2012 NRP

6th Edition Review of Changes in NRP

By: Cayce Hendrix, RRT-NPS

What is the Same?

Renewal every 2 yrs

Course is designed for those who work with

newborns (NICU, SCN, L&D, NBN)

NRP certification does not certify or ensure

competency to perform the skills learned in an

actual newborn resuscitation.

You will not be expected to place UAC, needle

decompress chest, intubate etc.

You will still work within your SCOPE of practice

What are some Differences?

Differences noted in Red for this PowerPoint

No more Renewal course…everyone takes a

Provider Course tailored to the learner’s

needs and scope of practice

9 CEU’s for Nursing and Respiratory

On-Line Examination

Online Examination is now required

There is no written Exam anymore…only available

Online beginning Jan. 1st 2012

Must complete the Online Exam within 14 days of

starting the exam

You may skip and return to questions, or change your

answers until the lesson is submitted

80% score needed to pass each lesson

Each test section can be retaken 1 time if needed

Once the Online Exam has been passed, the

student has 30 days to take the live NRP course

Provider Course Program Changes

No video viewing before Megacode

There is video for learning located in back cover of

NRP learners manual

Little to no lecture

More hands-on learning

Skill stations used for learning, review, and practice

Clinical Simulations & Megacode

Improves teamwork and communication

Constructive debriefings

Discuss how things could have been done better for

future learning and constructive communication

Simulation Simulation training is not required

Training is dependant on

Good methodology

Not technology

But the Sims Center is where we would like to do our NRP training

More life-like Sims baby

Less focus on asking questions

Is the baby breathing, what is heart rate etc.

More responding to Simulator baby

Baby can breathe…or not

Has a changing palpable heart rate

Visible tone & color changes

Can have seizures, pnuemothorax, UAC placement etc.

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

The following are no longer “optional”

but should be available for every birth

Compressed gas source

Blended Oxygen with flowmeter

Pulse Oximetry

LMA size 1 (Laryngeal Mask Airway)

There are 2 levels of post-resuscitation

care (instead of the 3 levels of care)

Routine Care:

Vigorous term infants with no risk factors

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 NBN

Post-Resuscitation Care:

Babies with depressed breathing or activity

Those requiring supplemental oxygen &/or

ongoing nursing care

Those with high risk factors to be evaluated in an

ICU setting

Those who require frequent evaluation

Baby may possibly then transfer to routine care

after a period of time

Transfer to NICU

There are 2 levels of post-resuscitation

care (instead of the 3 levels of care)

What to ask OB prior to delivery

What is the gestational age?

Is the fluid clear?

How many babies are expected?

Are there any additional risk factors?

This is the only new addition to this step

At birth, answer 3 questions to determine

the need for the initial steps at the RHW

Is the newborn term?

Is the newborn breathing or crying?

Does the newborn have good muscle tone?

If the answer is NO to any question…the newborn

should receive the initial steps at the RHW

Suctioning after birth :

Bulb or Catheter

Should be reserved for babies who have

Obvious obstruction to spontaneous breathing

Those requiring PPV (positive pressure ventilation)

Vigorous Meconium-Stained newborns

Are NO longer required to go to RHW

May receive Routine Care with Mother right after

birth

Appropriate monitoring

Evaluation Process

Subsequent evaluations and decision-making

are based on

Respiratory effort

Heart rate

Color / Oxygenation

Based on Pulse Oximetry

PPV & CPAP

After clearing airway as necessary, drying and

removing wet linen, repositioning & stimulation

Evaluate respirations and heart rate

Not color

If HR <100 or if newborn is apneic or gasping-PPV

If HR >100 but respirations are labored-CPAP

(continuous positive airway pressure)

Especially with preterm infants

Pulse Oximetry & Evaluation of Color

Use POX when:

Resuscitation is anticipated

PPV is required for more than a few breaths

Central cyanosis is persistent

To confirm your perception of central

cyanosis

Whenever supplemental oxygen is

administered

Pulse Ox & Oxygen

Administration Term infants may be resuscitated with 21% O2

Preterm infants may begin with a somewhat

higher oxygen concentration

Pulse Ox probe on right hand or wrist

Measures the pre-ductal saturation

Place on patient before connecting to Pox

machine to achieve the fastest readings

Pox & Oxygen Administration

Supplemental oxygen concentration should be

adjusted gradually to achieve pre-ductal

Saturations summarized in the NRP diagram

below (Both Term & Preterm)

Target Spo2 after birth:

1min 60-65%

2min 65-70%

3min 70-75%

4min 75-80%

5min 80-85%

10min 85-95%

PPV Indications

Apnea

Gasping

Heart rate <100

Even with strong respiratory drive

Persistent central cyanosis

Low oxygenation despite free-flow oxygen

increased to100%

PPV Devices

T-Piece Resuscitator

Self-inflating bags

Flow-inflating bags

Pressure Gauge Manometer on all AMBU

bags

PPV Assessment

PIP’s of 20cmH2O should be sufficient for good chest rise in most newborns

Best indicator that you are bagging correctly is an increase in heart rate

^ in HR should be evident within 5-10 breaths

If not-then following the corrective actions

MR SOPA

MR. SOPA

M- Adjust Mask in the face

R- Reposition the head to open airway Re-attempt to ventilate…if not effective then

S- Suction mouth then nose

O- Open mouth and lift jaw forward Re-attempt to ventilate…if not effective then

P- Gradually increase Pressure every few

breaths until visible chest rise is noted Max Pip 40cmH2O

If still not effective then…

A- Artificial Airway (ETT or LMA)

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

Chest Compressions

HR <60bpm despite effective ventilation

Coordinate with ventilations for at least 45-60sec

before stopping briefly to assess heart rate

2 hands wrapped around chest with 2 thumb

technique is preferred method of chest compressions

Be careful to concentrate pressure onto heart not over

entire chest

Note your thumb position

Compress 1/3 diameter of chest

90 compressions to 30 ventilations/minute (120 events)

One & two & three & breathe & One & two & three &

breathe &…

Chest Compressions

Increase FiO2 to 100% once you begin compressions

Adjust FiO2 to Pox readings

Pox may not work while newborn is receiving chest

compressions

Intubation is strongly recommended when

compressions begin

You now have 30sec to attempt intubation

LMA may be indicated as an alternative to intubation

when

Facial or upper airway malformations render bag-mask ventilations ineffective

PPV not effective and intubation is not possible

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 to allow room for

MD to place UVC

Epinephrine

Epinephrine is indicated when heart rate

remains <60

After 30 seconds of effective ventilations

And at least another 45-60sec of

coordinated compressions and ventilations

ETT route

Unreliable absorption

Less effective

But readily available so give while establishing UVC

UVC route

Preferred method

Requires skills to place line

May give dose soon as line is placed even after just

giving via ETT

Epinephrine

Epinephrine 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 0.5 – 1ml flush NS

Re-check heart rate after 1minute of compressions and ventilations

Maybe longer if give ETT

Repeat dose every 3 – 5 minutes

Epi can be given again immediately after UVC placement if given initially down ETT

Preterm Newborns

Increase temperature of the delivery room to

approx. 25’C – 26’C (77’F – 79’F)

Polyethylene plastic wrap

Place portable warming pad under the layers of

towels at the RHW

Blended O2

Consider CPAP for good heart rate but ^ WOB

Therapeutic Hypothermia for HIE

Cooling used for >/= 36wks

& meet special criteria for this modality

Usually initiated before 6 hours after birth

Please Contact Cathy White,

your NRP Regional Trainer at

cathy.white@palmettohealth.org

for any questions regarding

implementing the NRP 6th Edition

at your Institution.