Assessment of temporal variations in adherence to NRP using video recording in the delivery room

In the fall of 2005, the International Liaison Committee on Resuscitation (ILCOR) Consensus on Science and Treatment Recommendations (CoSTR) as well as the American Heart Association’s Guidelines for Emergency Cardiovascular Care (ECC) were published in Circulation. The guidelines were prepared by the American Heart Association Pediatric Subcommittee and American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee based on an extensive review of the existing literature on neonatal resuscitation. The guidelines were used to develop and revise the Textbook of Neonatal Resuscitation, 5th edition, and accompanying Neonatal Resuscitation Program (NRP) education materials. Based on their findings, various changes have been made to the NRP, including new recommendations for the use of supplemental oxygen and endotracheal epinephrine. These changes have the potential for a profound impact on medical practice around the world.Newborns who do not require resuscitation generally can be identified by a rapid assessment of the following four characteristics: Of note, a fifth question, “Is the baby pink?” no longer appears as part of the rapid assessment immediately after birth.The sequential approach to a newborn in the delivery room remains the same (FigureF1). NRP providers should continue to adhere to the ABCs of resuscitation: airway before breathing before circulation. The four categories of action in sequence are: Temperature control continues to be an important focus of resuscitation research. Both hypothermia and hyperthermia may have detrimental effects. Hypothermia has a clear association with increased mortality, especially among low-birthweight infants. Hyperthermia is associated with perinatal respiratory depression, neonatal seizures, and cerebral palsy. Hyperthermia after ischemia in experimental animals is associated with worsening of cerebral injury. Efforts in the delivery room should focus on maintaining normothermic temperatures. Use of polyethylene bags in the delivery room is recommended to help maintain body temperature during resuscitation of very low-birthweight (VLBW) infants.A randomized, controlled study to assess the effectiveness of intrapartum oropharyngeal and nasopharyngeal suctioning for babies born through meconium-stained amniotic fluid found that the common, widely accepted procedure of suctioning did not reduce the incidence of meconium aspiration sydrome. Based on these findings, the new guidelines no longer recommend that all meconium-stained babies routinely receive intrapartum suctioning (ie, before delivery of shoulders). Other recommendations about neonatal suctioning after delivery remain unchanged. The vigor of the infant, rather than the consistency of the meconium-stained fluid, determines whether endotracheal suctioning is necessary.Various changes have been instituted regarding the use of supplemental oxygen in the delivery room. For term infants, 100% supplemental oxygen is recommended when an infant has cyanosis or when positive-pressure ventilation is required during resuscitation. Whether room air (or something between room air and 100% Fio2) may be as successful for resuscitation remains controversial and continues to be investigated. However, if resuscitation is started with less than 100% oxygen, supplemental oxygen up to 100% should be administered if there is no appreciable improvement within 90 seconds following birth. If supplemental oxygen is unavailable, room air should be used to deliver positive-pressure ventilation.Both ILCOR and the NRP now recommend the use of an oxygen blender and pulse oximetry in the delivery room for preterm infants, especially those born at less than 32 weeks’ gestation. Initial resuscitation should begin with an oxygen concentration between room air and 100% oxygen (although no specific starting value is recommended), and the Fio2 should be increased only if the infant’s heart rate remains less than 100 beats/min or the infant exhibits cyanosis. The infant’s pulse oximetry reading should increase gradually toward 90% with successful resuscitation. The Fio2 should be weaned for an oxygen saturation greater than 95%. If no oxygen blender is available, 100% oxygen should be used. There is no convincing evidence that a brief period of 100% oxygen during resuscitation will be detrimental to the preterm infant. However, NRP suggests potentially transferring the mother to another facility with oxygen blenders and pulse oximeters in the delivery room prior to delivery, if possible. The potential economic impact of this major change in clinical practice may be substantial.Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised infant. Indications for positive-pressure ventilation include apnea/gasping, a heart rate of less than 100 beats/min, and persistent central cyanosis despite 100% free flow oxygen.Two types of resuscitation bags, self-inflating and flow-inflating, may be used to ventilate a baby. A third type of resuscitation device, the T-piece resuscitator, can be used to deliver positive-pressure ventilation and can deliver up to 100% oxygen. This mechanical device depends on a compressed gas source and must have a tight face-mask seal to inflate the lungs. The operator sets maximum circuit pressure and positive end expiratory pressure (PEEP). A positive-pressure breath is provided by alternately occluding and releasing the hole in the PEEP cap. Peak inspiratory pressure must be adjusted during resuscitation to achieve physiologic improvement (heart rate and color), audible breath sounds, and perceptible chest movements.It is now recommended that bag-and-mask ventilation include at least two persons, with one person performing ventilation, while the other evaluates the response. Heart rate is assessed initially, and if not improving, chest movement and breath sounds are verified. Increasing heart rate is the primary sign of effective ventilation during resuscitation. Other signs are improving color, spontaneous breathing, and improving muscle tone.The laryngeal mask airway has been shown to be effective for assisting ventilation of term and near-term newborns. Data are limited, however, for