The New Neonatal Resuscitation Program NRP Guidelines Mesfin

The New Neonatal Resuscitation Program (NRP) Guidelines Mesfin Woldesenbet, MD, FAAP Neonatologist, Medical Director NICU at Memorial Hermann Southwest Hospital Pediatrix Medical Group Houston, Texas April 2013

Introduction 10% of newborns require some assistance at birth <1% require extensive resuscitation Crude birth rate ~ 19/1000 population (~134 million) 15, 120 births/hour 252 births/min 4. 2 births/seconds ~150 babies born per hour USA- 5 babies/hour need extensive resuscitation

The Process of Developing Guidelines and Education Material Published Scientific Research Neonatal Resuscitation Program (NRP) 5 Years AAP/AHA Guidelines for CPR and cardiovascular Care of the Neonate International Liason Committee on Resuscitation (ILCOR) International Consensus on CPR and ECC with treatment recommendation (Co. STR)

Neonatal Resuscitation Program 1 st Edition introduced in 1987 1 st – 5 th Editions Slide and Education format Do not differentiate by job description or specialty 6 th Edition Less didactic More emphasis on simulation and Debriefing Didactic portion taken online with certificate of passing a test

Neonatal Resuscitation Program 6 th Edition Rationale for the changes to procedural guidelines and processes Evidence behind each step in resuscitation Rationale for the new educational approach Implication

2

Steps of resuscitations 1. Initial steps- dry, position, assess and stimulate 2. Ventilation 3. Chest Compression 4. Medication or volume expansion

Assessment of efficiency of CPR Progression to next step is based on Heart Rate Respiration The most sensitive indicator remains the heart rate Auscultation (best method) Palpation of umbilical cord (underestimate heart rate) Pulse oximetry (difficult to obtain reading consistently) Do not use color as an indicator Will avoid hyperoxia

Initial Step Term, breathing and good muscle tone: Dry and place the infant skin-to-skin with the mother Continue routine care and ongoing assessment This includes the vigorous infant with meconium-stained amniotic fluid. Use of the bulb suction is reserved for infants whose secretions obstruct breathing or the infant requiring PPV.

After Initial Steps HR >100 bpm, labored breathing and persistent cyanosis: Clear airway. Place pulse ox on infant’s right hand or wrist. Free flow oxygen if the infant’s O 2 sat is below the time specific target. Consider CPAP for persistent labored breathing. HR <100 bpm or infant is apneic or gasping: Apply pulse ox. Begin PPV.

Corrective Measures: MR SOPA Reapply Mask Reposition the head Suction mouth and nose Open infant’s mouth Increase Pressure every few breaths until BBS and chest rise are evident. Do not exceed an inspiratory pressure > 40 cm. H 2 O Use Alternative airway – endotracheal tube or laryngeal mask airway

Administering Oxygen Every delivery area should have access to an air/oxygen blender and pulse oximetry. Resuscitation of term newborns may begin with room air if blended oxygen is not available. If baby is bradycardic (<60/min) after 90 seconds of resuscitation with lower Fi. O 2, increase the Fi. O 2 to 100%. In preterm infants higher oxygen concentration may achieve target saturation more quickly. Oxygen concentration is adjusted according to age in minutes and oxygen saturation

3 rd, 10 th, 25 th, 50 th, 75 th, 90 th, and 97 th Sp. O 2 percentiles for all infants with no medical intervention after birth Dawson et al, 2010

3 rd, 10 th, 25 th, 50 th, 75 th, 90 th, and 97 th Sp. O 2 percentiles for term infants at ≥ 37 weeks of gestation with no medical intervention after birth. Dawson et al, 2010

Third, 10 th, 25 th, 50 th, 75 th, 90 th, and 97 th Sp. O 2 percentiles for term infants at 32 -36 weeks of gestation with no medical intervention after birth. Dawson et al, 2010

