European Resuscitation Council Guidelines for Resuscitation ... - CPR

18 de 0ctubre de 2010 www.elsuapdetodos.comS. Richmond, J. Wyllie / Resuscitation 81 (2010) 1389–1399 1393BicarbonateIf effective spontaneous cardiac output is not restored despiteadequate ventilation and adequate chest compressions, reversingintracardiac acidosis may improve myocardial function and achievea spontaneous circulation. There are insufficient data to recommendroutine use of bicarbonate in resuscitation of the newly born.The hyperosmolarity and carbon dioxide-generating properties ofsodium bicarbonate may impair myocardial and cerebral function.Use of sodium bicarbonate is discouraged during brief CPR. If itis used during prolonged arrests unresponsive to other therapy,it should be given only after adequate ventilation and circulationis established with CPR. A dose of 1–2 mmol kg −1 may be given byslow intravenous injection after adequate ventilation and perfusionhave been established.FluidsFig. 7.4. Ventilation and chest compression of newborn.The most effective technique for providing chest compressionsis to place the two thumbs side by side over the lower third of thesternum just below an imaginary line joining the nipples, with thefingers encircling the torso and supporting the back (Fig. 7.4). 16–19An alternative way to find the correct position of the thumbsis to identify the xiphisternum and then to place the thumbson the sternum one finger’s breadth above this point. The sternumis compressed to a depth of approximately one-third of theanterior–posterior diameter of the chest allowing the chest wall toreturn to its relaxed position between compressions. 20Use a ratio of three compressions to one ventilation, aiming toachieve approximately 120 events per minute, i.e. approximately90 compressions and 30 ventilations. There are theoretical advantagesto allowing a relaxation phase that is very slightly longer thanthe compression phase. 21 However, the quality of the compressionsand breaths are probably more important than the rate.Check the heart rate after about 30 s and every 30 s thereafter.Discontinue chest compressions when the spontaneous heart rateis faster than 60 min −1 .DrugsDrugs are rarely indicated in resuscitation of the newly borninfant. Bradycardia in the newborn infant is usually caused byinadequate lung inflation or profound hypoxia, and establishingadequate ventilation is the most important step to correct it. However,if the heart rate remains less than 60 min −1 despite adequateventilation and chest compressions, it is reasonable to consider theuse of drugs. These are best given via an umbilical venous catheter(Fig. 7.5).If there has been suspected blood loss or the infant appears to bein shock (pale, poor perfusion, weak pulse) and has not respondedadequately to other resuscitative measures then consider givingfluid. 22 This is a rare event. In the absence of suitable blood (i.e.irradiated and leucocyte-depleted group O Rh-negative blood), isotoniccrystalloid rather than albumin is the solution of choice forrestoring intravascular volume. Give a bolus of 10 ml kg −1 initially.If successful it may need to be repeated to maintain an improvement.Stopping resuscitationLocal and national committees will determine the indicationsfor stopping resuscitation. If the heart rate of a newly born babyis not detectable and remains undetectable for 10 min, it is thenappropriate to consider stopping resuscitation. The decision tocontinue resuscitation efforts when the heart rate has been undetectablefor longer than 10 min is often complex and may beinfluenced by issues such as the presumed aetiology, the gestationof the baby, the potential reversibility of the situation, andthe parents’ previous expressed feelings about acceptable risk ofmorbidity.In cases where the heart rate is less than 60 min −1 at birth anddoes not improve after 10 or 15 min of continuous and apparentlyadequate resuscitative efforts, the choice is much less clear. In thissituation there is insufficient evidence about outcome to enablefirm guidance on whether to withhold or to continue resuscitation.www.elsuapdetodos.comCommunication with the parentsIt is important that the team caring for the newborn babyinforms the parents of the baby’s progress. At delivery, adhere toAdrenalineDespite the lack of human data it is reasonable to use adrenalinewhen adequate ventilation and chest compressions have failed toincrease the heart rate above 60 min −1 . If adrenaline is used, a doseof 10–30 gkg −1 should be administered intravenously as soon aspossible.The tracheal route is not recommended (see below) but if itis used, it is highly likely that doses of 50–100 gkg −1 will berequired. Neither the safety nor the efficacy of these higher trachealdoses has been studied. Do not give these high doses intravenously.Fig. 7.5. Newborn umbilical cord showing the arteries and veins.