1. The New Neonatal Resuscitation Program (NRP) Guidelines
Mesfin Woldesenbet, MD, FAAP Neonatologist, Medical Director NICU at Memorial Hermann Southwest Hospital Pediatrix Medical Group Houston, Texas April 2013

2. Introduction 10% of newborns require some assistance at birth
<1% require extensive resuscitation
Crude birth rate ~ 19/1000 population (~134 million)
15,120 births/hour
252 births/min
4.2 births/seconds
~150 babies born per hour
USA- 5 babies/hour need extensive resuscitation
155 babies born per hr need extensive resuscitation

3. The Process of Developing Guidelines and Education Material
Published Scientific Research
International Liason Committee on Resuscitation (ILCOR)
International Consensus on CPR and ECC with treatment recommendation (CoSTR)
AAP/AHA Guidelines for CPR and cardiovascular Care of the Neonate
Neonatal Resuscitation Program (NRP)
5 Years

4. Neonatal Resuscitation Program
1st Edition introduced in 1987
1st – 5th Editions
Slide and Education format
Do not differentiate by job description or specialty
6th Edition
Less didactic
More emphasis on simulation and Debriefing
Didactic portion taken online with certificate of passing a test

5. Neonatal Resuscitation Program 6th Edition
Rationale for the changes to procedural guidelines and processes
Evidence behind each step in resuscitation
Rationale for the new educational approach
Implication

6. 2

7. Steps of resuscitations
Initial steps- dry, position, assess and stimulate
Ventilation
Chest Compression
Medication or volume expansion

8. Assessment of efficiency of CPR
Progression to next step is based on
Heart Rate
Respiration
The most sensitive indicator remains the heart rate
Auscultation (best method)
Palpation of umbilical cord (underestimate heart rate)
Pulse oximetry (difficult to obtain reading consistently)
Do not use color as an indicator
Will avoid hyperoxia

9. Initial Step Term, breathing and good muscle tone:
Dry and place the infant skin-to-skin with the mother
Continue routine care and ongoing assessment
This includes the vigorous infant with meconium-stained amniotic fluid.
Use of the bulb suction is reserved for infants whose secretions obstruct breathing or the infant requiring PPV.

10. After Initial Steps
HR >100bpm, labored breathing and persistent cyanosis:
Clear airway.
Place pulse ox on infant’s right hand or wrist.
Free flow oxygen if the infant’s O2 sat is below the time specific target.
Consider CPAP for persistent labored breathing.
HR <100bpm or infant is apneic or gasping:
Apply pulse ox.
Begin PPV.

11. Corrective Measures: MR SOPA
Reapply Mask
Reposition the head
Suction mouth and nose
Open infant’s mouth
Increase Pressure every few breaths until BBS and chest rise are evident. Do not exceed an inspiratory pressure > 40cmH2O
Use Alternative airway – endotracheal tube or laryngeal mask airway

12. Administering Oxygen
Every delivery area should have access to an air/oxygen blender and pulse oximetry.
Resuscitation of term newborns may begin with room air if blended oxygen is not available.
If baby is bradycardic (<60/min) after 90 seconds of resuscitation with lower FiO2, increase the FiO2 to 100%.
In preterm infants higher oxygen concentration may achieve target saturation more quickly.
Oxygen concentration is adjusted according to age in minutes and oxygen saturation

13. 3rd, 10th, 25th, 50th, 75th, 90th, and 97th SpO2 percentiles for all infants with no medical intervention after birth
Dawson et al, 2010

14. 3rd, 10th, 25th, 50th, 75th, 90th, and 97th SpO2 percentiles for term infants at ≥37 weeks of gestation with no medical intervention after birth.
Dawson et al, 2010

15. Third, 10th, 25th, 50th, 75th, 90th, and 97th SpO2 percentiles for term infants at weeks of gestation with no medical intervention after birth.
Dawson et al, 2010

16. Third, 10th, 25th, 50th, 75th, 90th, and 97th SpO2 percentiles for term infants at≤32 weeks of gestation with no medical intervention after birth.
Dawson et al, 2010

17. Targeted Pre-ductal SPO2 (Term infants)
60-65%
2 min
65-70%
3 min
70-75%
4 min
75-80%
5 min
80-85%
10 min
85-90%
This inter-quartile ranges are measured in term infants delivered following vaginal birth at sea level.

