The New Neonatal Resuscitation
Program (NRP) Guidelines
Mesfin Woldesenbet, MD, FAAP
Neonatologist, Medical Director
NICU at Memorial Hermann Southwest Hospital
Pediatrix Medical Group
Houston, Texas
April 2013
Introduction
 10% of newborns require some assistance at birth
 <1% require extensive resuscitation
 Crude birth rate ~ 19/1000 population (~134 million)
 15,120 births/hour
 252 births/min
 4.2 births/seconds
 ~150 babies born per hour
 USA- 5 babies/hour need extensive resuscitation
The Process of Developing
Guidelines and Education Material
Published Scientific
Research
Neonatal Resuscitation
Program (NRP)
5 Years
AAP/AHA Guidelines for
CPR and cardiovascular
Care of the Neonate
International Liason
Committee on
Resuscitation (ILCOR)
International Consensus on
CPR and ECC with
treatment
recommendation (CoSTR)
Neonatal Resuscitation Program
 1st Edition introduced in 1987
 1st – 5th Editions
 Slide and Education format
 Do not differentiate by job description or specialty
 6th Edition
 Less didactic
 More emphasis on simulation and Debriefing
 Didactic portion taken online with certificate of passing a
test
Neonatal Resuscitation Program
6th Edition
 Rationale for the changes to procedural guidelines
and processes
 Evidence behind each step in resuscitation
 Rationale for the new educational approach
 Implication
2
Steps of resuscitations
1. Initial steps- dry, position, assess and stimulate
2. Ventilation
3. Chest Compression
4. Medication or volume expansion
Assessment of efficiency of CPR
 Progression to next step is based on
 Heart Rate
 Respiration
 The most sensitive indicator remains the heart rate
 Auscultation (best method)
 Palpation of umbilical cord (underestimate heart rate)
 Pulse oximetry (difficult to obtain reading consistently)
 Do not use color as an indicator
 Will avoid hyperoxia
Initial Step
 Term, breathing and good muscle tone:
 Dry and place the infant skin-to-skin with the mother
 Continue routine care and ongoing assessment
 This includes the vigorous infant with meconium-stained
amniotic fluid.
 Use of the bulb suction is reserved for infants whose
secretions obstruct breathing or the infant requiring PPV.
After Initial Steps
 HR >100bpm, labored breathing and persistent cyanosis:
 Clear airway.
 Place pulse ox on infant’s right hand or wrist.
 Free flow oxygen if the infant’s O2 sat is below the time specific
target.
 Consider CPAP for persistent labored breathing.
 HR <100bpm or infant is apneic or gasping:
 Apply pulse ox.
 Begin PPV.
Corrective Measures: MR SOPA
 Reapply Mask
 Reposition the head
 Suction mouth and nose
 Open infant’s mouth
 Increase Pressure every few breaths until BBS and chest rise
are evident. Do not exceed an inspiratory pressure >
40cmH2O
 Use Alternative airway – endotracheal tube or laryngeal
mask airway
Administering Oxygen
 Every delivery area should have access to an air/oxygen
blender and pulse oximetry.
 Resuscitation of term newborns may begin with room air if
blended oxygen is not available.
 If baby is bradycardic (<60/min) after 90 seconds of
resuscitation with lower FiO2, increase the FiO2 to 100%.
 In preterm infants higher oxygen concentration may
achieve target saturation more quickly.
 Oxygen concentration is adjusted according to age in
minutes and oxygen saturation
3rd, 10th, 25th, 50th, 75th, 90th, and 97th SpO2
percentiles for all infants with no medical intervention
after birth
Dawson et al, 2010
3rd, 10th, 25th, 50th, 75th, 90th, and 97th SpO2
percentiles for term infants at ≥37 weeks of gestation with
no medical intervention after birth.
Dawson et al, 2010
Third, 10th, 25th, 50th, 75th, 90th, and 97th SpO2
percentiles for term infants at 32-36 weeks of
gestation with no medical intervention after birth.
Dawson et al, 2010
Third, 10th, 25th, 50th, 75th, 90th, and 97th SpO2
percentiles for term infants at≤32 weeks of
gestation with no medical intervention after birth.
