Presentation on theme: "Case based Discussions in NRP"— Presentation transcript:
1Case based Discussions in NRP Steven Ringer MD PhDOctober
2ConflictsI have no actual or potential conflict of interest in relation to this presentation.I am a member of the NRP Steering Committee
3Changes in Practice Practice Gap 1 - Resuscitation practice guidelines are based on review and compilationof available evidence- Initial questions posed when consulted for care at birth include GA, respiratory effort and toneGood communication is a key component of providing good care resolves in most casesLearning Objective 2Understand the ILCOR process and how it results in recommendations for careIdentify the critical areas for rapid and effective communication, best allowign adequate anticipation of needsRecognize that clear communication between disciplines is a key behavioral skill that must be fostered and facilitated
4Two 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 improvementPractice the use of oximetry guided oxygen use in different clinical scenarios and refine practice through the use of team based simulation and debriefing.
5Changes 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 infantsUse of oximetry allows better tailoring of oxygen and minimizes over useTeam structure and communication results in enhanced care and better adherence to practice guidelinesLearning Objective 2Understand the limitations of clinical assessment in the newly born infant with respect to color and oxygenIndentify the concept of target oxygen saturation levels at each minute after birth, and how they are usedUnderstand 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
6Neonatal Resuscitation Program- where do Guidelines come from? Evidence relating to resuscitation is reviewed on a five year cycle by ILCOR- International Liaison Committee on ResuscitationThe NRP Steering Committee participates in this processILCOR ultimately defines the scientific principles behind resuscitation and develops treatment recommendations
7Neonatal 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 2010Each 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
8Without specific evidence to recommend a change, the ruling on the field stands
9Neonatal 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 scenariosWhile the principles apply to most cases, in some you must interpret the approach to best fit the unusual patient
10What NRP offersNRP 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 qualificationsNot only are individual skills important, but resuscitation requires a well functioning team
11How 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 instructionSimulation also allows us to work through unusual cases that don’t seem to exactly fit the moldOn to cases…Major areas of change in 2010 GuidelinesTopics that have caused questions to ariseWhat is bothering you??
12Case 1A 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?
13ARQ 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?
14Initial Questions reduced to THREE: Is the baby term?Is the baby breathing?Is the tone good?Vigorous= normal, regardless of AFOximetry is the standard!In its absence: adequate ventilation is more important than higher FiO2
15Case 2The baby, who is term, is crying and moving all his extremities well.
16ARQ 2 What should be the sequence of care? A. Suctioned by Obstetric provider at perineum, evaluation at warmer by Pediatric teamB. Suctioned at perineum if secretions copious, taken to warmer, intubated, suctionedC. Suctioned at perineum if secretions copious, given to mother
17SuctioningEvidence indicates suctioning can cause bradycardia during resuscitation, or pulmonary decompensation and reduced cerebral blood flow in intubated patientsSuctioning secretions can decrease pulmonary resistance20o5 Guidelines stressed NO ROUTINE suctioning of airway before delivery of the bodyTrue whether fluid is clear or meconium stained
18Suctioning after birth If there is Clear Fluid: limit suctioning to those with obvious obstructionStop routine bulb suctioning of all babiesIf fluid is meconium stained, must determine if baby is vigorousVigor: Good HR, Good cry, Good toneIf infant is vigorous, as this baby appears to be, they do not need any special interventionLeave VIGOROUS babies with mother!
19Suctioning Meconium: Suction non vigorous babies Depressed infants with MSF are at increased risk of MASTracheal suctioning has not been associated with less MAS or mortality, other than single trial with historical controlsThere is no evidence to change practice of intubating and suctioning non vigorous babiesAttempts should not significantly delay PPV if there is bradycardiaLeave VIGOROUS babies with mother!
20Case 1After 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.
21ARQ 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 rangeC. Give oxygen until baby turns pink in opinion of all caregivers present
22How pink is a fetus?Dildy GA, et al. Am J Obstet Gynecol. 1994;171:679–684
23What 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.
24Post-ductal O2 sats in the DR N=50 SVD, TermVigorousToth et al. Arch Gynecol Obstet 2002;266:105-7.
25What 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
26Take Home MessageMajority 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??
27Is O2 in the Delivery Room better? We have increasing evidence that too much oxygen is not harmless in other clinical situationsPreemies:Chronic Lung DiseaseRetinopathy of PrematurityNewborns 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
28Consensus on Science for O2 Meta-analysis of 7 human studies of infants resuscitated with room air (RA) versus 100% O2 [LOE 1]Reduced MortalityNo evidence of harmOther concentrations not studiedHowever…The 4 largest studies were not blindedIf no response after 90 sec, RA infants switched to 100% O2Other significant methodologic concerns regarding patient selection, randomization methods, and follow-upNo data regarding RA vs O2 for resuscitation of infants withbirth weight < 1000 gcongenital pulmonary or cyanotic heart diseaseAsystole
29Is 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 leukemia2.5X the risk of ALL ( )> 3 minutes of O2 with BMV3.54X the risk of ALL ( )
30How 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.
31How 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 recommendedHow good are we at judging color?O’Donnell et al. ADC 2007.Video Recording with Hi-fidelity color and simultaneous SaO2 monitoringDo 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.
