Textbook of Neonatal Resuscitation

345 Pages·2011·7.99 MB·English

by  American Academy of Pediatrics

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Textbook of Neonatal Resuscitation™ o
Neonatal
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6th Edition t
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The extensively revised and updated 6th edition of the Neonatal Resuscitation
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Program™ (NRP)™ textbook and accompanying DVD-ROM are designed in accord with u
the program’s curriculum changes and sharpened focus on active, hands-on learning. s
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The text facilitates the newly recommended self-paced learning approach. Self-study i
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is optimized to help students prepare for the mandatory online examination that
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replaces the traditional written test. It also complements the simulations and case-based i T E X T B O O K
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scenarios at the heart of the new NRP.
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Content updates throughout the text and DVD-ROM reflect the 2010 American
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Academy of Pediatrics (AAP)/American Heart Association Guidelines for Neonatal e
Resuscitation. Must-know new material includes the latest recommendations across x
key areas of change, including t
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• Revisions in the NRP flow diagram
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• Elimination of evaluation of amniotic fluid in initial rapid assessment
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• Use of supplemental oxygen during resuscitation
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• Use of pulse oximetry
• Chest compression procedures
The book includes a companion DVD-ROM (for use on both PC and Mac), bringing
a higher level of interactivity to the learning process. Active learning features on the
DVD include multi-decision point scenarios and randomly generated clinical problems
and outcomes.
To order NRP materials, visit the AAP Online Bookstore at www.aap.org/bookstore.
Minimum System Requirements
Windows XP, Windows 7, or Vista
Intel Pentium III processor; Microsoft Windows XP with Service Pack 2, Windows 7 or Windows Vista; 256 MB of
RAM; High Color (16-bit) display; 800 × 600 display resolution; Sound Card; 8× DVD-ROM drive; 500 MB available
hard disk space.
Macintosh OS X
PowerPC® G5 or Intel processor; Mac OS X v10.4; 512MB of RAM; 500 MB free hard disk space; 8× DVD-ROM
drive; 800 × 600 display with thousands of colors; speakers or headphones.
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Textbook of Neonatal
Resuscitation,
6th Edition
EDITOR ASSOCIATE EDITORS NRPTM
John Kattwinkel, MD, FAAP Jane E. McGowan, MD, FAAP
Jeanette Zaichkin, RN, MN, NNP-BC
ASSISTANT EDITORS
Khalid Aziz, MD, FRCPC Jay P. Goldsmith, MD, FAAP Jeffrey M. Perlman, MB, ChB,
Christopher Colby, MD, FAAP Louis P. Halamek, MD, FAAP FAAP
Marilyn Escobedo, MD, FAAP Praveen Kumar, MD, FAAP Mildred Ramirez, MD, FACOG
Karen D. Fairchild, MD, FAAP George A. Little, MD, FAAP Steven Ringer, MD, PhD, FAAP
John Gallagher, RRT-NPS Barbara Nightengale, RN, MSN, Gary M. Weiner, MD, FAAP
NNP-BC Myra H. Wyckoff, MD, FAAP
EDUCATIONAL DESIGN EDITOR MANAGING EDITORS Based on original text by
Jerry Short, PhD Rachel Poulin, MPH Ronald S. Bloom, MD, FAAP
Wendy Marie Simon, MA, CAE Catherine Cropley, RN, MN
Textbook of Neonatal Resuscitation, 6th Edition, Interactive Multimedia DVD-ROM:
Editors
Louis P. Halamek, MD, FAAP Jeanette Zaichkin, RN, MN, NNP-BC
Associate Editors
JoDee Anderson, MD, MsEd, FAAP Susanna Lai, MPH
Dana A. V. Braner, MD, FAAP John Kattwinkel, MD, FAAP
Assistant Editors
Khalid Aziz, MD, FRCPC Louis P. Halamek, MD, FAAP Jeffrey M. Perlman, MB, ChB,
Christopher Colby, MD, FAAP Praveen Kumar, MD, FAAP FAAP
Marilyn Escobedo, MD, FAAP Douglas T. Leonard, MD, FAAP Mildred Ramirez, MD, FACOG
Karen D. Fairchild, MD, FAAP George A. Little, MD, FAAP Steven Ringer, MD, PhD, FAAP
John Gallagher, RRT-NPS Barbara Nightengale, RN, MSN, Gary M. Weiner, MD, FAAP
Jay P. Goldsmith, MD, FAAP NNP-BC Myra H. Wyckoff, MD, FAAP
Contributors Animator
Julie Arafeh, RN, MSN Cheryl Major, RNC-NIC, BSN Scott Eman
Kimberly D. Ernst, MD, MSMI, Ptolemy Runkel
FAAP Scott Runkel
Jay P. Goldsmith, MD, FAAP Bret Van Horn
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Sixth edition, 2011
Fifth edition, 2006
Fourth edition, 2000
Third edition, 1994
Second edition, 1990
First edition, 1987
Library of Congress Catalog Card No. 2010907499
ISBN-13: 978-1-58110-498-1
NRP301
All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright
Act of 1976, no part of the material protected by this copyright notice may be reproduced or utilized in any form,
electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system,
without written permission from the copyright owner.
