1. Case based Discussions in NRP
Steven Ringer MD PhD
October

2. Conflicts
I have no actual or potential conflict of interest in relation to this presentation.
I am a member of the NRP Steering Committee

3. Changes in Practice Practice 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 cases
Learning 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 facilitated

4. Two Changes you may wish to make in your practice
Facilitate 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.

5. Changes in Practice Practice 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

6. 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 Resuscitation
The NRP Steering Committee participates in this process
ILCOR ultimately defines the scientific principles behind resuscitation and develops treatment recommendations

7. 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 2010
Each 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

8. Without specific evidence to recommend a change, the ruling on the field stands

9. Neonatal 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 scenarios
While the principles apply to most cases, in some you must interpret the approach to best fit the unusual patient

10. What NRP offers
NRP is “an educational program that introduces concepts and basic skills of neonatal resuscitation”
NRP is not intended to set a strict “Standard of Care”
Completion of the program does not imply competence – Each hospital has a responsibility to determine competence and qualifications
Not only are individual skills important, but resuscitation requires a well functioning team

11. How do we learn and improve?
Not by looking at and listening to a lecture and slides…
Simulation and debriefing provide valuable insight and learning not available by passive instruction
Simulation also allows us to work through unusual cases that don’t seem to exactly fit the mold
On to cases…
Major areas of change in 2010 Guidelines
Topics that have caused questions to arise
What is bothering you??

12. Case 1
A 37 year old G2P1 female is in labor at 41 weeks. She develops a fever to 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?

13. ARQ 1 What 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?

14. 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 FiO2

15. Case 2
The baby, who is term, is crying and moving all his extremities well.

16. ARQ 2 What should be the sequence of care?
A. Suctioned by Obstetric provider at perineum, evaluation at warmer by Pediatric team
B. Suctioned at perineum if secretions copious, taken to warmer, intubated, suctioned
C. Suctioned at perineum if secretions copious, given to mother

17. Suctioning
Evidence indicates suctioning can cause bradycardia during resuscitation, or pulmonary decompensation and reduced cerebral blood flow in intubated patients
Suctioning secretions can decrease pulmonary resistance
20o5 Guidelines stressed NO ROUTINE suctioning of airway before delivery of the body
True whether fluid is clear or meconium stained

18. Suctioning after birth
If there is Clear Fluid: limit suctioning to those with obvious obstruction
Stop routine bulb suctioning of all babies
If fluid is meconium stained, must determine if baby is vigorous
Vigor: Good HR, Good cry, Good tone
If infant is vigorous, as this baby appears to be, they do not need any special intervention
Leave VIGOROUS babies with mother!

19. Suctioning Meconium: 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 controls
There 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!

20. Case 1
After 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.

21. ARQ 3 How 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 range
C. Give oxygen until baby turns pink in opinion of all caregivers present

22. How pink is a fetus?
Dildy GA, et al. Am J Obstet Gynecol. 1994;171:679–684

23. What are Normal O2 saturations in Vigorous Term Newborns in the DR?
3 min 66% (56-75%)
5 min 80% (55-85%)
7 min 83% (68-88%)
Lundstrøm et al Arch Dis Child 1995; 73:F81-6.

24. Post-ductal O2 sats in the DR
N=50 SVD, Term
Vigorous
Toth et al. Arch Gynecol Obstet 2002;266:105-7.

25. What are Normal Preductal O2 Sats in Vigorous Term Newborns at Birth?
1 min 63% (53-68%)
2 min 70% (58-78%)
3 min 76% (64-87%)
4 min 81% (71-91%)
5 min 90% (79-91%)
Kamlin et al J Peds 2006; 148:585-9.
Pre ductal readings are the ideal

26. Take Home Message
Majority 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??

27. Is O2 in the Delivery Room better?
We have increasing evidence that too much oxygen is not harmless in other clinical situations
Preemies:
Chronic Lung Disease
Retinopathy 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 tissues

28. Consensus on Science for O2
Meta-analysis of 7 human studies of infants resuscitated with room air (RA) versus 100% O2 [LOE 1]
Reduced Mortality
No evidence of harm
Other concentrations not studied
However…
The 4 largest studies were not blinded
If no response after 90 sec, RA infants switched to 100% O2
Other 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 g
congenital pulmonary or cyanotic heart disease
Asystole

29. Is there a Potential for Harm?
Naumburg et al. Supplementary oxygen and risk of childhood lymphatic leukemia. Acta Paediatr 2002;91: (Sweden)
Prospective association between any oxygen exposure in the DR and childhood acute lymphatic leukemia
2.5X the risk of ALL ( )
> 3 minutes of O2 with BMV
3.54X the risk of ALL ( )

30. How do you do it: O2 For Initiation of Resuscitation
Resuscitation 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.

