Resusitasi

Neonatus

Gabriella Sabrina Darmadji (20190420268)

Gani Arrafi Naufalah (20190420269)
 Resusitasi Neonatus
Sekitar 10% dari semua bayi baru lahir
menerima beberapa bentuk bantuan
lebih lanjut
Hanya 1% dari neonatus
memerlukan resusitasi yang
ekstensif
Pedoman terbaru mengutamakan
peran sentral dukungan pernapasan
dan peningkatan denyut jantung
sebagai indikator terbaik untuk ventilasi
yang efektif
Serta rekomendasi untuk memulai
resusitasi pada bayi cukup bulan
dengan udara ruangan daripada
oksigen 100%
Oksimetri denyut terus-menerus
dianjurkan untuk memantau detak
jantung dan peningkatan saturasi
oksigen preduktal yang tepat
Oksigen tambahan hanya boleh
digunakan jika sudah diberikan ventilasi
yang efektif tapi denyut jantung tidak
meningkat di atas 100 detak per menit
atau jika oksigenasi yang ditunjukkan
oleh oksimetri nadi tetap sangat rendah
Intro
Transisi dari kehidupan intrauterin ke ekstrauterin adalah
waktu yang berbahaya dalam kehidupan manusia

Penyebab kematian paling umum adalah prematuritas,

malformasi kongenital, dan asfiksia perinata

Pertolongan cepat dan memadai pada bayi baru lahir yang

gagal beradaptasi sangat penting untuk prognosis mereka

Pengetahuan tentang fisiologi janin, adaptasi normal, dan

penyebab kegagalan adaptasi merupakan dasar terbaik
untuk memahami elemen penting dari resusitasi neonatus
 Fisiologi Janin
Ruang-ruang yang akan berisi udara saat bernapas sebelumnya diisi dengan cairan paru-paru
saat janin dalam rahim

Produksinya diperantarai oleh sekresi klorida (Cl) oleh sel tipe II alveolar

Sodium (Na+) mengikuti secara pasif dan air mengalir menuruni gradien osmotik

Sekresi cairan paru meningkat dari 1,6 ml/kg/jam pada midgestation menjadi 3,5-5,5 ml/kg/jam
pada trimester ketiga

Pada hari sebelum kelahiran, jumlahnya turun menjadi kurang dari 3 ml/kg/jam
 Lanjutan
Pita suara bertindak sebagai katup satu arah, cairan paru akan meregangkan jaringan paru dan
merangsang pertumbuhannya

Melalui gerakan pernapasan janin intermiten, cairan paru-paru, dan surfaktan sesuai
pertumbuhan usia kehamilan, melalui pita suara dapat ditelan atau dikeluarkan ke cairan ketuban

Ketika persalinan terjadi sebelum waktunya (operasi caesar), tidak ada peningkatan hormon stres
janin dan penyerapan cairan paru-paru terganggu

Ditambah dengan gagalnya pengeluaran cairan paru-paru karena tidak adanya kontraksi uterus

Hal ini menyebabkan peningkatan morbiditas pernapasan yang terjadi setelah kelahiran melalui
operasi caesar
 Sirkulasi dari janin
hingga neonatal
• Plasenta bertanggung jawab atas
pertukaran gas janin dalam rahim
• Kotiledon janin dibersihkan dalam darah
ibu dari ruang intervillous dan CO2
dikeluarkan dan O2 diambil oleh darah
janin
• Darah janin kemudian dikumpulkan
dalam vena umbilikalis, melewati hati
melalui ductus venosus arantii dan
memasuki vena cava inferior tepat di
bawah atrium kanan
 Lanjutan ..

• Dicampur dengan darah dari tubuh

bagian bawah janin, darah vena
umbilikalis mengalir dari atrium kanan
melintasi foramen ovale ke atrium kiri
(intracardiac streaming)
• Kemudian dikeluarkan dari ventrikel kiri
ke aorta asendens
• Hasilnya, darah janin yang teroksigenasi
dengan baik diarahkan ke miokardium
dan otak janin
 Lanjutan ..

• Sebaliknya, darah yang terdeoksigenasi

dari vena cava superior diarahkan
melintasi atrium kanan ke ventrikel
kanan dan dipompa ke arteri pulmonalis.
• Karena tahanan pembuluh darah paru
sangat tinggi dalam rahim, yaitu lebih
dari 85 - 90% dari cardiac output
ventrikel kanan, melewati paru-paru dan
mengalir melalui ductus arteriosus botalli
ke aorta desendens
 Lanjutan ..

