Nrp pearls dr raju us texas

1. Neonatal Resuscitation Program
NRP 8 - Pearls
Acknowledgements to
Drs. Kapadia, Satyan & Weiner

3. Team Work

5. Team Debriefing
Facilitated discussion with group
to improve the outcomes
• Facilitate
Ask - How did that go?
It’s a Shared mental model
• GAS model
Gather information – Analyze Situation – Summarize events

6. Debriefing
• Debrief with 3 questions
What went well?
What didn’t go well?
How could we make it better, next time?
• If all went well – Appreciate the team

7. Short duration – Lasting Impression
Perfection from Practice
• Decisions made in first hour have huge long-term implications
• Many tasks in short period with multiple caregivers
• > 100 tasks in 1st hour of life I DR & NICU
• PIT STOP Perfection

8. NRP
• A – Airway
• B – Breathing (IPPV / CPAP / O2 Flow blow by)
• C – Chest Compressions for Circulations
• D – Decide the Weight and Drop UVC
• E- Epinephrine (IV preferably) - ETT 1:10,000 (0.2 mL/k)
• F – Fluids (NS bolus) 10 mL/k

9. Risk Factors
• About 4-10% term and late term newborns will receive PPV
(Positive Pressure Ventilation)
• When a risk factor is present 10-20% receive PPV
• Risk is greater if GA is < 36 weeks or > 40 weeks
• Only 1-3 per 1000 will receive chest compressions or emergency medications

10. Risk Factor and Need for Resuscitation
Risk Factor Odds Ratio (OR)
Fetal Bradycardia 24
IUGR 20
Chorioamnionitis 17
Forceps or Vacuum 17
MSAF 17
Gestational DM 16
Abruption 12
General Anesthesia 11

11. Delivery Room Temperature
• 740F – 770F 230 C– 250 C
• Turn on the Warmer
• Keep Plastic wrap / Chemical warmer ready for Preterm babies
• Do not forget Hat

14. Transition at Birth

15. Term - Good Tone - Breathing or Crying
Leave with Mom

16. Neonatal Resuscitation
Program Algorithm
• No major changes to the
NRP Algorithm in NRP 8th
edition
• Minor practice changes to
improve patient safety and
educational efficiency
Aziz et al_Pediatrics 2020

17. High Performance Teamwork
• Defined roles and responsibilities
• Checklist - Always
• Precise, reliable and consistent execution (Choregraphed)

18. Most Important Message
Ventilation
Preparation
Communication

19. Ventilation
Baby is not breathing - IPPV Via Mask – LMA – Intubation - Add PEEP
Baby is breathing but ineffectively – Give CPAP
Baby is breathing effectively but cyanotic – Free flow O2 to reach Target Sats

20. •Preparation

21. Effective Communication
• Ray
• Cathy, I need 2.5 mm ET Tube without stylet
• Cathy
You want 2.5 mm ET Tube without stylet, right!
• Ray
Correct

22. Need to know vs Nice to know
• What are the four Pre-Birth Questions ?
• GRASP
Gestation
Risk Factors
Amniotic Fluid
Single / Multiple (instead Say “Hi” to OB & Parents
Plan of Cord Clamping

23. Umbilical Cord Management Plan Added
to 4 Pre-Birth Questions
What questions should you ask before every birth?
1. What is the expected GA?
2. Is the amniotic fluid clear?
3. How many babies are expected?
4. Are there additional risk factors?
1. What is the expected GA?
2. Is the amniotic fluid clear?
3. Are there additional risk factors?
4. What is our umbilical cord
management plan?
2015 NRP Guidelines 2020 NRP Guidelines
Textbook of Neonatal Resuscitation, 8th Edition by AAP and AHA

26. Delayed Cord
Clamping
• Fetal Placental Unit ~ 110 mL/k of Blood
• Delay of 3 min after Vaginal Birth – 20 mL/kg Transfer
• Almost 90% by 1 min
• Less with C.Section
• Cord Milking
• Sneak in with OB to delay the cord clamping (for > 28
weeks)
• Risk of IVH with Milking if < 28 weeks (Anup Khateria)

27. Delayed Cord Clamping – Meta analysis
• Decreases Mortality (NNT 33)
• Lowers risk of Blood Transfusion (NNT 10)
• Risk Polycythemia (NNT 33)
• No difference*** (18 studies Fogarty)
• in IVH, PVL, BPD, PDA, NEC, ROP
• But, decreased Mortality & Transfusions

29. Courtesy Dr. Kapadia

30. Initial Steps - Clarification
Dry – Stimulate – Position - Suction
• Provide Warmth
• Position the head and neck
• Clear secretions if needed
• Dry
• Stimulate
2015 NRP Guidelines
• Provide warmth
• Dry
• Stimulate
• Position the head and neck
• Clear secretions if needed
2020 NRP Guidelines
Textbook of Neonatal Resuscitation, 8th Edition by AAP and AHA

31. • Arpita Chiruvolu – Pediatrics, Wiswell’s Commentary

33. When to apply
EKG Leads
• Use Cardiac Monitor for
Assessment of Heart Rate if
Available
• Cardiac monitor is
recommended when alternate
airway is placed

34. Only Two Studies so far (Limited Number)

35. Pulse Oximeter Sensor Application During
Neonatal Resuscitation:
A Randomized Controlled Trial
Deepak Louis, - Pediatrics 2013
• Attaching sensor first to oximeter and then
to neonate picked up signal faster than
attaching it to the neonate first and then to
the equipment. However, the time from
birth to display of reliable signal was similar
between the methods.

