Case based Discussions in NRP

Steven Ringer MD PhD
October 19 2012
I have no actual or potential conflict of interest in
relation to this presentation.
I am a member of the NRP Steering Committee
Changes in Practice
 Practice Gap 1
 Learning Objective 2
 - Resuscitation practice guidelines
 Understand the ILCOR process and how it
are based on review and compilation
of available evidence
 - Initial questions posed when
consulted for care at birth include GA,
respiratory effort and tone
 Good communication is a key
component of providing good care
resolves in most cases
results in recommendations for care
 Identify the critical areas for rapid and
effective communication, best allowign
adequate anticipation of needs
 Recognize that clear communication
between disciplines is a key behavioral skill
that must be fostered and facilitated
Two Changes you may wish to
make in your practice
 Facilitate team assessment and debriefing as part of
resuscitation to identify understanding of practice
guidelines, areas of good practice and those requiring
 Practice the use of oximetry guided oxygen use in
different clinical scenarios and refine practice through
the use of team based simulation and debriefing.
Changes in Practice
 Practice Gap 2
 Learning Objective 2
 - Clinical assessment of oxygenation is
 Understand the limitations of clinical
unreliable in the newly born
assessment in the newly born infant with
respect to color and oxygen
 -”Normal” oxygen levels are not
achieved until 5-10 minutes in healthy
term infants
 Use of oximetry allows better tailoring
of oxygen and minimizes over use
 Team structure and communication
results in enhanced care and better
adherence to practice guidelines
 Indentify the concept of target oxygen
saturation levels at each minute after birth,
and how they are used
 Understand the use of oximetry to guide
oxygen use, including correct placement of
monitoring probes, changes in oxygen
concentration in response to measured
 Describe the way team functioning
facilitates better care and the need to
identify and communicate roles within the
Neonatal Resuscitation Program- where do
Guidelines come from?
 Evidence relating to resuscitation is reviewed on a five
year cycle by ILCOR- International Liaison Committee
on Resuscitation
 The NRP Steering Committee participates in this
 ILCOR ultimately defines the scientific principles
behind resuscitation and develops treatment
Neonatal Resuscitation Program- where do
Guidelines come from?
 The Consensus on Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care Science with
Treatment Recommendations (CoSTR) published by
ILCOR in October 2010
 Each resuscitation council, including NRP for USA,
developed and published Resuscitation Guidelines and
treatment recommendations, appropriate for its own
resources (based on CoSTR)
 If evidence is lacking, treatment recommendations
stay the same, even if there is no evidence for them
Without specific evidence to
recommend a change, the
ruling on the field stands
Neonatal Resuscitation Program- where do
Guidelines come from?
 Guidelines are evidenced based- to the extent that
evidence is available!
 They are guidelines. As such, they can not fully
anticipate all the nuances of clinical situations.
 They do provide a framework that is well suited to
almost all resuscitation scenarios
 While the principles apply to most cases, in some
you must interpret the approach to best fit the
unusual patient
What NRP offers
 NRP is “an educational program that introduces
concepts and basic skills of neonatal resuscitation”
 NRP is not intended to set a strict “Standard of
 Completion of the program does not imply
competence – Each hospital has a responsibility to
determine competence and qualifications
 Not only are individual skills important, but
resuscitation requires a well functioning team
How do we learn and improve?
 Not by looking at and listening to a lecture and slides…
 Simulation and debriefing provide valuable insight
and learning not available by passive instruction
 Simulation also allows us to work through unusual
cases that don’t seem to exactly fit the mold
 On to cases…
 Major areas of change in 2010 Guidelines
 Topics that have caused questions to arise
 What is bothering you??
Case 1
 A 37 year old G2P1 female is in labor at 41 weeks. She
develops a fever to 101.2 and is treated with antibiotics
during labor. The membranes rupture spontaneously
and the fluid is noted to be meconium stained. Other
than some variable decelerations the fetal heart rate
tracing is unremarkable. The mother progresses to a
spontaneous vaginal delivery.