The material is made available as part of the professional education programs of the American Academy of
Pediatrics and the American Heart Association. No endorsement of any product or service should be inferred or is
intended. Every effort has been made to ensure that contributors to the Neonatal Resuscitation Program materials
are knowledgeable authorities in their fields. Readers are nevertheless advised that the statements and opinions
expressed are provided as guidelines and should not be construed as official policy of the American Academy of
Pediatrics or the American Heart Association. The recommendations in this publication and the accompanying
materials do not indicate an exclusive course of treatment. Variations, taking into account individual circumstances,
nature of medical oversight, and local protocols, may be appropriate. The American Academy of Pediatrics and the
American Heart Association disclaim any liability or responsibility for the consequences of any actions taken in
reliance on these statements or opinions.
The American Academy of Pediatrics reserves the right to disclose personal information related to course completion
of course participants/providers for administrative purposes such as to verify participation or classes taken or to
validate the status of any Course Completion Card. In no event shall the American Academy of Pediatrics or
American Heart Association have any liability for disclosure or use of information for such purposes or responsibility
for the consequences of any actions taken in reliance on such information.
Copyright © 2011 by American Academy of Pediatrics and American Heart Association
5-246/0411
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Acknowledgments
NRP Steering Committee Members
Louis P. Halamek, MD, FAAP, Co-chair, 2007-2011
Jane E. McGowan, MD, FAAP, Co-chair, 2009-2011 NRPTM
Christopher Colby, MD, FAAP
Marilyn Escobedo, MD, FAAP
Karen D. Fairchild, MD, FAAP
George A. Little, MD, FAAP
Steven Ringer, MD, PhD, FAAP
Gary M. Weiner, MD, FAAP
Myra H. Wyckoff, MD, FAAP
Liaison Representatives
Mildred Ramirez, MD, FACOG,
American College of Obstetricians and Gynecologists
Barbara Nightengale, RN, MSN, NNP-BC,
National Association of Neonatal Nurses
Praveen Kumar, MD, FAAP,
AAP Committee on Fetus and Newborn
Khalid Aziz, MD, FRCPC,
Canadian Paediatric Society
John Gallagher, RRT-NPS,
American Association for Respiratory Care
The committee would like to express thanks to the following reviewers and
contributors to this textbook:
American Academy of Pediatrics Committee on Fetus and Newborn
International Liaison Committee on Resuscitation, Neonatal Delegation
Jeffrey M. Perlman, MB, ChB, FAAP, Co-chair
Sam Richmond, MD, Co-chair
Jonathan Wylie, MD
Francis Rushton, MD, FAAP, AAP Board-appointed Reviewer
American Heart Association Emergency Cardiovascular Care Leadership
Leon Chameides, MD, FAAP
Brian Eigel, PhD
Mary Fran Hazinski, RN, MSN
Robert Hickey, MD, FAAP
Vinay Nadkarni, MD, FAAP
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Acknowledgments
Associated Education Materials for the Textbook of Neonatal Resuscitation, 6th Edition
Instructor Manual for Neonatal Resuscitation, Jeanette Zaichkin, RN, MN, NNP-BC, Editor
NRP Instructor DVD: An Interactive Tool for Facilitation of Simulation-based Learning, Louis P. Halamek,
MD, FAAP, and Jeanette Zaichkin, RN, MN, NNP-BC, Editors
NRP Online Examination, Steven Ringer, MD, PhD, FAAP, and Jerry Short, PhD, Editors
NRP Reference Chart, Code Cart Cards, and Pocket Cards, Karen D. Fairchild, MD, FAAP, Editor
NRP Simulation Poster, Louis P. Halamek, MD, FAAP, Editor
Simply NRP™, Gary Weiner, MD, FAAP, and Jeanette Zaichkin, RN, MN, NNP-BC, Editors
Neonatal Resuscitation Scenarios, Gary Weiner, MD, FAAP, and Jeanette Zaichkin, RN, MN, NNP-BC,
Editors
Hypix Media
Scott Runkel
Ptolemy Runkel
Bret Van Horn
Photo Credits
Gigi O’Dea, RN, NICU at Sarasota Memorial Hospital
AAP Life Support Staff
Wendy Marie Simon, MA, CAE Nancy Gardner
Rory K. Hand, EdM Melissa Marx
Rachel Poulin, MPH Bonnie Molnar
