Introduction

Introduction – In this course, we will go over neonatal resuscitation protocol (NRP) as determined by the American Heart Association (AHA) and American Academy of Pediatrics (AAP) for managing cardiopulmonary resuscitation and cardiac emergencies in the neonate.

Neonatal Resuscitation Foundations

Neonatal Resuscitation Foundations – NRP provides a framework to determine the knowledge, procedures and teamwork that will ensure the health or neonates in distress.

How are Neonates Different form Adults in Terms of Resuscitation? – The cause of cardiac emergencies differ between adults and neonates. In the former, the cause is often underlying heart disease or trauma.

Physiology and Changes of Birth – Neonatal caregivers must be aware of the physiological changes that occur at birth in order to ensure the best possible care for their patients.

NRP Algorithm – The NRP algorithm provides the structure to guide your treatment of the neonate in distress.

Effective Team Building for NRP – Team building is vital to NRP. Poor communication and lack of teamwork is the most common and preventable cause of neonatal death in an emergency.

Neonatal Resuscitation Preparations

Neonatal Resuscitation Preparations – Risk factors that predispose to neonatal resuscitation, assembling a team, four pertinent questions to ask the obstetrician, performing briefing before NRP, checking NRP equipment and supplies

Risk Factors that Predispose to Neonatal Resuscitation – Some neonates may have several risk factors that increase the likelihood of resuscitation.

Why Should You Always Assess the Need for NRP in Every Birth? – Any neonate may require resuscitation. However, it is useful to be aware of the risk factors that increase this likelihood.

Four Pertinent Questions to Ask the Obstetrician – A birth is a coordination between the obstetrics team and the neonatal team.

Assembling a Resuscitation Team – While not every birth may require an entire NRP team in attendance, every single birth should have at least one individual who is responsible for the neonate’s management.

Performing Briefing before NRP – The NRP should always complete a briefing before the birth.

Checking NRP Equipment and Supplies – For every birth, all NRP equipment and supplies should be easily available.

Common questions – How many team members should we have? How can we choose a team leader?

Points to Remember – The four questions the NRP team should always ask are: What is the gestational age?; Is there clear amniotic fluid?; What is the number of fetuses?; and Are there any other risks?

Neonatal Resuscitation: First Steps

Neonatal Resuscitation: First Steps – Having a good sense of the neonate’s prenatal and birth history are vital for providing the first steps of NRP.

Birth Time and Umbilical Cord Clamping – When the neonate is born, the placenta still has significant amount of blood and often continues with gas exchange as long as maternal blood flow continues and the umbilical cord is not clamped.

Performing a Rapid Neonatal Assessment – Immediately following birth, all neonates will need to be rapidly assessed to determine if they are well enough to stay with their mother or if more assessment under a radiant warmer is prudent.

The First Steps in Neonatal Care – The first steps for caring for a neonate are providing warmth, ensuring the airway is clear and open and providing stimulation.

Determining if Additional Steps are Needed – During the first steps of neonatal care, it is vital to assess the response.

Managing Cyanosis – Sometimes there are abnormalities even though the baby is breathing and is not bradycardic.

Using and Interpreting Pulse Oximetry – The pulse oximeter is a useful tool for determining oxygen saturation as it takes advantage of the difference in light absorption between oxygenated and deoxygenated hemoglobin in red blood cells.

Providing Supplemental Oxygen – Use supplemental oxygen if the pulse oximeter reading is below the normal range for the neonate.

Managing Amniotic Fluid Stained with Meconium – Meconium in the amniotic fluid indicates a distressed fetus and makes subsequent resuscitation more likely.

Common Questions – Must all neonates be suctioned?

Points to Remember – Clamp the umbilical cord between 30-60 seconds for healthy neonates who do not require resuscitation.

Positive Pressure Ventilation (PPV)

Positive Pressure Ventilation (PPV) – Understand self-inflating, flow-inflating and T-piece resuscitators

Defining PPV – The primary focus of NRP should always be to ensure adequate pulmonary ventilation in the neonate.