small preterm infants, and there is no direct comparison of laryngeal mask with bag-and-mask ventilation for initial resuscitation. When bag-and-mask ventilation is unsuccessful and endotracheal intubation is not possible, the laryngeal mask may be an effective alternative.The combination of an increasing heart rate and CO2 detection now is considered the primary method for confirming endotracheal tube placement and adequate ventilation. When the heart rate does not increase promptly after endotracheal intubation, use of a CO2 detector can help differentiate between tube malposition and the need for greater ventilatory support. Two types of CO2 detectors are used commonly in the delivery room to validate proper placement of the endotracheal tube. The first is a colorimetric device, the most commonly used method to detect CO2. This device connects to the endotracheal tube and changes color in the presence of CO2. The other method, capnography, relies on placement of a special electrode at the endotracheal tube connector. The capnograph displays a specific CO2 concentration and should indicate more than 2% to 3% saturation of CO2 if the tube is in the trachea. The CO2 detector should be connected as soon as the endotracheal tube has been inserted, noting the presence or absence of CO2 during exhalation. If CO2 is not detected after several positive-pressure breaths, the clinician should consider removing the tube, resuming bag-and-mask ventilation, and repeating the intubation process. It is important to note that a CO2 detector may not change color if a baby’s cardiac output is very low or absent, such as in the event of cardiac arrest.Significant changes are reflected in the dosing guidelines for endotracheal epinephrine administration. Numerous animal models and studies in adults have suggested that larger doses of endotracheal epinephrine are needed to achieve physiologic effects comparable to intravenous (IV) epinephrine doses. IV administration is preferred because endotracheal dosing is less predictable and efficacious. However, while IV access is being obtained, administration of a higher dose of endotracheal epinephrine (0.03 to 0.1 mg/kg) may be considered. The safety and efficacy of these higher doses, however, have not been studied sufficiently in neonatal resuscitation. Until such information is available, IV administration is the preferred route of delivery. A 3-mL syringe should be used for endotracheal administration and a 1-mL syringe for IV dosing. Recommended doses are: Naloxone administration is not recommended during the primary steps of resuscitation. This agent should be used only in infants who experience continued respiratory depression after positive-pressure ventilation has restored a normal heart rate and color and when there is a history of maternal narcotics within 4 hours of delivery. The preferred routes are either IV or intramuscular. Given the lack of clinical data in newborns, endotracheal administration of naloxone is not recommended.Infants who require resuscitation are at risk for deterioration after their vital signs have returned to normal. Once adequate ventilation and circulation have been established, the infant should be maintained in or transferred to an environment in which close monitoring and anticipatory care can be provided.Infants who require significant resuscitation should be monitored and treated to maintain glucose in the normal range.Hypothermia may reduce the extent of brain injury following hypoxia-ischemia. There are insufficient data to recommend routine use of modest selective or systemic hypothermia after resuscitation of infants in whom asphyxia is suspected. Further clinical trials are needed to determine which infants benefit and which method of cooling is most effective as well as timing and duration of therapy. Avoidance of hyperthermia is particularly important in babies who may have had a hypoxic-ischemic event.A consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents is an important goal. Noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent, and clinicians should not hesitate to withdraw support when functional survival is highly unlikely. The following guidelines must be interpreted according to current regional outcomes: Under any circumstances, discontinuation of resuscitation efforts may be appropriate after 10 minutes of absent heart rate following complete and adequate resuscitation efforts. Consistent, sensitive, and compassionate care for dying infants and their families requires advance preparation, coordination, training, practice, and skillful communication with cultural appropriateness.The NRP always has incorporated performance checklists and a megacode to assess behavioral and psychomotor skills as well as cognitive knowledge. Many educators have argued that this form of assessment is too subjective. In response to such arguments, the new edition of NRP incorporates a new validated and scored megacode checklist assessment. This checklist was developed using feedback from more than 800 NRP instructors and video footage from actual megacodes. A student must score greater than 85% to pass the megacode, which is a required element of course completion. The new edition also provides educational suggestions based in well-founded educational theory to improve instruction. For example, instructors are encouraged to model expert behavior prior to initiating the megacode. Bandura’s Social Behavioral Learning Theory, which deals with the acquisition of behaviors, contends that people acquire behaviors through the observation of others, and they then imitate what they have observed. As crises in the delivery room are unpredictable, so will be the students’ exposure to such emergencies. Modeling expert behavior in a training situation allows trainees to incorporate more than technical and cognitive skills into their internal database of NRP knowledge. The new edition also provides detailed suggestions aimed at enhancing the learning environment for delivery of NRP instruction.Familiarization with the changes in the new NRP guidelines should improve instructor preparedness. Timely implementation of educational plans to incorporate the guidelines into NRP training is imperative.

