The New NRP The New NRP AlgorithmAlgorithm

NRP 2006 – Western Canada NRP 2006 – Western Canada LaunchLaunch

Vancouver, BCVancouver, BC

ObjectivesObjectives

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

recommendations affect the algorithmrecommendations affect the algorithm

ObjectivesObjectives

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

presentpresent

National guidelines to neonatal resuscitation National guidelines to neonatal resuscitation across several continents are based on the across several continents are based on the consensus statements of the International consensus statements of the International Liaison Committee on Resuscitation Liaison Committee on Resuscitation (ILCOR).(ILCOR).

Each country is expected to develop Each country is expected to develop guidelines that reflect their own context. guidelines that reflect their own context.

The Canadian Expert The Canadian Expert CommitteeCommittee

Is resuscitation needed?Is resuscitation needed?

Routine CareRoutine Care

Is resuscitation needed?Is resuscitation needed?

Routine CareRoutine Care

NRP NRP 20002000Routine CareRoutine Care

NRP NRP 20062006

Is resuscitation needed?Is resuscitation needed?

Routine CareRoutine Care

NRP NRP 20062006

Oxygen is gone …Oxygen is gone …

Routine CareRoutine Care

NRP NRP 20020066

NRP NRP 20002000

Gestational age Gestational age 37.737.7

Birth weightBirth weight 3036g3036g

SpOSpO2 2 >75% >75% 207 s207 s

SpOSpO2 2 >90%>90% 343 s343 s

.

Kamlin, O'Donnell, Davis, Morley. Kamlin, O'Donnell, Davis, Morley. SPR 2005. A2050SPR 2005. A2050

Normal transitionNormal transition

Slide courtesy of ACoRN 2006Slide courtesy of ACoRN 2006

ACoRN © 2006ACoRN © 2006

Normal transitionNormal transition

Rabi Y, Yee W, Chen SY, Singhal N. Rabi Y, Yee W, Chen SY, Singhal N. J Pediatrics 2006 148( 5):590-594J Pediatrics 2006 148( 5):590-594

Slide courtesy of ACoRN 2006Slide courtesy of ACoRN 2006

ACoRN © 2006ACoRN © 2006

Rabi Y, Yee W, Chen SY, Singhal N. Rabi Y, Yee W, Chen SY, Singhal N. J Pediatrics 2006 148( 5):590-594J Pediatrics 2006 148( 5):590-594

Normal transitionNormal transition

Slide courtesy of ACoRN 2006Slide courtesy of ACoRN 2006

ACoRN © 2006ACoRN © 2006

Rabi Y, Yee W, Chen SY, Singhal N. Rabi Y, Yee W, Chen SY, Singhal N. J Pediatrics 2006 148( 5):590-594J Pediatrics 2006 148( 5):590-594

Normal transitionNormal transition

Slide courtesy of ACoRN 2006Slide courtesy of ACoRN 2006

ACoRN © 2006ACoRN © 2006

Canadian Expert Canadian Expert CommitteeCommittee

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

Routine CareRoutine Care

NRP NRP 20020066

Routine CareRoutine Care

NRP NRP 20020066

NRP NRP 20002000

Routine CareRoutine Care

NRP NRP 20020066

What if this “well What if this “well baby” baby baby” baby

remains cyanotic remains cyanotic > 90 sec?> 90 sec?

The initial stepsThe initial steps

20062006

2000200020062006

The initial stepsThe initial steps

20062006

… no oxygen given

The initial stepsThe initial steps

Exception to “dry the baby”

Routine Routine CareCare

Firs

t 30

seco

nds

NRP algorithmNRP algorithm

Wait 90 seconds

Observational CareObservational Care

Routine Routine CareCare

Firs

t 30

seco

nds

NRP algorithmNRP algorithm

NRP algorithmNRP algorithm

Observational CareObservational Care

Routine Routine CareCare

… at 90 seconds

Firs

t 30

seco

nds

The persistently cyanotic The persistently cyanotic babybaby

Oxygen administrationOxygen administration Only central cyanosis requires intervention. Only central cyanosis requires intervention.

Acrocyanosis does not indicate hypoxemia.Acrocyanosis does not indicate hypoxemia. ““If the baby is breathing but appears blue, If the baby is breathing but appears blue,

administration of supplemental oxygen is administration of supplemental oxygen is indicated” indicated” at 90 secondsat 90 seconds……

““Supplemental oxygen also may be needed Supplemental oxygen also may be needed when respirations are being assisted” when respirations are being assisted” at 90 at 90 secondsseconds……

““There is evidence that resuscitation with air There is evidence that resuscitation with air is as effective as with 100% oxygen …” is as effective as with 100% oxygen …”