40. Use T Piece Resuscitator, if available
• Where resources permit, use T-Piece resuscitator
over the use of a self-inflating bag in infants
receiving positive pressure ventilation at birth.
• A self-inflating bag should be available as a back-
up device for the T-piece resuscitator in case of
gas supply failure.
(Courtesy Dr. Kapadia)

45. • Spell Out MRSOPA (Suction MR) - MRSOPIA – MR SOPPA – Leak or Block

46. Use Direct Video Laryngoscope (if available & comfortable)
Limit Intubation time to 30 sec
First successful Intubation attempt (One study)
Fellows - ~ 60%
NNPs - 65%
Neos - 65%
LMA - > 1250 grams and above
Success rate - 95% (across all levels)
Limitation is the size of the baby
Learn Intubation – Learn to use LMA

47. • Weight 6 + Weight in Kg

50. Epinephrine

52. Numbers to Remember
• Delay the Cord Clamping for at least 60 seconds
• Remember (JAM) – Just A Minute
• NS Bolus – 10 mL/k – (over 5-10 min)
• Oxygen Flow Meter – 10 L/min
• Suction catheter – Negative Pressure – 100 mm of Hg on occlusion
• O2 Concentration 21% for Term – ~30% for Preterm
• PPV pressures 20-25/5 cm of H2O
• ( In NICU if you need - D10 – Bolus – 2 mL/k )

53. Numbers to Remember
• HR – Goal - > 100 /min
• HR - < 100/min – PPV - MRSOPA
• HR < 60/min – after 30 sec of effective PPV -
Initiate Chest Compressions
• For effective chest compressions – intubate or use LMA
• Check HR after 60 seconds of Chest compressions for
• ECG is preferred with Chest compressions to check HR

54. Numbers to Remember
• PPV – 40-60 /min
(Breathe 2,3)
• PPV with Chest compressions
90:30 (90 compressions – 30 breaths)
(1 and 2 and 3 and breathe)

55. Numbers to Remember
EPI dose - NS Flush
• Epinephrine
• Strength - 1: 10,000 (0.1mg/mL)
• IV / IO Dose - 0.2 mL/kg
• ETT Dose - 1 mL/kg
• Flush 3 mL of NS
• Repeat every 3-5 min

56. UVC length of insertion
• 2-4 cm – until free flow
• Less in Preterm babies
• Withdraw – Make sure that there are no air bubbles

57. HIE – Therapeutic Hypothermia
• Therapeutic Hypothermia significantly improves survival and
disability, including cerebral palsy and neurocognitive outcomes, in
full-term infants with moderate to severe hypoxic–ischemic
encephalopathy (HIE) – Well studied with strict criteria.
• Target Temp 33.5 C ( 3 degrees less than Normal)
• For 72 Hours (For 3 days)
• Start with in 6 hours (ASAP)
Do not let Temperature above Normal in ER – Consider Passive Cooling

58. NRP 8
(Eight
Points)
1)— 1mL/k
Epi via ETT
2)— 0.2
mL/k Epi
via UVC
3)— 3 mL
of NS push
after Epi
4)— 4th
Question
Umbilical
Cord -
Manageme
nt Plan
5)— FINITE
Timeline -
20 min to
stop Resus
(Vigintiphil
ia)
6)— RQI
/Essential
vs
Advanced
NRP
7)- LMA
Use
8) - Initial
Steps
clarificatio
n - Dry -
Stimulate -
Position -
Suction.
(20 is popular number in
Neonatology- Dop, DOB,
INO, Caffeine loading is
all 20. Bili of 20 -
Vigintiphobia)...

59. Neonatal Resuscitation
Program Algorithm
• No major changes to the
NRP Algorithm in NRP 8th
edition
• Minor practice changes to
improve patient safety and
educational efficiency

60. NRP beyond ABCDE
Airway - Breathing - Circulation- Debriefing- Ethics & Ergonomics
Home Births
Airway - Breathing - Circulation
& Hypothermia we’re addressed well.
2. Polycythemia / Jaundice
3. Erythromycin
4. Vit K
5. TIG (if cord cutting was unreliable / unsterile)
6. Following rest of the Maternal Labs (VDRL / HIV/ HepB etc)
7. Sepsis work up + Antibiotics
(For the benefit of juniors)
1. Airway - Breathing - Circulation
2. Prevent / Teat Hypothermia
3. Polycythemia / Jaundice
4. Give Erythromycin
5. Give Vit K
6. Give TIG (if cord cutting was unreliable / unsterile)
7. Draw and follow Maternal Labs (VDRL / HIV/ HepB etc)
8. Sepsis work up + Antibiotics
Home Birth – Born enroute to ER

62. NRP Provider Status
• NRP Essentials: Anyone involved in the care of a
newborn should take at least NRP essentials course
• NRP advanced: appropriate for those who attend birth
and are responsible for anticipated resuscitation of the
newborn with known risk factors and for those who
participate in neonatal resuscitation beyond PPV
• Each facility determines its own policy
Zaichkin et al, Adv Neonatal Care 2021 – Slide Courtesy Dr. Kapadia

63. NRP 8th Edition Textbook and eBook
• Supplemental Lessons
12. Improving Resuscitation Team
Performance
13. Resuscitation Outside the Delivery
Room
14. Bringing Quality Improvement to
Your Resuscitation Team
Textbook of Neonatal Resuscitation, 8th Edition by AAP and AHA – Slide Courtesy Dr. Kapadia

64. NRP 8th Edition Textbook and eBook
• Each lesson ends with Quality Improvement
Opportunities and Frequently Asked Questions.
Textbook of Neonatal Resuscitation, 8th Edition by AAP and AHA (Slide Courtesy Dr. Kapadia)