nrp 2010
TRANSCRIPT
NRP 2010NRP 2010What has changed?What has changed?
Circulation 2010;122;S909-S919Circulation 2010;122;S516-S538
Rhishikesh ThakreDM (Neo), MD, DNB, DCH, FCPS, MBBS
Subject populationSubject population
• Applicable to-- Newly born infants undergoing transition
from intrauterine to extrauterine life- Neonates during first few weeks to months following birth
Responsibility of caregiverResponsibility of caregiver
• At every delivery there should be at least 1 person whose primary responsibility is the newly born
• The person must be capable of initiating resuscitation, including administration of positive-pressure ventilation and chest compressions
Personnel Needs at ElectivePersonnel Needs at ElectiveCesarean SectionsCesarean Sections
• A provider capable of performing assisted ventilation should be present at the delivery
• It is not necessary for a provider skilled in neonatal intubation to be present at that delivery
Maternal feverMaternal fever
• There should be an increased awareness that the presence of maternal hyperthermia may lead to a need for neonatal resuscitation
• There is insufficient evidence to support or refute the routine use of interventions to lower maternal fever to reduce neonatal morbidity and mortality
Cord ClampingCord Clamping• Delay in umbilical cord clamping for at least 1
minute is recommended for newborn infants not requiring resuscitation
• Evidence of a benefit to delaying cord clamping for a minimum time ranging from 30 seconds to 3 minutes after well preterm delivery
• Evidence of a benefit to delaying cord clamping for a minimum time ranging from 1 minute until the cord stops pulsating after well term delivery
Rapid assessmentRapid assessment
Term gestation?Term gestation?Crying or breathing?Crying or breathing?Good muscle tone?Good muscle tone?
Routine care can be provided with the baby Routine care can be provided with the baby lying on the motherlying on the mother’’s chest and should not s chest and should not
require separation of mother and babyrequire separation of mother and baby
Cord clamping should be delayed for at least 1 minute in babies who do not require
resuscitation
Rapid assessmentRapid assessment
• Initial steps in stabilization
• Ventilation
• Chest compressions
• Administration of epinephrine and/or volume expansion
• Term gestation?
• Crying or breathing?
• Good muscle tone?
NO
Progression to the next stepProgression to the next step
• Apnea• Gasping, or • Labored or
unlabored breathing)
RESPIRATIONRESPIRATION HEART RATEHEART RATE
• > 100 bpm
• < 100 bpm
Simultaneous assessment of
HR / Pulse Check?HR / Pulse Check?
• Auscultation of the precordium should remain the primary means of assessing heart rate
• With a palpable pulse, palpation of the umbilical pulse is more accurate than palpation at other sites
Simultaneously assess Simultaneously assess
Heart Rate
Respiration Oxygenation*
* Pulse oximetry
Practice PointerPractice Pointer
The most sensitive indicator of a The most sensitive indicator of a successful response to each successful response to each
step is an step is an increase in heart rateincrease in heart rate
Initial steps: Maintaining TemperatureInitial steps: Maintaining Temperature
• Additional warming techniques are recommended for preterm (<1500 g)
�Pre-warming the delivery room to 26°C, covering the baby in plastic wrapping (food or medical grade, heat-resistant plastic) Class I, LOE A
�Placing the baby on an exothermic mattress Class IIb, LOE B16
� Placing the baby under radiant heat Class IIb, LOE C17
• Delivery room temperatures should be at least 26°C for infants of < 28 weeks’
• Pre-warming the linen• Drying and swaddling• Placing the baby skin-to-skin with the
mother• Covering mother-baby with a blanket
Initial steps: Maintaining TemperatureInitial steps: Maintaining Temperature
Class IIb, LOE C
• Hyperthermia should be avoided (Class IIb, LOE)
Initial steps: Maintaining TemperatureInitial steps: Maintaining Temperature
The goal is to achieve normothermia&
avoid iatrogenic hyperthermia
Clearing the AirwayClearing the AirwayWhen Amniotic Fluid Is ClearWhen Amniotic Fluid Is Clear
• Suctioning immediately following birth (including suctioning with a bulb syringe) should be reserved for -
� babies who have obvious obstruction tospontaneous breathing or
� who require positive-pressure ventilation (PPV)
Class IIb, LOE C
• In healthy neonates suctioning of the mouth and nose is associated with cardio-respiratory complications LOE 1
• There is no evidence to support or refute suctioning of the mouth and nose of depressed neonates at birth when the infant is born through clear amniotic fluid
