NRP 2006

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NRP 2006

• Patti Murphy MD FRCPC
• Department of Anesthesiology University of Ottawa
• February 14th, 2007

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NRP

• Intended for practitioners responsible for
  resuscitation of neonates
• Primarily for neonates undergoing transition from
  intra to extra-uterine life
• Also applies to newborns within first few weeks
  to months following birth

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Why do we need to know this?
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NRP 2006

• ILCOR process
• Overview / Review
• Initial steps
• Airway management
• Ventilation
• Oxygen
• Medications
• Ottawa Hospital Civic Campus

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ILCOR Consensus Process
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The ILCOR Consensus Process

• Step 1 State the Proposal
• a. Refine the research question(s)
• b. Gather the evidence
• Step 2 Assess the Quality of Each Study
• a. Determine the level of evidence (levels
  1-8)
• b. Critically assess each article for quality
  of design methods
• c. Determine the direction of the
  results/statistics
• d. Cross-tabulate by level, quality and
  direction combine summarize

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The ILCOR Consensus ProcessStep 3 Determine the
Class of Recommendation
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ILCOR Neonatal Delegation

• Heart and Stroke Foundation of Canada (HSFC)
• Australian Resuscitation Council (ARC)
• Council of Latin America for Resuscitation (CLAR)
• Dutch Resuscitation Council (DRC)
• European Resuscitation Council (ERC)
• New Zealand Resuscitation Council
• Resuscitation Council of South America (RCSA)
• World Health Organization (WHO)
• American Academy of Pediatrics / American Heart
  Association NRP Steering Committee

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The Canadian Expert Committee

• Based on ILCOR consensus
• Each country is expected to develop their own
  guidelines

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Overview
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Initial Steps
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Is resuscitation needed?
NRP 2006
NRP 2000
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Oxygen Saturation After Birth
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Rabi, 2006
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Routine Care
NRP 2006
What if this well baby baby remains cyanotic gt
90 sec?
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Canadian Expert Committee

• Oxygen should be administered to babies who
  remain cyanotic at 90 seconds of age

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The initial steps
2000
2006
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The initial steps
no oxygen given
Exception to dry the baby
2006
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Dry-exposed Resuscitation
Gestational Age gt 28w
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Wet-in-bag Resuscitation
Gestational Age lt 28w
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Wet-in-bag Resuscitation

• 88 infants
• Infants placed in the polyurethane bags were less
  likely to have a temp lt36.40C on admission
• 44 vs. 70 (plt0.001)
• Better if room at 25-26oC

Gestational Age 28w
Knobel et al. Heat loss prevention for preterm
infants in the delivery room. J Perinat
200525304-308
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Wet-in-bag Resuscitation

• Canadian Pediatric Society
• Maintenance of DR at 25 to 26oC will diminish
  heat loss
• If GA lt 28w, below the neck in a polyethylene bag
• All babies (term/preterm) under radiant warmer by
  10 min should have servo-control probe

Gestational Age lt 28w
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Resuscitation when meconium present
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The Apgar Score
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Airway
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Canadian Expert Committee

• Every baby that is intubated (other than for the
  suction of meconium) should have tracheal tube
  placement confirmed by an exhaled CO2 detector
• CO2 detectors should be used as the primary
  method for confirming endotracheal tube placement

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Exhaled CO2 detector

• Indicates placement if the trachea within 2 to 4
  breaths.
• May not turn color when cardiac output or
  pulmonary circulation are minimal
• Will not work if wet, or contaminated with drugs
  such as epinephrine.

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Caution

• No randomized, controlled trials on the use of
  the LMA during neonatal resuscitation.
• Cannot be considered a substitute for the
  tracheal tube
• Easier than intubation
• Further studies are necessary

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Ventilation
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Initial Ventilation - Term

• An initial ventilation pressure of 20 cm H2O may
  be effective (ILCOR).
• gt30-40 cm H2O may be necessary in some term
  babies (ILCOR).