18. Use of Supplemental Oxygen
Term infant requiring IPPV
100% Oxygen vs. Air
No advantage
Increase time to first breath
Higher mortality
Potential harm at a cellular level in asphyxia model
Infants weeks- insufficient evidence

19. Use of Supplemental Oxygen
Infants <32 weeks
Do not reach targeted SpO2 in the first 10 minutes of life
Use blended oxygen to avoid hypoxia or hyperoxia
21% or 100% vs. 30% or 90%
In the absence of a blender, start with room air

20. Resuscitation of newborns: Room air vs. 100% oxygen
Resuscitation of newborns: Room air vs. 100% oxygen. Effect on Mortality.
RR<1 favors room air
Saugstad et al. 2005

21. When To Use Pulse Oximetry
Resuscitation is anticipated
PPV is administered for more than a few breaths
Cyanosis is persistent
Supplementary oxygen is used
The pulse oximeter probe is placed on the infant’s right hand or wrist and then connected to a pulse oximeter

22. Suctioning of airway Upper airway Tracheal suctioning
Not evidence to support or refute
Associated with cardio-respiratory complications
Tracheal suctioning
No evidence to suggest decrease in MAS
Decrease in Oxygenation
Increase cerebral blood flow
Increase intracranial pressure

23. Intubation
Attempts to complete intubation may now take up to 30 seconds.
Do not administer free-flow oxygen during intubation to an infant who is not breathing. It has no benefit.

24. None-Vigorous Infants with Meconium stained fluid
Care is in general unchanged
If intubation is difficult and the infant is bradycardic consider going to the next steps of resuscitation (dry, stimulate and clear the airway)
The only evidence available for use of tracheal suctioning is the study comparing suctioned babies with historical controls

25. Ventilation Initial breath in newborns requiring IPPV
Can use short or longer inspiratory time
Initial Peak pressure
Use to achieve increase heart rate and good chest rise
Preterm infants: cm H2O
Term infants: cm H2O
Optimal PEEP
Increase FRC, oxygenation and lung compliance
Reduce lung injury
Avoid High PEEP (8-12)

26. Positive Pressure Ventilation
A rising heart rate is the best indicator of effective PPV
If the heart rate does not show immediate improvement assess breath sounds and chest movement.
If these indicators are not present in the first attempted breaths of PPV the team proceeds to corrective action.

27. Monitoring during/after resuscitation
Tidal volume
No clinical outcome studies
Exhaled CO2 detectors to confirm intubation
Rapid and accurate than clinical methods
False Negative
Cardiac arrest
False Positive
Contamination with epinephrine, surfactant and atropine
** Use Exhaled CO2 detection + clinical assessment

28. CPAP CPAP vs. intubation+IPPV Preterm infants >25 weeks
No difference in death or CLD
Decrease use of surfactant
Increase in Pneumothorax
Term infants
No evidence

29. CPAP CPAP vs. IPPV with face mask Preterm infants
Decrease rate of mechanical ventilation
Decrease in CLD
* May use CPAP or Intubation in the delivery room!

30. Assisted Devices T-piece vs. Self-inflating vs. Flow-inflating bags
No clinical studies
Mechanical models favor T-piece resuscitator
Laryngeal Mask Airway
No extensive study
In cases where face mask or intubation fails
May use in infants >2000g or >34 weeks
No Evidence
Meconium stained amniotic fluid
Chest compression

31. Chest Compressions Indication: heart rate remains <60 bpm
Use 100% oxygen concentration
Coordinate PPV with chest compressions for seconds before reassessing heart rate
Intubation is recommended if chest compressions are required.

