NRP 2006 - PowerPoint PPT Presentation

Loading...

PPT – NRP 2006 PowerPoint presentation | free to view - id: 10fad0-MWRiZ



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

NRP 2006

Description:

Resuscitation when meconium present. The Apgar Score. Airway. Canadian Expert Committee ... for the suction of meconium) should have tracheal tube placement ... – PowerPoint PPT presentation

Number of Views:407
Avg rating:3.0/5.0
Slides: 74
Provided by: pattimurp
Category:
Tags: nrp | meconium

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: NRP 2006


1
NRP 2006
  • Patti Murphy MD FRCPC
  • Department of Anesthesiology University of Ottawa
  • February 14th, 2007

2
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

3
Why do we need to know this?
4
NRP 2006
  • ILCOR process
  • Overview / Review
  • Initial steps
  • Airway management
  • Ventilation
  • Oxygen
  • Medications
  • Ottawa Hospital Civic Campus

5
ILCOR Consensus Process
6

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

7
The ILCOR Consensus Process Step 3 Determine the
Class of Recommendation
8
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

9
The Canadian Expert Committee
  • Based on ILCOR consensus
  • Each country is expected to develop their own
    guidelines

10
Overview
11
(No Transcript)
12
Initial Steps
13
Is resuscitation needed?
NRP 2006
NRP 2000
14
Oxygen Saturation After Birth
15
Rabi, 2006
16
Routine Care
NRP 2006
What if this well baby baby remains cyanotic gt
90 sec?
17
Canadian Expert Committee
  • Oxygen should be administered to babies who
    remain cyanotic at 90 seconds of age

18
The initial steps
2000
2006
19
The initial steps
… no oxygen given
Exception to dry the baby
2006
20
Dry-exposed Resuscitation
Gestational Age gt 28w
21
Wet-in-bag Resuscitation
Gestational Age lt 28w
22
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
23
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
24
Resuscitation when meconium present
25
The Apgar Score
26
Airway
27
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

28
(No Transcript)
29
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.

30
(No Transcript)
31
(No Transcript)
32
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

33
Ventilation
34
(No Transcript)
35
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).

36
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

37
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

38
NRP The T-Piece Resuscitator
39
NRP The T-Piece Resuscitator
40
Oxygen
41
Organ Site Of Free Oxygen Radical Damage
  • Lungs
  • Eyes
  • Brain
  • Gastrointestinal Tract
  • Kidneys
  • Other

42
  • What is the evidence to support
  • room air over 100 oxygen
  • for newborn resuscitation?

43
Lambs Breathing 100 O2 Bressack 1979
44
  • 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

45
Mortality with Oxygen or Air for Resuscitation-
Saugstad, 2005
46
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

47
  • 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

48
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

49
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

50
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.

51
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

52
Medication
53
NRP 2006 Algorithm
With skillful and timely implementation of
resuscitation steps, 99 of newborns will improve
without the need for medications
54
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

55
Science?
  • Studies on Epinephrine in newborns are sorely
    lacking
  • Current practices based on history and/or
    extrapolation from adult and animal studies

56
  • 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

57
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

58
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

59
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
60
Medication Given No Improvement
61
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

62
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)

63
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)

64
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

65
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)

66
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!

67
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

68
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

69
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

70
IF NO IMPROVEMENT …
71
New Equipment- NRP 2006
  • Blended oxygen
  • Pulse oximeter
  • Ventilation with PEEP
  • Laryngeal mask airway
  • CO2 detector
  • Servo-control probe
  • Plastic baggies
  • Room temperature

72
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

73
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
About PowerShow.com