Neonatal Resuscitation Program Guidelines Research Articles

Development and Evaluation of a Rural Longitudinal Neonatal Resuscitation Program Telesimulation Program (MOOSE: Maine Ongoing Outreach Simulation Education).

Neonatal resuscitation is a high-acuity, low-occurrence event and many rural pediatricians report feeling underprepared for these events. We piloted a longitudinal telesimulation (TS) program with a rural hospital's interprofessional delivery room teams aimed at improving adherence to Neonatal Resuscitation Program (NRP) guidelines and teamwork. A TS study was conducted monthly in one rural hospital over a 10-month period from November 2020 to August 2021. TS sessions were remotely viewed and debriefed by experts, a neonatologist and a simulation educator. Sessions were video recorded and assessed using a scoring tool with validity evidence for NRP adherence. Teamwork was assessed using both TeamSTEPPS 2.0 Team Performance Observation Tool and Mayo High-Performance Teamwork Scale. We conducted 10 TS sessions in one rural hospital. There were 24 total participants, who rotated through monthly sessions, ensuring interdisciplinary team composition was reflective of realistic staffing. NRP adherence rate for full code scenarios improved from a baseline of 39 to 95%. Compared with baseline data for efficiency, multiple NRP skills improved (e.g., cardiac lead placement occurred 12× faster, 0:31 seconds vs. 6:21 minutes). Teamwork scores showed improvement in all domains. Our results demonstrate that a TS program aimed at improving NRP and team performance is possible to implement in a rural setting. Our pilot study showed a trend toward improved NRP adherence, increased skill efficiency, and higher-quality teamwork and communication in one rural hospital. Additional research is needed to analyze program efficacy on a larger scale and to understand the impact of training on patient outcomes. · Optimal newborn outcomes depend on skillful implementation of NRP.. · Telesimulation can deliver medical education that circumvents challenges in rural areas.. · A longitudinal NRP TS program is possible to implement in a rural setting.. · A rural NRP telesimulation program may improve interprofessional resuscitation performance.. · A rural NRP telesimulation program may improve interprofessional resuscitation teamwork..

Use of a SimBox, a Video-Augmented, Newborn Resuscitation Simulation for Prehospital Providers to Measure Clinical Performance and Educational Experience.

Few studies have described the current clinical practices, adherence to guidelines, and outcomes of newborn resuscitations attended by emergency medical services (EMS). SimBox, a novel, video-augmented simulation, was used to describe the adherence of prehospital providers to Neonatal Resuscitation Program guidelines, to measure satisfaction with the simulation intervention, and to describe the self-reported improvement in knowledge, skills, and attitudes after the simulation. A prospective observational cohort study of EMS providers was designed and conducted using SimBox, an open-access simulation platform, and facilitated by EMS educators. Clinical performance measures were collected using a five-item checklist. Simulation satisfaction measures were collected through net promoter scores. Learners' demographics, and self-reported knowledge, skills, and attitudes were measured using a retrospective survey of 25 questions. In total, 33 facilitator and 55 learner surveys were collected across Connecticut, Colorado, and Alaska between July 2021 and September 2022. At least one deviation from clinical guidelines occurred in 22/30 (73.3%) of the sessions, with 10/30 (33.3%) teams inappropriately performing chest compressions, 5/31 (16.1%) teams not warming, drying, stimulating, and suctioning the newborn, and 7/31 (22.6%) teams not performing positive pressure ventilation correctly. Lastly, 10/30 (33.3%) teams administered an incorrect dose of dextrose-containing fluids. Very high levels of satisfaction were reported with net promoter scores of 97 and 82 out of 100 for the facilitator and learner surveys, respectively. Finally, all 55/55 (100%) of the learners strongly or somewhat agreed that the simulation improved their knowledge, teamwork, communication, and psychomotor skills. In this cohort of prehospital providers, clinical management decisions during a newborn resuscitation simulation often deviated from the gold-standard, newborn resuscitation guidelines. Free, online, open-access simulation resources like SimBox can be used to identify and measure practice deviations from standardized resuscitation protocols in the prehospital setting.

Femoral Occlusion during Neonatal Cardiopulmonary Resuscitation Improves Outcomes in an Ovine Model of Perinatal Cardiac Arrest.

