Newborn Resuscitation: The Science Of NRP 7th Edition

Newborn Resuscitation:The Science of NRP 7th Edition Webinar will begin at 1PM Central. To reduce background noise, all phone lines willbe muted during webinar. Please submit questions via the Chat panel onWebEx Console.SAMPLE PHOTO

3-PART WEBINAR SERIESJuly 26Aug 16 Highlights of theNew NRP 7thEdition NRP 7th Edition:What InstructorsNeed to Know Recording Available Recording AvailableSept 7 NewbornResuscitation:The Science ofNRP 7th Edition

WELCOME!POLL QUESTION #1

FACULTY DISCLOSURE INFORMATIONIn the past 12 months, we have no relevant financial relationships with the manufacturer(s) ofany commercial product(s) and/or provider(s) of commercial services discussed in this CMEactivity. J Zaichkin is a compensated editor and consultant for the American Academy ofPediatrics/NRP and, as such, has contractual relationships to produce AAP/Laerdal cobranded educational materials. She receives no financial benefit from the sale of thesematerialsS Ringer has nothing to discloseWe do not intend to discuss an unapproved/investigative use of a commercial product/device inthis presentation.

POLL QUESTION #1 RESULTS

SESSION OBJECTIVE Interpret the 2015 American Heart AssociationGuidelines for neonatal resuscitation andapply them to clinical practice.

WHERE DOES NRP COME FROM? The International Liaison Committee on Resuscitation (ILCOR) coordinates arigorous, 5 year evidence-based review of topicsILCOR reaches international consensus on the science of resuscitation fornewborns, children, and adults and publishes the science in the CoSTR documentEach council/country that participates in ILCOR refines the science intoresuscitation guidelines that fit the culture and resources of their regionThe American Heart Association and American Academy of Pediatrics wrote theneonatal guidelines for resuscitation and released these in October 2015.The NRP Steering Committee uses the guidelines as the foundation for NRP 7thedition materials.

HTTP://WWW2.AAP.ORG/NRP/

What’s newabout thetextbook’sstructure?

NRP 7TH EDITION TEXTBOOK1.2.3.4.5.6.Foundations of NeonatalResuscitationPreparing forResuscitationInitial Steps of NewbornCarePositive-pressureVentilationAlternative AirwaysChest Compressions7.8.9.MedicationsPost-resuscitation CareResuscitation andStabilization of BabiesBorn Preterm10. Special Considerations11. Ethics and Care at the Endof LifeNo textbook DVD-ROM

NEW SECTIONS IN EACHLESSON Focus on TeamworkIntegrates emphasis on teamwork andcommunication with lesson content Frequently Asked QuestionsControversies and questions commonly sentto the NRPSC Ethical considerationsHighlight questions to consider in context oflesson content Additional reading

DRAWINGS REPLACED WITH COLORPHOTOS

What are the major changes inthe NRP practicerecommendations?

INCREASED EMPHASIS Teamwork Preparation beforeresuscitation– Structured check ofequipment and supplies– Identifying roles Accurate documentation

BEFORE THE BIRTH

TEAM BRIEFING Determine the leader, clarify roles andresponsibilities, delegate tasks Perform a standardized Equipment Check Introduce yourself and discuss the plan of care withthe parent(s) if not already done Ask the OB provider the plan for delayed cordclamping

RAPID EVALUATION OF THENEWBORN

DELAYED CORD CLAMPING Delay cord clamping for 30-60 seconds for most vigorousterm and preterm newborns– May place skin-to-skin with mom– May cover with towel or plastic No delay if placental circulation is disrupted (abruption,bleeding placenta previa, bleeding vasa previa, cord avulsion) Insufficient evidence– Timing if baby is not vigorous– Multiple gestation births

IMPLICATIONS OF DCC Time of birth is when the babyemerges from its mother, not thetime of cord clamping Determine where the newbornwill be placed during DCC What are thermoregulationstrategies and who does them? Who determines when the cordis clamped and cut?

MAINTAIN THE NEWBORN’S AXILLARYTEMPERATURE 36.5 – 37.5 C Hypothermia increases risk of RDS,hypoglycemia, IVH, late-onset sepsis Increased risk of mortality associatedwith hypothermia at admission room temp to 74-77 F (23-25 C) Use a hat If 32 wks, use a thermal mattressand cover baby in plastic wrap/bagConsider using temp sensor and servocontrol mode

INITIAL STEPS OF NEWBORN CARE Provide warmthPosition head and neckSuction if neededDry (or cover in plastic)StimulateASSESS BREATHINGIf breathing, assess heart rateIf apneic, START PPV

Routine tracheal suction nolonger recommended forNON-VIGOROUS babies withmeconium stained fluid– MSAF is a risk factor thatrequires at least 2 people atthe birth and– Someone with intubationskills IMMEDIATELY available– If there are additional riskfactors, someone with fullresuscitation skills should bepresent at the birth

