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Pediatric resuscitation of newborns in the hospital. What is needed for resuscitation in the delivery room? Hemorrhages in the brain

1. General principles

Immediately after the birth of the head, mucus is removed from the nasopharynx and oropharynx of the fetus using a rubber pear or a catheter connected to a special suction. When the baby is born completely, it is wiped dry with a sterile towel. After the appearance of spontaneous breathing or the cessation of pulsation of the umbilical cord, a clamp is applied to the umbilical cord and the newborn is placed in the incubator, giving it a position with a slightly lowered head end. With obvious asphyxia, the umbilical cord is immediately clamped and resuscitation begins. Normally, the newborn takes the first breath within 30 seconds after delivery, and steady spontaneous breathing is established within 90 seconds. The norm of respiratory rate is 30-60/mip, and heart rate is 120-160/min. Respiration is assessed by auscultation of the lungs, heart rate - by auscultation of the lungs or by palpation of the pulse at the base of the umbilical cord.

In addition to respiration and heart rate, it is necessary to evaluate the color skin, muscle tone and reflex excitability. The generally accepted method is to assess the child's condition on the Apgar scale (Table 43-4), produced at the 1st and 5th minute of life. The Apgar score at the 1st minute of life correlates with survival, at the 5th minute - with the risk of neurological disorders.

The norm is an Apgar score of 8-10 points. Such children need only mild stimulation (patting on the feet, rubbing the back, vigorous towel drying). The catheter is carefully passed through each nasal passage to rule out choanal atresia, and through the mouth into the stomach to rule out esophageal atresia.

2. Admixture of meconium in amniotic fluid

The admixture of meconium in the amniotic fluid is observed in approximately 10% of all births. Intrauterine hypoxia, especially at a gestational age of more than 42 weeks, is often associated with dense staining of amniotic fluid with meconium. With intrauterine hypoxia, the fetus develops deep convulsive breaths, during which meconium, along with amniotic fluid, can enter the lungs. During the first breaths after birth, meconium moves from the trachea and main bronchi to the small bronchi and alveoli. Meconium that is thick or contains solid particles can close the lumen of the small bronchi, which is the cause of severe respiratory failure, which occurs in 15% of cases with the admixture of meconium in the amniotic fluid. In addition, with this complication, the risk of persistence of the fetal circulation type is high (Chapter 42).

With light staining of amniotic fluid with meconium, sanitation of the respiratory tract is not required. If the amniotic fluid is densely stained with meconium (pea soup), then immediately after the birth of the head, before the shoulders are removed, the obstetrician must quickly suck out the contents of the nasopharynx and oropharynx using a catheter. Immediately after birth, the newborn is placed on a heated table, the trachea is intubated and the contents of the trachea are sucked off. A special suction is connected directly to the endotracheal tube, which is slowly removed. If meconium is found in the trachea, intubation and aspiration of the contents continue until it stops flowing through the tube - but no more than three times, after which further attempts cease to be effective. A mask is placed near the mouth of the newborn, through which humidified oxygen is supplied. It is also necessary to aspirate the contents of the stomach to prevent passive meconium regurgitation. Meconium aspiration is a risk factor for pneumothorax (the frequency of pneumothorax with meconium aspiration is 10%, while with vaginal delivery it is 1%).

3. Asphyxia of the newborn

At least two people are needed to resuscitate a newborn: one person secures the airway and administers

TABLE 43-4. Apgar score

IVL, the second performs an indirect heart massage. The participation of a third person, who catheterizes the vessels, injects drugs and infusion solutions, is very useful.

The most common cause of neonatal asphyxia is intrauterine hypoxia Therefore, the key to resuscitation is the normalization of breathing. Another important cause of asphyxia is hypovolemia. Causes of hypovolemia: too early clamping of the umbilical cord, too high position of the child relative to the birth canal at the time of clamping of the umbilical cord, prematurity, bleeding in the mother, crossing the placenta during caesarean section, sepsis, cross-circulation in twins.

If the neonate does not improve despite adequate respiratory resuscitation, vascular access and arterial blood gas analysis should be performed; pneumothorax (1% prevalence) and congenital airway anomalies, including tracheoesophageal fistula (1:3000-5000 newborns) and congenital diaphragmatic hernia (1:2000-4000) should be ruled out.

Apgar score at the 1st minute of life allows to standardize the approach to resuscitation: (1) mild asphyxia (5-7 points): stimulation (wiping the body, patting on the feet, debridement of the respiratory tract) is indicated in combination with inhalation of pure oxygen through a face mask located near the mouth; (2) moderate asphyxia (3-4 points: mechanical ventilation with a breathing bag through a mask is indicated; (3) severe asphyxia (0-2 points): immediate tracheal intubation is indicated, external cardiac massage may be required.

Indications for mechanical ventilation in a newborn: (1) apnea; (2) heart rate

If, despite adequate ventilation, the heart rate does not exceed 80 / min, then closed heart massage is indicated.