Kristy Crilly
NRP Education Workgroup Chair
Gary M. Weiner, MD, FAAP
American Heart Association Emergency Cardiovascular Care Pediatric Subcommittee
Marc D. Berg, MD, FAAP, Chair, 2009-2011 Patricia Howard
Monica E. Kleinman, MD, FAAP, Kelly Kadlec, MD, FAAP
Immediate Past Chair, 2007-2009 Sharon E. Mace, MD, FAAP
Dianne L. Atkins, MD, FAAP Bradley S. Marino, MD, FAAP, MPP, MSCE
Jeffrey M. Berman, MD Reylon Meeks, RN, BSN, MS, MSN, EMT, PhD
Kathleen Brown, MD, FAAP Vinay Nadkarni, MD, FAAP
Adam Cheng, MD Jeffrey M. Perlman, MB, ChB, FAAP
Laura Conley, BS, RRT, RCP, NPS Lester Proctor, MD, FAAP
Allan R. de Caen, MD Faiqa A. Qureshi, MD, FAAP
Aaron Donoghue, MD, FAAP, MSCE Kennith Hans Sartorelli, MD, FAAP
Melinda L. Fiedor Hamilton, MD, MSc Wendy Simon, MA
Ericka L. Fink, MD, FAAP Mark A. Terry, MPA, NREMT-P
Eugene B. Freid, MD, FAAP Alexis Topjian, MD, FAAP
Cheryl K. Gooden, MD, FAAP Elise W. van der Jagt, MD, FAAP, MPH
John Gosford, BS, EMT-P Arno Zaritsky, MD, FAAP
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Contents
NRPTM
Preface
NRP Provider Course Overview
1:
Overview and Principles of Resuscitation ...........1
L E S S O N
2:
Initial Steps of Resuscitation ..............................37
L E S S O N
3:
Use of Resuscitation Devices for
L E S S O N
Positive-Pressure Ventilation ............................71
4:
Chest Compressions ..........................................133
L E S S O N
5:
Endotracheal Intubation and
L E S S O N
Laryngeal Mask Airway Insertion ....................159
6:
Medications .......................................................211
L E S S O N
7:
Special Considerations ......................................237
L E S S O N
8:
Resuscitation of Babies Born Preterm .............267
L E S S O N
9:
Ethics and Care at the End of Life ...................283
L E S S O N
Integrated Skills Station Performance
Checklist (Basic) .................................................299
Integrated Skills Station Performance
Checklist (Advanced) .........................................301
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Contents
Appendix:
2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care ...................................................................303
Index ................................................................................321
Evaluation Form
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Preface
NRPTM
Birth is a beautiful, miraculous, help can be associated with evolving at about that time and, by
and very personal event for all problems that last a lifetime or 1985, the AAP and the AHA
involved. It’s an intimate and even lead to death. The most expressed a joint commitment to
emotional time for a new mother gratifying aspect of providing develop a training program aimed
and father when the baby they skillful assistance to a at teaching the principles of
created together makes that initial compromised newborn is that neonatal resuscitation. The
cry and establishes first eye contact your efforts are most likely to be pioneering leaders of this effort
with the new parents. But it’s also successful, in contrast to the were George Peckham and Leon
probably the single most discouraging statistics associated Chameides. A committee was
dangerous event that most of us with resuscitation attempts of convened to determine the
will ever encounter in our adults or older children. The time appropriate format for the
lifetimes. Our bodies are required that you devote to learning how to program, and the material written
to make more radical physiologic resuscitate newborns is time very by Ron Bloom and Cathy Cropley
adjustments immediately following well spent. was selected to serve as the model
birth than they will ever have to do for the new NRP textbook. Some
This textbook has a long history,
again. It’s remarkable that more of the text contained in this book
with many pioneers from both the
than 90% of babies make the has been unchanged from the
American Academy of Pediatrics
transition from intrauterine to original textbook.