The goal of chest compressions during neonatal resuscitation is to increase cerebral and coronary blood flow leading to the return of spontaneous circulation (ROSC). During chest compressions, bilateral femoral occlusion may increase afterload and promote carotid and coronary flow, an effect similar to epinephrine. Our objectives were to determine the impact of bilateral femoral occlusion during chest compressions on the incidence and timing of ROSC and hemodynamics. In this randomized study, 19 term fetal lambs in cardiac arrest were resuscitated based on the Neonatal Resuscitation Program guidelines and randomized into two groups: femoral occlusion or controls. Bilateral femoral arteries were occluded by applying pressure using two fingers during chest compressions. Seventy percent (7/10) of the lambs in the femoral occlusion group achieved ROSC in 5 ± 2 min and three lambs (30%) did not receive epinephrine. ROSC was achieved in 44% (4/9) of the controls in 13 ± 6 min and all lambs received epinephrine. The femoral occlusion group had higher diastolic blood pressures, carotid and coronary blood flow. Femoral occlusion resulted in faster and higher incidence of ROSC, most likely due to attaining increased diastolic pressures, coronary and carotid flow. This is a low-tech intervention that can be easily adapted in resource limited settings, with the potential to improve survival and neurodevelopmental outcomes.

Neonatal resuscitation with continuous chest compressions and high frequency percussive ventilation in preterm lambs.

Cerebral oxygen delivery (cDO2) is low during chest compressions (CC). We hypothesized that gas exchange and cDO2 are better with continuous CC with high frequency percussive ventilation (CCC + HFPV) compared to conventional 3:1 compressions-to-ventilation (C:V) resuscitation during neonatal resuscitation in preterm lambs with cardiac arrest induced by umbilical cord compression. Fourteen lambs in cardiac arrest were randomized to 3:1 C:V resuscitation (90CC + 30 breaths/min) per the Neonatal Resuscitation Program guidelines or CCC + HFPV (120CC + HFPV continuously). Intravenous epinephrine was given every 3 min until return of spontaneous circulation (ROSC). There was no difference in the incidence and time to ROSC between both groups. Median (IQR) PaCO2 was significantly lower with CCC + HFPV during CC, at ROSC and 15 min post-ROSC-[104 (99-112), 83 (77-99), and 43 (40-64)], respectively compared to 3:1 C:V-[149 (139-167), 153 (143-168), and 153 (138-178) mmHg. PaO2 and cDO2 were higher with CCC + HFPV during CC and at ROSC. PaO2 was similar 15 min post-ROSC with a lower FiO2 in the CCC + HFPV group 0.4 (0.4-0.5) vs. 1 (0.6-1). In preterm lambs with perinatal cardiac-arrest, continuous chest compressions with HFPV does not improve ROSC but enhances gas exchange and increases cerebral oxygen delivery compared to 3:1 C:V during neonatal resuscitation. Ventilation is the most important intervention in newborn resuscitation. Currently recommended 3:1 compression-to-ventilation ratio is associated with hypercarbia and poor oxygen delivery to the brain. Providing uninterrupted continuous chest compressions during high frequency percussive ventilation is feasible in a lamb model of perinatal cardiac arrest, and demonstrates improved gas exchange and oxygen delivery to the brain. This is the first study in premature lambs evaluating high frequency percussive ventilation with asynchronous chest compressions and lays the groundwork for future clinical studies to optimize gas exchange and hemodynamics during chest compressions in newborns.

Outcomes of neonates born through meconium-stained amniotic fluid pre and post 2015 NRP guideline implementation.

A shift in the Neonatal Resuscitation Program (NRP) guidelines occurred in 2015 from routine intubation and endotracheal suctioning of all meconium-stained non-vigorous infants towards less aggressive interventions based on response to initial resuscitation. This study aims to examine the impact of this change on outcomes of non-vigorous infants born through meconium-stained amniotic fluid at a level III academic NICU encompassing years before and after the change in guideline. This single-center retrospective study compared NICU therapies and clinical outcomes of 117 non-vigorous newborns pre-guideline implementation to 106 non-vigorous newborns post-guideline implementation. Nearly two thirds of infants in the pre-guideline cohort received endotracheal suctioning with recovery of meconium compared to less than a third of infants in the post-guideline cohort (p<0.01). Though a higher proportion of the pre-guideline cohort were admitted to the NICU for respiratory issues compared to the post-guideline cohort, the two groups did not differ significantly with regard to morbidity and therapies. Despite a marked reduction in rates of intubation and endotracheal suctioning, there is no difference in outcomes between pre-guideline implementation vs post-guideline implementation in non-vigorous meconium-stained infants, supporting the recent NRP guideline change and highlighting the benefit of expectant management.

