This document reviews the key changes in the 8th edition of the Neonatal Resuscitation Program (NRP) guidelines in Canada. It discusses updated recommendations for umbilical cord clamping and cutting, sustained lung inflation, and epinephrine dosing based on the latest scientific evidence. It also notes administrative changes like the new Essentials and Advanced course formats, online learning assessments, and the transition timeline for Canada. Overall, the 8th edition aims to optimize neonatal resuscitation based on continual reviews of clinical trials and quality improvement initiatives.
Thank you for the detailed presentation on mechanical ventilation in pediatrics. I appreciate you taking the time to explain the key concepts and parameters.
The document discusses the components and goals of Pediatric Advanced Life Support (PALS). PALS involves assessing and supporting pulmonary and circulatory functions before, during, and after cardiac arrest in children. It utilizes basic life support techniques as well as advanced medical devices and pharmacological interventions. The document outlines the initial diagnosis process using ABCDE (airway, breathing, circulation, disability, exposure), as well as secondary diagnosis involving a focused history and physical exam. Key resuscitation tools like intraosseous access and bag-mask ventilation are also described. The ultimate goal of PALS is to save children's lives during medical emergencies.
This document provides guidelines for paediatric basic life support. It outlines the key differences in caring for children compared to adults in emergency situations. The guidelines cover safety, response, calling for help, chest compressions, airway management, rescue breathing, and use of an automated external defibrillator. Emphasis is placed on high quality chest compressions and minimizing interruptions to compressions.
This document provides an algorithm and guidelines for endotracheal intubation in neonates. It outlines the indications for intubation, necessary equipment, proper technique including positioning, visualizing the glottis, confirming tube placement, actions after intubation, and complications to minimize. Key steps include preparing the laryngoscope and selecting the appropriately sized endotracheal tube based on gestational age and weight. Placement is confirmed through bilateral breath sounds, chest rise, and monitoring exhaled carbon dioxide levels.
This presentation deals with the basic physics of human ventillation. I have made an effort to clarify most of the venti lingo , so as to make way for further discussions on ventilator use. Hope it turns out to be helpful for you. Thank you.
This document discusses neonatal mechanical ventilation. It begins by introducing mechanical ventilation and its importance in improving neonatal survival since the 1960s. It then discusses the benefits of mechanical ventilation in improving gas exchange and decreasing work of breathing. Various indications for ventilation are provided. Common conditions requiring ventilation are also listed. The document goes on to describe different types of ventilators and modes, how to initiate a breath, and studies comparing different modes. It concludes by discussing parameters for conventional ventilation like PIP, PEEP, flow rates, and methods for controlling oxygenation and ventilation.
Neonatal resuscitation is an intervention performed on babies after birth to help them breathe and for their heart to beat properly. It is needed for about 10% of babies who have trouble transitioning from receiving oxygen from the placenta to breathing on their own. Proper neonatal resuscitation training and equipment can reduce infant mortality from complications during birth by 30%.
Thank you for the detailed presentation on mechanical ventilation in pediatrics. I appreciate you taking the time to explain the key concepts and parameters.
The document discusses the components and goals of Pediatric Advanced Life Support (PALS). PALS involves assessing and supporting pulmonary and circulatory functions before, during, and after cardiac arrest in children. It utilizes basic life support techniques as well as advanced medical devices and pharmacological interventions. The document outlines the initial diagnosis process using ABCDE (airway, breathing, circulation, disability, exposure), as well as secondary diagnosis involving a focused history and physical exam. Key resuscitation tools like intraosseous access and bag-mask ventilation are also described. The ultimate goal of PALS is to save children's lives during medical emergencies.
This document provides guidelines for paediatric basic life support. It outlines the key differences in caring for children compared to adults in emergency situations. The guidelines cover safety, response, calling for help, chest compressions, airway management, rescue breathing, and use of an automated external defibrillator. Emphasis is placed on high quality chest compressions and minimizing interruptions to compressions.
This document provides an algorithm and guidelines for endotracheal intubation in neonates. It outlines the indications for intubation, necessary equipment, proper technique including positioning, visualizing the glottis, confirming tube placement, actions after intubation, and complications to minimize. Key steps include preparing the laryngoscope and selecting the appropriately sized endotracheal tube based on gestational age and weight. Placement is confirmed through bilateral breath sounds, chest rise, and monitoring exhaled carbon dioxide levels.
This presentation deals with the basic physics of human ventillation. I have made an effort to clarify most of the venti lingo , so as to make way for further discussions on ventilator use. Hope it turns out to be helpful for you. Thank you.
This document discusses neonatal mechanical ventilation. It begins by introducing mechanical ventilation and its importance in improving neonatal survival since the 1960s. It then discusses the benefits of mechanical ventilation in improving gas exchange and decreasing work of breathing. Various indications for ventilation are provided. Common conditions requiring ventilation are also listed. The document goes on to describe different types of ventilators and modes, how to initiate a breath, and studies comparing different modes. It concludes by discussing parameters for conventional ventilation like PIP, PEEP, flow rates, and methods for controlling oxygenation and ventilation.
Neonatal resuscitation is an intervention performed on babies after birth to help them breathe and for their heart to beat properly. It is needed for about 10% of babies who have trouble transitioning from receiving oxygen from the placenta to breathing on their own. Proper neonatal resuscitation training and equipment can reduce infant mortality from complications during birth by 30%.
The document discusses the Pediatric Early Warning Score (PEWS) system, which is a standardized tool used to assess early clinical deterioration in pediatric patients. PEWS uses parameters like behavior, cardiovascular status, and respiratory status to assign a score that determines the appropriate level of monitoring and care. Higher scores indicate greater risk and require more frequent reassessment and escalation of care, including notification of providers and calling rapid responses. The goal of PEWS is to help clinicians recognize subtle changes in pediatric patients and intervene earlier to prevent cardiac or respiratory arrest.
This document provides an overview of neonatal resuscitation principles and procedures. It discusses the initial steps of resuscitation including providing warmth, positioning, clearing the airway, and stimulating breathing. It describes positive pressure ventilation techniques and the use of endotracheal intubation. Medications like epinephrine and volume expanders are outlined. Special considerations for preterm babies and ethics in end of life care are also summarized.
This document summarizes pediatric basic and advanced life support. It outlines 5 key steps for pediatric basic life support: 1) prevent cardiac arrest, 2) early CPR, 3) prompt emergency response, 4) rapid pediatric advanced life support, and 5) integrated post-cardiac arrest care. Common causes of cardiac arrest in children include respiratory issues, burns, drowning, dysrhythmias, foreign body aspiration, gastroenteritis, sepsis, seizures, and trauma. The document also provides details on assessments, CPR techniques, airway management, defibrillation, and medications for cardiac arrest, bradycardia, and tachycardia in pediatric patients.
The document discusses mechanical ventilation in neonates. It provides a brief history of mechanical ventilation and describes various modes of ventilation including positive pressure ventilation. Key aspects of intubation and ventilation such as indications, procedures, settings and complications are outlined. Lung physiology considerations specific to neonates such as compliance, resistance and time constant are also reviewed.