Clearing the AirwayClearing the AirwayWhen Amniotic Fluid Is ClearWhen Amniotic Fluid Is Clear
Clearing the AirwayClearing the AirwayWhen When meconiummeconium is presentis present
• Use of tracheal suctioning has not been associated with a reduction in the incidence of meconium aspiration syndrome or mortality LOE 4; LOE 5
• If attempted intubation is prolonged and unsuccessful, bag-mask ventilation should be considered, particularly if there is persistent bradycardia
MSAF: To suction or notMSAF: To suction or not
• Routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born with clear or MSAF is no longer recommended
• Insufficient evidence to recommend a change in the current practice of performing endotrachealsuctioning of non-vigorous babies with meconiumstained amniotic fluid Class IIb,LOE C
Role of OxygenRole of Oxygen
• Evidence suggests that either insufficient or excessive oxygenation can be harmful to the newborn infant
• Adverse outcomes may result from even brief exposure to excessive oxygen during and following resuscitation
Using oxygenUsing oxygen
• Administration of supplementary oxygen should be regulated by blending oxygenand air, and the concentration delivered should be guided by oximetry
• In term infants receiving resuscitation at birth with PPV, it is best to begin with airrather than 100% oxygen
• If despite effective ventilation there is no increase in heart rate or if oxygenation (guided by oximetry) remains unacceptable, use of a higher concentration of oxygen should be considered
• Because many preterm babies of 32 weeks’gestation will not reach target saturations in air, blended oxygen and air may be given judiciously and ideally guided by pulse oximetry
Using oxygenUsing oxygen
Role of pulse Role of pulse oximetryoximetry
• For babies who require ongoing resuscitation or respiratory support or both, the goal should be to use pulse oximetry
• Should be used in conjunction with and should not replace clinical assessment of heart rate
Role of pulse Role of pulse oximetryoximetry
• Newer pulse oximeters, which employ probes designed specifically for neonates, have been shown to provide reliable readings within 1 to 2 minutes following birth
• Reliable as long as there is sufficient cardiac output and skin blood flow for the oximeter to detect a pulse
• Oximetry be used i) when resuscitation can be anticipatedii) when positive pressure is administered
for more than a few breathsiii) when cyanosis is persistent, oriv) when supplementary oxygen is administered
When to use pulse When to use pulse oximetryoximetry
Class I, LOE B
How to use pulse How to use pulse oximetryoximetry
• Probe should be attached to a preductallocation (ie, the right upper extremity, usually the wrist or medial surface of the palm)
• Attaching the probe to the baby before connecting the probe to the instrument facilitates the most rapid acquisition of signalClass IIb, LOE C
Administration of OxygenAdministration of Oxygen
• Goal in babies being resuscitated at birth, whether born at term or preterm, should be an oxygen saturation value in the interquartile rangeof preductal saturation measured in healthy term babies following vaginal birth at sea level
Class IIb, LOE B
Optimizing oxygen useOptimizing oxygen use
• Initiate resuscitation with air or a blended oxygen and titrating the oxygen concentration to achieve an SpO2 in the target range as
described using pulse oximetryClass IIb, LOE C
• If blended oxygen is not available, resuscitation should be initiated with air
Class IIb, LOE B
Optimizing oxygen useOptimizing oxygen use
• If the baby is bradycardic (HR 60 per minute) after 90 seconds of resuscitation with a lower concentration of oxygen, oxygen concentration should be increased to 100% until recovery of a normal heart rate
Class IIb, LOE B
Positive pressure ventilationPositive pressure ventilation
• After administering the initial steps, start PPV if
- infant remains apneic, or- gasping, or - if the heart rate remains 100 per minute
Assessment of PPVAssessment of PPV
• The primary measure of adequate initial ventilation is prompt improvement in heart rate
• Chest wall movement should be assessed if heart rate does not improve
• The initial inflation pressure should beindividualized to achieve an increase in heart rate or movement of the chest with each breath
• Inflation pressure should be monitored
Goal of PPVGoal of PPV
• Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to promptly achieve or maintain a heart rate 100 per minute
Class IIb,LOE C
How much pressure for PPV?How much pressure for PPV?
