NRP 7th edition

What is the new?

DR MAHMOUD EL NAGGARNRP instructor

Mecca-HGH2016

The class of recommendation of NRP guidelinesClass I - definitely recommended

Class II - acceptable and useful

Class II a - Acceptable and useful, very good evidence provides support

Class II b - Acceptable and useful, fair to good evidence provides support

Class III - Not acceptable, not useful, may be harmful

RESUSCITATION TEAM Every birth should be attended by at least 1

person who can perform the initial steps of newborn resuscitation and PPV perfectly, and whose only responsibility is care of the newborn.

When perinatal risk factors are identified, a resuscitation team should be assigned and a team leader identified.

Meconium-stained amniotic fluid is a perinatal risk factor that requires presence of one resuscitation team member with full resuscitation skills, including endotracheal intubation. In spite of no routine intubation and tracheal suctioning.

As time permits, the leader should conduct a pre-resuscitation briefing, identify interventions that may be required, and assign roles and responsibilities to the team members.

During resuscitation, it is vital that the team demonstrates effective communication and teamwork skills to help ensure quality and patient safety.

RESUSCITATION TEAM

NRP’s 10 Key Behavioral Skills Know your environment Anticipate and plan Assume the leadership role Communicate effectively Delegate workload optimally Allocate attention wisely Use all available information Use all available resources Call for help when needed Maintain professional behavior

Before delivery of the baby the team should do: A) Antenatal counseling B) Ask OB/GY 4 Q?; gestational age? Clear amniotic fluid? How many babies? Any additional risk factors? C) Team briefing D) Equipment check

Delayed cord clamping

There is a new recommendation that delayed cord clamping for 30 -60 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth. (Class IIa)

If placental circulation is not intact, such as after a placental abruption, bleeding placenta previa, bleeding vasa previa, or cord avulsion, the cord should be clamped immediately after birth.

Delayed cord clamping

But there is insufficient evidence to recommend an approach to cord clamping for infants who require resuscitation at birth, and a suggestion against the routine use of cord milking for infants born at less than 29 weeks of gestation, until more is known of benefits and complications. (Class IIb)

Delayed cord clampingIs associated with:1- less intraventricular hemorrhage2- Higher blood pressure and blood volume 3- less need for transfusion after birth4- less necrotizing enterocolitis.

5- Slightly increased level of bilirubin, associated with more need for phototherapy.

There are 2 levels of post-resuscitation care A) Routine Care for: 1- Vigorous term infants with no risk factors 2- Babies who required but responded to initial steps

They now can stay with Mother Skin to skin contact recommended, Clear airway, dry newborn, provide ongoing evaluation:

Breathing Activity Color Transfer to postnatal with mother

There are 2 levels of post-resuscitation care Post-Resuscitation Care for: 1- Babies with depressed breathing or activity 2- Those requiring supplemental oxygen &/or ongoing nursing care 3- Those with high risk factors to be evaluated in an ICU setting 4- Those who require frequent evaluation Transfer to NICU

INITIAL ASSESMENT The order of the 3 assessment questions

has changed to: (1) Term gestation? (2) Good tone? (3)Breathing or crying?

The Golden Minute

The Golden Minute (60-second) mark for completing the initial assessment, initial steps, reevaluating, and beginning ventilation (if required) is retained to emphasize the importance of avoiding unnecessary delay in initiation of ventilation witch is the most important step for successful resuscitation of the newly born who has not responded to the initial steps.

INITIAL STEPS 1- Provide warm and maintain normal

temperature during resuscitation 2- Positioning…..sniffing 3- Clear the airway only if copious

and/or obstructing the airway. (Class IIb)

4- Dry thoroughly 5- Tactile stimulation 6- Remove wet linen 7- Repositioning to sniffing position

PROVIDE WARM Temperature of newly born non

asphyxiated infants should be maintained between 36.5°C and 37.5°C after birth through admission and stabilization.(Class I)

Temperature should be recorded as a predictor of outcomes and as a quality indicator. (Class I)

PROVIDE WARM A variety of strategies may be reasonable to prevent

hypothermia in preterm infants less than 32 W: 1- Radiant warmers 2- plastic wrap with a cap 3- thermal mattress 4- warmed humidified gases 5- increased room temperature to 26 6- Portable incubator(Class IIb) All resuscitation procedures, including endotracheal

intubation, chest compression, and insertion of intravenous lines, can be performed with these temperature-controlling interventions in place.(Class IIb)

PROVIDE WARM In resource-limited settings simple measures

to prevent hypothermia in the first hours of life :

1-Use of plastic wraps 2- Skin to-skin contact 3- Placing the infant after drying in a clean food-grade plastic bag up to the neck, May reduce mortality. (Class IIb)

Hyperthermia (temperature greater than 38°C) should be avoided because it introduces potential associated risks. (Class III: Harm)

MECONIUM STAINED AMNIOTIC FLUID If an infant is born through meconium-stained

amniotic fluid and presents non vigorous the infant should be placed under a radiant warmer and PPV should be initiated if needed.