Understand Self-inflating, Flow-inflating and T-piece Resuscitators – There are three common devices uses for NRP ventilation.

When to use PPV – PPV is the next step if there is still abnormal respirations or heart rate after the first steps are completed.

Setting up PPV – There are several steps to setting up PPV.

Providing PPV – There are certain steps to providing excellent PPV.

Assessing Response to PPV – The most significant assessment of PPV is the heart rate response.

When to Provide CPAP – CPAP is used in the spontaneously breathing neonate who has laborious breathing or has low oxygen saturation.

Using Orogastric tube – Orogastric tubes can help decrease over-inflation of the stomach to improve ventilation.

Common Questions – Is the carbon dioxide detector effective for assessing ventilation? What are the pros and cons of the different PPV devices? Which devices can you use to give free flow oxygen? Can you use 100% oxygen for every resuscitation effort?

Points to Remember – Start PPV if the heart rate is under 100 bpm, apnea or gasping is present or the oxygen saturation is abnormal despite the use of CPAP or supplemental oxygen.

Advanced Airway – Endotracheal Tube (ETT) & Laryngeal Mask Airway (LMA)

Advanced Airway – Endotracheal Tube (ETT) & Laryngeal Mask Airway (LMA) – There are two main advanced airways that can be used in a neonate who fails non-invasive management.

When to Use an Advanced Airway – Consider an Advanced Airway if PPV using a non-invasive device does not result in effective breathing or increased heart rate.

How to Set up for ETT Insertion – To be effective at inserting an ETT, caregivers should know the airway anatomy and the tools required for success.

Inserting and Assessing Placement of ETT – ETT tubes for neonatal resuscitation should be uniform in diameter and often have markings to measure distance from the tube tip.

ETT for Tracheal Suction – If a neonate has thick secretions that are obstructing the trachea and making ventilation difficult, tracheal suctioning may be necessary.

When to Use an LMA – The LMA is a supraglottic advanced airway that is often used if PPV is ineffective or ETT insertion is unsuccessful.

How to Insert and Use an LMA – Inserting the LMA is a clean, not sterile procedure, which follows standard precautions.

Common Questions – Should the ETT be placed before beginning chest compressions? Can the provider with intubation skills be on home call?

Points to Remember – An advanced airway may be placed if PPV using a non-invasive device does not result in effective breathing or increased heart rate or if PPV is required for several minutes to improve its efficacy.

Chest Compressions

Chest Compressions – If the neonate does not appropriately respond following intubation, then he likely has very poor oxygen saturation, severe acidosis and poor blood flow to the coronary vessels.

When to Start Chest Compressions – Begin chest compressions if the heart rate is below 60 bpm after effective PPV (with chest rise) has been ongoing for 30 seconds.

How to Provide Chest Compression – The caregiver providing chest compressions should move to the neonate’s head after the advanced airway is secured.

Coordinating Chest Compressions and PPV – To coordinate chest compression and PPV, provide 3 compressions and one breath every two seconds. It is useful to count compressions aloud to coordinate the breaths.

When to End Chest Compressions – End chest compressions when the heart rate is above 60bpm.

Common Questions – What are complications of chest compressions? Why does NRP follow A-B-C rather than C-A-B? Why is a 3:1 compression to breath ratio used in NRP?

Points to Remember – Chest compressions should be started if the heart rate is under 60 bpm after 30 seconds of PPV. Often an advanced airway would be in place at this point.

Medicines and Fluid

Medicines and Fluid – It is the rare neonate that will require resuscitation medications.

When to Administer Epinephrine – Epinephrine is a vasopressor medicine that increases heart rate and vascular constriction outside of the heart.

How to Administer Epinephrine – Use the 1:10,000 (0.1mg/mL) concentration of epinephrine for NRP.

When to Administer Fluid Resuscitation – Fluid resuscitation is indicated if there is a concern for hypovolemia and the neonate has not responded to the previous steps of the NRP algorithm.