Dawson et al, 2010
Targeted Pre-ductal SPO2
(Term infants)
1 min
60-65%
2 min
65-70%
3 min
70-75%
4 min
75-80%
5 min
80-85%
10 min
85-90%
Use of Supplemental Oxygen
 Term infant requiring IPPV
 100% Oxygen vs. Air
 No advantage
 Increase time to first breath
 Higher mortality
 Potential harm at a cellular level in asphyxia model
 Infants 32- 37 weeks- insufficient evidence
Use of Supplemental Oxygen
 Infants <32 weeks
 Do not reach targeted SpO2 in the first 10 minutes of life
 Use blended oxygen to avoid hypoxia or hyperoxia
 21% or 100% vs. 30% or 90%
 In the absence of a blender, start with room air
Resuscitation of newborns: Room air vs.
100% oxygen. Effect on Mortality.
RR<1 favors room air
Saugstad et al. 2005
When To Use Pulse Oximetry
 Resuscitation is anticipated
 PPV is administered for more than a few breaths
 Cyanosis is persistent
 Supplementary oxygen is used
The pulse oximeter probe is placed on the infant’s right
hand or wrist and then connected to a pulse oximeter
Suctioning of airway
 Upper airway
 Not evidence to support or refute
 Associated with cardio-respiratory complications
 Tracheal suctioning
 No evidence to suggest decrease in MAS
 Decrease in Oxygenation
 Increase cerebral blood flow
 Increase intracranial pressure
Intubation
 Attempts to complete intubation may now take up to 30
seconds.
 Do not administer free-flow oxygen during intubation to
an infant who is not breathing. It has no benefit.
None-Vigorous Infants with Meconium
stained fluid
 Care is in general unchanged
 If intubation is difficult and the infant is bradycardic
consider going to the next steps of resuscitation (dry,
stimulate and clear the airway)
 The only evidence available for use of tracheal suctioning
is the study comparing suctioned babies with historical
controls
Ventilation
 Initial breath in newborns requiring IPPV
 Can use short or longer inspiratory time
 Initial Peak pressure
 Use to achieve increase heart rate and good chest rise
 Preterm infants: 20-25 cm H2O
 Term infants: 30-40 cm H2O
 Optimal PEEP
 Increase FRC, oxygenation and lung compliance
 Reduce lung injury
 Avoid High PEEP (8-12)
Positive Pressure Ventilation
 A rising heart rate is the best indicator of effective PPV
 If the heart rate does not show immediate improvement
assess breath sounds and chest movement.
 If these indicators are not present in the first 5-10
attempted breaths of PPV the team proceeds to
corrective action.
Monitoring during/after resuscitation
 Tidal volume
 No clinical outcome studies
 Exhaled CO2 detectors to confirm intubation
 Rapid and accurate than clinical methods
 False Negative
 Cardiac arrest
 False Positive
 Contamination with epinephrine, surfactant and atropine
** Use Exhaled CO2 detection + clinical assessment
CPAP
 CPAP vs. intubation+IPPV
 Preterm infants >25 weeks
 No difference in death or CLD
 Decrease use of surfactant
 Increase in Pneumothorax
 Term infants
 No evidence
CPAP
 CPAP vs. IPPV with face mask
 Preterm infants
 Decrease rate of mechanical ventilation
 Decrease in CLD
* May use CPAP or Intubation in the delivery room!
Assisted Devices
 T-piece vs. Self-inflating vs. Flow-inflating bags
 No clinical studies
 Mechanical models favor T-piece resuscitator
 Laryngeal Mask Airway
 No extensive study
 In cases where face mask or intubation fails
 May use in infants >2000g or >34 weeks
 No Evidence
 Meconium stained amniotic fluid
 Chest compression
Chest Compressions
 Indication: heart rate remains <60 bpm
 Use 100% oxygen concentration
 Coordinate PPV with chest compressions for 45-60
seconds before reassessing heart rate
 Intubation is recommended if chest compressions are
required.