Part 11: Neonatal Resuscitation

Few data are available regarding the influence of the timing of ischemic stroke management, such as daytime and nighttime hours, on the delay of mechanical thrombectomy, the effectiveness of revascularization, and clinical outcomes. We aimed to investigate whether admission during nighttime hours could impact the clinical outcome (mRS at 90 days) of patients with acute ischemic stroke treated by mechanical thrombectomy. We retrospectively analyzed 169 patients (112 treated during daytime hours and 57 treated during nighttime hours) with acute ischemic stroke in the anterior cerebral circulation. The main outcome was the rate of patients achieving functional independence at 90 days (mRS ≤2), depending on admission time. In patients admitted during nighttime hours, the rate of mRS ≤ 2 at 90 days was significantly higher (51% versus 35%, P = .05) compared with those admitted in daytime hours. Patients in daytime and nighttime hours were comparable regarding admission and treatment characteristics. However, patients in nighttime hours tended to have a higher median NIHSS score at admission (P = .08) and to be younger (P = .08), especially among the mothership group (P = .09). The multivariate logistic regression analysis confirmed that patients in nighttime hours had better functional outcomes at 90 days than those in daytime hours (P = .018; 95% CI, 0.064-0.770; OR = 0.221). In a highly organized stroke care network, mechanical thrombectomy is quite effective in the nighttime hours among acute ischemic stroke presentations. Unexpectedly, we found that those patients achieved favorable clinical outcomes more frequently than those treated during daytime hours. Larger series are needed to confirm these results.

Supraglottic Airways, Tennis, and Neonatal Resuscitation.

