The New NRP Algorithm: The New NRP Algorithm NRP 2006 – Central Canada Launch Toronto, ON


Objectives: Objectives Show the new 2006 Resuscitation algorithm Discuss the NRP 2006 Initial Steps What has changed since NRP 2000 How specific Canadian Expert Committee recommendations affect the algorithm


The Canadian Expert Committee: National guidelines to neonatal resuscitation across several continents are based on the consensus statements of the International Liaison Committee on Resuscitation (ILCOR). Each country is expected to develop guidelines that reflect their own context. The Canadian Expert Committee


Other documents: Adapted algorithm Adapted performance checklists …. Educational aids? …. Slides? …. Other? Other documents


Objectives: Objectives The Initial Steps Decide if resuscitation is needed Provide initial steps of resuscitation Decide if / when oxygen should be given Exception to “dry the baby” Resuscitate a newborn when meconium is present


Is resuscitation needed?: Is resuscitation needed? Routine Care


Is resuscitation needed?: Is resuscitation needed? Routine Care NRP 2000 Routine Care NRP 2006


Is resuscitation needed?: Is resuscitation needed? Routine Care NRP 2006 Oxygen is gone …


Routine Care: Routine Care NRP 2006 NRP 2000


Normal transition: Gestational age 37.7 Birth weight 3036g SpO2 >75% 207 s SpO2 >90% 343 s . Kamlin, O'Donnell, Davis, Morley. SPR 2005. A2050 Normal transition Slide courtesy of ACoRN 2006 ACoRN © 2006


Slide12: Normal transition Rabi Y, Yee W, Chen SY, Singhal N. J Pediatrics 2006 148( 5):590-594 Slide courtesy of ACoRN 2006 ACoRN © 2006


Slide13: Rabi Y, Yee W, Chen SY, Singhal N. J Pediatrics 2006 148( 5):590-594 Normal transition Slide courtesy of ACoRN 2006 ACoRN © 2006


Slide14: Rabi Y, Yee W, Chen SY, Singhal N. J Pediatrics 2006 148( 5):590-594 Normal transition Slide courtesy of ACoRN 2006 ACoRN © 2006


Canadian Expert Committee: Canadian Expert Committee “Oxygen should be administered to babies who remain cyanotic at 90 seconds of age”


Routine Care: Routine Care NRP 2006


Routine Care: Routine Care NRP 2006 NRP 2000


Routine Care: Routine Care NRP 2006 What if this “well baby” baby remains cyanotic > 90 sec?


NRP algorithm: Routine Care NRP algorithm Wait 90 seconds


The initial steps: The initial steps 2006


The initial steps: 2000 2006 The initial steps


The initial steps: 2006 … no oxygen given The initial steps Exception to “dry the baby”


NRP algorithm: Routine Care NRP algorithm


NRP algorithm: Routine Care NRP algorithm


NRP algorithm: Routine Care First 30 seconds NRP algorithm Wait 90 seconds


NRP algorithm: Observational Care Routine Care First 30 seconds NRP algorithm


NRP algorithm: NRP algorithm Observational Care Routine Care … at 90 seconds First 30 seconds


Open the airway and provide initial steps: Open the airway and provide initial steps Observational Care Routine Care 30 sec


Cyanotic baby “who appears well”: Routine Care Cyanosis at 90 sec Cyanotic baby “who appears well”


Cyanotic baby “who appears well”: Observational Care Routine Care ? Cyanosis at 90 sec Cyanotic baby “who appears well”


Cyanotic baby “who appears well”: Observational Care Routine Care ? Cyanosis at 90 sec Cyanotic baby “who appears well”


Cyanotic baby “who appears well”: Cyanotic baby “who appears well” No line in NRP … to get back to algorithm AAP: Start oxygen CPS: Start oxygen at 90 seconds Baby requires evaluation for further stabilization ...


Cyanotic baby “who appears well”: Observational Care Routine Care ? Stabilization ? Cyanotic baby “who appears well” Cyanosis at 90 sec


The persistently cyanotic baby: The persistently cyanotic baby


Oxygen administration: Oxygen administration Only central cyanosis requires intervention. Acrocyanosis does not indicate hypoxemia. “If the baby is breathing but appears blue, administration of supplemental oxygen is indicated” at 90 seconds… “Supplemental oxygen also may be needed when respirations are being assisted” at 90 seconds… “There is evidence that resuscitation with air is as effective as with 100% oxygen …”


Slide36: Oxygen administration


Slide37: Blending oxygen


Slide38: Blending oxygen


“Dry-exposed” Resuscitation: “Dry-exposed” Resuscitation Gestational Age > 28w


“Dry-exposed” Resuscitation: “Dry-exposed” Resuscitation Gestational Age > 28w


“Wet-in-bag” Resuscitation: “Wet-in-bag” Resuscitation Gestational Age < 28w


“Wet-in-bag” Resuscitation: “Wet-in-bag” Resuscitation Gestational Age < 28w


“Wet-in-bag” Resuscitation: “Wet-in-bag” Resuscitation Gestational Age < 28w


“Wet-in-bag” Resuscitation: “Wet-in-bag” Resuscitation Gestational Age < 28w


“Wet-in-bag” Resuscitation: “Wet-in-bag” Resuscitation Gestational Age < 28w Photo courtesy: BC’s Children’s Hospital NICU


Slide46: “Wet-in-bag” Resuscitation Gestational Age ≤ 28w 88 infants Infants placed in the polyurethane bags were less likely to have a temp <36.40C on admission 44 vs. 70% (p<0.001) Better if room at 25-26oC Knobel et al. Heat loss prevention for preterm infants in the delivery room. J Perinat 2005;25:304-308


Slide47: “Wet-in-bag” Resuscitation


Slide48: “Wet-in-bag” Resuscitation


Slide49: “Wet-in-bag” Resuscitation Polyethylene bags significantly reduce the risk of hypothermia in infants <28 weeks on admission to NICU RR 0.63 (C.I. 0.42-0.93) NNT 4


“Wet-in-bag” Resuscitation: “Wet-in-bag” Resuscitation Gestational Age < 28w CPS Maintenance of DR at 25 to 26oC will diminish heat loss If GA < 28w place him below the neck in a polyethylene bag All babies (term/preterm) under radiant warmer by 10 min should have servocontrol probe


The Apgar Score: The Apgar Score


The Apgar Score: The Apgar Score


Slide53: Resuscitation when meconium present


The Initial Steps: The Initial Steps … at 90 seconds Or wet in bag?


Preterm < 32 weeks: Preterm 100 bpm, correct any ventilation problem and use FiO2 1.00.