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

2. 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

3. 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

4. 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.

6. Is resuscitation needed?
Routine Care

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

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

9. Routine Care
NRP 2006
NRP 2000

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

11. 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 ( 5):
ACoRN © 2006

12. 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 ( 5):
ACoRN © 2006

13. 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 ( 5):
ACoRN © 2006

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

15. Routine Care
NRP 2006

16. Routine Care
NRP 2006
NRP 2000

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

18. The initial steps
2006

19. The initial steps
2006
2000

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

21. NRP algorithm
Routine Care

22. NRP algorithm
Routine Care

23. NRP algorithm
Routine Care
First 30 seconds
Wait 90 seconds

24. NRP algorithm
Routine Care
First 30 seconds
Observational Care

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

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

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

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

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

30. 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 ...

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

32. The persistently cyanotic baby

33. 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 …”

34. Oxygen administration

35. Blending oxygen

36. Blending oxygen

37. “Dry-exposed” Resuscitation
Gestational Age > 28w

38. “Dry-exposed” Resuscitation
Gestational Age > 28w

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

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

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

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

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

44. “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:

45. “Wet-in-bag” Resuscitation

46. “Wet-in-bag” Resuscitation

47. “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 )
NNT 4

48. “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

49. The Apgar Score

50. Resuscitation when meconium present

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

52. Preterm < 32 weeks Use blended oxygen and air, and a pulse oximeter
Begin PPV with FiO2 between 0.21 and 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 FiO

53. Should oxygen be administered to babies receiving chest compressions?

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

56. Medications
2:1000 newborns

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

58. 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”

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

60. 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

61. Epinephrine - Administration
Shows recommendation in CPS NRP addendum, 2006

62. Epinephrine - Administration
Can repeat after 3-5 minutes

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

64. If no improvement