Neonatal Resus Tips with Drs Mel Thompson and Liz Bannister
August 1, 2013
Welcome back – it has been a busy week on the job, so not much new stuff.
Today I am putting out a podcast I recorded with a few of our local travelling PAediatricians – Dr Mel Thompson – who has previously delivered a couple of “lessons hard learned” and her mate Dr Liz Bannister.
We discuss all things to do with the practical resuscitation of neonates. Not the super-sick and crashing ones – but those in the middle, where decision -making can be tougher at times, trying to balance “normal” birth with a need to be safe.
Enjoy here, or DIRECT DOWNLOAD
Great podcast, thanks team!
A couple of questions:
– Re: The initial neopuff pressure setting for IPPV. Both Liz and Mel are saying 25 cm H20. I was always taught (and the KEMH protocol) says 30 cm H20 for term babies. Is it really risky for barotrauma at 30 cm? Should I be changing my practice?
– What do you do if you do inadvertently cause laryngospasm? How long does it take to resolve?
*touch wood* all my babies have come good themselves after a few minutes of panic on my behalf. Hopefully I never have to deal with a laryngospasm or pneumothorax or persistent apnoea.
You are correct, the Aust Resus Council (and King Edwards in Perth) do recommend 30cm H20 for term babies. I suspect Liz & I are showing our shared training background (non-WA), however generally 25cm is sufficient unless there is real difficulty ventilating, in which case I would wind up the PIP anyway. Even with babies requiring ongoing ventilation, such high pressures are not usually required, and the kids that need it are already at high risk of barotrauma due to underlying poor lung compliance anyway. As for the exact difference in risk between 25 & 30cm H20, and the evidence behind the recommendation of 30, I’ll have to get back to you.
As for laryngospasm, usually removal of the stimulus, continuing IPPV and waiting will work. The neonate has a pronounced laryngeal chemoreflex, in which laryngeal irritation (esp by fluid / mucus) triggers apnoea & bradycardia as well as spasm. Therefore avoiding unnecessary airway stimulation is critical, e.g. not suctioning for mec in a child who has already started breathing.
Consider winding up the oxygen, but turn it back down once airway & oxygenation re-established. This may also useful to break spasm: http://anaestricks.tumblr.com/post/17163403783/simple-device-for-spraying-vocal-cords-all-you – I have seen this done in older kids but not tried it for neonatal laryngospasm. Given you are unlikely to have an IV, there are not lots of other options. Pushing a tube through is risky via potentially prolonging the spasm or damaging the cords (which, of course, is a secondary issue).
I would be holding my own breath so I know that it’s not really going on for the three hours it feels like! Thankfully, this is a rare situation.
Casey, want to weigh in from an anaesthetics point of view? In the meantime, I’ll endeavour to ask a full time neonatologist if they have any other tricks up their sleeves…