(AAP) and the American Heart
extrauterine life perfectly
Association (AHA) responsible for Pediatric leaders, such as Bill
smoothly, with little to no
its evolution. National guidelines Keenan, Errol Alden, Ron Bloom,
assistance required, and it’s
for resuscitation of adults were and John Raye, developed a
important that we not disrupt that
initially recommended in 1966 by strategy for disseminating the
intimate and memorable moment
the National Academy of Sciences. NRP. The strategy first involved
for the 90% of families where an
In 1978, a Working Group on training a national faculty
uncomplicated birth takes place
Pediatric Resuscitation was formed consisting of at least one
smoothly. It’s for the remaining
by the AHA Emergency Cardiac physician-nurse team from each
few percent that the Neonatal
Care Committee. The group state. The national faculty taught
Resuscitation Program™ (NRP™)
quickly concluded that regional trainers who then trained
was designed. While the
resuscitation of newborns required hospital-based instructors. By the
proportion of newborns requiring
a different emphasis than end of 2010, more than 2.9 million
assistance may be small, the real
resuscitation of adults, with a focus health care providers in the United
number of babies requiring help is
on ventilation, rather than States had been trained in the
substantial because of the large
restitution of cardiac activity, techniques of neonatal
number of births taking place. The
being paramount. The formal resuscitation—quite an
implications of not receiving that
specialty of neonatology was accomplishment when one
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Preface
considers that the original goal was resuscitation of children and principles defined in CoSTR. The
to strive to have at least one person newborns. neonatal portion of the U. S.
trained in neonatal resuscitation in Treatment Guidelines was
The most recent CPR-ECC activity
attendance in each of the published in Circulation
took place over nearly 5 years and
approximately 5,000 delivery (2010;122:S909-S919), and
was conducted in 2 parts. First,
rooms in the United States. The Pediatrics (2010;126;e1400-e1413),
starting in late 2006, a series of 32
NRP also has been used as a model and is reprinted in the back of this
questions identifying controversial
for similar neonatal resuscitation textbook. As a result of this
issues regarding neonatal
programs in 92 other countries. process, each successive edition of
resuscitation were identified by the
NRP contains more
The science behind the program neonatology subgroup of the
recommendations that are based
has also undergone significant International Liaison Committee
on evidence, rather than simply
evolution. While the ABCD on Resuscitation (ILCOR), led by
reflecting common practice. We
(Airway, Breathing, Circulation, Jeff Perlman from the United
encourage you to review the
Drugs) principles of resuscitation States and Jonathan Wyllie from
evidence and, more importantly,
have been standard for several the United Kingdom. Individual
to conduct the future studies
decades, the details of how and ILCOR members were then
necessary to further define the
when to accomplish each of the assigned to develop worksheets for
optimum practices.
