Neonatal Resuscitation Programme 2010
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The document summarizes the key differences between the 2005 and 2010 Neonatal Resuscitation Program (NRP) guidelines. The 2010 guidelines placed more emphasis on pre-resuscitation routines like immediate skin-to-skin contact. Assessment of heart rate and respiration were simplified. Guidelines around oxygen use were clarified, recommending the use of pulse oximetry for preterm infants receiving positive pressure ventilation. Chest compressions and other resuscitation steps were modified with more focus on ensuring adequate ventilation. Post-resuscitation care guidelines were also updated, including recommendations for therapeutic hypothermia.
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Neonatal Resuscitation Programme 2010
- 1. Guide Dr. H. P. Singh NRP 2010 How and why it is different from 2005 Dr. Saurabh K. Patel
- 2. REFERENCES • Neonatal Resuscitation Textbook- 6th edition • Neonatal Resuscitation Textbook- 5th edition • 2010 American heart association guideline for cardiopulmonary resuscitation and emergency cardiovascular care. • www.aao.org/nrp • www.healthstream.com/hcl/aap
- 3. Neonatal resuscitation To assist a newborn to initiate extrauterine life immediately after birth
- 4. Need • Birth asphyxia accounts for about 23% of the approximately 4 million neonatal death occur each year world wide. Lancet. 2010;375:1969-1987
- 5. Neonatal Resuscitation • Majority (90%) – no resuscitation • 10% - some assistance • <1% - extensive resuscitation
- 6. Neonatal Resuscitation Program • NRP was originally designed in mid 1970 • By AAP and AHA • Updates – 2005 2010
- 9. Comparison of 2005 & 2010
- 10. NRP Update • Pre- Resuscitation • Resuscitation Algorithm • Post Resuscitation Care
- 11. Personnel • Skilled personnel for every birth • For all deliveries should be skilled in PPV & assisting CC • Skilled personnel for complete CPR be readily available • For anticipated high risk deliveries additional personnels be recruited Old New
- 12. Personnel • Resuscitation team • Resuscitation team with behavioral skills & communication Old New
- 13. Equipments • Equipment list • Optional .. Blender, LMA, ETCO2, CPAP • Equipment checklist • No longer optional Old New
- 14. Initial Assessment • Term gestation • Amniotic fluid clear • Breathing/crying • Good tone • Term gestation • Breathing/crying • Good tone Old New
- 15. NRP Update • Pre- Resuscitation • Resuscitation Algorithm • Post Resuscitation Care
- 16. Old New
- 17. Old New
- 18. Assess at Birth •Term gestation ? • Amniotic fluid clear ? • Breathing or crying ? • Good muscle tone ? • Term gestation ? • Breathing or crying ? • Good muscle tone ? Old New
- 19. Routine Care • Provide warmth • Clear airway • Dry • Assess color • Provide warmth • Assure open airway • Dry • Ongoing evaluation (color (SPO2), activity and breathing) Old New “ Emphasis on placing baby on mothers chest in skin to skin contact ”
- 20. Initial Steps • Provide warmth • Position • Clear airway (if required) • Dry • Stimulate • Reposition • Provide warmth • Open airway (no routine suction) • Dry , stimulate Old New
- 21. Suctioning • No routine suction • Suction only if : - Obvious obstruction to spontaneous breathing - Require PPV
- 22. Initial Assessment • Look for 3 signs • Heart rate • Color • Respiration • Look for 2 signs • Heart rate • Respiration (Labored, unlabored, apnea, gasping) Old New
- 23. Checking Heart Rate • Palpation of umbilical cord pulsation • Pre-cordial auscultation preferred to umbilical cord palpation for heart rate Old New
- 24. PPV Device • Use either flow inflating, self inflating or T piece resucitator • Same • Emphasis on use of manometer for PPV Old New
- 25. PPV • During PPV look at chest rise and improvement in HR • CALL for help • Apply pulse ox Old New
- 26. The Best Indication of Effective Ventilation is Improvement in Heart Rate
- 27. PPV: If ineffective • Take remedial measures • M...Reapply mask • R…Reposition airway • S….Suction • O…Open mouth • P….Pressure increase • A….Alternate airway NewOld