Routine intubation for tracheal suction is no longer suggested because there is insufficient evidence to continue this recommendation.

Appropriate intervention to support ventilation and oxygenation should be initiated as indicated for each individual infant.

This may include intubation and suction if the airway is obstructed.

MECONIUM STAINED AMNIOTIC FLUID If the infant born through meconium-stained

amniotic fluid presents with poor muscle tone and inadequate breathing efforts(non-vigorous), the initial steps of resuscitation should be completed under the radiant warmer.

PPV should be initiated if the infant is not

breathing or the heart rate is less than 100/min after the initial steps are completed.

Routine intubation for tracheal suction in this setting is not suggested, because there is insufficient evidence to continue recommending this practice. (Class IIb)

Evaluation Process Subsequent evaluations and decision

making are based on: a) Respiratory effort b) Heart rate c) Oxygenation based on Pulse Oximetry

ASSESMENT OF THE HEART RATE

Assessment of heart rate remains critical during the first minute of resuscitation and the use of a 3-lead ECG may be reasonable (Class IIb)

Because providers may not assess heart rate accurately by auscultation or palpation, and pulse oximetry may underestimate heart rate.

Use of the ECG does not replace the need for pulse oximetry to evaluate the newborn’s oxygenation.

Pulse OximetryIt is recommended that oximetry be used when:

1. Resuscitation can be anticipated.

2. Positive pressure is administered for more than a few breaths.

3. Cyanosis is persistent.

4.Supplem-entary O2 is administer-ed.

After initial steps Evaluate respirations and heart rate ,Not color if: a) HR <100 or if newborn is apneic or gasping give PPV b) HR >100 but spontaneous respiration with respiratory distress may be supported by continuous positive airway pressure rather than with routine intubation for administering PPV either preterm or full term. (Class IIb)

Oxygen administration

Term infants start resuscitation with 21% O2 (Class IIb)

If blended oxygen is not available, resuscitation should be initiated with air. (Class IIb)

Preterm less than 35 W should be initiated with low oxygen (21% to 30%) and the oxygen titrated to achieve preductal oxygen saturation approximating the range achieved in healthy term infants. (Class I)

Initiating resuscitation of preterm newborns with high oxygen (65% or greater) is not recommended. (Class III—No Benefit)

OXYGEN ADMINSTRATION If a baby is breathing but oxygen saturation (Sp02) is

not within target range, free-flow oxygen administration may begin at 30%. Adjust the flowmeter to 10 L/min. Using the blender, adjust oxygen concentration as needed to achieve the oxygen saturation (Sp02) target.

Free-flow oxygen cannot be given through the mask of a self-inflating bag; however, it may be given through the tail of an open reservoir

If the newborn has labored breathing or Sp02 cannot be maintained within target range despite 100% free-flow oxygen, consider a trial of continuous positive airway pressure (CPAP).

Targeted preductal Spo2 after birth

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

Pulse oximeter provide reliable reading with in 1 to 2 minutes following birth.

PPV Indications 1. Apnea /Gasping 2. Heart rate <100 even with strong

respiratory drive 3. Oxygen saturation cannot be

maintained within target range despite free flow oxygen or CPAP.

PPV Adjust the flowmeter to 10 L/min.

Inflation pressure should be monitored; an initial inflation pressure of 20-25 cm H2O may be effective, but ?30 to 40 cm H2O may be required in some term babies without spontaneous ventilation.(Class IIb)

recommendation that, when PPV is administered to preterm newborns, approximately 5 cm H2O PEEP is suggested. (Class IIb)

PPV Start with oxygen concentration 21% for

Full Term and 30% for Preterm and adjust later.

Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to promptly achieve or maintain a heart rate >100 per minute. (Class IIb)

When PPV begins, consider using an electronic cardiac monitor for accurate assessment of the heart rate.

PPV Rate of PPV 40-60 / minute.

Song Breathe, two, three…….Breathe, two , three……….

Duration of effective ventilation 30 seconds then assessment.

PPV Assessment Best indicator that you are bagging correctly is

an rising heart rate

Increase in HR should be evident for the first 15 seconds of PPV.

If heart rate not rising you asses chest movement and bilateral breath sounds with ventilation.