steps and what to do differently for each question. Advances in
newborns versus older children or computerized databases and search The past edition of NRP
adults have required constant engines facilitated the literature introduced 2 new chapters to
evaluation and change. Also, while review and permitted updating of address the unique challenges
the recommendations traditionally the voluminous AHA detailed presented by stabilization and
have been based on opinions from database of publications regarding resuscitation of the baby born
experts in the field, recently there resuscitation. The information preterm (Lesson 8) and to discuss
has been a concerted effort to base from the worksheets was debated the important issues related to the
the recommendations on in a series of conferences, ethics of neonatal resuscitation
experimental or experiential following which an international (Lesson 9). Those chapters have
evidence, collected from studies document titled Consensus on been retained and updated in the
performed in the laboratory, Cardiopulmonary Resuscitation 6th edition. You will note a new
randomized control studies (CPR) and Emergency algorithm (“flow diagram”) in this
conducted in hospitals, and Cardiovascular Care (ECC) edition, with the evaluation and
observational series systematically Science With Treatment action blocks changed to better
collected from clinicians. Recommendations (CoSTR) was reflect scientific format. There are
published simultaneously in a few important changes that will
The AHA has addressed this
Circulation (2010;122[suppl be recognized by the seasoned
evaluation process by facilitating
2]:S516-S538), Resuscitation NRP student. First, the initial
periodic international
(2010;81[suppl]:e260-287), and questions posed at the top of the
Cardiopulmonary Resuscitation
Pediatrics (2010;126;e1319-e1344). flow diagram have been reduced
and Emergency Cardiac Care
Second, each resuscitation council from 4 to 3, with “clear amniotic
(CPR-ECC) conferences every 5 to
that makes up ILCOR was charged fluid?” removed. While the
8 years to establish guidelines for
with developing resuscitation guidelines for suctioning
resuscitation of all age groups and
guidelines appropriate for the meconium from the airway have
for all causes of cardiopulmonary
health care resources existing in not changed, a careful review of
arrest. The AAP formally joined
(each of) its own region(s) of the the evidence failed to demonstrate
that process in 1992 for
world, but based on the scientific a need to intervene with a baby
development of the guidelines for
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born at term who is meconium required and the actions indicated compromise; in the case of the
stained but is breathing easily and in the early stages of the flow newly born baby, the answer will
exhibiting good muscle tone. This diagram. Oximeters, a compressed almost always be respiratory,
situation will occur in more than air source, and oxygen/air blenders rather than cardiac. A related
10% of births and the Committee will need to be readily available in observation is that some
felt that such babies should not be the birthing area and are now resuscitators of the newborn have
taken from their mothers, as recommended for use whenever appeared to be initiating chest
further assessment can be done sustained supplemental oxygen is compressions before adequate
with minimal disruption of her thought to be necessary or ventilation has been assured.
first moments with her new whenever the stage in the flow Therefore, an additional step has
daughter or son. diagram is reached at which been inserted in the flow diagram,
positive pressure, either as involving a new pneumonic (“MR
Second, far more evidence has
positive-pressure ventilation (PPV) SOPA”), to ensure the provision of
been published to strengthen our
or continuous positive airway adequate ventilation.
understanding that increasing the
pressure (CPAP), is instituted. A
blood oxygen levels above those There are innumerable smaller but
table has been added to designate
exhibited by healthy babies born at important changes in this new
the Spo target goals, which have
term provides no advantage, and 2 edition that may be overlooked
been defined by studying healthy
that administering excessive without a careful reading. Watch
term babies. Accommodating this
oxygen can be injurious to tissues for a stronger emphasis in the later
change will present challenges to
that have been previously stages of the flow diagram on
some small hospitals and birthing
compromised. Therefore, the new establishing vascular access, a
centers that may not have all of the
edition introduces new strategies further de-emphasis of
supplies mentioned above as
for avoiding hyperoxemia. Also, endotracheal administration of
standard equipment.
several studies have demonstrated epinephrine, and some changes in
that cyanosis can be normal for the Third, while new the endotracheal dose of
first few minutes following birth recommendations for resuscitation epinephrine if it is used. Also,
and that skin color can be a very of older children and adults have there are some new strategies
poor indicator of oxygen shifted focus to the importance of suggested for keeping extremely
saturation. Therefore, color has chest compressions, with a low birth weight (ELBW) babies
been removed from the list of reduced emphasis on ventilation warm during the resuscitation or
primary clinical signs unless (“C-A-B”, rather than “A-B-C”), stabilization process, and a
cyanosis is felt to be persistent, and the evidence continues to support stronger endorsement for
color has been replaced by the primary importance of considering therapeutic
oximetry as the more reliable assuring adequate ventilation hypothermia for the term baby
means of judging oxygen need. It (“A-B-C”) when resuscitating the who has experienced a significant
was the consensus of the newly born baby. When hypoxic-ischemic event. There are
Committee that if resuscitation is confronted with this difference, other changes scattered
anticipated or required, the goal some learners have asked, “When throughout the program, so we
should be to try to match the is the appropriate age to switch encourage even veteran students to
increase in blood oxygenation from ABC to the new CAB?” read the entire new program. Also,
exhibited by the uncompromised While there is no definitive data the Guidelines publication at the
healthy baby born at term. These from which to be guided for this back of the textbook and the
observations and this conundrum, probably the simplest Instructor Manual summarize
recommendation will result in answer is to consider the likely most of these new issues.
some changes in the equipment etiology of the subject’s
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