intubation difficult. The right bronchus and even more often the esophagus are often mistakenly intubated.

When using a breathing mask, the head is sometimes compressed, and this is dangerous for an immature newborn. The stomach almost always becomes full, bloated and makes breathing difficult. In the case of a diaphragmatic hernia, this can be fatal.

Breathing with a balloon and T-piece without adjusting the pressure can cause pneumothorax. Depending on the case, the balloon is compressed between the thumb and one or two subsequent fingers with 3.92 kPa (40 cm of water column).

Ventilation is sometimes mistakenly performed when the oxygen supply is empty or closed.

Hypothermia of a child during resuscitation due to untimely changing of diapers or the use of cold oxygen and refrigerated solutions is unacceptable.

During transportation, there is a danger in the absence of a source of heat, oxygen, hypo- or hyperventilation.

Rough cardiac massage performed in the area of ​​the lower edge of the sternum can cause liver rupture. Urgent surgery is required.

An appointment happens medicines in inappropriate dosages. They are late in prescribing albumin, adrenaline, and blood transfusions. With rapid jet infusion of concentrated solutions into the umbilical artery or into portal vein Vasoconstriction or extensive necrosis of tissues and organs in the genitourinary area may occur. Rapid infusion of buffer solutions may cause apnea. Preparedness for respiratory resuscitation is required. A causal relationship between intracranial hemorrhages and the resulting hyperosmolar peaks during treatment with buffer agents is assumed.

Primary resuscitation for life-threatening conditions of the newborn

Meconium aspiration. Children with meconium aspiration are most often full-term or post-term, with signs of intrauterine depression. The amniotic fluid and skin become meconium-colored. After releasing the head, aspiration from the oral cavity and pharynx of the trapped masses is necessary. After birth, the trachea is intubated and, with the help of an aspirator, the airways are cleared of meconium, otherwise meconium is aspirated into the lungs, severe aspiration syndrome, hypoxia and acidosis occur. Prolonged assisted ventilation is often necessary. Timely intubation and aspiration significantly reduces morbidity and mortality.

Pneumothorax. If a child with asphyxia worsens after intubation, bradycardia, and deafness of sounds appear, one should think about pneumothorax. Immediately puncture and aspiration of air from the pleural cavity are performed using a No. 22 needle with a syringe and a T-distractor. This kit should always be on the resuscitation table. Needle aspiration confirms the presence of pneumothorax. Constant drainage is required using a water pressure tube or drainage apparatus.

Diaphragmatic hernia. If after birth the newborn has severe respiratory distress, a flat stomach is noted, and bowel sounds above the chest, one should think about the presence of a diaphragmatic hernia. As a rule, a left-sided hernia is observed. Each experience of expanding the lungs with the help of a mask worsens the child’s condition; the mediastinum and heart sounds shift to the right. The child needs immediate endotracheal intubation and ventilation, so as not to cause pneumothorax. On the side of the hernia, the lung is hypoplastic and vigorous inflation with a balloon can cause pneumothorax. Urgent surgical intervention is required.

Airway obstruction. Severe respiratory failure in the very early period can be caused by atresia of the posterior nasal openings, laryngeal stenosis and congenital membranes. The presence of posterior nasal atresia can be determined by inserting a polyethylene catheter through the nostrils. The pharyngeal tube is found by palpation and the chin is fixed downwards. The child can be saved by intubation. Laryngeal membranes are diagnosed by direct inspection with a laryngoscope. A tracheotomy is immediately performed to provide ventilation. With Pierre-Robin syndrome, the tongue is pulled forward and fixed. Sometimes positioning your head and stomach down helps - the tongue moves down and air access is provided.

Ascites in a newborn. Detected in severe cases hemolytic disease, congenital anomaly of the urinary tract or lymphatic system. Resuscitation in such children involves aspiration of ascitic fluid using a needle, which is inserted into a point bisecting the line from the umbilicus to the anterior superior iliac spine. When giving birth to women in labor with previous Rh-incompatible pregnancies, the presence of a neonatologist is necessary. Along with preparation for resuscitation, preparation for immediate exchange blood transfusion is also carried out. These children sometimes have lower blood volume and anemia, so phlebotomy is not performed. It is recommended to immediately transfuse 5-10 ml/kg body weight of full blood or red blood cells in the delivery room. The blood is sent for urgent serological testing. In case of low blood pressure, albumin administration is recommended before blood transfusion. With the help of blood transfusion, the number of red blood cells increases, the volume of oxygen delivered and the activity of the heart improves. It is advisable to have donors with certain blood groups and serological data on hand. According to indications (hydrops) - immediate exanguine transfusion and evacuation of ascitic fluid in the delivery room.

Twins, anemia and shock. Blood pressure in newborns is rarely measured. In children with very low Apgar scores, this may be significant and necessitate therapeutic intervention. Decreased blood pressure in a child with anemia or shock, it can be corrected by blood transfusion, infusion of albumin and other plasma substitutes.

The second twin has more severe respiratory distress than the first. Transfusion from one twin to the other can result in anemia in one and polycythemia in the other. An anemic newborn may go into shock and require immediate blood transfusion. A newborn with polycythemia may have difficulty breathing and may require a partial exchange transfusion of blood, mainly plasma.

Fetoplacental or fetofetal hemorrhage, blood loss from abruptio placentae or through the umbilical cord can lead to severe anemia and shock in the newborn, and therefore there is a need to combat these conditions.

