NRP & STABLE UPDATES

Lori Fairfax, APRN-Rx & Jaymie H.

Pinho, APRN-Rx
NRP Initial Steps

Position infant, suction the mouth then

the nose PRN if secretions visible
Dry the infant off & remove wet
blankets
Stimulate the infant by rubbing back
or flicking soles of feet
Begin PPV if infant apneic or gasping
Initial Steps cont
Check heart rate by listening with a
stethoscope or palpating umbilical cord (tap
out HR for all to see)
Assess O2 sat- provide O2 blow-by (8LPM
starting with FIO2 @ 40%) if infant remains
cyanotic
For premature infant
If HR > 100 but distress noted, give CPAP
of 5-6 cm (PEEP) with bag & mask
Target SpO2 values

1 min 60-65 %
2 min 65-70 %
3 min 70-75 %
4 min 75-80 %
5 min 80-85 %
10 min 85-95 %
Key Points

Ventilation is the key to newborn

resuscitation
Increasing HR is a signal that
resuscitation efforts are effective
If mom is on a MgSO4 gtt, infant likely
to have decreased respiratory effort &
will require PPV
ABCs
Reminders
Infant < 28 weeks, use 2.5 ETT
weight: <1000 gms
Infant 28-34 weeks, use 3.0 ETT

weight: 1000-2000 gms

Infant 34-38 weeks, use 3.5 ETT

weight: 2000-3000 gms

Infant >38 weeks use, 4.0 ETT

weight: >3000 gms

Emergency UVC place to 2-4 cms until blood return
noted
Medication Doses

Epinephrine 1:10,000 concentration

0.1-0.3 ml/kg for UVC/IV, 0.5-1.0
ml/kg for ETT use, given rapidly
Normal Saline bolus 10ml/kg via
UVC/IV use give over 5-10 mins
unless a known placental abruption or
previa
Major changes to NRP
2010
Infants without antenatal risk factors who
are born by elective C/S performed under
general anesthesia at 37-39 weeks of
gestation have a decreased requirement for
intubation but a slightly increased need for
mask ventilation compared to infants after
NSVD. Such deliveries must be attended by
a person capable of providing mask
ventilation but not necessarily by a person
skilled in neonatal intubation.
 Once PPV or supplemental O2
administration is begun, assessment
should consist of simultaneous
evaluation of clinical characteristics: HR,
RR, and evaluation of the state of
oxygenation. State of oxygenation is
optimally determined by a pulse
oximeter rather than by simple
assessment of color. Assessment of
color is subjective. There is now data
regarding normal trends in
oxyhemoglobin saturation monitored by
pulse oximeter.
 Pulse oximetry, with the probe attached to the
right upper extremity, should be used to
assess any need for supplementary O2. For
infants born at term, it is best to begin
resuscitation with air rather than 100 % O2.
Administration of supplementary O2 should be
regulated by blending O2 and air, and the
amount to be delivered should be guided by
oximetry monitored from the right upper
extremity. (i.e.: usually the wrist or palm)
Evidence is now strong that healthy infants
born at term start with an arterial
oxyhemoglobin saturation of < 60% and can
require more than 10 minutes to reach
saturations of > 90%. Hyperoxia can be
toxic, particularly to the preterm infant.
 Suctioning immediately after birth (including
with a bulb syringe) should be reserved for
infants who have an obvious obstruction to
spontaneous breathing or require PPV. There
is insufficient evidence to recommend a
change in the current practice of performing
ET suctioning of non vigorous infants with
meconium-stained amniotic fluid. There is no
evidence that active infants benefit from
airway suctioning, even in the presence of
meconium, and there is evidence of risk
associated with this suctioning. The available
evidence does not support or refute the
routine ET suctioning of depressed infants
born through meconium-stained amniotic fluid.
 Exhaled CO2 detectors are
recommended to confirm ET
intubation, although there are rare
false negatives in the face of
inadequate cardiac output and false
positives with contamination of the
detectors. Further evidence is
available regarding the efficacy of this
monitoring device as an adjunct to
confirming ET intubation.
 The recommended compression-to-ventilation
ratio remains 3:1. If the arrest is known to be
of cardiac etiology, a higher ratio (15:2)
should be considered. The optimal
compression-to-ventilation ratio remains
unknown. The 3:1 ratio for newborns
facilitates provision of adequate minute
ventilation, which is considered critical for the
vast majority of newborns who have an
asphyxial arrest. The consideration of a 15:2
ratio (for 2 rescuers) recognizes that
newborns with a cardiac etiology of arrest
may benefit from a higher compression-to-
ventilation ratio.
 It is recommended that infants born >/= 36
weeks of gestation with evolving moderate
to severe HIE should be offered therapeutic
hypothermia. Therapeutic hypothermia
should be administered under clearly
defined protocols similar to those used in
published clinical trials and in facilities with
the capabilities for multidisciplinary care and
longitudinal follow-up. Several randomized
controlled multicenter trials of induced
hypothermia of newborns >/=36 weeks
gestational age with moderate to severe HIE
showed infants who were cooled had
significantly lower mortality and less
neurodevelopmental disability at 18-month
follow-up.
 There is increasing evidence of benefit
of delaying cord clamping for at least
1 minute in term and preterm infants
not requiring resuscitation. There is
insufficient evidence to support or
refute a recommendation to delay cord
clamping in infants requiring
resuscitation.
 In a newly born infant with no detectable
heart rate, which remains undetectable for
10 minutes, it is appropriate to consider
stopping resuscitation. The decision to
continue resuscitation efforts beyond 10
minutes of no HR should take into
consideration factors such as the presumed
etiology of the arrest, the gestation of the
infant, the presence or absence of
complications, the potential role of
therapeutic hypothermia, and the parents
previously expressed feelings about
acceptable risk of morbidity. When
gestation, birth weight, or congenital
anomalies are associated with almost certain
early death and an unacceptably high
morbidity is likely among the rare survivors
resuscitation is not indicated.
STABLE PEARLS

S stands for sugar

Normal neonatal glucose 50-150
RX: 2 ml/kg of D10W over 5 minutes,
check glucose again in 30 mins, may
repeat the dose if still <50
Should also have a running IV of
D10W @ 80ml/kg/d to maintain
glucose
STABLE
T stands for temperature
Make sure to thoroughly dry the infant and place
on a port-a-warmer mattress or heat packs
If baby & mom are OK, place infant on moms
chest skin-to-skin for warmth and cover with a
blanket
Maintain core temperature between 36.5C (97.7F)
and 37.5C (99.5F), axillary at 37C (98.6). Check
temp Q15-30 mins until its is in the normal range
then Q1hr until transported.
STABLE
A stands for airway
Most important of all-provide PPV if
necessary
PPV is provided via bag/mask ventilation
(8LPM of 40% FIO2) or Neopuff
Use CPAP 5-6 cm if infant is breathing but
showing signs of respiratory distress, e.g.:
retractions, nasal flaring, cyanosis, grunting
and/or tachpnea (RR>60)
Keep O2 sats >90%
STABLE

B is for blood pressure

MBPs range around gestational age
for first 24 hours. MAP = DAP +
(PP)/3. PP = SAP - DAP.
Give NS bolus 10ml/kg if you think the
infant is hypovolemic
STABLE
L is for labs
CBC, BCx, glucose & blood gas
Calculate ANC & I/T ratio
ANC 5,000-10,000
I/T ratio <0.2
Left shift = increased # of immature cells
(bands + meta + myelos)
Platelet count range 100,000-150,000
STABLE
E is for emotional support
Reassure the mother if possible,
investigate/validate their feelings
Offer to call support people clergy, friends
& family
Take pictures of infant prior to transport
Encourage breastfeeding as one way for
moms to contribute to their infants care
Summary

Goals:
Remember to
ANTICIPATE problems that may arise

RECOGNIZE the problems when they

occur and then
ACT on them promptly and effectively.
Tips for starting IVs in
newborns
Use 2 people to start the IV. One to bundle/contain infant and
offer/hold the pacifier, the other to gather/prepare the
materials and to place the IV.
Use Tran illuminator or bright pen light to help localize the
best vein.
Warm hand or foot to dilate the veins.
Palpate for possible arterial pulsations when placing IVs in
scalp veins. Wipe with alcohol swab prior to insertion to
dilate vein.
Move slowly and be patient. Blood flow may be sluggish.
If no blood return, but you think you are in the vein, remove
the stylette and wait a few more seconds for blood return.
Adjust catheter and attempt to flush with saline.
Correct placement of
umbilical catheters
On x-ray:
UAC between T6-T9
UVC just above the diaphragm in the
inferior vena cava vessel at the right
atrial junction
 When evaluating blood gases, always
ask these three questions:
1. Is the pH normal?
2. Is the PCO2 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
interpretation
1. Carbon dioxide (CO2) = Acid
Changes in PCO2 reflect the
respiratory component of acid base
balance.
2. Bicarbonate (HCO3) = Base
Changes in HCO3 reflect the
metabolic component of acid-base
balance.
 3. If the pH is normal, the blood gas is
normal or compensation has occurred.
4. If the pH is low, the blood gas is
uncompensated secondary to metabolic &/or
respiratory acidosis.
5. If the pH, HCO3 & PCO2 is low or PCO2 is
normal, the blood gas is uncompensated
secondary to metabolic acidosis.
6. If the pH is low, the PCO2 & HCO3 is high
(or normal) the blood gas is uncompensated
secondary to respiratory acidosis.
7. If the pH & HCO3 is low and the PCO2 is
high, the blood gas is uncompensated
secondary to mixed metabolic & 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 END
ANY QUESTIONS?