BACKGROUND: There is poor adherence to the Neonatal Resuscitation Program (NRP) algorithm by all levels of providers in simulated and clinical settings. While audio- visual prompting improves adherence to cardiopulmonary resuscitation, visual prompting alone has not been effective in improving NRP compliance. For this study, an iOS mobile app, NRP Prompt, was designed to provide audio -visual prompts based on user responses at NRP decision points. OBJECTIVES: To determine if NRP Prompt improves the adherence of novice NRP providers to the NRP algorithm compared to visual- only prompting in simulated neonatal resuscitation. DESIGN/METHODS: First year residents attending NRP training were randomized into intervention and control groups. Resident pairs used standard visual aids with NRP Prompt (intervention) or visual aids only (control) in two low- fidelity neonatal resuscitation simulations, where each resident took turns as team leader. Pairs were then evaluated in a third simulated scenario that was video -recorded, where neither group used NRP Prompt nor visual aids. The primary outcome was comparing the median checklist score in NRP Prompt versus control. Tw o independent NRP providers evaluated the video recordings of each pair using a validated NRP checklist. Secondary outcomes were: time to positive pressure ventilation (PPV), time to chest compressions and time to intubation. Inter-observer variability was determined using a two- way mixed -effects intra -class correlation coefficient (ICC). Median NRP scores and time to interventions were compared between intervention and control using the Wilcoxon ranked- sum test. RESULTs: 39 residents participated, 8 pairs in intervention and 7 pairs (and 1 group of 3) in control. The ICC was 0.69, indicating good inter-rater agreement. Median NRP scores did not differ in intervention 21 (interquartile range (IQR): 1.5) vs. control 21 (IQR: 1.5), p=0.89. Median time in seconds did not differ for time to PPV (60.5 (IQR: 19.5) vs. 48 (IQR: 13.5) p=0.12), chest compressions (202.5 (IQR: 54) vs. 216 (IQR: 71) p=0.69), and intubation (234 (IQR: 145) vs. 264 (IQR: 94.5) p=0.25). CONCLUSION: Training using NRP Prompt did not improve performance in simulated neonatal resuscitation. Potential reasons include voice prompts being distracting and smaller than hypothesized effect size. Future development of prompting apps should have options for different degrees of prompting tailored to user preferences.

The 2005 Consensus on Science and Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR) serves as the scientific basis for neonatal resuscitation. This consensus reflects the world’s published medical literature and the various perspectives of the representatives to ILCOR from North and South America, Europe, Africa, Australia, and New Zealand. Guidelines reflect not only the science, but also the regional differences in equipment and health priorities. Accordingly, guidelines for the United States may differ in some respects from those of Great Britain or South Africa. The United States guidelines serve as the foundation for the Neonatal Resuscitation Program (NRP) educational program. What are the implications of the new consensus, guidelines, and educational program at the most local level – that of the hospitals and the professionals providing perinatal services? How should the changes be implemented in everyday practice? The 2005 guidelines incorporate several major changes in approach that mean not only behavioral changes, but also new equipment. New educational tools and areas of emphasis in the NRP offer opportunities and challenges to both instructors and providers of neonatal resuscitation. Clearly, the most sweeping change in the 2005 guidelines is the possibility of providing positive-pressure ventilation with oxygen concentrations less than 100% during initial resuscitation. This alters the conduct of resuscitation from the immediate rapid assessment performed in the first several seconds after birth. No longer is the question “Is the baby pink?” asked simultaneously with “Is the amniotic fluid clear?”, “Is the baby breathing or crying?”, “Is there good muscle tone?”, and “Is the baby term?”. Instead, the first 10 to 15 minutes …

After completing this article, readers should be able to: 1. Define the indeterminate class of recommendations for neonatal resuscitation. 2. Describe the two areas of current investigation within the indeterminate class recommendations. 3. Describe the application of two techniques from other settings within the indeterminate class recommendations. 4. Describe the indeterminate class recommendation for which conflicting evidence is emerging. With the shift to evidence-based guidelines, the process of revising the scientific framework for neonatal resuscitation and the derivative educational efforts will become more predictable and accessible. Beginning with the International Guidelines 2000, an Indeterminate Class of recommendations appeared. These focused on areas of intense scientific research that may lead to clinically important therapies; technological developments widely adopted for use in other age groups that may find a role in neonatal resuscitation; or emerging evidence that conflicts substantially with previous data, resulting in a revision of recommendations to withdraw support of a particular therapeutic approach. The advent of changes in evidence-based guidelines carries the obligation to monitor the impact of such changes. Finally, entirely new questions and proposed guideline recommendations will be submitted to evidence evaluation in the future. Five Indeterminate Class recommendations appeared in the neonatal resuscitation portion of the International Guidelines 2000 (Table⇓ ). Cerebral hypothermia following hypoxic-ischemic insult and positive-pressure ventilation with room air represent proposals in the translational research phase, moving from animal and molecular models into clinical trials. The recommendations relating to adjunctive airway techniques, laryngeal mask airway and exhaled carbon dioxide detection, recognize the importance of these techniques in the older pediatric and adult populations, but acknowledge the significant limitations in their application to neonates. The statement regarding high-dose epinephrine reinforces the conflicting nature of evidence relating to this therapy, yet it acknowledges that available evidence is extrapolated largely from older age groups and falls short of supporting …