• Karena pencampuran darah beroksigen

rendah ini, bagian bawah tubuh diperfusi
dengan darah yang hanya memiliki
saturasi oksigen 45%
• Resistensi pembuluh darah pada
plasenta rendah, dan sekitar 50% dari
gabungan curah jantung kiri dan kanan
mengalir melalui arteri iliaka internal ke
arteri umbilikalis dan akhirnya mencapai
plasenta melalui tali pusar
 Lanjutan ..

• Setelah lahir, terjadi perubahan dalam

sistem sirkulasi
• Ketika tali pusat terputus, vaskular
plasenta tidak termasuk sirkulasi lagi dan
resistensi vaskular sistemik meningkat
secara tiba-tiba
• Penghentian aliran darah melalui vena
umbilikalis menyebabkan collapse-nya
ductus venosus arantii
 Lanjutan ..

• Pada saat yang sama, dengan terjadinya

pernapasan udara, konsentrasi oksigen
yang tinggi mencapai pembuluh darah
paru yang menyebabkan vasodilatasi
• Dengan penurunan resistensi pembuluh
darah paru, perfusi paru meningkat dan
pertukaran gas paru dapat terjadi
• Ketika return vena paru meningkat,
tekanan atrium kiri naik di atas tekanan
atrium kanan, foramen ovale menutup
 Lanjutan ..