For tracheal intubation (Fig. 43-3), a Miller laryngoscope is used. The size of the laryngoscope blade and endotracheal tube depends on the weight of the child: 2 kg - 1 and 3.5 mm. If the tube is chosen correctly, then at an airway pressure of 20 cm of water. Art. there is a slight discharge of the respiratory mixture. Intubation of the right main bronchus is ruled out by auscultation. The depth of insertion of the endotracheal tube (from its distal end to the child's lips) is calculated as follows: 6 is added to the child's weight in kilograms, the result is expressed in centimeters. It is advisable to carry out pulse oximetry using a handheld sensor. The use of a transcutaneous oxygen tension monitor is also quite informative, but it takes a lot of time to set it up.

External cardiac massage

External cardiac massage is indicated when, after 30 hours of adequate ventilation with 100% oxygen, the heart rate is
Heart massage is carried out simultaneously with IVL with 100 oxygen. The frequency of pressure on the sternum should be 90-120 / min (Fig. 43-4). Heart massage technique described for children younger age(chapter 48) may be used for neonates weighing > 3 kg. The ratio of the frequency of compressions and injections should be 3:1, so that within 1 minute 90 compressions and 30 injections are performed. Heart rate should be checked periodically. At heart rate > 80/min, chest compressions are stopped.

Rice. 43-3. Newborn intubation. The head is in a neutral position. The laryngoscope is held between the large and index finger left hand, holding the chin middle and nameless. The little finger of the left hand is pressed against the hyoid bone, which helps to see the vocal cords. Best Review provides a straight blade, e.g. a #0 or #1 Miller laryngoscope

Vascular access

Most best method vascular access is the placement of a 3.5F or 5F catheter into the umbilical vein. It is necessary that the distal tip of the catheter is located directly below the level of the skin and the reverse flow of blood when the syringe plunger is pulled is free; with deeper administration, transfused hypertonic solutions can go directly to the liver.

Catheterization of one of the two umbilical arteries, which allows monitoring blood pressure and facilitating the analysis of arterial blood gases, is technically more difficult. Special catheters for the umbilical artery have been developed, which allow not only to measure blood pressure, but also to conduct long-term monitoring of PaO2 and SaO2. Care must be taken to prevent air from entering the vein or artery.

Infusion therapy

Of the newborns who require resuscitation, hypovolemia is present in some full-term and two-thirds of preterm infants. Hypovolemia is diagnosed with arterial hypotension and pallor of the skin, combined with a poor response to resuscitation. In newborns, BP correlates with BCC, so all newborns should have BP measured. Normally, blood pressure depends on weight and ranges from 50/25 mm Hg. Art. (weight 1-2 kg) up to 70/40 mm Hg. Art. (weight > 3 kg). Arterial hypotension indicates hypovolemia. To replenish the BCC, an erythrocyte mass of group 0 (I) Rh (neg), combined with maternal blood, or a 5% solution of albumin or Ringer's solution with lactate at a dose of 10 ml / kg is used. Rarer causes of arterial hypotension include hypocalcemia, hypermagnesemia, and hypoglycemia.

Rice. 43-4. Closed heart massage in a newborn. With both hands they clasp the newborn so that the thumbs are located on the sternum immediately below the line connecting both nipples, and the remaining fingers are closed on the back of the body. The depth of depression of the sternum is 1-2 cm, the frequency of pressure is 120/min. (Reproduced with modifications from Neonatal life support, Part VI. JAMA 1986;255:2969.)

Medications

A. Adrenaline: Indications: asystole; Heart rate less than 80 beats / min, despite adequate mechanical ventilation and cardiac massage. A dose of 0.01-0.03 mg / kg (0.1-0.3 ml / kg of a 1:10,000 solution) is administered every 3-5 minutes until the effect is achieved. If there is no venous access, it can be introduced into the trachea through an endotracheal tube.

B. Naloxone: Indications: elimination of respiratory depression caused by the administration of opioids to the mother in the last 4 hours before delivery. Dose: 0.01 mg/kg IV or 0.02 mg/kg IM. If the mother has abused opioids, then naloxone can provoke a withdrawal syndrome in the fetus.

B. Other drugs: B individual cases other drugs are also used. Sodium bicarbonate (dose 2 meq/kg body weight, 1 ml solution contains 0.5 meq) is indicated only for severe metabolic acidosis verified by arterial blood gas analysis. Sodium bicarbonate is also used in prolonged resuscitation (> 5 min), especially if arterial blood gas analysis is not technically possible. The rate of administration should not exceed 1 meq/kg/min to avoid hyperosmolarity and intracranial hemorrhage. In addition, to avoid hyperosmolarity-induced damage to hepatocytes, the distal tip of the catheter should not be located in the liver. Calcium gluconate 100 mg/kg (or calcium chloride 30 mg/kg) is only indicated for documented hypocalcemia or suspected hypermagnesemia (usually due to maternal magnesium sulfate); clinical manifestations include hypotension, decreased muscle tone, and vasodilation. Glucose (200 mg/kg, a 10% solution is used) is only indicated for documented hypoglycemia, as hyperglycemia exacerbates neurological deficits. Surfactant is indicated for respiratory distress syndrome in preterm infants, it can be injected into the trachea through an endotracheal tube.

