NRP & STABLE NRP & STABLE UPDATESUPDATES

Lori Fairfax, APRN-Rx & Lori Fairfax, APRN-Rx & Jaymie H. Pinho, APRN-RxJaymie H. Pinho, APRN-Rx

NRP Initial StepsNRP Initial Steps

Position infant, suction the mouth Position infant, suction the mouth then the nose PRN if secretions then the nose PRN if secretions visiblevisible

Dry the infant off & remove wet Dry the infant off & remove wet blanketsblankets

Stimulate the infant by rubbing back Stimulate the infant by rubbing back or flicking soles of feetor flicking soles of feet

Begin PPV if infant apneic or gaspingBegin PPV if infant apneic or gasping

Initial Steps con’tInitial Steps con’t

Check heart rate by listening with a Check heart rate by listening with a stethoscope or palpating umbilical stethoscope or palpating umbilical cord (tap out HR for all to see)cord (tap out HR for all to see)

Assess O2 sat- provide O2 blow-by Assess O2 sat- provide O2 blow-by (8LPM starting with FIO2 @ 40%) if (8LPM starting with FIO2 @ 40%) if infant remains cyanoticinfant remains cyanotic

For premature infantFor premature infant If HR > 100 but distress noted, give If HR > 100 but distress noted, give

CPAP of 5-6 cm (PEEP) with bag & CPAP of 5-6 cm (PEEP) with bag & maskmask

Target SpO2 valuesTarget SpO2 values

1 min1 min 60-65 %60-65 %

2 min2 min 65-70 %65-70 %

3 min3 min 70-75 %70-75 %

4 min4 min 75-80 %75-80 %

5 min5 min 80-85 %80-85 %

10 min10 min 85-95 %85-95 %

Key PointsKey Points

Ventilation is the key to newborn Ventilation is the key to newborn resuscitationresuscitation

Increasing HR is a signal that Increasing HR is a signal that resuscitation efforts are effectiveresuscitation efforts are effective

If mom is on a MgSO4 gtt, infant If mom is on a MgSO4 gtt, infant likely to have decreased likely to have decreased respiratory effort & will require PPVrespiratory effort & will require PPV

ABC’sABC’s

RemindersReminders

Infant < 28 weeks, use 2.5 ETTInfant < 28 weeks, use 2.5 ETT weight: <1000 gmsweight: <1000 gms Infant 28-34 weeks, use 3.0 ETTInfant 28-34 weeks, use 3.0 ETT weight: 1000-2000 gmsweight: 1000-2000 gms Infant 34-38 weeks, use 3.5 ETTInfant 34-38 weeks, use 3.5 ETT weight: 2000-3000 gmsweight: 2000-3000 gms Infant >38 weeks use, 4.0 ETTInfant >38 weeks use, 4.0 ETT weight: >3000 gmsweight: >3000 gmsEmergency UVC place to 2-4 cms until blood Emergency UVC place to 2-4 cms until blood

return notedreturn noted

Medication DosesMedication Doses

Epinephrine 1:10,000 Epinephrine 1:10,000 concentration 0.1-0.3 ml/kg for concentration 0.1-0.3 ml/kg for UVC/IV, 0.5-1.0 ml/kg for ETT use, UVC/IV, 0.5-1.0 ml/kg for ETT use, given rapidlygiven rapidly

Normal Saline bolus 10ml/kg via Normal Saline bolus 10ml/kg via UVC/IV use –give over 5-10 mins UVC/IV use –give over 5-10 mins unless a known placental unless a known placental abruption or previa abruption or previa

Major changes to NRP Major changes to NRP 20102010 Infants without antenatal risk factors Infants without antenatal risk factors

who are born by elective C/S performed who are born by elective C/S performed under general anesthesia at 37-39 under general anesthesia at 37-39 weeks of gestation have a decreased weeks of gestation have a decreased requirement for intubation but a slightly requirement for intubation but a slightly increased need for mask ventilationincreased need for mask ventilation compared to infants after NSVD. Such compared to infants after NSVD. Such deliveries must be attended by a person deliveries must be attended by a person capable of providing mask ventilation capable of providing mask ventilation but not necessarily by a person skilled in but not necessarily by a person skilled in neonatal intubation.neonatal intubation.