 What questions ought you to quickly ask at delivery?
 What questions should you ask at delivery?
 A. Is the baby term, is there meconium stained fluid, is
the baby vigorous?
 B. Is the baby breathing, Is the baby term, Is the tone
 C. Is there meconium stained fluid, is the baby term, is
the baby breathing?
Initial Questions
reduced to THREE:
Is the baby term?
Is the baby breathing?
Is the tone good?
Vigorous= normal,
regardless of AF
Oximetry is the
In its absence:
adequate ventilation is
more important than
higher FiO2
Case 2
 The baby, who is term, is crying and moving all his
extremities well.
 What should be the sequence of care?
 A. Suctioned by Obstetric provider at perineum,
evaluation at warmer by Pediatric team
 B. Suctioned at perineum if secretions copious, taken
to warmer, intubated, suctioned
 C. Suctioned at perineum if secretions copious, given
to mother
 Evidence indicates suctioning can cause bradycardia
during resuscitation, or pulmonary decompensation
and reduced cerebral blood flow in intubated patients
 Suctioning secretions can decrease pulmonary
 20o5 Guidelines stressed NO ROUTINE suctioning of
airway before delivery of the body
 True whether fluid is clear or meconium stained
Suctioning after birth
 If there is Clear Fluid: limit suctioning to those with
obvious obstruction
 Stop routine bulb suctioning of all babies
 If fluid is meconium stained, must determine if baby
is vigorous
 Vigor: Good HR, Good cry, Good tone
 If infant is vigorous, as this baby appears to be, they
do not need any special intervention
 Leave VIGOROUS babies with mother!
 Meconium: Suction non vigorous babies
 Depressed infants with MSF are at increased risk of MAS
 Tracheal suctioning has not been associated with
less MAS or mortality, other than single trial with
historical controls
 There is no evidence to change practice of intubating
and suctioning non vigorous babies
 Attempts should not significantly delay PPV if there
is bradycardia
Leave VIGOROUS babies with mother!
Case 1
 After two minutes with his mother, the baby has some
mild grunting and flaring and is brought to the
warmer. Your team evaluates him- he appears to be
term, well-formed but has some noticeable grunting.
One member of your team notes that he appears
cyanotic, and wants to give him blow by oxygen.
 How might you approach this, and why?
 A. Ask team member to place oximeter probe on leg,
give oxygen if saturation is less than 90%
 B. Ask team member to place oximeter on right upper
extremity, give oxygen if saturation is below target
 C. Give oxygen until baby turns pink in opinion of all
caregivers present
How pink is a fetus?
Dildy GA, et al. Am J Obstet Gynecol. 1994;171:679–684
What are Normal O2 saturations in Vigorous
Term Newborns in the DR?
 3 min
 5 min
 7 min
66% (56-75%)
80% (55-85%)
83% (68-88%)
 Lundstrøm et al Arch Dis Child 1995; 73:F81-6.
Post-ductal O2 sats in the DR
N=50 SVD, Term
Toth et al. Arch Gynecol Obstet 2002;266:105-7.
What are Normal Preductal O2 Sats in
Vigorous Term Newborns at Birth?
 1 min
 2 min
 3 min
 4 min
 5 min
63% (53-68%)
70% (58-78%)
76% (64-87%)
81% (71-91%)
90% (79-91%)
 Kamlin et al J Peds 2006; 148:585-9.
Pre ductal readings are the ideal
Take Home Message
 Majority of evidence suggests it takes ~5-10 minutes
for healthy, term newborns to reach O2 saturations
>90% (pink)
 Therefore, giving O2 to vigorous, term infants before 5-
10 minutes is unnecessary.
How often do you think this happens now when
pediatric team is present??
Is O2 in the Delivery Room better?
