Guide

Dr. H. P. Singh

NRP 2010 How and why it is different from 2005

Dr. Saurabh K. Patel

REFERENCES

• Neonatal Resuscitation Textbook- 6th edition

• Neonatal Resuscitation Textbook- 5th edition

• 2010 American heart association guideline for cardiopulmonary resuscitation and emergency cardiovascular care.

• www.aao.org/nrp

• www.healthstream.com/hcl/aap

Neonatal resuscitation

To assist a newborn to initiate extrauterine life immediately after birth

Need

• Birth asphyxia accounts for about 23% of the approximately 4 million neonatal death occur each year world wide.

Lancet. 2010;375:1969-1987

Neonatal Resuscitation

• Majority (90%) – no resuscitation

• 10% - some assistance

• <1% - extensive resuscitation

Neonatal Resuscitation Program

• NRP was originally designed in mid 1970

• By AAP and AHA

• Updates – 2005

2010

Comparison of 2005 & 2010

NRP Update

• Pre- Resuscitation

• Resuscitation Algorithm

• Post Resuscitation Care

Personnel

• Skilled personnel for every birth

• For all deliveries should be skilled in PPV & assisting CC

• Skilled personnel for complete CPR be readily available

• For anticipated high risk deliveries additional personnels be recruited

OldNew

Personnel

• Resuscitation team • Resuscitation team with behavioral skills & communication

Old New

Equipments

• Equipment list

• Optional ..

Blender, LMA, ETCO2,

CPAP

• Equipment checklist

• No longer optional

Old New

Initial Assessment

• Term gestation

• Amniotic fluid clear

• Breathing/crying

• Good tone

• Term gestation

• Breathing/crying

• Good tone

Old New

NRP Update

• Pre- Resuscitation

• Resuscitation Algorithm

• Post Resuscitation Care

Old New

Old New

Assess at Birth

•Term gestation ?

• Amniotic fluid clear ?

• Breathing or crying ?

• Good muscle tone ?

• Term gestation ?

• Breathing or crying ?

• Good muscle tone ?

Old New

Routine Care

• Provide warmth

• Clear airway

• Dry

• Assess color

• Provide warmth

• Assure open airway

• Dry

• Ongoing evaluation

(color (SPO2), activity and breathing)

Old New

“ Emphasis on placing baby on mothers chest in skin to skin contact ”

Initial Steps

• Provide warmth

• Position

• Clear airway

(if required)

• Dry

• Stimulate

• Reposition

• Provide warmth

• Open airway

(no routine suction)

• Dry , stimulate

Old New

Suctioning

• No routine suction

• Suction only if :

- Obvious obstruction to spontaneous breathing

- Require PPV

Initial Assessment

• Look for 3 signs

• Heart rate

• Color

• Respiration

• Look for 2 signs

• Heart rate

• Respiration (Labored,

unlabored, apnea, gasping)

Old New

Checking Heart Rate

• Palpation of umbilical cord pulsation

• Pre-cordial auscultation

preferred to umbilical cord palpation for heart rate

OldNew

PPV Device

• Use either flow inflating, self inflating or T piece resucitator

• Same

• Emphasis on use of manometer for PPV

Old New

PPV

• During PPV look at chest rise and improvement in HR

• CALL for help

• Apply pulse ox

Old New

The Best Indication

of

Effective Ventilation is

Improvement in Heart Rate

PPV: If ineffective

• Take remedial measures • M...Reapply mask

• R…Reposition airway

• S….Suction

• O…Open mouth

• P….Pressure increase

• A….Alternate airway

NewOld

PPV

• Start with 100% O2 during PPV

• Use room air for term

• No evidence to give appropriate initial oxygen strategy for infants 32-37 weeks

• Initiate resuscitation using O2 concentration between 30-90% (< 32w)

NewOld

Oxygenation

• Based on color

• Free flow oxygen if

central cyanosis

• Based on oximetry

NewOld

Oxygenation

• Pulse oximetryrecommended for only preterm < 32weeks with need for PPV

• Use oximeter

1. Anticipated need for

resuscitation

2. Need for PPV for more than few breaths

3. Persistent cyanosis

4. Supplementary oxygen

Old New

Oxygenation

• No info on using pulse ox

• Attach probe to right hand or wrist (measure pre-ductal saturations)

• Attach neonatal probe before connecting it to machine

• Recording of tracing may take 1-2 m

OldNew

Oxygenation

• Use of blender for compressed air and oxygen, optional

• Start with oxygen concentration somewhere between 21-100%

• Oxygen blender is

essential

• Preterm start with O2 concentration 30-90% and then increase or decrease

Old New

Oxygenation

• Target saturations not defined

OldNew

(same for both term andpreterm)

When to give 100% Oxygen

• Start with 100% O2 during PPV

• Shift to 100 % during chest compressions

Old New

Ventilation

“Ensure adequacy of ventilation before initiating chest

compressions ”

Subsequent Assessment

Old New

Heart Rate

Respiration

Oxygenation*

* Pulse oximetry

Respiration

Heart Rate

Color

Intubation

• Indications

• Technique

• Confirmation

• Same

• Exhaled Co2 is primary method of confirmation

Old New

Chest Compression

• Site

• Depth

• Technique

• CC: Ventilation ratio

• 2 thumb encircling hand technique preferred

• Same steps

• Provide for 45-60 sec un-interrupted

• Head end CC

Old New

Intubation

New

Old

Laryngeal Mask Airway

• For near term and term infants > 2500g may be used

• No definite mention of indications

• LMA may be used for infants >2000g and ≥ 34 weeks when

1. bag and mask is ineffective

2. tracheal intubation is unsuccessful or not feasible

Old New

Preterm Resuscitation: CPAP

• Suggested for preterm babies ( < 32 weeks) with respiratory distress

• Be considered for persistent cyanosis or labored breathing after initial steps

• Spontaneously breathing preterm infants with respiratory distress may be supported with CPAP or ventilation as per local practice

OldNew

Preterm Resuscitation: Temp

• Polytehylene bag for

< 28 weeks

• Exothermic mattress

• Covering in plastic wrap without drying

• Pre-warming the delivery room to at least 26C

• Monitor temp closely

Old New

Algorithm Timeline

• Assessment every 30 seconds • “First Golden Minute”

concept

• After PPV + CC assess by 45-60 sec

• After epinephrine assess HR by 1 minute

OldNew

NRP Update

• Pre- Resuscitation

• Resuscitation Algorithm

• Post Resuscitation Care

Level of Care

• Routine care

• Observational care

• Post resuscitation care

• Routine care

• Post resuscitation care

Old New

Therapeutic Hypothermia

• No sufficient evidence to recommend routine use of modest systemic or selective cerebral hypothermia

• Recommended for infants ≥ 36weeks with moderate to severe hypoxic ischemic encephalopathy as per protocol with provision for monitoring for side effects and long term follow up

Old New

Glucose

• Infants who require significant resuscitation should be monitored and treated to maintain glucose in the normal range

• Glucose infusion should be considered as soon as practical after resuscitation, with the goal of avoiding hypoglycemia

• No specific target conc.

Old New

Withholding resuscitation

• According to local policy • Same

Old New

Discontinuing resuscitation

• No detectable HR > 10 minutes despite complete measures

• SameNewOld

SUMMARY• Old Guidelines become obsolete with new

evidence

• At times guidelines seem more complex and complicated

• Individualize the care and utilize the local resources

• Primum non Nocere (First Do No Harm)

THANKS