If not-then following the corrective actions MR SOPA

MR. SOPA (ventilation corrective steps)

1. M- Adjust Mask in the face 2. R- Reposition the head to open airway Re-attempt to ventilate…if not effective then 3. S- Suction mouth then nose 4. O- Open mouth and lift jaw forward Re-attempt to ventilate…if not effective then 5. P- Gradually increase Pressure every few

breaths until visible chest rise is noted Maximum PIP 30 for PT and 40cmH2O for FT If still not effective then… 6. A- Artificial Airway (ETT or LMA)

LARYNGEAL MASK A laryngeal mask may be considered as an

alternative to tracheal intubation if face-mask ventilation is unsuccessful. (Class IIb)

a laryngeal mask is recommended during resuscitation of newborns 34 weeks or more of gestation when tracheal intubation is unsuccessful or not feasible. (Class I)

TRACHEAL SUCTION If you are attempting PPV but the baby is not

improving and the chest is not moving despite performing each of the ventilation corrective steps (MR. SOPA), including intubation, the trachea may be obstructed by thick secretions…………………… Suction the trachea using a suction catheter inserted through the endotracheal tube or directly suction the trachea with a meconium aspirator

Highest Priority in Neonatal Resuscitation

Establishing effective ventilation It may take longer than 30sec to establish

effective ventilations Corrective actions required MR SOPA Do not start chest compressions without 1st

ensuring effective ventilations defined by bilateral breath sounds & chest movement

SUSTAINED INFILATION There is insufficient data regarding

short and long-term safety and the most appropriate duration and pressure of inflation to support routine application of sustained inflation of greater than 5 seconds’ duration to the transitioning newborn. (Class IIb)

Chest Compressions

HR <60bpm despite effective ventilation Coordinate with ventilations for at least 60sec

before assess of heart rate 2 hands wrapped around chest with 2 thumb

technique is preferred method of chest compressions(Class IIb)

Be careful to concentrate pressure on the heart not over entire chest

Note your thumb position

Chest Compressions

Compress 1/3 diameter of chest(Class IIb)

90 compressions to 30 ventilations/minute (120 events ) (Class IIa)

(3:1) One & two & three & breathe & One & two & three & breathe &…

rescuers may consider using higher ratios (e.g., 15:2) if the arrest is believed to be of cardiac origin. (Class IIb)

Increase FiO2 to 100% once you begin compressions (Class IIa)

Adjust FiO2 to pulse oxmetry readings

To reduce the risks of complications associated with hyperoxia the supplementary oxygen concentration should be weaned as soon as the heart rate recovers. (Class I)

Pulse oxetry may not work while newborn is receiving chest compressions

Intubation is strongly recommended when compressions begin

UVC Consider placement of UVC once

compressions are initiated or if extended resuscitation is anticipated

Continue chest compressions by moving around to head of bed using thumb technique to allow room for insertion of UVC

Intraosseous needle is a reasonable alternative.

Epinephrine

Epinephrine is indicated when heart rate remains <60 after 30 seconds of effective ventilations and another 60sec of coordinated compressions and ventilations

ETT route Unreliable absorption Less effective But readily available so give while establishing UVC (Class IIb)

UVC route Preferred method (Class IIb)Requires skills to place line May give dose soon as line is placed even after just giving via ETT (Class IIb)

Give rapidly Concentration 1:10,000 (0.1mg/ml) ETT dose 0.5 – 1 ml/kg UVC / IV dose 0.1- 0.3 ml/kg Follow with a

1ml flush NS Re-check heart rate after 1minute of

compressions and ventilations, Maybe longer if give ETT

Repeat dose every 3 – 5 minutes Epinephrine can be given again

immediately after UVC placement if given initially through ETT do not wait 3 minutes.

VOLUME EXPANSION Volume expansion should be considered

when blood loss is known or suspected (pale skin, poor perfusion, weak pulse) and the infant’s heart rate has not responded adequately to other resuscitative measures.(Class IIb)

An isotonic crystalloid solution or blood O-ve may be useful for volume expansion in the delivery room. (Class IIb)

Therapeutic Hypothermia for HIE Cooling used for >/= 36wks & meet special

criteria for this modality Usually initiated before 6 hours after birth In resource-limited settings, use of therapeutic

hypothermia may be considered under clearly defined protocols similar to those used in clinical trials and in facilities with the capabilities for multidisciplinary care and follow-up.

SODIUM BICARBONATE Sodium bicarbonate should not be

routinely given to babies with metabolic acidosis.

There is currently no evidence to support this routine practice.

NALOXONE There is insufficient evidence to evaluate

safety and efficacy of administering naloxone to a newborn with respiratory depression due to maternal opiate exposure. Animal studies and case reports cite complications from naloxone, including pulmonary edema, cardiac arrest, and seizures.

When to stop resuscitation?

In general, no new data have been published to justify a change in the 2010 recommendations about withholding or withdrawing resuscitation.

An Apgar score of 0 at 10 minutes is a strong predictor of mortality and morbidity in late preterm and term infants, but decisions to continue or discontinue resuscitation efforts must be individualized.

It is suggested that neonatal

resuscitation task training occur more frequently than the

current 2-years interval.

THANK YOU