What is the protocol for a Neonatal Resuscitation Program (NRP)?

From the Guidelines

The Neonatal Resuscitation Program (NRP) should follow a systematic approach using the ABCD sequence: Airway, Breathing, Circulation, and Drugs, with initial steps including warming, drying, and stimulating the infant while assessing heart rate, respiration, and color, as recommended by the 2020 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations 1.

Key Components of NRP

• Initial assessment of the newborn, including term gestation, good tone, and breathing or crying, to determine the need for resuscitation
• Positive pressure ventilation at a rate of 40-60 breaths per minute using a bag-mask device with 21% oxygen initially for term infants and 21-30% for preterm infants, as needed
• Chest compressions indicated if the heart rate remains below 60 beats per minute despite effective ventilation, performed at a 3:1 ratio with ventilations at a rate of 90 compressions and 30 breaths per minute, as supported by the 2020 international consensus 1
• Medication administration, including epinephrine (0.01-0.03 mg/kg of 1:10,000 solution) for persistent bradycardia and volume expansion (10 mL/kg of normal saline) for suspected hypovolemia, as recommended by the American Heart Association guidelines 1

Importance of Continuous Reassessment

• The program emphasizes continuous reassessment and adjustment of interventions based on the infant's response, with the goal of maximizing the chances of successful resuscitation and minimizing potential complications from delayed or inappropriate interventions
• The most sensitive indicator of a successful response to each step is an increase in heart rate, as noted in the 2015 American Heart Association guidelines 1

Evidence-Based Recommendations

• The 2020 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations supports the use of a 3:1 compression-to-ventilation ratio for neonatal resuscitation 1
• The American Heart Association guidelines recommend increasing the oxygen concentration to 100% whenever chest compressions are provided, and weaning the supplementary oxygen concentration as soon as the heart rate recovers, to reduce the risks of complications associated with hyperoxia 1

From the Research

Protocol for Neonatal Resuscitation Program (NRP)

The protocol for a Neonatal Resuscitation Program (NRP) involves several key steps, including:

• Assessment of the newborn's breathing, heart rate, and oxygen saturation 2, 3, 4
• Prevention of heat loss and provision of a warm environment 2, 3
• Opening of the airways and provision of respiratory support if necessary 2, 3, 5, 6
• Use of positive pressure ventilation (PPV) if the baby is apneic or has a low heart rate 2, 3, 5, 6
• Administration of chest compressions if the heart rate is <60 bpm despite adequate ventilation 2, 3, 4
• Use of medications, such as epinephrine, if necessary 2, 4
• Consideration of non-initiation or discontinuation of resuscitation in certain circumstances, such as extreme prematurity or congenital anomalies 2, 3, 4

Key Components of NRP

Some key components of the NRP protocol include:

• The use of a laryngeal mask airway as an alternative to endotracheal intubation if bag-mask ventilation is ineffective or attempts at intubation have failed 2
• The use of exhaled CO(2) detection to confirm endotracheal intubation 2
• The administration of epinephrine in a dose of 0.01-0.03 mg/kg if the heart rate remains <60 bpm despite adequate ventilation and chest compressions 2, 4
• The use of intraosseous access as an alternative route for medications or volume expansion if umbilical or other direct venous access is not readily available 2

Updates to NRP Guidelines

Recent updates to the NRP guidelines include changes to the prebirth questions, initial steps, use of electronic cardiac monitors, and the initial dose of epinephrine 4. Additionally, the guidelines now recommend the use of continuous positive airway pressure (CPAP) rather than routine intubation for positive pressure ventilation (PPV) in preterm infants 6.