How to Administer Fluid Resuscitation – There are two common options for fluid resuscitation in the neonate.

Managing a Neonate Who Is Not Improving with Epinephrine or Fluid Resuscitation – During administration of epinephrine and fluid resuscitation, the NRP team should continue effective chest compressions and ventilations.

Common Questions – What does 1:10,000 concentration mean? Why is IV access preferred to ETT? Do you aspirate the IO needle?

Points to Remember – Epinephrine is a vasopressor medicine that increases the fore and frequency of heart contractions as well as the blood flow to the heart.

After Resuscitation

After Resuscitation – Care after resuscitation, concerns after resuscitation, treatment plan after resuscitation, therapeutic hypothermia after resuscitation.

Care after Resuscitation – All neonates regardless of whether or not they require resuscitation will need to complete the transition from fetal to neonatal life.

Routine Management – The vast majority of neonates (90%) will need only routine management.

After Resuscitation Management – Any neonate who required NRP management will need even more observation.

Medical Concerns Following Resuscitation – There may be multiple medical concerns following resuscitation both from the initial causes of respiratory distress and resuscitation management.

Therapeutic Hypothermia after Resuscitation – Avoiding hyperthermia is recommended in neonates as this increasing survival and neurologic function, especially in neonates with HIE.

Common Questions – Must after resuscitation care take place in the NICU or nursery? Is sodium bicarbonate recommended for metabolic acidosis after neonatal resuscitation?

Points to Remember – After resuscitation, the neonate must be closely observed with frequent evaluation of vital signs, electrolytes, glucose, neurological status and urine output.

Managing Preterm Neonates in NRP

Managing Preterm Neonates in NRP – Risks of preterm neonates

Risks of Preterm Neonates – Neonates born before maturity have additional obstacles to face as they are not fully prepared for life outside the uterus.

Resources to Manage Preterm Neonates – Preterm status is itself a risk factor for resuscitation, even in the late preterm neonates between 34-36 weeks gestation.

Managing Preterm Thermal Regulation – Preterm neonates are less likely to effectively regulate their temperature, increasing the risk of hypothermia (core temperature less than 36.5oC).

Managing Ventilation in the Preterm Neonate – Preterm neonates have immature lungs that put them at risk for respiratory distress and damage from external ventilation.

Oxygen Use in Preterm Neonates – While hypoxia is best avoided, in all neonates, excessive use of oxygen after good perfusion is restored can cause unwanted problems.

Reducing Complications in Preterm Neonates – Preterm neonates are at risk for multiple complications. The neonate that is born before he is ready to survive outside the uterus requires special considerations.

Managing Parental Expectation for the Preterm Neonate – It is quite helpful to meet with the parents before the birth of a very preterm neonate.

Common Questions – Should you delay clamping the cord in preterm neonates?

Points to Remember – Preterm neonate are increased risk both for requiring resuscitation and having complications from resuscitation.

Specific Treatments

Specific Treatments – Managing pneumothorax and pleural effusions

Managing Pneumothorax and Pleural Effusions – Air or fluid around the neonate’s lung can lead to respiratory distress as the lung is not able to fully expand.

Managing Obstruction of the Airway – Airway obstruction can cause respiratory distress and must be relieved at once. Causes of obstruction include secretions, congenital anomalies.

Managing Congenital Lung Anomalies – Several conditions conditions affecting the lung can cause respiratory distress in the neonate.

Managing Narcotic Exposure – Maternal exposure to narcotics can impair respiratory drive in the neonate.

Managing Resuscitation Outside the Hospital or After the Immediate Neonatal Period – Sometimes neonate develop respiratory distress outside the hospital or after the immediate neonatal period.

Points to Remember – A pneumothorax is likely if the neonates worsens following appropriate ventilation or suddenly develops respiratory distress.

NRP Certification Exam

NRP Certification Exam – The NRP Certification Exam requires a passing score of 80%.