Neonatal resuscitation program 8 th edition updates

NRP 8th edition

1. NEONATAL RESUSCITATION PROGRAM -8 TH EDITION UPDATES Presenter: Dr Jason Dsouza Moderator : Dr Saritha Paul

2. 6 UPDATES SINCE NRP 7 TH EDITION

3. Introduction Successful transition from intrauterine to extrauterine life is dependent upon significant physiologic changes that occur at birth Within 30sec after birth , 85% Term newborns will begin breathing while an additional 10% begin breathing in response to drying and stimulation One to 3 babies per 1000 live births will receive chest compressions or emergency medications

4. Neonatal resuscitation 1. Foundations of Neonatal Resuscitation 2. Preparing for resuscitation 3. Initial steps of newborn care 4. Positive pressure ventilation 5. Alternative airways :endotracheal tubes and laryngeal masks 6. Chest compressions 7. Medications 8. Summary

5. Fetal circulation

6. Neonatal Resuscitation Program Flow Diagram 5 Blocks -Initial assessment -Airway(A) -Breathing (B) -Circulation(C) -Drugs (D)

7. Preparing for resuscitation Know the risk factors Assemble Resuscitation team Ask Obstetric provider 4 key questions before birth Pre resuscitation team briefing Assemble and check Resuscitation supplies and equipments

8. Risk factors

9. Assemble the resuscitation team Every birth must be attended by at least 1 qualified individual skilled in the initial steps of new born care and positive pressure ventilation If risk factors are present at least 2 qualified people should be present solely to manage the baby Team leader ? How many members ?

10. Pre Birth question ? 4 Questions: What is the expected gestational age? Is the amniotic fluid clear? How many babies are expected ?  Umbilical cord management plan? (NRP-8th) Are there any additional risk factors ? UPDATE 1: Umbilical cord management plan added to 4 prebirth questions, replacing “ How many babies?”

11. Assemble and check supplies Warm Clear airway Auscultate Ventilate Oxygenate Intubate Medicate

12. The Golden Minute Assessment Airway

13. Update 2: Initial steps are reordered to better reflect Common practice NRP-7 th edition NRP-8 th edition

14. INITIAL STEPS OF NEWBORN CARE

15. Position WARM(36.5-37.5C) BIRTH

16. Clear secretion from airway (M  N )

17. STIMULATE Gently rub the newborns back, trunk or extremities Over vigorous stimulation is not helpful and can cause Injury NEVER SHAKE A BABY

18. UMBILICAL CORD MANAGEMENT AHA 2010 recommendation No recommendation Given AHA 2015 recommendation Cord clamping should be delayed for > 30 seconds No recommendation for infants resuscitated at birth Cord milking –Routine use is not recommended AHA 2021 recommendation Vigorous Preterm/Term Newborn : Delayed For 30-60seconds No definite recommendation in newborns who are not vigorous UCM <28weeks POG not recommended

19. Remarks Pros 1. Less intraventricular hemorrhage of any grade 2. Higher blood pressure and blood volume 3. Higher hemoglobin levels , Iron stores, better neurodevelopmental outcome(T) 3 .Less need for transfusion after birth 4 .Less necrotizing enterocolitis Cons Slightly increased level of bilirubin associated with more need of phototherapy Delayed cord clamping definition: WHO: 60 seconds ACOG: 30-60 seconds

20. Normal temperature of Newborn in the Delivery Room AHA 2010 recommendation No temperature range specified AHA 2015 Recommendation Temperature of Non asphyxiated infants should be maintained between 36.5-37.5 C AHA 2021 recommendation Baby’s(PT/T) body temperature should be maintained at 36.5-37.5 C Room temperature of 23-25C

21. Intervention to maintain normal temperature AHA 2010 recommendation In VLBW (<1500) Preterm babies, Delivery room temperature to 26C ,Plastic wraps, exothermic mattress , Radiant warmer AHA 2015 recommendation In infants (<32 weeks) Radiant warmers and plastic wraps with cap Increased room temperature Thermal mattress Warmed humidified resuscitation gases AHA 2021 recommendation Same as above(AHA 2015) DR temp:23-25C < 32weeks POG, Pre warmed transport incubator, thermal gel and maintain babys axillary temperature between 36.5-37.5C