• In term infants an inflation pressure of 30 cm H2O (LOE 4) and in preterm infants with pressures of 20 to 25 cm H2O (LOE 4)
are necessary to achieve improvement in heart rate or chest expansion
• Occasionally higher pressures are required (LOE 4)
Use of colorimetric CO2 detectors Use of colorimetric CO2 detectors during PPVduring PPV
• It is unclear whether the use of CO2 detectors during mask ventilation confers additional benefit above clinical assessment alone
Class IIb, LOE C
Role of CPAP in DRRole of CPAP in DR
• There is no evidence to support or refute the use of CPAP/PEEP in the delivery room in the term baby with respiratory distress
• Starting infants on CPAP reduced the rates of intubation and mechanical ventilation, surfactant use, and duration of ventilation, but increased the rate of pneumothorax
Role of CPAP in DRRole of CPAP in DR
• Spontaneously breathing preterm infants who have respiratory distress may be supported with CPAP or with intubationand mechanical ventilation
Class IIb, LOE B
• The most appropriate choice may be guided by local expertise and preferences
Role of CPAP in DRRole of CPAP in DR
• PEEP is likely to be beneficial and should be used if suitable equipment is available
Class IIb, LOE C
• PEEP can easily be given � With a flow-inflating bag or � T-piece resuscitator� A self-inflating bag with an optional PEEP valve
AssistedAssisted--Ventilation DevicesVentilation Devices
• A flow-inflating bag, a self-inflating bag, or a pressure-limited T-piece resuscitator can be used for PPV
• The pop-off valves of self-inflating bags are dependent on the flow rate of incoming gas, and pressures generated may exceed the value specified by the manufacturer
• Resuscitators are insensitive to changes in lung compliance, regardless of the device being used
Class IIb, LOE C
Interface
• There is insufficient evidence to support or refute the use of one type of mask over another
• Whichever interface is used, providers should ensure that they are skilled in using the interface devices available at the institution
Exhaled air ventilationExhaled air ventilation
• Use of mouth-to-mask ventilation at 30 insufflations per minute is as effective as self-inflating bag-mask ventilation in increasing heart rate in the first 5 minutes after birth LOE 2
• Mouth-to-mouth ventilation is less effective than a self-inflating bag or tube and mask LOE 3
• Mask-to-tube ventilation may cause infection in newborn infants LOE 2
Role of LMARole of LMA
• Effective for ventilating newborns > 2000 g or delivered 34 weeks gestation Class IIb, LOE B
• LMA be considered during resuscitation if � facemask ventilation is unsuccessful� tracheal intubation is unsuccessful� tracheal intubation is not feasible
Class IIa, LOE B
Limitations of LMALimitations of LMA
• Limited data for < 2000 g or 34 w infants
• Not been evaluated in cases of meconium-stained fluid, during chest compressions, or for administration of emergency intratracheal medications
Golden MinuteGolden Minute
Indications for ETIndications for ET
� Initial ET suctioning of non-vigorous MSAF� If bag-mask ventilation is ineffective or
prolonged� When chest compressions are performed� For special resuscitation circumstances, such
as congenital diaphragmatic hernia or ELBW
The timing of ET may also depend on the skill and experience of the available provider
Confirmation of ETConfirmation of ET
• With PPV, a prompt increase in heart rate is the best indicator that the tube is in the tracheobronchial tree and providing effective ventilation
• Exhaled CO2 detection is effective for confirmation of ET placement in infants, including VLBW infants Class IIa, LOE B
• Exhaled CO2 detection is the recommendedmethod of confirmation of endotracheal tubeplacement in addition to clinical assessmentClass IIa, LOE B
Confirmation of ETConfirmation of ET
• Condensation in the endotracheal tube• Chest movement• Presence of equal breath sounds bilaterally
Class 11b, LOE C
• There is insufficient evidence to recommend routine use of colorimetric exhaled CO2 detectors during mask ventilation of newborns in the delivery room.
