1. Amber McCaw RNC BSN BirthPlace Fall 2011
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 communication are 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, practice and 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
Warm
Preheat warmer
Towels or blankets
Clear airway
Bulb syringe
10F or 12F suction cath attached to wall suction set at mm Hg
Meconium aspirator
Auscultate
Stethoscope
Oxygenate
Method to give free flow O2
Gases flowing just prior to birth, 5-10 L/min
Blender
Pulse oximeter and probe
Ventilate
PPV device with term and preterm masks—test to assure that the PPV device is working
Have air/oxygen source
8F feeding tube with 20mL syringe
Intubate
Laryngoscope and blade size 0 and 1—assure light is working
ET tubes size 2.5, 3.0, 3.5 and 4.0
Stylets
End tidal CO2 detector
LMA size (1) and 5 mL syringe
Medicate
Access to 1:10,000 epinephrine and NS
Supplies for administering meds and placing emergency umbilical venous catheter
Code cart sheet
Thermoregulate
Plastic bag or plastic wrap (code cart)
Chemically activated warming pad (code cart)
other

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. Consider CPAP; esp. for preterm infants
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 %
2 min %
3 min %
4 min %
5 min %
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: 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 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
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 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. Click Here to View Video
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 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): 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 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 Click Here to View Video #1
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!