Randomized Trial of 21% versus 100% Oxygen during Chest Compressions Followed by Gradual versus Abrupt Oxygen Titration after Return of Spontaneous Circulation in Neonatal Lambs

The combination of perinatal acidemia with postnatal hyperoxia is associated with a higher incidence of hypoxic-ischemic encephalopathy (HIE) in newborn infants. In neonatal cardiac arrest, current International Liaison Committee on Resuscitation (ILCOR) and Neonatal Resuscitation Program (NRP) guidelines recommend increasing inspired O2 to 100% during chest compressions (CC). Following the return of spontaneous circulation (ROSC), gradual weaning from 100% O2 based on pulse oximetry (SpO2) can be associated with hyperoxia and risk for cerebral tissue injury owing to oxidative stress. We hypothesize that compared to gradual weaning from 100% O2 with titration based on preductal SpO2, abrupt or rapid weaning of inspired O2 to 21% after ROSC or use of 21% O2 during CC followed by upward titration of inspired O2 to achieve target SpO2 after ROSC will limit hyperoxia after ROSC. Nineteen lambs were randomized before delivery and asphyxial arrest was induced by umbilical cord occlusion. There was no difference in oxygenation during chest compressions between the three groups. Gradual weaning of inspired O2 from 100% O2 after ROSC resulted in supraphysiological PaO2 and higher cerebral oxygen delivery compared to 21% O2 during CC or 100% O2 during CC followed by abrupt weaning to 21% O2 after ROSC. The use of 21% O2 during CC was associated with very low PaO2 after ROSC and higher brain tissue lactic acid compared to other groups. Our findings support the current recommendations to use 100% O2 during CC and additionally suggest the benefit of abrupt decrease in inspired oxygen to 21% O2 after ROSC. Clinical studies are warranted to investigate optimal oxygen titration after chest compressions and ROSC during neonatal resuscitation.

Is intraparum suctioning is safe in newborn born to mother with meconium stain amniotic liquor

Background: Meconium aspiration syndrome (MAS) is a life-threatening respiratory disorder in infants born through meconium-stained amniotic fluid (MSAF). Although anecdotal data concerning the efficacy of intrapartum oropharyngeal and nasopharyngeal suctioning of MSAF are conflicting, the procedure is widely used. We aimed to assess the effectiveness of intrapartum suctioning for the prevention of MAS. Methods: We designed a prospective quasi randomized control trial, assessor blind, single centre study. 312 patients with MSAF of any consistency, gestational age at least 37 weeks, and cephalic presentation were randomly assigned to suctioning of the oropharynx and nasopharynx (including the hypopharynx) before delivery of the shoulders (n=127), or no suctioning before delivery (n=185). Postnatal delivery-room management followed Neonatal Resuscitation Program guidelines. The primary outcome was incidence of MAS. Clinicians diagnosing the syndrome and designating other study outcomes were masked to group assignment. An informed consent waiver was used. Findings: No significant difference between treatment groups was seen in the incidence of MAS (36 [26.7%] suction vs 36 [19.5%] no suction; p=0.167),mortality in suction (5 [3.91%] vs no suction( 5 [2.74%]; p=0.779, ) or in the duration of ventilation, oxygen treatment, and hospital care.