This study compared the efficacy of heated humidified high flow nasal cannula (HHHFNC) versus nasal continuous positive airway pressure (NCPAP) as the primary mode of respiratory support in preterm infants with mild to moderate respiratory distress. 88 preterm infants were included in the study and allocated non-randomly to receive either HHHFNC or NCPAP. The primary outcome of treatment failure within 72 hours was not significantly different between the two groups. However, moderate to severe nasal trauma occurred less frequently in infants receiving HHHFNC. While HHHFNC appears to be as effective as NCPAP with less nasal trauma, the study was limited by its non-randomized design and small sample size
This document provides an overview of pediatric advanced life support (PALS). It discusses the basics of BLS including the ABCs and differences between adult and pediatric BLS. It then introduces PALS, covering principles, recognizing a sick child with a structured approach, and initial and primary patient assessments. The structured approach involves evaluating appearance, breathing, color, identifying severity and type of respiratory/circulatory issues, and intervening. Primary assessment uses the pediatric assessment triangle and pentagon to evaluate airway, breathing, circulation, disability and exposure. Case examples demonstrate use of this approach to identify issues like respiratory failure and compensated shock and guide interventions.
This document provides information about mechanical ventilation in neonates from the NICU at Al Shifaa Hospital in Gaza. It discusses [1] the goals and indications for mechanical ventilation in neonates, [2] procedures for intubation and setting appropriate ventilator settings, and [3] concepts of lung physiology and mechanics relevant to neonatal ventilation. The document is intended to guide clinicians on best practices for mechanically ventilating neonates.
This document discusses fluid calculation and homeostasis in neonates. It notes that water and electrolyte balance is vital but different in neonates compared to older children and adults due to rapid developmental changes. It outlines the physiology of total body water, intracellular water, and extracellular water. It also discusses changes that occur at birth and how to assess hydration status in neonates through monitoring things like urine output, weight, physical exam findings and lab tests. Maintaining appropriate fluid and electrolyte balance is important for health in preterm infants.
This document discusses umbilical venous catheters used in neonates, including three case studies. It outlines complications that can arise from malpositioning of the catheter tip, such as perforation of blood vessels, ascites, cardiac issues, and liver damage. Predicting the proper insertion length is difficult and radiography is not always reliable in confirming tip location. The recommendation is that further research is needed to determine the best length of insertion and that repeated imaging may help ensure the tip remains in the correct position.
This document discusses the importance of clinical monitoring for hospitalized newborns. It outlines that neonatal monitoring is the first step toward improved survival without morbidity. The objectives of monitoring are to evaluate the newborn's status at birth, detect early signs of illness, and assess nutritional intake and growth. Key aspects that should be monitored include vital signs, signs of illness, biochemical markers, drug administration, nutritional intake, growth, and equipment functioning. Monitoring should be done by trained nurses and doctors at a frequency depending on the newborn's risk level and sickness. Traditional monitoring tools like observation of vital signs are still crucial, with technology supplementing rather than replacing them. The role of the mother in monitoring is also discussed.
This document provides guidelines for pediatric advanced life support (PALS). It outlines the systematic approach algorithm which begins with checking responsiveness, calling for help, and checking for a pulse. The BLS assessment evaluates consciousness, breathing, and skin color to determine if the child is unresponsive with no breathing. For infants and children under 8, CPR should be provided first before calling for help, while those over 8 receive phone assistance first before CPR. The guidelines describe performing CPR, providing oxygen, inserting airways, monitoring the child, establishing IV/IO access, administering adrenaline, and considering reversible causes and an advanced airway. The primary and secondary assessment evaluates the child's airway, breathing, circulation, and
Este documento presenta una guía sobre desfibriladores. Explica que los desfibriladores son dispositivos médicos que aplican un choque eléctrico al corazón para establecer un ritmo cardiaco más normal en pacientes que sufren fibrilación ventricular u otros ritmos irregulares. Describe los principios de operación de los desfibriladores, incluyendo la desfibrilación externa e interna y la cardioversión sincronizada. También cubre el monitoreo del electrocardiograma y la opción de marcapasos no invas
La reanimación neonatal implica tres pasos principales: 1) expandir los pulmones y mantener la ventilación, 2) mantener un gasto cardiaco y perfusión óptimos, y 3) mantener la temperatura central. Esto se logra mediante ventilación con presión positiva, compresiones torácicas y medicamentos como la adrenalina, si es necesario. Los cuidados mediatos incluyen ligadura del cordón umbilical, profilaxis oftálmica y aplicación de vitamina K. La atención temprana es crucial para el recién nacido
This document provides recommendations from the 2015 Neonatal Resuscitation Guidelines on various topics relating to neonatal resuscitation. It discusses recommendations regarding umbilical cord management, maintaining normal temperature, warming hypothermic newborns, administration of oxygen, positive pressure ventilation, and other aspects of resuscitation. The recommendations are based on levels of evidence and aim to optimize resuscitation practices for improved newborn outcomes.
This document provides an overview of neonatal resuscitation guidelines. It discusses the historical aspects of neonatal resuscitation and developments in guidelines over time. It also outlines the key steps in neonatal resuscitation including providing warmth, positioning, clearing the airway, drying and stimulating the baby, assisting ventilation, and administering chest compressions and medications if needed. Target oxygen saturations and assessment of heart rate, breathing, and color are also reviewed.
The document discusses noninvasive ventilation (NIV) in pediatrics. It notes that while NIV use has increased, pediatric data is limited compared to adults and neonates. There are significant challenges to pediatric NIV including a wide range of patient sizes, limited technology designed for small children, and interface issues. However, NIV may help avoid intubation and mechanical ventilation in situations like respiratory failure, airway obstruction, and neuromuscular weakness. Further research and improved pediatric-specific technology are still needed.
Care of normal newborn, sick and not sick, transportArijit Bhowmik
The document discusses the care of normal newborns, sick newborns, and neonatal transport. It outlines principles of care for normal newborns including establishing respiration, preventing hypothermia and infection, and identifying at-risk neonates. Phases of care include preparation before delivery, immediate care at birth, and essential postnatal care. Signs of sick newborns are discussed along with causes of problems like vomiting, diarrhea, and cyanosis. Neonatal transport involves moving preterm or sick infants to hospitals with intensive care; it requires maintaining temperature, airway, blood pressure, lab work, and emotional support during transfer.
Este documento resume los principales cambios realizados en las Guías 2020 de la Asociación Americana del Corazón (AHA) para reanimación cardiopulmonar (RCP) y atención cardiovascular de emergencia. Algunos de los cambios clave incluyen: enfatizar el inicio temprano de RCP por parte de reanimadores legos, recomendar la administración temprana de adrenalina, y actualizar los algoritmos para guiar la RCP y atención posparo. Las guías también abordan temas como la RCP en el embarazo y durante emer
This document provides an overview of non-invasive ventilation in neonates. It begins by explaining the objectives and need for non-invasive ventilation, as respiratory problems are a major complication for preterm neonates. The document then contrasts invasive ventilation with non-invasive ventilation (NIV), noting that NIV avoids ventilator-induced lung injuries seen with invasive ventilation. Continuous positive airway pressure (CPAP) is discussed as a form of NIV. Evidence is presented that supports NIV and CPAP for indications like respiratory distress syndrome, apnea of prematurity, and post-extubation support. Finally, the document covers nasal devices, ventilators, and care considerations for neonates receiving NIV.
This document provides an overview of antepartum fetal surveillance methods. It discusses that the majority of fetal deaths occur in the antepartum period due to causes like fetal hypoxia, maternal complications, congenital malformations, and unexplained causes. The primary objective of antenatal fetal assessment is to avoid fetal death. It then describes various monitoring methods including clinical monitoring, special investigations like biochemical tests, cytogenetic tests, biophysical profiling, and Doppler ultrasound assessments of the fetus and amniotic fluid volume.