22. Warming of unintentionally hypothermic Newborns AHA 2010 RECOMMENDATION NO RECOMMNEDATION GIVEN AHA 2015 RECOMMENDATION EITHER RAPID (0.5C/HOUR OR GREATER ) OR SLOW REWARMING (LESS THAN 0.5 C /H) REMARKS THE AHA 2021, NO CLEAR RECOMMENDATION BUT SUGGESTS THAT SLOW REWARMING IS BETTER APPROACH AHA 2021 RECOMMENDATION AGGRESSIVE WARMING AND HYPERTHERMIA WORSENS THE OUTCOME AND IS AVOIDED

23. Maintaining of Normothermia in Resource limited settings AHA 2010 RECOMMENDATION No recommendation given AHA 2015 RECOMMENDATION Covering the newborn in a clean food grade plastic bag up to the level of neck and swaddle them after drying ,skin to skin contact or kangaroo mother care AHA 2021 RECOMMENDATION No new recommendation; same as 2015

24. Clear the airway when meconium is present AHA 2010 RECOMMENDATION Endotracheal suction in non vigorous babies AHA 2015 RECOMMENDATION Routine intubation for endotracheal suction in non vigorous babies is not suggested initial steps followed by positive pressure ventilation (PPV) should be done as per routine indication REMARKS Since MSAF indicates fetal distress therefore harm avoidance without delay in providing PPV takes a priority over unknown benefit of tracheal suction. AHA 2021 RECOMMENDATION Same as 2015 recommendation; In case of non vigourous babies with evidence of airway block ET suction is allowed

25. ASSESMENT OF HEART RATE AHA 2010 RECOMMENDATION No specific recommendation given AHA 2015 RECOMMENDATION Use of 3 lead ECG for measurement of newborns heart rate REMARKS The first 2 mins of life ,pulse oximetry had shown to underestimate Heart rate while more accurate results was obtained with ECG;Doubtful if this is utilized in resource limited settings AHA 2021 recommendation Use of electronic cardiac monitor earlier in the algorithm

26. UPDATE 3: E lectronic cardiac monitor is recommended earlier in the algorithm NRP-7 th NRP-8th

27. Administration of oxygen in preterm infants AHA 2010 RECOMMENDATION No Specific recommendation given AHA 2015 RECOMMENDATION Newborn <35 of week of gestation begin resuscitation with low oxygen (21-30%) Titrate according to the preductal oxygen saturation REMARKS This recommendation reflects preference for not exposing preterm newborns to additional oxygen AHA 2021 RECOMMENDATION Same as 2015;Algorithm now includes a box indicating the initial Fio2 for resuscitation

28. P REDUCTAL Spo2 target (Always Right hand)

29. Spontaneously Breathing preterm infants with respiratory distress AHA 2010 RECOMMENDATION Either continuous positive airway pressure (CPAP) or intubation with mechanical ventilation AHA 2015 RECOMMENDATION CPAP is preferred than routine intubation AHA 2021 RECOMMENDATION Initial CPAP is preferred

30. Different types of resuscitation devices for ventilation (PPV) Self inflating bags Flow inflating bags T-piece Resuscitator

31. Initial pressures?? Peak Inspiratory pressure(PIP)  20-25cm H2O Positive End Expiratory Pressure(PEEP)  5cm H2O

32. 40-60 Breath per minute

33. Assess the heart Rate after 15 seconds of PPV

34. Ventilation Corrective steps –MR.SOPA

35. 2 nd assessment after 30 sec of PPV that moves the chest

36. When should alternative airway be considered ? Endotracheal tube or LMA, Should be considered : If PPV with a face mask does not result in clinical improvement  to improve ventilation efficacy If PPV last for more than a few minutes  improve the efficacy of ventilation and ease of assisted ventilation

