NRP & STABLE UPDATES

1. NRP & STABLE UPDATES Lori Fairfax, APRN-Rx & Jaymie H. Pinho, APRN-Rx

2. NRP Initial Steps • Position infant, suction the mouth then the nose PRN if secretions visible • Dry the infant off & remove wet blankets • Stimulate the infant by rubbing back or flicking soles of feet • Begin PPV if infant apneic or gasping

3. Initial Steps con’t • Check heart rate by listening with a stethoscope or palpating umbilical cord (tap out HR for all to see) • Assess O2 sat- provide O2 blow-by (8LPM starting with FIO2 @ 40%) if infant remains cyanotic • For premature infant If HR > 100 but distress noted, give CPAP of 5-6 cm (PEEP) with bag & mask

4. Target SpO2 values

5. Key Points • Ventilation is the key to newborn resuscitation • Increasing HR is a signal that resuscitation efforts are effective • If mom is on a MgSO4 gtt, infant likely to have decreased respiratory effort & will require PPV • ABC’s

6. Reminders • Infant < 28 weeks, use 2.5 ETT weight: <1000 gms • Infant 28-34 weeks, use 3.0 ETT weight: 1000-2000 gms • Infant 34-38 weeks, use 3.5 ETT weight: 2000-3000 gms • Infant >38 weeks use, 4.0 ETT weight: >3000 gms Emergency UVC place to 2-4 cms until blood return noted

7. Medication Doses • Epinephrine 1:10,000 concentration 0.1-0.3 ml/kg for UVC/IV, 0.5-1.0 ml/kg for ETT use, given rapidly • Normal Saline bolus 10ml/kg via UVC/IV use –give over 5-10 mins unless a known placental abruption or previa

8. Major changes to NRP 2010 • Infants without antenatal risk factors who are born by elective C/S performed under general anesthesia at 37-39 weeks of gestation have a decreased requirement for intubation but a slightly increased need for mask ventilation compared to infants after NSVD. Such deliveries must be attended by a person capable of providing mask ventilation but not necessarily by a person skilled in neonatal intubation.

9. Once PPV or supplemental O2 administration is begun, assessment should consist of simultaneous evaluation of clinical characteristics: HR, RR, and evaluation of the state of oxygenation. State of oxygenation is optimally determined by a pulse oximeter rather than by simple assessment of color. Assessment of color is subjective. There is now data regarding normal trends in oxyhemoglobin saturation monitored by pulse oximeter.

10. Pulse oximetry, with the probe attached to the right upper extremity, should be used to assess any need for supplementary O2. For infants born at term, it is best to begin resuscitation with air rather than 100 % O2. Administration of supplementary O2 should be regulated by blending O2 and air, and the amount to be delivered should be guided by oximetry monitored from the right upper extremity. (i.e.: usually the wrist or palm) Evidence is now strong that healthy infants born at term start with an arterial oxyhemoglobin saturation of < 60% and can require more than 10 minutes to reach saturations of > 90%. Hyperoxia can be toxic, particularly to the preterm infant.

11. Suctioning immediately after birth (including with a bulb syringe) should be reserved for infants who have an obvious obstruction to spontaneous breathing or require PPV. There is insufficient evidence to recommend a change in the current practice of performing ET suctioning of non vigorous infants with meconium-stained amniotic fluid. There is no evidence that active infants benefit from airway suctioning, even in the presence of meconium, and there is evidence of risk associated with this suctioning. The available evidence does not support or refute the routine ET suctioning of depressed infants born through meconium-stained amniotic fluid.

12. Exhaled CO2 detectors are recommended to confirm ET intubation, although there are rare false negatives in the face of inadequate cardiac output and false positives with contamination of the detectors. Further evidence is available regarding the efficacy of this monitoring device as an adjunct to confirming ET intubation.

13. The recommended compression-to-ventilation ratio remains 3:1. If the arrest is known to be of cardiac etiology, a higher ratio (15:2) should be considered. The optimal compression-to-ventilation ratio remains unknown. The 3:1 ratio for newborns facilitates provision of adequate minute ventilation, which is considered critical for the vast majority of newborns who have an asphyxial arrest. The consideration of a 15:2 ratio (for 2 rescuers) recognizes that newborns with a cardiac etiology of arrest may benefit from a higher compression-to-ventilation ratio.

14. It is recommended that infants born >/= 36 weeks of gestation with evolving moderate to severe HIE should be offered therapeutic hypothermia. Therapeutic hypothermia should be administered under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-up. Several randomized controlled multicenter trials of induced hypothermia of newborns >/=36 weeks’ gestational age with moderate to severe HIE showed infants who were cooled had significantly lower mortality and less neurodevelopmental disability at 18-month follow-up.