• Ketika tekanan pada arteri pulmonalis

turun dan tekanan di aorta meningkat,
sel-sel otot polos dari ductus arteriosus
botalli merespons peningkatan PaO2
dengan penyempitan
• Akhirnya mengalami penyumbatan
anatomi fungsional
Respons janin terhadap hipoksia intrauterin
Adaptasi normal
• Syarat untuk adaptasi normal adalah inisiasi/awal mula
pernapasan. Saat pertama kali bernafas, sisa cairan paru-paru
janin digantikan oleh udara.
• Biasanya, bayi baru lahir yang sehat mulai bernapas atau
menangis dalam 30-60 detik setelah melahirkan. Saturasi oksigen
preductal meningkat pada janin dari 65% menjadi lebih dari 90%
dalam 10 menit pertama kehidupan.
• Oleh karena itu, selama resusitasi di ruang bersalin, saturasi
oksigen harus diukur di tangan kanan (preduktal) untuk memantau
denyut jantung bayi dan mendokumentasikan peningkatan saturasi
oksigen yang diharapkan selama menit-menit pertama kehidupan.
 Adaptasi terganggu
• Ada banyak kondisi ibu dan janin yang berhubungan dengan
peningkatan risiko gangguan adaptasi
• Banyak dari kondisi ini dapat dikenali secara antenatal dan kebutuhan
akan tindakan resusitasi dapat diantisipasi.
• Namun, beberapa komplikasi terjadi secara tak terduga (mis. Solusio
plasenta, prolaps cord, ruptur uterus, dan sebagainya) dan dapat
memengaruhi individu.
Gangguan pembersihan cairan paru paru
• Pembersihan cairan paru yang tertunda atau tidak cukup dapat terjadi
setelah seksio sesarea, setelah persalinan cepat atau prematur. Selama
bayi baru lahir memiliki pernafasan yang memadai, gangguan
pembersihan cairan paru-paru akan bermanifestasi sebagai gangguan
pernapasan dengan takipnea (laju pernapasan di atas 60 napas), retraksi,
flaring, grunting/mendengus, dan mungkin sianosis. Tingkat dukungan
pernafasan yang diperlukan oleh bayi dengan tachypnoea transien pada
bayi baru lahir (TTN atau paru-paru basah) akan tergantung pada tingkat
keparahan gangguan pernapasan, mulai dari pemberian oksigen
tambahan hingga penggunaan tekanan udara positif terus menerus atau
bahkan intubasi dan ventilasi mekanis
 Gangguan dorongan pernapasan
• Dua hal yang paling umum pada gangguan pernapasan setelah
melahirkan adalah asfiksia perinatal dan prematuritas.
• Dalam kasus yang jarang terjadi, obat yang telah diberikan kepada
ibu selama persalinan dapat mempengaruhi pernapasan bayi (mis.
Opioid) atau melemahkan kekuatan ototnya (mis. Magnesium sulfat
untuk pre-eklampsia).
 Gangguan adaptasi sirkulasi
• terjadi setelah asfiksia perinatal, aspirasi mekonium, setelah
pecahnya membran dengan oligohidramnion, akibat hipoplasia,
sepsis berat, ada hipoksemia dan asidosis berat.
Faktor risiko yang terkait dengan gangguan adaptasi neonatal
 Algoritma resusitasi neonatal
Kira-kira, 10% dari semua bayi yang baru lahir memerlukan beberapa intervensi kecil seperti stimulasi taktil,
posisi yang tepat dan pengisapan mulut dan hidung dan oksigen tambahan setelah melahirkan.
Pada bayi cukup bulan, resusitasi dengan intubasi, kompresi dada, dan pemberian obat resusitasi sangat
jarang diperlukan, sekitar 1: 1000 persalinan.
Tim resusitasi yang terorganisasi dengan baik dengan peran yang jelas untuk setiap anggota tim, termasuk
penunjukan pemimpin tim yang berpengalaman, serta persiapan peralatan resusitasi yang tepat merupakan
syarat untuk keberhasilan resusitasi.
 Algoritma resusitasi neonatus
• Setelah diketahui bahwa bayi beresiko, setelah tali pusarnya
dipotong, bayi harus segera ditempatkan pada unit resusitasi.
• Langkah awal adalah pengeringan bayi untuk mencegah kehilangan
panas, memberikan stimulasi taktil, posisi kepala yang benar
(setengah ekstensi), dan membersihkan jalan napas dengan
menyedot mulut dan hidung.
• Kemudian penilaian baik upaya pernapasan dan detak jantung.
• Jika bayi megap-megap atau tidak bernapas sama sekali, atau detak
jantungnya kurang dari 100 kali/min, dilakukan ventilasi tekanan
positif.
• Di ruang bersalin, flow inflating bag atau resusitasi T-piece dapat
digunakan untuk mendukung pernapasan
 Algoritma resusitasi neonatus
• Di ruang bersalin, flow inflating bag atau resusitasi T-piece dapat
digunakan untuk mendukung pernapasan.
• Ventilasi yang sukses membutuhkan masker yang pas, jalan napas
terbuka, dan tekanan inflasi yang memadai.
• Perkembangan dada harus terlihat tetapi tidak berlebihan untuk
menghindari volutrauma.
• Denyut jantung harus meningkat di atas 100 beats/min dan saturasi
oksigen preductal harus mencapai nilai di atas 90% pada usia 10
menit.
 Algoritma resusitasi neonatus
• Jika denyut jantung turun menjadi kurang dari 60/menit meskipun
ventilasi memadai, dilakukan kompresi.
• Kompresi dilakukan dengan rasio kompresi banding ventilasi 3:1,
dengan kecepatan 90 kompresi dan 30 napas dalam 1 menit.
• Kompresi dada diterapkan pada sepertiga bagian bawah sternum dan
menggunakan dua ibu jari.
• Jika ventilasi tekanan positif dan kompresi dada tidak mengembalikan
sirkulasi spontan setelah 30 detik, epinefrin intravena harus diberikan
dengan dosis 10-30mg/kg
• Jika tidak ada akses vena, epinefrin dapat diberikan intratrakeal
dengan dosis 50-100mg. Namun, kemanjuran rute ini cenderung lebih
rendah daripada intravena.
Algoritma resusitasi neonatus
Ukuran tabung endotrakeal, dosis epinefrin, serta cairan yang digunakan pada
neonatal
Perubahan besar dalam pedoman resusitasi
internasional antara 2005 dan 2010
 Pulse Oksimetri
• Seperti yang telah didiskusikan sebelumnya, perubahan saturasi
oksigen pada menit pertama kehidupan adalah bertahap dan
dibutuhkan beberapa menit sebelum bayi yang sehat mencapai
saturasi oksigen di atas 90%.
• Oksimetri nadi adalah metode terbaik. Selama transisi, lokasi
preduktal dari sensor oksigen penting, karena nilai SaO2 preduktal
mungkin 10–15% lebih tinggi dari nilai SaO2 postductal. Pulse
Oksimeter juga memberikan informasi terus menerus tentang detak
jantung dan membantu memandu resusitasi.
 Kesimpulan
• Hingga 10% dari semua bayi yang baru lahir memerlukan beberapa
bentuk bantuan setelah lahir, tetapi hanya 1% dari semua neonatus
memerlukan langkah-langkah dukungan kehidupan yang lebih maju.
• Adaptasi normal membutuhkan pembersihan tepat waktu
(penyerapan, pengeluaran) cairan paru-paru, dorongan pernapasan
yang memadai dan transisi yang sukses dari sirkulasi janin ke
neonatal.
• Ventilasi yang efektif, ditunjukkan oleh gerakan dada dan
peningkatan denyut jantung, adalah intervensi paling penting
dalam resusitasi neonatal .
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