Third, 10 th, 25 th, 50 th, 75 th, 90 th, and 97 th Sp. O 2 percentiles for term infants at≤ 32 weeks of gestation with no medical intervention after birth. Dawson et al, 2010

Targeted Pre-ductal SPO 2 (Term infants) 1 min 60 -65% 2 min 65 -70% 3 min 70 -75% 4 min 75 -80% 5 min 80 -85% 10 min 85 -90%

Use of Supplemental Oxygen Term infant requiring IPPV 100% Oxygen vs. Air No advantage Increase time to first breath Higher mortality Potential harm at a cellular level in asphyxia model Infants 32 - 37 weeks- insufficient evidence

Use of Supplemental Oxygen Infants <32 weeks Do not reach targeted Sp. O 2 in the first 10 minutes of life Use blended oxygen to avoid hypoxia or hyperoxia 21% or 100% vs. 30% or 90% In the absence of a blender, start with room air

Resuscitation of newborns: Room air vs. 100% oxygen. Effect on Mortality. RR<1 favors room air Saugstad et al. 2005

When To Use Pulse Oximetry Resuscitation is anticipated PPV is administered for more than a few breaths Cyanosis is persistent Supplementary oxygen is used The pulse oximeter probe is placed on the infant’s right hand or wrist and then connected to a pulse oximeter

Suctioning of airway Upper airway Not evidence to support or refute Associated with cardio-respiratory complications Tracheal suctioning No evidence to suggest decrease in MAS Decrease in Oxygenation Increase cerebral blood flow Increase intracranial pressure

Intubation Attempts to complete intubation may now take up to 30 seconds. Do not administer free-flow oxygen during intubation to an infant who is not breathing. It has no benefit.

None-Vigorous Infants with Meconium stained fluid Care is in general unchanged If intubation is difficult and the infant is bradycardic consider going to the next steps of resuscitation (dry, stimulate and clear the airway) The only evidence available for use of tracheal suctioning is the study comparing suctioned babies with historical controls

Ventilation Initial breath in newborns requiring IPPV Can use short or longer inspiratory time Initial Peak pressure Use to achieve increase heart rate and good chest rise Preterm infants: 20 -25 cm H 2 O Term infants: 30 -40 cm H 2 O Optimal PEEP Increase FRC, oxygenation and lung compliance Reduce lung injury Avoid High PEEP (8 -12)

Positive Pressure Ventilation A rising heart rate is the best indicator of effective PPV If the heart rate does not show immediate improvement assess breath sounds and chest movement. If these indicators are not present in the first 5 -10 attempted breaths of PPV the team proceeds to corrective action.

Monitoring during/after resuscitation Tidal volume No clinical outcome studies Exhaled CO 2 detectors to confirm intubation Rapid and accurate than clinical methods False Negative Cardiac arrest False Positive Contamination with epinephrine, surfactant and atropine ** Use Exhaled CO 2 detection + clinical assessment

CPAP vs. intubation+IPPV Preterm infants >25 weeks No difference in death or CLD Decrease use of surfactant Increase in Pneumothorax Term infants No evidence

CPAP vs. IPPV with face mask Preterm infants Decrease rate of mechanical ventilation Decrease in CLD * May use CPAP or Intubation in the delivery room!

Assisted Devices T-piece vs. Self-inflating vs. Flow-inflating bags No clinical studies Mechanical models favor T-piece resuscitator Laryngeal Mask Airway No extensive study In cases where face mask or intubation fails May use in infants >2000 g or >34 weeks No Evidence Meconium stained amniotic fluid Chest compression

Chest Compressions Indication: heart rate remains <60 bpm Use 100% oxygen concentration Coordinate PPV with chest compressions for 45 -60 seconds before reassessing heart rate Intubation is recommended if chest compressions are required.