31. 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?
O’Donnell et al. ADC 2007.
Video Recording with Hi-fidelity color and simultaneous SaO2 monitoring
Do clinicians agree whether infants are pink?
At what preductal SaO2 are infants first perceived as pink?
They 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.

32. Clinical Assessment of Infant Color at Delivery
O’Donnell et al.. ADC 2007.

33. O2 Sat at Which Infant “Pink”
Boxplots 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.
O’Donnell et al. ADC 2007.

34. Oximeter needed, but Can you get it to work?
Study of healthy term and preterm infants- low cardiac output can reduce signal
You can get it on, but it takes TEAM work and practice!!
Kamlin et al J Peds 2006; 148:585-9.

35. Preductal oxygen saturation targets
1 minute
60-65%
2 minutes
65-70%
3 minutes
70-75%
4 minutes
75-80%
5 minutes
80-85%
10 minutes
85-95%

36. ARQ 4 When is the use of oximetry indicated?
BLUE
When is the use of oximetry indicated?
A. Only for premature infants
B. When using oxygen or PPV
C. At all births attended by Pediatric team
PINK

37. The Practice: Term and Late Preterm babies
Monitor 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 pulse
Oximetry often not usable when cardiac output is low.

38. ARQ 5
If 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%

39. Case 1
The 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.

40. Case 2
A 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.

41. ARQ 6 What steps would you take next?
A. Immediately give oxygen and stimulate
B. Place in plastic wrap under warmer, ask team member to place oximeter on RUE
C. Place oximeter on RUE, stimulate

42. Temperature Control
All newborns are at risk for hypothermia after birth:
Relatively cool environment
High surface area to volume
Risk factor for morbidity and mortality
Babies <1500 g are the population at risk:
VON (2008) 51% had admission temperature to NICU < 36.5 degrees C. ( Roughly the same in my own hospital)

43. Can hypothermia be prevented?
Plastic Wrap
The baby, undried, is immediately placed in plastic wrap covering body and extremities
Delivery Room Temperature 26 degrees
Exothermic mattresses (Sodium Acetate Gel)

44. Occlusive Plastic Wrap
Evaluated in many studies- systemic review done
3 Randomized controlled trials
5 historical controlled trials
Gestational age < weeks, < 1000g
Original data was reviewed and analyzed

45. Admission Temperature
Cramer K, et al. J. Perinatol 2005:25;

46. Mortality
No differences in respiratory outcomes, severe neurologic outcomes, or LOS.

47. OR Temperature & Plastic Wrap
Epoch 1- Standard OR temperatures
Epoch 2- Increased OR temperature to 26 degrees
Epoch 3- Occlusive Plastic wrap used
Kent AL, Williams J . J Pediatr Child Health 2008:44:

48. OR Temperature & Plastic Wrap
No difference in survival, days of ventilation, days of oxygen, NEC, severe IVH or infection

49. Plastic Wrap and Exothermic Mattress
Analysis of three case series:
Traditional care (drying and wrapping in towel)
Wrapping in standard food polyethylene bag
Wrapping in food bag, nursing on exothermic mattress
Retrospective observational study, three different time periods, <30 weeks gestation
Singh A, et al. J Perinatol 2010:30:45-49

50. Plastic Wrap and Exothermic Mattress

51. Plastic Wrap and Exothermic Mattress
Hypothermia least frequent in “bag/mattress” group (26%) vs. “bag” (69%) or traditional care(84%)
Mean increase of 1.04 degrees

52. The evidence has mounted
In thermal wraps were a suggested intervention
Now, these interventions are RECOMMENDED
BUT, aren’t they a big pain to use??
We have used them effectively without complaints or problems
Requires team work and clear identification of roles: “Choreography” learned through simulation

53. Case 2
The baby is placed in plastic wrap and an oximeter is placed on RUE. Because the baby has minimal respiratory effort , Positive pressure ventilation is begun using a bag and mask?

