Case based Discussions in NRP

Case based Discussions in NRPSteven Ringer MD PhDOctober 19 2012ConflictsI have no actual or potential conflict of interest in relation to this presentation.I am a member of the NRP Steering CommitteeChanges in PracticePractice Gap 1

- Resuscitation practice guidelines are based on review and compilation of available evidence

- Initial questions posed when consulted for care at birth include GA, respiratory effort and tone

Good communication is a key component of providing good care resolves in most casesLearning Objective 2

Understand the ILCOR process and how it results in recommendations for care

Identify the critical areas for rapid and effective communication, best allowign adequate anticipation of needs

Recognize that clear communication between disciplines is a key behavioral skill that must be fostered and facilitatedTwo Changes you may wish to make in your practiceFacilitate team assessment and debriefing as part of resuscitation to identify understanding of practice guidelines, areas of good practice and those requiring improvement

Practice the use of oximetry guided oxygen use in different clinical scenarios and refine practice through the use of team based simulation and debriefing.

Changes in PracticePractice Gap 2

- Clinical assessment of oxygenation is unreliable in the newly born

-Normal oxygen levels are not achieved until 5-10 minutes in healthy term infants

Use of oximetry allows better tailoring of oxygen and minimizes over use

Team structure and communication results in enhanced care and better adherence to practice guidelines

Learning Objective 2

Understand the limitations of clinical assessment in the newly born infant with respect to color and oxygen

Indentify the concept of target oxygen saturation levels at each minute after birth, and how they are used

Understand the use of oximetry to guide oxygen use, including correct placement of monitoring probes, changes in oxygen concentration in response to measured levels.

Describe the way team functioning facilitates better care and the need to identify and communicate roles within the team

Neonatal Resuscitation Program- where do Guidelines come from?Evidence relating to resuscitation is reviewed on a five year cycle by ILCOR- International Liaison Committee on ResuscitationThe NRP Steering Committee participates in this processILCOR ultimately defines the scientific principles behind resuscitation and develops treatment recommendations Neonatal Resuscitation Program- where do Guidelines come from?The Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR) published by ILCOR in October 2010Each resuscitation council, including NRP for USA, developed and published Resuscitation Guidelines and treatment recommendations, appropriate for its own resources (based on CoSTR)If evidence is lacking, treatment recommendations stay the same, even if there is no evidence for them

Without specific evidence to recommend a change, the ruling on the field standsNeonatal Resuscitation Program- where do Guidelines come from?Guidelines are evidenced based- to the extent that evidence is available!They are guidelines. As such, they can not fully anticipate all the nuances of clinical situations.They do provide a framework that is well suited to almost all resuscitation scenariosWhile the principles apply to most cases, in some you must interpret the approach to best fit the unusual patient

What NRP offersNRP is an educational program that introduces concepts and basic skills of neonatal resuscitationNRP is not intended to set a strict Standard of CareCompletion of the program does not imply competence Each hospital has a responsibility to determine competence and qualificationsNot only are individual skills important, but resuscitation requires a well functioning teamHow do we learn and improve?Not by looking at and listening to a lecture and slidesSimulation and debriefing provide valuable insight and learning not available by passive instructionSimulation also allows us to work through unusual cases that dont seem to exactly fit the moldOn to casesMajor areas of change in 2010 GuidelinesTopics that have caused questions to ariseWhat is bothering you??Case 1A 37 year old G2P1 female is in labor at 41 weeks. She develops a fever to 101.2 and is treated with antibiotics during labor. The membranes rupture spontaneously and the fluid is noted to be meconium stained. Other than some variable decelerations the fetal heart rate tracing is unremarkable. The mother progresses to a spontaneous vaginal delivery. What questions ought you to quickly ask at delivery?ARQ 1What questions should you ask at delivery?A. Is the baby term, is there meconium stained fluid, is the baby vigorous?B. Is the baby breathing, Is the baby term, Is the tone good?C. Is there meconium stained fluid, is the baby term, is the baby breathing?

