2012 NRP

6
th
Edition
Review of Changes in NRP

By: Cayce Hendrix, RRT-NPS
What is the Same?
Renewal every 2 yrs
Course is designed for those who work with
newborns (NICU, SCN, L&D, NBN)
NRP certification does not certify or ensure
competency to perform the skills learned in an
actual newborn resuscitation.
You will not be expected to place UAC, needle
decompress chest, intubate etc.
You will still work within your SCOPE of practice
What are some Differences?
Differences noted in Red for this PowerPoint
No more Renewal courseeveryone takes a
Provider Course tailored to the learners
needs and scope of practice
9 CEUs for Nursing and Respiratory

On-Line Examination
Online Examination is now required
There is no written Exam anymoreonly available
Online beginning Jan. 1
st
2012
Must complete the Online Exam within 14 days of
starting the exam
You may skip and return to questions, or change your
answers until the lesson is submitted
80% score needed to pass each lesson
Each test section can be retaken 1 time if needed
Once the Online Exam has been passed, the
student has 30 days to take the live NRP course



Provider Course Program Changes
No video viewing before Megacode
There is video for learning located in back cover of
NRP learners manual
Little to no lecture
More hands-on learning
Skill stations used for learning, review, and practice
Clinical Simulations & Megacode
Improves teamwork and communication
Constructive debriefings
Discuss how things could have been done better for
future learning and constructive communication

Simulation
Simulation training is not required
Training is dependant on
Good methodology
Not technology
But the Sims Center is where we would like to do our
NRP training
More life-like Sims baby
Less focus on asking questions
Is the baby breathing, what is heart rate etc.
More responding to Simulator baby
Baby can breatheor not
Has a changing palpable heart rate
Visible tone & color changes
Can have seizures, pnuemothorax, UAC placement etc.


NRPs 10 Key Behavioral Skills
Know your environment
Anticipate and plan
Assume the leadership role
Communicate effectively
Delegate workload optimally
Allocate attention wisely
Use all available information
Use all available resources
Call for help when needed
Maintain professional behavior


The following are no longer optional
but should be available for every birth
Compressed gas source
Blended Oxygen with flowmeter
Pulse Oximetry
LMA size 1 (Laryngeal Mask Airway)


There are 2 levels of post-resuscitation
care (instead of the 3 levels of care)
Routine Care:
Vigorous term infants with no risk factors
Babies who required but responded to initial steps
They now can stay with Mother
Skin to skin contact recommended
Clear airway, dry newborn, provide ongoing evaluation:
Breathing
Activity
Color
Transfer to NBN
Post-Resuscitation Care:
Babies with depressed breathing or activity
Those requiring supplemental oxygen &/or
ongoing nursing care
Those with high risk factors to be evaluated in an
ICU setting
Those who require frequent evaluation
Baby may possibly then transfer to routine care
after a period of time
Transfer to NICU

There are 2 levels of post-resuscitation
care (instead of the 3 levels of care)
What to ask OB prior to delivery
What is the gestational age?
Is the fluid clear?
How many babies are expected?
Are there any additional risk factors?
This is the only new addition to this step
At birth, answer 3 questions to determine
the need for the initial steps at the RHW
Is the newborn term?
Is the newborn breathing or crying?
Does the newborn have good muscle tone?

If the answer is NO to any questionthe newborn
should receive the initial steps at the RHW
Suctioning after birth :
Bulb or Catheter
Should be reserved for babies who have
Obvious obstruction to spontaneous breathing
Those requiring PPV (positive pressure ventilation)
Vigorous Meconium-Stained newborns
Are NO longer required to go to RHW
May receive Routine Care with Mother right after
birth
Appropriate monitoring
Evaluation Process
Subsequent evaluations and decision-making
are based on
Respiratory effort
Heart rate
Color / Oxygenation
Based on Pulse Oximetry
PPV & CPAP
After clearing airway as necessary, drying and
removing wet linen, repositioning & stimulation
Evaluate respirations and heart rate
Not color
If HR <100 or if newborn is apneic or gasping-PPV
If HR >100 but respirations are labored-CPAP
(continuous positive airway pressure)
Especially with preterm infants
Pulse Oximetry & Evaluation of Color
Use POX when:
Resuscitation is anticipated
PPV is required for more than a few breaths
Central cyanosis is persistent
To confirm your perception of central
cyanosis
Whenever supplemental oxygen is
administered