- 28. PPV • Start with 100% O2 during PPV • Use room air for term • No evidence to give appropriate initial oxygen strategy for infants 32-37 weeks • Initiate resuscitation using O2 concentration between 30-90% (< 32w) NewOld
- 29. Oxygenation • Based on color • Free flow oxygen if central cyanosis • Based on oximetry NewOld
- 30. Oxygenation • Pulse oximetry recommended for only preterm < 32weeks with need for PPV • Use oximeter 1. Anticipated need for resuscitation 2. Need for PPV for more than few breaths 3. Persistent cyanosis 4. Supplementary oxygen Old New
- 31. Oxygenation • No info on using pulse ox • Attach probe to right hand or wrist (measure pre-ductal saturations) • Attach neonatal probe before connecting it to machine • Recording of tracing may take 1-2 m Old New
- 32. Oxygenation • Use of blender for compressed air and oxygen, optional • Start with oxygen concentration somewhere between 21-100% • Oxygen blender is essential • Preterm start with O2 concentration 30-90% and then increase or decrease Old New
- 33. Oxygenation • Target saturations not defined Old New (same for both term and preterm)
- 34. When to give 100% Oxygen • Start with 100% O2 during PPV • Shift to 100 % during chest compressions Old New
- 35. Ventilation “Ensure adequacy of ventilation before initiating chest compressions ”
- 36. Subsequent Assessment Old New Heart Rate Respiration Oxygenation* * Pulse oximetry Respiration Heart Rate Color
- 37. Intubation • Indications • Technique • Confirmation • Same • Exhaled Co2 is primary method of confirmation Old New
- 38. Chest Compression • Site • Depth • Technique • CC: Ventilation ratio • 2 thumb encircling hand technique preferred • Same steps • Provide for 45-60 sec un-interrupted • Head end CC Old New
- 40. Laryngeal Mask Airway • For near term and term infants > 2500g may be used • No definite mention of indications • LMA may be used for infants >2000g and ≥ 34 weeks when 1. bag and mask is ineffective 2. tracheal intubation is unsuccessful or not feasible Old New
- 41. Preterm Resuscitation: CPAP • Suggested for preterm babies ( < 32 weeks) with respiratory distress • Be considered for persistent cyanosis or labored breathing after initial steps • Spontaneously breathing preterm infants with respiratory distress may be supported with CPAP or ventilation as per local practice Old New
- 42. Preterm Resuscitation: Temp • Polytehylene bag for < 28 weeks • Exothermic mattress • Covering in plastic wrap without drying • Pre-warming the delivery room to at least 26C • Monitor temp closely Old New
- 43. Algorithm Timeline • Assessment every 30 seconds • “First Golden Minute” concept • After PPV + CC assess by 45-60 sec • After epinephrine assess HR by 1 minute Old New
- 44. NRP Update • Pre- Resuscitation • Resuscitation Algorithm • Post Resuscitation Care
- 45. Level of Care • Routine care • Observational care • Post resuscitation care • Routine care • Post resuscitation care Old New
- 46. Therapeutic Hypothermia • No sufficient evidence to recommend routine use of modest systemic or selective cerebral hypothermia • Recommended for infants ≥ 36weeks with moderate to severe hypoxic ischemic encephalopathy as per protocol with provision for monitoring for side effects and long term follow up Old New
- 47. Glucose • Infants who require significant resuscitation should be monitored and treated to maintain glucose in the normal range • Glucose infusion should be considered as soon as practical after resuscitation, with the goal of avoiding hypoglycemia • No specific target conc. Old New
- 48. Withholding resuscitation • According to local policy • Same Old New
- 49. Discontinuing resuscitation • No detectable HR > 10 minutes despite complete measures • Same NewOld
- 51. SUMMARY • Old Guidelines become obsolete with new evidence • At times guidelines seem more complex and complicated • Individualize the care and utilize the local resources • Primum non Nocere (First Do No Harm)
- 52. THANKS