Oxygen administrationOxygen administration

Blending oxygenBlending oxygen

Blending oxygenBlending oxygen

““Dry-exposed” Dry-exposed” ResuscitationResuscitation

GestatioGestational Age nal Age > 28w> 28w

““Dry-exposed” Dry-exposed” ResuscitationResuscitation

GestatioGestational Age nal Age > 28w> 28w

““Wet-in-bag” Wet-in-bag” ResuscitationResuscitation

GestatioGestational Age nal Age < 28w< 28w

““Wet-in-bag” Wet-in-bag” ResuscitationResuscitation

GestatioGestational Age nal Age < 28w< 28w

““Wet-in-bag” Wet-in-bag” ResuscitationResuscitation

GestatioGestational Age nal Age < 28w< 28w

““Wet-in-bag” Wet-in-bag” ResuscitationResuscitation

GestatioGestational Age nal Age < 28w< 28w

““Wet-in-bag” Wet-in-bag” ResuscitationResuscitation

GestatioGestational Age nal Age ≤ 28w≤ 28w

88 infants88 infants Infants placed in the Infants placed in the

polyurethane bags were polyurethane bags were less likely to have a temp less likely to have a temp <36.4<36.400C on admissionC on admission

44 vs. 70% (p<0.001)44 vs. 70% (p<0.001) Better if room at 25-26Better if room at 25-26ooCC

Knobel Knobel et alet al. Heat loss prevention for preterm infants in the delivery room. J Perinat 2005;25:304-308. Heat loss prevention for preterm infants in the delivery room. J Perinat 2005;25:304-308

““Wet-in-bag” Wet-in-bag” ResuscitationResuscitation

““Wet-in-bag” Wet-in-bag” ResuscitationResuscitation

““Wet-in-bag” Wet-in-bag” ResuscitationResuscitation

Polyethylene bags Polyethylene bags significantly reduce the risk significantly reduce the risk of hypothermia in infants of hypothermia in infants <28 weeks on admission to <28 weeks on admission to NICUNICU

RR 0.63 (C.I. 0.42-0.93)RR 0.63 (C.I. 0.42-0.93) NNT 4 NNT 4

““Wet-in-bag” Wet-in-bag” ResuscitationResuscitation

GestatioGestational Age nal Age < 28w< 28w

CPSCPS Maintenance of DR at 25 to Maintenance of DR at 25 to

2626ooC will diminish heat lossC will diminish heat loss If GA < 28w place him below If GA < 28w place him below

the neck in a polyethylene bagthe neck in a polyethylene bag AllAll babiesbabies (term/preterm) (term/preterm)

under radiant warmer by 10 under radiant warmer by 10 min should have servocontrol min should have servocontrol probe probe

The Apgar ScoreThe Apgar Score

Resuscitation when Resuscitation when meconium presentmeconium present

The Initial StepsThe Initial Steps

… at 90 seconds

Or wet in bag?

Preterm < 32 weeksPreterm < 32 weeks

Use blended oxygen and air, and a pulse Use blended oxygen and air, and a pulse oximeteroximeter

Begin PPV with FiOBegin PPV with FiO22 between 0.21 and 1.00. between 0.21 and 1.00. Studies are lacking to be more precise.Studies are lacking to be more precise.

Adjust FiOAdjust FiO22 to achieve SpO to achieve SpO22 gradually gradually increasing towards 90%. Decrease the FiOincreasing towards 90%. Decrease the FiO22 as SpOas SpO22 rises over 95% rises over 95%

If the heart rate does not respond by If the heart rate does not respond by increasing rapidly to > 100 bpm, correct any increasing rapidly to > 100 bpm, correct any ventilation problem and use FiOventilation problem and use FiO22 1.00. 1.00.

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

MedicationsMedications

NRP 2006NRP 2006

St. John’s - NewfoundlandSt. John’s - Newfoundland

MedicationsMedications

2:1000 newborns

NRP NRP 20062006

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

EpinephrineEpinephrine

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

!

Epinephrine RouteEpinephrine Route

UVC UVC low positionlow position

ETTETT Slow absorption → higher dose?Slow absorption → higher dose?

Poor evidence, expert opinionPoor evidence, expert opinion IntraosseousIntraosseous

Outpatient setting; limited data → not Outpatient setting; limited data → not taughttaught

Epinephrine - Epinephrine - AdministrationAdministration

CPS:CPS: ““First dose via ETT while preparing for First dose via ETT while preparing for

insertion of UVC”insertion of UVC” 3 mL syringe3 mL syringe 1 mL/kg of 1:10,000 epinephrine1 mL/kg of 1:10,000 epinephrine

““When given via UVC …”When given via UVC …” 1 mL syringe1 mL syringe 0.1 mL/kg of 1:10,000 epinephrine0.1 mL/kg of 1:10,000 epinephrine Follow with 5 mL of 0.9& saline flushFollow with 5 mL of 0.9& saline flush

Epinephrine - Epinephrine - AdministratioAdministratio

nn

Shows recommendation in CPS NRP addendum, 2006

Can repeat after 3-5 minutes

Epinephrine - Epinephrine - AdministratioAdministratio

nn

Shock / Shock / hypovolemiahypovolemia

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

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If no If no improvemeimproveme

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