1. Neonatal Resuscitation Program 7th edition Update June 21, An excerpt from the 2016 CPS NRP Resuscitation Science Club
Preamble: The following presentation was presented at the CPS NRP Resuscitation Science Club by Dr. Emer Finan. This presentation outlines the changes in clinical content and education delivery for the 7th edition of the Neonatal Resuscitation Program.

2. Background
5-year resuscitation science review by International Liaison Committee on Resuscitation Neonatal Task Force
Guidelines reviewed and integrated into education programs such as the 7th edition NRP guidelines and resources developed by AAP
CPS NRP Committee review of ILCOR consensus statement and 7th edition materials
AAP launched 7th edition NRP Spring Launch in Canada Fall 2016: September and November
September 30, 2017: 7th edition mandatory implementation date
Every five years, the International Liaison Committee on Resuscitation Neonatal Task Force reviews the available resuscitation science and thereafter provides recommendations based on the available evidence at that time. This Task Force comprises representation from 13 countries worldwide. The consensus on science is then reviewed and integrated into educational programs worldwide. The ILCOR guidelines were published in October 2015 and the AAP launched its 7th edition of NRP in May 2016.
Within the past number of months, the CPS NRP Committee has been reviewing the ILCOR guidelines and 7th edition materials. 7th edition NRP will be launched in Canada in Fall 2016 (September 26 and 28 in Toronto and November in Montreal). A one year implementation phase is planned with the 7th edition materials only being used after September 30, 2017.

3. Clinical Changes
The 7th edition algorithm remains unchanged in many ways. However there is a focus throughout the 7th edition NRP on team preparation and role assignment. In anticipation of delivery, counseling should occur as necessary along with team briefing, role assignment and equipment check. Within the first minute, an initial assessment should be made and initial steps provided including warming, drying, suctioning as required and stimulation. Indications for PPV remain unchanged (heart rate less than 100 bpm or ineffective respirations). When PPV is provided, a pulse oximeter should be applied. An EKG monitor can be considered once resuscitation is required as it may provide a faster and more reliable heart rate assessment. After 15 seconds of PPV, the heart rate and chest movement should be assessed. If the heart rate is not increasing or chest movement is not noted, corrective steps (MR.SOPA) should be instituted. As was the case in the 6th edition, alternate airways include the endotracheal tube or laryngeal mask airway.
If the heart rate falls below 60 bpm in spite of 30 seconds of effective ventilation, chest compressions should be initiated. If intubation has not already been performed, it should be done at this point. Recommended compression to ventilation ratio remains 3:1 and 100% oxygen should be administered. Chest compressions should continue for 60 seconds before reassessment and if the heart rate remains less than 60 bpm in spite of 60 seconds of chest compressions, then IV epinephrine should be administered.
If bradycardia persists, other underlying aetiologies such as pneumothorax and hypovolaemia should be considered.
Weiner, G. M., & Zaichkin, J. (2016). Textbook of neonatal resuscitation. Elk Grove Village, IL: American Academy of Pediatrics.

4. Preparation Focus on history Team briefing and role assignment
Equipment check
Preparation focuses on obtaining a relevant and pertinent history and providing a team brief with a focus on role assignment and performing an equipment check.

5. Initial Steps
Non-vigorous infants delivered through meconium stained amniotic fluid (MSAF) do not routinely require intubation and tracheal suction
MSAF remains a risk factor for abnormal transition, and teams must ensure a member with advanced airway and resuscitation skills is in attendance
While the latest NRP guidelines suggest routine intubation and suction of the non-vigorous infant delivered through meconium stained amniotic fluid is not required, MSAF remains a perinatal risk factor and it is important that the team comprises at least one member with advanced resuscitation skills including advanced airway skills.

6. Initial Steps Initial assessment: term, tone and breathing/crying?
Warmth and position airway
Suction if necessary
Dry and stimulate
Initial assessment and initial resuscitation steps remain unchanged.

7. Initial Steps
Temperature should be maintained between 36.5 and 37.5 Celsius
For preterm infants, combination of interventions
- Plastic wrap or bag
- Thermal mattress
- Hat
Focus on thermoregulation throughout resuscitation
Thermoregulation is emphasized and a combination of interventions is recommended for temperature control in the preterm infant. The aim for all infants is to maintain normothermia with temperature in the range of 36. to 37.5.

