S544 Circulation November 3, 2015 Anticipation of Resuscitation Need available. Furthermore, because a newborn without apparent risk Readiness for neonatal resuscitation requires assessment of peri- factors may unexpectedly require resuscitation, each institution natal risk, a system to assemble the appropriate personnel based should have a procedure in place for rapidly mobilizing a team on that risk, an organized method for ensuring immediate access with complete newborn resuscitation skills for any birth. to supplies and equipment, and standardization of behavioral The neonatal resuscitation provider and/or team is at a skills that help assure effective teamwork and communication. major disadvantage if supplies are missing or equipment is Every birth should be attended by at least 1 person who can not functioning. A standardized checklist to ensure that all perform the initial steps of newborn resuscitation and PPV, and necessary supplies and equipment are present and functioning whose only responsibility is care of the newborn. In the presence may be helpful. A known perinatal risk factor, such as preterm of significant perinatal risk factors that increase the likelihood of birth, requires preparation of supplies specific to thermoregu- the need for resuscitation,5,6 additional personnel with resuscita- lation and respiratory support for this vulnerable population. tion skills, including chest compressions, endotracheal intuba- When perinatal risk factors are identified, a team should tion, and umbilical vein catheter insertion, should be immediately be mobilized and a team leader identified. As time permits, Physiology of Pregnancy Post-Natal Post-Partum Hemorrhage (PPH) Neonatal Resuscitation Obstetric Anesthesia - ↑ CO 30-50% 2/2 SV > HR, highest CO immeDiately postpartum APGAR Normal PCO2 PO2 4 T’s: Tone (atony), Thrombin (coagulopathy), Tissue (retained OP/NP Suctioning: reserveD for neonates - ↑ BlooD volume 50% Cord Gases UA 50 20 placenta), Trauma (artery laceration) 0-3 severely depressed who have oBvious oBstruction to - ↓ SVR, PVR. UnchangeD PCWP, CVP UV 40 30 Downloaded from 4-6 moderately depressed Vaginal: > 500 mL || C-section: > 1000 mL spontaneous Breathing or who require PPV Pocket Guide CV - Eccentric LVH with TR, MR Points 0 1 2 (Class IIb, LOE C) - S3 common from rapiD filling Card design by numerous collaborators. Please send comments to: Activity ABsent Arm/leg Flex Active movement Oxytocin/Pitocin - MOA: ?; ↑ intracellular Ca - May have LAD, Flat TIII, ST Depr limB/chest M. Lipnick (ZSFG), J. Markley (ZSFG), K. Harter (ZSFG) or A. Kintu (MakCHS) Pulse ABsent < 100 > 100 - IM/IV/intrauterine routes (WHO rec: 10 U IM/IV) - Do NOT Bolus IV rapiDly Grimace No response to stim Grimace to stim Cry, cough to stim - ↑ MV 2/2 TV > RR; ↑ O2 consumption; ↓ FRC 20% - ConsiDer rule oF 3’s: 3 U loaD IV over 30 sec, consiDer Pulm http://circ.ahajournals.org/ - 7.44/30/105/20 normal ABG at enD oF 1st trimester Appearance Cyanosis Acrocyanosis Pink all over repeat 3 U rescue loaDs q 3 min For total oF 3 Doses; gtt at Respiration ABsent Weak, irregular Vigorous cry 3 U/hr for up to 3^3 (9) hr postop Renal - ↑ GFR By 50% à BUN/Cr ~ 9/0.6 - COMMUNICATE W/ OB TEAM RE: UTERINE TONE Miscellaneous Techniques Q 3 MIN UNTIL ADEQUATE Meconium Stained Amniotic Fluid: ETT Makerere University - Dilutional anemia (Hct > 33) 2/2 ↑ plasma vol > RBC vol - SiDe EFFects: hypoTN, N/V, coronary spasm suctioning no longer recommenDeD, even for non-vigorous neonates. - Nose BleeDs (Boggy, FriaBle mucosa 2/2 progesterone) Kovacheva et al, Anesthesiology, 2015 Version 1.2 Retained POC, - NTG: 100-400 mcg IV Boluses up to 500 mcg or 1-3 SL sprays - ↑ most clotting Factors + FiBrinogen (~400-500 mg/dL) = PRN (400 mcg/spray); Both +/- phenylephrine IV 50-200 mcg Heme hypercoagulaBle aFter 1st trimester Phone # Uterine Invrsn - GA: Req 2-3 MAC volatile gases - Ergot alkaloiD (Dopa, serotonin, by guest on December 2, 2017 alpha aDrenergic) à - Leukocytosis Methylergonovine ZSFG OB anes 1st call (resident) 30010 smooth muscle contraction - 5% gestational thromBocytopenia = Asx, usually plt > 100k /Methergine ZSFG OB anes 2nd call (attndg) 30011 (day), 30001 (nite/wknd/holid) - Existing epiDural: 10-15 mL 2% liDocaine w/ epi + NaHCO3 or - 0.2 mg IM; q 5-10 min max 2 Doses, then q 2-4 hr PPS/ 10-15 mL 3% chloroprocaine + NaHCO3 to T4-6 level - AvoiD IV, But iF IV, 0.2 mg/10 mL NS, give 2 mL q 1 min ZSFG L&D front desK (628-20) 68725 - GERD 2/2 progesterone anD ↓ LES tone PPTL - Spinal: hyperBaric 0.75% bupiv 1.6 mL + 10 mcg Fentanyl; or 2% - Relatively ContrainDicateD if GHTN, HTN, Pre-E - DelayeD gastric emptying only during laBor ZSFG OB chief resident (628-20) 60383 mepivacaine 45-60 mg w/ 1 mL D5W; or 3% chloroprocaine 45 mg - SiDe eFFects: HTN, seizures, HA, N/V, chest tightness ZSFG ante/post partum (628-20) 69259 GI - Constipation From ↑ Na anD H2O aBsorption anD ↓ GI motility - ↑ Alk Phos 3x B/c of heat staBle isoenzyme from placenta ZSFG NICU (628-20) 68363 - Resuscitate PRN, T&C 2 U PRBCs PRN, ConsiDer NPO status, Hemabate/ - 0.25 mg IM (only IM or intrauterine) q 15-90 min, - ↓ albumin potential coagulopathy UCSF OB anes 1st call (415-50) 20452 Carboprost NTE 2 mg/ 24 hr - MAC/paracervical Block (most common); verseD, Fentanyl, ketamine, - ContrainDicateD iF asthma (15-methyl-PGF2a) UCSF OB anes fellow (415-50) 20463 - ↓ MAC req By 20% until 3D postpartum D&C propofol PRN - SiDe eFFects: N/V, Flushing, Bronchospasm, - Larger volume oF DistriBution UCSF OB anes attndg (415-50) 20459 (day) 20447 (nite/wKnd/holid) Anes - Existing EpiDural: Same as PPS/PPTL diarrhea (2/3rd oF pts have Diarrhea) UCSF L&D front desK (415-47) 67670 - N2O/propoFol have little eFFect on uterine tone - Spinal: Same as PPS/PPTL - ↑ sensitivity to local anesthetics UCSF OB chief resident (415-50) 21155 Misoprostol/ - 600-1000 mcg Buccal/PR (10 min onset) UCSF ante/post partum/triage (415-47) 67644/67699/67788 NeeD T4-6 surgical anesthesia level in case oF c-section. Spinal Cytotec - SiDe eFFects: temp ↑ to ~ 38.1, N/V, diarrhea preFerreD: hyperBaric bupiv +/- Fentanyl. Long-acting opioiD DepenDs on UCSF MB NICU (415-35) 31565 (PGE1 analog) Hypertensive Disorders External Disposition: PPV: Cephalic 1. iF staying For inDuction iF version successful, give morphine IT RR 40-60, Tranexamic Acid/ - InhiBits conversion oF plaminogen