Unfortunately, not all births pass and end successfully. Sometimes a child needs special help. The presence of an intensive care unit for newborns in the 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 respiration. Resuscitation of newborns is called therapeutic measures that are carried out immediately at birth and on the next day of a child's life to remove them from 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 with a reduced baby's pulse - less than 100 beats per minute, shortness of breath, apnea, hypotension - that is, with the so-called cardiopulmonary depression. According to WHO, up to 10% of newborns need specialized care at birth.

Primary neonatal resuscitation

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

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

The first measures of resuscitation of newborns in the delivery room are performed by a neonatologist, an anastasiologist-resuscitator and two nurses, each of whom performs strictly defined tasks. When a newly born baby is wiped off amniotic fluid and put on the table for resuscitation of newborns with heating, the neonatologist measures the body temperature and cleans the baby's airways from mucus. The resuscitator calculates the heart rate, performs an indirect heart massage, listens to the lungs. If necessary, artificial ventilation of the lungs is prescribed using special mask and a bag until a pink color of the skin appears. If, after this measure of resuscitation, the newborn does not begin to breathe on his own, he is subjected to tracheal intubation. The methods of resuscitation of newborns also include the introduction of substances (adrenaline, cocarboxylase), which contribute to the restoration of vascular tone.

If the child does not take an independent breath, resuscitation is completed after 15-20 minutes.

The second stage - neonatal intensive care unit

If the initial measures ended in the establishment of respiratory and heart functions, the child is transferred to the intensive care unit and intensive care newborns. There, all the actions of doctors will be aimed at preventing or eliminating cerebral edema, restoring blood circulation, and kidney function. The baby is given the so-called hypothermia - local cooling of the baby's head. In addition, a newborn child 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 controlled: 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 bowel function are monitored. Feeding a child is possible no earlier than 12 hours after birth with expressed milk through a bottle or tube, depending on the severity of the lesion.

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

Prediction of the probability of having a child in asphyxia or drug-induced depression is based on the analysis of antenatal and intranatal history.

Risk factors

Antenatal risk factors include maternal conditions such as diabetes mellitus, hypertension, infections, and maternal drug and alcohol use. Of the pathology of pregnancy, it should be noted a lot - or oligohydramnios, overdose, delay prenatal development fetus and presence multiple pregnancy.

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

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

  • spontaneous breathing,
  • heartbeat,
  • cord pulsations,
  • voluntary muscle movements.

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

Resuscitation algorithm

The resuscitation care algorithm is determined by three main features:

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

The Apgar score is made, 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.

Primary care for newborns in the maternity hospital

Initial activities(duration 20-40 s).

In the absence of risk factors and light amniotic fluid, the umbilical cord is cut immediately after birth, the child is wiped dry with a warm diaper and placed under a source of radiant heat. If there is a large amount of mucus in the upper respiratory tract, then it is suctioned out of oral cavity and nasal passages using a balloon or catheter connected to an electric suction. 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 the state and action:

A. Breathing.

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

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

Independent regular - to assess the heart rate (HR).

B. Heart rate.

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

B. Skin color.

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

Cyanotic - carry out inhalation of 100% oxygen through a face mask until cyanosis disappears.

Technics artificial ventilation lungs

Artificial ventilation of the lungs 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. A roller is placed under the shoulders of the child and the head is slightly thrown back. The mask is applied to the face so that it lies on the bridge of the nose with the upper part of the obturator, and on the chin with the lower part. When pressing on the bag, the excursion should be clearly visible. chest.

Indications for the use of an oral airway for mask ventilation are: bilateral choanal atresia, Pierre-Robin syndrome and the inability to ensure free airway patency with correct styling child.

Tracheal intubation and switching to mechanical ventilation through an endotracheal tube is indicated for suspected diaphragmatic hernia, ineffective mask ventilation for 1 minute, and also for apnea or inadequate breathing in a child with gestational age less than 28 weeks.

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

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

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 - continue mechanical ventilation, start chest compressions.

Chest Compression Technique

The child is placed on a hard surface. Two fingers (middle and index) of one hand or two thumbs of both hands produce pressure on the border of the lower and middle thirds 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 heart massage do not synchronize, i.e. each manipulation is carried out in its own rhythm.

30 seconds after the start of a closed heart massage, the heart rate is again controlled.

If the heart rate is above 80 beats per minute - stop the heart 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 start drug therapy.

Medical therapy

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

Every 30 seconds, the heart rate is re-controlled.

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

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

Repeat the administration of epinephrine in 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, a weak threadlike pulse, low blood pressure, then the child is shown the introduction of a 5% albumin solution or saline at a dose of 10-15 ml / kg of body weight. Solutions are administered intravenously over 5-10 minutes. If signs of hypovolemia persist, repeated administration of these solutions at the same dose is acceptable.