This is a prospective audit to determine the frequency of resuscitation interventions in the clinical setting and to compare self-reports of clinical performance with the existing Neonatal Resuscitation Program (NRP) and Canadian National Guidelines for Neonatal Resuscitation. Fifty-six level I, II, and III hospitals in Canada participated. Any infant requiring resuscitation, as defined by the need for at least positive pressure ventilation (PPV), was eligible for inclusion (n = 783 resuscitations). A prospective self-report audit was chosen and data were collected over a 6-month period in 1998. The audit focused on the use of PPV, intubation, chest compressions, free-flow oxygen, or medications during the resuscitation. The infant's temperature at the end of resuscitation was also noted. The data were analyzed with descriptive statistics. The composition of the resuscitation team and their NRP certification status were recorded. The need for resuscitation was not anticipated in 76% of the cases (596 of 783). Errors in the sequencing of care, such as delays in initiating PPV, provision of chest compressions before or without establishing an airway and ventilatory support, and administering naloxone before PPV, were reported. Resuscitations attended by a team of NRP certified providers had improved sequencing when compared with those in which only some individual providers were certified. Chest compressions were provided in 8% of the cases (65 of 783). Medications were used in 14% (113/783) of all cases. Providers in level I hospitals performed chest compressions more frequently than those in level II and III settings. At the end of the resuscitation, 27% of the infants were hypothermic (142 of 520), and 25% were hyperthermic (128 of 520). Overall, 52% were out of the normal neutral range. Clear differences between the NRP guidelines and actual clinical practice were shown. A high rate of unanticipated resuscitations, delivery room medications, and chest compressions was described. Postresuscitation hypothermia or hyperthermia were common. Improved sequencing was noted when the entire resuscitation team was NRP certified. Certification in NRP does not assure competency, nor does it ensure compliance with established standards of care.