When the central nervous system and convulsions, simultaneously with the evacuation of secretions and fixation of the tongue forward, the head is turned to the side and, if necessary, an air duct is inserted. For apnea lasting more than 30 seconds, ventilation with intermittent positive pressure using a mask or endotracheal tube. It should also be taken into account the possible need surgical removal subdural hematoma. Maintain electrolyte and acid-base homeostasis. Hypoglycemia and vitamin B6 deficiency are corrected (50 mg intramuscularly or intravenously). For severe convulsions - Diazepam 1 mg/kg body weight slowly intravenously or phenobarbital 0.005 g/kg body weight intramuscularly, prednisone, mannitol - 1-2 g/kg body weight in 18% solution over 45-90 minutes.

For congenital heart disease. 1. Elimination of hypoxemia with oxygen. Breathing with varying positive pressure (as indicated). While in pulmonary diseases oxygen therapy and continuous positive pressure lead to rapid improvement, with prolonged right-to-left shunt or reduced stroke volume, hypoxemia increases. The CO2 partial pressure may be normal or lower (hyperventilation). 2. A neutral thermal environment during resuscitation reduces the need for oxygen. 3. Maintain the volume of circulating red blood cells, if necessary, by infusing red blood cells while maintaining fluid balance. 4. Elimination of acidosis due to its harmful effects on the metabolism and contractility of the heart muscle. For heart failure - appropriate digitalization, Furosemid, Furanthril 1-3 mg/kg body weight intramuscularly 4-6 times a day, Isoproterenol 1-1.5 mg/kg body weight/hour slowly intravenously, treatment of metabolic acidosis.

The earliest care for a child weighing less than 1500 g includes:
1. Timely, effective and gentle primary resuscitation.
2. If indicated, catheterization of the umbilical vessels for diagnostic purposes for medicinal infusions and parenteral nutrition. A peripheral vein is preferred due to the risk of infusing hypertonic solutions; a centrally placed intravenous tube can be used.
3. Oxygen therapy so as to maintain the partial pressure of 02 between 6.67-9.33 kPa. You should think about the right-left shunt and the danger of retinal hyperoxia - short-term hyperoxia can also be dangerous if they are repeated.
4. Early parenteral nutrition.
5. Antiacidotic treatment.
6. Optimal ambient temperature.
7. Electrolyte balance.
8. Continuous respiratory resuscitation: continuous positive pressure or intermittent pressure. A tent, mask, and nasal catheter are preferred.
9. Corticosteroids according to indications.

Bacterial sepsis may present as shock during initial resuscitation. Early opening of the amniotic sac or the presence of foul-smelling amniotic fluid are sufficient grounds for starting antibiotic treatment in the delivery room.

Care and transportation after initial resuscitation. In cases where the described primary resuscitation measures did not lead to complete recovery, the child becomes the object of observation in the sector (department) of intensive care and treatment of the newborn. Depending on the condition, the newborn is transferred to the new environment intubated, preferably nasally with more secure fixation without stopping assisted or artificial ventilation. If indicated, a catheter filled with saline or heparin solution and tightly closed or adapted for continuous infusion has already been inserted into the umbilical vein. The first stage of antiacidotic treatment is completed. If necessary, the child is immediately placed in an incubator.

Sometimes it is necessary to decide whether the maternity ward meets the conditions necessary for the treatment of a newborn or whether a child in a life-threatening condition should be transferred to a special district (district) center.

The conditions for transportation are the following circumstances and indications:
1. Weight less than 2000g.
2. Oxygen requirement for more than 3 hours.
3. Gas analysis data: partial pressure of 02 when breathing 100% 02 (hyperoxic test) below 13.3 kPa, pH below 7.20, partial pressure of CO2 above 7.33 kPa.
4. Gestation age is less than 35 weeks.
5. A child from a woman in labor with diabetes or prediabetes.
6. Assumption of the presence of viral or bacterial infections.
7. Severe depressive state - Apgar score of 3 or less at the 1st minute.
8. Jaundice exceeding physiological limits.
9. Complication, for example, pneumothorax, but after drainage.
10. Anamnestic data about the newborn who died in the family.
11. Developmental abnormalities (eg, congenital heart disease) that require investigation or surgery.
12. Congenital anomalies exchange.
13. Anemia.
14. Hypoglycemia, hypocalcemia.
15. Convulsions.
16. Birth trauma.

The decision to transfer to a regional center depends not only on the capabilities of the maternity ward or on the condition of the child, which is analyzed again after initial resuscitation. Distance, roads, availability of vehicles and climate characteristics also matter. The vehicle must be provided with electrical energy, heating, oxygen and air under pressure for 90 minutes (corresponding to the distance).

Accompanied by a resuscitator and a sister, with a detailed epicrisis, blood from the mother and from the umbilical cord appropriately inscribed, the child is transported in a special incubator with all the necessary means for respiratory resuscitation, anti-acidotic treatment and parenteral nutrition (as indicated). The consequences of transportation are assessed based on the necessary studies at the center.

Any, even optimally organized transport, has an adverse effect on the newborn in a life-threatening condition. That is why, for childbirth, it is more correct to send women with complicated pregnancies to bases that create conditions for intensive treatment of the child.