8. Initial Steps
In stable infants, delayed cord clamping should be performed for at least 30 seconds. Insufficient evidence to recommend approach in those requiring resuscitation
Starting resuscitation gas for term infant should be 21%
In infants <35 weeks, starting gas should be 21-30%. Specific starting concentration of oxygen should be incorporated into local-agreed guidelines
Continue to target saturations using preductal saturation monitor
In the stable infant who does not require resuscitation, delayed cord clamping is recommended for at least 30 seconds. There is insufficient evidence to recommend an approach to the infant requiring resuscitation so the recommendation remains that in that situation, the cord should be clamped and resuscitation commenced.
Starting resuscitation gas for term infants is 21% oxygen. Following review of the ILCOR worksheet and recommendation in regard to preterm infants, in those infants born less than 35 weeks gestation, the starting oxygen concentration should be in low (21-30%) rather than high range. There is insufficient evidence to make a clear recommendation within this range and choice of starting concentration of oxygen should be as per local guidelines.
Oxygen saturations should continue to be measured using a preductal saturation probe and oxygen should be titrated to meet target guidelines.

9. PPV
Positive pressure ventilation (PPV) if HR <100 bpm or ineffective respirations. Initial PIP cm H20
When resuscitation of preterm baby is required, PEEP is recommended (starting PEEP 5 cm H20)
Consider electronic cardiac monitor when resuscitation required
After PPV started, reassess in 15 seconds. If no response, MR SOPA corrective measures should be incorporated. If no response to MR SOPA, consider obstruction and suction through ETT or with meconium aspirator
Indications for PPV remain unchanged, those being a heart rate less than 100 bpm or ineffective respirations. Initial PIP is suggested in the range of cm H20. As per ILCOR guidelines, when resuscitation of the preterm infants is required, PEEP should be used. Recommended starting PEEP is 5 cm H20. When resuscitation is required, an electronic cardiac monitor can be considered as it may provide a faster and more reliable assessment of heart rate.
After PPV has been started, after 15 seconds an assessment of heart rate and chest movement should take place. If heart rate is not increasing at this time and there is no chest movement, corrective actions should be instituted (MR SOPA). If there has been no response to MR SOPA corrective steps, obstruction should be considered and suction can be performed either using a catheter through the ETT or a meconium aspirator.

10. Advanced airway Intubation recommended before chest compressions
If intubation is not successful or feasible, laryngeal mask airway (LMA) should be used
Depth of insertion using table or by measuring nasal-tragus length (NTL) + 1 cm
The importance of ventilation is again reinforced and intubation is recommended prior to chest compressions. If intubation is not feasible, the laryngeal mask airway should be used as an alternate advanced airway. Recommendations for depth of insertion are gestation-based or based on formula using nasal-tragus length (NTL) measurement.
Weiner, G. M., & Zaichkin, J. (2016). Textbook of neonatal resuscitation.
Elk Grove Village, IL: American Academy of Pediatrics

11. DOPE
The ”DOPE” pneumonic has been adapted from Paediatric Advanced Life Support guidelines for use in the assessment of the infant who deteriorates after intubation. The causes include displacement of the ETT, obstruction of the tube, pneumothorax and equipment failure.

12. Chest compressions
HR <60 bpm in spite of 30 seconds of effective PPV. Oxygen should be increased to 100%
2-thumb technique is still recommended. Once airway secured, switch to head of bed
Electronic cardiac monitor preferred for assessment of heart rate
Continue chest compressions for 60 seconds before rechecking
The indication for chest compressions remains unchanged, this being a heart rate less than 60 bpm in spite of 30 seconds of effective PPV. 100% oxygen continues to be recommended when administering chest compressions. The 2-thumb technique is recommended and once the airway has been secured, the team member administering compressions should switch to the head of the bed and the team member providing PPV should move to side. An electronic cardiac monitor is the preferred method for assessment of heart rate when delivering chest compressions. Chest compressions should be continued for 60 seconds before reassessment of heart rate.
Photo credit : www2.aap.org

13. Epinephrine
Indicated if HR remains <60 bpm after at least 30 secs of effective PPV and another 60 seconds of chest compressions using 100% oxygen
One dose may be given through ETT. If no response, give intravenous dose via emergency UVC or IO access
In Canada, simplified Epinephrine dosing continues to be recommended
The indication for epinephrine is heart rate below 60 bpm after at least 30 seconds of effective PPV and another 60 seconds of chest compressions using 100% oxygen. The preferred route is IV (or IO if IV access cannot be obtained). One dose may be given through the ETT while awaiting IV access but if no response, it should be followed with an IV dose as soon as access is secured. In Canada, simplified epinephrine dosing continues to be recommended (0.1 cc/kg 1:10,000 IV or 1 cc/kg 1:10,000 via ETT (to max 3 cc)).

