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NRP 2012 Putting New
Resuscitation uidelines
into Practice
!eanette "aich#in$ RN$ %N$ NNP&'(
)ece*ber 2$ 2010
Progra* Handouts
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Care System and its related organizations (CHCS). Persons
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is not responsible or liable for any claim loss or damage
arising from the use of the information. The vie!s and
opinions of the document authors do not necessarily state or
reflect those of CHCS. "either the authors nor CHCS nor any
other party !ho has been involved in the preparation or
publication of this !or# !arrants that the information
contained herein is in every respect accurate or complete and
they are not responsible for any errors or omissions or for the
results obtained from the use of such information.
NRP 2011
Raising the Bar for Providers and Instructors
What is the same?
1. Minimum course requirement is Lessons 1 through 4 and Lesson 9. The NRP Provider
Card requires renewal every years. !our "acility may require more "requent renewal.
2. #ny $erson who wor%s with new&orns is eligi&le to ta%e an NRP Provider course' however(
the course has little relevance "or a $erson who has never seen a healthy term new&orn at
&irth.
3. #ll learners may study( $ractice and demonstrate all NRP s%ills i" desired( including
intu&ation and emergency um&ilical venous catheter $lacement. NRP does not certi"y or
ensure com$etence to $er"orm these s%ills in an actual resuscitation.
4. The recommended NRP instructor to learner ratio at a Provider course is 1 instructor) *+4
learners.
Programmatic Changes
1. Two new Per"ormance Chec%lists)
1. Lesson 1) ,qui$ment Chec%
2. Lesson -) Laryngeal Mas% #irway Placement
2. There is no more Renewal Course. ,veryone ta%es a Provider Course tailored to learners.
needs.
3. ,ach institution determines its own $olicy a&out what ha$$ens i" NRP $rovider status e/$ires.
4. The 0nline ,/amination is required "or the 1
th
edition. The -
th
edition e/amination may &e
o2ered as a hard co$y e/am or online e/am until 3ecem&er *1( 411. No more hard co$y
e/amination is availa&le a"ter 3ecem&er 411.
5. Provider Course includes little or no lecture( uses course time "or hands+on learning(
immersive simulations( and constructive de&rie5ngs.
1. The Per"ormance 6%ills 6tations are o$tional and used "or learning( review( and
$ractice.
2. The NRP online e/amination and 7ntegrated 6%ills 6tation 8similar to Megacode9 are
required and used "or evaluation.
3. The 6imulation and 3e&rie5ng com$onent is required and used to im$rove
teamwor% and communication.
6. Teamwor% and communication s%ills are :ust as im$ortant as cognitive and technical s%ills.
The 14 NRP ;ey <ehavioral 6%ills are
;now your
environment.
#ntici$ate and $lan.
#ssume the leadershi$
role. Communicate
e2ectively.
3elegate wor%load
o$timally. #llocate
attention wisely
=se all availa&le
in"ormation. =se all
availa&le resources
Call "or hel$ when needed.
Maintain $ro"essional &ehavior.
NRP 2011: Raising the Bar for Providers and Instructors)
Revised ->?>11 Page 1 o"
!cience Changes
1. The following items are no longer "o#tional$ in the %irth setting& and should %e
availa%le for ever' %irth(
1. Com$ressed air source
2. 0/ygen &lender to mi/ o/ygen and com$ressed air with @owmeter
3. Pulse o/imeter "or neonatal use and o/imeter $ro&e
4. Laryngeal mas% airway 8siAe 19
2. There are levels o" $ost+resuscitation care 8instead o" * levels9)
1. Routine Care) Bor vigorous term &a&ies with no ris% "actors and &a&ies who have
res$onded to the initial ste$s. <a&ies who required initial ste$s may not need to &e
se$arated "rom their mothers a"ter &irth to receive close monitoring and "urther
sta&iliAation.