Chest Compression Chest compression and/or Ventilation More efficient when combined Sustained chest compression Deleterious effect on myocardial and cerebral perfusion Chest Compression : Ventilation ratio 3: 1, 5: 1, 15: 2, 30: 2 Less minute ventilation as the ratio increases No human data available

Chest Compression 2 thumb-encircling hand technique-superior Diastolic BP, quality chest compression and less tiring Lower sternum than Midsternum Depth: 1/3 AP diameter than deeper compressions

Epinephrine Indication: Heart rate <60 bpm after at least 45 -60 seconds of coordinated PPV and chest compressions. Administration through an umbilical line remains the preferred route. ETT vs. IV administration No randomized clinical trials Case series and animal studies ETT less effective than IV ETT route has less blood concentration of epinephrine

Epinephrine-Ideal Dose No randomized clinical trials IV dose: 0. 1 -0. 3 ml/kg Labeled 1 ml syringe and draw minimal dose of 0. 1 m. L/kg. IV epi >0. 3 ml/kg- no benefit IV epi >1 ml/kg Increased risk of mortality Interfere with cerebral perfusion and cardiac output ETT epi (ETT Dose has changed) 0. 5 -1 ml/kg to achieve adequate blood concentration Labeled 3 -6 ml syringe and draw up 1 m. L/kg.

Naloxone and Volume Expansion Naloxone No difference in clinical outcome Associated with seizures if mother opiate addict Concern about short and long-term safety Volume expansion If chest compression, ventilation and epinephrine fails Most useful if history of blood loss Maybe harmful if no history of blood loss

Use of volume expansion during delivery room resuscitation in nearterm and term infants. -Received Volume infusion -No Volume infusion * p<. 05 Wycoff et al, 2005

Temperature Control Large body of evidences Methods: Polythene wraps or Bags Exothermic mattresses Delivery room temp >26°C Risks associated with hyperthermia Respiratory depression Neonatal Seizure Cerebral Palsy Mortality

Elevated Temperature After Hypoxic-Ischemic Encephalopathy: Risk Factor for Adverse Outcomes Esophageal Temperature OR (95% CI) Death or Disability (n=99) Death (n=99) Disability (n=65) Highest 4. 0 (1. 5 -11. 2) 6. 2 (2. 1 -17. 9) 1. 8 (0. 4 -8. 2) Median 3. 2 (0. 9 -11. 2) 5. 9 (1. 5 -22. 7) 1. 0 (0. 2 -5. 1) Lowest quartile 1. 5 (0. 6 -3. 5) 1. 4 (0. 6 -3. 3) 1. 1 (0. 3 -3. 5) Laptook et al. Pediatrics 2008

Induced Hypothermia Large body of evidence Term and near-term infants Initiated within 6 hours of life Significant reduction in death and neurodevelopmental disability at 18 months of life NNT: 9 Patient recruited based on specific criteria Cord or first ABG Clinical findings (moderate to severe HIE)

Improved Pathology scores in Hippocampus when treated with therapeutic hypothermia and/or 21% oxygen during resuscitation. *P<0. 05 Suagstad, 2012

Glucose Hypoglycemia + HIE= brain injury Hyperglycemia + HIE No adverse effect Maybe protective No randomized study to show specific glucose level

Cord Clamping Term: 1 min to no cord pulsation Improved iron status Preterm: 30 seconds to 3 minutes Higher blood pressure Low IVH Less transfusion More phototherapy Insufficient evidence

Non-Initiation of Resuscitation Vary according to providers, regions and availability of resources Parental role in decision making Categories: 1 - GA, birth weight or congenital anomaly suggest certain early death or unacceptably high morbidity 2 - High rate of survival and acceptable morbidity 3 - Uncertain prognosis, borderline survival and relatively high morbidity Coordinated approach between Obstetrician, Neonatologist and parents.