Prolonged neonatal resuscitation. The second stage of resuscitation is carried out in the sector (department) for intensive treatment. Its population is about 7% children. On average, 1 intensive care unit is provided per 1000 live births. Area requirements: for one intensive bed (incubator) an area of ​​8 m2 is required, and if additional rooms are included - 25 m2. An oxygen installation, purified air under pressure, a vacuum, an average of 6 electrical contacts per intensive care bed are expected. There is the possibility of gas analysis at any time, laboratory, x-ray, operating room. Suction and intubation aids, ventilation devices, appropriate medications and devices are maintained in good working order and easily accessible. Required average number medical personnel refers to the number of beds as 2: 1. At the child’s bedside on intensive treatment(assisted breathing) requires the constant presence of a nurse. A conscientious and well-trained nurse is the best "monitor". She must be familiar with the diagnosis, clinical picture and treatment plan of the child entrusted to her. The new electronic devices and devices she has mastered are valuable aids for observation and treatment.

Monitoring the child's condition. A great relief for monitoring cardiac activity is the recording of an ECG on the screen and cardiorespiraography with parallel recording of the breathing curve. Respiratory activity is monitored using a nasal thermistor or breathing movements child. A signal is activated for apnea lasting more than 20 s. Constant monitoring of temperature can be carried out using skin electrodes, which are connected to the heating of the incubator, which is automatically controlled and provided with an alarm signal. Intermittent temperature measurement is carried out in the usual way or using an electronic thermistor. Constantly monitoring the temperature in the incubator is of great importance. The child's blood pressure can be monitored using the pinking method after compressing the brachial artery to 13.3 kPa and gradually releasing it. Probes with an electrode inserted into an artery or umbilical vein are rarely used. When catheterizing the umbilical vein to the right atrium, the pressure is determined by the height of the blood column in a vertically installed catheter - normally from 0 to 8 cm. Indicators acid-base balance observed using the Astrup apparatus or using another device. Recently, electrodes have been used for transcutaneous continuous measurement of pCO2 and p02, which are indicators of dynamic changes in the body. Devices are needed for dosing oxygen in the breathing mixture and in the incubator.

In the prescription sheet (resuscitation sheet), weight, head circumference, blood picture, ionogram and changes in vital functions are noted, as well as changes in indicators recorded by equipment. Skin color, irrigation, temperature, heart rate, respiratory rate, circulation are noted hourly to monitor the synchronization of chest movement using the device, auscultation checks whether the endotracheal tube is in place. Every 4 hours, blood pressure, the presence of active and spontaneous movements, and the release of feces and urine are noted. At least every 12 hours, a medical examination is performed with auscultation of the lungs and heart (the operation of the noisy respirator or continuous positive pressure device is suspended for a short time). They also listen to the stomach. The abdomen, liver, pulse in the femoral artery and fontanelles are examined by palpation. Prescribed according to clinical indications X-ray examination. During artificial respiration gas analysis carried out at least every 4 hours. Together with the anesthesiologist, they monitor the relative proportion of oxygen in the inhaled stream (FiO2), frequency, pressure (inspiratory and expiratory), duration of inspiration, inspiratory volume, minute volume, humidifier temperature. The need to use relaxation agents and sedatives is discussed with the anesthesiologist. The possibility of removing the device and extubation after a gradual decrease in frequency, respectively pressure, and gradual activation of one’s own breathing is being discussed.

Long-term oxygen therapy carried out at p02 less than 6.67 kPa (50 mm Hg). To diagnose hypoxia, a hyperoxic test (modified) is used. With a relative proportion of oxygen in the inhaled air of 60% (i.e. Fi02 0.6) in 15 minutes. In premature babies, p02 increases by more than 20 pPa (150 mm Hg). Oxygen treatment is necessary at lower levels. In a sick child, they try to maintain arterial p02 at a level of 8.0-12.0 kPa (60-90 mm Hg). The hyperoxic test is also used in differential diagnosis congenital heart defects.

Prolonged respiratory resuscitation necessary for arterial p02 below 6.67 kPa (50 mm Hg) or pCO2 above 10.0-/10.7 kPa (75-80 mm Hg) or for apnea with a duration of more than 20 s. The following symptoms are clinically analyzed: tachypnea, tachycardia, inspiratory circulation, expiratory groan, cyanosis and apnea. Oxygen therapy can also be provided in an incubator - in some devices the concentration reaches 80%. They also use a small additional tent for the child's head, constant positive or negative pressure, or variable positive pressure (respirator).

Continuous positive airway pressure- PPD or so-called. CP AR is carried out with preserved spontaneous breathing using a box or a polyethylene tube located near the child’s head, with tips inserted into the nose (nasal method), or a tracheal tube. It is also carried out as positive pressure at the end of expiration during mechanical breathing. The PPD system consists of a mixer of oxygen and air in the desired ratio, an insulated humidifier, a pressure gauge and the final part - a bag (box), respectively, with nasal tips or an endotracheal tube. The method increases the functional residual volume, opens and maintains open atelectatic areas, favors the release of surfactant (superficial active substance), improves diffusion and increases arterial p02. Indicated mainly for hyaline-membranous disease (idiopathic disordered breathing syndrome - IRD) and for apnotic attacks with good results. The most commonly used method is the nasal method. Begin by supplying 60% oxygen at a flow rate of 3-5 l/min, a pressure of 0.392-0.490 kPa (4-6 cm of water column). Gradually the pressure is increased by 2 cm to 0.981 - 1.18 rPa (10-12 cm of water column). If there is no effect, increase the oxygen concentration by 5-10% to 95%. Continuous Negative Pressure (CNP) reverse method PPD - the chest is under low pressure, and therefore a similar result is achieved. With both systems, if the result is good, shutdown is done gradually, reducing the percentage of oxygen and then the pressure.