Once PPV or supplemental O2 Once PPV or supplemental O2 administration is begun, administration is begun, assessment should consist of assessment should consist of simultaneous evaluation of clinical simultaneous evaluation of clinical characteristics: HR, RR, and characteristics: HR, RR, and evaluation of the state of evaluation of the state of oxygenation. oxygenation. State of oxygenation State of oxygenation is optimally determined by a pulse is optimally determined by a pulse oximeter rather than by simple oximeter rather than by simple assessment of color. Assessment assessment of color. Assessment of color is subjective.of color is subjective. There is now There is now data regarding normal trends in data regarding normal trends in oxyhemoglobin saturation oxyhemoglobin saturation monitored by pulse oximeter.monitored by pulse oximeter.

Pulse oximetry, with the probe attached to Pulse oximetry, with the probe attached to the right upper extremity, should be used the right upper extremity, should be used to assess any need for supplementary O2.to assess any need for supplementary O2. For infants born at term, it is best to For infants born at term, it is best to begin resuscitation with air rather than begin resuscitation with air rather than 100 % O2. Administration of 100 % O2. Administration of supplementary O2 should be regulated by supplementary O2 should be regulated by blending O2 and air, and the amount to be blending O2 and air, and the amount to be delivered should be guided by oximetry delivered should be guided by oximetry monitored from the right upper extremity. monitored from the right upper extremity. (i.e.: usually the wrist or palm) Evidence (i.e.: usually the wrist or palm) Evidence is now strong that healthy infants born at is now strong that healthy infants born at term start with an arterial oxyhemoglobin term start with an arterial oxyhemoglobin saturation of < 60% and can require more saturation of < 60% and can require more than 10 minutes to reach saturations of > than 10 minutes to reach saturations of > 90%. Hyperoxia can be toxic, particularly 90%. Hyperoxia can be toxic, particularly to the preterm infant.to the preterm infant.

Suctioning immediately after birth Suctioning immediately after birth (including with a bulb syringe) should be (including with a bulb syringe) should be reserved for infants who have an obvious reserved for infants who have an obvious obstruction to spontaneous breathing or obstruction to spontaneous breathing or require PPV.require PPV. There is insufficient evidence There is insufficient evidence to recommend a change in the current to recommend a change in the current practice of performing ET suctioning of non practice of performing ET suctioning of non vigorous infants with meconium-stained vigorous infants with meconium-stained amniotic fluid. There is no evidence that amniotic fluid. There is no evidence that active infants benefit from airway active infants benefit from airway suctioning, even in the presence of suctioning, even in the presence of meconium, and there is evidence of risk meconium, and there is evidence of risk associated with this suctioning. The associated with this suctioning. The available evidence does not support or available evidence does not support or refute the routine ET suctioning of refute the routine ET suctioning of depressed infants born through meconium-depressed infants born through meconium-stained amniotic fluid.stained amniotic fluid.

Exhaled CO2 detectors are Exhaled CO2 detectors are recommended to confirm ET recommended to confirm ET intubationintubation, although there are , although there are rare false negatives in the face of rare false negatives in the face of inadequate cardiac output and inadequate cardiac output and false positives with contamination false positives with contamination of the detectors. Further of the detectors. Further evidence is available regarding evidence is available regarding the efficacy of this monitoring the efficacy of this monitoring device as an adjunct to device as an adjunct to confirming ET intubation.confirming ET intubation.

