New born resuscitation program

1. Newborn Resuscitation Program
(NRP)
By
Dr . Mohamed Abdelmaaboud, MD
Prof and Head of Pediatric Department
Minia University

2. 7th Edition NRP Guidelines
5 year evidence based topic review by
The International Liaison
Committee On Resuscitation.

3. Burden of the problem
• Birth asphyxia.
• 23% of the causes of neonatal deaths.
• Long term neurological complications.
• Death.
• NNR (Neonatal resuscitation) :simple,
inexpensive, cost effective method.
• Problem: NNR often not initiated, incorrect
use of methods.

5. 2017 NRP Major Changes
Preparing for resuscitation:
** Team briefing
** Before birth ask:
•What is the suspected gestational age?
•Is the amniotic fluid clear?
•How many babies to expect?
•Are there any additional risk factors?
** Use equipment check lists in pre-
resuscitation briefing .
** In high risk
deliveries equipment should be
unpacked and ready for use.

7. 2017 NRP Major Changes
Cord Clamping:
• Evidence suggests that cord clamping should be delayed for at least
30 to 60 seconds for most vigorous term and preterm newborns.
• Insufficient evidence for recommendation for infants who require
resuscitation or who have known risk factors for decreased placental
circulation (placental abruption, bleeding placenta previa, bleeding
vasa previa, or cord avulsion(.
Pro: Less IVH, high BPs, higher blood volume,less
need for transfusions and less NEC.
Con: Slightly increased bilirubin levels and need for phototherapy.
Recommendations:
OB will provide delay of cord clamping per request of the patient if the
mother and newborn are clinically stable.

8. Meconium-stained fluid
Non-vigorous newborns with meconium-stained fluid do not require
routine intubation and tracheal suctioning; however, meconium-stained
amniotic fluid is a perinatal risk factor that requires presence of one
resuscitation team member with full resuscitation skills, including
endotracheal intubation.
2017 NRP Major Changes

9. The Golden minute
• The “first minute after birth”
• Anxiety for parents, health providers
• Period of transition from intrauterine to extra
uterine life
• Major: No/minimal assistance
• 10%: assistance to begin breathing at birth
• 1%: extensive resuscitative measures
• First Golden Minute Project: skill based training

10. Factors for successful NNR
• Anticipation: call a skilled personnel
• Adequate preparation
• Accurate evaluation, algorithm based
• Prompt initiation of support

12. Resuscitation: initial steps
• Provide warmth
• Head position “ sniffing position”
• Clearing the airway
• Drying the baby
• Tactile stimulation for breathing

13. Sniffing position
Extension of neck with help shoulder roll:: to
open the airway

14. Newly born infant
• Specifically the Infant at time of birth
• (A)Do not require resuscitation
• (B)Require resuscitation
• Rapid assessment of 3 characters
– Term gestation?
– Crying or breathing?
– Good muscle tone?

15. Newly born infant
Term gestation?
Crying or breathing?
Good muscle tone?
YES :Do not require resuscitation
– Dry
– Skin to skin contact
– Covered with dry linen to maintain
temperature
– Ongoing observation: breathing, color, activity

16. Newly born infant
Term gestation?
Crying or breathing?
Good muscle tone?
NO : require resuscitation; One/more of the
following actions in sequence
– Initial steps in stabilization(warmth, clear
airway, dry, stimulate)
– Ventilation
– Chest compressions
– Administration of epinephrine& /or volume
expansion

17. AAP
Algorithm

18. IAP
Algorithm

19. The golden minute
• < 30 seconds: complete initial steps
• Warmth
• Drying
• Clear airway if necessary
• Stimulate
• 30-60 seconds: assess 2 vital characteristics
• Respiration (apnea/gasping/labored/unlabored)
• Heart rate (<100/>100bpm)