The introduction of sodium bicarbonate is indicated for confirmed decompensated metabolic acidosis (pH 7.0; BE -12), as well as in the absence of the effect of mechanical ventilation, heart massage and drug therapy (suggested severe acidosis that prevents the restoration of cardiac activity). A solution of sodium bicarbonate (4%) is injected into the vein of the umbilical cord at the rate of 4 ml/kg of body weight (2 meq/kg). The rate of drug administration is 1 meq/kg/min.

If within 20 minutes after birth, despite the full resuscitation measures, the child does not recover cardiac activity (there are no heartbeats), resuscitation in the delivery room is stopped.

With a positive effect from resuscitation, the child should be transferred to the intensive care unit (ward), where specialized treatment will be continued.

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 the heart and breathing, although quickly, but not instantly. Most of all suffer from the cessation of oxygen supply to the cells of the brain, especially its cortex, that is, the department on the functioning of which consciousness, spiritual life, and the activity of a person as a person depend.

If oxygen does not enter the cells of the cerebral cortex within 4-5 minutes, then 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, then the vital activity of these cells will resume. However, this will be only the biological existence of the organism, while consciousness, mental activity will either not be restored at all, or 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, prevent death and revive the body. Knowing how to do this is everyone's duty. Inactivity in anticipation medical workers, whatever it is motivated by - confusion, fear, inability - should be considered as a failure to fulfill a moral and civic duty in relation to a dying person. If it concerns your beloved crumbs, it is simply necessary to know the basics of resuscitation care!

Resuscitation of a newborn

How is it carried out primary resuscitation children?

Cardiopulmonary and cerebral resuscitation (LCCR) is a set of measures aimed at restoring the basic vital functions of the body (heart and respiration) impaired in terminal conditions in order to prevent brain death. Such resuscitation is aimed at reviving a person after stopping breathing.

The leading causes of terminal conditions that developed outside of medical institutions in childhood are the syndrome sudden death newborns, car accident, drowning, upper airway obstruction. Maximum number deaths children are under the age of 2 years.

Periods of cardiopulmonary and cerebral resuscitation:

  • Period of elementary life support. In our country it is called the immediate stage;
  • Life support period. It is often labeled as a specialized stage;
  • The period of prolonged and prolonged life support, or post-resuscitation.

At the stage of elementary life support, techniques are performed to replace ("prosthetics") the vital functions of the body - the heart and respiration. At the same time, the events and their sequence are conventionally denoted 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 heart massage.

Transportation of victims

Functionally justified for the transportation of children is:

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

Profound changes occur in the cardiovascular and respiratory systems at birth. Violation of these changes can lead to death or damage to the CNS. Accordingly, at all births, a doctor who knows how to resuscitate newborns should be present. Wasting time looking for someone who can resuscitate a newborn can be disastrous for the baby. This article discusses the causes and consequences of cardiorespiratory failure at birth and methods of resuscitation. Where possible, the recommendations of the American Academy of Pediatrics were followed.

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

Newborn resuscitation requires training and practical experience. Unfortunately, there is little opportunity for most anesthesiologists to acquire and maintain neonatal resuscitation skills as few of their patients require resuscitation. Simulators can solve this problem. In the near future, neonatal resuscitators will need to train on a simulator and repeat this training several times a year to maintain certification.

Detecting potential problems and preparing to address them before birth increases the likelihood of successful resuscitation of patients. Fetal heart rate monitoring is a very reliable and widely used method for the early detection of serious fetal problems. Analysis of blood gases and fetal pH can be used to detect hypoxia and decide on the need for urgent premature removal of the fetus.

Asphyxia (ie, decreased PaO 2 and pHa and increased PaCO 2 ) occurs when gas exchange between the placenta (fetus) and lungs (newborn) is inadequate or when there is right-to-left shunting of blood to the heart or lungs after birth. It also occurs in myocardial dysfunction.

With fetal asphyxia, PaO 2 decreases from the normal 25-40 mm Hg. Art. to less than 5 mm Hg. Art. for about 2 minutes, followed by anaerobic metabolism. After five minutes of asphyxia, the pH drops to 6.90 or less, PaCO 2 increases to more than 100 mm Hg, and PaO 2 decreases to a level at which it is not detectable. Blood flow to the liver, kidneys, intestines, skin, and muscles decreases, while blood flow to the heart, brain, adrenal glands, and placenta remains unchanged or increases. The consumption of oxygen from the blood is greatly increased. Myocardial function is maintained by myocardial glycogen and lactic acid metabolism. Heart rate 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, properly performed, 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 score predicts neurological outcome, but not always. To obtain overall score, each parameter must be evaluated at 1 and 5 minutes. However, neonates with severe acidosis may have relatively normal performance according to Apgar at 1 and 5 minutes due to peripheral vasoconstriction, which is manifested by pallor of the skin with a normal heart rate and blood pressure.