This educational videotape was created as part of a multidisciplinary quality improvement effort to improve performance during neonatal resuscitations in the NICU at Boston Children’s Hospital (BCH). The BCH NICU is a level III/IV 24-bed referral center for critically ill infants requiring complex medical and surgical care. Given that the unit cares for outborn infants ranging from 0 to 9 months old, Pediatric Advanced Life Support (PALS) is the default algorithm followed in the event of neonatal codes and resuscitations.Over a 6-month period, a project team of physicians, nurses, and respiratory therapists observed 24 resuscitations and mock codes in the BCH NICU. Review of these events revealed several key areas that could be targeted with educational interventions. Built around a scenario likely to happen in the NICU, a mock code video was developed to educate the staff and trainees rotating through the unit, with about 8 key practices that could improve performance in neonatal resuscitations.An educational videotape (Video) was developed by a multidisciplinary neonatology team to reinforce the PALS algorithm. The video shows a 4-month-old infant with acute desaturation after undergoing an exploratory laparotomy with bowel resection and primary reanastomosis for an intestinal obstruction. Which of the following steps in the video was performed incorrectly? A backboard was placed before starting chest compressionsAn inline filter was used with a flow-inflating bag mask during resuscitationThe code leader was self-appointedThe endotracheal tube (ETT) was removed after breath sounds were noted to be diminished unilaterallyTransillumination of the chest was performed before needle decompressionOf the options listed, the step that was performed incorrectly was removal of the ETT after breath sounds were found to be diminished bilaterally but louder on the right side (time 2:26). It is possible that the ETT insertion was too deep and the tip was in the right bronchus, leading to louder sounds on the right side. To assess for this, the team should have confirmed the depth of the ETT insertion by looking at the ETT markings at the lips. Several other steps could have been performed before removal of the ETT, such as suctioning of the ETT to assess for (and potentially remove) an obstruction and applying higher pressure during bag-ETT ventilation. Checking the end-tidal carbon dioxide (CO2) or using a CO2 detector to confirm whether the ETT is in place also is a good practice before removing the ETT. Visualization of the ETT passing through the video cords using a laryngoscope (with or without video) would be an ideal way of confirming correct ETT placement. In addition, though breath sounds were diminished bilaterally, breath sounds were louder on the left than on the right, which may have served as an early indicator of a left pneumothorax (time 5:59). The mnemonic DOPE (Displacement of tube from the trachea, Obstruction of the tube, Pneumothorax, Equipment failure) serves as a useful guide in the event that an intubated patient develops acute respiratory failure and decompensation. Although not provided as an answer option, the resuscitation could have also been improved by having the team members lock their elbows when providing chest compression (time 4:11) to be maximally effective.Placement of a backboard before starting compressions in a 4-month-old infant is an important step of infant resuscitation that is often overlooked. In younger and small infants, the placement of the resuscitator’s hands on the infant’s back with the thumbs encircling the chest provides a backboard effect. Providing a firm backing ensures maximal displacement of the anterior chest wall and cardiac compression without loss of force into the surface on which a patient is lying. Research has found that backboards improve efficacy of compressions especially when the patient is on a soft surface and has a lightweight torso. (1)Designating a code team leader during neonatal resuscitation is critical to ensure that the resuscitative effort is effectively coordinated and managed. In the video, a code team leader was self-appointed. It is imperative that everyone involved in the code recognizes who the code leader is. In our unit, the code leader stands on a stool that is stored on the code cart, but other units have used different approaches, such as the use of a code leader vest. Other roles should be clearly delineated and include airway management, medication preparation/administration, event recorder/time-keeper, chest compressor, and family liaison. In the video (time 1:37), the nurse lead designated the roles; this is important as this person knows the strength and scope of each team member.In infants with acute decompensation and diminished breath sounds unilaterally, a pneumothorax must be considered. Prior to needle decompression, the presence of a pneumothorax should be confirmed with either a chest radiograph or transillumination if a patient is too unstable to wait for or tolerate imaging studies. Of note, in older infants and children, transillumination may not be diagnostic as a larger body habitus impedes transmission of light into the pleural spaces.Minimizing transmission of SARS-CoV-2 during high-risk procedures such as intubations requires detailed protocols and is well-described elsewhere. (2) As outlined in the video, use of proper personal protective equipment (PPE) including N95 masks, protective eyewear, gowns, and gloves is crucial. Each staff member in the unit carries a small backpack with personal PPE (eyewear and N95 mask) as seen in the video. In addition, any airway equipment that comes into contact with the patient, such as bag masks and ventilator tubing, should have appropriate high-efficiency particulate air (HEPA) filtration to prevent spread