The recommended compression-to-The recommended compression-to-ventilation ratio remains 3:1. If the ventilation ratio remains 3:1. If the arrest is known to be of cardiac etiology, arrest is known to be of cardiac etiology, a higher ratio (15:2) should be a higher ratio (15:2) should be considered. The optimal compression-to-considered. The optimal compression-to-ventilation ratio remains unknown. ventilation ratio remains unknown. The The 3:1 ratio for newborns facilitates 3:1 ratio for newborns facilitates provision of adequate minute ventilation, provision of adequate minute ventilation, which is considered critical for the vast which is considered critical for the vast majority of newborns who have an majority of newborns who have an asphyxial arrest.asphyxial arrest. The consideration of a The consideration of a 15:2 ratio (for 2 rescuers) recognizes 15:2 ratio (for 2 rescuers) recognizes that newborns with a cardiac etiology of that newborns with a cardiac etiology of arrest may benefit from a higher arrest may benefit from a higher compression-to-ventilation ratio.compression-to-ventilation ratio.

It is recommended that infants born It is recommended that infants born >/= 36 weeks of gestation with evolving >/= 36 weeks of gestation with evolving moderate to severe HIE should be moderate to severe HIE should be offered therapeutic hypothermia.offered therapeutic hypothermia. Therapeutic hypothermia should be Therapeutic hypothermia should be administered under clearly defined administered under clearly defined protocols similar to those used in protocols similar to those used in published clinical trials and in facilities published clinical trials and in facilities with the capabilities for multidisciplinary with the capabilities for multidisciplinary care and longitudinal follow-up. Several care and longitudinal follow-up. Several randomized controlled multicenter trials randomized controlled multicenter trials of induced hypothermia of newborns of induced hypothermia of newborns >/=36 weeks’ gestational age with >/=36 weeks’ gestational age with moderate to severe HIE showed infants moderate to severe HIE showed infants who were cooled had significantly lower who were cooled had significantly lower mortality and less neurodevelopmental mortality and less neurodevelopmental disability at 18-month follow-up.disability at 18-month follow-up.

There is There is increasing evidence of increasing evidence of benefit of delaying cord clamping benefit of delaying cord clamping for at least 1 minute in term and for at least 1 minute in term and preterm infants not requiring preterm infants not requiring resuscitation.resuscitation. There is insufficient There is insufficient evidence to support or refute a evidence to support or refute a recommendation to delay cord recommendation to delay cord clamping in infants requiring clamping in infants requiring resuscitation.resuscitation.

In a newly born infant with no detectable In a newly born infant with no detectable heart rate, which remains undetectable heart rate, which remains undetectable for 10 minutes, it is appropriate to for 10 minutes, it is appropriate to consider stopping resuscitation.consider stopping resuscitation. The The decision to continue resuscitation efforts decision to continue resuscitation efforts beyond 10 minutes of no HR should take beyond 10 minutes of no HR should take into consideration factors such as the into consideration factors such as the presumed etiology of the arrest, the presumed etiology of the arrest, the gestation of the infant, the presence or gestation of the infant, the presence or absence of complications, the potential absence of complications, the potential role of therapeutic hypothermia, and the role of therapeutic hypothermia, and the parents’ previously expressed feelings parents’ previously expressed feelings about acceptable risk of morbidity. about acceptable risk of morbidity. When gestation, birth weight, or When gestation, birth weight, or congenital anomalies are associated congenital anomalies are associated with almost certain early death and an with almost certain early death and an unacceptably high morbidity is likely unacceptably high morbidity is likely among the rare survivors resuscitation is among the rare survivors resuscitation is not indicated.not indicated.