15. There is increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation. There is insufficient evidence to support or refute a recommendation to delay cord clamping in infants requiring resuscitation.

16. In a newly born infant with no detectable heart rate, which remains undetectable for 10 minutes, it is appropriate to consider stopping resuscitation. The decision to continue resuscitation efforts beyond 10 minutes of no HR should take into consideration factors such as the presumed etiology of the arrest, the gestation of the infant, the presence or absence of complications, the potential role of therapeutic hypothermia, and the parents’ previously expressed feelings about acceptable risk of morbidity. When gestation, birth weight, or congenital anomalies are associated with almost certain early death and an unacceptably high morbidity is likely among the rare survivors resuscitation is not indicated.

17. STABLE PEARLS • S stands for sugar • Normal neonatal glucose 50-150 RX: 2 ml/kg of D10W over 5 minutes, check glucose again in 30 mins, may repeat the dose if still <50 • Should also have a running IV of D10W @ 80ml/kg/d to maintain glucose

18. STABLE • T stands for temperature • Make sure to thoroughly dry the infant and place on a port-a-warmer mattress or heat packs • If baby & mom are OK, place infant on mom’s chest skin-to-skin for warmth and cover with a blanket • Maintain core temperature between 36.5C (97.7F) and 37.5C (99.5F), axillary at 37C (98.6). Check temp Q15-30 mins until it’s is in the normal range then Q1hr until transported.

19. STABLE • A stands for airway • Most important of all-provide PPV if necessary • PPV is provided via bag/mask ventilation (8LPM of 40% FIO2) or Neopuff • Use CPAP 5-6 cm if infant is breathing but showing signs of respiratory distress, e.g.: retractions, nasal flaring, cyanosis, grunting and/or tachpnea (RR>60) • Keep O2 sats >90%

20. STABLE • B is for blood pressure • MBP’s range around gestational age for first 24 hours. MAP = DAP + (PP)/3. PP = SAP - DAP. • Give NS bolus 10ml/kg if you think the infant is hypovolemic

21. STABLE • L is for labs • CBC, BCx, glucose & blood gas • Calculate ANC & I/T ratio ANC 5,000-10,000 I/T ratio <0.2 • Left shift = increased # of immature cells (bands + meta + myelos) • Platelet count range 100,000-150,000

22. STABLE • E is for emotional support • Reassure the mother if possible, investigate/validate their feelings • Offer to call support people – clergy, friends & family • Take pictures of infant prior to transport • Encourage breastfeeding as one way for moms to contribute to their infant’s care

23. Summary Goals: Remember to… • ANTICIPATE problems that may arise • RECOGNIZE the problems when they occur and then • ACT on them promptly and effectively.

24. Tips for starting IV’s in newborns • Use 2 people to start the IV. One to bundle/contain infant and offer/hold the pacifier, the other to gather/prepare the materials and to place the IV. • Use Tran illuminator or bright pen light to help localize the best vein. • Warm hand or foot to dilate the veins. • Palpate for possible arterial pulsations when placing IV’s in scalp veins. Wipe with alcohol swab prior to insertion to dilate vein. • Move slowly and be patient. Blood flow may be sluggish. • If no blood return, but you think you are in the vein, remove the stylette and wait a few more seconds for blood return. Adjust catheter and attempt to flush with saline.

25. Correct placement of umbilical catheters • On x-ray: UAC between T6-T9 UVC just above the diaphragm in the inferior vena cava vessel at the right atrial junction

26. When evaluating blood gases, always ask these three questions: • 1. Is the pH normal? • 2. Is the PCO2 normal? • 3. Is the HCO3 normal?

28. 7 rules for blood gas interpretation • 1. Carbon dioxide (CO2) = Acid Changes in PCO2 reflect the respiratory component of acid base balance. 2. Bicarbonate (HCO3) = Base Changes in HCO3 reflect the metabolic component of acid-base balance.

29. 3. If the pH is normal, the blood gas is normal or compensation has occurred. • 4. If the pH is low, the blood gas is uncompensated secondary to metabolic &/or respiratory acidosis. • 5. If the pH, HCO3 & PCO2 is low or PCO2 is normal, the blood gas is uncompensated secondary to metabolic acidosis. • 6. If the pH is low, the PCO2 & HCO3 is high (or normal) the blood gas is uncompensated secondary to respiratory acidosis. • 7. If the pH & HCO3 is low and the PCO2 is high, the blood gas is uncompensated secondary to mixed metabolic & respiratory acidosis.

31. THE END ANY QUESTIONS?