NRP 2006 – Western Canada Launch Vancouver, BC The New NRP Algorithm NRP 2006 – Western Canada Launch Vancouver, BC

Objectives Show the new 2006 Resuscitation algorithm Discuss the NRP 2006 Initial Steps What has changed since NRP 2000 How specific Canadian Expert Committee recommendations affect the algorithm

Objectives The Initial Steps Decide if resuscitation is needed Provide initial steps of resuscitation Decide if / when oxygen should be given Exception to “dry the baby” Resuscitate a newborn when meconium is present

The Canadian Expert Committee National guidelines to neonatal resuscitation across several continents are based on the consensus statements of the International Liaison Committee on Resuscitation (ILCOR). Each country is expected to develop guidelines that reflect their own context. Why is there a difference between recommendations in the text and Canadian recommendations? National guidelines to neonatal resuscitation across several continents are based on the consensus statements of the International Liaison Committee on Resuscitation (ILCOR). Each country is expected to develop guidelines that reflect their own context. Similarities between the American healthcare system and our own have fostered a strong and fruitful relationship with the American NRP Committee, permitting us to have input into development of the AAP NRP guidelines and textbook and to base our neonatal resuscitation education on the Neonatal Resuscitation Program. However, on occasion, we have felt this relationship constrains the development of guidelines specific to Canadian institutions in the absence of a Canadian textbook. The National NRP Committee for Canada has, therefore, felt that we should identify and promote approaches to resuscitation which have been interpreted by Canadian clinicians, scientists and educators to reflect our own unique healthcare system and culture, just as the AAP NRP guidelines are on occasion constrained by the American healthcare system. This philosophy is key to the growth of our neonatal community, but its consequence will be, on occasion, a disparity between practices north and south of the border.

Is resuscitation needed? Routine Care

Is resuscitation needed? NRP 2006 Routine Care NRP 2000 Routine Care

Is resuscitation needed? NRP 2006 Routine Care Oxygen is gone …

Routine Care NRP 2006 NRP 2000

Normal transition Gestational age 37.7 Birth weight 3036g SpO2 >75% 207 s SpO2 >90% 343 s . Slide courtesy of ACoRN 2006 Kamlin, O'Donnell, Davis, Morley. SPR 2005. A2050 ACoRN © 2006

Normal transition Slide courtesy of ACoRN 2006 Normal increase in oxygenation after birth in healthy term babies Study done in Calgary …. Average saturation doesn’t get > 80 until 5 minutes of age, sats 90 around 8 minutes of age --- shows process takes time in the normal, healthy term baby C/S babies took longer. Why the difference? Could be babies born by C/S may take longer to transition to extrauterine life. If we start to measure sats in the delivery room more regularly, we will see this. Slide courtesy of ACoRN 2006 Rabi Y, Yee W, Chen SY, Singhal N. J Pediatrics 2006 148( 5):590-594 ACoRN © 2006

Normal transition Slide courtesy of ACoRN 2006 Normal increase in oxygenation after birth in healthy term babies Illustrates length of time transition takes. Slide courtesy of ACoRN 2006 Rabi Y, Yee W, Chen SY, Singhal N. J Pediatrics 2006 148( 5):590-594 ACoRN © 2006

Normal transition Slide courtesy of ACoRN 2006 Normal increase in oxygenation after birth in healthy term babies Illustrates length of time transition takes. Slide courtesy of ACoRN 2006 Rabi Y, Yee W, Chen SY, Singhal N. J Pediatrics 2006 148( 5):590-594 ACoRN © 2006

Canadian Expert Committee “Oxygen should be administered to babies who remain cyanotic at 90 seconds of age”

Routine Care NRP 2006

Routine Care NRP 2006 NRP 2000

What if this “well baby” baby remains cyanotic > 90 sec? Routine Care NRP 2006 What if this “well baby” baby remains cyanotic > 90 sec?