Chest Compression
 Chest compression and/or Ventilation
 More efficient when combined
 Sustained chest compression
 Deleterious effect on myocardial and cerebral perfusion
 Chest Compression : Ventilation ratio
 3:1, 5:1, 15:2, 30:2
 Less minute ventilation as the ratio increases
 No human data available
Chest Compression
 2 thumb-encircling hand technique-superior

Diastolic BP, quality chest compression and less tiring
 Lower sternum than Midsternum
 Depth: 1/3 AP diameter than deeper compressions
Epinephrine
 Indication: Heart rate <60 bpm after at least 45-60 seconds of
coordinated PPV and chest compressions.
 Administration through an umbilical line remains the
preferred route.
 ETT vs. IV administration
 No randomized clinical trials
 Case series and animal studies
 ETT less effective than IV
 ETT route has less blood concentration of epinephrine
Epinephrine-Ideal Dose
 No randomized clinical trials
 IV dose: 0.1-0.3 ml/kg
 Labeled 1 ml syringe and draw minimal dose of 0.1mL/kg.
 IV epi >0.3ml/kg- no benefit
 IV epi >1ml/kg
 Increased risk of mortality
 Interfere with cerebral perfusion and cardiac output
 ETT epi (ETT Dose has changed)
 0.5-1ml/kg to achieve adequate blood concentration
 Labeled 3-6 ml syringe and draw up 1mL/kg.
Naloxone and Volume Expansion
 Naloxone
 No difference in clinical outcome
 Associated with seizures if mother opiate addict
 Concern about short and long-term safety
 Volume expansion
 If chest compression, ventilation and epinephrine fails
 Most useful if history of blood loss
 Maybe harmful if no history of blood loss
Use of volume expansion during
delivery room resuscitation in nearterm and term infants.
-Received Volume infusion
⏏-No Volume infusion
* p<.05
Wycoff et al, 2005
Temperature Control
 Large body of evidences
 Methods:
 Polythene wraps or Bags
 Exothermic mattresses
 Delivery room temp >26°C
 Risks associated with hyperthermia
 Respiratory depression
 Neonatal Seizure
 Cerebral Palsy
 Mortality
Elevated Temperature After Hypoxic-Ischemic
Encephalopathy: Risk Factor for Adverse Outcomes
Esophageal
Temperature
OR (95% CI)
Death or Disability
(n=99)
Death
(n=99)
Disability
(n=65)
Highest
4.0 (1.5-11.2)
6.2 (2.1-17.9)
1.8 (0.4-8.2)
Median
3.2 (0.9-11.2)
5.9 (1.5-22.7)
1.0 (0.2-5.1)
Lowest quartile
1.5 (0.6-3.5)
1.4 (0.6-3.3)
1.1 (0.3-3.5)
Laptook et al. Pediatrics 2008
Induced Hypothermia
 Large body of evidence
 Term and near-term infants
 Initiated within 6hours of life
 Significant reduction in death and neurodevelopmental
disability at 18 months of life
 NNT: 9
 Patient recruited based on specific criteria
 Cord or first ABG
 Clinical findings (moderate to severe HIE)
Improved Pathology scores in Hippocampus when treated
with therapeutic hypothermia and/or 21% oxygen during
resuscitation.
*P<0.05
Suagstad, 2012
Glucose
 Hypoglycemia + HIE= brain injury
 Hyperglycemia + HIE
 No adverse effect
 Maybe protective
 No randomized study to show specific glucose level
Cord Clamping
 Term: 1 min to no cord pulsation
 Improved iron status
 Preterm: 30 seconds to 3 minutes
 Higher blood pressure
 Low IVH
 Less transfusion
 More phototherapy
 Insufficient evidence
Non-Initiation of Resuscitation
 Vary according to providers, regions and availability of
resources
 Parental role in decision making
 Categories:
 1- GA, birth weight or congenital anomaly suggest certain early
death or unacceptably high morbidity
 2- High rate of survival and acceptable morbidity
 3- Uncertain prognosis, borderline survival and relatively high
morbidity
 Coordinated approach between Obstetrician, Neonatologist
and parents.
Discontinuation of Resuscitation
 No heart beat for 10 minutes
 Death or Severe neurologic disability
 Evidence: small number of babies
 Decision influenced by:
 Gestational age
 Etiology of arrest
 Parents previous expressed feeling
A New Educational Approach
 2004-Joint Commission Report: 47 infant deaths and or
injuries related to the birth process
 The root cause was related to ineffective teamwork and
communication.