Initial Questions reduced to THREE:Is the baby term?Is the baby breathing?Is the tone good?Vigorous= normal, regardless of AF

Oximetry is the standard!In its absence: adequate ventilation is more important than higher FiO2Case 2The baby, who is term, is crying and moving all his extremities well.ARQ 2What should be the sequence of care?

A. Suctioned by Obstetric provider at perineum, evaluation at warmer by Pediatric teamB. Suctioned at perineum if secretions copious, taken to warmer, intubated, suctionedC. Suctioned at perineum if secretions copious, given to mother SuctioningEvidence indicates suctioning can cause bradycardia during resuscitation, or pulmonary decompensation and reduced cerebral blood flow in intubated patientsSuctioning secretions can decrease pulmonary resistance20o5 Guidelines stressed NO ROUTINE suctioning of airway before delivery of the bodyTrue whether fluid is clear or meconium stained

Suctioning after birthIf there is Clear Fluid: limit suctioning to those with obvious obstructionStop routine bulb suctioning of all babiesIf fluid is meconium stained, must determine if baby is vigorousVigor: Good HR, Good cry, Good toneIf infant is vigorous, as this baby appears to be, they do not need any special interventionLeave VIGOROUS babies with mother!

SuctioningMeconium: Suction non vigorous babies Depressed infants with MSF are at increased risk of MAS Tracheal suctioning has not been associated with less MAS or mortality, other than single trial with historical controlsThere is no evidence to change practice of intubating and suctioning non vigorous babies Attempts should not significantly delay PPV if there is bradycardia Leave VIGOROUS babies with mother!Case 1After two minutes with his mother, the baby has some mild grunting and flaring and is brought to the warmer. Your team evaluates him- he appears to be term, well-formed but has some noticeable grunting. One member of your team notes that he appears cyanotic, and wants to give him blow by oxygen.

ARQ 3How might you approach this, and why?

A. Ask team member to place oximeter probe on leg, give oxygen if saturation is less than 90%B. Ask team member to place oximeter on right upper extremity, give oxygen if saturation is below target rangeC. Give oxygen until baby turns pink in opinion of all caregivers presentHow pink is a fetus?

Dildy GA, et al. Am J Obstet Gynecol. 1994;171:679684What are Normal O2 saturations in Vigorous Term Newborns in the DR?3 min66% (56-75%)5 min80% (55-85%)7 min 83% (68-88%)

Lundstrm et al Arch Dis Child 1995; 73:F81-6.

Toth et al. Arch Gynecol Obstet 2002;266:105-7.N=50 SVD, TermVigorousPost-ductal O2 sats in the DRWhat are Normal Preductal O2 Sats in Vigorous Term Newborns at Birth?1 min63% (53-68%)2 min70% (58-78%)3 min 76% (64-87%)4 min81% (71-91%)5 min 90%(79-91%)

Kamlin et al J Peds 2006; 148:585-9.Pre ductal readings are the idealTake Home MessageMajority of evidence suggests it takes ~5-10 minutes for healthy, term newborns to reach O2 saturations >90% (pink)

Therefore, giving O2 to vigorous, term infants before 5-10 minutes is unnecessary.How often do you think this happens now when pediatric team is present??Is O2 in the Delivery Room better?We have increasing evidence that too much oxygen is not harmless in other clinical situationsPreemies:Chronic Lung DiseaseRetinopathy of Prematurity

Newborns are relatively deficient in defense mechanisms that protect against oxygen toxicity and therefore too much oxygen may result in oxygen free radicals that are highly reactive and can cause damage to tissuesConsensus on Science for O2Meta-analysis of 7 human studies of infants resuscitated with room air (RA) versus 100% O2 [LOE 1] Reduced Mortality No evidence of harmOther concentrations not studiedHoweverThe 4 largest studies were not blindedIf no response after 90 sec, RA infants switched to 100% O2Other significant methodologic concerns regarding patient selection, randomization methods, and follow-up

