Reanimación Neonatal: Principios y Diagrama de Flujo
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La lección introduce los principios y procedimientos básicos de la reanimación neonatal, incluyendo los cambios fisiológicos que ocurren durante la transición al nacimiento, los posibles problemas que pueden surgir, y los pasos a seguir según la evaluación del recién nacido. Explica el diagrama de flujo de la reanimación que evalúa la respiración, frecuencia cardíaca y coloración del bebé, proporcionando ventilación, masaje cardíaco u otros tratamientos según sea necesario. Finalmente, enfatiza la importancia
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Reanimación Neonatal: Principios y Diagrama de Flujo
- 1. Lección 1: PANORAMA GENERAL Y PRINCIPIOS DE LA REANIMACIÓN
- 2. Panorama y Principios de la Reanimación Contenido de la Lección: • • • • Cambios fisiológicos al nacimiento Diagrama de flujo de la Reanimación Factores de riesgo de la Reanimación Equipo y personal necesarios 1-2
- 3. ¿Qué Bebés Requieren Reanimación? • La mayoría de los neonatos nacen vigorosos • Solamente el 10% de los recién nacidos requieren alguna asistencia • Solo el 1% necesitan medidas mayores de reanimación (intubación, compresiones torácicas, y/o medicamentos) para sobrevivir 1-3
- 4. Fisiología Fetal En el feto: • Los alvéolos están llenos de líquido pulmonar • In útero, el feto es dependiente de la placenta para el intercambio gaseoso 1-4
- 5. Fisiología Fetal En el feto: • Las arteriolas pulmonares están contraídas. • El flujo pulmonar disminuido. • El flujo sanguíneo se divide y pasa una parte a través del conducto arterioso. Click on the image to play video 1-5
- 6. Pulmones y Circulación Después del Nacimiento • Los pulmones se expanden con aire • El líquido pulmonar se elimina. Click on the image to play video 1-6
- 7. Pulmones y Circulación • Las arteriolas pulmonares se dilatan • El flujo sanguíneo pulmonar se incrementa 1-7
- 8. Pulmones y Circulación • Los niveles de oxígeno en sangre se elevan • El conducto arterioso se contrae • La sangre fluye a través de los pulmones para captar oxígeno Click on the image to play video 1-8
- 9. Transición Normal Los siguientes cambios importantes ocurren en segundos después del nacimiento: • El líquido en los alvéolos es absorvido • Las arterias umbilicales y la vena se contraen provocando aumento de la presión sanguínea. • Los vasos pulmonares se relajan 1-9
- 10. Que Puede Ir Mal Durante La Transición • La falta de ventilación de los pulmones del neonato provoca constricción sostenida de las arteriolas pulmonares, evitando así que la sangre arterial sistémica se oxigene • La falla prolongada de una perfusión y oxigenación adecuadas a los órganos del bebé puede resultar en daño cerebral, daño a otros órganos o muerte 1-10
- 11. Signos de Compromiso del Recién Nacido • Pobre tono muscular • Depresión respiratoria • Bradicardia • Presión sanguínea baja • Taquipnea • Cianosis Buen tono con cianosis Mal tono con cianosis 1-11
- 12. Compromiso In Útero o Perinatal Apnea Primaria • Cuando un feto ó neonato es deprivado de oxígeno, se origina un período inicial de intentos de respiración rápida, que es seguido de aparición de apnea primaria y de caída de la frecuencia cardíaca que puede mejorar con estimulación táctil 1-12
- 13. Apnea Secundaria • Si la deprivación de oxígeno continúa, aparece una Apnea Secundaria, acompañada de una caída continua de la frecuencia cardíaca y de la presión sanguínea. • La Apnea Secundaria no puede ser revertida mediante estimulación; debe iniciarse ventilación asistida QuickTime™ and a Sorenson Video 3 decompres sor are needed to see this picture. Click on the image to play video 1-13
- 14. Reanimación de un Neonato con Apnea Secundaria El inicio de presión positiva efectiva durante la apnea secundaria generalmente resulta en • Mejoría rápida de la frecuencia cardíaca 1-14
- 15. Evaluación del Reanimador Todos los recién nacidos requieren de una valoración inicial para determinar que reanimación van a necesitar 1-15
- 16. Pasos Iniciales (Bloque A) • Provea calor • Posicione la cabeza y limpie las vías aéreas* • Seque y estimule al bebé para que respire Nacimiento • Embarazo de término? • Líq. Amniótico claro? • Respira o llora? • Buen tono muscular? Evaluación • Provea calor • Posicione la cabeza y las vías aéreas • Seque, estimule, reposicione *Considere intubación de la traquea en este punto (para neonatos deprimidos con líquido amniótico meconial) 1-16
