NRP 8th edition

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

2. 6 UPDATES SINCE NRP 7TH 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

7. NEONATAL
RESUSCITATION
PROGRAM FLOW
DIAGRAM
5 Blocks
-Initial assessment
-Airway(A)
-Breathing (B)
-Circulation(C)
-Drugs (D)

8. 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

9. RISK FACTORS

10. 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 ?

11. 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?”

12. ASSEMBLE AND CHECK SUPPLIES
• Warm
• Clear airway
• Auscultate
• Ventilate
• Oxygenate
• Intubate
• Medicate

15. THE GOLDEN MINUTE
• Assessment
• Airway

16. UPDATE 2: INITIAL STEPS ARE
REORDERED TO BETTER REFLECT
COMMON PRACTICE
NRP-7th
edition
NRP-8th
edition

17. INITIAL STEPS OF NEWBORN CARE

19. POSITION
WARM(36.5-37.5C)
BIRTH

20. CLEAR SECRETION FROM AIRWAY (M N)

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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. UPDATE 3: ELECTRONIC CARDIAC MONITOR IS
RECOMMENDED EARLIER IN THE ALGORITHM
NRP-7th NRP-8th

31. 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

32. PREDUCTAL SPO2 TARGET (ALWAYS RIGHT HAND)

33. 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

36. DIFFERENT TYPES OF RESUSCITATION
DEVICES FOR VENTILATION (PPV)
• Self inflating bags
• Flow inflating bags
• T-piece Resuscitator

39. INITIAL PRESSURES??
• Peak Inspiratory pressure(PIP)  20-25cm H2O
• Positive End Expiratory Pressure(PEEP)  5cm H2O

40. 40-60 BREATH PER MINUTE

41. ASSESS THE HEART RATE AFTER 15
SECONDS OF PPV

42. VENTILATION CORRECTIVE STEPS –
MR.SOPA

43. 2ND ASSESSMENT AFTER 30sec OF PPV THAT
MOVES THE CHEST

44. 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

45. ALTERNATIVE AIRWAYS
• Endotracheal Tubes
• Laryngeal Masks

46. ET TUBE SIZE AND TECHNIQUE

49. 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

51. CHEST COMPRESSIONS

52. 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

53. COMPRESSION RATES:
90 COMPRESSIONS/MINUTE

54. 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

55. 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

56. 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

58. MEDICATIONS

59. 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

60. EPINEPHRINE SUMMARY CHART

61. CHANGE NRP 7th NRP 8th
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
and gestational ages )
Epinephrine IV/IO Range for IV /IO dose =
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

62. VOLUME EXPANDER SUMMARY

63. 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 )

64. 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.

65. 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.

66. THANK YOU