of viral particles.Overall, as outlined in the video, our quality improvement team identified 8 key components of the PALS algorithm as opportunities for improving performance (unpublished data). These include the following: Ensure early and clear identification of the code leader at the onset of the code.Use closed loop communication to ensure timely execution of necessary interventions.Anticipate the need for potential medications and products to ensure their prompt availability during a code.Perform high-quality cardiopulmonary resuscitation (CPR) by ensuring that compressions occur on a backboard with a compression depth of one-third the anteroposterior depth of the chest. If the patient is intubated, aim for 100 compressions/min and 8 to 10 breaths/min uncoordinated. If not intubated, perform coordinated compressions and breath at a ratio of 15:2.Review reversible etiologies that could lead to cardiac or respiratory arrest if a patient does not respond as expected.Switch the person who is performing CPR compressions every 2 minutes to ensure high-quality CPR.Check the patient’s pulse every 2 minutes as compressions can affect telemetry readings.Ensure the proper concentration and dose, route, and interval for common code medications, such as epinephrine.Although each NICU and pediatric intensive care unit (PICU) that uses the PALS algorithm should perform its own assessment of code performance, we believe that this video highlighting the aforementioned practices could be of value to units with a similar patient population that are interested in improving outcomes during PALS-based resuscitations.What are the differences between Pediatric Advanced Life Support (PALS) and Neonatal Resuscitation Program (NRP) algorithms when 2 rescuers are available? Choose an answer option that correctly describes practices for both NRP and PALS (more than 1 option may be correct).NRP: Sequencing of airway, breathing, and circulationSynchronous vs. asynchronous ventilation after advanced airway is establishedCompression to ventilation ratioFrequency of pulse checksPALS: Compressions, airway, breathing (CAB) sequenceAsynchronous compression to ventilation after advanced airway is establishedCompression to ventilation 3:1Pulse checks every 2 minutesCurrently, there are no clear guidelines on when it is appropriate to switch from an NRP to PALS-based algorithm for resuscitation. Research has shown that there is a wide variation in when ICUs use either NRP or PALS, with NICUs often using NRP for significantly older children than seen in PICUs. (3) Given the complexity of patients in the BCH NICU and the absence of a delivery room, our practice has been to exclusively use PALS for codes and resuscitations, based on the wide range of causes that lead to patient decompensation in our unit. In a unit where the primary etiology of codes is respiratory in nature, it may make more sense to use NRP.The sequence airway, breathing, and circulation (ABC) was a hallmark of both NRP and PALS. However, in 2010, the American Heart Association guideline recommended that PALS rescuers alter the sequence to compressions, airway, and breathing (CAB). The focus on rapid initiation of compressions in PALS was inspired by the higher rates of cardiac arrest in adults, in which initiation of compressions could deliver already existing oxygen in the lungs and bloodstream to vital organs. (4) Delay of these compressions to evaluate the airway and adequately deliver ventilation was thought to worsen outcomes, and practically teaching a single approach for children and adults simplified the educational process for resuscitation. However, because the majority of arrests in the delivery room and newborn period are respiratory, NRP has maintained the ABC focus during resuscitation.While NRP recommends continuation of synchronous compression to ventilation even after advanced airway, PALS endorses asynchronous compression to ventilation after an advanced airway is established. No clinical studies have determined the benefit of synchronized compressions and ventilations in the newborn, but given that the chest wall of a newborn is significantly more compliant than that of an older child, asynchronous compressions may impede effective air delivery through ventilations that have to overcome added resistance in a compressed chest.The compression to ventilation ratio recommended in NRP is 3:1, whereas for PALS, it is 15:2. As stated before, given that most arrests in the delivery room and newborn period are respiratory in nature, the ratio of 3:1 has been found to provide the most effective ventilation and therefore remains the ideal ratio for NRP.The recommendation for frequency of checking a pulse is different in NRP and PALS. While the pulse should only be checked once every 2 minutes during PALS, NRP guidelines recommend evaluating the pulse at least every 60 seconds. Rapid changes in heart rate that can occur in newborns once effective ventilation is established necessitate the need for more frequent pulse checks, whereas in older children with more complex etiologies of arrest, stopping to check pulses more often leads to an interruption of chest compressions. Research has demonstrated that continuous and sustained compressions are required to generate gradual increases in coronary perfusion pressure (CPP), and that interrupted compressions dramatically decrease CPP and the chance of return of spontaneous circulation. (5)D. The ETT was removed after breath sounds were noted to be diminished unilaterally.NRP: A. Sequencing of airway, breathing, and circulation; and B. Synchronous vs. asynchronous ventilation after advanced advanced airway is established. PALS: A. Compressions, airway, breathing (CAB) sequence; B. Asynchronous compression to ventilation after advanced airway is established.