Characterization of teamwork and guideline compliance in prehospital neonatal resuscitation simulations

AimNeonatal cardiopulmonary arrests are rare but serious events. There is limited information on compliance to best-practice guidelines due to rarity, but deviations can have dire consequences. This research aimed to characterize compliance with and deviations from Neonatal Resuscitation Program (NRP) guidelines and their association with teamwork. MethodsWe observed Emergency Medical Service (EMS) teams responding to standardized neonatal resuscitation simulations following a precipitous home delivery. A Clinical expert evaluated teamwork during simulations using the Clinical Teamwork Scale (CTS™). A neonatologist evaluated technical performance in blinded video review according to NRP guidelines. We report the types, counts, and severity of observed deviations. Logistic regression tested the association of CTS™ factors with the occurrence of deviations. ResultsForty-five (45) teams of 265 EMS personnel from fire and transport agencies participated in the simulations. Eighty-seven percent (39/45) of teams were rated as having good teamwork according to CTS™. Nearly all teams (44 of 45) delayed or did not perform one or more of the initial steps of dry, warm, or stimulate; delayed bag-valve mask ventilation (BVM); or performed continuous compressions instead of the recommended 3:1 compression-to-ventilation ratio. Logistic regression revealed an 82% (p < 0.04) decrease in the odds of airway errors for each level of improvement in teams’ decision-making. ConclusionDrying, warming, and stimulating, and ventilation tailored to the physiologic needs of infants continue to be top priorities in neonatal care for out-of-hospital settings. EMS teamwork is good and higher quality of decision-making appears to decrease the odds of ventilation errors.

Pediatric Advanced Life Support in a Neonatal Context.

Pediatric Advanced Life Support in a Neonatal Context.

Updates for the Neonatal Resuscitation Program and Resuscitation Guidelines.

Although most newborns require no assistance to successfully transition to extrauterine life, the large number of births each year and limited ability to predict which newborns will need assistance means that skilled clinicians must be prepared to respond quickly and efficiently for every birth. A successful outcome is dependent on a rapid response from skilled staff who have mastered the cognitive, technical, and behavioral skills of neonatal resuscitation. Since its release in 1987, over 4.5 million clinicians have been trained by the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Program®. The guidelines used to develop this program were updated in 2020 and the Textbook of Neonatal Resuscitation, 8th edition, was released in June 2021. The updated guidelines have not changed the basic approach to neonatal resuscitation, which emphasizes the importance of anticipation, preparation, teamwork, and effective ventilation. Several practices have changed, including the prebirth questions, initial steps, use of electronic cardiac monitors, the initial dose of epinephrine, the flush volume after intravascular epinephrine, and the duration of resuscitation with an absent heart rate. In addition, the program has enhanced components of the textbook to improve learning, added new course delivery options, and offers 2 course levels to allow learners to study the material that is most relevant to their role during neonatal resuscitation. This review summarizes the recent changes to the resuscitation guidelines, the textbook, and the Neonatal Resuscitation Program course.

A Nonimmune Hydrops Case.

A Nonimmune Hydrops Case.

NRP Versus PALS for Infants Outside the Delivery Room: Not If, but When?

Both the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines can be used for infants requiring cardiopulmonary resuscitation outside the delivery room. Each set of guidelines has supporting algorithms for resuscitation; however, there are no current recommendations for transitioning older infants outside the delivery room. To provide background information on the algorithms in the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines and to discuss the role that nurses and advanced practice nurses play in advancing scientific research on resuscitation. Summaries of both sets of guidelines, differences in practices, and recommendations for practice changes will be discussed. Provider preference and unit practice determine which guidelines are used for infants outside the delivery room. Providers in pediatric intensive care units and pediatric cardiac intensive care units often use the Pediatric Advanced Life Support guidelines, whereas providers in neonatal intensive care units use the Neonatal Resuscitation Program guidelines for infants of the same age. The variation in resuscitation practices for infants outside the delivery room can negatively affect resuscitation outcomes.

Neonatal resuscitation in the NICU; Challenges beyond NRP.

Resuscitation of neonates in the newborn period requires attention to cardiopulmonary health with a focus on ventilation and return of spontaneous circulation.1 Newborn resuscitation at delivery is performed according to the Neonatal Resuscitation Program (NRP) algorithm. Infants and children are resuscitated by Pediatric Advanced Life Support (PALS) guidelines from The American Heart Association (AHA). Resuscitation of infants beyond the 24 hours of age represents a challenge in selecting the most suitable algorithm. In general, both the AHA and NRP recommend using NRP guidelines during the immediate newborn period and through their initial hospitalization.1,2 However, questions remain whether all aspects of NRP are appropriate for infants who have long hospitalization times, well beyond the transition period, especially preterm infants.