The initial steps 2006

The initial steps 2006 2000

The initial steps … no oxygen given Exception to “dry the baby” 2006

NRP algorithm Routine Care

NRP algorithm Routine Care

NRP algorithm Routine Care First 30 seconds Wait 90 seconds

NRP algorithm Routine Care First 30 seconds Observational Care

NRP algorithm Routine Care Observational Care First 30 seconds … at 90 seconds

Open the airway and provide initial steps Routine Care 30 sec Observational Care

Cyanotic baby “who appears well” Routine Care Cyanosis at 90 sec

Cyanotic baby “who appears well” Routine Care Cyanosis at 90 sec ? Observational Care

Cyanotic baby “who appears well” Routine Care Cyanosis at 90 sec ? Observational Care

Cyanotic baby “who appears well” No line in NRP … to get back to algorithm AAP: Start oxygen CPS: Start oxygen at 90 seconds Baby requires evaluation for further stabilization ...

Cyanotic baby “who appears well” Routine Care ? Cyanosis at 90 sec Stabilization ? Observational Care

The persistently cyanotic baby

Oxygen administration Only central cyanosis requires intervention. Acrocyanosis does not indicate hypoxemia. “If the baby is breathing but appears blue, administration of supplemental oxygen is indicated” at 90 seconds… “Supplemental oxygen also may be needed when respirations are being assisted” at 90 seconds… “There is evidence that resuscitation with air is as effective as with 100% oxygen …”

Oxygen administration

Blending oxygen

Blending oxygen

“Dry-exposed” Resuscitation Gestational Age > 28w

“Dry-exposed” Resuscitation Gestational Age > 28w

“Wet-in-bag” Resuscitation Gestational Age < 28w

“Wet-in-bag” Resuscitation Gestational Age < 28w

“Wet-in-bag” Resuscitation Gestational Age < 28w

“Wet-in-bag” Resuscitation Gestational Age < 28w

“Wet-in-bag” Resuscitation Gestational Age < 28w Photo courtesy: BC’s Children’s Hospital NICU

“Wet-in-bag” Resuscitation 88 infants Infants placed in the polyurethane bags were less likely to have a temp <36.40C on admission 44 vs. 70% (p<0.001) Better if room at 25-26oC Gestational Age ≤ 28w Knobel et al. Heat loss prevention for preterm infants in the delivery room. J Perinat 2005;25:304-308

“Wet-in-bag” Resuscitation

“Wet-in-bag” Resuscitation

“Wet-in-bag” Resuscitation Polyethylene bags significantly reduce the risk of hypothermia in infants <28 weeks on admission to NICU RR 0.63 (C.I. 0.42-0.93) NNT 4

“Wet-in-bag” Resuscitation CPS Maintenance of DR at 25 to 26oC will diminish heat loss If GA < 28w place him below the neck in a polyethylene bag All babies (term/preterm) under radiant warmer by 10 min should have servocontrol probe Gestational Age < 28w

The Apgar Score

Resuscitation when meconium present

The Initial Steps Or wet in bag? … at 90 seconds

Preterm < 32 weeks Use blended oxygen and air, and a pulse oximeter Begin PPV with FiO2 between 0.21 and 1.00. Studies are lacking to be more precise. Adjust FiO2 to achieve SpO2 gradually increasing towards 90%. Decrease the FiO2 as SpO2 rises over 95% If the heart rate does not respond by increasing rapidly to > 100 bpm, correct any ventilation problem and use FiO2 1.00.

Should oxygen be administered to babies receiving chest compressions?

NRP 2006 St. John’s - Newfoundland Medications NRP 2006 St. John’s - Newfoundland

Medications 2:1000 newborns

NRP 2006 When to use oxygen: Cyanotic at 90 seconds (supplemental) Receiving chest compressions (100%)

Epinephrine ! “If the heart rate remains below 60 bpm despite administration of ventilation and chest compressions your first action is to ensure that ventilation and chest compressions are being given optimally and that you are using 100% oxygen”

Epinephrine Route UVC ETT Intraosseous low position Slow absorption → higher dose? Poor evidence, expert opinion Intraosseous Outpatient setting; limited data → not taught

Epinephrine - Administration CPS: “First dose via ETT while preparing for insertion of UVC” 3 mL syringe 1 mL/kg of 1:10,000 epinephrine “When given via UVC …” 1 mL syringe 0.1 mL/kg of 1:10,000 epinephrine Follow with 5 mL of 0.9& saline flush

Epinephrine - Administration Shows recommendation in CPS NRP addendum, 2006

Epinephrine - Administration Can repeat after 3-5 minutes

Shock / hypovolemia ! “If the baby appears in shock and is not responding to resuscitation administration of a volume expander may be indicated”

If no improvement