20. < 60 seconds of birth
• If gasping/apnea
If heart rate<100 beats per minute
PPV( positive pressure ventilation)
Spo2 monitoring by pulse oximeter
• Simultaneous evaluation of 3 vitals
• Heart Rate,
• Respiration,
• oxygenation status

21. 2017 NRP Major Changes
Oxygen Use:
• Infants > 35 weeks gestation begin with 21% oxygen (room air).
• Infants < 35 weeks gestation resuscitation should begin with 21-30%
FiO2 to maintain appropriate target pre-ductal oxygen saturations.
• Continued recommendation of the use of 100% FiO2 whenever chest
compressions are provided.
Recommendations:
All FIO2 blenders set at 21%
Preterm infants <35 weeks begin at 30%
Target pre-ductal Spo2 after birth
1 min 60%-65%
2 min 65%-70%
3 min 70%-75%
4 min 75%-80%
5 min 80%-85%
10 min 85%-95%

22. Targeted SPO2 after birth
1 minute 60-65%
2 minutes 65-70%
3 minutes 70-75%
4 minutes 75-80%
5 minutes 80-85%
10 minutes 85-90%

23. Increase in heart rate is the most
sensitive indicator of a successful
response to each step practiced

24. PPV: Positive Pressure Ventilation
• Form of assisted ventilation
• Needed when there is no improvement in HR
• Also assess chest wall movements
• Should be delivered at rate of 40-60
breaths /min, maintain HR>100 /min
• Devices: BMV, ET (endotracheal
tube),LMA(laryngeal mask airway)

25. Bag & mask ventilation

26. Chest
moving
HR
increasing
within 15
seconds
No
PPV for anther 15
seconds and reassess
HR
Step Action
M Consider 2-hand
R Head position
S Suction
O Open mouth
P Increase PIP 5-10 / 15
sec
A ETT or LMA
PPV 15
sec
Ye
s
Ye
s
15 sec
PPV 15
sec
30 sec
PPV
SpO2 monitor
Consider ECG monitor
Continue PPV with chest
movement for 30 seconds

27. Endotracheal tube
• Initial endotracheal suctioning of non vigorous
meconium stained new-born.
• If BMV is ineffective/prolonged.
• When chest compressions are performed.

28. 2017 NRP Major Changes
Endotracheal Intubation and Laryngeal Masks:
•Intubation is strongly recommended prior to
beginning chest
compressions.
•If intubation is not successful or not feasible, a laryngeal mask may
be used.
•Newborns greater than 2 kg and greater than 34 weeks’ gestation
require a size 3.5 endotracheal tube.
•The size 4.0 endotracheal tube is no longer listed on the NRP Quick
Equipment Checklist.
•The vocal cord guide on the endotracheal tube is only an
approximation and may not reliably indicate the correct insertion
depth.
•The tip-to-lip measurement, or depth of the endotracheal tube, is
determined by using the “Initial Endotracheal Tube Insertion
Depth” table or by measuring the nasal-tragus length (NTL).

29. Endotracheal tube

30. LMA (Laryngeal mask airway)
• Fits over laryngeal inlet
• Done when BMV is unsuccessful
• When tracheal intubation is unsuccessful or
not feasible

31. LMA (Laryngeal mask airway)

32. Chest Compressions:
• Chest compressions are indicated when the heart rate
remains less than 60 beats/min after at least 30 seconds
of PPV that inflates the lungs, as evidenced by chest
movement with ventilation. In most cases, you should have
given at least 30 seconds of ventilation through a properly
inserted endotracheal tube or laryngeal mask
• Intubation is strongly recommended prior to beginning
chest compressions. If intubation is not successful or not
feasible, a laryngeal mask may be used.
• Chest compressions continue for 60 seconds prior to
checking a heart rate.
2017 NRP Major Changes

33. Chest compressions
• Started when HR < 60 per minute despite adequate ventilation
with 100% oxygen for 30 sec
• Delivered at lower third of sternum, to depth 1/3 of AP
diameter of chest
• 2 techniques:
– 2 thumb-encircling hands technique
– Compression with 2 fingers ,second hand supporting the
back
– 3:1 ratio: 90 comp:30 ventilations
– Chest compressions continue for 60 seconds prior to
checking a heart rate.

