NRP Case Study 5 – Diaphragmatic Hernia

Description:

Today, you are assigned as the ‘admit nurse.’ While in the NICU and waiting for any delivery in L&D, your main duty is to prepare and check the admission bed, check the procedure cart, resuscitation equipment, and Kangaroo Board supplies that you may need to use during the admission process. Set-up an admission bed with all the necessary equipment and supplies within reach.

Eight (8) Things to Remember when setting up an admission bed in case you need to resuscitate a newborn. Always keep in mind to have all of these available on hand in case you encounter an emergency situation.

1. Warmer
2. Clear the airway if necessary
3. Dry the newborn
4. Auscultate
5. Oxygenate
6. Ventilate
7. Intubate
8. Medicate

You received an emergency cesarean section call from L&D. Mom was scheduled for an elective C/S three days later, but has come to the emergency room, and present herself with an advancing labor accompanied with fetal late decelerations.  Mother is in active labor and about to deliver anytime soon. She is 26 year old, G 3 P 1, who has good prenatal care. Previous antenatal check-up shows a 35 weeks gestational age baby girl with right-sided diaphragmatic hernia. Mom has consulted with OB-GYN, the perinatal, and ethical counseling clinics. There is no risk for sepsis infections. 

Given the above scenario, you ask yourself:

• How would you prepare for the resuscitation of this baby?

As soon as you received the call from the L&D nurse, you immediately CALL for additional HELP.

Then, start the following checks: EQUIPMENT CHECKLIST

• Prepare all the needed equipment and supplies for this delivery.
• Obtain relevant perinatal history.
• Performs equipment check.
• Assembles resuscitation team.
• Prepares for intubation.

When you receive the call, you should have ask the following questions: 

• Is the baby term? What is the gestational age (GA)? Preterm – 35 weeks
• Is the fluid clear?  Yes
• How many babies? One baby
• Other risk factors? Right-sided diaphragmatic hernia
• Do you need additional equipment? Yes
• Do you need more team members? Yes

Check the following in L&D: EIGHT (8) THINGS THAT YOU NEED TO REMEMBER THE MOST

1. Warmer
2. Clear the airway if necessary
3. Dry the newborn
4. Auscultate
5. Oxygenate
6. Ventilate
7. Intubate
8. Medicate

Four (4) Important Questions to Ask the OB provider:

1. Is the baby term? The baby is preterm at 35 weeks
2. Is the fluid clear? The fluid is clear.
3. How many babies are there? Singleton
4. Any other risk factors? It’s a vaginal delivery and baby’s antenatal scans at 24 weeks shows that baby has right-sided diaphragmatic hernia.

Baby is out…

Important question to ask yourself: Can this baby go to mom? No, the baby cannot go to the mom due to condition – right-sided diaphragmatic hernia

• Baby is PRETERM. 
• Baby is born floppy and blue. 
• Baby NO good muscle tone.

Additional help is around, other team members come to the rescue

• Placed the baby on the warmer
• Dry and stimulate the newborn for 30 seconds
• Check heart rate (HR) and listen to breath sounds

• HR = 60 bpm
• RR = 60 per minute

Baby remains floppy and blue after the 30 seconds initial steps

• Breath sounds are unequal
• Poor chest rise on the right side of the chest
• Bowel sounds auscultated on the upper right side of the chest

 Immediate actions: 

• Intubate the newborn
• Place umbilical venous catheter (UVC)
• Administer muscle relaxant as ordered

Important: Avoid Bag Mask ventilation

At 1 minute of life…

• If correct actions are performed, baby will improve:
  • HR = 120’s bpm and rising
  • FiO2 requirement increased to 100%
  • SpO2 will reach at 65%
  • right side of the chest will show no air trap

• If correct actions NOT delivered on time
  • HR = 110’s bpm
  • RR = 50’s and dropping
  • SpO2 will continue to drop < 50%
  • Baby’s condition worsens