54. ARQ 7 With what concentration of oxygen would you start?
A. Room air, like term baby
B. 40%
C. 60%
D. 100 %

55. Premature babies are different
Neither Room Air or 100% oxygen are optimal
Something in between is just right.

56. Resuscitation of ELBWs with 90% vs 30% oxygen
Escrig et al. Pediatrics 2008; 121;

57. Resuscitation of premature infants with 100% oxygen or Room Air
Wang et al. Pediatrics 2008; 121:

58. Use of Oxygen During Resuscitation in Preterm Infants
To provide adequate, but avoid excessive tissue oxygenation in very preterm baby (less than ~32 weeks) during resuscitation at birth:
Use an O2 blender and pulse oximeter during resuscitation.
Begin PPV or “blow-by” O2 with some concentration between room air and 100%, but not either extreme.
No studies justify starting at any particular concentration. Why is 60% a reasonable starting point?
Adjust O2 concentration up or down to achieve an O2 saturation that gradually increases toward 90%, in a pattern like that of term babies.
Decrease O2 as saturations rise over 93-95%.

59. Term oxygen saturation targets
1 minute
60-65%
2 minutes
65-70%
3 minutes
70-75%
4 minutes
75-80%
5 minutes
80-85%
10 minutes
85-95%

60. Use of Oxygen During Resuscitation of Preterm Infants
If the heart rate does not respond by increasing rapidly to > 100 beats per minute, correct any ventilation problem and use 100% oxygen.
If an oxygen blender and pulse oximeter is not available in the delivery room the resources and oxygen management described for a term baby are appropriate.
There is no convincing evidence that a brief period of 100% oxygen during resuscitation will be detrimental to the preterm infant.

61. ARQ 8
For this 27 week gestation infant who has spontaneous breaths and respiratory distress, what is your preferred initial method of respiratory support?
A. CPAP +5
B. CPAP +8
C. Intubation and positive pressure ventilation

62. ARQ 9
In your institution, you have adopted a practice of delayed cord clamping for 45 seconds after the baby is delivered
When would you assign the first Apgar Score?
One minute after the baby itself is delivered
One minute after the cord is clamped and cut
One minute after cord pulsations stop

63. Case 3
A 38 year old female with gestational diabetes presents in spontaneous labor at 37 weeks gestation. During monitoring, the fetal heart rate pattern becomes non-reassuring, a Category 3 tracing. The mother is taken for emergency Cesarean section. The baby emerges limp and pale with no discernable respiratory effort. The amniotic fluid is clear. A quick assessment of the heart rate reveals it to be 50 beats per minute.

64. ARQ 10 What step do you take next?
A. Immediately begin chest compressions at 90/minute, with blow by oxygen
B. Begin positive pressure ventilation with 40 bpm, sufficient to move chest. Ask a team member to place oximeter probe on RUE
C. Place oximeter, begin chest compressions immediately at 90/minute, begin positive pressure ventilation

65. Etiology of bradycardia right after birth
Essentially always a respiratory event at its basis (or respiratory depression secondary to CNS depression)
The immediate first step is to begin assisted ventilation with pressures adequate to move the baby’s chest
Initially paying attention to heart rate only distracts you from the first responsibility- to ensure adequate ventilation
The heart rate most often will increase within about 30 seconds of effective ventilation

66. ARQ 11 When would you recheck the heart rate after starting PPV?
A. Right away
B. 30 seconds
C seconds

67. Case 3
After about 30 seconds of PPV with good chest movement, a team member rechecks the heart rate. It is 40 bpm.
Note that for an apneic baby like this, two people are needed almost immediately after birth
You ask the team member to beign chest compressions at 90/minute, while you continue ventilation at 30 bpm

68. ARQ 12 When would you want the heart rate checked again? Right away
After 30 seconds
After seconds

69. Checking the heart rate
Usually, it makes sense to check the heart rate and status every 30 seconds
While doing chest compressions, studies hav eshown that the critical diastolic blood pressure necessary for coronary perfusion drops very quickly when compressions are interrupted
Therefore, during chest compressions, a longer checking interval of seconds is recommended

70. ARQ 13 What method(s) may be used for chest compressions?
A. Two thumbs from base of bed
B. Two fingers perpendicular to sternum
C. Two thumbs from head of bed**
D. Any of these**

71. ARQ 14
If ventilation does not result in an increase in heart rate, what interventions should you attempt?
Are you familiar with MR. SOPA or MRS. OPA?
A. Yes
B. No

72. MR SOPA M- R- S- O P A-

73. Case 4- ARQ 15
A 6 day old who has remained in the hospital while his mother recovers from an apparent infection is found to be apneic and bradycardic in the Newborn Nursery.
Which approach to resuscitation makes sense for this baby?
A. NRP
B. PALS

74. NRP vs. PALS
For this baby, the apparent etiology of the event is respiratory, which mirrors the common situations that occur at birth. It makes sense to apply the NRP approach
“It’s not the age, it’s the etiology!!”

75. Perplexing, confusing or unclear
What questions do you have?