Effect of a Larger Flush Volume on Bioavailability and Efficacy of Umbilical Venous Epinephrine during Neonatal Resuscitation in Ovine Asphyxial Arrest.

The 7th edition of the Textbook of Neonatal Resuscitation recommends administration of epinephrine via an umbilical venous catheter (UVC) inserted 2–4 cm below the skin, followed by a 0.5-mL to 1-mL flush for severe bradycardia despite effective ventilation and chest compressions (CC). This volume of flush may not be adequate to push epinephrine to the right atrium in the absence of intrinsic cardiac activity during CC. The objective of our study was to evaluate the effect of 1-mL and 2.5-mL flush volumes after UVC epinephrine administration on the incidence and time to achieve return of spontaneous circulation (ROSC) in a near-term ovine model of perinatal asphyxia induced cardiac arrest. After 5 min of asystole, lambs were resuscitated per Neonatal Resuscitation Program (NRP) guidelines. During resuscitation, lambs received epinephrine through a UVC followed by 1-mL or 2.5-mL normal saline flush. Hemodynamics and plasma epinephrine concentrations were monitored. Three out of seven (43%) and 12/15 (80%) lambs achieved ROSC after the first dose of epinephrine with 1-mL and 2.5-mL flush respectively (p = 0.08). Median time to ROSC and cumulative epinephrine dose required were not different. Plasma epinephrine concentrations at 1 min after epinephrine administration were not different. From our pilot study, higher flush volume after first dose of epinephrine may be of benefit during neonatal resuscitation. More translational and clinical trials are needed.

Characterizing prehospital response to neonatal resuscitation

ObjectiveTo evaluate performance of initial steps of newborn resuscitation according to the American Heart Association and American Academy of Pediatrics’ Neonatal Resuscitation Program (NRP) guidelines in the prehospital setting. Study DesignObservational study of 265 paramedics and Emergency Medical Technicians (EMTs) from 45 EMS teams recruited from public fire and private transport agencies in a major metropolitan area. Participants completed a baseline questionnaire assessing demographics, experience, and comfort in caring for children. Simulations were conducted April 2015 to March 2016. Technical performance was evaluated by blinded video review. NRP actions were assessed using a structured performance tool. ResultsTwo hundred sixty-five EMS providers responded to survey questions and participated in simulations. In total, 16% reported feeling very or extremely comfortable caring for children <30 days of age (vs. 71% for children aged 12–18 years). Among 45 EMS teams participating in simulations, 22% (n = 10) dried, 18% (n = 8) stimulated, and 2% (n = 1) warmed within 30 s from arrival and 11% (n = 5) provided BMV within 60 s from arrival, as recommended by NRP. All teams provided BMV. Eighty-eight percent bagged below NRP rate recommendations and 96% bagged with tidal volume exceeding guidelines. Looking over the entire 10-min simulation for ever performing measures, 73% started to dry the baby within a median of 51 (range 0−539) seconds from arrival, 38% started to stimulate the baby within a median of 34 s (range 0−181), and 44% started to warm the baby within a median 291 s (range 27−575 s). ConclusionsThese data from field simulations suggest NRP steps recommended for the first minute after birth are seldom performed in a timely manner and suggests opportunities for improvement.

Continuous chest compressions with asynchronous ventilations increase carotid blood flow in the perinatal asphyxiated lamb model.

Background:The neonatal resuscitation program (NRP) recommends interrupted chest compressions (CC) with ventilation in the severely bradycardic neonate. The conventional 3:1 compression-to-ventilation (C:V) resuscitation provides 90 CC/min, significantly lower than the intrinsic newborn heart rate (120–160 beats/min). Continuous CC with asynchronous ventilation (CCCaV) may improve success of return of spontaneous circulation (ROSC).Methods:Twenty-two near-term fetal lambs were randomized to interrupted 3:1 C:V (90 CC + 30 breaths/min) or CCCaV (120 CC + 30 breaths/min). Asphyxiation was induced by cord occlusion. After five min of asystole, resuscitation began following NRP guidelines. The first dose of epinephrine was given at 6 minutes. Invasive arterial blood pressure and left carotid blood flow were continuously measured. Serial arterial blood gases were collected.Results:Baseline characteristics between groups were similar. Rate of and time to ROSC was similar between groups. CCCaV was associated with a higher PaO2 (22±5.3 vs. 15±3.5 mmHg, p<0.01), greater left carotid blood flow (7.5±3.1 vs. 4.3±2.6 ml/kg/min, p<0.01) and oxygen delivery (0.40±0.15 vs. 0.13±0.07 mL O2/kg/min, p <0.01) compared to 3:1 C:V.Conclusion:In a perinatal asphyxiated cardiac arrest lamb model, CCCaV showed greater carotid blood flow and cerebral oxygen delivery compared to 3:1 C:V resuscitation.

