Top 10 NRP Questions Posed by You

NRP Current Issues Seminar October 10, 2014 San Diego, Ca

Jeanette Zaichkin, RN, MN, NNP-BCTacoma, Washington

Gary Weiner, MD, FAAPUniversity of Michigan, Ann Arbor, MI

Faculty Disclosure Information

•In the past 12 months, we have had no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity.

• We are compensated editors for the American Academy of Pediatrics/NRP and, as such, have contractual relationships to produce AAP/Laerdal co-branded educational materials

• We receive no financial benefit from the sale of these materials

• This presentation includes references to the un-approved or investigative use of commercial products and devices

Session Objectives

•Identify NRP best practices and answer frequently asked NRP questions

•Identify strategies to incorporate answers to frequently asked questions into NRP courses.

How did we come up with these questions?

•Questions were emailed to the Life Support Staff from December 2010 to the present time•We looked at about 200 questions and chose the most common themes

Starting with Question #10

Question #10What is the best method for assessing the newborn’s heart rate in the delivery room?

Question #10What is the best method for assessing the newborn’s heart rate in the delivery room?

• Palpation?• Auscultation?• Pulse oximetry?• ECG monitor?

• ~ Half of errors made during NRP simulation because of incorrect HR assessment

• Cord pulse not palpable in 20-25% of healthy, newborns

Voogdt (2010), Chitkara (2012), Kamlin (2006), Owen (2004)

What is the Heart Rate?

What is the HR?

A. < 60 and not risingB. < 60 and risingC. 60 – 100 and not risingD. 60 – 100 and risingE. > 100

• Palpated and auscultated HRs are frequently inaccurate

• Leads to incorrect action• 20 – 30%

Voogdt (2010), Chitkara (2012), Kamlin (2006), Owen (2004)

Electrical Monitors

• Pulse ox reads HR and oxygen saturation– Takes ~ 90 seconds– May not work if very poor perfusion

• ECG continuous even with poor perfusion– Leads may not stick– Pulseless electrical activity (PEA)

O’Donnell CP, 2005

Question #9How can I get the pulse oximeter to register a reliable signal quickly?

• Is your oximeter calibrated for newborns and motion tolerant?

• Max sensitivity and short averaging time?

• Placed correctly? • Ambient light occluded?• Attach sensor to baby or to

oximeter first (STIF vs. STOF)?

Question #9How can I get the pulse oximeter to register a reliable

signal quickly?

O’Donnell CP, 2005Louis D, 2014

Either way gets you to the right place within ~ 60-90 seconds of birth

Question #8Do we really need a full resuscitation team at a

c-section with no apparent risk factors?

Need for PPV in DR

Atherton (2006)

Need for ETT in DR

Atherton (2006)

Question #8

Do we really need a full resuscitation team at a c-section with no apparent risk factors?

• When was perinatal/neonatal risk assessed and discussed with neonatal providers?

• Who is assigned responsibility for the newborn?

• Is someone with complete resuscitation skills immediately available?

Question #7 How often should we record vital signs during a

neonatal code?

Question #7 How often should we record vital signs during a

neonatal code?• What is a “neonatal code”? • When do you need a recorder?

– PPV? Chest compression?• Who should be the recorder?• Do you have a “neonatal code” sheet? • Do you video-record resuscitation?

Question #6If my staff finds a baby apneic, limp, and cyanotic

in the mother’s room, what should they do?• Send the mom for help and begin mouth-to-

mouth respirations• Pick up the baby and run down the hall to the

nursery• Hit the “CODE” button in the room and begin

ventilating with a self-inflating bag• None of the above

Question #6If my staff finds a baby apneic, limp, and cyanotic in

the mother’s room, what should they do?

• The post-partum unit is a recovery unit for both mother and baby

• Anticipate, plan, simulate

Question #5 If the OB provider delays cord clamping, when

does the Apgar timer start?

Question #5 If the OB provider delays cord clamping, when

does the Apgar timer start?

• “Birth” is the time when the last part of the newborn exits the mother.

• Start the Apgar timer at birth.

• When is DCC recommended?

Question #4

When do I use NRP vs PALS?

NRP• “A-B-C”• Compressions:Ventilations

– 3:1 ratio • Synchronize compressions

and ventilation

PALS• “C-A-B”• Compressions: Ventilations

– Lone rescuer = 30:2 – Two rescuer = 15:2

• Synchronize if BMV• Asynchronous if ETT in

place

Question #4•Optimal CPR in infants and children includes compressions and ventilations

Ventilation + CPR better outcome than CPR alone in non-cardiac arrests

Ventilation + CPR similar outcome as CPR alone in cardiac origin arrests

Question #4•If lay providers start pediatric resuscitation with compressions

– Only a brief delay in ventilation, but..– Improved educational efficiency (same rules as

adults), so it’s easier to teach, and…– In adults, hands-only CPR is more effective

When do I use NRP vs PALS?“For ease of training, we recommend that

newborns who require CPR in the newborn nursery or NICU receive CPR (using NRP guidelines). Newborns who require CPR in other settings (e.g. pre-hospital, ED, PICU, etc.) should receive CPR according to (PALS guidelines)…It is reasonable to resuscitate newborns with a primary cardiac etiology…regardless of location, according to (PALS guidelines) with emphasis on chest compressions”

2010 AHA Guidelines for CPR and ECC, Part 14, PALSCirculation. 2010;122:S876

Question #3My NRP class has a mix of really experienced staff and first-timers.

• How can I organize the class so I meet the requirements and keep them all engaged?

• Should I run separate simulations for the experts and the first-timers?

Question #3My NRP class has a mix of really experienced staff and first-timers.