2. Post+resuscitation care) Bor &a&ies who have de$ressed &reathing or activity( and>or
require su$$lemental o/ygen. Require "requent evaluation. 6ome may transition to
routine care' others will require ongoing su$$ort. Trans"er to an intensive care nursery
may &e necessary.
3. Prior to &eginning the ste$s in the NRP Blow 3iagram( as% the 0< $rovider "or relevant
$erinatal history( including these questions)
1. Chat is the gestational ageD
2. 7s the @uid clearD
3. Eow many &a&ies are e/$ectedD
4. #re there any additional ris% "actorsD
4. #t &irth( answer * questions to determine the need "or initial ste$s at the radiant warmer)
1. 7s the new&orn termD
2. 7s the new&orn &reathing or cryingD
3. 3oes the new&orn have good muscle toneD
If any answer is No, the newborn shoud receive initia ste!s at the radiant
war"er#
5. The vigorous meconium)stained new%orn need not receive initial ste#s at the
radiant warmer& %ut ma' receive routine care *with a##ro#riate monitoring+ with
his mother,
6. Routine care o" new&orn staying with mother)
1. Carm 8s%in+to+s%in contact is recommended9( clear airway &y wi$ing the &a&y.s mouth
and nose i" necessary( dry the new&orn( $rovide ongoing evaluation o" &reathing(
activity( and color.
7. !uctioning following %irth *including %ul% suctioning with a %ul% s'ringe+ should
%e reserved for %a%ies who have o%vious o%struction to s#ontaneous %reathing or
who re-uire #ositive)#ressure ventilation,
8. #"ter clearing the airway as necessary( drying and removing wet linen( re$ositioning( and
stimulating( evaluate res$irations and heart rate 8not color9.
1. 7" ER is less than 144 &$m( or i" new&orn is a$neic or gas$ing( &egin $ositive+$ressure
ventilation.
2. 7" ER is more than 144 &$m and res$irations are la&ored( consider CP#P( es$ecially
"or $reterm new&orns.
9. !u%se-uentl'& evaluation and decision)ma.ing are %ased on
res#irations& /R& and o0'genation *#er #ulse o0imetr'+,
NRP 2011: Raising the Bar for Providers and Instructors) Revised ->?>11 Page 2 o"
10. Resuscitation of term new%orns ma' %egin with 211 o0'gen2 resuscitation o"
$reterm new&orns may &egin with a somewhat higher o/ygen concentration.
11. 3se #ulse o0imetr' when(
1. Resuscitation is antici$ated
2. PPF is required "or more than a "ew &reaths
3. Central cyanosis is $ersistent( or you need to con5rm your $erce$tion o" central
cyanosis
4. 6u$$lemental o/ygen is administered
12. Place the o0imeter #ro%e on the new%orn4s right hand or wrist 8measure $re+
ductal saturation9 and then connect it to the instrument.
13. 3sing #ulse o0imetr'& su##lemental o0'gen concentration should %e ad5usted to
achieve the target values for #re)ductal saturations summari6ed in the ta%le on
the NRP 7low 8iagram,
The ta&le is used "or &oth term and $reterm &a&ies.
14. 7ndications "or $ositive+$ressure ventilation)
1. #$nea>gas$ing
2. Eeart rate &elow 144 &$m( even i" &reathing
3. Persistent central cyanosis and low o/ygen saturation( des$ite "ree+@ow o/ygen
increased to 144G.
15. 9ll #ositive)#ressure devices& including the self)in:ating %ag& should have an
integral #ressure gauge& or i" there is a site "or attaching a $ressure gauge 8manometer9( it
should &e attached.
16. Chen PPF &egins( assess "or rising heart rate and im$roving o/ygen saturation 8$er $ulse
o/imetry9. 7" not evident 8within -+14 &reaths9( as% your assistant to assess &ilateral &reath
sounds and chest movement. 7" these are not immediately evident( $er"orm as many o" the
ventilation corrective ste$s as needed to achieve &ilateral &reath sounds and chest
movement.
