Nrp 2010

NRP 2010NRP 2010
What has changed?What has changed?
Circulation 2010;122;S909-S919
Circulation 2010;122;S516-S538
Rhishikesh Thakre
DM (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 Elective
Cesarean 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 babyRoutine care can be provided with the baby
lying on the motherlying on the mother’’s chest and should nots 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 assessSimultaneously assess
Heart Rate
Respiration Oxygenation*
* Pulse oximetry

Practice PointerPractice Pointer
The most sensitive indicator of aThe most sensitive indicator of a
successful response to eachsuccessful response to each
step is anstep 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
Class IIb, LOE C

• Hyperthermia should be avoided
(Class IIb, LOE)
The goal is to achieve normothermia
&
avoid iatrogenic hyperthermia

Clearing the AirwayClearing the Airway
When 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 to
spontaneous 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
When Amniotic Fluid Is ClearWhen Amniotic Fluid Is Clear

WhenWhen 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 endotracheal
suctioning of non-vigorous babies with meconium
stained 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 oxygen
and 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 air
rather 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 pulseRole 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 pulseRole 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 anticipated
ii) when positive pressure is administered
for more than a few breaths
iii) when cyanosis is persistent, or
iv) when supplementary oxygen is administered
When to use pulseWhen to use pulse oximetryoximetry
Class I, LOE B

How to use pulseHow to use pulse oximetryoximetry
• Probe should be attached to a preductal
location (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 signal
Class 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 range
of 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 oximetry
Class 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 be
individualized 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 detectorsUse 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

• Spontaneously breathing preterm infants
who have respiratory distress may be
supported with CPAP or with intubation
and mechanical ventilation
Class IIb, LOE B
• The most appropriate choice may be
guided by local expertise and preferences

• 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

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 recommended
method of confirmation of endotracheal tube
placement in addition to clinical assessment
Class 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 endotracheal
intubation) with 100% oxygen and chest
compressions, administration of epinephrine or
volume expansion, or both, may be indicated.
• Buffers, a narcotic antagonist, or vasopressors
may 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 endotracheal
epinephrine, 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 ofRole 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 importance
of 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

Compiled by
Rhishikesh Thakre
rhishikesht@gmail.com

Nrp 2010

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Nrp 2010