Evaluation of audio-voice guided application for neonatal resuscitation: a prospective, randomized, pilot study.

To examine whether audio-voice guidance application improves adherence to resuscitation sequence and recommended time frames during neonatal resuscitation. A prospective, randomized, pilot study examining the use of an audio-voice application for guiding resuscitation on newborn mannequins, based on the Neonatal Resuscitation Program (NRP) algorithm. Two different scenarios, with and without voice guidance, were presented to 20 medical personnel (2 midwives, 8 nurses, and 10 physicians) in random order, and their performance videotaped. Audio-voice guided resuscitation compared with non-guided resuscitation, resulted in significantly better compliance with NRP order sequence (p<0.01), correct use of oxygen supplementation (p<0.01) and performance of MR SOPA (Mask, reposition, suction, open mouth, pressure, airway) (p<0.01), and shortened the time to "positive pressure ventilation" (p<0.01). In this pilot study, audio-voice guidance application for newborn resuscitation simulation on mannequins, based on the NRP algorithm, improved adherence and performance of NRP guidelines.

Peak Inspiratory Pressure During Delivery Room Resuscitation for Infants Born at Less Than 500 Grams.

Introduction: With the advent of technological advancement and better scientific understanding it is possible now to successfully resuscitate and save babies born at less than 500 grams. Stabilization of these infants in the delivery room (DR) is one of the goals of the golden hour management. While some factors, including temperature management and airway care have standards, there is paucity of data on the optimal peak inspiratory pressure (PIP). The Neonatal Resuscitation Program (NRP) recommends using the same inflation pressure of 20 cm to 25 cm H2O for preterm infants as used for term infants. Preterm lungs are not the same as term infants. Due to the smaller lung volume, capacities and dynamic pulmonary mechanics, these preterm infants are prone to pulmonary complications including pneumothorax. Therefore, there is need to use PIP judiciously in the DR. Methods and Results: In this brief report we present two cases of newborn infants that were born at less than 500 grams and were successfully resuscitated with a lower PIP. The success criteria in the DR were heart rate greater than 100 per minute and adequate oxygen saturations minute by minute per NRP guidelines with minimal use of supplemental oxygen. Conclusion: While we need good prospectively designed studies to document the ideal PIP for these extreme preterm infants, we suggest a PIP lower than the currently recommended may be sufficient for some extremely preterm infants.

When Seconds Matter: Neonatal Resuscitation in the Prehospital Setting

Background: There are approximately 3500 out-of-hospital births per year in the United States. Up to 10% of newborns require some assistance to establish breathing at birth. Neonatal Resuscitation Program(NRP) guidelines recommend maintaining normothermia by drying and warming and initiating BVM within the first minute after delivery. Emergency medical services (EMS) responders must be prepared to provide expert resuscitative measures immediately after birth, but their effectiveness may be limited because pediatric calls are infrequent, age-appropriate pediatric equipment is sparse, and first responders face unpredictable settings. …

The Resuscitation of Apparently Stillborn Neonates: A Peek Into the Practice in China.

Apparently stillborn neonates are born in the terminal stage of secondary apnoea and respond poorly to basic resuscitation procedures proposed by the Neonatal Resuscitation Program (NRP). Increasing experimental and clinical evidence shows that stringently adhering to the NRP guidelines may delay sufficient ventilation and chest compressions and consequently prolong the duration of asystole in apparently stillborn neonates. To add to this information, we summarized our experience with the resuscitation of apparently stillborn neonates and reported the neonatal outcomes in a cohort of apparently stillborn neonates resuscitated at a tertiary care center in China.