- 17. Evaluación Después de los pasos iniciales, las acciones posteriores están basadas en la evaluación de • • • Respiraciones Frecuencia cardíaca Coloración • Evalúe respiración, frecuencia cardíaca y coloración Tienes aproximadamente 30 segundos para obtener respuesta de un paso antes de decidir ir al siguiente 1-17
- 18. Respiración (Bloque B) Si está apnéico o la FC es < 100 lpm: • Provea ventilación con presión positiva* • Si esta respirando y la FC es >100 lpm pero el bebé está cianótico, ofrezca oxígeno suplementario. Si la cianosis persiste, administre ventilación con PPI Evalúe respiración, frecuencia cardíaca y coloración Respira, FC >100 pero cianótico Apnea ó FC < 100 • Provea oxígeno suplementario Cianosis persistente Suministre Ventilación con Presión Positiva *La intubación endotraqueal debe ser considerada en varios pasos 1-18
- 19. Circulación (Bloque C) Si la frecuencia cardíaca es <60 lpm a pesar de una adecuada ventilación por 30 segundos, • Dé masaje cardíaco mientras continúa la ventilación con PPI* • Después evalúe nuevamente. Si la FC es <60 lpm, proceda con el Bloque D •Provea Ventilación con Presión Positiva* •Administre Masaje Cardíaco* *Considere la intubación de la tráquea en este punto 1-19
- 20. Medicamentos (Bloque D) Si la frecuencia cardíaca es <60 lpm a pesar de una adecuada ventilación y masaje cardíaco • Administre adrenalina mientras continúa con ventilación asistida y compresiones torácicas* 30 seg • Provea Ventilación con Presión Positiva* • Administre Masaje Cardíaco* FC <60 Evaluación • Administre Adrenalina* *Considere la intubación de la tráquea en este punto 1-20
- 21. Puntos Importantes en el Diagrama de Flujo de la Reanimación Neonatal • La acción más importante y efectiva en la reanimación neonatal es ventilar los pulmones del bebé • La ventilación con presión positiva efectiva en la apnea secundaria generalmente da como resultado una rápida mejoría de la frecuencia cardíaca • Si la frecuencia cardíaca no se incrementa, puede suceder que la ventilación es inadecuada y/o el masaje cardíaco o que sea necesario administrar adrenalina 1-21
- 22. Puntos Importantes en el Diagrama de Flujo de la Reanimación Neonatal • • • FC <60 lpm → Se requieren pasos adicionales FC >60 lpm → El masaje cardíaco puede detenerse FC >100 lpm y respiración espontánea → la ventilación con PPI puede suspenderse • Asterisco (*): la intubación endotraqueal debe ser considerada en varios pasos • Límite de Tiempo: si no hay mejoría en 30 segundos pase al siguiente paso 1-22
- 23. Preparación para Reanimación: Personal y Equipo • Cada nacimiento debe ser atendido cuando menos por una persona cuya única responsabilidad es el bebé y que sea capaz de iniciar la reanimación. Esa persona o alguien más qué esté disponible inmediatamente deben tener las destrezas necesarias para llevar a cabo una reanimación completa • Cuando de prevé que se requerirá una reanimación, debe estar presente personal adicional antes de que ocurra el nacimiento • Prepare el equipo necesario – Encienda el calentador radiante – Cheque el equipo de reanimación 1-23
- 24. Preparación para la Reanimación: Factores de Riesgo • En la mayoría de los casos, la reanimación neonatal puede ser anticipada si se identifican los factores de riesgo anteparto e intraparto 1-24
- 25. 1-25
- 26. ¿Porqué los Prematuros Tienen un Mayor Riesgo? • • • • • • Posible deficiencia de surfactante Menor control respiratorio Pérdida rápida de calor, pobre control de temperatura Posible infección Susceptible de hemorragia cerebral Susceptible de hipovolemia secundario a pérdida de sangre • Músculos débiles que dificultan una respiración espontánea • Los tejidos inmaduros pueden ser dañados por oxígeno excesivo 1-26
- 27. Tres niveles de Cuidados Post-Reanimación 1-27
- 28. Fin de la Lección 1 1-28
Notas del editor
- In Lesson 1 you will learn the Changes in physiology that occur when a baby is born Sequence of steps to follow during resuscitation Risk factors that can help predict which babies will require resuscitation Equipment and personnel needed to resuscitate a newborn
- Which babies require resuscitation? Most newly born babies are vigorous. About 10% of newborns require some assistance to begin breathing at birth. Only about 1% need extensive resuscitation measures (intubation, chest compressions, and/or medications) to survive. Instructor Tip: Practice resuscitation skills frequently, especially if skills are not used often. This may be done with “mock codes.”
