WHAT’S NEW IN THE NRP 2010 ? : WHAT’S NEW IN THE NRP 2010 ? According to the Neonatal Resuscitation: 2010
American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care NEW A Maulik Shah Presentation Evaluating the Newborn : Evaluating the Newborn Immediately after birth, the following questions must be asked: (2005) a maulik shah presentation Evaluating the Newborn : Evaluating the Newborn Immediately after birth, the following questions must be asked: Ongoing evaluation NEW a maulik shah presentation Provide Warmth : Provide Warmth Prevent heat loss by (2005)
Placing newborn under radiant warmer
Removing wet towels a maulik shah presentation Additional warming techniques for preterm (<1500 g) : Additional warming techniques for preterm (<1500 g) Pre-warming the delivery room to 26°C
covering the baby in plastic wrapping
(food or medical grade, heat-resistant plastic)
Class I, LOE A
Placing the baby on an exothermic mattress
Class IIb, LOE B16
Placing the baby under radiant heat
Class IIb, LOE C17 a maulik shah presentation Plastic wrap in < 28 wks : Plastic wrap in < 28 wks Newborn infants of 28 weeks’ gestation should be completely covered in a polythene wrap or bag up to their necks without drying immediately after birth and then placed under a radiant heater .
To be resuscitated or stabilized in a standard fashion.
Infants should be kept wrapped until admission and temperature check. a maulik shah presentation TEMPERATURE CONTROL : TEMPERATURE CONTROL All procedures should be done keeping in mind temperature control.
Hyperthermia should be avoided …Why ?
It increases the risk of perinatal respiratory depression, neonatal seizures, cerebral palsy and mortality. a maulik shah presentation Next : airway cleaning : Next : airway cleaning a maulik shah presentation CLEARING THE AIRWAY – in Clear Liquor : CLEARING THE AIRWAY – in Clear Liquor Is suctioning required in all births??
Suctioning is not recommended in all births.
Suctioning of airways to be done only if :
- obvious obstruction to spontaneous breathing
- when positive pressure ventilation is required a maulik shah presentation Management of Meconium (2007) : Management of Meconium (2007) 2010
??? a maulik shah presentation Tracheal Suction NOT required ?!! : Tracheal Suction NOT required ?!! Why ??
Tracheal suctioning has not been associated with decrease in incidence of MAS or decrease in mortality. NEW a maulik shah presentation Slide 12: WHEN MECONIUM IS PRESENT…..
Ambiguity persists …..
Due to absence of randomized control trials, there is no evidence to change present protocols of performing endotracheal suctioning of non-vigorous baby with MSAF.
So what to do ?? a maulik shah presentation Bag & mask ventilation – in MSAF?? : Bag & mask ventilation – in MSAF?? If attempted intubation is prolonged and unsuccessfull .
& if there is persistent bradycardia. a maulik shah presentation Initial steps … : Term gestation
Breathing or crying?
Good tone? YES ROUTINE CARE
Stays with mother
Ongoing evaluation Initial steps … NO Evaluate HR
Stimulate a maulik shah presentation Evaluation of heart rate : Evaluation of heart rate Heart rate remains the primary vital sign to judge the need and efficacy of resuscitation.
Auscultation of the precordium
Palpation of the umbilical pulse.
(For babies who require ongoing resuscitation or respiratory support or both) a maulik shah presentation Initial steps … : Term gestation
Breathing or crying?
Good tone? YES ROUTINE CARE
Stays with mother
Ongoing evaluation Initial steps … NO Evaluate HR
Stimulate a maulik shah presentation NRP algorithm (2010) : NRP algorithm (2010) HR below 100, gasping, or apnea? PPV, Spo2 monitoring HR below 100? Take ventilation corrective steps Labored breathing or persistent cyanosis? Clear airway,
Consider CPAP Post Resuscitation Care YES NO NO Yes a maulik shah presentation OXYGEN ASSESSMENT : OXYGEN ASSESSMENT Skin colour is a poor indicator of oxyhemoglobin saturation
OxyHb sat normally remains in 70-80% for many minutes after birth.
Harmful to neonate a maulik shah presentation PULSE OXIMETRY : PULSE OXIMETRY When to use spo2?