ASSESS HEART RATE BY AUSCULTATION– Palpation of the umbilical cordis less reliable and less accuratethan auscultation– Auscultation is often inaccurate;if baby is not vigorous and youcan’t assess HR withstethoscope, apply pulseoximeter.– If pulse oximeter unreliable,apply ECG leads and use cardiacmonitor

Apply ECG leads (chest orlimb leads) and a monitor– When auscultation is difficultand baby is not vigorous– When the pulse oximeterdoesn’t work due to low HR– Consider a monitor when PPVbegins– A monitor is the preferredmethod for assessing HRwhen compressions begin

OXYGEN MANAGEMENTStart free-flow oxygen at 30%Liter flow is 10 L/min.Initial FiO2 for PPV– 35 weeks’ GA 21%– 35 weeks’ GA 21-30%Always use pulse oximetry to guideoxygen concentrationUse 100% oxygen during compressions

BABIES LESS THAN 32 WEEKS’GESTATION Consider CPAP if baby isbreathing immediately afterbirth as an alternative toroutine intubation andsurfactant administration 5 cm H20 PEEP isrecommended

TO ADMINISTER PPV, STAND ATTHE BABY’S HEAD

PPV TECHNIQUES TO NOTE IN NRP 7TH EDITIONTwo-hand techniquewith jaw thrustUse PEEP when providing PPV topreterm infants

PPV STEPS CLARIFIED:ASSESS THE HR IN THE FIRST 15 SECONDS OF PPV

CHECK HR AFTER 15 SECONDS OF PPV

CHECK HR AFTER 15 SECONDS OF PPV

CHECK HR AFTER 15 SECONDS OF PPV

MR. SOPACorrective StepsActionsMMask adjustment.Reapply the mask. Consider the 2-hand technique.RReposition airway.Place head neutral or slightly extended.Try PPV and reassess chest movement.SSuction mouth and nose.Use a bulb syringe or suction catheter.OOpen mouth.Open the mouth and lift the jaw forward.Try PPV and reassess chest movement.PPressure increase.Increase pressure in 5 to 10 cm H2O increments, max 40 cm H2O.Try PPV and reassess chest movement.AAlternative AirwayPlace an endotracheal tube or laryngeal mask.Try PPV and assess chest movement and breath sounds.

ASSESS HR AFTER 30 SECONDS OFPPV THAT MOVES THE CHEST

INTUBATION Strongly recommendedbefore starting chestcompressions Estimate tip-to-lip distance– nasal-tragus length (NTL)or– initial ET tube insertion depthtable (in the textbook)

ENDOTRACHEAL TUBE SIZEWeight (g)Gestational Age(wks)ET Tube Size (mm)(internal diameter)Below 1,000Below 282.51,000-2,00028-343.0Greater than 2,000Greater than 343.5

CHEST COMPRESSIONS Use 2-thumb techniqueUse 100% oxygenHead-of-bed compressionsOne-and-2-and-3-and-breatheand . Cardiac monitor recommended Continue for 60 seconds priorto checking HR

MEDICATIONS Only 2 medications toremember– Epinephrine IV or IO preferred ET x 1 while achievingintravascular access– Normal saline or type-ORh-negative blood

ETHICS AND CARE AT THE END OFLIFE If responsible physicians believe that the baby hasno chance for survival, initiation of resuscitation isnot an ethical treatment option and should not beoffered– Birth a confirmed GA of 22 weeks gestation– Some severe congenital malformations andchromosomal anomalies– Caregivers should allow parents to participate in decisions whetherresuscitation is in their baby’s best interest Birth between 22 and 24 weeks’ gestationSome serious congenital and chromosomal anomalies

WHAT HAS NOT CHANGED? AAP requires renewalof Provider statusevery 2 years All learners maypractice all skills. NRPis not a certificationcourse. Recommendedinstructor to learnerratio at a Providercourse is 1: 3-4Ventilation of the lungs isthe single most importantand most effective step incardiopulmonaryresuscitation of thecompromised newborn.

NRP RESOURCES:HTTP://WWW2.AAP.ORG/NRPClick the 7th Ed Info tab for: 2015 AHA CPR and ECCU GuidelinesInformation eSim practice case and system requirements Communications archive Helpful infographics

TRANSITION7th Edition Instructor-Led Events May be taught now and recordedin new LMS Must be taught beginning January1, 2017The NRP 6th Edition May be taught through December31, 2016 Should be recorded in existingNRP Database.

WRAP-UP What questions do you have?

THANK YOU FOR JOINING!A recording and PPT slides will be sent out to allregistrants in a follow-up email from HealthStream.Contact Us: contact@healthstream.com

1. Foundations of Neonatal Resuscitation 2. Preparing for Resuscitation 3. Initial Steps of Newborn Care 4. Positive-pressure Ventilation 5. Alternative Airways 6. Chest Compressions 7. Medications 8. Post-resuscitation Care 9. Resuscitation and Stabilization of Babies Born Preterm 10. Special Considerations 11. Ethics and Care at the End of Life