Chest compressionsChest compressions
• Rescuers should ensure that assisted ventilation is being delivered optimally before starting chest compressions
• Compressions should be delivered on the lower third of the sternum to a depth of approximately 1/3 of the AP diameter of the chest
Class IIb, LOE C
Chest compressions: TechniqueChest compressions: Technique
• 2 thumb–encircling hands technique is recommended for performing chest compressions in newly born infants
Class IIb, LOE C
• The chest should be permitted to re-expand fully during relaxation, but the rescuer’s thumbs should not leave the chest Class IIb, LOE C
CC to ventilation ratioCC to ventilation ratio
• It is recommended that a 3:1 compression to ventilation ratio be used for neonatal resuscitation
• Rescuers should consider using higher ratios (eg, 15:2) if the arrest is believed to be of cardiac origin Class IIb, LOE C
Drugs in CPRDrugs in CPR
• If the heart rate remains 60 per minute despite adequate ventilation (usually with endotrachealintubation) with 100% oxygen and chest compressions, administration of epinephrine or volume expansion, or both, may be indicated.
• Buffers, a narcotic antagonist, or vasopressorsmay be useful after resuscitation, but these are not recommended in the delivery room
Vascular AccessVascular Access
• Temporary intraosseous access to provide fluids and medications to resuscitate critically ill neonates may be indicated following unsuccessful attempts to establish intravenous vascular access
EpinephrineEpinephrine
• Epinephrine is recommended to be administered IV Class IIb, LOE C
• Lack of supportive data for endotrachealepinephrine, the IV route should be used as soon as venous access is established Class IIb, LOE C
EpinephrineEpinephrine
• 0.01 to 0.03 mg/kg per dose, IV
• While access is being obtained, administration of a higher dose (0.05 to 0.1 mg/kg) through the ETT may be considered, but the safety and efficacy of this practice have not been evaluated
Class IIb, LOE C
• The concentration of epinephrine for either route should be 1:10,000
Volume expansionVolume expansion
• The recommended dose is 10 mL/kg, which may need to be repeated
• Care should be taken to avoid giving volume expanders rapidly in preterms
• An isotonic crystalloid solution or blood is recommended for volume expansion in the delivery room
• Indicated for babies with blood loss who are not responding to resuscitation
• Because blood loss may be occult, a trial of volume administration may be considered in babies who do not respond to resuscitation
Volume expansionVolume expansion
Role of Role of NaloxoneNaloxone
• Administration of naloxone is not recommended as part of initial resuscitative efforts in the delivery room for newborns with respiratory depression
Role of glucoseRole of glucose• Newborns with lower blood glucose levels are at
increased risk for brain injury and adverse outcomes
• No specific glucose level associated with worse outcome has been identified
• No specific target glucose concentration range can be identified at present
• IV glucose infusion should be considered as soon as practical after resuscitation, with the goal of avoiding hypoglycemia Class IIb, LOE C
Therapeutic HypothermiaTherapeutic Hypothermia
• Infants born at/ > 36 weeks gestation with evolving moderate to severe HIE should be offered therapeutic hypothermia
• Therapeutic hypothermia should be administered under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-up
Class IIa, LOE A
Withholding ResuscitationWithholding Resuscitation
• Non-initiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent, and clinicians should not hesitate to withdraw support when functional survival is highly unlikely
• A consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents is an important goal
Withholding ResuscitationWithholding Resuscitation
• Assessment of morbidity and mortality risks should take into consideration available data
• These uncertainties underscore the importanceof not making firm commitments about withholding or providing resuscitation until you have the opportunity to examine the baby after birth
Discontinuing Resuscitative EffortsDiscontinuing Resuscitative Efforts
• In a newly born baby with no detectable heart rate, it is appropriate to consider stopping resuscitation if the heart rate remains undetectable for 10 minutes
Class IIb, LOE C
Teaching NRPTeaching NRP
• Adopt simulation, briefing, and debriefing techniques in designing an education program for the acquisition and maintenance of the skills necessary for effective neonatal resuscitation
Class IIb, LOE C
