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NRP 8 Edition in Canada: A Review of New Recommendations and Their Rationale

The document reviews changes to the 8th edition of the Neonatal Resuscitation Program (NRP) guidelines in Canada. Key changes include reordering initial steps, emphasizing ventilation, updated epinephrine dosing, and individualizing the timing for discontinuing resuscitation efforts based on patient factors and optimal resuscitation being provided. The rationale for changes is supported by recent evidence showing benefits of delayed cord clamping for most infants, risks of cord milking, and improved outcomes for some infants requiring prolonged resuscitation.

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Ravikiran Suryanarayanamurthy
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506 views32 pages

NRP 8 Edition in Canada: A Review of New Recommendations and Their Rationale

The document reviews changes to the 8th edition of the Neonatal Resuscitation Program (NRP) guidelines in Canada. Key changes include reordering initial steps, emphasizing ventilation, updated epinephrine dosing, and individualizing the timing for discontinuing resuscitation efforts based on patient factors and optimal resuscitation being provided. The rationale for changes is supported by recent evidence showing benefits of delayed cord clamping for most infants, risks of cord milking, and improved outcomes for some infants requiring prolonged resuscitation.

Uploaded by

Ravikiran Suryanarayanamurthy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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NRP 8th edition in Canada: a

review of new recommendations


and their rationale
Dr Emer Finan,
Dr Amuchou Soraisham,
CPS NRP Steering Committee
Disclosure Statement
• Faculty: Dr Emer Finan and Dr Amuchou Soraisham

• Relationships with commercial interests:

We have no affiliation (financial or otherwise) with a


pharmaceutical, medical device or communications
organization
Objectives

• Review the changes in 8th edition of NRP in Canada

• Review the relevant science underlying updated


recommendations

• Review the administrative and educational changes


related to 8th edition NRP in Canada
Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics and
American Heart Association. Edited by Gary M. Weiner and Jeanette Zaichkin
• NRP Essentials
Lessons 1 to 4 inclusive
(incl. PPV and LMA)

• NRP Advanced
Lessons 1 to 11 incl
(incl. intubation and beyond)

Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics and American
Heart Association. Edited by Gary M. Weiner and Jeanette Zaichkin
Preparing for resuscitation
• Team and equipment preparation: the “brief”

• 4 pre-birth questions
 Expected gestational age
 Is the AF clear ?
 Any additional risk factors?
 Umbilical cord management plan

Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics and


American Heart Association. Edited by Gary M. Weiner and RN MN NNP-BC Jeanette
Zaichkin
The “Golden minute”
• Initial steps reordered

• Initial respiratory
assessment/HR check

• Indications for PPV


unchanged

• Possible role of CPAP as in


past
Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics and American
Heart Association. Edited by Gary M. Weiner and Jeanette Zaichkin
Ventilation is key !
• MR.SOPA if no ↑ HR/no
chest mmt after 15 secs

• If HR low despite
ventilation, alternate
airway and 30 secs PPV

• Saturation targets
unchanged

Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics


and American Heart Association. Edited by Gary M. Weiner and Jeanette Zaichkin
Circulatory support
• 30 seconds PPV via AA

• CC if HR < 60. 3:1 ratio


and 100% FiO2

• If no ↑HR: “CARDIO”

• If HR < 60 after 60 secs


CC→ epinephrine

Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics and American
Heart Association. Edited by Gary M. Weiner and Jeanette Zaichkin
Medications
• Epinephrine IV/IO dose range 0.01-0.03mg/kg

• Suggested initial IV/IO =0.02mg/kg.


Suggested initial ET dose =0.1mg/kg

• Flush with 3 ml normal saline

• Can rpt every 3-5 mins: “consider ↑subsequent


doses”

Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics


and American Heart Association. Edited by Gary M. Weiner and Jeanette Zaichkin
Additional considerations
• Normal saline remains crystalloid expander of choice

• Packed cells in cases of suspected fetal anemia

• Consideration of other causes if not responding, eg ptx

• “Reasonable time frame for considering cessation of


resuscitation efforts is around 20 minutes after birth”….
“individualized based on patient and contextual factors”
Textbook of Neonatal Resuscitation, 8th Ed. By American Academy of Pediatrics and
American Heart Association. Edited by Gary M. Weiner and Jeanette Zaichkin
Objective -2

• Review the relevant science underlying


updated recommendations
Timing of umbilical cord clamping

• DCC for 30-60 s is reasonable for both term


and preterm infants who do not require
resuscitation at birth.
Timing of CC for non-vigorous babies

• Research on resuscitation with intact cord


ongoing

• If PPV required, cord should be cut and infant


transferred to overbed warmer for
resuscitation
Umbilical Cord Milking (UCM)

15
Cord Milking versus DCC

Risk of severe IVH:


UCM (22%) vs DCC (6%);
[ 26%, NNH=6]

Cord milking is not


recommended for
infants <28 weeks

Number of Infants with Severe IVH by GA


Katheria et al. JAMA 2019;322(19):1877-1886
Hemodynamic Changes During Cord Milking
Lack of cerebral autoregulation and
right to left ductal shunt result in
fluctuations in flow to an immature IVH
brain with fragile germinal matrix.

