Neonatal Resuscitation Latest and Greatest

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1 Neonatal Resuscitation Latest and Greatest Ashley S. Ross, M.D. Neonatal Resuscitation Program Regional Trainer September 25, 2013

2 Objectives 1. Discuss changes to and evidence that was evaluated that led to the NRP 2012 recommendations. 2. Discuss changes to roles and responsibilities 3. Answer questions about how to implement practical changes in your hospital.

3 Neonatal Resuscitation There are three grand principles governing the treatment of asphyxia neonatorum: first, maintain the body heat; second, free the air passages from obstruction; third, stimulate respiration, or supply air to the lungs for oxygenation of the blood. De Lee JB. Medicine 1897;3:

4 NRP Course Options Everyone takes a Provider Course No more renewal courses No more lectures and slides Online examination before the course Hands-on learning Simulation/Debriefing

5 How many babies need resuscitation? 10% of all newly born infants require some resuscitation. 1-5% of term newborns will require PPV The majority of infants who need resuscitation will respond to effective positive-pressure ventilation. Only 1% require full resuscitation 1-2 per 1,000 births.

6 Preparing for resuscitation Must have equipment Compressed gas source Oxygen blender Pulse oximeter Laryngeal mask airway (size 1) Deleted Items Sodium bicarbonate Naloxone

7 Teamwork Clear, closed loop communication Identified leader Hospital dependent Clearly announce who the leader will be before each resuscitation Leader should define clear roles Each participant has a valuable voice Leader may change due to ongoing resuscitation needs Example: Emergency UVC placement Leader may change so line can be placed without distraction

8 How much oxygen to start with? Previous NRP recommendation: Vague Term: 2 meta-analysis comparing 100% O 2 versus room air showed survival with room air No data on other O2 concentrations Preterm: hyper and hypoxemia when resuscitation initiated with blended versus resuscitation started with either RA or 100% and then titrated.

9 Keep them warm! Delivery room/resuscitation areas 77 F to 79 F Plastic wrap for babies <29 week Can use 1 gallon plastic bag, sheets of plastic food wrap, or commercially available polyethylene plastic

10 2012 Oxygen recommendation Term or Preterm? Goal: Target oxygen saturation goals For term: Start with room air and titrate Blended air should be available For preterm: Start with higher concentration (30-40%) If blender not available: Start with room air. If HR <60 after 90 seconds of resuscitation O2 to 100% until HR is normal

11 Assisted Ventilation Devices Flow inflating or self-inflating bag, T-piece device Targeted inflation pressures and I-times are better achieved with T-piece devices Clinical implication is not clear Laryngeal mask airway Should be available for all deliveries >2000 grams or 34 weeks Consider if PPV unsuccessful and tracheal intubation not successful or feasible

12 Rapid assessment: 3 Questions 1. Term gestation? 2. Breathing or crying? 3. Good tone? Prior NRP also asked: Is fluid clear?

Yes to 3 assessment questions If baby does not need resuscitation Should not be separated from mother Provide warmth: Dried /Placed skin-skin /Covered with dry linen

13 Yes to 3 assessment questions If baby does not need resuscitation Should not be separated from mother Provide warmth: Dried /Placed skin-skin /Covered with dry linen Clear airway if necessary Use bulb syringe or catheter only if obvious obstruction to breathing or if patient requires PPV Ongoing evaluation: breathing, activity, color

No to 3 assessment questions Warm Warmer / Pre-warmed blankets Premature: Plastic bag / wrap / mattress Clear airway only if necessary Use bulb syringe or catheter only if obvious obstruction to

14 No to 3 assessment questions Warm Warmer / Pre-warmed blankets Premature: Plastic bag / wrap / mattress Clear airway only if necessary Use bulb syringe or catheter only if obvious obstruction to breathing or if patient requires PPV Why? Suctioning can create bradycardia via vagal stimulation NICU data: Routine suctioning: cerebral blood flow and pulmonary compliance and oxygenation Dry Stimulate

15 Meconium??? History: Suctioning of oropharyx before delivery of shoulders: No Value Suctioning vigorous babies No Value Possible benefit to suctioning non-vigorous infants with meconium Not shown to reduce MAS or mortality 2012 recommendation: Not specified in the algorithm Unchanged from previous recommendation Intubate and suction non-vigorous babies If prolonged and unsuccessful attempts at intubation: PPV (particularly if there is bradycardia)

16 The golden minute 60 seconds to complete: More focus on establishing ventilation, allows for extra 30 seconds. 6 step pneumonic for ventilation adjustment

17 Evaluation after first step Heart Rate <100? Breathing Apnea or gasping?

18 HR >100, Patient breathing and not gasping but with labored breathing / cyanosis Clear Airway Bulb syringe (M-N) Place pulse oximeter Preductal (R hand) Consider CPAP Peep: Likely to be beneficial (FRC)

19 CPAP in the delivery room Most helpful in the preterm baby whose alveoli tend to collapse due to surfactant deficiency Reduced need for intubation, ventilation, and surfactant administration No formal study-based evidence to support or refute use of CPAP in the term baby with respiratory distress