Pulse Ox & Oxygen
Administration
Term infants may be resuscitated with 21% O2
Preterm infants may begin with a somewhat
higher oxygen concentration
Pulse Ox probe on right hand or wrist
Measures the pre-ductal saturation
Place on patient before connecting to Pox
machine to achieve the fastest readings

Pox & Oxygen Administration
Supplemental oxygen concentration should be
adjusted gradually to achieve pre-ductal
Saturations summarized in the NRP diagram
below (Both Term & Preterm)
Target Spo2 after birth:
1min 60-65%
2min 65-70%
3min 70-75%
4min 75-80%
5min 80-85%
10min 85-95%
PPV Indications
Apnea
Gasping
Heart rate <100
Even with strong respiratory drive
Persistent central cyanosis
Low oxygenation despite free-flow oxygen
increased to100%

PPV Devices
T-Piece Resuscitator
Self-inflating bags
Flow-inflating bags

Pressure Gauge Manometer on all AMBU
bags


PPV Assessment
PIPs of 20cmH2O should be sufficient for
good chest rise in most newborns

Best indicator that you are bagging
correctly is an increase in heart rate
^ in HR should be evident within 5-10
breaths
If not-then following the corrective actions
MR SOPA

MR. SOPA
M- Adjust Mask in the face
R- Reposition the head to open airway
Re-attempt to ventilateif not effective then
S- Suction mouth then nose
O- Open mouth and lift jaw forward
Re-attempt to ventilateif not effective then
P- Gradually increase Pressure every few
breaths until visible chest rise is noted
Max Pip 40cmH2O
If still not effective then
A- Artificial Airway (ETT or LMA)

Highest Priority in Neonatal
Resuscitation
Establishing EFFECTIVE Ventilation
It may take longer than 30sec to establish
effective ventilations
Corrective actions required
MR SOPA
DO NOT start chest compressions without
1
st
ensuring effective ventilations
Defined by bilateral breath sounds & chest
movement
Chest Compressions
HR <60bpm despite effective ventilation
Coordinate with ventilations for at least 45-60sec
before stopping briefly to assess heart rate
2 hands wrapped around chest with 2 thumb
technique is preferred method of chest compressions
Be careful to concentrate pressure onto heart not over
entire chest
Note your thumb position
Compress 1/3 diameter of chest
90 compressions to 30 ventilations/minute (120 events)
One & two & three & breathe & One & two & three &
breathe &
Chest Compressions
Increase FiO2 to 100% once you begin compressions
Adjust FiO2 to Pox readings
Pox may not work while newborn is receiving chest
compressions
Intubation is strongly recommended when
compressions begin
You now have 30sec to attempt intubation
LMA may be indicated as an alternative to intubation
when
Facial or upper airway malformations render bag-mask
ventilations ineffective
PPV not effective and intubation is not possible


UVC
Consider placement of UVC once
compressions are initiated or if extended
resuscitation is anticipated

Continue chest compressions by moving
around to head of bed to allow room for
MD to place UVC


Epinephrine
Epinephrine is indicated when heart rate
remains <60
After 30 seconds of effective ventilations
And at least another 45-60sec of
coordinated compressions and ventilations

ETT route
Unreliable absorption
Less effective
But readily available so give while establishing UVC

UVC route
Preferred method
Requires skills to place line
May give dose soon as line is placed even after just
giving via ETT

Epinephrine
Epinephrine
Give rapidly
Concentration 1:10,000 (0.1mg/ml)
ETT dose
0.5 1 ml/kg
UVC / IV dose
0.1- 0.3 ml/kg
Follow with a 0.5 1ml flush NS
Re-check heart rate after 1minute of compressions
and ventilations
Maybe longer if give ETT
Repeat dose every 3 5 minutes
Epi can be given again immediately after UVC
placement if given initially down ETT


Preterm Newborns
Increase temperature of the delivery room to
approx. 25C 26C (77F 79F)
Polyethylene plastic wrap
Place portable warming pad under the layers of
towels at the RHW
Blended O2
Consider CPAP for good heart rate but ^ WOB
Therapeutic Hypothermia for HIE
Cooling used for >/= 36wks
& meet special criteria for this modality
Usually initiated before 6 hours after birth

Please Contact Cathy White,
your NRP Regional Trainer at
cathy.white@palmettohealth.org
for any questions regarding
implementing the NRP 6
th
Edition
at your Institution.