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Initial Ventilation - Preterm

• Avoid creation of excessive chest wall movement
  (ILCOR 2005)
• Use lowest pressures necessary to achieve a
  response
• An initial inflation pressure of 20-25 cm H2O is
  adequate for most preterm infants (ILCOR 2005).
• Consider surfactant if lt 30 weeks gestation

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Positive End-Expiratory Pressure

• If ongoing positive pressure ventilation is
  required, PEEP of 3-6 cm of water should be used
  (Canadian NRP 2006).
• PEEP may be given with
• a flow-inflating bag
• T-piece resuscitator
• A self-inflating bag with a PEEP valve (Canadian
  NRP 2006).
• Self-inflating bags without a PEEP valve cannot
  provide CPAP

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NRP The T-Piece Resuscitator
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NRP The T-Piece Resuscitator
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Oxygen
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Organ Site Of Free Oxygen Radical Damage

• Lungs
• Eyes
• Brain
• Gastrointestinal Tract
• Kidneys
• Other

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• What is the evidence to support
• room air over 100 oxygen
• for newborn resuscitation?

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Lambs Breathing 100 O2Bressack 1979
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• Five clinical studies including 1737 newborn
  infants in need of resuscitation have been
  published in which the resuscitation groups were
  randomized to 21 or 100 O2
• Pure oxygen
• Significantly delayed the first breath
• Time to establish normal regular breathing
  delayed
• Duration of resuscitation was also significantly
  prolonged
• Saugstad Pediatrics 1998102(1)e1-7.  
• Vento Biol Neonate 200179261-7.  
• Vento M, J Pediatr 2003142242-8
• Ramji Indian Pediatr 200340510-7
• Ramji Pediatr Res 199334809-12

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Mortality with Oxygen or Air for Resuscitation-
Saugstad, 2005
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Problems with studies

• Limited number of studies/babies
• Majority in developing countries
• High mortality rates
• Variable/imprecise criteria for resuscitation
• Crossover between groups
• Failure to blind
• Design to show equivalence

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• Association between oxygen exposure at birth and
  later childhood lymphatic leukemia. In their
  study, a brief oxygen exposure of 3 to 10 minutes
  was associated with a significant augmented odds
  ratio of 3.5 for developing leukemia.
• Naumburg EActa Paediatr 2002911328-33

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Is there Opposing Evidence?

• No human studies
• Newborn piglets resuscitated with air (Solas)
• - Increased CNS amino acids (eg.glutamate)
• - Lower mean BP CNS microcirculation
• Others show no difference in animal studies

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Canadian Recommendations

• PPV should be initiated with 21 O2
• Supplemental O2 should be used if the baby is
  cyanotic or HRlt100 at 90 seconds of age
• Blended gases should be available
• Pulse oximetry should be available for babies lt
  33 weeks
• It seems reasonable to avoid SPO2 . 95

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American NRP Guidelines 2006

• Use 100 oxygen when a baby is cyanotic or when
  positive-pressure ventilation is required
• Research suggests that resuscitation with less
  than 100 may be just as successful.
• For preterm babies, begin PPV with oxygen
  concentration between room air and 100 oxygen.
  No studies justify starting at any particular
  concentration.

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Managing oxygen in the premature infant

• Options until blended gases are common practice
  for neonatal care
• self-inflating bags 21, 40, or gt80 oxygen
• mixing air (piped or cylinder) with 100 oxygen
  using air and oxygen flow-meters and Y-connector
• purchasing at least one blender to be used for
  high-risk deliveries

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Medication
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NRP 2006 Algorithm
With skillful and timely implementation of
resuscitation steps, 99 of newborns will improve
without the need for medications
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Epinephrine
!

• If the heart rate remains below 60 bpm, despite
  administration of ventilation and chest
  compressions, your first action is to ensure that
  ventilation and chest compressions are being
  given optimally and that you are using 100
  oxygen

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Science?