32Clinical Assessment of Infant Color at Delivery O’Donnell et al.. ADC 2007.
33O2 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.
34Oximeter needed, but Can you get it to work? Study of healthy term and preterm infants- low cardiac output can reduce signalYou can get it on, but it takes TEAM work and practice!!Kamlin et al J Peds 2006; 148:585-9.
36ARQ 4 When is the use of oximetry indicated? BLUEWhen is the use of oximetry indicated?A. Only for premature infantsB. When using oxygen or PPVC. At all births attended by Pediatric teamPINK
37The 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 rangeOximeter also often helpful to monitor pulseOximetry often not usable when cardiac output is low.
38ARQ 5If 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%
39Case 1The 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.
40Case 2A 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.
41ARQ 6 What steps would you take next? A. Immediately give oxygen and stimulateB. Place in plastic wrap under warmer, ask team member to place oximeter on RUEC. Place oximeter on RUE, stimulate
42Temperature ControlAll newborns are at risk for hypothermia after birth:Relatively cool environmentHigh surface area to volumeRisk factor for morbidity and mortalityBabies <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)
43Can hypothermia be prevented? Plastic WrapThe baby, undried, is immediately placed in plastic wrap covering body and extremitiesDelivery Room Temperature 26 degreesExothermic mattresses (Sodium Acetate Gel)
44Occlusive Plastic Wrap Evaluated in many studies- systemic review done3 Randomized controlled trials5 historical controlled trialsGestational age < weeks, < 1000gOriginal data was reviewed and analyzed
45Admission Temperature Cramer K, et al. J. Perinatol 2005:25;
46MortalityNo differences in respiratory outcomes, severe neurologic outcomes, or LOS.
47OR Temperature & Plastic Wrap Epoch 1- Standard OR temperaturesEpoch 2- Increased OR temperature to 26 degreesEpoch 3- Occlusive Plastic wrap usedKent AL, Williams J . J Pediatr Child Health 2008:44:
48OR Temperature & Plastic Wrap No difference in survival, days of ventilation, days of oxygen, NEC, severe IVH or infection
49Plastic Wrap and Exothermic Mattress Analysis of three case series:Traditional care (drying and wrapping in towel)Wrapping in standard food polyethylene bagWrapping in food bag, nursing on exothermic mattressRetrospective observational study, three different time periods, <30 weeks gestationSingh A, et al. J Perinatol 2010:30:45-49
51Plastic 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
52The evidence has mounted In thermal wraps were a suggested interventionNow, these interventions are RECOMMENDEDBUT, aren’t they a big pain to use??We have used them effectively without complaints or problemsRequires team work and clear identification of roles: “Choreography” learned through simulation
53Case 2The 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?
54ARQ 7 With what concentration of oxygen would you start? A. Room air, like term babyB. 40%C. 60%D. 100 %
55Premature babies are different Neither Room Air or 100% oxygen are optimalSomething in between is just right.
56Resuscitation of ELBWs with 90% vs 30% oxygen Escrig et al. Pediatrics 2008; 121;
57Resuscitation of premature infants with 100% oxygen or Room Air Wang et al. Pediatrics 2008; 121:
58Use 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%.
60Use 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.
61ARQ 8For this 27 week gestation infant who has spontaneous breaths and respiratory distress, what is your preferred initial method of respiratory support?A. CPAP +5B. CPAP +8C. Intubation and positive pressure ventilation
62ARQ 9In your institution, you have adopted a practice of delayed cord clamping for 45 seconds after the baby is deliveredWhen would you assign the first Apgar Score?One minute after the baby itself is deliveredOne minute after the cord is clamped and cutOne minute after cord pulsations stop
63Case 3A 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.
64ARQ 10 What step do you take next? A. Immediately begin chest compressions at 90/minute, with blow by oxygenB. Begin positive pressure ventilation with 40 bpm, sufficient to move chest. Ask a team member to place oximeter probe on RUEC. Place oximeter, begin chest compressions immediately at 90/minute, begin positive pressure ventilation
65Etiology 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 chestInitially paying attention to heart rate only distracts you from the first responsibility- to ensure adequate ventilationThe heart rate most often will increase within about 30 seconds of effective ventilation
66ARQ 11 When would you recheck the heart rate after starting PPV? A. Right awayB. 30 secondsC seconds
67Case 3After 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 birthYou ask the team member to beign chest compressions at 90/minute, while you continue ventilation at 30 bpm
68ARQ 12 When would you want the heart rate checked again? Right away After 30 secondsAfter seconds
69Checking the heart rate Usually, it makes sense to check the heart rate and status every 30 secondsWhile doing chest compressions, studies hav eshown that the critical diastolic blood pressure necessary for coronary perfusion drops very quickly when compressions are interruptedTherefore, during chest compressions, a longer checking interval of seconds is recommended
70ARQ 13 What method(s) may be used for chest compressions? A. Two thumbs from base of bedB. Two fingers perpendicular to sternumC. Two thumbs from head of bed**D. Any of these**
71ARQ 14If 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. YesB. No
73Case 4- ARQ 15A 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. NRPB. PALS
74NRP vs. PALSFor 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!!”
75Perplexing, confusing or unclear What questions do you have?