heart rate

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

Breath

Respiration 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 to develop and maintain FRC. Apnea and bradypnea prolong expiration, decrease FRC, and cause hypoxia. Apnea and bradypnea can be caused by severe acidosis, asphyxia, maternal drugs, infections, and CNS damage. Tachypnea (>60 breaths/min) occurs due to:

    hypoxemia;

    hypovolemia;

    metabolic and respiratory acidosis;

    hemorrhage of the central nervous system;

    air leakage syndrome;

    lung 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 be detrimental. 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. The supply of oxygen in excess of that in room air increases the likelihood of an inflammatory reaction. When 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. Postponed asphyxia, CNS damage, congenital amyotonia and myasthenia gravis, as well as the appointment of maternal drugs can contribute to a decrease in muscle tone in the newborn. Flexion contractures and lack of skin folds in the area of ​​​​the joints are signs of intrauterine damage to the central nervous system.

reflex activity

Newborn baby in normal condition reacts motor activity in response to stimulation, and when the catheter is inserted into the nasal passage, he cries or shows a grimace of crying on his face. The newborn may not move if transferred hypoxia and acidosis, as well as in the presence of CNS damage, congenital muscular diseases and when prescribing sedatives to the mother.

Color of the skin

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

Pale skin at birth is often observed in children in the case of asphyxia, hypovolemia, acidosis, or in the presence of a congenital malformation of the cardiovascular system. If a newborn pale color skin persists for more than 2 minutes, it should be suspected of alcohol intoxication, hypermagnesemia or alkalosis (pH> 7.50). Rubeosis of the skin is observed with 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 the drainage of lung fluid and prevent aspiration of gastric contents. In the absence of asphyxia, it is necessary to maintain the body temperature of the newborn at the level of 36-37°C. To do this, use an infrared heater with servo control. In the case of asphyxia, to ensure the protection of the brain, the child's body temperature must be reduced to 34-35 ° C. The resuscitation area should be equipped with a suction device with adjustable suction pressure; it is unacceptable to use pressure less than - 100 mm Hg. Art.

Tracheal intubation requires straight laryngoscope blades in sizes 00 and 0; pencil type laryngoscope; endotracheal tubes with an internal diameter of 2.5, 3.0 and 3.5 mm; suction catheters of the appropriate diameter.

The ventilator must be able to ventilate the lungs at a rate of up to 150 breaths/min and maintain PEEP. It is necessary to remember about potential"Sticking" of the valves of the breathing circuit, especially when performing ventilation with high frequency and high gas flow. If the specialist has the appropriate training, modified Jackon-Rice or Eyre circuits can be used for ventilation. Overinflation of the lungs during ventilation with a large tidal volume causes lung damage and activation of the systemic inflammatory response, which can lead to the development of chronic lung disease. Careful ventilation of the lungs has less damaging effect. When performing assisted or controlled ventilation in a delivery room environment, peak inspiratory pressure should be constantly monitored and overpressure and high tidal volume ventilation should be avoided.

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

Arterial blood saturation (SaO 2 ) 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, SaO 2 is 87-95%, which corresponds to a PaO 2 of 55-70 mm Hg. Art.

Pulmonary resuscitation

If the heart rate is less than 80 beats/min and SaO 2 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 each fifth breath should be 2 s. This increase in inspiratory time allows the atelectatic lungs to open and the lung fluid to be removed. PEEP is maintained at 3-5 cm H 2 O. Excessive peak inspiratory pressure should be avoided. In an experiment on preterm lambs, it has been shown that delivering just six overpressure rescue breaths significantly increases lung tissue damage and interferes with surfactant response. Excess tidal volume is also associated with inflammation and chronic lung disease. Airway pressure detection helps prevent overpressure and tidal volume ventilation.

Tracheal intubation

During mask ventilation and tracheal intubation, the child's head should be in the "sniffing" position. After visualization of 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. This usually corresponds to a depth of 7, 8, 9, 10 cm from the anterior edge of the gums in a newborn weighing 1, 2, 3 and 4 kg, respectively. When ventilating with a peak pressure of 15-25 cm H 2 O, a small air leak should be heard on auscultation at the child's mouth. This is usually observed when using tubes with an internal diameter of 2.5 mm in children weighing less than 1.5 kg, tubes with a diameter of 3.0 mm in children weighing 1.5-2.5 kg and tubes with a diameter of 3, 5 mm in children weighing more than 2.5 kg. Confirmation of successful tracheal intubation is the visualization of the passage of the endotracheal tube behind the vocal cords, the movement of both halves of the chest with each artificial breath, the appearance of perspiration on inner surface tube during each exhalation. Breath sounds should be louder on lung auscultation than on abdominal auscultation. Once positive pressure ventilation is initiated, skin color should improve, as should heart rate and SaO. At the time of exhalation, carbon dioxide should be determined (capnometry).

However, the small tidal volume and low pulmonary blood flow that some infants experience at birth can make it difficult to effective use capnography.