No data regarding RA vs O2 for resuscitation of infants with birth weight < 1000 gcongenital pulmonary or cyanotic heart diseaseAsystole

Is there a Potential for Harm?Naumburg et al. Supplementary oxygen and risk of childhood lymphatic leukemia. Acta Paediatr 2002;91:1328-33. (Sweden)Prospective association between any oxygen exposure in the DR and childhood acute lymphatic leukemia 2.5X the risk of ALL (1.21-6.82)> 3 minutes of O2 with BMV3.54X the risk of ALL (1.16-10.8)

How do you do it: O2 For Initiation of ResuscitationResuscitation should be focused on results (normally increasing oxygen saturations) not on oxygen concentration. For term and late preterm infants it makes sense to begin in RA and wean-up as dictated. There is no data on use of intermediate concentrations.If resuscitation is started with less than 100% O2, supplemental O2 up to 100% should be administered if there is no appreciable improvement within 90 seconds following birth.

If supplemental oxygen is unavailable, it is fine to use air while delivering positive-pressure ventilation.

How do we assess the baby, or Why do we Need Pulse Oximetry in the DR?NRP previously recommended using color to decide if oxygen is needed. Now an Oximeter is recommended

How good are we at judging color?

ODonnell et al. ADC 2007.Video Recording with Hi-fidelity color and simultaneous SaO2 monitoringDo clinicians agree whether infants are pink?At what preductal SaO2 are infants first perceived as pink?

31They were asked to indicate, for each video, whether the infant looked pink at the beginning, whether the infant became pink during the video or whether the infant never looked pink. If the judged the infant turned pink, they indicated the time on the clock when this occurred. The infants sat at this time was subsequently determined by the research team.Clinical Assessment of Infant Color at Delivery

ODonnell et al.. ADC 2007.O2 Sat at Which Infant PinkODonnell et al. ADC 2007.

33Boxplots showing median, interquartile range, outliers and extremes of o2 sats at which observers determined infants in 20 videos to be pink. Infants are ranked by increasing median sat at which they were determined pink.Kamlin et al J Peds 2006; 148:585-9.

Oximeter needed, but Can you get it to work?Study of healthy term and preterm infants- low cardiac output can reduce signalYou can get it on, but it takes TEAM work and practice!!Preductal oxygen saturation targets1 minute60-65%2 minutes65-70%3 minutes70-75%4 minutes75-80%5 minutes80-85%10 minutes85-95%BLUEPINK ARQ 4When is the use of oximetry indicated?

A. Only for premature infantsB. When using oxygen or PPVC. At all births attended by Pediatric teamThe Practice: Term and Late Preterm babiesMonitor saturations, compare at interval times to posted chart. Team monitoring works best.Adjust oxygen as needed to achieve target saturation range

Oximeter also often helpful to monitor pulseOximetry often not usable when cardiac output is low. ARQ 5If saturation level is below target for age in minutes, how much do you increase to amount of oxygen?A. 10%B. 20%C. 30%D. To 100%Case 1The measured saturations are initially below the target range for minute after birth. The oxygen level is gradually increased until saturations are in target range.The baby stabilizes, and is able to wean out of supplemental oxygen over 10 minutes. Case 2A G3P2 woman presents at 27 weeks gestation with recent onset of elevated blood pressures and an evolving picture of rising liver enzymes and decreasing platelet count. She is given a dose of betamethasone and standard therapy for preeclampsia/HELLP syndrome, but her condition worsens and she is taken for Cesarean delivery about 2 hours after admission. The baby emerges with fair tone and minimal respiratory effort. ARQ 6What steps would you take next?A. Immediately give oxygen and stimulateB. Place in plastic wrap under warmer, ask team member to place oximeter on RUEC. Place oximeter on RUE, stimulateTemperature ControlAll newborns are at risk for hypothermia after birth:Relatively cool environmentHigh surface area to volumeRisk factor for morbidity and mortalityBabies