AMBER MCCAW RNC BSNBIRTHPLACEFALL 2011

NRP 6th Edition Update

Neonatal resuscitation is most effective when performed by a designated and coordinated team. Periodic practice of skills is

key!

Key Behavioral Skills in NRP

* Behavior skills such as teamwork, leadership and effective communication are critical to successful resuscitation of the newborn* 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

What is different in the flow chart?

At birth, answer 3 questions to determine the need for initial steps at the radiant warmer:

Is this newborn term? Is this newborn breathing or crying?Does this newborn have good muscle tone?** If any answer is “no” the newborn should receive initial steps on the radiant warmer**

NRP Course Options

No more renewal course. Everyone takes a Provider Course tailored to the needs of the learners.

All learners must self-study the NRP book, take an online exam and then participate in a group simulation.

Simulations

There is little or no lecture. Simulations intended for learner to have HANDS

ON learning, immersive simulations and constructive debriefings.

• Integrated and Performance skill stations are used for learning, review, practice and evaluation.

Equipment Check

Equipment check is a new ‘Performance Skills Station’ in Lesson 1. DEMO on CD in back of book!

“Quick Pre-Resuscitation Checklist” is a new tool that enables you to check the presence and function of the most essential equipment and supplies at the radiant warmer.

Equipment Check Video

Click on Video to View

Quick Pre-Resuscitation Checklist

Warm Preheat warmerTowels or blankets

Clear airway Bulb syringe10F or 12F suction cath attached to wall suction set at 80-100 mm HgMeconium aspirator

Auscultate StethoscopeOxygenate Method to give free flow O2

Gases flowing just prior to birth, 5-10 L/minBlenderPulse oximeter and probe

Ventilate PPV device with term and preterm masks—test to assure that the PPV device is workingHave air/oxygen source8F feeding tube with 20mL syringe

Intubate Laryngoscope and blade size 0 and 1—assure light is workingET tubes size 2.5, 3.0, 3.5 and 4.0StyletsEnd tidal CO2 detectorLMA size (1) and 5 mL syringe

Medicate Access to 1:10,000 epinephrine and NSSupplies for administering meds and placing emergency umbilical venous catheterCode cart sheet

Thermoregulate Plastic bag or plastic wrap (code cart)Chemically activated warming pad (code cart)

other

No longer Optional:

Compressed air source

Oxygen blender to mix oxygen and compressed air to flowmeter.

Pulse oximeter and oximeter probe

Laryngeal mask airway

New Flow Chart!

What is different in the flow chart?

Prior to beginning the steps ask the provider for relevant perinatal history, including these questions:

What is the gestational age? Is the fluid clear?How many babies are expected?Are there any other risk factors?

Flow chart changes cont;

The vigorous meconium stained newborn need not receive initial steps at the radiant warmer, but may receive routine care (with appropriate monitoring) with his mother.

Clear airway by wiping the baby’s mouth and nose (if necessary), dry, and provide ongoing evaluation of breathing, activity and color on mom’s chest—skin to skin.

Suctioning following birth (INCLUDING bulb suctioning with a bulb syringe) should be reserved for babies who have obvious obstruction to spontaneous breathing or who require positive-pressure ventilation.

Flow chart changes cont;

***Note*** : The flow diagram stops at 60 seconds and adds an extra step (take ventilation corrective steps—more info. later) to ensure effective ventilation.

Birth-----30 secs: The baby should be warmed, dried, the airway cleared, stimulated and you should be checking the HR.

Initial Steps:

o Position head to open airway. Dry, stimulate, reposition to open airway.

o Evaluate respirations and heart rate. If HR <100 OR newborn is apneic or

gasping:

BEGIN PPV!

If HR >100 but respirations are labored:Consider CPAP; esp. for preterm infants

Initial Steps:

Evaluation and decision making are based on respirations, HR and oxygenation via PULSE OXIMETER.

After ENSURING effective ventilation for 30 secs, if HR remains <60, provide chest compressions.

Use of Oxygen and Pulse Oximetry

A compressed air source, oxygen blender and a pulse oximeter should be available in the immediate delivery area for birth.

While there is still controversy over how much oxygen to use during neonatal resuscitaiton, the resuscitation of TERM newborns may begin with 21% oxygen; with PRETERM newborns it is ok to begin with a somewhat higher concentration.

Pulse Oximetry

APPLY pulse oximeter to the RIGHT HAND when: Resuscitation is anticipatedPPV is required for more than a few breathsPersistent central cyanosis, or if you need to

confirm your perception of central cyanosisAny administration of supplemental oxygen

**Place on hand first; then attach to machine**

Targeted Pre-ductal SaO2

Targeted Pre-ductal SPO2After Birth

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

Pulse Oximetry Table

Use the targeted O2 saturations to gage your amount of oxygen to give the newborn

Care should be taken to AVOID oxygen saturation exceeding 95%

It may take up to 10 minutes for a healthy newborn to exceed to the normal range of over 90%

Pulse Oximetry Video

Click on Video to View

CPAP

CPAP: continuous positive airway pressure Consider if:1. If a baby is breathing spontaneously and has a HR

>100, but has labored respirations, is cyanotic or has low O2 saturation (not meeting targeted saturation levels in the ‘Targeted O2 Sat’ table.