The document discusses the Pediatric Early Warning Score (PEWS) system, which is a standardized tool used to assess early clinical deterioration in pediatric patients. PEWS uses parameters like behavior, cardiovascular status, and respiratory status to assign a score that determines the appropriate level of monitoring and care. Higher scores indicate greater risk and require more frequent reassessment and escalation of care, including notification of providers and calling rapid responses. The goal of PEWS is to help clinicians recognize subtle changes in pediatric patients and intervene earlier to prevent cardiac or respiratory arrest.
This document provides an overview of neonatal resuscitation principles and procedures. It discusses the initial steps of resuscitation including providing warmth, positioning, clearing the airway, and stimulating breathing. It describes positive pressure ventilation techniques and the use of endotracheal intubation. Medications like epinephrine and volume expanders are outlined. Special considerations for preterm babies and ethics in end of life care are also summarized.
This document summarizes pediatric basic and advanced life support. It outlines 5 key steps for pediatric basic life support: 1) prevent cardiac arrest, 2) early CPR, 3) prompt emergency response, 4) rapid pediatric advanced life support, and 5) integrated post-cardiac arrest care. Common causes of cardiac arrest in children include respiratory issues, burns, drowning, dysrhythmias, foreign body aspiration, gastroenteritis, sepsis, seizures, and trauma. The document also provides details on assessments, CPR techniques, airway management, defibrillation, and medications for cardiac arrest, bradycardia, and tachycardia in pediatric patients.
The document discusses mechanical ventilation in neonates. It provides a brief history of mechanical ventilation and describes various modes of ventilation including positive pressure ventilation. Key aspects of intubation and ventilation such as indications, procedures, settings and complications are outlined. Lung physiology considerations specific to neonates such as compliance, resistance and time constant are also reviewed.
This study compared the efficacy of heated humidified high flow nasal cannula (HHHFNC) versus nasal continuous positive airway pressure (NCPAP) as the primary mode of respiratory support in preterm infants with mild to moderate respiratory distress. 88 preterm infants were included in the study and allocated non-randomly to receive either HHHFNC or NCPAP. The primary outcome of treatment failure within 72 hours was not significantly different between the two groups. However, moderate to severe nasal trauma occurred less frequently in infants receiving HHHFNC. While HHHFNC appears to be as effective as NCPAP with less nasal trauma, the study was limited by its non-randomized design and small sample size
This document provides an overview of pediatric advanced life support (PALS). It discusses the basics of BLS including the ABCs and differences between adult and pediatric BLS. It then introduces PALS, covering principles, recognizing a sick child with a structured approach, and initial and primary patient assessments. The structured approach involves evaluating appearance, breathing, color, identifying severity and type of respiratory/circulatory issues, and intervening. Primary assessment uses the pediatric assessment triangle and pentagon to evaluate airway, breathing, circulation, disability and exposure. Case examples demonstrate use of this approach to identify issues like respiratory failure and compensated shock and guide interventions.
This document provides information about mechanical ventilation in neonates from the NICU at Al Shifaa Hospital in Gaza. It discusses [1] the goals and indications for mechanical ventilation in neonates, [2] procedures for intubation and setting appropriate ventilator settings, and [3] concepts of lung physiology and mechanics relevant to neonatal ventilation. The document is intended to guide clinicians on best practices for mechanically ventilating neonates.
This document discusses fluid calculation and homeostasis in neonates. It notes that water and electrolyte balance is vital but different in neonates compared to older children and adults due to rapid developmental changes. It outlines the physiology of total body water, intracellular water, and extracellular water. It also discusses changes that occur at birth and how to assess hydration status in neonates through monitoring things like urine output, weight, physical exam findings and lab tests. Maintaining appropriate fluid and electrolyte balance is important for health in preterm infants.
This document discusses umbilical venous catheters used in neonates, including three case studies. It outlines complications that can arise from malpositioning of the catheter tip, such as perforation of blood vessels, ascites, cardiac issues, and liver damage. Predicting the proper insertion length is difficult and radiography is not always reliable in confirming tip location. The recommendation is that further research is needed to determine the best length of insertion and that repeated imaging may help ensure the tip remains in the correct position.
This document discusses the importance of clinical monitoring for hospitalized newborns. It outlines that neonatal monitoring is the first step toward improved survival without morbidity. The objectives of monitoring are to evaluate the newborn's status at birth, detect early signs of illness, and assess nutritional intake and growth. Key aspects that should be monitored include vital signs, signs of illness, biochemical markers, drug administration, nutritional intake, growth, and equipment functioning. Monitoring should be done by trained nurses and doctors at a frequency depending on the newborn's risk level and sickness. Traditional monitoring tools like observation of vital signs are still crucial, with technology supplementing rather than replacing them. The role of the mother in monitoring is also discussed.
This document provides guidelines for pediatric advanced life support (PALS). It outlines the systematic approach algorithm which begins with checking responsiveness, calling for help, and checking for a pulse. The BLS assessment evaluates consciousness, breathing, and skin color to determine if the child is unresponsive with no breathing. For infants and children under 8, CPR should be provided first before calling for help, while those over 8 receive phone assistance first before CPR. The guidelines describe performing CPR, providing oxygen, inserting airways, monitoring the child, establishing IV/IO access, administering adrenaline, and considering reversible causes and an advanced airway. The primary and secondary assessment evaluates the child's airway, breathing, circulation, and
Este documento presenta una guía sobre desfibriladores. Explica que los desfibriladores son dispositivos médicos que aplican un choque eléctrico al corazón para establecer un ritmo cardiaco más normal en pacientes que sufren fibrilación ventricular u otros ritmos irregulares. Describe los principios de operación de los desfibriladores, incluyendo la desfibrilación externa e interna y la cardioversión sincronizada. También cubre el monitoreo del electrocardiograma y la opción de marcapasos no invas
La reanimación neonatal implica tres pasos principales: 1) expandir los pulmones y mantener la ventilación, 2) mantener un gasto cardiaco y perfusión óptimos, y 3) mantener la temperatura central. Esto se logra mediante ventilación con presión positiva, compresiones torácicas y medicamentos como la adrenalina, si es necesario. Los cuidados mediatos incluyen ligadura del cordón umbilical, profilaxis oftálmica y aplicación de vitamina K. La atención temprana es crucial para el recién nacido
This document provides recommendations from the 2015 Neonatal Resuscitation Guidelines on various topics relating to neonatal resuscitation. It discusses recommendations regarding umbilical cord management, maintaining normal temperature, warming hypothermic newborns, administration of oxygen, positive pressure ventilation, and other aspects of resuscitation. The recommendations are based on levels of evidence and aim to optimize resuscitation practices for improved newborn outcomes.
This document provides an overview of neonatal resuscitation guidelines. It discusses the historical aspects of neonatal resuscitation and developments in guidelines over time. It also outlines the key steps in neonatal resuscitation including providing warmth, positioning, clearing the airway, drying and stimulating the baby, assisting ventilation, and administering chest compressions and medications if needed. Target oxygen saturations and assessment of heart rate, breathing, and color are also reviewed.
The document discusses noninvasive ventilation (NIV) in pediatrics. It notes that while NIV use has increased, pediatric data is limited compared to adults and neonates. There are significant challenges to pediatric NIV including a wide range of patient sizes, limited technology designed for small children, and interface issues. However, NIV may help avoid intubation and mechanical ventilation in situations like respiratory failure, airway obstruction, and neuromuscular weakness. Further research and improved pediatric-specific technology are still needed.