- In the fetus, oxygen is transferred across the placenta, and the lungs contain no air. The alveoli (potential air sacs) of the fetus are filled with fluid that has been produced within the lungs.
- Blood flow through the fetal lung is markedly diminished compared with that required after birth, as the pulmonary arterioles are constricted and blood flow is diverted across the ductus arteriosus.
- At birth, as the newborn takes the first few breaths, several changes occur, whereby the lungs take over the lifelong function of respiration. Following birth, the lungs expand as they are filled with air. The fetal lung fluid gradually leaves the alveoli.
- At the same time as the lungs are expanding and the fetal lung fluid is clearing, the arterioles in the lungs begin to open, allowing a considerable increase in the amount of blood flowing through the lungs.
- As blood levels of oxygen rise, the ductus arteriosus begins to constrict. Blood previously diverted through the ductus arteriosus flows through the lungs, where it picks up oxygen for transport to tissues throughout the body. The ductus remains constricted, and the normal extrauterine circulatory pattern is established.
- Normally, there are 3 major changes that take place within seconds after birth. Alveolar fluid is absorbed into lung tissue and replaced by air. Umbilical arteries and veins are clamped, removing the low resistance placental circuit and increasing systemic blood pressure. Blood vessels in lung tissue relax, increasing pulmonary blood flow.
- A baby may encounter difficulty before labor, during labor, or after birth. Some of the problems that may disrupt normal transition are The baby may not breathe sufficiently to force fluid from the alveoli, or foreign material such as meconium may prevent air from entering the alveoli. Excessive blood loss may occur, or there may be inadequate cardiac contractility or bradycardia from hypoxia and ischemia. Lack of oxygen or ventilation of the newborn’s lungs results in sustained constriction of the pulmonary arterioles, preventing arterial blood from becoming oxygenated. Prolonged lack of adequate perfusion and oxygenation to the baby’s organs can lead to brain damage, damage to other organs, or death.
- The compromised baby may exhibit one or more of the following clinical findings: Poor muscle tone Depression of respiratory drive due to insufficient oxygen reaching the brain Bradycardia Low blood pressure Tachypnea (rapid respirations) Cyanosis (blue color) Other conditions, such as infection, hypoglycemia, or depressant drugs given to the mother before birth, may also cause these symptoms.
- When babies are deprived of oxygen (in utero or after delivery), they undergo a well-defined sequence of events that starts with cessation of respiration. Primary apnea follows the sequence noted on this slide. An important point is that, during primary apnea, the newborn responds to stimulation. Instructor Tip: Initiate resuscitation immediately. Resuscitation may be inappropriately delayed if the health care provider does not recognize the need for neonatal resuscitation. Any delay in transferring a compromised newborn to the resuscitation team is unacceptable practice.
- If oxygen deprivation continues, deep gasping respirations develop, the heart rate continues to decrease, and the blood pressure decreases. An important point is that, during secondary apnea, stimulation will not restart the baby’s breathing. Assisted ventilation must be provided to reverse the process triggered by oxygen deprivation. If a baby doesn’t begin to breathe immediately after being stimulated, he or she is likely in secondary apnea and will require positive-pressure ventilation. Instructor Tip: Quickly achieve and maintain oxygenation in full-term and post-term newborns after perinatal hypoxia-ischemia because they are especially prone to persistent pulmonary hypertension.
- Most babies in secondary apnea will respond to effective ventilation with a rapid improvement in heart rate. The longer a baby has been in secondary apnea, the longer it will take for spontaneous breathing to resume. If heart rate does not improve rapidly with effective ventilation, myocardial function may be compromised and chest compressions and/or medications may be required.
- The flow diagram begins with the birth of the baby. Each resuscitation step is shown in a block. Below each block is a decision point to help decide whether proceeding to the next step is needed. At the time of birth, you should ask yourself 4 questions about the newborn. These questions are shown in the Assessment block. Term gestation? Amniotic fluid clear? Breathing or crying? Good muscle tone? If any answer is “no,” you should continue to the next steps.
- These are the initial steps you take to establish an airway and begin resuscitating a newborn. An asterisk (*) indicates intubation may be considered or required (eg, in a depressed newborn with meconium).
- After initial steps, evaluate the newborn often, about every 30 seconds. If the newborn is not breathing (has apnea) or has a heart rate less than 100 beats per minute (bpm), proceed to Block B. Instructor Tip: Respirations and color are naturally assessed during the initial steps because you are handling the baby and assessing progress through the first moments of transition.