34. Chest compressions

35. Medications
• Rarely indicated
• Most important step to treat bradycardia is
establishing adequate ventilation
• HR remains < 60 bpm, despite adequate
ventilation (ET) with 100% Oxygen & chest
compressions
• Epinephrine or volume expansion or both

36. Epinephrine
• Route of administration: intravenous(IV),ideal
• Recommended dose: 0.01-0.03 mg/kg per
dose
• Desired concentration: 1:10,000
0.1 mg/ml

37. Volume expansion
• Suspected or known blood loss
• Isotonic crystalloid solution
• Blood
• Dose calculation: 10 ml/kg

38. Thermoregulation:
The goal is an axillary temperature between 36.5°C and 37.5°C.
• Increase temperature in the room where the baby will receive initial care to
approximately 23°C to 25°C (74°F–77°F)
• Babies ≥ 33 & ≥1500g: dry with blankets & stimulate
• Babies ≤32 & OR ≤1500g :place wet baby in skin wrap & stimulate
• Apply servo control if remained under wormer for more than a few minutes
• Record axillary & skin temp prior to departure and within 15 minutes of
NICU arrival
2017 NRP Major Changes

39. Post resuscitation care
• Needed for those who required PPV
• At risk of deterioration
• Need monitoring ,evaluation
• NICU may be necessary

40. NNR : not indicated
• Conditions with certainly early death
• Extreme prematurity(GA < 24 weeks)
• Birth weight <500g
• Futile conditions such as Anencephaly and
Chromosomal abnormalities: Trisomy 13 and
Trisomy 18

41. NNR: nearly always indicated
• High rate of survival
• Acceptable morbidity
• GA ≥ 24 weeks
• Those with most congenital malformations

42. NNR?
• Conditions associated with uncertain prognosis
• Survival borderline
• Parental desires concerning initiation of
resuscitation should be supported

43. Discontinuing resuscitative efforts
• Newly born baby with no detectable heart
rate, consider stopping NNR if the heart rate
remains undetectable for 10 minutes

44. MCQ1
For successful neonatal resuscitation following
is/are needed except:
1.Anticipation
2.Adequate preparation
3.Skilled personnel
4.Delayed initiation of support

45. MCQ2
• All the following are true in relation to initial
steps of neonatal resuscitation except
1.Provide warmth
2.Tactile stimulation
3.Clear airway and intubation
4.Drying the baby

46. MCQ3
• The following is the primary measure of
adequate ventilation
1.Chest wall movement
2.Improvement in heart rate
3.Pink extremities
4.Spo2 of 80%

47. MCQ4
• Endotracheal intubation may be indicated at
several points during neonatal resuscitation
except
1. If BMV is ineffective
2. When chest compressions are performed
3. Endotracheal suctioning of vigorous meconium stained
newborns
4. For special resuscitation circumstances like extremely
LBW

48. MCQ5
• The recommended compression to
ventilation ratio in neonatal resuscitation is
1.2:1
2.3:1
3.4:1
4.5:1

49. MCQ6
• The recommended dose(mg/kg per dose) and
route of epinephrine in neonatal resuscitation is
1.0.1-0.3,IV
2.0.01-0.03,IM
3.0.03-0.05,1V
4.0.05-0.1,IV

50. MCQ7
• Recommended method/clinical indicator of
confirming ET placement is
1.Condensation in ET
2.Chest movement
3.Equal breath sounds on auscultation
4.Exhaled C02 Detection

51. http://www2.aap.org/nrp/
https://eccguidelines.heart.org/index.php/circulatio
n/cpr-ecc-guidelines-2/part-13-neonatal-
resuscitation/
2017 NRP Major Changes