37. Alternative Airways Endotracheal Tubes Laryngeal Masks

38. Et tube size and technique

39. Laryngeal Mask ( SupraGlottic Airway) when to consider? Newborns with Congenital anomalies involving mouth ,Lip, Tongue ,Palate or neck Small mandible and large tongue (Robin sequence and trisomy 21) PPV with face mask ineffective and attempts at intubation are unsuccessful

40. Chest compressions

41. When to begin chest compression Indicated when HR remains less than 60 bpm after at least 30 seconds of effective PPV Do not begin chest compressions unless you have achieved chest movement with your ventilation attempts

42. Compression rates: 90 compressions/minute

43. Chest compression AHA 2010 RECOMMENDATION No specific recommendations were provided for oxygen use during chest compressions However ,it mentioned providing 100% oxygen ,in newborns with bradycardia even after 90 seconds of resuscitation with lower concentration of oxygen AHA 2015 RECOMMENDATION : Give 100% oxygen with chest compression AHA 2021 RECOMMENDATION : Use 100% oxygen during chest compression

44. When to check heart rate after starting compressions 60 seconds Take one minute or more for for the heart rate to increase after chest compression When compressions are stopped ,coronary perfusion is decreased and requires time for recovery Avoid unnecessary interruptions When to stop chest compressions : Heart rate is >60bpm

45. Sodium bicarbonate infusion AHA 2010 RECOMMENDATION No recommendation AHA 2015 RECOMMENDATION No recommendation REMARKS Uasage of sodium bicarbonate in prolonged arrests doesn’t find any mention in AHA guidelines AHA 2021 recommendation No recommendation

46. Medications

47. When is epinephrine indicated? Heart rate below 60bpm after, Atleast 30 seconds of PPV that inflates the lungs & Another 60 seconds of chest compression coordinated with PPV using 100% oxygen

48. EPINEPHRINE SUMMARY CHART

49. CHANGE NRP 7 th NRP 8 th Epinephrine IV/IO flush volume increased Flush IV/IO epinephrine with 0.5 to 1 ml NS Flush IV/IO epinephrine with 3ml NS (applies to all weights and gestational ages ) Epinephrine IV/IO Range for IV /IO dose = 0.01-0.03 mg/kg (equal to 0.1-0.3ml/kg) The suggested initial IV or IO dose = 0.02mg/kg (equal to 0.2ml/kg) Epinephrine Endotracheal doses Range for Endotracheal dose = 0.05-0.1mg/kg(equal to 0.5-1ml/kg) The suggested endotracheal dose (while establishing vascular access)= 0.1mg/kg(equal to 1ml/kg) UPDATE 4 & 5: Epinephrine flush volume and doses

50. VOLUME EXPANDER SUMMARY

51. UPDATE 6: When to stop? AHA 2015 Recommendation : If there is a confirmed absence of heart rate after 10 mins of resuscitation. It is reasonable to stop resuscitative efforts; however, the decision to continue or discontinue should be individualized AHA 2021 Recommendation: If confirmed absence of HR after all appropriate steps performed ,consider cessation of resuscitation efforts around 20 minutes after birth (decision individualized on patient and contextual factors )

52. TOP 10 TAKE-HOME MESSAGES FOR NEONATAL LIFE SUPPORT 1. Newborn resuscitation requires anticipation and preparation by providers who train individually and as teams. 2. Most newly born infants do not require immediate cord clamping or resuscitation and can be evaluated and monitored during skin-to-skin contact with their mothers after birth. 3. Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth. 4. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. 5. Pulse oximetry is used to guide oxygen therapy and meet oxygen saturation goals.

53. 6. Chest compressions are provided if there is a poor heart rate response to ventilation after appropriate ventilation corrective steps, . 7. The heart rate response to chest compressions and medications should be monitored electrocardiographically. 8. If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route. 9. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion. 10. If all these steps of resuscitation are effectively completed and there is no heart rate response by 20 minutes, redirection of care should be discussed with the team and family.

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