Care of normal newborn, sick and not sick, transportArijit Bhowmik
The document discusses the care of normal newborns, sick newborns, and neonatal transport. It outlines principles of care for normal newborns including establishing respiration, preventing hypothermia and infection, and identifying at-risk neonates. Phases of care include preparation before delivery, immediate care at birth, and essential postnatal care. Signs of sick newborns are discussed along with causes of problems like vomiting, diarrhea, and cyanosis. Neonatal transport involves moving preterm or sick infants to hospitals with intensive care; it requires maintaining temperature, airway, blood pressure, lab work, and emotional support during transfer.
Este documento resume los principales cambios realizados en las Guías 2020 de la Asociación Americana del Corazón (AHA) para reanimación cardiopulmonar (RCP) y atención cardiovascular de emergencia. Algunos de los cambios clave incluyen: enfatizar el inicio temprano de RCP por parte de reanimadores legos, recomendar la administración temprana de adrenalina, y actualizar los algoritmos para guiar la RCP y atención posparo. Las guías también abordan temas como la RCP en el embarazo y durante emer
This document provides an overview of non-invasive ventilation in neonates. It begins by explaining the objectives and need for non-invasive ventilation, as respiratory problems are a major complication for preterm neonates. The document then contrasts invasive ventilation with non-invasive ventilation (NIV), noting that NIV avoids ventilator-induced lung injuries seen with invasive ventilation. Continuous positive airway pressure (CPAP) is discussed as a form of NIV. Evidence is presented that supports NIV and CPAP for indications like respiratory distress syndrome, apnea of prematurity, and post-extubation support. Finally, the document covers nasal devices, ventilators, and care considerations for neonates receiving NIV.
This document provides an overview of antepartum fetal surveillance methods. It discusses that the majority of fetal deaths occur in the antepartum period due to causes like fetal hypoxia, maternal complications, congenital malformations, and unexplained causes. The primary objective of antenatal fetal assessment is to avoid fetal death. It then describes various monitoring methods including clinical monitoring, special investigations like biochemical tests, cytogenetic tests, biophysical profiling, and Doppler ultrasound assessments of the fetus and amniotic fluid volume.
Pediatric Advanced Life Support Overview.pptxMarkJoaquin7
1. The document provides an overview of Pediatric Advanced Life Support (PALS) including normal vital signs, basic life support, high quality CPR, the pediatric systematic approach, the pediatric assessment triangle, primary and secondary surveys, post-resuscitation care, pediatric trauma key points, and Covid-19 resuscitation updates.
2. It reviews algorithms for the pediatric systematic approach, cardiac arrest, bradycardia, tachycardia, and return of spontaneous circulation.
3. Guidelines are provided for assessment, emergency management, ventilation, circulation, neurologic goals, and personal protective equipment for Covid-19 patients.
This document summarizes the key points from the 2020 American Heart Association neonatal resuscitation guidelines presented by Dr. K. Navnitha Reddy and moderated by Dr. Arnab Sengupta. It outlines questions that should be asked before birth, clinical findings of abnormal transition after birth, perinatal risk factors that increase the need for resuscitation, and recommendations regarding delayed cord clamping, routine suctioning, when to start CPR and preferred technique, preferred route for vascular access, and skin-to-skin care. Topics from previous guidelines that did not change or receive additional recommendations are also reviewed.
The document discusses a case of maternal cardiac arrest in a 34-week pregnant patient. Key points include:
- Causes of maternal arrest include pulmonary embolism, preeclampsia, and hemorrhage.
- Resuscitation algorithms are similar but require lateral positioning for chest compressions and earlier intubation and cesarean delivery.
- Perimortem c-section within 5 minutes of arrest improves neonatal outcomes when gestation is ≥24 weeks. The goal is to save both mother and fetus.
This document provides information on assessing and managing neonatal emergencies. It discusses key topics including epidemiology, terminology, transitioning from in utero to extrauterine life, and the mnemonic "ABCs" for assessing airway, breathing, and circulation. For breathing issues, the document recommends positive pressure ventilation with a bag-valve mask. For circulation problems unresponsive to ventilation, chest compressions at a 3:1 ratio are advised. Hypoglycemia and hypothermia are also addressed. A case study example applies these concepts to an unresponsive 3-week-old infant.
This document summarizes the key points from the 2020 American Heart Association (AHA) neonatal resuscitation guidelines presented by Dr. K. Navnitha Reddy. It discusses questions that should be asked before every birth, clinical findings of abnormal transition, perinatal risk factors that increase the need for resuscitation, and recommendations regarding delayed cord clamping, routine suctioning, initiating CPR, vascular access route, and skin-to-skin care. Topics from previous guidelines that saw no changes are also listed. The document concludes by citing the sources for the 2020 AHA neonatal resuscitation guidelines.
IAH and ACS are underrecognized in critically ill children despite being associated with high morbidity and mortality. Studies show that up to half of pediatric healthcare providers are unaware of or unable to correctly define ACS. Measurement of IAP is also not routinely performed. The normal IAP range in children is 4-10 mmHg. IAH is defined as IAP above 10 mmHg and ACS is IAP above 10 mmHg with new organ dysfunction. Risk factors for IAH/ACS in children include diminished abdominal wall compliance, increased intra-abdominal contents, and fluid resuscitation. Treatment involves medical management through optimization of fluids and improving abdominal wall compliance. Surgical decompression through decompressive laparotomy may
This document summarizes current evidence and clinical practice regarding the use of traditional Chinese medicine (TCM) for patients undergoing in vitro fertilization (IVF). It discusses several studies that found varying rates of TCM use among IVF patients and notes that use is likely underreported. The document then outlines the whole-systems TCM approach used at one center, including individualized treatment based on pattern diagnosis and the menstrual cycle phase. Key points of treatment during different IVF cycle stages are provided. Finally, the document reviews several retrospective studies that found improved live birth rates and outcomes with the integration of TCM and acupuncture for both fresh and frozen embryo transfers.
This document reviews several topics in neonatology, including:
1) Delayed cord clamping which provides benefits like increased hemoglobin but risks like polycythemia. Guidelines recommend 30-60 seconds for vigorous infants.
2) Therapeutic hypothermia for hypoxic ischemic encephalopathy, which improves mortality and neurodevelopment when started in the first 6 hours of life.
3) Exogenous surfactant for respiratory distress syndrome, which is most effective with early administration and antenatal steroids. Less invasive methods like INSURE/MIST provide benefits over intubation.
4) Non-invasive ventilation strategies to reduce intubation including CPAP developed in the 1970s.
This document discusses the assessment of fetal well-being through various antenatal monitoring techniques. It outlines the objectives of fetal monitoring as avoiding fetal death and ensuring growth. Common indications requiring monitoring include pregnancies with obstetric or medical complications. Components of assessment include clinical monitoring of maternal weight, blood pressure, uterine size and liquor volume. Antenatal tests described are fetal movement monitoring, the non-stress test (NST), contraction stress test (CST), biophysical profile, and Doppler ultrasonography of the umbilical artery blood flow. The NST and CST assess fetal heart rate patterns in response to movement or contractions respectively.
Therapeutic advances in neonatal care include delayed cord clamping, therapeutic hypothermia, exogenous surfactant, and non-invasive ventilation. Delayed cord clamping provides benefits for preterm infants such as fewer transfusions and less intraventricular hemorrhage. Therapeutic hypothermia improves outcomes for infants with hypoxic-ischemic encephalopathy, reducing mortality and neurodevelopmental disabilities. Exogenous surfactant reduces the severity of respiratory distress syndrome but the least invasive mode of administration should be used. Non-invasive ventilation strategies such as CPAP aim to support respiration without intubation and its risks.