32. Chest Compression Chest compression and/or Ventilation
More efficient when combined
Sustained chest compression
Deleterious effect on myocardial and cerebral perfusion
Chest Compression : Ventilation ratio
3:1, 5:1, 15:2, 30:2
Less minute ventilation as the ratio increases
No human data available

33. Chest Compression 2 thumb-encircling hand technique-superior
Diastolic BP, quality chest compression and less tiring
Lower sternum than Midsternum
Depth: 1/3 AP diameter than deeper compressions

34. Epinephrine
Indication: Heart rate <60 bpm after at least seconds of coordinated PPV and chest compressions.
Administration through an umbilical line remains the preferred route.
ETT vs. IV administration
No randomized clinical trials
Case series and animal studies
ETT less effective than IV
ETT route has less blood concentration of epinephrine

35. Epinephrine-Ideal Dose
No randomized clinical trials
IV dose: ml/kg
Labeled 1 ml syringe and draw minimal dose of 0.1mL/kg.
IV epi >0.3ml/kg- no benefit
IV epi >1ml/kg
Increased risk of mortality
Interfere with cerebral perfusion and cardiac output
ETT epi (ETT Dose has changed)
0.5-1ml/kg to achieve adequate blood concentration
Labeled 3-6 ml syringe and draw up 1mL/kg.

36. Naloxone and Volume Expansion
No difference in clinical outcome
Associated with seizures if mother opiate addict
Concern about short and long-term safety
Volume expansion
If chest compression, ventilation and epinephrine fails
Most useful if history of blood loss
Maybe harmful if no history of blood loss

37. l-Received Volume infusion
Use of volume expansion during delivery room resuscitation in near-term and term infants.
l-Received Volume infusion
⏏-No Volume infusion
* p<.05
Wycoff et al, 2005

38. Temperature Control Large body of evidences Methods:
Polythene wraps or Bags
Exothermic mattresses
Delivery room temp >26°C
Risks associated with hyperthermia
Respiratory depression
Neonatal Seizure
Cerebral Palsy
Mortality

39. Laptook et al. Pediatrics 2008
Elevated Temperature After Hypoxic-Ischemic Encephalopathy: Risk Factor for Adverse Outcomes
Esophageal Temperature
OR (95% CI)
Death or Disability (n=99)
Death
(n=99)
Disability
(n=65)
Highest
4.0 ( )
6.2 ( )
1.8 ( )
Median
3.2 ( )
5.9 ( )
1.0 ( )
Lowest quartile
1.5 ( )
1.4 ( )
1.1 ( )
Laptook et al. Pediatrics 2008

40. Induced Hypothermia Large body of evidence Term and near-term infants
Initiated within 6hours of life
Significant reduction in death and neurodevelopmental disability at 18 months of life
NNT: 9
Patient recruited based on specific criteria
Cord or first ABG
Clinical findings (moderate to severe HIE)

41. Improved Pathology scores in Hippocampus when treated with therapeutic hypothermia and/or 21% oxygen during resuscitation.
*P<0.05
Suagstad, 2012

42. Glucose Hypoglycemia + HIE= brain injury Hyperglycemia + HIE
No adverse effect
Maybe protective
No randomized study to show specific glucose level

43. Cord Clamping Term: 1 min to no cord pulsation Improved iron status
Preterm: 30 seconds to 3 minutes
Higher blood pressure
Low IVH
Less transfusion
More phototherapy
Insufficient evidence

44. Non-Initiation of Resuscitation
Vary according to providers, regions and availability of resources
Parental role in decision making
Categories:
1- GA, birth weight or congenital anomaly suggest certain early death or unacceptably high morbidity
2- High rate of survival and acceptable morbidity
3- Uncertain prognosis, borderline survival and relatively high morbidity
Coordinated approach between Obstetrician, Neonatologist and parents.