• Studies on Epinephrine in newborns are sorely
  lacking
• Current practices based on history and/or
  extrapolation from adult and animal studies

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• Data in children shows no benefit to high dose
  therapy
• Peroni 2004 worse outcomes in paediatric
  population with high dose epinephrine
• No data specific to neonatal population
• Insufficient data to support routine use of
  High-dose epinephrine
• Class Indeterminate

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Endotracheal Epinephrine

• No randomized trials using endotracheal
  epinephrine
• One neonatal cohort study and one case series
  showed benefit at 10X the dose
• Most animal trials that showed any positive
  effect used 5 10 times the currently recommended
  IV dose
• One neonatal model trial using the currently
  recommended dose showed no benefit

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Endotracheal Epinephrine

• If endotracheal route is used, a dose up to 10X
  the current IV dose should be used
• Class indeterminate
• IV route should be used as soon as venous access
  is established
• Endotracheal epinephrine must not interfere with
  the establishment of good quality ventilation
  not effective in any dose without ventilation

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Epinephrine Administration
AAP
Canadian Addendum
Concentration 110,000 Preferred route is IV
but give first dose endotracheally while IV is
obtained. Dose IV 0.1 ml/kg Dose Endotracheal
1.0 ml/kg Administration Rate rapidly
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Medication Given No Improvement
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Signs of Hypovolemia

• Pallor persisting beyond oxygenation
• Weak pulses
• Low blood pressure
• Lack of response to resuscitation
• Hypovolemia is a common but often unrecognized
  cause of need for resuscitation

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Hypovolemia

• Overt bleeding
• Placenta previa
• Vaso previa, cord avulsion
• Abruption
• Occult blood loss
• Feto-maternal hemorrhage
• Feto-fetal hemorrhage
• Feto-placental hemorrhage (e.g. nuchal cord)

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Volume Expansion

• Indicated when there is no response to
  resuscitation and there is evidence of blood loss
  or hypovolemia
• Repeated doses may be necessary if there is
  minimal response after the first dose
• Umbilical vein remains preferred route but
  intra-osseous acceptable (class IIb)

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Volume Expanders

• Isotonic crystalloid is the preferred solution
  for volume expansion in neonatal resuscitation
• Class IIa recommendation
• O-negative blood used for large volume blood loss

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Volume Expanders

• Dose and Rate
• 10 ml /kg slow IV push
• Rapid administration may result in intracranial
  hemorrhage, particularly in preterm infants .
• Infusion rate over 5 10 minutes (no clinical
  trials have been conducted to define an optimal
  rate)

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Naloxone

• No studies examining the recommended dose of
  0.1mg/kg in any clinical situation in newborns.
• Endotracheal route has been evaluated in adults
  but no evidence for the use of this route in
  newborns.
• Not necessary during the acute phase of
  resuscitation VENTILATE!

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Naloxone

• Indications for use
• Continued respiratory depression after PPV has
  restored a normal heart rate and colour
• AND
• History of maternal narcotic administration in
  the 4 hours prior to birth
• Contraindicated in presence of maternal narcotic
  dependence
• Class Indeterminate recommendation

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Sodium Bicarbonate

• Discouraged during brief CPR
• May be useful during prolonged arrests AFTER
  adequate ventilation is established and there is
  no response to other therapies
• Class II b recommendation

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Sodium Bicarbonate

• Known and potential side effects
• Rapid infusion may reduce myocardial function
• Bicarbonate increases extra cellular pH, but
  intracellular pH may remain unchanged
• Decreased cerebral blood flow described in
  infants post bicarbonate infusion
• Risk of IVH in preterm infants

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IF NO IMPROVEMENT
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New Equipment- NRP 2006

• Blended oxygen
• Pulse oximeter
• Ventilation with PEEP
• Laryngeal mask airway
• CO2 detector
• Servo-control probe
• Plastic baggies
• Room temperature

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Ottawa Hospital Civic Campus

• Birthing Unit
• Self-inflating bags
• No piped air in the rooms, only O2
• Resuscitation room
• Flow inflating bags
• Birthing Rooms
• Air presently available
• CO2 detectors available
• LMAs available
• lt32 weeks gestation at General Campus

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O2 at TOH

• Infants gt 34 weeks begin with room air if
  cyanotic or need PPV
• If no appreciable improvement within 90 seconds,
  with at least 30 seconds of effective
  ventilation, provide 100
• For infants lt 34 weeks begin with 40 oxygen,
  adjust O2 concentration up or down to achieve
  saturation 88 90
• If heart rate does not respond by increasing to
  gt100/min, use 100 oxygen