- When resuscitation can be anticipated
- When positive pressure respiration is administered for more than a few breaths
- When cyanosis is persistent
- When supplemental oxygen is administered NEW a maulik shah presentation preductal SpO2 Variables : preductal SpO2 Variables a maulik shah presentation Pulse oxymetry – method : Pulse oxymetry – method Probe should be attached to a preductal location (ie, the right upper extremity, usually the wrist or medial surface of the palm)
Attaching the probe to the baby before connecting the probe to the instrument facilitates the most rapid acquisition of signal
Class IIb, LOE C a maulik shah presentation OXYGEN ADMINISTRATION : OXYGEN ADMINISTRATION Target OxyHb saturations values should be in the inter-quartile range of pre-ductal saturations. (Class IIb LOE C) a maulik shah presentation Oxygen administration : Oxygen administration To achieve these target levels:
Supplement Air or Blended oxygen (Class IIb LOE B)
If after 90 minutes of resuscitation
Heart Rate remains < 60 per minute
Supplement 100 % oxygen until recovery of normal heart rate. a maulik shah presentation Oxygen administration : Oxygen administration a maulik shah presentation NRP algorithm (2010) : NRP algorithm (2010) a maulik shah presentation Slide 26: HR below 100? Take ventilation corrective steps HR below 60 ? Consider intubation
Coordinate with PPV HR below 60 ? i.v. epinephrine Take ventilation corrective steps
Intubate if no chest rise! Consider
Pneumothorax yes Yes Yes No No NRP
2010 Yes a maulik shah presentation Ventilation Strategies : Ventilation Strategies Initial breaths & PEEP
Devices to assist ventilation
Strategies when resources are limited. a maulik shah presentation Positive Pressure Ventilation : Positive Pressure Ventilation When to administer PPV ?
If the infant remains apneic or is gasping
or the Heart Rate remains < 100
after initial steps of resuscitation. a maulik shah presentation Adequacy of PPV : Adequacy of PPV - an increase in the heart rate is the primary measure of adequacy of PPV.
- Chest wall movement should be assessed if heart rate does not improve. a maulik shah presentation Positive Pressure Ventilation : Positive Pressure Ventilation What should be the inflation pressure?
- An initial inflation pressure of
20 cm H2O may be effective,
but 30 to 40 cm H2O may be required in some term babies without spontaneous ventilation
(Class IIb, LOE C). a maulik shah presentation Positive Pressure Ventilation : Positive Pressure Ventilation What should be the optimum inflation time?
assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to promptly achieve or maintain a heart rate 100 per minute (Class IIb, LOE C) a maulik shah presentation PEEP : PEEP PEEP is likely to be beneficial during initial
stabilization of apneic preterm infants who
require positive-pressure ventilation and should
be used if suitable equipment is available. a maulik shah presentation When to use a CPAP? : When to use a CPAP? - Spontaneously breathing preterm infants who have respiratory distress may be supported with CPAP or with intubation and mechanical ventilation (Class IIb,LOE B). a maulik shah presentation Role of CPAP in Dilevery Room : Role of CPAP in Dilevery Room PEEP is likely to be beneficial and should be used if suitable equipment is available Class IIb, LOE C
PEEP can easily be given
With a flow-inflating bag or
A self-inflating bag with an optional PEEP valve a maulik shah presentation When to use a LMA? : When to use a LMA? Effective for ventilating newborns weighing more than 2000 g or delivered 34 weeks gestation (Class IIb, LOE B).
To be considered during resuscitation if facemask ventilation is unsuccessful and tracheal intubation is unsuccessful or not feasible (Class IIa, LOE B). a maulik shah presentation When to place an E.T. Tube? : When to place an E.T. Tube? If bag-mask ventilation is ineffective or prolonged
When chest compressions are performed
For special resuscitation circumstances, such as congenital diaphragmatic hernia or ELBW.
Initial endotracheal suctioning of nonvigorous meconium stained newborns……!!?? a maulik shah presentation Chest Compressions : Chest Compressions When to do ?
a heart rate that is 60 per minute despite adequate ventilation with supplementary oxygen for 30 seconds.
the 2 thumb–encircling hands technique better than the 2-finger technique(Class IIb,LOE C).