This document summarizes antepartum fetal assessment techniques. It describes the aims of fetal monitoring as ensuring fetal growth and well-being. Various clinical evaluation methods are outlined, including fetal movements, breathing, biophysical profile, amniotic fluid volume, and Doppler velocimetry. Specific tests like non-stress tests and contraction stress tests are also defined. The document provides details on interpreting test results and guidelines for testing frequency from organizations like ACOG. The overall purpose is to screen for high-risk factors affecting the fetus and guide management to improve perinatal outcomes.
This document discusses guidelines for evaluating and managing brief resolved unexplained events (BRUEs), formerly known as apparent life-threatening events (ALTEs), in infants. It outlines criteria for classifying infants as low or high risk based on the characteristics and duration of the event. Low risk BRUEs can often be sent home after education and follow up, while high risk cases may warrant further testing and observation to identify potential underlying causes and ensure safety before discharge. The goal is to prevent over-testing and reduce parental anxiety by distinguishing self-limited from concerning episodes.
The patient is a 14-month-old female admitted with rectal bleeding, anemia, and colon polyps. She has a history of colonic polyposis, dependence on blood transfusions and albumin infusions. A recent colonoscopy found 16 polyps of various sizes, some with active bleeding. Laboratory results show improving but still low hemoglobin, hematocrit, and platelets. The primary problems are anemia and colon polyps.
The panel discussion summarized:
1) Serum amylase and lipase levels are reliable markers for acute pancreatitis during pregnancy.
2) MRCP is the best imaging modality for evaluating the bile duct for choledocholithiasis in pregnancy due to lack of radiation exposure, though EUS provides the highest accuracy.
3) Therapeutic ERCP can be performed safely in pregnancy with precautions to minimize radiation exposure to the fetus, and is safest during the second trimester.
Presentation TS neocone fluid and electrolyte dr hemant - Copy - Copy.pptxssuser00be96
This infant presented at 9 days of age with loose stools, refusal of feeds, lethargy, respiratory distress, and shock. On examination, the infant was severely dehydrated, bradycardic, tachypnic, and in shock. Laboratory findings showed severe metabolic acidosis, hyponatremia, hyperkalemia, and elevated blood urea. The differential diagnosis includes congenital adrenal hyperplasia, Bartter syndrome, and renal tubular acidosis. Close monitoring and management of fluid, electrolyte, and acid-base abnormalities is needed.
This document discusses fetal monitoring techniques during labor and delivery. It notes that electronic fetal monitoring (EFM) is associated with decreased mortality but increased cesarean rates compared to auscultation. The document then focuses on fetal ST analysis (STAN), which analyzes changes in the fetal ECG that indicate hypoxia. Studies in the UK and Sweden found that combining EFM with STAN reduced metabolic acidosis in umbilical cord blood gases and lowered operative delivery rates compared to EFM alone. STAN provides a more precise assessment of fetal condition during labor to guide management and avoid unnecessary interventions.
Weaning from mechanical ventilation and extubation by dr tareqtareq rahman
Weaning from mechanical ventilation and extubation requires careful assessment of patient readiness and involves gradually reducing ventilator support. While no single protocol can predict successful weaning in all cases, clinical judgment and experience are important. Early weaning when possible can reduce risks like nosocomial infection and improve patient outcomes. Factors such as respiratory status, hemodynamics, oxygen needs and sedation levels must be optimized before attempting weaning through slowly reducing settings on the ventilator. Noninvasive respiratory support like nasal CPAP is preferred after extubation over headbox oxygen. Caffeine, corticosteroids and chest physiotherapy may also improve chances of successful extubation.
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Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
BBB and BCF
control the entry of compounds into the brain and
regulate brain homeostasis.
restricts access to brain cells of blood–borne compounds and
facilitates nutrients essential for normal metabolism to reach brain cells
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
The Children are very vulnerable to get affected with respiratory disease.
In our country, the respiratory Disease conditions are consider as major cause for mortality and Morbidity in Child.
Can Traditional Chinese Medicine Treat Blocked Fallopian Tubes.pptxFFragrant
There are many traditional Chinese medicine therapies to treat blocked fallopian tubes. And herbal medicine Fuyan Pill is one of the more effective choices.
“Environmental sanitation means the art and science of applying sanitary, biological and physical science principles and knowledge to improve and control the environment therein for the protection of the health and welfare of the public”.The overall importance of sanitation are to provide a healthy living environment for everyone, to protect the natural resources (such as surface water, groundwater, soil ), and to provide safety, security and dignity for people when they defecate or urinate .Sanitation refers to public health conditions such as drinking clean water, sewage treatment, etc. All the effective tools and actions that help in keeping the environment clean come under sanitation. Sanitation refers to public health conditions such as drinking clean water, sewage treatment. All the effective tools and actions that help in keeping the environment clean and promotes public health is the necessary in todays life.
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
Ageing, the Elderly, Gerontology and Public Health
NRP_8th_Edition-Whats_new_webinar-2021-09-07.pptx
1. NRP 8th edition in Canada: a
review of new recommendations
and their rationale
Dr Emer Finan,
Dr Amuchou Soraisham,
CPS NRP Steering Committee
2. Disclosure Statement
• Faculty: Dr Emer Finan and Dr Amuchou Soraisham
• Relationships with commercial interests:
We have no affiliation (financial or otherwise) with a
pharmaceutical, medical device or communications
organization
3. Objectives
• Review the changes in 8th edition of NRP in Canada
• Review the relevant science underlying updated
recommendations
• Review the administrative and educational changes
related to 8th edition NRP in Canada
4. Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics and
American Heart Association. Edited by Gary M. Weiner and Jeanette Zaichkin
5. • NRP Essentials
Lessons 1 to 4 inclusive
(incl. PPV and LMA)
• NRP Advanced
Lessons 1 to 11 incl
(incl. intubation and beyond)
Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics and American
Heart Association. Edited by Gary M. Weiner and Jeanette Zaichkin
6. Preparing for resuscitation
• Team and equipment preparation: the “brief”
• 4 pre-birth questions
Expected gestational age
Is the AF clear ?
Any additional risk factors?
Umbilical cord management plan
Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics and
American Heart Association. Edited by Gary M. Weiner and RN MN NNP-BC Jeanette
Zaichkin
7. The “Golden minute”
• Initial steps reordered
• Initial respiratory
assessment/HR check
• Indications for PPV
unchanged
• Possible role of CPAP as in
past
Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics and American
Heart Association. Edited by Gary M. Weiner and Jeanette Zaichkin
8. Ventilation is key !
• MR.SOPA if no ↑ HR/no
chest mmt after 15 secs
• If HR low despite
ventilation, alternate
airway and 30 secs PPV
• Saturation targets
unchanged
Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics
and American Heart Association. Edited by Gary M. Weiner and Jeanette Zaichkin
9. Circulatory support
• 30 seconds PPV via AA
• CC if HR < 60. 3:1 ratio
and 100% FiO2
• If no ↑HR: “CARDIO”
• If HR < 60 after 60 secs
CC→ epinephrine
Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics and American
Heart Association. Edited by Gary M. Weiner and Jeanette Zaichkin
10. Medications
• Epinephrine IV/IO dose range 0.01-0.03mg/kg
• Suggested initial IV/IO =0.02mg/kg.