STABLE PEARLSSTABLE PEARLS

S stands for sugarS stands for sugar Normal neonatal glucose 50-150 Normal neonatal glucose 50-150 RX: 2 ml/kg of D10W over 5 RX: 2 ml/kg of D10W over 5

minutes, check glucose again in minutes, check glucose again in 30 mins, may repeat the dose if 30 mins, may repeat the dose if still <50still <50

Should also have a running IV of Should also have a running IV of D10W @ 80ml/kg/d to maintain D10W @ 80ml/kg/d to maintain glucoseglucose

STABLESTABLE

T stands for temperature T stands for temperature Make sure to thoroughly dry the infant and Make sure to thoroughly dry the infant and

place on a port-a-warmer mattress or heat place on a port-a-warmer mattress or heat packspacks

If baby & mom are OK, place infant on mom’s If baby & mom are OK, place infant on mom’s chest skin-to-skin for warmth and cover with chest skin-to-skin for warmth and cover with a blanketa blanket

Maintain core temperature between 36.5C Maintain core temperature between 36.5C (97.7F) and 37.5C (99.5F), axillary at 37C (97.7F) and 37.5C (99.5F), axillary at 37C (98.6). Check temp Q15-30 mins until it’s is (98.6). Check temp Q15-30 mins until it’s is in the normal range then Q1hr until in the normal range then Q1hr until transported.transported.

STABLESTABLE

A stands for airwayA stands for airway Most important of all-provide PPV if Most important of all-provide PPV if

necessarynecessary PPV is provided via bag/mask ventilation PPV is provided via bag/mask ventilation

(8LPM of 40% FIO2) or Neopuff(8LPM of 40% FIO2) or Neopuff Use CPAP 5-6 cm if infant is breathing Use CPAP 5-6 cm if infant is breathing

but showing signs of respiratory distress, but showing signs of respiratory distress, e.g.: retractions, nasal flaring, cyanosis, e.g.: retractions, nasal flaring, cyanosis, grunting and/or tachpnea (RR>60)grunting and/or tachpnea (RR>60)

Keep O2 sats >90%Keep O2 sats >90%

STABLESTABLE

B is for blood pressureB is for blood pressure MBP’s range around gestational MBP’s range around gestational

age for first 24 hours. MAP = DAP age for first 24 hours. MAP = DAP + (PP)/3. PP = SAP - DAP.+ (PP)/3. PP = SAP - DAP.

Give NS bolus 10ml/kg if you Give NS bolus 10ml/kg if you think the infant is hypovolemicthink the infant is hypovolemic

STABLESTABLE

L is for labsL is for labs CBC, BCx, glucose & blood gasCBC, BCx, glucose & blood gas Calculate ANC & I/T ratioCalculate ANC & I/T ratio

ANC 5,000-10,000ANC 5,000-10,000

I/T ratio <0.2I/T ratio <0.2 Left shift = increased # of immature Left shift = increased # of immature

cells (bands + meta + myelos)cells (bands + meta + myelos) Platelet count range 100,000-150,000Platelet count range 100,000-150,000

STABLESTABLE

E is for emotional supportE is for emotional support Reassure the mother if possible, Reassure the mother if possible,

investigate/validate their feelingsinvestigate/validate their feelings Offer to call support people – clergy, Offer to call support people – clergy,

friends & familyfriends & family Take pictures of infant prior to transportTake pictures of infant prior to transport Encourage breastfeeding as one way for Encourage breastfeeding as one way for

moms to contribute to their infant’s caremoms to contribute to their infant’s care

SummarySummary

Goals: Goals:

Remember to…Remember to… ANTICIPATE problems that may ANTICIPATE problems that may

arisearise RECOGNIZE the problems when RECOGNIZE the problems when

they occur and thenthey occur and then ACT on them promptly and ACT on them promptly and

effectively.effectively.

Tips for starting IV’s in Tips for starting IV’s in newbornsnewborns Use 2 people to start the IV. One to bundle/contain Use 2 people to start the IV. One to bundle/contain

infant and offer/hold the pacifier, the other to infant and offer/hold the pacifier, the other to gather/prepare the materials and to place the IV.gather/prepare the materials and to place the IV.

Use Tran illuminator or bright pen light to help localize Use Tran illuminator or bright pen light to help localize the best vein.the best vein.