The 2-finger technique may be preferable when access to the umbilicus is required during insertion of an umbilical catheter. a maulik shah presentation Chest Compressions : What should be the ratio of CC / PPV?
3:1 CC/PPV ratio in usual Resucsitation
But rescuers should consider using higher ratios (eg, 15:2) if the arrest is believed to be of cardiac origin (Class IIb, LOE C). Chest Compressions a maulik shah presentation Epinephrine : Epinephrine Indication:
if the heart rate remains <60 per minute despite adequate ventilation (usually with endotracheal intubation) with 100% oxygen and chest compressions.
The route of administration
- Given the lack of supportive data for endotracheal epinephrine, the IV route should be used as soon as venous access is established (Class IIb, LOE C). a maulik shah presentation Epinephrine : Epinephrine DOSE:
IV dose : 0.01 to 0.03 mg/kg per dose.
endotracheal route : 0.01 or 0.03 mg/kg
Higher IV doses may cause exaggerated
hypertension, decreased myocardial function,
and worse neurological function. a maulik shah presentation Volume Expansion : Volume Expansion Indication:
when blood loss is known or suspected (pale skin, poor perfusion, weak pulse) and the baby’s heart rate has not responded adequately to other resuscitative measures(Class IIb,LOE C)
- An isotonic crystalloid solution or blood is recommended (Class IIb, LOE C).
The dose : 10 mL/kg, repeated SOS.
Rapid infusions of large volumes have been associated with intraventricular hemorrhage (Class IIb, LOE C). a maulik shah presentation Should Naloxone be given? : Should Naloxone be given? Administration of naloxone is not recommended as part of initial resuscitative efforts in the delivery room for newborns with respiratory depression.
Heart rate and oxygenation should be restored by supporting ventilation. a maulik shah presentation Glucose administration : Glucose administration Intravenous glucose infusion should be considered as soon as practical after resuscitation, with the goal of avoiding hypoglycemia (Class IIb, LOE C).
Due to the paucity of data, no specific target glucose concentration range can be identified at present. a maulik shah presentation Induced Therapeutic Hypothermia : Induced Therapeutic Hypothermia The treatment should be implemented according to the studied protocols, which currently include commencement within 6 hours following birth, continuation for 72 hours, and slow rewarming over at least 4 hours. a maulik shah presentation When to withhold resuscitation? : When to withhold resuscitation? When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated.
Examples include extreme prematurity (gestational age 23 weeks or birth weight 400 g), anencephaly, and some major chromosomal abnormalities, such as trisomy 13 (Class IIb, LOE C). a maulik shah presentation When to withhold resucitation : When to withhold resucitation What does indian law say ??
Share your views….. a maulik shah presentation When to discontinue resuscitation? : When to discontinue resuscitation? In a newly born baby with no detectable heart rate, it is appropriate to consider stopping resuscitation if the heart rate remains undetectable for 10 minutes (Class IIb, LOE C) a maulik shah presentation NRP algorithm (2010) : NRP algorithm (2010) a maulik shah presentation Slide 49: a maulik shah presentation What’s the expert say…. : What’s the expert say…. ignored the feasibility and scalability of these guidelines in resource-limited settings, which bear the maximum burden of intrapartum related neonatal deaths.
….tailor-made for guiding resuscitation in tertiary care centers, with limited practical applicability in resource(financial and manpower)-crunched low- and middle-income countries, primarily due to recommending use of costly equipments like pulse oximetry, blenders for graded increase in supplemental oxygen etc, thereby making the whole process complex and less user friendly. a maulik shah presentation What’s the expert say…. : What’s the expert say…. However there are positive welcome changes like use of room air for initiation of resuscitation and less vigorous push for tracheal suctioning in non- vigorous neonates born through meconium-stained amniotic fluid
AHA/AAP Neonatal Resuscitation Guidelines 2010: Summary of major changes and their application in Resource-Limited SettingsArun Sasi1, Deepak Chawla2, Ashok.K. Deorari1 a maulik shah presentation Slide 52: Learning is a never ending process….! a maulik shah presentation Slide 53: a maulik shah presentation