Suggested initial ET dose =0.1mg/kg ( no max. dose)
• Flush with 3 ml normal saline
• Can rpt every 3-5 mins: “consider ↑subsequent
doses”
Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics
and American Heart Association. Edited by Gary M. Weiner and Jeanette Zaichkin
11. Additional considerations
• Normal saline remains crystalloid expander of choice
• Packed cells in cases of suspected fetal anemia
• Consideration of other causes if not responding, eg ptx
• “Reasonable time frame for considering cessation of
resuscitation efforts is around 20 minutes after birth”….
“individualized based on patient and contextual factors”
Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics and
American Heart Association. Edited by Gary M. Weiner and Jeanette Zaichkin
13. Timing of umbilical cord clamping
• DCC for 30-60 s is reasonable for both term
and preterm infants who do not require
resuscitation at birth.
14. Timing of CC for non-vigorous babies
• Research on resuscitation with intact cord
ongoing
• If PPV required, cord should be cut and infant
transferred to overbed warmer for
resuscitation
16. Cord Milking versus DCC
Katheria et al. JAMA 2019;322(19):1877-1886
Number of Infants with Severe IVH by GA
Risk of severe IVH:
UCM (22%) vs DCC (6%);
[ 26%, NNH=6]
Cord milking is not
recommended for
infants <28 weeks
17. Increased venous
return to the right
atrium enters PFO
and aorta
Umbilical cord
milking
Pulmonary
vasoconstriction
Lack of cerebral autoregulation and
right to left ductal shunt result in
fluctuations in flow to an immature
brain with fragile germinal matrix.
IVH
Hemodynamic Changes During Cord Milking
18. Sustained Lung Inflation(SLI)
• Providing longer SLI before initiating PPV can inflate
the lungs and increase FRC.
• Meta-analysis showed SLI- ↑ mortality in preterm
infants < 29 wk and SI is not recommended
• There is insufficient evidence for or against the use of
SLI for term and late preterm infants.
Wyckoff M et al. Circulation, 2020;142(Supp): S185-S221
Kapadia VS, et al. Pediatrics. 2021;147:e2020021204.
19. Epinephrine dosing
• Dose
• IV or IO = 0.02 mg/kg (equal to 0.2 mL/kg)
• May repeat every 3 to 5 minutes
• Range = 0.01 to 0.03 mg/kg (equal to 0.1 to 0.3
mL/kg)
• Endotracheal = 0.1 mg/kg ( equal to 1 mL/kg)
• Range = 0.05 to 0.1 mg/kg (0.5 to 1 mL/kg)
• Flush: Follow IV or IO dose with a 3-mL saline flush
(previous 0.5-1ml)
20. Sankaran D, et al. Arch Dis Child Fetal Neonatal Ed 2021;0:F1–F6.
21. Epinephrine
• Epi (0.03mg/kg) - earlier and ↑ ROSC compared with
the 0.01mg/kg dose.
• Epi (0.03mg/kg) followed by a 3mL/kg flush - ↑ the
incidence of ROSC (100%) and quicker ROSC without
higher HR or BP compared with 0.01mg/kg dose.
Sankaran D, et al. Arch Dis Child Fetal Neonatal Ed 2021;0:F1–F6.
22. Timing of discontinuation of
resuscitation
• Difficult to decide how long to continue
resuscitation at birth
• In recent years, long-term outcomes for
survivors requiring prolonged resuscitation
have improved somewhat.
23. Systemic review of 15 studies , N=470
Survival to discharge, 13 studies
176 /432 (41%)
Survival to last follow up, 15 studies
187/470 (40%)
Survival without NDI, 13 studies , n=277 infant
18%- survived with NDI
11% - survived without NDI
69% died by follow-up, 2% lost to follow up
Wyckoff M et al. Circulation, 2020;142(Supp): S185-S221
Outcome of infants experiencing resuscitation
beyond 10 minutes
24. Outcomes of newborn infants who
received ≥ 20 min of CPR after birth
• Only 39 infants in whom first detectable HR or HR
>100/min occurred at or beyond 20 minutes after
birth.
• 15/39 (38%) survived until last follow-up
• 6/15 (40%) of survivors did not have NDI
Wyckoff M et al. Circulation, 2020;142(Supp): S185-S221
25. Timing for discontinuation
• Reasonable time frame for considering cessation of
resuscitation effort is around 20 minutes after birth
• It should be individualized based on patient and
contextual factor:
– Optimal resuscitation
– Availability of advanced NICU care
– Specific circumstances before delivery
– Wishes expressed by the family
26. Objectives 3
• Review the administrative and educational
changes related to 8th edition NRP
27. Administrative/Educational Changes
• Focus on team factors and QI considerations
in each chapter
• Additional chapters on ergonomics and
human performance, resuscitation outside
delivery room, integration of QI initiatives
28. Course Format in Canada
• Essentials and Advanced options
• Online exam, skills practice, Integrated Skills
Assessment, simulation & debriefing
• Essentials online learning: chapters 1-4
Advanced online exam: chapters 5-11
• Course completion every 2 years
29. Online Learning Assessment
• Interactive online assessment
• Learner asks to self-assess
• Feedback and time to complete contingent on
performance and alignment with self-
assessment
30. Implementation in Canada
• 7th edition exam not available after Dec 31, 2021. Launch
of 8th edition January 1, 2022
• Instructors will be required to the 8th edition exam prior
to teaching courses
• Resources:
-Updated FAQ
-Revision of ISSA
-Speaker-noted slides and recording from this presentation
-CPS Pedagogy site: instructor resources including sim and
debriefing videos, instructor course resources
Good afternoon and welcome to our presentation on the NRP 8th edition in Canada; a review of new recommendations and their rationale
Neither myself or Dr Soraisham have any conflicts to declare
The objectives of today’s talk are :
To review the clinical changes in the 8th edition of NRP in Canada
To review the relevant science underlying updated recommendations
To review the administrative and educational changes related to 8th edition NRP in Canada
This slide illustrates the new 8th edition NRP algorithm along with the target oxygen saturations and starting oxygen concentrations, both of which remain unchanged from the previous recommendations. To recap, starting FiO2 is 21% for infants greater than or equal to 35 weeks GA and for those less than 35 weeks the starting Fi02 is 21-30%. In the upcoming slides, we will go sequentially through the algorithm and highlight practice changes in the 8th edition.
With the implementation of 8th edition NRP there will be a return to the previous practice of providing two types of course depending on needs of the learner, these being NRP Essentials and NRP Advanced. As highlighted in the adjacent part of the algorithm, NRP Essentials will cover aspects of the resuscitation up to and including corrective steps and insertion of a laryngeal mask airway. This corresponds to lessons 1 through 4 in the 8th edition NRP textbook.
NRP Advanced will incorporate further components of the algorithm including endotracheal intubation, chest compressions and medications.
The rationale for this change is not to shorten the course for providers and as such the CPS NRP Committee still recommends that courses should take at least 4 hours. Essentials and Advanced options however enable instructors to spend time focusing on skills training which is most pertinent to the needs of the provider. It is recommended however that any member of the team who may attend high risk deliveries continues to take the NRP Advanced course so they are familiar with all aspects of the resuscitation in which they may be involved.
The first step in the algorithm involves preparation of the team and organization of the necessary equipment to be able to provide advanced resuscitation as required. As in the past, the role of the team “brief” is emphasized as a means not only to assign roles and accompanying tasks but also to discuss possible underlying disease processes and potential interventions required in stabilization.