- If the newborn is not breathing adequately (has apnea or is gasping), has a heart rate of <100 beats per minute (bpm), or appears blue (cyanotic), you proceed to block B. If the baby is apneic or has a heart rate of <100 bpm, give positive-pressure ventilation. If the baby is breathing and has a heart rate of >100 bpm but has central cyanosis, you should give supplemental oxygen. If central cyanosis persists after giving oxygen, you should then proceed to positive-pressure ventilation.
- If, after 30 seconds of adequate positive-pressure ventilation, the heart rate is less than 60 bpm, chest compressions and epinephrine may be needed for sufficient cardiac output so that blood can reach the lungs to pick up oxygen. Support circulation by starting chest compressions while continuing ventilation. After 30 seconds of chest compressions, evaluate the newborn again. If the heart rate is still less than 60 beats per minute, proceed to Block D.
- If the heart rate remains less than 60 beats per minute, the actions in Blocks C and D are continued and repeated. This is indicated by the curved arrow.
- Studies have shown that the most important aspect of neonatal resuscitation is effective ventilation. Once effective ventilation is established and the baby does not respond, it can be assumed that blood and tissue oxygen levels have become extremely low and that the baby is in secondary apnea. Chest compressions and epinephrine will be needed for sufficient cardiac output so that blood can reach the lungs to pick up oxygen.
- To follow the resuscitation flow diagram, it is important to remember the following heart rates and time sequences. Instructor Tip: The flow diagram may look complex at first, but the Neonatal Resuscitation Program (NRP) takes you through each step. Practice helps ensure rapid, simultaneous assessment of the newborn and timely interventions.
- Every birth should be attended by at least 1 person whose only responsibility is the baby and who is capable of initiating resuscitation. Either that person or someone else who is immediately available should be able to perform a complete resuscitation. It is not sufficient to have someone “on call” (either at home or in a remote area of the hospital) for neonatal resuscitation in the delivery room. If the delivery is anticipated to be high risk and thus may require more advanced neonatal resuscitation, or if the resuscitation will be of a baby less than approximately 32 weeks’ gestation, additional equipment and personnel are necessary in the delivery room. (See Lesson 8.) All personnel should observe appropriate body fluid precautions during resuscitation as defined by hospital policy. Instructor Tip: You should ask yourself these questions: Is every birth in this setting attended by a person who can initiate resuscitation? What is the protocol for assembling team members for an anticipated high-risk birth? Is equipment set up the same in every room so that no one has to search for items?
- In many cases, delivery of a depressed newborn can be anticipated on the basis of the antepartum and intrapartum history.
- Premature babies have anatomical and physiologic characteristics that are quite different from babies born at term. These and other unique characteristics present special challenges during resuscitation of premature babies. These and other aspects of prematurity should alert you to seek extra help when anticipating a preterm birth. (See Lesson 8.)
- Newborns who have required resuscitation are at risk for deterioration after their vital signs have returned to normal. Following are 3 levels of post-resuscitation care: Routine Care Vigorous newborns with no risk factors and clear amniotic fluid. Instructor Tip: Put a vigorous baby directly on mother’s chest (after checking with the mother that this is okay), dry, and cover with dry linen. Observational Care Newborns who have prenatal or intrapartum risk factors who are still at risk for developing problems associated with perinatal complications and should be evaluated frequently during the immediate postpartum period. Instructor Tip: Initial assessment occurs under the radiant warmer where baby receives the initial steps; transfer to the nursery for monitoring may be necessary. Example: meconium-stained fluid, initial depressed breathing or activity, or cyanosis requiring brief free-flow oxygen. Post-resuscitation Care Babies who require positive-pressure ventilation or more extensive resuscitation and who may require ongoing support should generally be managed in an environment where ongoing evaluation and monitoring are available.
- Newborns who have required resuscitation are at risk for deterioration after their vital signs have returned to normal. Following are 3 levels of post-resuscitation care: Routine Care Vigorous newborns with no risk factors and clear amniotic fluid. Instructor Tip: Put a vigorous baby directly on mother’s chest (after checking with the mother that this is okay), dry, and cover with dry linen. Observational Care Newborns who have prenatal or intrapartum risk factors who are still at risk for developing problems associated with perinatal complications and should be evaluated frequently during the immediate postpartum period. Instructor Tip: Initial assessment occurs under the radiant warmer where baby receives the initial steps; transfer to the nursery for monitoring may be necessary. Example: meconium-stained fluid, initial depressed breathing or activity, or cyanosis requiring brief free-flow oxygen. Post-resuscitation Care Babies who require positive-pressure ventilation or more extensive resuscitation and who may require ongoing support should generally be managed in an environment where ongoing evaluation and monitoring are available.