Addendum to the NRP Provider Textbook 6th Edition

Recommendations for specific modifications in the

Canadian context
A subcommittee of the Canadian Neonatal Resuscitation Program (NRP) Steering
Committee was convened to review the recent changes to the 6th edition NRP
textbook as they may apply within the Canadian context. The 2010 International
Liaison Committee on Resuscitation (ILCOR) guidelines and worksheets and the 2010
American Heart Association (AHA) guidelines were used as the primary source
documents. The composition of the subcommittee included representation from the
Canadian NRP Steering Committee, the Canadian NRP Executive Committee and
invited experts.

The mandate of the subcommittee was as follows:

a) Review of ILCOR neonatal worksheets and guidelines and the American
Academy of Pediatrics (AAP) NRP 6th edition textbook (based on the 2010 AHA
guidelines).
b) Assess and determine if any of the content in the AAP NRP 6th edition
textbook, AHA, or ILCOR documents was not applicable or may be interpreted
differently in Canada, therein requiring adaptation within the Canadian
neonatal community.
c) Provide recommendations on any specific modifications and communicate
these to NRP instructors and parent institutions as an addendum to the 6th
edition of the NRP textbook

All recommendations from this subcommittee have been approved by the Canadian
NRP Steering Committee.

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Recommendations
These treatment recommendations reflect the ILCOR consensus as applied in the
Canadian context. They are limited to changes that narrow, broaden or further clarify
management options.

A. Delayed Cord Clamping

ILCOR commentary: Cord clamping should be delayed for at least 1 minute in infants
who do not require resuscitation. Evidence is insufficient to recommend a time for
clamping in those who require resuscitation.

Recommendation for delayed cord clamping:

1. The available evidence does not support or refute delayed cord clamping
in those neonates who require active resuscitation. It is preferable to
delay cord clamping in well neonates who do not require resuscitation.

B. Attendance at Elective Caesarean Section Deliveries

ILCOR Commentary: When an infant without antenatally identified risk factors is
delivered at term by caesarean section under regional anaesthesia, evidence
suggests that the need for intubation during resuscitation is low.

Recommendation for attendance at elective caesarean section deliveries:

1. At a caesarean section for term delivery under regional anaesthesia with
no antenatally identified risk factors, a provider capable of performing
assisted ventilation should be present. This provider does not necessarily
need to be skilled in neonatal intubation.

C. Meconium-Stained Amniotic Fluid (Lessons 1, 2)

ILCOR Commentary: The available evidence does not support or refute the routine
endotracheal suctioning of infants born through meconium-stained amniotic fluid,
even when the newborn is depressed.

The rapid assessment questions no longer include asking whether there was a
history of meconium stained amniotic fluid (MSAF). Consequently, a vigorous infant
who is born through MSAF would not enter the resuscitation sequence and would
receive routine care with the mother. However, the management of the non-vigorous
infant born through MSAF still includes tracheal suction as part of the initial steps of
resuscitation.

Recommendation for management of non-vigorous infants born through MSAF:

1. The current practice of intubation and suction below the cords should be
continued when a non-vigorous infant is born with a history of meconium-
stained amniotic fluid.

D. The Use of Pulse Oximetry (Lessons 2, 3, 5, 6)

American Heart Association (AHA) NRP 2010 commentary: The algorithm
recommends saturation monitoring when resuscitation can be anticipated and for all
infants receiving supplemental oxygen or positive pressure ventilation (PPV).

It is recommended that oximetry be used when resuscitation can be anticipated,2

when positive pressure is administered for more than a few breaths, when cyanosis
is persistent, or when supplementary oxygen is administered (Class I, LOE B).
(AHA, 2010, p. S912)

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Recommendations for the routine use of pulse oximetry during resuscitation:
1. Pulse oximetry should be used for all infants who require PPV, appear
cyanotic at 5 minutes or more of age or have laboured respirations.
2. Every delivery area should have access to a pulse oximeter, set to
manufacturers specified mode for neonatal resuscitation, with an
appropriately sized probe for newborn infants.
3. The probe should be applied on the right hand or wrist first and then
attached to the pulse oximeter in order to achieve the fastest readings.

Refer to the NRP Flow Diagram for a table of appropriate pre-ductal (right
wrist/hand) saturation targets to guide supplemental oxygen therapy.