In the 8th edition, the 4 pre-birth questions have changed with the removal of the question related to number of babies expected. Instead this question is replaced with a question related to the umbilical cord management plan. This reflects the importance of umbilical cord management in the care of the newborn and Dr Soraisham will highlight the updated evidence in this regard later in the talk.
The 4 pre-birth questions are now:
What is the expected gestational age ?
Is the amniotic fluid clear ?
Are there any additional risk factors ?
What is the umbilical cord management plan?
As in the 7th edition the goal in the first minute is to perform an initial assessment of tone and breathing, perform initial steps and provide positive pressure ventilation as required.
The 3 initial assessment questions remain unchanged these being:
Is the infant term?
Do they have good tone?
3. Are they breathing or crying?
Of note, the order of the initial steps has changed in the 8th edition to “warm, dry, stimulate, position the airway and suction if needed”. This is to reflect common clinical practice.
As in the previous edition, it is important to note that suction should be provided only as necessary and that providers should be aware of the potential complications of vigorous deep suction such as vagal stimulation and resultant bradycardia.
Following initial steps, the provider should assess breathing and heart rate. The indications for PPV remain unchanged, namely apnoea or gasping respirations or HR < 100 bpm. If PPV is required, pulse oximeter placement is recommended as in the past. Cardiac monitor placement can also be considered at this point.
As in the past CPAP can be considered for infants who have effective spontaneous respirations but have persistent cyanosis or laboured breathing.
As in previous editions, the importance of effective ventilation is paramount.
Similar to the 7th edition, it is recommended that 15 seconds into administration of PPV, the heart rate is reassessed. If the heart rate is not increasing, chest movement should be evaluated. If the heart rate is not increasing and there is no chest movement, ventilation is ineffective and corrective steps should be taken.
As in the past this involves the MR.SOPA mnemonic. It is recommended that this is primarily done in couplets, ie Mask and Reposition the head and neck, then provide 5 further positive pressure breaths to see if any improvement; if not the next steps are to Suction the mouth and nose and Open the mouth then provide 5 further positive pressure breaths. If no improvement, the Pressure should be increased by 5-10 cm H20 and if still no improvement an Alternate airway should be placed, ie a LMA or ETT. If any of these interventions are effective in resulting in chest movement, ie adequate ventilation then PPV should be provided for 30 seconds (8th edition textbook, page 82)
If an alternate airway is required, 30 seconds of PPV should be provided through the alternate airway before reassessment of the heart rate to determine next steps .
As previously noted, oxygen saturation targets remain unchanged and Fi02 should be titrated in accordance.
The 8th edition algorithm suggests a cardiac monitor is placed at the point of alternate airway placement if not already done. This will aid in speed and accuracy of heart rate detection.
Once an alternate airway has been sited, 30 seconds of PPV should be provided through the airway before the heart rate is reassessed. As in the past, the indication for chest compressions is a heart rate < 60 bpm after at least 30 seconds of effective ventilation. FiO2 should be increased to 100% and chest compressions should be provided at a compression to ventilation ratio of 3:1. As in the 7th edition, the two-thumb encircling technique is recommended and with an alternate airway in place and secured it is recommended that the person performing chest compressions moves to the head of the bed to faciltate access for another member of the team to insert an UVC.
The heart rate should be reassessed after 60 seconds. The mnemonic CARDIO is introduced in the 8th edition and can be used by the team to troubleshoot if the heart rate is not increasing :
“Chest movement: is the chest moving with every breath ?
Airway: Is the airway secured with an ETT or LMA?
Rate: Are 3 compressions coordinated with 1 ventilation being delivered every 2 seconds?
Depth: is the depth of compressions one-third of the AP diameter of the chest?
Inspired Oxygen: Is 100% oxygen being administered through the PPV device?” (8th edition textbook, page 169)
If the heart rate remains below 60 bpm after 60 seconds of effective ventilation and chest compressions, epinephrine is indicated along with emergency access
As in the past the epinephrine dose range is 0.01-0.03 mg/kg via IV/IO route and 0.05-0.1mg/kg via ETT. The IV/IO routes remain preferred though the ETT route can be used while awaiting intravenous access.
The 8th edition introduces an abbreviated initial dose of 0.02mg/kg IV and 0.1 mg/kg for ETT. The ETT dose is the same as the previous abbreviated dose used for this route by the CPS however we will no longer recommend a maximum dose via the ETT, ie a 4 kg infant would now receive 0.4mg as ETT dose. This is in line with the AAP recommendations and as such there will no longer be a separate CPS medication table.
The choice of 0.02 mg/kg as the abbreviated dosage is based primarily around educational efficiency. The updated recommendation is that the IV dose is flushed with 3cc normal saline irrespective of gestational age or birthweight. Dr Soraisham will review some of the science related to these changes later in the talk.
As in past editions, epinephrine doses can be repeated every 3-5 mins however given the range in dosing and initial dose suggestions, the textbook notes that if the first dose was 0.02mg/kg IV or lower, one can consider increasing the dosage in subsequent doses
As in the 7th edition, normal saline remains the crystalloid volume expander of choice however as in the past, judicious use of volume expanders is recommended in particular in preterm infants at risk of intraventricular hemorrhage. Volume expanders should be reserved for situations in which there is a significant history or clinical concern for hypovolaemia. If concerns for anaemia, emergency 0- blood may be required. As always, if the infant is not responding to resuscitation efforts, it is important to consider other etiologies such a pneumothorax which would require thoracocentesis.
The 8th edition notes that 20 minutes may be a reasonable timeframe in which to consider discontinuation of resuscitative efforts if no response but notes that this is “individualized based on patient and contextual factors”. Dr Soraisham will also refer to some of literature related to this topic in his upcoming slides.
And with that I will now hand over to Dr Soraisham who will review the relevant science underlying some of the changes we have just discussed .
Thank you Emer. I will review the relevant science underlying updated recommendations.
Resuscitation science is based on the ILCOR review (International Liaison Committee on Resuscitation- it is consortium of experts from 7 resuscitation councils around the world, The Neonatal task force of ILCOR evaluates current state of resuscitation science and publishes the consensus statement and recommendation. Now it is published continuously instead of every 5 years in the past.
Delayed cord clamping (DCC) for at least 30 to 60 sec is recommended for term and preterm infants who do not require resuscitation at birth. This is based on the findings that DCC improves hemodynamic stability and preterm infants who receive DCC are less likely to receive inotropes and blood transfusion while term infants are more likely to have improved hematological parameters ( increased Hb and ferritin at 3-6 months).
Currently the optimal timing of cord clamping for non-vigorous infants who require immediate resuscitation is not known. Research is ongoing on resuscitation with intact placental circulation.
Within the clinical setting however, while some initial suction or stimulation with the cord intact may be reasonable if the infant requires further intervention such as PPV it is currently recommended that the cord is cut and the infant is brought to the overbed warmer for resuscitation.
Early cord clamping should be considered for cases when placental transfusion is unlikely to occur, such as maternal hemorrhage or hemodynamic instability, placental abruption, or placenta previa.
Cord milking (CM) has been used as an alternative to DCC
Cord milking can be done either after the cord is cut or when the cord is still intact (before cord clamp is applied)
In a multicentre trial, Katheria et all compared DCC versus CM. There was a significant increase in incidence of severe IVH among CM compared to DCC groups among infants <28 weeks ( 22% versus 6%). Hence umbilical cord milking is not recommended for infants <28 weeks.