14. Other medications
Ringer’s Lactate no longer recommended for management of hypovolaemic shock
UVC preferred route of emergency vascular access, but IO can be used as alternative
“No evidence to support the routine practice” of NaHCO3 to correct metabolic acidosis
“Insufficient evidence to evaluate safety and efficacy” of Naloxone and risks of complications
For treatment of hypovolaemic shock, normal saline and blood are the solutions of choice and the recommended volume is 10 cc/kg. Ringer’s lactate is no longer recommended for management of hypovolaemic shock. UVC is the preferred route of access but the intraosseous route (IO) can be used as an alternative if UV access cannot be obtained. The routine use of NaHCO3 to correct metabolic acidosis or the use of naloxone to manage respiratory depression in infants born to mothers with narcotic exposure in labour is NOT recommended.

15. Preterm Infants Temperature control
- Room temperature degrees Celsius
- Plastic wrap or bag
- Thermal mattress and hat
3-lead EKG monitor for rapid and reliable HR assessment
If resuscitation required, PEEP recommended; no particular device recommended
CPAP can be used if stable but increased work of breathing (PEEP 5-8 cmH20 suggested )
In preparation for delivery of preterm infants, a combination of interventions aimed at maintaining normothermia is recommended. A three-lead EKG can provide rapid and reliable heart rate assessment. If resuscitation is required, PEEP is recommended starting at pressure of 5cmH20. For infants who are stable but have increased work of breathing, CPAP can be used. Based on available evidence, PEEP 5-8 cmH20 is suggested .

16. Educational Changes Instructor Trainer role will continue in Canada.
Online examination now for both providers and instructors. Instructors will complete with renewal
All providers will complete same components of online exam
Course continues to focus on learner needs with skills stations adapted to learners’ clinical practice
Course continues to comprise skills stations, integrated skills stations and evaluation (Megacode), simulation and debriefing
The Instructor-Trainer role will be maintained in Canada. The Instructor-Trainer is an invaluable teacher, mentor and NRP leader within their institution and region.
7th edition online examination will now be taken by both instructors and instructor-trainers (at time of renewal) and by providers.
All providers will complete the same components of the online examination and these will be based on all chapters of the NRP textbook. The NRP course will continue to be tailored to learner’s needs and the practical skills and integrated skills stations should be adapted in accordance with the learner’s clinical practice.
The components of the course will continue to comprise skills stations and integrated skills stations and evaluation using the Megacode. The final component of the course will comprise team-based practice using simulation and debriefing.

17. Educational Changes con’t
Integrated skills station evaluation (Megacode) will remain as both “basic” and “advanced” evaluative tools. Should be used summatively and formatively
Recommendation for “recurrent” training outside of two-year course
Evidence shows benefit particularly in regard to psychomotor skills. Insufficient evidence to recommend particular method of teaching or frequency
Learner-focused and based on clear objectives
The integrated skills stations evaluation (Megacode) continues to be recommended as a means of evaluating the individual’s ability to integrate all components of the algorithm. It should be used summatively to ensure each individual can lead a neonatal resuscitation. It can also be used formatively for all members of the group to reflect on the components of the algorithm. The Megacode will continue to be used in both a “basic” and “advanced” format depending on the scope of practice of the provider.
The ILCOR guidelines recommended that “recurrent” training should occur outside of a two year course. Evidence shows benefit to repeated practice , particularly in regard to acquisition of psychomotor skills. There is however insufficient evidence at present to recommend a particular method of teaching or frequency. Repeated or recurrent training can focus on skills such as bag-mask ventilation and corrective steps. Training sessions are most effective when learner-focused and based on clear objectives.

18. Clinical Changes
Weiner, G. M., & Zaichkin, J. (2016). Textbook of neonatal resuscitation. Elk Grove Village, IL: American Academy of Pediatrics.