NRP 6 th Edition Update

1. NRP 6th Edition Update Amber McCaw RNC BSN BirthPlace Fall 2011

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

3. Key Behavioral Skills in NRP * Behavior skills such as teamwork, leadership and effective communicationare 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

4. 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**

5. 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.

6. 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, practiceand evaluation.

7. 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.

8. Equipment Check Video Click on Video to View

9. Quick Pre-Resuscitation Checklist

10. No longer Optional: Compressed air source Oxygen blender to mix oxygen and compressed air to flowmeter. Pulse oximeter and oximeter probe Laryngeal mask airway

11. New Flow Chart!

12. 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?

13. 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.

14. 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.

15. Initial Steps: • Position head to open airway. Dry, stimulate, reposition to open airway. • 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

16. 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.

17. 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.

18. Pulse Oximetry APPLY pulse oximeter to the RIGHT HAND when: • Resuscitation is anticipated • PPV is required for more than a few breaths • Persistent central cyanosis, or if you need to confirm your perception of central cyanosis • Any administration of supplemental oxygen **Place on hand first; then attach to machine**

19. Targeted Pre-ductal SaO2 Targeted Pre-ductal SPO2 After 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%

20. 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%

21. Pulse Oximetry Video Click on Video to View

22. CPAP CPAP: continuous positive airway pressure • Consider if: • 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

23. CPAP Video Click on Video to View

24. 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

25. 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

26. Neopuff Video Click on Video to View

27. MR SOPA Ventilation Corrective Steps: (if no chest movement or breath sounds with PPV) M-mask readjustment R-reposition head -Reattempt PPV- S-suction mouth and nose O-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

28. MR SOPA Video Click on Video to View

29. Effective Ventilation DEFINITION: • Bilateral Breath Sounds • Chest Movement--*Note: HR may rise without visible chest movement, especially in preterm newborns

30. 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; and May be given from the head of the bed. Intubation strongly recommended with chest compressions.

31. 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.

32. 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

33. 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.

34. LMA Video Click Here to View Video

35. 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

36. 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.

37. 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

38. Preparing and Placing an Emergency UVC-Two Video’s 1st video: Preparing for Emergency UVC Insertion 2nd video: Placing an Emergency UVC Line Click on video #1 to begin Click on video #2 to begin

39. 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.

40. 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

41. 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.

42. 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

43. American Academy of Pediatric Support Double click picture below to view full article regarding these changes:

44. Thank you! It takes a village!