 We have increasing evidence that too much oxygen
is not harmless in other clinical situations
 Preemies:
 Chronic Lung Disease
 Retinopathy of Prematurity
 Newborns are relatively deficient in defense
mechanisms that protect against oxygen toxicity
and therefore too much oxygen may result in
oxygen free radicals that are highly reactive and
can cause damage to tissues
Consensus on Science for O2
 Meta-analysis of 7 human studies of infants resuscitated with
room air (RA) versus 100% O2 [LOE 1]
 Reduced Mortality
 No evidence of harm
 Other concentrations not studied
 However…
 The 4 largest studies were not blinded
 If no response after 90 sec, RA infants switched to 100% O2
 Other significant methodologic concerns regarding patient selection,
randomization methods, and follow-up
 No data regarding RA vs O2 for resuscitation of infants with
 birth weight < 1000 g
 congenital pulmonary or cyanotic heart disease
 Asystole
Is there a Potential for Harm?
 Naumburg et al. Supplementary oxygen and risk of
childhood lymphatic leukemia. Acta Paediatr
2002;91:1328-33. (Sweden)
 Prospective association between any oxygen exposure in the
DR and childhood acute lymphatic leukemia
2.5X the risk of ALL (1.21-6.82)
 > 3 minutes of O2 with BMV
3.54X the risk of ALL (1.16-10.8)
How do you do it: O2 For Initiation of
 Resuscitation should be focused on results (normally increasing
oxygen saturations) not on oxygen concentration.
 For term and late preterm infants it makes sense to begin in
RA and “wean-up” as dictated. There is no data on use of
intermediate concentrations.
 If resuscitation is started with less than 100% O2, supplemental
O2 up to 100% should be administered if there is no appreciable
improvement within 90 seconds following birth.
 If supplemental oxygen is unavailable, it is fine to use air while
delivering positive-pressure ventilation.
How do we assess the baby, or Why do we
Need Pulse Oximetry in the DR?
 NRP previously recommended using color to decide if
oxygen is needed. Now an Oximeter is recommended
 How good are we at judging color?
 O’Donnell et al. ADC 2007.
 Video Recording with Hi-fidelity color and simultaneous
SaO2 monitoring
 Do clinicians agree whether infants are pink?
 At what preductal SaO2 are infants first perceived as pink?
Clinical Assessment of Infant Color at
O’Donnell et al.. ADC 2007.
O2 Sat at Which Infant “Pink”
O’Donnell et al. ADC 2007.
Oximeter needed, but Can you get
it to work?
Kamlin et al J Peds 2006; 148:585-9.
Study of healthy term and preterm
infants- low cardiac output can
reduce signal
You can get it on, but it
takes TEAM work and
Preductal oxygen saturation targets
1 minute
2 minutes
3 minutes
4 minutes
5 minutes
10 minutes
 When is the use of oximetry indicated?
 A. Only for premature infants
 B. When using oxygen or PPV
 C. At all births attended by Pediatric team
The Practice: Term and Late
Preterm babies
 Monitor saturations, compare at interval times to
posted chart. Team monitoring works best.
 Adjust oxygen as needed to achieve target saturation
 Oximeter also often helpful to monitor pulse
 Oximetry often not usable when cardiac output is low.
 If saturation level is below target for age in minutes,
how much do you increase to amount of oxygen?
 A. 10%
 B. 20%
 C. 30%
 D. To 100%
Case 1
 The measured saturations are initially below the target
range for minute after birth. The oxygen level is
gradually increased until saturations are in target
 The baby stabilizes, and is able to wean out of
supplemental oxygen over 10 minutes.
Case 2
 A G3P2 woman presents at 27 weeks gestation with
recent onset of elevated blood pressures and an
evolving picture of rising liver enzymes and decreasing
platelet count. She is given a dose of betamethasone
and standard therapy for preeclampsia/HELLP
syndrome, but her condition worsens and she is taken
for Cesarean delivery about 2 hours after admission.