Intermittent positive pressure. Used in case of unsuccessful use of continuous positive pressure or when p02 is below 6.67 kPa (50 mm Hg) after a hyperoxic test, when pCO is above 9.33-0.7 kPa (70-80 mm Hg), acidosis , slow breathing (less than 30), very rapid shallow breathing (more than 120) or bradycardia (less than 80), tachycardia (more than 160) or after 2-3 apnotic attacks within 1 hour lasting more than 30 seconds. In Bulgaria, with good results, they use the Loosco device, which creates a constant air flow and inhalation is controlled at a certain time. Modern devices allow automatic switching from controlled breathing to auxiliary (assisted) breathing in accordance with the respiratory effort and rhythm of the child’s intermittent mandotor breathing - IMV. Continuous positive end-expiratory pressure can also be created. The success of treatment depends not so much on the type of respirator, but on the training and qualities of the personnel.

Infection Prevention with prolonged resuscitation represents serious problem. It is necessary to strictly adhere to the known rules for child care and sterilization of instruments, surface treatment with modern disinfectants, automatic and ordinary gas disinfection, irradiation, etc. After disinfection and sterilization, instruments and accessories must be placed in sterile, transparent packaging material. Antibiotic prophylaxis is not recommended due to the risk of pulmonary infections and sepsis caused by resistant Gram-negative pathogens, which pose treatment challenges.

Side effects and adverse events during prolonged resuscitation. Danger for the child is associated with obstruction of the tracheal tube and its displacement to one bronchus or to the esophagus, as well as separation of the connecting tubes. If the device malfunctions, replace it correctly and then eliminate the malfunction.

Trauma and damage to the airways are common. Sometimes they forget that oxygen is a medicine that requires precise dosing. Late consequences of its use include bronchopulmonary dysplasia and retrolental fibroplasia (consultation with an ophthalmologist at least once a week).

With constant positive pressure, an increase in pCO2 is possible, and with higher pressure and with longer use, interstitial emphysema, pneumomediastinum, pneumothorax and even pneumoperitoneum can be observed. It is assumed that the head method with a cuff around the neck, if applied inappropriately, can intensify or increase the number of intracranial hemorrhages. Adverse effects from the cardiovascular system are also observed with negative transthoracic pressure. Damage to the skin of the neck is observed due to excessive compression by the cuff.

The dangers from the development of infection are associated with non-compliance with the rules of asepsis and antisepsis when applying a mask, intubation, aspiration, toileting the tube and during non-sterile catheterization of the umbilical vessels.

Parenteral nutrition and acidosis management. For acidosis, sodium bicarbonate is preferred. For hypernatremia, high pCO2 and repeated infusions of bicarbonate, a 0.3 molar trisbuffer can be prescribed. The quantities calculated by the formula are diluted with glucose solution at least 1:1 and poured in at a rate of 3 to 5 drops/kg body weight/min. In the absence of gas analysis, BE is taken as -10 mmol/l.

In life-threatening conditions, in parallel with respiratory resuscitation, an 8.4% sodium bicarbonate solution is prescribed at 3-5 ml/kg of body weight, respectively, a 0.3 molar trisbuffer up to 9 ml/kg per minute. Taking into account the side effects and possible damage to the peripheral veins, doctors have recently refrained from medicinal elimination of acidosis and are looking for more strict indications. If the child’s condition allows, then the alkalizing effect is achieved by prescribing sodium bicarbonate in a 2.8 or 5.6% solution together with a 10% solution of Sir. simplex through a permanent gastric tube, dosed by a drip system of 12 ml/kg body weight/hour - 4 drops/kg per minute. Reliable changes in pH, BE and SB are established.

Parenteral nutrition until the child’s condition is completely stabilized. It starts with 70-80 ml/kg weight (i.e., 1 drop/kg weight/min) and if there is no danger from cerebral edema in the following days, gradually increase to 120-150 ml/kg weight (up to 2 drops/ kg weight/min). From the second day, 1/5 of the total amount of physiological sodium chloride solution is infused, and with good diuresis, after transient post-asphyxic hyperkalemia, from the third day 1-1.5 ml/kg of body weight/day is prescribed potassium chloride in a 14.9% solution. Calcium gluconate 10%, 1.5-2 ml/kg body weight, and vitamins are prescribed daily. After 48 hours, a solution of amino acids is prescribed, for example, Alvesin 20-25 ml/kg body weight/day and fatty solutions 10-20 ml/kg body weight/day in two doses, without mixing with other solutions. If possible, breast milk is prescribed in parallel in small quantities, but often, through a drip system and a permanent gastric tube. Contraindications for oral feeding are breathing under continuous positive pressure, a period of 6 hours after extubation or after the use of relaxants.

Antibiotic treatment is carried out according to general rules. Semi-synthetic drugs from the penicillin group and those with an effect on resistant staphylococci are recommended. Garbenicillin, as well as Gentamycin, Amicacin, Tobramycin are prescribed in appropriate doses, preferably under bacteriological control.

Timely drainage of the nasopharynx, vibration and percussion massage, general care and the child's toilet are of great importance for a favorable outcome.