Adequate ventilation

During inspiration, both halves of the chest should move simultaneously and symmetrically, however, the expansion of the chest during artificial ventilation should not exceed the excursion during normal spontaneous breathing of the newborn. Breath sounds on auscultation are not reliable sign adequacy of ventilation, due to the possibility of conducting breath sounds from another lung in newborns with a small chest. Asymmetric breath sounds on bilateral lung auscultation may indicate endobronchial intubation, pneumothorax, atelectasis, or a congenital lung anomaly. The presence of loud breath sounds on auscultation in the epigastric region suggests esophageal intubation or tracheoesophageal fistula. In the case of adequate ventilation, the child turns pink, spontaneous breathing appears and the heart rate normalizes.

Because most suffocated neonates do not have lung disease, they can be effectively ventilated with a peak pressure of less than 25 mmHg. Art., including at the first breaths. Neonates with "tough" lungs (eg, fetal erythroblastosis, congenital pulmonary anomalies, pulmonary edema, severe meconium aspiration, diaphragmatic hernia) may require high peak inspiratory pressure ventilation, which increases the likelihood of air leak syndrome. It can be prevented by ventilating at a peak pressure of 15-20 cm H 2 O and a rate of 150-200 breaths/min. If low pressure (low volume) and high frequency ventilation does not improve oxygenation, ventilation with high pressure and high tidal volume. Ineffective ventilation at birth can exacerbate hypoxemia and lead to CNS damage and even death. With an increase in PaO 2 more than 70-80 mm Hg. Art. or SaO 2 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 SaO 2 and PaO 2 will be maintained at normal age level. In children 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 newborn in a state of hypoxia, there is a risk of arrhythmias, and therefore, the heart rate should be constantly monitored.

Routine tracheal sanitation

In the presence of 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 contents of the trachea. The description of the meconium aspirator is widely presented in the literature.

Meconium particulates must be removed from the lungs prior to ventilation. The mouth and throat must be sanitized immediately after the birth of the baby's head. After tracheal intubation, the endotracheal tube is connected to a special suction device and removed from the trachea at the time of aspiration. The laryngoscope is not removed. After aspiration of meconium, an endotracheal tube is inserted into the trachea, after which a second aspiration is performed. Then careful ventilation of the lungs is carried out. At the time of laryngoscopy and aspiration, it is necessary to constantly monitor heartbeat and insufflate 100% oxygen near the face of the newborn. 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 suctioning. Removal of liquid meconium from the trachea of ​​a newborn at the time of birth has no positive effect, while the removal of dense 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 mechanical ventilation in the delivery room. In the presence of unilateral pneumothorax, one half of the chest is overinflated and its respiratory excursion is limited. The heart beat is shifted to healthy side. Heart sounds may be muffled.

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

Prescribing a surfactant

Administration of a surfactant resulted in a significant reduction in the incidence of air leak syndrome, including interstitial emphysema, as well as 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 introduction of a surfactant is accompanied by a short episode of desaturation. In most cases, SaO 2 rises rapidly in the future due to an increase in pulmonary compliance, which, in turn, can lead to hyperinflation of the lungs with subsequent damage to the lung tissue or the occurrence of an air leak syndrome, if a timely decrease in inspiratory pressure is not made.

Premature babies often require nasal CPAP after birth to reduce the chance of tracheal intubation and mechanical ventilation. However, this does not reduce the incidence of CNS hemorrhage and chronic lung disease. The duration of oxygen dependence and chronic lung disease does not change.

Vascular resuscitation

Vascular resuscitation is not a major aspect of neonatal resuscitation. If the condition of the newborn does not improve with ventilation, oxygenation (if necessary) and tactile stimulation, it is necessary to catheterize the umbilical artery in order to take blood for the study of the gas composition and pH level, and also for the purpose of carrying out infusion therapy if necessary.

Acidosis correction

Correction of respiratory acidosis is carried out with the help of artificial lung ventilation. To correct metabolic acidosis, sodium bicarbonate solution is introduced. Its osmolarity is 1800 mosmol/l, so rapid administration of this solution (>1 mmol/kg/min) in preterm infants may 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 PaCO 2 ; with inadequate ventilation, a significant increase in PaCO 2 occurs, which can cause cardiac arrest and / or intracranial hemorrhage. Therefore, sodium bicarbonate solution should only be given to newborns with metabolic acidosis, provided there is adequate pulmonary ventilation. In hypovolaemic neonates, administration of sodium bicarbonate may cause hypotension by reversing the peripheral vasoconstriction caused by acidosis. Trisamine (THAM) is an alternative drug. Its appointment leads to a decrease in the level of PaCO.

If, despite tactile stimulation and ventilation, the Apgar score is 2 or less at 2 minutes or 5 or less at 5 minutes, administration of sodium bicarbonate at a dose of 2 mmol / kg may be required against the background of ongoing ventilation. If the pH is less than 7.0, PaCO 2 is less than 35 mm Hg. Art., and at the same time 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 of the lungs and correct one-fourth of the deficiency of buffer bases by administering sodium bicarbonate or trisamine. No significant increase in PaO 2 was observed until the pH increased from 7.1 to 7.2, when Rudolph and Yuen found the most significant decrease in PVR.

Typically, metabolic acidosis develops as a result of reduced tissue perfusion as a consequence of hypovolemia or heart failure. Acidosis-induced heart failure usually occurs when the pH drops below. With an increase in pH over 7.15, cardiac output improves. In heart failure against the background of congenital bradycardia, isoproterenol is prescribed (at an initial dose of 0.05 μg / kg / min, with a further increase if necessary) or a transvenous pacemaker is installed. Hypoglycemia may be the cause of heart failure. Therefore, during resuscitation of a newborn, it is necessary to control the level of glucose in the blood.

Expansion of intravascular volume

If the umbilical cord is clamped early, or if the umbilical cord is tightly wrapped around the fetal neck, when the umbilical cord must be cut for the baby to be born, the baby may become hypovolemic. It is also observed with asphyxia in childbirth, abruption and placenta previa.

Diagnosis of hypovolemia

Hypovolemia is determined by measuring blood pressure and physical examination (i.e., 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 H 2 O. If the CVP is less than 2 cm H 2 O, hypovolemia should be suspected.

Therapy for hypovolemia

To treat hypovolemia, it is required to replenish the intravascular volume with blood and crystalloids. Albumin can also be used, but the evidence for its effectiveness is limited. If a newborn is suspected to 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, it takes huge quantities blood and solutions. At times, more than 50% of the blood volume needs to be replaced (85 ml/kg in term newborns and 100 ml/kg in preterm infants), especially if placental abruption or trauma occurs during childbirth. In most cases, up to 10-20 ml / kg of solutions are required to restore the mean arterial pressure to normal.

Excessive intravascular volume expansion should be avoided because sudden systemic hypertension can rupture brain vessels, leading to intracranial hemorrhage, especially in preterm infants.

Other causes of hypotension

Hypoglycemia, hypocalcemia, and hypermagnesemia cause hypotension in neonates. Hypotension caused by alcohol or magnesium intoxication usually responds well to volume replacement or dopamine, or both. Neonatal hypermagnesaemia is usually treated with 100–200 mg/kg of calcium gluconate given over 5 minutes.

Heart massage

If, despite stimulation and ventilation, the heart rate at the 1st minute of life or earlier is less than 80 beats / min, it is necessary to intubate the trachea, carry out mechanical ventilation with oxygen and start a closed heart massage. Place both thumbs on the sternum, support the back of the child with the rest of your fingers. Squeeze the sternum 2-2.5 cm at a frequency of 100-120 per minute. There is no need to interrupt ventilation during cardiac massage. The effectiveness of heart massage is assessed by measuring blood gases and pH generated blood pressure and examination of the pupils, which should be in the middle position or constricted. If the pupils are dilated and atropine was not used, then this means that cerebral blood flow and oxygenation are inadequate.

Preparations for resuscitation

In severe acidosis (pH< 7,0) эффективность этих лекарств уменьшается. Т.е. необходимо как можно быстрее поднять рН выше. Все препараты необходимо вводить в минимальном объеме растворителя, чтобы снизить риск возникновения гиперволемии.

When to stop resuscitation

The decision to stop resuscitation is usually based on the experience of the doctor, the condition of the patient, and the wishes of the parents. If the chances of being productive, successful life are very low, consideration should be given to stopping all revitalization efforts. Is it possible to resuscitate deeply preterm infants? big question, since the outcomes of nursing newborns born before the 26th week of gestation are very deplorable. If possible, the situation should be discussed frankly with the family before the baby is born. If this is not done, then you need to start resuscitation and stop it after talking with the parents.

“Little clumps, some the size of a palm, vulnerable to infections and complications, but extraordinarily resilient, ready to fight for their lives from the first second of their birth. The other day we visited the intensive care unit for premature babies and want to tell you how this unit works,” writes Stanislav Dvoeglazova.

(Total 20 photos)

1. The department receives the heaviest children from all maternity hospitals in Moscow. Transportation of these children is carried out by a mobile resuscitation neonatal team.

From maternity hospital a call comes in, and a team consisting of a doctor and a paramedic leaves the place and brings the child to the intensive care unit. Here the children lie until their condition stabilizes.

Children are on mechanical ventilation, as their lungs are not fully expanded, and also when there is a manifestation of severe respiratory failure. Restoration of respiratory function occurs just in this department.

2. For Lately medicine has made serious progress in the treatment of respiratory failure, a lot of new equipment has appeared, and for children, especially premature babies with extremely low body weight, doctors are trying to carry out non-invasive artificial ventilation of the lungs, that is, without intubation (without inserting a tube into the larynx) of the child. Doctors use a technique called "nasal sipap" that creates the same pressure in the lungs as when intubating the trachea during complete mechanical ventilation.

Specialization of this resuscitation - premature babies, since the entire children's corps is designed for nursing exactly them, but full-term children with birth trauma who swallowed water during childbirth or those who have a convulsive syndrome.

There are several similar departments of the second stage in Moscow: the department at the 7th (from where, in fact, we are reporting), the 13th, at Filatovskaya, at the 70th and 8th City Clinical Hospital.

3. On the basis of the 7th City Clinical Hospital there is a single dispatch center where calls are received from all maternity hospitals in Moscow, and then the dispatcher directs the children to the intensive care unit of a particular hospital, depending on the distance from the maternity hospital and the workload of beds.

4. In total, 3 reanimobiles are on duty in Moscow, two of them are attached to the 7th city hospital and one to the 8th.

5. modern medicine allows you to nurse children weighing 500 grams, from the 22nd week of gestation. The size of such a child is approximately 32-33 centimeters from the top of the head to the heels.

6. When parents ask what are the chances of their child surviving, doctors say that it is 50/50, but in fact, thanks to the good equipment and qualifications of doctors, the mortality rate this year was 0.3 percent. When it comes to life, words like "just something" are completely inappropriate. You need to understand that doctors here are fighting for every child, for every day of his life, for every gram of his weight.

7. On average, 1100-1200 children enter this department per year, this is 2-3, maximum 4 children per day. They are in intensive care from 5 to 30 days, but if we are talking about very small children, then they can stay in the department for up to 3 months. The cost of nursing such a child can reach half a million rubles. But this does not mean at all that parents need to be millionaires in order to pay for treatment. Everything is provided within the framework of state guarantees under the policy of mandatory health insurance, which is available to all citizens of the Russian Federation.

8. As far as I know, the other day the Moscow City Compulsory Medical Insurance Fund announced an increase in expenses for the provision of a number of types of medical care, including the direction of nursing children, in particular, 122,000 hospitals will receive 122,000 instead of the 61,000 due today for nursing newborns with congenital anomalies of digestion. Previously, not all tariffs covered the cost of treatment, especially if children weighing 600-800 grams were nursed, and a child is discharged only when the mother is able to cope with him, that is, the child must be able to breathe on his own, keep warm and suck on a nipple.

And here, if I may, I will deviate a little from the topic and stay a boring teacher, remembering my teaching experience at the university. So, compulsory medical insurance policy- this is not just a piece of paper, but such a thing, according to which every citizen of the Russian Federation is entitled to free health care in the compulsory health insurance system. At the same time, it doesn’t matter at all that you received the policy in Uryupinsk, for example, you were registered in Vladivostok at all, and you or your child needed medical care in Moscow. So, if suddenly they refused to provide you with this very medical assistance, arguing that you are not a resident of the capital, or even demanded money for treatment, then do this: 1. Write an application addressed to the head physician of the medical institution, where you state the situation, and 2. send the same letter of happiness to the insurance company that issued your policy, as well as to the Compulsory Medical Insurance Fund, and, believe me, you will be happy, and those who tried to refuse treatment or demanded money - atata in the soft spot.

9. Let's go back to the department.

All children in the department lie in special cuveuses, in which a certain temperature and humidity are maintained.

10. All flasks are covered with blankets. This is not done for aesthetics, but due to the fact that the eyes of premature babies react painfully to daylight, and in order not to irritate them and aggravate the development of retinopathy, incubators are covered all over the world.

11. Monitors with sensors are connected to each child, and if the parameters go beyond the norm, then an alarm is given, which is also duplicated on the monitor, which is located at the nurse's station.

Alla Lazarevna - neonatologist, head perinatal center GBUZ "City Clinical Hospital No. 7 DZM", proudly told us that the department, which is in her department, is better than those that she saw in foreign clinics, where she and her employees went to exchange experience. Yes, the incubators there are exactly the same, of the same manufacturers and modifications, but they have more crowding of children in boxing, which does not correspond to Russian SanPins. In our country, children are placed in one box from one maternity hospital, and in another box - from another, so as not to mix the flora of maternity hospitals. They do it all at the same time.

12. Parents come to the intensive care unit every day, and they are given information about the child's condition, they can also go to the intensive care unit and sit next to the child. If the child is on independent breathing, then mothers are allowed into the department, they express milk and begin to feed their children with this milk.

13. Two laboratories for express diagnostics work around the clock in the department. One of the main tests is the determination of the acid-base state of children, blood gases are taken for analysis every four hours in all children who are on artificial lung ventilation, to determine the correctness of the selected parameters.

14. Biochemical analysis blood is done in another laboratory, it is located on the third floor of the department.

15. If there is a need to take an x-ray, then the child is not taken anywhere, the radiologist is called, and he carries the x-ray machine to the incubator. Everything is close to the child. Resuscitation children cannot be moved anywhere else, all assistance is provided on the spot.

16. If you need to put a catheter or intubate, then the child is transferred from the incubator to a special heated table. It is properly called "Open Resuscitation System".

19. Reminders of this hang in front of every door.

20. After discharge, children under three years of age are observed not only in polyclinics at the place of residence, but also in the polyclinic at the department.

And finally, I would like to express my deep gratitude personally to Erlikh Alla Lazarevna and her staff for doing such a great and bright work, as well as for the tour.

Special thanks to my beloved husband for the photos 🙂