 Joint Commission recommendations:
 Team training
 Clinical drills
 Debriefings
NRP Response to Joint Commission




5th Edition
Passive learning
Poorly prepared participants
Components for content and
technical skills, not teamwork
and communication
 Instructors and participants were
not challenged by the class
format
 6th Edition
 Active learning
 Self study and online
examination prior to class
participation
 Skill practice and simulationbased scenarios aimed at
promoting teamwork and
communication
 Debriefing
NRP Education
 Simulation
 As adjunct to traditional training
 Enhance performance
 Experience obtained from high risk organizations
 Airlines, NASA, Military
 Briefing and de-briefing
 Improve knowledge, skill and behavior
Simulation and Debriefing
 Key Behavioral skills targeted
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Know your environment
Anticipate and plan
Assume leadership role
Communicate effectively
Delegate workload optimally
Allocate attention wisely
Use all available information
Use all available resources
Call for help when needed, and early
Maintain professional behavior
Summary
 Progression to next step following initial resuscitation
depends on heart rate and respiration.
 Oximetry to be used to assess oxygenation
 Term babies- best to start resuscitation with room air than
100% oxygen
 Use blender when oxygen is needed and should be guided
by oximetry
 No evidence to support or refute endotracheal suctioning in
meconium stained fluid, even in depressed newborn
Summary
 Chest compression: ventilation ratio stays 3:1
 Consider therapeutic hypothermia in term and near-term
infants with moderate to severe HIE
 Consider stopping resuscitation if no detectable heart rate
for 10 minutes
 Delay cord clamp for at least 1 minute in those who does not
require resuscitation
Implication
 Old habit vs. New information
 More time vs. Efficiency vs. Cost
 Education or Debriefing
 Pulse oximeter
 Shared responsibility vs. Neonatal Team
 Conditions where Oxygen is needed
 PPHN
 Meconium Stained Amniotic Fluid
 Lack or need for more evidence
Implication
 Legal Implication (especially in depressed newborns)
 All hospital need to have oxygen blender in the DR
 Use room air
 Self inflating bag without reservoir (40% O2)
 CO2 detectors
 Correct BMV taught to providers not skilled in intubation
 Hypothermia
 Preventable condition in a court setting
 Therapeutic Hypothermia within 6hrs of life
 Preference of IV route to give epinephrine
 States law credentialing nurses to put a UVC
Do we need a new Apgar score?
Virginia Apgar
0
1
2
Heart Rate
0
<100
>100
Respiration
0
Weak, irregular
Good cry
Reaction
0
Slight
Good
Color
Blue/pale
All pink, limb blue
Body pink
Tone
Limp
Some movement
Active movement,
well flexed limbs
Reference
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1- Carson et al. American J Obstet Gynecol. 1976:126:712-715
2- Ting et al. American J Obstet Gynecol. 1975;122:767-771
3- Gregory et al. J Pediatr. 1974;85:848-852
4- O’Donnell et al. J Pediatr. 2005;147:698-699
5- Davis et al. Lancet. 2004;364:1329-1333
6- Rabi et al. Resuscitation. 2007;72:353-363
7- Escrig et al. Pediatrics. 2008;121:875-881
8- Wycoff et al. Pediatrics 2005;115:950-955
9- Finer et al. Pediatrics 1999;104:428-434
10- Wycoff and Berg Seminars Fetal and Neonatal Med 2008;13:410-415
11- Perlman et al. Pediatrics 2010;126:e1319-e1344
12-Perlman et al. Circulation;122(suppl 2):S516-S538
13-AAP News, October 2011
14-Dawson et al. Pediatrics 2010; 125 (6),e1340-e1347
15-Suagstad et al. Pediatrics Research 2012;71:247-52
16-Wycoff et al. Pediatrics. 2005, Apr;115(4):950-5.
17-Laptook et al. Pediatrics 2008, Sept;122 (3):491-499
18-Saugstad et al. Biol Neon 2005
Do Not Attempt This!
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Questions / Comments