111. IMPLEMENTATION OF A NEONATAL QUALITY IMPROVEMENT SIMULATION PROGRAM FOR PEDIATRIC RESIDENTS

Analysis and classification of errors made by teams during neonatal resuscitation

Context: Simulation facilitates learning with practice opportunities with feedback for the students in preparatory programme in health care profession. Objectives: This study examined the effectiveness of Clinical simulation in acquiring knowledge and skill in performing Neonatal Resuscitation among B.Sc. Nursing students. Methods and Materials: With Quasi experimental approach Eighty five students of B.Sc Nursing III year were enrolled by Non Randomized purposive sampling technique. Study was conducted in Simulation Lab, PSG IMSR, Coimbatore. The student’s knowledge was assessed by using questionnaire on Neonatal Resuscitation Programme (NRP). The students were educated on NRP in case scenarios through clinical simulation approach in four groups. After the period of one week the student’s knowledge and Psychomotor skill in performing Neonatal Resuscitation was assessed through questionnaire and Objective Structured Clinical Examination (OSCE) on Neonatal Resuscitation Programme. Results/Findings: The results revealed that half of the nursing students 44 (52%) had inadequate knowledge, forty one nursing students (48%) had moderately adequate knowledge and none of them had adequate knowledge on neonatal resuscitation in pre test. Mean knowledge score at Pre test was 8.83±2.80 and the post test knowledge score was 21.7±2.68. Comparison of pre test and post test Knowledge score on NRP was 12.89±3.92 (t=30.31, p-value=0.0001, p<0.05) and statistically significant difference was found in post test knowledge score. There was a significant increase in post test skill of nursing students on various areas like Basic Life support, newborn not breathing, Positive pressure ventilation and chest compression with calculation and administration of medications. The overall mean post test skill was 21.52±4.21. Moreover, it was found that the nursing students after post test skill reported that they were confident in performing Neonatal resuscitation. Conclusion: This finding demonstrates that the clinical simulation transforms the pedagogy of nursing education from theory and clinical learning to theory, simulation and clinical application.

Aims: The Neonatal Resuscitation Program (NRP) is a course for healthcare professionals who can be called "those who touch the baby at the time of birth". The knowledge and skills obtained through this training program can be used in infant resuscitation at the time of birth and neonatal period resuscitation, which includes the first 30 days of life. It is aimed to evaluate the approaches of pediatric surgeons and research assistants in terms of their opinions and practices regarding NRP, as there are publications in the literature about the NRP experiences of other healthcare professionals. Methods: After receiving the approval of the Ethics Committee,the survey was published as a descriptive and cross-sectional study via the Google Docs system, and the participation of pediatric surgeons and research assistants was requested. Our research was conducted between October 2023 and March 2024 by asking the participants survey form questions via communication tools such as e-mail, telephone, social media, Internet. Data were sent to participants in the form of electronically prepared survey forms via e-mail addresses and social media platforms. It was collected electronically within the date ranges determined for the research. Results: Thirty-seven participants were male, and 40 participants were female. The average age of 77 pediatric surgeons who participated in the survey was determined to be 43.8 years old. Seventeen of the participants are research assistants; 24 of them are specialist physicians; 10 of them are Dr. Lecturers; 12 of them are associate professors; 14 of them were professors. It was determined that 48 of 77 physicians took the NRP course. It has been determined that those who took the NRP course can contribute more to resuscitation practices. Conclusion: It has been stated that pediatric surgeons are familiar with NRP applications and that as clinical experience increases, even among those who have not taken the course, interventions by NRP can be performed. It is seen that pediatric surgeons can effectively participate in NRP courses.

Prenatal counseling and resuscitation decisions at extremely premature gestation

The following guidelines are an interpretation of the evidence presented in the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations 1 ). They apply primarily to newly born infants undergoing transition from intrauterine to extrauterine life, but the recommendations are also applicable to neonates who have completed perinatal transition and require resuscitation during the first few weeks to months following birth. Practitioners who resuscitate infants at birth or at any time during the initial hospital admission should consider following these guidelines. For the purposes of these guidelines, the terms newborn and neonate are intended to apply to any infant during the initial hospitalization. The term newly born is intended to apply specifically to an infant at the time of birth. Approximately 10% of newborns require some assistance to begin breathing at birth. Less than 1% require extensive resuscitative measures. 2,3 Although the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life, because of the large total number of births, a sizable number will require some degree of resuscitation. Those newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following 3 characteristics: ● Term gestation? ● Crying or breathing? ● Good muscle tone? If the answer to all 3 of these questions is “yes,” the baby does not need resuscitation and should not be separated from the mother. The baby should be dried, placed skin-to-skin with the mother, and covered with dry linen to maintain temperature. Observation of breathing, activity, and color should be ongoing. If the answer to any of these assessment questions is “no,” the infant should receive one or more of the following 4 categories of action in sequence: