Case based Discussions in NRP. Steven Ringer MD PhD October 19 2012. Conflicts. I have no actual or potential conflict of interest in relation to this presentation. I am a member of the NRP Steering Committee. Changes in Practice. Practice Gap 1 - Resuscitation practice guidelines
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Case based Discussions in NRP Steven Ringer MD PhD October 19 2012
Conflicts I have no actual or potential conflict of interest in relation to this presentation. I am a member of the NRP Steering Committee
Changes in Practice Practice Gap 1 - Resuscitation practice guidelines are based on review and compilation of available evidence - Initial questions posed when consulted for care at birth include GA, respiratory effort and tone Good communication is a key component of providing good care resolves in most cases Learning Objective 2 Understand the ILCOR process and how it results in recommendations for care Identify the critical areas for rapid and effective communication, best allowign adequate anticipation of needs Recognize that clear communication between disciplines is a key behavioral skill that must be fostered and facilitated
Two Changes you may wish to make in your practice Facilitate team assessment and debriefing as part of resuscitation to identify understanding of practice guidelines, areas of good practice and those requiring improvement Practice the use of oximetry guided oxygen use in different clinical scenarios and refine practice through the use of team based simulation and debriefing.
Changes in Practice • Practice Gap 2 • - Clinical assessment of oxygenation is unreliable in the newly born • -”Normal” oxygen levels are not achieved until 5-10 minutes in healthy term infants • Use of oximetry allows better tailoring of oxygen and minimizes over use • Team structure and communication results in enhanced care and better adherence to practice guidelines • Learning Objective 2 • Understand the limitations of clinical assessment in the newly born infant with respect to color and oxygen • Indentify the concept of target oxygen saturation levels at each minute after birth, and how they are used • Understand the use of oximetry to guide oxygen use, including correct placement of monitoring probes, changes in oxygen concentration in response to measured levels. • Describe the way team functioning facilitates better care and the need to identify and communicate roles within the team
Neonatal Resuscitation Program- where do Guidelines come from? • Evidence relating to resuscitation is reviewed on a five year cycle by ILCOR- International Liaison Committee on Resuscitation • The NRP Steering Committee participates in this process • ILCOR ultimately defines the scientific principles behind resuscitation and develops treatment recommendations
Neonatal Resuscitation Program- where do Guidelines come from? • The Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR) published by ILCOR in October 2010 • Each resuscitation council, including NRP for USA, developed and published Resuscitation Guidelines and treatment recommendations, appropriate for its own resources (based on CoSTR) • If evidence is lacking, treatment recommendations stay the same, even if there is no evidence for them
Without specific evidence to recommend a change, the ruling on the field stands
Neonatal Resuscitation Program- where do Guidelines come from? • Guidelines are evidenced based- to the extent that evidence is available! • They are guidelines. As such, they can not fully anticipate all the nuances of clinical situations. • They do provide a framework that is well suited to almost all resuscitation scenarios • While the principles apply to most cases, in some you must interpret the approach to best fit the unusual patient
What NRP offers • NRP is “an educational program that introduces concepts and basic skills of neonatal resuscitation” • NRP is not intended to set a strict “Standard of Care” • Completion of the program does not imply competence – Each hospital has a responsibility to determine competence and qualifications • Not only are individual skills important, but resuscitation requires a well functioning team
How do we learn and improve? • Not by looking at and listening to a lecture and slides… • Simulation and debriefing provide valuable insight and learning not available by passive instruction • Simulation also allows us to work through unusual cases that don’t seem to exactly fit the mold • On to cases… • Major areas of change in 2010 Guidelines • Topics that have caused questions to arise • What is bothering you??
Case 1 • A 37 year old G2P1 female is in labor at 41 weeks. She develops a fever to 101.2 and is treated with antibiotics during labor. The membranes rupture spontaneously and the fluid is noted to be meconium stained. Other than some variable decelerations the fetal heart rate tracing is unremarkable. The mother progresses to a spontaneous vaginal delivery. • What questions ought you to quickly ask at delivery?
ARQ 1 • What questions should you ask at delivery? • A. Is the baby term, is there meconium stained fluid, is the baby vigorous? • B. Is the baby breathing, Is the baby term, Is the tone good? • C. Is there meconium stained fluid, is the baby term, is the baby breathing?
Initial Questions reduced to THREE: Is the baby term? Is the baby breathing? Is the tone good? Vigorous= normal, regardless of AF Oximetry is the standard! In its absence: adequate ventilation is more important than higher FiO2
Case 2 • The baby, who is term, is crying and moving all his extremities well.
ARQ 2 • What should be the sequence of care? • A. Suctioned by Obstetric provider at perineum, evaluation at warmer by Pediatric team • B. Suctioned at perineum if secretions copious, taken to warmer, intubated, suctioned • C. Suctioned at perineum if secretions copious, given to mother
Suctioning • Evidence indicates suctioning can cause bradycardia during resuscitation, or pulmonary decompensation and reduced cerebral blood flow in intubated patients • Suctioning secretions can decrease pulmonary resistance • 20o5 Guidelines stressed NO ROUTINE suctioning of airway before delivery of the body • True whether fluid is clear or meconium stained
Suctioning after birth • If there is Clear Fluid: limit suctioning to those with obvious obstruction • Stop routine bulb suctioning of all babies • If fluid is meconium stained, must determine if baby is vigorous • Vigor: Good HR, Good cry, Good tone • If infant is vigorous, as this baby appears to be, they do not need any special intervention • Leave VIGOROUS babies with mother!
Suctioning • Meconium: Suction non vigorous babies • Depressed infants with MSF are at increased risk of MAS • Tracheal suctioning has not been associated with less MAS or mortality, other than single trial with historical controls • There is no evidence to change practice of intubating and suctioning non vigorous babies • Attempts should not significantly delay PPV if there is bradycardia Leave VIGOROUS babies with mother!
Case 1 • After two minutes with his mother, the baby has some mild grunting and flaring and is brought to the warmer. Your team evaluates him- he appears to be term, well-formed but has some noticeable grunting. One member of your team notes that he appears cyanotic, and wants to give him blow by oxygen.
ARQ 3 • How might you approach this, and why? • A. Ask team member to place oximeter probe on leg, give oxygen if saturation is less than 90% • B. Ask team member to place oximeter on right upper extremity, give oxygen if saturation is below target range • C. Give oxygen until baby turns pink in opinion of all caregivers present
How pink is a fetus? Dildy GA, et al. Am J Obstet Gynecol. 1994;171:679–684
What are Normal O2 saturations in Vigorous Term Newborns in the DR? 3 min 66% (56-75%) 5 min 80% (55-85%) 7 min 83% (68-88%) Lundstrøm et al Arch Dis Child 1995; 73:F81-6.
Post-ductal O2 sats in the DR N=50 SVD, Term Vigorous Toth et al. Arch Gynecol Obstet 2002;266:105-7.
What are NormalPreductalO2Sats in Vigorous Term Newborns at Birth? Pre ductal readings are the ideal 1 min 63% (53-68%) 2 min 70% (58-78%) 3 min 76% (64-87%) 4 min 81% (71-91%) 5 min 90% (79-91%) Kamlin et al J Peds 2006; 148:585-9.
Take Home Message How often do you think this happens now when pediatric team is present?? Majority of evidence suggests it takes ~5-10 minutes for healthy, term newborns to reach O2 saturations >90% (pink) Therefore, giving O2 to vigorous, term infants before 5-10 minutes is unnecessary.
Is O2 in the Delivery Room better? • We have increasing evidence that too much oxygen is not harmless in other clinical situations • Preemies: • Chronic Lung Disease • Retinopathy of Prematurity • Newborns are relatively deficient in defense mechanisms that protect against oxygen toxicity and therefore too much oxygen may result in oxygen free radicals that are highly reactive and can cause damage to tissues
Consensus on Science for O2 • Meta-analysis of 7 human studies of infants resuscitated with room air (RA) versus 100% O2 [LOE 1] • Reduced Mortality • No evidence of harm • Other concentrations not studied • However… • The 4 largest studies were not blinded • If no response after 90 sec, RA infants switched to 100% O2 • Other significant methodologic concerns regarding patient selection, randomization methods, and follow-up • No data regarding RA vs O2 for resuscitation of infants with • birth weight < 1000 g • congenital pulmonary or cyanotic heart disease • Asystole
Is there a Potential for Harm? • Naumburg et al. Supplementary oxygen and risk of childhood lymphatic leukemia. Acta Paediatr 2002;91:1328-33. (Sweden) • Prospective association between any oxygen exposure in the DR and childhood acute lymphatic leukemia • 2.5X the risk of ALL (1.21-6.82) • > 3 minutes of O2 with BMV • 3.54X the risk of ALL (1.16-10.8)
How do you do it: O2 For Initiation of Resuscitation • Resuscitation should be focused on results (normally increasing oxygen saturations) not on oxygen concentration. • For term and late preterm infants it makes sense to begin in RA and “wean-up” as dictated. There is no data on use of intermediate concentrations. • If resuscitation is started with less than 100% O2, supplemental O2 up to 100% should be administered if there is no appreciable improvement within 90 seconds following birth. • If supplemental oxygen is unavailable, it is fine to use air while delivering positive-pressure ventilation.
How do we assess the baby, or Why do we Need Pulse Oximetry in the DR? • NRP previously recommended using color to decide if oxygen is needed. Now an Oximeter is recommended • How good are we at judging color? • O’Donnell et al. ADC 2007. • Video Recording with Hi-fidelity color and simultaneous SaO2 monitoring • Do clinicians agree whether infants are pink? • At what preductal SaO2 are infants first perceived as pink?
Clinical Assessment of Infant Color at Delivery O’Donnell et al.. ADC 2007.
O2 Sat at Which Infant “Pink” O’Donnell et al. ADC 2007.
Oximeter needed, but Can you get it to work? Study of healthy term and preterm infants- low cardiac output can reduce signal You can get it on, but it takes TEAM work and practice!! • Kamlin et al J Peds 2006; 148:585-9.
ARQ 4 BLUE • When is the use of oximetry indicated? • A. Only for premature infants • B. When using oxygen or PPV • C. At all births attended by Pediatric team PINK
The Practice: Term and Late Preterm babies • Monitor saturations, compare at interval times to posted chart. Team monitoring works best. • Adjust oxygen as needed to achieve target saturation range • Oximeter also often helpful to monitor pulse • Oximetry often not usable when cardiac output is low.
ARQ 5 • If saturation level is below target for age in minutes, how much do you increase to amount of oxygen? • A. 10% • B. 20% • C. 30% • D. To 100%
Case 1 • The measured saturations are initially below the target range for minute after birth. The oxygen level is gradually increased until saturations are in target range. • The baby stabilizes, and is able to wean out of supplemental oxygen over 10 minutes.
Case 2 • A G3P2 woman presents at 27 weeks gestation with recent onset of elevated blood pressures and an evolving picture of rising liver enzymes and decreasing platelet count. She is given a dose of betamethasone and standard therapy for preeclampsia/HELLP syndrome, but her condition worsens and she is taken for Cesarean delivery about 2 hours after admission. The baby emerges with fair tone and minimal respiratory effort.
ARQ 6 • What steps would you take next? • A. Immediately give oxygen and stimulate • B. Place in plastic wrap under warmer, ask team member to place oximeter on RUE • C. Place oximeter on RUE, stimulate
Temperature Control • All newborns are at risk for hypothermia after birth: • Relatively cool environment • High surface area to volume • Risk factor for morbidity and mortality • Babies <1500 g are the population at risk: • VON (2008) 51% had admission temperature to NICU < 36.5 degrees C. ( Roughly the same in my own hospital)
Can hypothermia be prevented? • Plastic Wrap • The baby, undried, is immediately placed in plastic wrap covering body and extremities • Delivery Room Temperature 26 degrees • Exothermic mattresses (Sodium Acetate Gel)
Occlusive Plastic Wrap • Evaluated in many studies- systemic review done • 3 Randomized controlled trials • 5 historical controlled trials • Gestational age < 28-33 weeks, < 1000g • Original data was reviewed and analyzed
Admission Temperature Cramer K, et al. J. Perinatol 2005:25; 763-69.
Mortality No differences in respiratory outcomes, severe neurologic outcomes, or LOS.
OR Temperature & Plastic Wrap Epoch 1- Standard OR temperatures Epoch 2- Increased OR temperature to 26 degrees Epoch 3- Occlusive Plastic wrap used Kent AL, Williams J . J Pediatr Child Health 2008:44:325-331
OR Temperature & Plastic Wrap No difference in survival, days of ventilation, days of oxygen, NEC, severe IVH or infection
Plastic Wrap and Exothermic Mattress • Analysis of three case series: • Traditional care (drying and wrapping in towel) • Wrapping in standard food polyethylene bag • Wrapping in food bag, nursing on exothermic mattress • Retrospective observational study, three different time periods, <30 weeks gestation Singh A, et al. J Perinatol 2010:30:45-49