E. Use of Supplemental Oxygen (Lessons 3, 4)

ILCOR Commentary: For infants born at term, it is best to begin resuscitation with
air rather than 100% oxygen. Administration of supplementary oxygen should be
regulated by blending oxygen and air, and the concentration delivered should be
guided by oximetry. Infants less than 32 weeks gestation are less likely to achieve
the gradual rise in oxygen saturations seen in healthy term infants if either room air
or 100% oxygen is used during initial resuscitation: blended oxygen and air may be
given judiciously, guided by pulse oximetry.

Recommendations for the use of supplemental oxygen:

1. Blended gases should be available in the delivery room and during
transport to the SCN/NICU.
2. In infants 32 weeks and greater who require PPV, the initial gas should be
21% oxygen (room air).
3. Until further evidence is available for the optimal initial oxygen
concentration in infants less than 32 weeks gestation who require PPV,
use of supplemental oxygen should be guided by institutional or referral
centre protocols.
4. In all gestational ages, supplemental oxygen should be titrated using pulse
oximetry to achieve saturation targets.

F. Persistent Cyanosis and/or Laboured Respirations (Lessons 2, 7)

Infants who, after the initial steps of resuscitation, have a heart rate over 100 beats
per minute, yet have persistent cyanosis or laboured respirations exit the
resuscitation algorithm and proceed to post-resuscitation care. For these infants, the
algorithm recommends clearing the airway, applying pulse oximetry and providing
continuous positive airway pressure (CPAP). In the context of persistent cyanosis and
laboured respirations, despite implementation of the aforementioned strategies, the
use of PPV should be also considered.

Recommendations for management of persisting cyanosis and/or laboured respirations:

1. Post-resuscitation care needs to include ongoing monitoring of vital signs,
management of temperature and close observation for complications and
deterioration or improvement in status.
2. If infants have persistent cyanosis (as evidenced by oxygen saturations,
measured by pulse oximetry, less than targeted levels) despite
supplemental oxygen and/or CPAP, positive pressure ventilation should be
considered.

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G. Use of Continuous Positive Airway Pressure (CPAP) in Resuscitation (Lessons 1, 8)
ILCOR Commentary: There is some evidence that the use of CPAP in the delivery
room may decrease the need for intubation and the use of mechanical ventilation in
premature infants.

There is no evidence to support or refute the use of CPAP in the term infant.

Recommendation for the use of CPAP in neonatal resuscitation:

1. CPAP may be considered as a post-resuscitation care strategy for infants
with persistent cyanosis (as evidenced by oxygen saturations less than
targeted levels) and/or laboured respirations.
2. Mask or endotracheal ventilation must be considered for all infants who
fail to respond to CPAP. Consider consultation with local experts and/or
protocols.

H. Assisted Ventilation Devices (Lessons 3, 4)

ILCOR Commentary: The three resuscitation devicesthe self-inflating bag, the flow-
inflating bag, the T-piece resuscitatorare all acceptable options for providing
positive pressure ventilation in the neonate. Initial inflation pressures should be the
minimal pressure needed to achieve an increase in heart rate. When a pressure
manometer is being used, initial inflation pressures of 20 to 25 cm of H2O are often
sufficient for premature infants. Term infants may require initial inflation pressures of
30 to 40 cm H2O.

Recommendations for the assisted ventilation devices in neonatal resuscitation:

1. PPV may be delivered using a self-inflating bag, flow-inflating bag or T-
piece resuscitator. Choice of device should be based on familiarity and
experience with the given device.

I. Laryngeal Mask Airway (Lesson 5)

ILCOR Commentary: Evidence suggests that laryngeal mask airway (LMA) has
comparable efficacy to intubation or face mask when ventilating newborns during
delivery room resuscitation. There, however, is limited evidence to evaluate the
effectiveness of using the LMA in the following settings: newborns less than 2000
grams or born at less than 34 weeks gestation; in the presence of meconium-
stained amniotic fluid; during chest compressions; or for the delivery of intratracheal
medications.

Recommendations for the laryngeal mask airway in neonatal resuscitation:

1. The LMA should be considered in neonatal resuscitation when PPV with a
face mask is ineffective and when attempts at endotracheal intubation are
not feasible or have not been successful.
2. Infants with a complex airway and respiratory distress should be
considered for an LMA as the primary strategy, particularly when the
resuscitator is not skilled at advanced airway support.