The baby emerges with fair tone and minimal
respiratory effort.
 What steps would you take next?
 A. Immediately give oxygen and stimulate
 B. Place in plastic wrap under warmer, ask team
member to place oximeter on RUE
 C. Place oximeter on RUE, stimulate
Temperature Control
 All newborns are at risk for hypothermia after birth:
 Relatively cool environment
 High surface area to volume
 Risk factor for morbidity and mortality
 Babies <1500 g are the population at risk:
 VON (2008) 51% had admission temperature to NICU
< 36.5 degrees C. ( Roughly the same in my own
Can hypothermia be prevented?
 Plastic Wrap
 The baby, undried, is immediately placed in plastic
wrap covering body and extremities
 Delivery Room Temperature 26 degrees
 Exothermic mattresses (Sodium Acetate Gel)
Occlusive Plastic Wrap
 Evaluated in many studies- systemic review done
 3 Randomized controlled trials
 5 historical controlled trials
 Gestational age < 28-33 weeks, < 1000g
 Original data was reviewed and analyzed
Admission Temperature
Cramer K, et al. J. Perinatol 2005:25; 763-69.
No differences in respiratory outcomes,
severe neurologic outcomes, or LOS.
OR Temperature & Plastic Wrap
Epoch 1- Standard OR temperatures
Epoch 2- Increased OR temperature to 26 degrees
Epoch 3- Occlusive Plastic wrap used
Kent AL, Williams J . J Pediatr Child Health 2008:44:325-331
OR Temperature & Plastic Wrap
No difference in survival,
days of ventilation, days of
oxygen, NEC, severe IVH or
Plastic Wrap and Exothermic Mattress
 Analysis of three case series:
 Traditional care (drying and wrapping in towel)
 Wrapping in standard food polyethylene bag
 Wrapping in food bag, nursing on exothermic mattress
 Retrospective observational study, three different time
periods, <30 weeks gestation
Singh A, et al. J Perinatol 2010:30:45-49
Plastic Wrap and Exothermic Mattress
Plastic Wrap and Exothermic Mattress
 Hypothermia least frequent in “bag/mattress” group
(26%) vs. “bag” (69%) or traditional care(84%)
 Mean increase of 1.04 degrees
The evidence has mounted
 In 2005 thermal wraps were a suggested intervention
 Now, these interventions are RECOMMENDED
 BUT, aren’t they a big pain to use??
 We have used them effectively without complaints or
 Requires
team work and clear identification of
roles: “Choreography” learned through simulation
Case 2
The baby is placed in plastic wrap and an oximeter is
placed on RUE. Because the baby has minimal
respiratory effort , Positive pressure ventilation is
begun using a bag and mask?
 With what concentration of oxygen would you start?
 A. Room air, like term baby
 B. 40%
 C. 60%
 D. 100 %
Premature babies are different
 Neither Room Air or 100% oxygen are optimal
 Something in between is just right.
Resuscitation of ELBWs with 90% vs 30%
Escrig et al. Pediatrics 2008; 121;875-881
Resuscitation of premature infants with
100% oxygen or Room Air
Wang et al. Pediatrics 2008; 121: 1083-1089
Use of Oxygen During Resuscitation in Preterm
 To provide adequate, but avoid excessive tissue
oxygenation in very preterm baby (less than
~32 weeks) during resuscitation at birth:
 Use an O2 blender and pulse oximeter
during resuscitation.
 Begin PPV or “blow-by” O2 with some
concentration between room air and 100%,
but not either extreme.
 No studies justify starting at any particular
concentration. Why is 60% a reasonable
starting point?
 Adjust O2 concentration up or down to
achieve an O2 saturation that gradually
increases toward 90%, in a pattern like that
of term babies.
 Decrease O2 as saturations rise over 9395%.