Cord milking leads to sudden increase in venous return to the right atrium, then through the patent foramen ovale to the left side of the heart and to the aorta. Lack of cerebral autoregulation and right to left ductal shunt results in sudden fluctuation in blood flow to the immature and fragile germinal matrix of the brain, resulting in Intraventricular hemorrhage. Hence umbilical cord milking is not recommended in the 8th edition.
Though Sustained Lung Inflations (SLI) are not used in the NRP algorithm, they are incorporated into certain resuscitation council guidelines around the world.
Multiple clinical trials of SLI have been published after the 2015 recommendations ( including the SAIL trial) prompting this recent systemic review.
This meta-analysis of 10 trials which included 1502 newborns who received PPV for bradycardia or ineffective respirations at birth showed no benefit or harm from initiating PPV with sustained inflation > 1 second compared with initiating PPV with intermittent inflations lasting 1 second or less.
However, there was an association between SLI and increased mortality in infants <29 wks and therefore SLI is not recommended
The suggested 8th edition epinephrine dosage is 0.02 mg/kg (to enhance the educational efficiency). The current dose ranges are extrapolated from the adult data.
The 7th edition NRP recommended flush volume of 0.5-1 cc only clears epinephrine past the 5 Fr UVC which has an internal volume of 0.55 cc and as such may deposit the medication in the umbilical vein /liver.
In the absence of umbilical blood flow (as in cardiac arrest), the inlet of the ductus venosus (DV) offers higher resistance to flow. The terminal portion of the inferior vena cava and DV do not have valves and pressure from chest compressions can potentially cause backflow.
Epinephrine increases portal venous resistance promoting distribution within the liver.
Epinephrine delivery to the right atrium can potentially be enhanced by a quick flush with a mini-bolus to maintain patency of the DV and enhance delivery to the heart in the absence of spontaneous circulation.
-In this study, the term newborn lambs with cardiac arrest were randomised to 4 groups- (a) Low dose epinephrine ( 0.01mg/kg) followed by low flush volume (1ml) (b) Low dose epinephrine (0.01mg/kg) followed by high flush volume (3 ml/kg), (c) High dose epinephrine (0.03 mg/kg) followed by low flush volume (1 ml) and (d) High dose epinephrine (0.03 mg/kg) followed by high flush volume(3ml/kg).
-Highest (100%) return of spontaneous circulation (ROSC) was achieved with high dose epinephrine with higher flush volume.
ROSC was five times faster with 0.03 mg/kg epinephrine compared with 0.01 mg/kg and three times faster with 3 mL/kg flush compared with 1 mL flush.
Epinephrine 0.03 mg/kg is associated with earlier and higher incidence of ROSC compared with the 0.01 mg/kg dose.
2 Administration of 0.03 mg/kg of epinephrine followed by a 3 mL/kg flush increases the incidence (100%) and quicker ROSC without higher HR or BP compared with 0.01 mg/kg dose.
It is very difficult to decide how long to continue CPR at birth. Previously it was suggested to stop after 10 minutes of CPR with asystole.
In recent years, long.-term outcomes for survivors requiring prolonged resuscitation have improved somewhat.
The ILCOR Neonatal Task Force recently reviewed this question
Systemic review was conducted by ILCOR-NLS task force. A total of 15 studies were included with a total of 470 infants (no of infant in study- range from 3 -177 infants)
41% survived to discharge from hospital.
40% were alive at the time of follow up ( follow up: 4 months -8 years)
Among those who survived, 80 were followed and 11% survive without moderate-severe neurodevelopmental impairment(NDI); 18% had NDI.
Failure to achieve ROSC in newborn despite 10 to 20 m of intensive resuscitation is associated with a high risk of mortality
and a high risk of moderate-to-severe neurodevelopmental impairment among survivors.
In recent years, long-term outcomes for survivors requiring prolonged resuscitation have improved somewhat.
Follow up range from 4 month-8 years in above studies ( no of infant range from 3 -177 infants)
80 suvivors were assessed for the NDI
There is extremely limited data on the outcomes of newborn infants who received 20 or more minutes of CPR after birth.
This systemic review included 5 studies with only 39 infants in whom the first detectable HR or HR >100/min occurred at or beyond 20 min
Of these, 38% (15/39) survived until last follow-up and 40% (6/15) of survivors did not have moderate or severe NDI
Finally we would like to review the administrative and educational changes related to the implementation of 8th edition NRP in Canada.
The 8th edition NRP textbook includes a focus in each chapter on team factors and Quality Improvement considerations.
In addition, additional chapters focus on ergonomics and human performance in neonatal resuscitation, resuscitation outside of the delivery room and the integration of QI initiatives in neonatal resuscitation.
As noted, the 8th edition of NRP will have both Essentials and Advanced options for provider courses. As previously noted, the minimum recommended duration of provider course is still 4 hours however the Essentials and Advanced options allow instructors to tailor the delivery of practical skills training to the needs of their learners. While it would be an institutional decision which provider course is required based on clinical practice, the CPS NRP committee recommends that any team member who may attend deliveries and care for newborns with risks factors for resuscitation complete the advanced course.
The CPS will retain the same instructor-led format for both essentials and advanced provider courses and this process will comprise prereading the textbook, attending for in-person skills practice and integrated skills practice and assessment following by a team-based simulation and debriefing exercise.
Those participants taking the NRP Essentials course will complete the essentials online exam prior to the instructor-led course while those taking the NRP Advanced course will complete the Essentials online exam along with the Advanced exam which will cover chapters 5-11
As in the past course completion is required every two years. As has always been the case, NRP course completion is not a certification and does not imply competence.
The NRP Essentials online learning assessment is tailored to meet the needs of the individual learner. In completing their assessment, participants are asked to self-assess and feedback is provided depending on performance and alignment with self-assessment. Time taken to complete the assessment is dependent on these factors.
As the 7th edition will no longer be available after December 31, 2021, the launch date for the 8th edition in Canada will be January 1, 2022. NRP instructors will be required to take the 8th edition online exam prior to teaching 8th edition provider courses.
This edition does not contain a significant number of educational clinical changes however the CPS NRP Education Subcommittee are currently working on a number of 8th edition resources including updated FAQs and revision of the Integrated Skills Station Assessment to reflect the 8th edition changes.
This presentation will also be made available with speaker notes for use by Instructors and Instructor-Trainers.
The CPS Pedagogy site includes a number of instructor resources which are regularly updated. As there is no longer an instructor manual, this site holds many important instructor tools including simulation and debriefing instructional videos and instructor course guides and resources. We always welcome suggestions for additional resources which are helpful to the NRP community so please contact us with any suggestions.
To summarize , the main changes in 8th edition NRP are outlined on this slide
Umbilical cord management replaces the question in regard to the number of babies in the 4 pre-birth questions
The initial steps of resuscitation have been reordered to reflect common clinical practice
The use of the cardiac monitor is suggested earlier in the algorithm
An abbreviated IV dose of epinephrine 0.02mg/kg is suggested as the initial dose. The ETT abbreviated dose remains unchanged and is 0.1mg/kg however there will no longer be a maximum recommended ETT dose, ie a 4 kg infant would receive 0.4 mg via the ETT . The recommended IV flush after epinephrine administration is 3 cc irrespective of gestational age or birthweight
In regard to discontinuation of resuscitation efforts the NRP textbook states that 20 minutes after birth is a “reasonable time frame for reconsidering cessation of resuscitation efforts” but notes the decision should be “individualized based on patient and contextual factors”