Warm hand or foot to dilate the veins.Warm hand or foot to dilate the veins. Palpate for possible arterial pulsations when placing Palpate for possible arterial pulsations when placing

IV’s in scalp veins. Wipe with alcohol swab prior to IV’s in scalp veins. Wipe with alcohol swab prior to insertion to dilate vein.insertion to dilate vein.

Move slowly and be patient. Blood flow may be Move slowly and be patient. Blood flow may be sluggish.sluggish.

If no blood return, but you think you are in the vein, If no blood return, but you think you are in the vein, remove the stylette and wait a few more seconds for remove the stylette and wait a few more seconds for blood return. Adjust catheter and attempt to flush blood return. Adjust catheter and attempt to flush with saline.with saline.

Correct placement of Correct placement of umbilical cathetersumbilical catheters On x-ray:On x-ray:

UAC between T6-T9UAC between T6-T9

UVC just above the diaphragm in UVC just above the diaphragm in the inferior vena cava vessel at the inferior vena cava vessel at the right atrial junctionthe right atrial junction

When evaluating blood gases, When evaluating blood gases, always ask these three questions:always ask these three questions:

1. Is the pH normal?1. Is the pH normal? 2. Is the PCO2 normal?2. Is the PCO2 normal? 3. Is the HCO3 normal?3. Is the HCO3 normal?

ABG VBG/CBG

pH 7.25-7.45 7.31-7.41

CO2 35-45 41-51

pO2 50-70 30-40

HCO3 16-26 22-29

BE/BD -4/+4 0-+4

O2 sats 88-96% 60-85%

7 rules for blood gas 7 rules for blood gas interpretationinterpretation 1. Carbon dioxide (CO2) = Acid1. Carbon dioxide (CO2) = Acid Changes in PCO2 reflect the Changes in PCO2 reflect the

respiratory component of acid respiratory component of acid base balance.base balance.

2. Bicarbonate (HCO3) = Base2. Bicarbonate (HCO3) = Base Changes in HCO3 reflect the Changes in HCO3 reflect the

metabolic component of acid-metabolic component of acid-base balance.base balance.

3. If the pH is normal, the blood gas is 3. If the pH is normal, the blood gas is normal or compensation has occurred.normal or compensation has occurred.

4. If the pH is low, the blood gas is 4. If the pH is low, the blood gas is uncompensated secondary to metabolic uncompensated secondary to metabolic &/or respiratory acidosis.&/or respiratory acidosis.

5. If the pH, HCO3 & PCO2 is low or PCO2 5. If the pH, HCO3 & PCO2 is low or PCO2 is normal, the blood gas is is normal, the blood gas is uncompensated secondary to metabolic uncompensated secondary to metabolic acidosis.acidosis.

6. If the pH is low, the PCO2 & HCO3 is 6. If the pH is low, the PCO2 & HCO3 is high (or normal) the blood gas is high (or normal) the blood gas is uncompensated secondary to respiratory uncompensated secondary to respiratory acidosis.acidosis.

7. If the pH & HCO3 is low and the PCO2 7. If the pH & HCO3 is low and the PCO2 is high, the blood gas is uncompensated is high, the blood gas is uncompensated secondary to mixed metabolic & secondary to mixed metabolic & respiratory acidosis. respiratory acidosis.

pH CO2 HCO3 BE

Respiratory acidosis < 7.25 > 45 16-26 -4/+4

Metabolic acidosis < 7.25 < 45 or 35-45 < 16 <-4/+4

Chronic respiratory acidosis 7.25-7.45 > 45 > 26 -4/+4

Metabolic alkalosis > 7.45 35-45 > 26 >-4/+4

Compensated metabolic acidosis </= 7.25 > 45 < 16 <-4/+4

Compensated metabolic alkalosis >/= 7.45 < 35 >26 >-4/+4

THE ENDTHE END

ANY QUESTIONS?ANY QUESTIONS?