• Not everyone needs the basics• What is your “actual” team composition?• Use behavioral modeling to help novices• Don’t be afraid to mix it up. Be flexible based on your

course learning objectives

Question #2If a newborn needs intubation and there is no

MD or NNP to do it, can the RN intubate?

Question #2

If a newborn needs intubation and there is no MD or NNP to do it, can the RN intubate?

• Why is there no MD or NNP immediately available?• Check your state’s nursing scope of practice

regulations• NRP does not certify or guarantee competency• Nurses should not be intubators by default• Be ready to defend your training in a legal setting• After intubation, what next? UVC, meds…….?

Question #1

Explain the current recommendations on suctioning the trachea of the newborn with

meconium-stained fluid; and the mouth, nose, and stomach of any newborn.

Who gets suctioned, when, how, and why?

• MSAF is common

– ~ 8% of deliveries– Increases with GA

• MAS is uncommon and decreasing– ~ 0.2% of deliveries– ~ 2% of MSAF– 2/3rds of MAS is “mild”, no

vent or CPAP– Risk factors for severe MAS

= moderate or thick meconium and abnormal FHR

Fischer C. Intnl J Pediatr, 2012.

How did we get where we are?Return to the 1970’s

George Gregory (1974)2013 Apgar Awardee

•80 babies w/ MSAF that got mouth-to-tube ETT suction

– Nearly all were vigorous– 60% had mec in ETT– 1/3rd of them got “sick”– Nobody got sick if no

mec in the ETT

Pauline Ting (1975)

•125 babies admitted to NICU w/ MSAF

– 1/3rd “symptomatic”– 60% of symptomatic had

been ETT suctioned• 7 died, not suctioned

– 85% of asymptomatic had been ETT suctioned

Bonita Carson (1976)•Chart review of 3 non-randomized groups. Focused on 2 groups.

No statistical difference, but a “trend” favoring OB suction

•“A cause and effect relationship cannot be established without a prospective randomized clinical trial…we do not feel that such a trial would be justified.”

NO OB suction+ ETT Suction

947 babies

OB suction +Selective ETT Suction

273 babies

MAS 18(1.9 %)

1(0.4 %)

How did we get where we are?Move Ahead to the 2000’s

Tom Wiswell (2000)•Randomized vigorous babies with MSAF to ETT vs NO ETT suction•No difference in MAS or ANY other respiratory problems

– NO difference even if the meconium was “thick”

– Suctioned babies had lower 1-min Apgar scores

– 3.8% had complications from ETT

ETT Suction

(n= 1051)

NO ETT Suction(n=1043)

MAS 34 (3.2%) 28 (2.7%)

MAS if thick MSAF

22 (7.3%) 20 (7.1%)

Apgar < 7 16%* 6%*

No benefit to ETT suction “vigorous” newborns

Nestor Vain (2004)•Randomized mothers with MSAF to OB suction vs. NO OB suction before delivery of shoulders•No difference in MAS

– NO difference even if the baby had an abnormal FHR, the meconium was “thick”, or the baby was “not vigorous” after delivery

Suction(n= 1263)

NO Suction(n=1251)

Need for ETT in DR

106 (8%) 113 (9%)

MAS 52 (4%) 47 (4%)

Vent 24 (2%) 18 (1%_

Death 9 (0.7%) 4 (0.4%)

O2 Days 5.7 5.1

No benefit to OB Suction

Other Suction Questions…•No benefit to “routine” suction immediately after birth (vaginal or C/S) in the absence of MSAF (4 RCTs)

– Wiping the nose & mouth is just as effective as bulb syringe (1 RCT)

•No benefit to “routine” gastric suction in the absence or presence of MSAF (3 RCT)

• Increased chance of needing ETT/suction with MSAF if abnormal FHR or maternal fever (~ 10% vs ~ 2%)

Current Recommendation (2010)•No routine oro-nasopharyngeal suction after birth•Assist the baby (suction or wipe) if secretions obstructing the airway, the baby is in distress, or if you’re anticipating the need for PPV•MSAF: Intubate and suction if the baby is not “vigorous”

– Need rigorous RCTs but very difficult to do

Evolving Evidence Being Evaluated•Abstract presented at Spring 2014 PAS meeting•Pilot RCT (India) of non-vigorous babies with MSAF

– MAS or death: 23/88 (26%) no ETT suction– MAS or death: 28/87 (32%) with ETT suction– No difference in MAS/death, O2 requirement,

ventilator, HIE, days in hospital

Nangia S. PAS 2014, Abstract 4680.1

“Judge a man by his questions rather than by his answers”

-Voltaire

Keep asking questions. It’s how we keep improving.

For more information on these topics, please see the following publications:

Scoop and Run: http://www2.aap.org/nrp/docs/IU/2013_SpringSummer.pdf Resuscitation documentation: http://www2.aap.org/nrp/docs/IU/2014_SpringSummer_iu.pdf Suction after birth:http://www2.aap.org/nrp/docs/IU/2013_FallWinter_iu.pdfAHA/NRP Guidelines (2010):http://circ.ahajournals.org/content/122/18_suppl_3/S909.full.pdf+htmlNRP Science Summary (2010):http://pediatrics.aappublications.org/content/126/5/e1319.full.pdf+html

Additional Question I don’t get a lot of discussion during my debriefings. What questions can I ask that will get the discussion moving along?

Additional Question I don’t get a lot of discussion during my debriefings. What questions can I ask that will get the discussion moving along?

• What would have happened if……• What would you want? And how would that sound...• How did that affect the team…….• Give me an example of the NRP Key Behavioral Skill…• Has this scenario happened to you?