*CPAP cannot be given via Self-Inflating bag*Practice your CPAP skills and see demo on NRP DVD

CPAP Video

Click on Video to View

Positive Pressure Ventilation

• Use self inflating bag or t-piece resuscitator (Neopuff)

Start with PIP (peak inspiratory pressure) of about 25 mmHg for Term Newborns and 15-20 mmHg for Pre-term Newborns. MAX IS STILL 40 mmHg!

Avoid EXCESSIVE chest movement. Use lowest inflation pressure to maintain HR >100

bpm and a gradually inproving O2 Sat. Assess for rising HR and improving O2 sat. If not

evident in 5-10 breaths…you may need to perform

The Ventilation Corrective Steps: Mr SOPA

T-piece Resuscitator a.k.a. Neopuff

Gas from a compressed air source enters at the gas inlet

Pressure controls for maximum pressure, desired peak inspiratory pressure (PIP) and peak end expiratory pressure (PEEP)

Can give blow by occluding PEEP cap

Neopuff Video

Click on Video to View

MR SOPA

Ventilation Corrective Steps:(if no chest movement or breath sounds with PPV)

M-mask readjustmentR-reposition head-Reattempt PPV-

S-suction mouth and noseO-open mouth-Reattempt PPV-

P-increase Pressure- increase pressure every few breaths to max of 40 cm H20 until chest movement and breath sounds.A-consider Alternate airway—ET, LMA

MR SOPA Video

Click on Video to View

Effective Ventilation

DEFINITION: Bilateral Breath Sounds

Chest Movement--*Note: HR may rise without visible chest movement, especially in preterm newborns

Chest Compressions

Chest compressions are indicated when HR remains below 60 despite 30 secs of effective ventilation.

Increase O2 to 100% upon starting chest compressions

Thumb technique preferred; andMay be given from the head of the bed.

Intubation strongly recommended with chest compressions.

Chest Compressions

Interruption of chest compressions to check heart rate may result in a decrease in perfusion pressure.

Therefore, continue chest compressions for at least 45-60 secs before stopping briefly to check the HR.

Endotracheal Intubation

Recommended when: Tracheal suctioning of non-vigorous mec-stained NB No improvement with PPV and bag mask ineffective despite

corrective actions The need for PPV beyond a few mins Upon starting chest compressions Extreme prematurity or other anomalies

New: You have up to 30 secs to complete intubation

Laryngeal Mask Airway: LMA

*The laryngeal mask airway has been shown to be an effective alternative for assisting ventilation.*INDICATIONS: Facial or upper airway malformations render ventilation by mask

ineffective PPV with mask fails to achieve effective ventilation and intubation

is not possible.LIMITATIONS: Size 1 device that we have is too large for babies 32 weeks or less. The device cannot be used to suction meconium. An air leak may result in inefficient pressure to the lungs Not enough evidence to support medication administration or for

prolonged use.

LMA Video

Click Here to View Video

Emergency Umbilical Kit

Epinephrine is indicated when HR < 60 bpm after 30 secs of effective ventilation and at least 45-60 secs of coordinated chest compressions and effective ventilation

Insert an emergency umbilical venous catheter for administration of epinephrine

Epinephrine dose

Recommended concentration: 1:10,000

IV dose (same): 0.1-0.3 mL/kg in a 1 mL syringe

Intratracheal dose NEW: 0.5 to 1 mL/kg in a 3-6 mL syringe.

Volume Administration Changes

Indications include: NB not responding to resuscitation AND Newborn appears to be in shock OR There is a history of a condition associated with

fetal blood loss. *Note: Volume may be considered even if there hasn’t been an obvious blood loss, but bradycardia persists.

Dose: 10mL/kg over 5-10 mins (NS, LR or O neg.)via the umbilical line

Preparing and Placing an Emergency UVC-Two Video’s

1st video: Preparing for Emergency UVC Insertion

2nd video: Placing an Emergency UVC LineClick on video #1 to begin

Click on video #2 to begin

Therapeutic Hypothermia

Used for babies who have been diagnosed with moderate to severe Hypoxic-Ischemic Encephalopathy (HIE) AND:

Babies > or = to 36 weeks Initiated within 6 hours after birth

We may be asked by physicians to simply turn off the radiant warmer, unwrap the baby or remove a hat.

The entire program is usually continued by tertiary care centers who have NICU’s.

Resuscitation of Preterm Babies

Additional Resources: 1 staff member to intubate and another staff member to place the emergency umbilical catheter needed.

Increase room temp to 77-79 degrees F. Use plastic wrap or food grade plastic for 29

weeks or less gestation

2 levels of Post-Resuscitation Care

Routine care: Babies who responded to the initial steps without further need for support.

Post-resuscitation care: For babies who have depressed breathing or activity, and/or require supplemental oxygen. Require frequent evaluation. Some may transition to routine care; others will require ongoing support.

Simulation Videos

View a simulation that you will be participating in when you either take NRP for the first time or renew.

Video #1 is a “basic technology” scenario

Click Here to View Video #1

Video # 2 is a “complex technology” scenario

Click here to view Video #2

American Academy of Pediatric Support

Double click picture below to view full article regarding these changes:

Thank you!

It takes a village!