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Sequence of three most important techniques cardiopulmonary resuscitation formulated by P. Safar (1984) in the form of the “ABC” rule:

1. Aire way orep (“open the way for air”) means the need to free the airways from obstacles: recessed tongue root, accumulation of mucus, blood, vomit and others foreign bodies;
2. Breath for victim (“breathing for the victim”) means mechanical ventilation;
3. Circulation his blood (“circulation of his blood”) means performing indirect or direct cardiac massage.

Measures aimed at restoring airway patency are carried out in the following sequence:

• the victim is placed on a rigid base supine (face up), and if possible, in the Trendelenburg position;
• straighten the head in the cervical region, bring it forward lower jaw and at the same time open the victim’s mouth (triple move by R. Safar);
• free the patient's mouth from various foreign bodies, mucus, vomit, blood clots using a finger wrapped in a scarf and suction.

Having ensured airway patency, begin mechanical ventilation immediately. There are several main methods:

• indirect, manual methods;
• methods of directly blowing air exhaled by a resuscitator into the victim’s respiratory tract;
• hardware methods.

The former are mainly of historical significance and are not considered at all in modern guidelines for cardiopulmonary resuscitation. At the same time, manual ventilation techniques should not be neglected in difficult situations when it is not possible to provide assistance to the victim in other ways. In particular, you can apply rhythmic compression (simultaneously with both hands) of the lower ribs of the victim's chest, synchronized with his exhalation. This technique may be useful during transportation of a patient with severe status asthmaticus (the patient lies or half-sits with his head thrown back, the doctor stands in front or to the side and rhythmically squeezes his chest from the sides during exhalation). Admission is not indicated for rib fractures or severe airway obstruction.

The advantage of direct inflation methods for the victim’s lungs is that a lot of air (1-1.5 liters) is introduced with one breath, with active stretching of the lungs (Hering-Breuer reflex) and the introduction of an air mixture containing an increased amount of carbon dioxide (carbogen) , the patient's respiratory center is stimulated. The methods used are “mouth to mouth”, “mouth to nose”, “mouth to nose and mouth”; the latter method is usually used in the resuscitation of young children.

The rescuer kneels at the side of the victim. Holding his head in an extended position and holding his nose with two fingers, he tightly covers the victim’s mouth with his lips and makes 2-4 vigorous, not rapid (within 1-1.5 s) exhalations in a row (excursion of the patient’s chest should be noticeable). An adult is usually provided with up to 16 respiratory cycles per minute, a child - up to 40 (taking into account age).

Ventilators vary in design complexity. At the prehospital stage, you can use breathing self-expanding bags of the “Ambu” type, simple mechanical devices of the “Pneumat” type or constant air flow interrupters, for example, using the Eyre method (through a tee - with your finger). In hospitals, complex electromechanical devices are used that provide mechanical ventilation for a long period (weeks, months, years). Short-term forced ventilation is provided through a nasal mask, long-term - through an endotracheal or tracheotomy tube.

Typically, mechanical ventilation is combined with external, indirect cardiac massage, achieved through compression - compression of the chest in the transverse direction: from the sternum to the spine. In older children and adults, this is the border between the lower and middle third of the sternum; in young children, it is a conventional line passing one transverse finger above the nipples. The frequency of chest compressions in adults is 60-80, in infants - 100-120, in newborns - 120-140 per minute.

In infants, one breath occurs per 3-4 chest compressions; in older children and adults, this ratio is 1:5.

The effectiveness of indirect cardiac massage is evidenced by a decrease in cyanosis of the lips, ears and skin, constriction of the pupils and the appearance of a photoreaction, an increase in blood pressure, and the appearance of individual respiratory movements in the patient.

Due to incorrect positioning of the resuscitator's hands and excessive efforts, complications of cardiopulmonary resuscitation are possible: fractures of the ribs and sternum, damage to internal organs. Direct cardiac massage is done for cardiac tamponade and multiple rib fractures.

Specialized cardiopulmonary resuscitation includes more adequate mechanical ventilation techniques, as well as intravenous or intratracheal administration of medications. When administered intratracheally, the dose of drugs should be 2 times higher in adults, and 5 times higher in infants, than when administered intravenously. Intracardiac administration of drugs is not currently practiced.

The condition for the success of cardiopulmonary resuscitation in children is the release of the airways, mechanical ventilation and oxygen supply. The most common cause of circulatory arrest in children is hypoxemia. Therefore, during CPR, 100% oxygen is supplied through a mask or endotracheal tube. V. A. Mikhelson et al. (2001) supplemented R. Safar’s “ABC” rule with 3 more letters: D (Drag) - drugs, E (ECG) - electrocardiographic control, F (Fibrillation) - defibrillation as a method of treating cardiac arrhythmias. Modern cardiopulmonary resuscitation in children is unthinkable without these components, however, the algorithm for their use depends on the type of cardiac dysfunction.

For asystole, intravenous or intratracheal administration of the following drugs is used:

• adrenaline (0.1% solution); 1st dose - 0.01 ml/kg, subsequent doses - 0.1 ml/kg (every 3-5 minutes until the effect is obtained). When administered intratracheally, the dose is increased;
• atropine (in asystole is ineffective) is usually administered after adrenaline and ensuring adequate ventilation (0.02 ml/kg of 0.1% solution); repeat no more than 2 times in the same dose after 10 minutes;
• sodium bicarbonate is administered only in conditions of prolonged cardiopulmonary resuscitation, and also if it is known that circulatory arrest has occurred against the background of decompensated metabolic acidosis. The usual dose is 1 ml of 8.4% solution. The drug can be administered again only under the supervision of CBS;
• dopamine (dopamine, dopmin) is used after restoration of cardiac activity against the background of unstable hemodynamics at a dose of 5-20 mcg/(kg min), to improve diuresis 1-2 mcg/(kg min) for a long time;
• lidocaine is administered after restoration of cardiac activity against the background of post-resuscitation ventricular tachyarrhythmia as a bolus at a dose of 1.0-1.5 mg/kg, followed by infusion at a dose of 1-3 mg/kg-h), or 20-50 mcg/(kg-min) .