20 Pulse oximetry Why?: Too little or too much O 2 can be harmful. Assessment of skin color is a very poor indicator of oxyhemoglobin saturation. When to use pulse oximetry? Anticipated resuscitation (preemies) PPV for more than a few breaths Cyanosis present Supplemental oxygen administered What should SpO 2 be? Data from term babies Post table on each bed

21 HR <100 / Patient Apneic or Gasping (Ineffective Respiratory Effort) Start PPV (If you are doing this you need SpO 2 monitoring) Establish FRC breaths per minute Initial inflation pressure: 20 cm H2O cm H2O may be needed Individualize to achieve ( HR, chest wall movement) Best measure of effective PPV: Heart Rate (Goal>100) Other measures: Chest wall movement

22 Giving PPV / monitoring SpO 2, now what? Assess Heart rate Auscultate precordial pulse Or: Palpation umbilical pulse <100 Ventilation corrective steps MRSOPA Reposition: sniffing position Mask seal Adequate chest movement Check equipment

23 You have corrected your PPV now HR 60 Go back in algorithm check Heart Rate If: HR 60 but <100 Ventilation corrective steps HR 100 Post-resuscitation care

HR < 60 You have corrected your PPV, now check heart rate again Consider intubation Intubation indicated in NRP: Initial endotracheal suctioning of non vigorous

24 HR < 60 You have corrected your PPV, now check heart rate again Consider intubation Intubation indicated in NRP: Initial endotracheal suctioning of non vigorous meconium stained newborns. If bag-mask ventilation is ineffective or prolonged When chest compressions are performed Special circumstances: ELBW, congenital diaphragmatic hernia

You have corrected your PPV, now check heart rate again (con t.) Chest compressions If HR <60 despite adequate ventilation with supplemental O 2 for 30 seconds.

25 You have corrected your PPV, now check heart rate again (con t.) Chest compressions If HR <60 despite adequate ventilation with supplemental O 2 for 30 seconds. Coordinate with ventilation 1 breath: 3 compressions Lower third of sternum 1/3 of AP diameter of chest Techniques: 2 thumbs with fingers supporting back: Preferred technique, can move to head when placing lines.

26 After intubation / PPV / Chest Compressions Check Heart Rate HR 60 (but still not what you need it to be) Correct ventilation Consider intubation Intubate if you have not If HR <60 Intubate Ventilation corrective steps? Is there another problem Hypovolemia Pneumothorax Have equipment near by

27 After intubation / PPV / Chest Compressions Check Heart Rate HR <60 (con t.) Despite: Adequate ventilation (usually with ETT) With 100% FiO 2 And chest compressions: IV Epinephrine and / or Volume Expansion Stop chest compressions when HR 60, avoid frequent interruptions for assessment of HR

28 Epinephrine 1:10,000 (0.1 mg/ml) Recommended route: IV IV Dose: 0.01 to 0.03 mg/kg/dose IV 0.1 to 0.3 ml/kg/dose IV While access (UVC) is obtained: Consider endotracheal route Safety and efficacy not evaluated ETT dose: 0.05 to 0.1 mg/kg/dose ETT 0.5 to 1 ml/kg/dose ETT

29 Volume Expansion When? Blood loss is known Blood loss is suspected Pale, poor perfusion, weak pulse, HR not responded to adequate resuscitation. Solution: Isotonic crystalloid (i.e. normal saline) OR Blood Dose: 10 ml/kg Note: Premature: Avoid rapid infusion (IVH)

30 Other Medications Not recommended as part of initial resuscitation Naloxone not part of resuscitation anymore Buffers Vasopressors Glucose No specific target range identified IV glucose infusion should be considered as soon as practical after resuscitation Avoid hypoglycemia

31 Delayed Cord Clamping Benefit in uncomplicated preterm delivery Higher blood pressures Reduced IVH risk ILCOR recommends waiting at least 1 minute if resuscitation is not needed Requires discussion with OB colleagues

33 Post-Resuscitative Care The next talk Routine Post-resuscitative care

34 Induced Therapeutic Hypothermia Cooling Think about this after resuscitation of infants 36 weeks gestation. ph <7 Infants 36 wks gestation with evolving moderate to severe HIE should be offered therapeutic hypothermia. Remember: 6 hours

35 When to not resuscitate? Still not as clear as one might hope. Emphasis: Parental role / Use regional guidelines Broad guidelines: Resuscitation not indicated: When gestation, birth weight or congenital anomalies are associated with almost certain death and unacceptable high mortality. Examples: < 23 weeks gestation, <400 grams, anencephaly and certain chromosomal abnormalities (Trisomy 13) - Parental desires concerning initiation of resuscitation should be supported: In conditions associated with uncertain prognosis in which survival is borderline, morbidity rate is high, the anticipated burden to the child is high. E.g weeks. - Resuscitation almost always indicated: Conditions associated with a high rate of survival and acceptable morbidity. E.g. >25 wk gestation and most congenital anomalies.

36 When to stop resuscitation? No detectable heart rate after 10 minutes What about really low heart rate???

AHA/AAP Neonatal Resuscitation Guidelines 2010: Summary of Major Changes and Comment on its Utility in Resource-Limited Settings

AHA/AAP Neonatal Resuscitation Guidelines 2010: Summary of Major Changes and Comment on its Utility in Resource-Limited Settings Resuscitation step Recommendations (2005) Recommendations (2010) Comments/LOE