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J. Ensuring Adequate Ventilation (Lessons 3, 4)
Adequate ventilation is essential for successful resuscitation of the newborn. the
NRP text recommends that corrective steps (using the acronym MRSOPA) should
be done before starting chest compressions on an infant who is not responding to
PPV.

Recommendations to ensure adequate ventilation:

Prior to commencing chest compressions, the effectiveness of positive pressure
ventilation should be evaluated by performing the following corrective steps,
identified by the acronym MR SOPA:

M Mask adjustment
R Reposition airway
S Suction mouth and nose
O Open mouth
P Pressure increase
A Airway alternative

The choice of alternative airway will depend on the experience of the practitioner,
and should not unduly delay the institution of chest compressions.

K. Administration of Epinephrine (Lesson 6)

AAP NRP 2010 commentary: The IV route is recommended, with consideration of the
endotracheal route only while IV access is being obtained. The recommended dose of
epinephrine (1:10,000 solution) is 0.01 to 0.03 mg/kg IV which equates to 0.1 to
0.3 mL/kg. If giving endotracheally, consider a higher dose of 0.05 to 0.1 mg/kg
which equates to 0.5 to 1 mL/kg of 1:10,000 solution.

Canadian context: The recommendations for the Canadian context remain

unchanged from the previous (NRP 2006) doses. The Canadian interpretation of the
science over the past 6 years is that there is no evidence to suggest consideration of
a higher dose of intravenous or endotracheal epinephrine.

Recommendations for the administration of epinephrine (adrenaline):

1. Endotracheal Tube: The first dose of epinephrine may be given via the
endotracheal tube while preparing for insertion of umbilical venous
catheter (UVC). Prepare a 3 mL syringe of 1:10,000 epinephrine (dose of
1 mL/kg). (Maximum endotracheal dose is 3 mL of 1:10,000 epinephrine).
2. Intravenous (Umbilical Venous Catheter): Prepare a 1 mL syringe of
1:10,000 epinephrine (dose of 0.1 mL/kg). Flush with up to 5 mL of 0.9%
NaCl.

L. Post-resuscitation Management: Hypothermia (Lesson 7)

ILCOR Commentary: Therapeutic hypothermia should be considered for infants born
at term or near-term with evolving moderate to severe hypoxic-ischemic
encephalopathy. The administration of therapeutic hypothermia should be conducted
in accordance with a strict and evidence based protocol and coordinated through a
regional perinatal system.

Evidence to-date from animal experimental models and human randomized

controlled trials demonstrates that therapeutic hypothermia (selective head and total
body) improves the outcome of selected newborns with signs of hypoxic ischemic
encephalopathy. There are also observational data that suggest that overheating

July 13, 2011

leading to hyperpyrexia may be detrimental to the neonatal brain. There is however,
little or no evidence to suggest that cooling should begin in the first minutes of age
(i.e.: during or immediately following resuscitation) or before the resuscitation has
been completed. All of the studies included patients in whom cooling was only
initiated in the post-resuscitation phase, and at least 60 to 90 minutes after birth.
Given the need for specialized equipment and expertise to apply therapeutic
hypothermia effectively and safely, infants who may benefit from this therapy should
be transported to the regional tertiary care centre as soon as possible.

Recommendations for the use of therapeutic hypothermia:

1. Decisions regarding ongoing temperature management of potential
candidates for induced hypothermia or targeting borderline low
temperatures should be discussed with your tertiary centre.
2. Avoid causing inadvertent hyperthermia by over-warming infants. All
infants (term and preterm) who remain under a radiant warmer by 10
minutes of age should have a servo control probe placed to avoid both
hypo- and hyperthermia.

References

Kattwinkel, J., Perlman, J.M., Aziz, K., Colby, C., Fairchild, K., Gallagher, J.,
Zaichkin, J. (2010). Part 15: Neonatal resuscitation: 2010 American Heart
Association guidelines for cardiopulmonary resuscitation and emergency
cardiovascular care. Circulation, 122, S909-S919.
doi:10.1161/circulationaha.110.971119

Perlman, J.M., Wylie, J., Kattwinkel, J., Atkins, D.L., Chameides, L., Goldsmith, J.P.,
Neonatal Resuscitation Chapter Collaborators. (2010). Part 11: Neonatal
resuscitation: 2010 International consensus of cardiopulmonary resuscitation and
emergency cardiovascular care science with treatment recommendations.
Circulation, 122, S516-S538. doi: 10.1161/circulationaha.111.971127

July 13, 2011