Defibrillation is performed against the background of ventricular fibrillation or ventricular tachycardia in the absence of a pulse in the carotid or brachial artery. The power of the 1st discharge is 2 J/kg, subsequent ones - 4 J/kg; the first 3 discharges can be done in a row without monitoring with an ECG monitor. If the device has a different scale (voltmeter), 1st digit for children infancy should be in the range of 500-700 V, repeated - 2 times more. In adults, 2 and 4 thousand, respectively. V (maximum 7 thousand V). The effectiveness of defibrillation is increased by repeated administration of the entire complex of drug therapy (including a polarizing mixture, and sometimes magnesium sulfate, aminophylline);

For EMD in children with no pulse in the carotid and brachial arteries, the following intensive therapy methods are used:

• adrenaline intravenously, intratracheally (if catheterization is impossible after 3 attempts or within 90 s); 1st dose 0.01 mg/kg, subsequent doses - 0.1 mg/kg. Administration of the drug is repeated every 3-5 minutes until the effect is obtained (restoration of hemodynamics, pulse), then in the form of infusions at a dose of 0.1-1.0 μg/(kgmin);
• fluid to replenish the central nervous system; It is better to use a 5% solution of albumin or stabizol, you can use rheopolyglucin in a dose of 5-7 ml/kg quickly, drip-wise;
• atropine at a dose of 0.02-0.03 mg/kg; possible repeated administration after 5-10 minutes;
• sodium bicarbonate - usually 1 time 1 ml of 8.4% solution intravenously slowly; the effectiveness of its introduction is questionable;
• if the listed means of therapy are ineffective, electrical cardiac pacing (external, transesophageal, endocardial) is performed immediately.

If in adults ventricular tachycardia or ventricular fibrillation are the main forms of circulatory arrest, then in young children they are observed extremely rarely, so defibrillation is almost never used in them.

In cases where the damage to the brain is so deep and extensive that it becomes impossible to restore its functions, including brain stem functions, brain death is diagnosed. The latter is equated to the death of the organism as a whole.

Currently, there are no legal grounds for stopping initiated and actively ongoing intensive care in children before natural circulatory arrest. Resuscitation does not begin and is not carried out in the presence of a chronic disease and pathology incompatible with life, which is determined in advance by a council of doctors, as well as in the presence of objective signs of biological death (cadaveric spots, rigor mortis). In all other cases, cardiopulmonary resuscitation in children should begin in case of any sudden cardiac arrest and be carried out according to all the rules described above.

The duration of standard resuscitation in the absence of effect should be at least 30 minutes after circulatory arrest.

With successful cardiopulmonary resuscitation in children, it is possible to restore the heart, sometimes simultaneously respiratory function(primary revival) in at least half of the victims, but in the future survival in patients is observed much less frequently. The reason for this is post-resuscitation illness.

The outcome of recovery is largely determined by the conditions of the blood supply to the brain in the early post-resuscitation period. In the first 15 minutes, blood flow can exceed the initial one by 2-3 times, after 3-4 hours it drops by 30-50% in combination with an increase in vascular resistance by 4 times. Repeated deterioration of cerebral circulation may occur 2-4 days or 2-3 weeks after CPR against the background of almost full recovery CNS functions - delayed posthypoxic encephalopathy syndrome. By the end of the 1st to the beginning of the 2nd day after CPR, a repeated decrease in blood oxygenation may be observed, associated with nonspecific lung damage - respiratory distress syndrome (RDS) and the development of shunt-diffusion respiratory failure.

Complications of post-resuscitation illness:

• in the first 2-3 days after CPR - swelling of the brain, lungs, increased tissue bleeding;
• 3-5 days after CPR - dysfunction of parenchymal organs, development of manifest multiple organ failure (MOF);
• at a later date - inflammatory and suppurative processes. In the early post-resuscitation period (1-2 weeks) intensive therapy
• is carried out against the background of impaired consciousness (somnolence, stupor, coma) of mechanical ventilation. Its main tasks in this period are stabilization of hemodynamics and protection of the brain from aggression.

Restoration of the central nervous system and rheological properties of blood is carried out with hemodilutants (albumin, protein, dry and native plasma, rheopolyglucin, saline solutions, less often a polarizing mixture with the administration of insulin at the rate of 1 unit per 2-5 g of dry glucose). Plasma protein concentration should be at least 65 g/l. Improved gas exchange is achieved by restoring the oxygen capacity of the blood (transfusion of red blood cells), mechanical ventilation (with the oxygen concentration in the air mixture preferably less than 50%). With reliable restoration of spontaneous breathing and stabilization of hemodynamics, HBOT is possible, for a course of 5-10 procedures daily at 0.5 ATI (1.5 ATA) and a plateau of 30-40 minutes under cover antioxidant therapy(tocopherol, ascorbic acid, etc.). Maintaining blood circulation is ensured by small doses of dopamine (1-3 mcg/kg per minute for a long time) and maintenance cardiotrophic therapy (polarizing mixture, panangin). Normalization of microcirculation is ensured by effective pain relief for injuries, neurovegetative blockade, administration of antiplatelet agents (Curantyl 2-3 mg/kg, heparin up to 300 IU/kg per day) and vasodilators (Cavinton up to 2 ml drip or Trental 2-5 mg/kg per day drip, Sermion , aminophylline, a nicotinic acid, complamin, etc.).