to plasmin P < 20 cm H20 Acronyms Gestational - New HTN that Develops aFter week 20, resolves aFter Delivery; Version 2. iF going home iF version successful, NO morphine IT TXA - ConsiDer For all PPH iF possiBle HTN no associateD aBnormalities (ECV) 3. iF proceeDing immeDiately w/ c-section iF version unsuccessful, give - 1 g IV over 10 min, repeat x 1 aFter 30 min if needed (anti-FiBrinolytic) (Class IIb, TOLAC – Trial oF LaBor AFter Cesarean IOL – InDuction oF LaBor morphine IT - ↓ mortality Due to PPH: WOMAN, Lancet, 2017 AROM – ArtiFicial Rupture oF Membranes 4. iF going home iF version unsuccessful, NO morphine IT LOE C) VBAC – Vaginal Birth After Cesarean - DX: BP > 140/90 w/ > 0.3 g prot/1+ urine dip anD/or enD - Little data For aminocaproic aciD (Amicar) in PPH SROM – Spontaneous “” AMA – ADvanceD Maternal Age organ Dysfunc; Severe Features: BP > 160/110; HA, epigastric IUPC – Intrauterine Pressure Catheter PROM – Premature “” 3:1 pain, 2x LFTs, visual ∆, plt < 100k, Pulm edema, Cr > 1.1 - Human-DeriveD, pooleD Fibrinogen compression:vent IUGR – Intrauterine Growth Restriction PPROM – Preterm Premature “” - TX: ConsiDer Delivery ACLS & ATLS in Parturients - ConsiDer For PPH w/ conFirmeD or suspecteD low FiB state PPS/TL – Postpartum Sterilization/TuBal concentrate/ at 120 events/min GxP - Mg: 4-6 gm IV loaD over 15-20 min; 1-2 gm/hr gtt until 24 hr (DIC, AFE, aBruption, major hemorrhage) TPAL Ligation Pre- post Delivery (Do NOT D/c in OR); 10 g IM loaD DescriBeD - Manual LUD (do not tilt pt) (IVC compresseD > 20 wks) RiaSTAP - 2 g Fibrinogen conc = 2 vials RiaSTAP = 2-4 U FFP X = # Pregnancies Beta Complete – s/p Betamethasone x2 Eclampsia Epi 10-30 mcg/kg IV Mg tox: 6-10 mg/dL ↓ DTRs; > 10 mg/dL resp compromise; - RSI/cricoid if ETT needed = 10-20 cryo U (1-2 pools) T = Term LUD – Left Uterine Displacement Epi 50-100 mcg/kg ETT (*unvaliDateD) > 15 mg/dL cardiac comp: Tx CaCl 1 g IV or CaGluc 1-3 g IV - If recent Mg, d/c Mg gtt and give CaCl 1 g IV - To ↑ fiBrinogen 100 mg/dL, give 2-4 g Fibrinogen conc P = Premature HELLP - Hemolysis, Elev. LFTs, Low Plts IVF 10 mL/kg Bolus PRN A = Abortions/Miscarriages - PeDs present at all Deliveries 2/2 Floppy BaBy w/ Mg - IV access above diaphragm - Look For upcoming ranDomizeD trial: Aawar, Trials, 2015 SBAR – situation, BackgrounD, Modified from: L = Living Children - IF laryngoscopy necessary, control BP (laBetalol, Mg, Wikkelso et al, BJA, 2015 assessment, recommenDations - CPR in normal location on chest AlFentinil, Remifentinil) First to avoiD CVA - Emptying uterus < 5 min ↑ maternal survival ONLY IF > 20 wks Figure 1. Neonatal Resuscitation KgAlgorithm—2015ETT Update.@ Lips Blade LMA RR HR MAP - BEAUCHOPS: Bleeding/DIC, Embolism (PE/AFE), Anesthesia Other - Keep pt warm Disclaimer: This card is intended to be educational in nature and is not a substitute for clinical - LUD, airway support +/- ETT (control BP peri-laryngoscopy) - Don’t Forget CaCl < 1 2.5 7 cm Mil 0 1 < 60 140s 30s - IV access For Mg/Benzos. ConsiDer IM/IO routes. (LA tox; tx intralipid 20% 1.5 mg/kg bolus then 0.25-0.5 mg/kg gtt), Uterine atony, - ConsiDer activating MTP decision making based on the medical condition presented.