Term oxygen saturation targets
1 minute
2 minutes
3 minutes
4 minutes
5 minutes
10 minutes
Use of Oxygen During Resuscitation of Preterm
 If the heart rate does not respond by increasing rapidly to >
100 beats per minute, correct any ventilation problem and
use 100% oxygen.
 If an oxygen blender and pulse oximeter is not available in
the delivery room the resources and oxygen management
described for a term baby are appropriate.
 There is no convincing evidence that a brief period of 100%
oxygen during resuscitation will be detrimental to the
preterm infant.
 For this 27 week gestation infant who has spontaneous
breaths and respiratory distress, what is your preferred
initial method of respiratory support?
 A. CPAP +5
 B. CPAP +8
 C. Intubation and positive pressure ventilation
 In your institution, you have adopted a practice of
delayed cord clamping for 45 seconds after the baby is
 When would you assign the first Apgar Score?
A. One minute after the baby itself is delivered
B. One minute after the cord is clamped and cut
C. One minute after cord pulsations stop
Case 3
 A 38 year old female with gestational diabetes presents
in spontaneous labor at 37 weeks gestation. During
monitoring, the fetal heart rate pattern becomes nonreassuring, a Category 3 tracing. The mother is taken
for emergency Cesarean section. The baby emerges
limp and pale with no discernable respiratory effort.
The amniotic fluid is clear. A quick assessment of the
heart rate reveals it to be 50 beats per minute.
ARQ 10
 What step do you take next?
 A. Immediately begin chest compressions at
90/minute, with blow by oxygen
 B. Begin positive pressure ventilation with 40 bpm,
sufficient to move chest. Ask a team member to place
oximeter probe on RUE
 C. Place oximeter, begin chest compressions
immediately at 90/minute, begin positive pressure
Etiology of bradycardia right
after birth
 Essentially always a respiratory event at its basis (or
respiratory depression secondary to CNS depression)
 The immediate first step is to begin assisted
ventilation with pressures adequate to move the baby’s
 Initially paying attention to heart rate only distracts
you from the first responsibility- to ensure adequate
 The heart rate most often will increase within about 30
seconds of effective ventilation
ARQ 11
 When would you recheck the heart rate after starting
 A. Right away
 B. 30 seconds
 C. 45-60 seconds
Case 3
 After about 30 seconds of PPV with good chest
movement, a team member rechecks the heart rate. It
is 40 bpm.
Note that for an apneic baby like this, two people are
needed almost immediately after birth
 You ask the team member to beign chest compressions
at 90/minute, while you continue ventilation at
30 bpm
ARQ 12
 When would you want the heart rate checked again?
A. Right away
B. After 30 seconds
C. After 45-60 seconds
Checking the heart rate
 Usually, it makes sense to check the heart rate and
status every 30 seconds
 While doing chest compressions, studies hav eshown
that the critical diastolic blood pressure necessary for
coronary perfusion drops very quickly when
compressions are interrupted
 Therefore, during chest compressions, a longer
checking interval of 45-60 seconds is recommended
ARQ 13
 What method(s) may be used for chest compressions?
 A. Two thumbs from base of bed
 B. Two fingers perpendicular to sternum
 C. Two thumbs from head of bed**
 D. Any of these**
ARQ 14
 If ventilation does not result in an increase in heart
rate, what interventions should you attempt?
 Are you familiar with MR. SOPA or MRS. OPA?
 A. Yes
 B. No
 M R S-
 A-
Case 4- ARQ 15
 A 6 day old who has remained in the hospital while his
mother recovers from an apparent infection is found to
be apneic and bradycardic in the Newborn Nursery.
 Which approach to resuscitation makes sense for this
 A. NRP
 For this baby, the apparent etiology of the event is
respiratory, which mirrors the common situations that
occur at birth. It makes sense to apply the NRP
 “It’s not the age, it’s the etiology!!”
Perplexing, confusing or
 What questions do you have?

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