Antihypoxic therapy is carried out (Relanium 0.2-0.5 mg/kg, barbiturates in a saturation dose of up to 15 mg/kg on the 1st day, on subsequent days - up to 5 mg/kg, GHB 70-150 mg/kg after 4-6 hours , enkephalins, opioids) and antioxidant (vitamin E - 50% oil solution at a dose of 20-30 mg/kg strictly intramuscularly daily, for a course of 15-20 injections) therapy. To stabilize membranes and normalize blood circulation, large doses of prednisolone, metipred (up to 10-30 mg/kg) are prescribed intravenously as a bolus or in fractions over 1 day.

Prevention of post-hypoxic cerebral edema: cranial hypothermia, administration of diuretics, dexazone (0.5-1.5 mg/kg per day), 5-10% albumin solution.

Correction of VEO, WWTP and energy metabolism. Detoxification therapy is carried out (infusion therapy, hemosorption, plasmapheresis according to indications) to prevent toxic encephalopathy and secondary toxic (autotoxic) organ damage. Intestinal decontamination with aminoglycosides. Timely and effective anticonvulsant and antipyretic therapy in young children prevents the development of post-hypoxic encephalopathy.

Prevention and treatment of bedsores (treatment with camphor oil, curiosin of places with impaired microcirculation), hospital infections (asepsis) are necessary.

If the patient quickly recovers from a critical condition (within 1-2 hours), the complex of therapy and its duration should be adjusted depending on the clinical manifestations and the presence of post-resuscitation illness.

Treatment in the late post-resuscitation period

Therapy in the late (subacute) post-resuscitation period is carried out for a long time - months and years. Its main focus is restoration of brain function. Treatment is carried out jointly with neurologists.

• The administration of drugs that reduce metabolic processes in the brain is reduced.
• Drugs that stimulate metabolism are prescribed: cytochrome C 0.25% (10-50 ml/day 0.25% solution in 4-6 doses depending on age), Actovegin, solcoseryl (0.4-2.00 intravenous drips for 5 % glucose solution for 6 hours), piracetam (10-50 ml/day), Cerebrolysin (up to 5-15 ml/day) for older children intravenously during the day. Subsequently, encephabol, acephen, and nootropil are prescribed orally for a long time.
• 2-3 weeks after CPR, a (primary or repeated) course of HBO therapy is indicated.
• The introduction of antioxidants and disaggregants is continued.
• Vitamins B, C, multivitamins.
• Antifungal drugs (Diflucan, Ancotil, Candizol), biological products. Termination antibacterial therapy according to indications.
• Membrane stabilizers, physiotherapy, physical therapy (physical therapy) and massage according to indications.
• General restorative therapy: vitamins, ATP, creatine phosphate, biostimulants, adaptogens in long-term courses.

The main differences between cardiopulmonary resuscitation in children and adults

Conditions preceding circulatory arrest

Bradycardia in a child with respiratory disorders is a sign of circulatory arrest. Newborns, infants and young children develop bradycardia in response to hypoxia, while older children initially develop tachycardia. In newborns and children with a heart rate less than 60 beats per minute and signs of low organ perfusion in the absence of improvement after the start of artificial respiration, closed cardiac massage should be performed.

After adequate oxygenation and ventilation, epinephrine is the drug of choice.

Blood pressure must be measured with a correctly sized cuff; invasive blood pressure measurement is indicated only in cases of extreme severity of the child.

Since blood pressure depends on age, it is easy to remember the lower limit of normal as follows: less than 1 month - 60 mm Hg. Art.; 1 month - 1 year - 70 mm Hg. Art.; more than 1 year - 70 + 2 x age in years. It is important to note that children are able to maintain pressure for a long time due to powerful compensatory mechanisms (increased heart rate and peripheral vascular resistance). However, hypotension is quickly followed by cardiac and respiratory arrest. Therefore, even before the onset of hypotension, all efforts should be aimed at treating shock (manifestations of which are increased heart rate, cold extremities, capillary refill more than 2 s, weak peripheral pulses).

Equipment and external conditions

Equipment size, drug dosage, and CPR parameters depend on age and body weight. When choosing doses, the child’s age should be rounded down, for example, at the age of 2 years, a dose for the age of 2 years is prescribed.

In newborns and children, heat transfer is increased due to the larger body surface area relative to body weight and the small amount of subcutaneous fat. The ambient temperature during and after cardiopulmonary resuscitation should be constant, ranging from 36.5 °C in newborns to 35 °C in children. When basal body temperature is below 35 "C CPR becomes problematic (in contrast to the beneficial effect of hypothermia in the post-resuscitation period).

Airways

Children have structural features of the upper respiratory tract. The size of the tongue relative to the oral cavity is disproportionately large. The larynx is located higher and more inclined forward. The epiglottis is long. The most narrow part The trachea is located below the vocal cords at the level of the cricoid cartilage, which makes it possible to use tubes without a cuff. The straight blade of the laryngoscope allows better visualization of the glottis, since the larynx is located more ventrally and the epiglottis is very mobile.