At 2 minutes of life…

• If correct actions NOT delivered on time
  • HR = 100’s bpm
  • RR = 40’s and dropping
  • SpO2 will continue to drop < 45%
  • Baby’s condition worsens
  • Baby remains limp and blue

At 2 minutes and 30 seconds of life…

• If correct actions NOT delivered on time
  • HR = 80’s’s bpm
  • RR = 30’s and dropping
  • SpO2 will continue to drop < 40%
  • Baby’s condition continues to deteriorate
  • Baby remains limp and blue

At 3 minutes of life…

• If correct actions NOT delivered on time
  • HR = 40’s bpm
  • Baby becomes APNEIC
  • No exchange of gases on right side
  • No ventilation on right side
  • Baby remains blue
  • SpO2 does not register; does not pick up sats
• Baby’s condition worsens

DEATH is imminent – full cardiorespiratory arrest

—————————————————————————

Note: NRP Guidelines for Healthcare Professionals

Corrective Steps

• M – Mask adjustment
• R – Reposition airway
• S – Suction mouth and nose
• O – Open mouth
• P – Pressure increase
• A – Airway alternative

Targeted Pre-ductal SpO2 After Birth

• 1 min          60% – 65%
• 2 min          65% – 70%
• 3 min          70% – 75%
• 4 min          75% – 80%
• 5 min          80% – 85%
• 10 min        85% – 95%

Endotracheal Intubation

• Gestational Age (weeks)              Weight                 ET Tube Size*           Depth of insertion **
  • < 28 weeks                              < 1 kg                              2.5                                         6 – 7
  • 28 – 34                                       1 – 2 kg                            3.0                                         7 – 8
  • 34 – 38                                       2 – 3 kg                            3.5                                         8 – 9
  • > 38                                             > 3 kg                         3.5 – 4.0                                    9 – 10

• Depth of Insertion ( cm from upper lip) = 6 cm + weight (in kilograms [kg])
• (Internal Diamete [ID2] mm)

Medications:

Epinephrine via UVC

• Precaution:
  • Give rapidly
  • Repeat every 3 to 5 minutes if HR < 60 bpm with chest compressions
  • Higher IV doses not recommended
• Route: Intravenous (IV)  —> Umbilical Vein Catheter
  • UVC is the preferred route
• Dosage: 0.1 to 0.3 ml/kg
• Concentration: 1 : 10,000

 

• WEIGHT (kg)                       Total IV volume (ml)
  1                                                    0.1 to 0.3 ml
  2                                                    0.2 to 0.6 ml
  3                                                    0.3 to 0.9 ml
  4                                                    0.4 to 1.2 ml

Epinephrine via ETT *

• Concentration: 1 : 10,000
• Dosage: 0.5 to 1 ml/kg
• Route: ETT

• WEIGHT (kg)                        Total IV volume (ml)
  1                                                     0.5  to 1 ml
  2                                                          1 to 2 ml
  3                                                      1.5 to 3 ml
  4                                                          2 to 4 ml

• Note : Endotracheal dose may not result in effective plasma concentration of drug, so vascular access should be  established as soon as possible. Drugs given endotracheally require higher dosing than when given IV.

Volume Expanders

• Isotonic or crystalloid – Normal Saline (NS) or blood
• Dosage: 10 ml/kg
• Route: Intravenous (IV) or UVC
  • not to be given via ETT
• Precautions:
  • Give over 5 to 10 minutes
  • Reassess after each bolus
• Indication: Indicated for shock

• WEIGHT (kg)                           Total IV volume (ml)
  1                                                             10 ml
  2                                                             20 ml
  3                                                             30 ml
  4                                                             40 ml

 

Final thoughts on your skills return demonstration:

• As you work, say your thoughts and actions aloud so I will know what you are doing.

 

Sources: All rights reserved.

• American Academy of Pediatrics 2011
• American Heart Association (AHA)