Increased venous
return to the right
Pulmonary
atrium enters PFO vasoconstriction
and aorta

Umbilical cord
milking
Sustained Lung Inflation(SLI)
• Providing longer SLI before initiating PPV can inflate
the lungs and increase FRC.

• Meta-analysis showed SLI- ↑ mortality in preterm


infants < 29 wk and SI is not recommended

• There is insufficient evidence for or against the use of


SLI for term and late preterm infants.

Wyckoff M et al. Circulation, 2020;142(Supp): S185-S221


Kapadia VS, et al. Pediatrics. 2021;147:e2020021204.
Epinephrine dosing
• Dose
• IV or IO = 0.02 mg/kg (equal to 0.2 mL/kg)
• May repeat every 3 to 5 minutes
• Range = 0.01 to 0.03 mg/kg (equal to 0.1 to 0.3
mL/kg)
• Endotracheal = 0.1 mg/kg ( equal to 1 mL/kg)
• Range = 0.05 to 0.1 mg/kg (0.5 to 1 mL/kg)
• Flush: Follow IV or IO dose with a 3-mL saline flush
(previous 0.5-1ml)
Sankaran D, et al. Arch Dis Child Fetal Neonatal Ed 2021;0:F1–F6.
Epinephrine
• Epi (0.03mg/kg) - earlier and ↑ ROSC compared with
the 0.01mg/kg dose.

• Epi (0.03mg/kg) followed by a 3mL/kg flush - ↑ the


incidence of ROSC (100%) and quicker ROSC without
higher HR or BP compared with 0.01mg/kg dose.

Sankaran D, et al. Arch Dis Child Fetal Neonatal Ed 2021;0:F1–F6.


Timing of discontinuation of
resuscitation

• Difficult to decide how long to continue


resuscitation at birth

• In recent years, long-term outcomes for


survivors requiring prolonged resuscitation
have improved somewhat.
Outcome of infants experiencing resuscitation
beyond 10 minutes
Systemic review of 15 studies , N=470

Survival to discharge, 13 studies


176 /432 (41%)

Survival to last follow up, 15 studies


187/470 (40%)

Survival without NDI, 13 studies , n=277 infant


18%- survived with NDI
11% - survived without NDI
69% died by follow-up, 2% lost to follow up
Wyckoff M et al. Circulation, 2020;142(Supp): S185-S221
Outcomes of newborn infants who
received ≥ 20 min of CPR after birth
• Only 39 infants in whom first detectable HR or HR
>100/min occurred at or beyond 20 minutes after
birth.

• 15/39 (38%) survived until last follow-up

• 6/15 (40%) of survivors did not have NDI

Wyckoff M et al. Circulation, 2020;142(Supp): S185-S221


Timing for discontinuation
• Reasonable time frame for considering cessation of
resuscitation effort is around 20 minutes after birth

• It should be individualized based on patient and


contextual factor:
– Optimal resuscitation
– Availability of advanced NICU care
– Specific circumstances before delivery
– Wishes expressed by the family
Objectives 3

• Review the administrative and educational


changes related to 8th edition NRP
Administrative/Educational Changes

• Focus on team factors and QI considerations


in each chapter

• Additional chapters on ergonomics and


human performance, resuscitation outside
delivery room, integration of QI initiatives
Course Format in Canada
• Essentials and Advanced options

• Online exam, skills practice, Integrated Skills


Assessment, simulation & debriefing

• Essentials online learning: chapters 1-4


Advanced online exam: chapters 5-11

• Course completion every 2 years


Online Learning Assessment
• Interactive online assessment

• Learner asks to self-assess

• Feedback and time to complete contingent on


performance and alignment with self-
assessment
Implementation in Canada
• 7th edition exam not available after Dec 31, 2021. Launch
of 8th edition January 1, 2022

• Instructors will be required to the 8th edition exam prior


to teaching courses

• Resources:
-Updated FAQ
-Revision of ISSA
-Speaker-noted slides and recording from this presentation
-CPS Pedagogy site: instructor resources including sim and
debriefing videos, instructor course resources
https://downloads.aap.org/AAP/PDF/NRP%208th%20Edition%20Busy%20People%20Update%20(1).pdf

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