Rhythm disorders

For asystole, atropine and artificial rhythm stimulation are not used.

VF and VT with unstable hemodynamics occurs in 15-20% of cases of circulatory arrest. Vasopressin is not prescribed. When using cardioversion, the shock force should be 2-4 J/kg for a monophasic defibrillator. It is recommended to start with 2 J/kg and increase as necessary to a maximum of 4 J/kg for the third shock.

Statistics show that cardiopulmonary resuscitation in children allows you to return to full life at least 1% are sick or injured in accidents.

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 function.

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. Among the pathologies of pregnancy, it is worth noting polyhydramnios or oligohydramnios, post-maturity, intrauterine growth retardation and the presence of multiple pregnancies.

Intrapartum risk factors include: premature or delayed birth, pathological presentation or fetal position, placental abruption, prolapse of umbilical cord loops, use of general anesthesia, labor anomalies, the presence of meconium in the amniotic fluid, etc.

Before resuscitation begins, the child’s condition is assessed based on the following signs of live birth:

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

If all 4 signs are absent, the child is considered stillborn and cannot be resuscitated. The presence of at least one sign of live birth is an indication for the immediate initiation of resuscitation measures.

Resuscitation algorithm

The resuscitation algorithm is determined by three main features:

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

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 for 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, it is suctioned from the 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, the excursion of the chest should be clearly visible.

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 is indicated for suspected diaphragmatic hernia, ineffectiveness of mask ventilation within 1 minute, as well as for 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, begin chest compressions.

Indirect cardiac massage technique

The child is placed on a hard surface. Using two fingers (middle and index) of one hand or two thumbs of 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 the start of closed cardiac massage, the heart rate is again monitored.

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 administration of other medications.

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 (supposed severe acidosis, preventing the restoration of cardiac activity). 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.

If there is a positive effect from resuscitation measures, the child should be transferred to the intensive care unit (ward), where specialized treatment will continue.

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 a sudden stop of heart and breathing, although quickly, but not instantly. 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 is why everyone needs to know the methods of primary resuscitation of 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 of the body (heart and breathing) impaired in terminal conditions in order to prevent brain death. This resuscitation is aimed at reviving a person after breathing has stopped.

The leading causes of terminal conditions that developed outside of medical institutions in childhood are the syndrome sudden death newborns, car trauma, drowning, obstruction of the upper respiratory tract. The maximum number of deaths in children occurs under 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 of further life support. 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. At the same time, 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 its blood flow, external massage of the heart.

Transportation of victims

Functionally justified for transporting children is:

• in case of severe hypotension - horizontal position with the head end lowered by 15°;
• in case of damage to the chest, acute respiratory failure of various etiologies - semi-sitting;
• in case of spinal injury – horizontal on the backboard;
• for fractures of the pelvic bones, injuries to the abdominal organs - the legs are 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 spine 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 Scientific Center for 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. State Healthcare Institution Regional Children's Clinical Hospital No. 1 of Yekaterinburg.

5. Ministry of Health and Social Development of the Russian Federation.

List of abbreviations:

HR – heart rate ALV – artificial ventilation 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.

According to various 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.

The 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, extensive clinical experience has been accumulated in the primary resuscitation of newborns of various gestational ages, the generalization of which has 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 of medical personnel in the delivery room, medical practices that were unjustified from the point of view of evidence-based medicine and even potentially dangerous were discovered. 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 introduction into medical practice and maintaining the quality of medical care for newborns at a high level, 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 a medical institution of any functional level to immediately provide 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 obstetric and gynecological care, a person 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 with asphyxia, the birth of a premature baby at 32 weeks of gestation or less, is predicted, a resuscitation team consisting of

of two people trained in all neonatal resuscitation techniques (preferably a neonatologist and a trained pediatric nurse). Providing care to 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, begin resuscitation measures 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 condition, the nature and volume of resuscitation measures performed, an Apgar assessment of the child’s condition should be performed 1 and 5 minutes after birth (Table 1). If resuscitation continues beyond 5 minutes of life, a third Apgar assessment should be performed 10 minutes after birth. When assessing Apgar against the background of mechanical ventilation, only the presence of spontaneous respiratory efforts of the child is taken into account: if present, breathing is scored 1 point, if absent - 0, regardless of the excursion of the chest in response to forced ventilation.

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.

A score of 8 points or more 1 minute after birth indicates the absence of asphyxia in the newborn, 4–7 points indicate mild and moderate asphyxia, 1–3 points indicate severe asphyxia. The Apgar score 5 minutes after birth has 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 grounds for stopping primary resuscitation.

In all cases of live birth, the first and second Apgar scores are entered into the corresponding columns in the developmental history of the newborn.

In cases of primary resuscitation, a completed insert card for primary resuscitation of newborns (Appendix No. 5) is additionally pasted into the developmental history 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 initiation 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.) Is the amniotic fluid clear and there are no obvious signs of infection?

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 close supervision of medical personnel. If the specialist answers “NO” to at least one of the above questions, he should transfer the child to a heated table (in an open resuscitation system) for an in-depth assessment of the child’s condition and, if necessary, to carry out initial resuscitation measures.

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

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

Voluntary muscle movements.

1.5. If all signs of a live birth are absent, the child is considered stillborn.