45. Discontinuation of Resuscitation
No heart beat for 10 minutes
Death or Severe neurologic disability
Evidence: small number of babies
Decision influenced by:
Gestational age
Etiology of arrest
Parents previous expressed feeling

46. A New Educational Approach
2004-Joint Commission Report: 47 infant deaths and or injuries related to the birth process
The root cause was related to ineffective teamwork and communication.
Joint Commission recommendations:
Team training
Clinical drills
Debriefings

47. NRP Response to Joint Commission
5th Edition
Passive learning
Poorly prepared participants
Components for content and technical skills, not teamwork and communication
Instructors and participants were not challenged by the class format
6th Edition
Active learning
Self study and online examination prior to class participation
Skill practice and simulation-based scenarios aimed at promoting teamwork and communication
Debriefing

48. NRP Education Simulation As adjunct to traditional training
Enhance performance
Experience obtained from high risk organizations
Airlines, NASA, Military
Briefing and de-briefing
Improve knowledge, skill and behavior

49. Simulation and Debriefing
Key Behavioral skills targeted
Know your environment
Anticipate and plan
Assume leadership role
Communicate effectively
Delegate workload optimally
Allocate attention wisely
Use all available information
Use all available resources
Call for help when needed, and early
Maintain professional behavior

50. Summary
Progression to next step following initial resuscitation depends on heart rate and respiration.
Oximetry to be used to assess oxygenation
Term babies- best to start resuscitation with room air than 100% oxygen
Use blender when oxygen is needed and should be guided by oximetry
No evidence to support or refute endotracheal suctioning in meconium stained fluid, even in depressed newborn

51. Summary Chest compression: ventilation ratio stays 3:1
Consider therapeutic hypothermia in term and near-term infants with moderate to severe HIE
Consider stopping resuscitation if no detectable heart rate for 10 minutes
Delay cord clamp for at least 1 minute in those who does not require resuscitation

52. Implication Old habit vs. New information
More time vs. Efficiency vs. Cost
Education or Debriefing
Pulse oximeter
Shared responsibility vs. Neonatal Team
Conditions where Oxygen is needed
PPHN
Meconium Stained Amniotic Fluid
Lack or need for more evidence

53. Implication Legal Implication (especially in depressed newborns)
All hospital need to have oxygen blender in the DR
Use room air
Self inflating bag without reservoir (40% O2)
CO2 detectors
Correct BMV taught to providers not skilled in intubation
Hypothermia
Preventable condition in a court setting
Therapeutic Hypothermia within 6hrs of life
Preference of IV route to give epinephrine
States law credentialing nurses to put a UVC

54. Do we need a new Apgar score?
Virginia Apgar 1 2
Heart Rate
<100
>100
Respiration
Weak, irregular
Good cry
Reaction
Slight
Good
Color
Blue/pale
All pink, limb blue
Body pink
Tone
Limp
Some movement
Active movement, well flexed limbs

55. Reference 1- Carson et al. American J Obstet Gynecol. 1976:126:712-715
2- Ting et al. American J Obstet Gynecol. 1975;122:
3- Gregory et al. J Pediatr. 1974;85:
4- O’Donnell et al. J Pediatr. 2005;147:
5- Davis et al. Lancet. 2004;364:
6- Rabi et al. Resuscitation. 2007;72:
7- Escrig et al. Pediatrics. 2008;121:
8- Wycoff et al. Pediatrics 2005;115:
9- Finer et al. Pediatrics 1999;104:
10- Wycoff and Berg Seminars Fetal and Neonatal Med 2008;13:
11- Perlman et al. Pediatrics 2010;126:e1319-e1344
12-Perlman et al. Circulation;122(suppl 2):S516-S538
13-AAP News, October 2011
14-Dawson et al. Pediatrics 2010; 125 (6),e1340-e1347
15-Suagstad et al. Pediatrics Research 2012;71:247-52
16-Wycoff et al. Pediatrics. 2005, Apr;115(4):950-5.
17-Laptook et al. Pediatrics 2008, Sept;122 (3):
18-Saugstad et al. Biol Neon 2005

56. Do Not Attempt This! ?
Questions / Comments 56