Discontinuation of Resuscitation No heart beat for 10 minutes Death or Severe neurologic disability Evidence: small number of babies Decision influenced by: Gestational age Etiology of arrest Parents previous expressed feeling

A New Educational Approach 2004 -Joint Commission Report: 47 infant deaths and or injuries related to the birth process The root cause was related to ineffective teamwork and communication. Joint Commission recommendations: Team training Clinical drills Debriefings

NRP Response to Joint Commission 5 th Edition Passive learning Poorly prepared participants Components for content and technical skills, not teamwork and communication Instructors and participants were not challenged by the class format 6 th Edition Active learning Self study and online examination prior to class participation Skill practice and simulationbased scenarios aimed at promoting teamwork and communication Debriefing

NRP Education Simulation As adjunct to traditional training Enhance performance Experience obtained from high risk organizations Airlines, NASA, Military Briefing and de-briefing Improve knowledge, skill and behavior

Simulation and Debriefing Key Behavioral skills targeted 1. Know your environment 2. Anticipate and plan 3. Assume leadership role 4. Communicate effectively 5. Delegate workload optimally 6. Allocate attention wisely 7. Use all available information 8. Use all available resources 9. Call for help when needed, and early 10. Maintain professional behavior

Summary Progression to next step following initial resuscitation depends on heart rate and respiration. Oximetry to be used to assess oxygenation Term babies- best to start resuscitation with room air than 100% oxygen Use blender when oxygen is needed and should be guided by oximetry No evidence to support or refute endotracheal suctioning in meconium stained fluid, even in depressed newborn

Summary Chest compression: ventilation ratio stays 3: 1 Consider therapeutic hypothermia in term and near-term infants with moderate to severe HIE Consider stopping resuscitation if no detectable heart rate for 10 minutes Delay cord clamp for at least 1 minute in those who does not require resuscitation

Implication Old habit vs. New information More time vs. Efficiency vs. Cost Education or Debriefing Pulse oximeter Shared responsibility vs. Neonatal Team Conditions where Oxygen is needed PPHN Meconium Stained Amniotic Fluid Lack or need for more evidence

Implication Legal Implication (especially in depressed newborns) All hospital need to have oxygen blender in the DR Use room air Self inflating bag without reservoir (40% O 2) CO 2 detectors Correct BMV taught to providers not skilled in intubation Hypothermia Preventable condition in a court setting Therapeutic Hypothermia within 6 hrs of life Preference of IV route to give epinephrine States law credentialing nurses to put a UVC

Do we need a new Apgar score? Virginia Apgar 0 1 2 Heart Rate 0 <100 >100 Respiration 0 Weak, irregular Good cry Reaction 0 Slight Good Color Blue/pale All pink, limb blue Body pink Tone Limp Some movement Active movement, well flexed limbs

Reference 1 - Carson et al. American J Obstet Gynecol. 1976: 126: 712 -715 2 - Ting et al. American J Obstet Gynecol. 1975; 122: 767 -771 3 - Gregory et al. J Pediatr. 1974; 85: 848 -852 4 - O’Donnell et al. J Pediatr. 2005; 147: 698 -699 5 - Davis et al. Lancet. 2004; 364: 1329 -1333 6 - Rabi et al. Resuscitation. 2007; 72: 353 -363 7 - Escrig et al. Pediatrics. 2008; 121: 875 -881 8 - Wycoff et al. Pediatrics 2005; 115: 950 -955 9 - Finer et al. Pediatrics 1999; 104: 428 -434 10 - Wycoff and Berg Seminars Fetal and Neonatal Med 2008; 13: 410 -415 11 - Perlman et al. Pediatrics 2010; 126: e 1319 -e 1344 12 -Perlman et al. Circulation; 122(suppl 2): S 516 -S 538 13 -AAP News, October 2011 14 -Dawson et al. Pediatrics 2010; 125 (6), e 1340 -e 1347 15 -Suagstad et al. Pediatrics Research 2012; 71: 247 -52 16 -Wycoff et al. Pediatrics. 2005, Apr; 115(4): 950 -5. 17 -Laptook et al. Pediatrics 2008, Sept; 122 (3): 491 -499 18 -Saugstad et al. Biol Neon 2005

Do Not Attempt This! ? Questions / Comments