17. Note that the timeline down the side o" the NRP Blow 3iagram sto$s here( &ut it may ta%e
longer than *4 seconds to esta&lish e2ective $ositive+$ressure ventilation 8de5ned &y
&ilateral &reath sounds and chest movement9.
18. 3se ;R !<P9 to hel# 'ou remem%er the ventilation corrective ste#s in order(
;) #d:ust the mas% on the "ace.
R) Re$osition the head to ensure an o$en airway. Re+attem$t ventilation.
If not e$ective,
!) !uction the mouth and nose
<) Fentilate with the &a&y.s mouth slightly o$en and li"t the :aw "orward. Re+attem$t
ventilation
If not e$ective,
P) Hradually increase #ressure every "ew &reaths( 8cautiously( and to a ma/imum o" 44
cm E

49( until there are &ilateral &reath sounds and visi&le chest movement.
If sti not e$ective,
9) Consider airway alternative 8endotracheal tu&e or laryngeal mas% airway9
19. ,sta&lishing e2ective ventilations is the highest $riority in neonatal resuscitation. 3o not start
chest com$ressions without 5rst esta&lishing e2ective ventilation 8de5ned &y audi&le
&ilateral &reath sounds and chest movement9. If heart rate is still %elow 0 %#m des#ite
=0 seconds of e>ective #ositive)#ressure ventilation& increase the o0'gen
concentration to 1001 and %egin chest com#ressions,
20. Chen the heart rate is &elow 14 &$m( the o/imeter may not "unction. Chen chest
com$ressions &egin( increase the o/ygen concentration to 144G until the o/imeter is giving
a relia&le signal and can guide the a$$ro$riate ad:ustment o" su$$lemental o/ygen.
NRP 2011: Raising the Bar for Providers and
Instructors) Revised ->?>11 Page = o"
21. Intu%ation is strongl' recommended when chest com#ressions %egin to hel$
ensure e2ective ventilation.
22. The intu%ation #rocedure ideall' should %e com#leted within =0 seconds 8not 4
seconds9. 3o not administer "ree+@ow o/ygen during the intu&ation $rocedure to an a$neic
new&orn.
23. 7nterru$tion o" chest com$ressions to chec% the heart rate may result in a decrease o"
$er"usion $ressure in the coronary arteries. Therefore& continue chest com#ressions and
coordinated ventilations for at least ?@)0 seconds %efore sto##ing %rie:' to
assess the heart rate,
24. 7" you antici$ate the need to $lace an emergency um&ilical venous catheter( continue
chest com#ressions %' moving to the head of the %ed *near the infant4s head+
and continuing the +thum& technique. This is most easily accom$lished i" the new&orn is
intu&ated.
25. The laryngeal mas% airway has &een shown to &e an e2ective alternative "or assisting
ventilation. =se may &e indicated when
1. Bacial or u$$er airway mal"ormations render ventilation &y mas% ine2ective.
2. Positive+$ressure ventilation with a "ace mas% "ails to achieve e2ective ventilation and
intu&ation is not $ossi&le.
26. A#ine#hrine is indicated when the heart rate remains %elow 0 %#m after =0
seconds of e>ective assisted ventilation *#refera%l' via endotracheal tu%e+ and
at least another ?@)0 seconds of coordinated chest com#ressions and e>ective
ventilation,
27. The intratracheal route is associated with unrelia&le a&sor$tion and is li%ely to &e ine2ective.
Nevertheless( since the endotracheal route is the most readily accessi&le( administration o" a
dose o" e$ine$hrine via an endotracheal tu&e may &e considered while the intravenous route
is &eing esta&lished.
28. ,$ine$hrine administration 87F $arameters unchanged' note new dose for intratracheal
e#ine#hrine9
1. Recommended concentration) 1)14(444 84.1 mg>mL9
2. Recommended route) 7ntravenous 8um&ilical vein9. Consider endotracheal route
0NL! while 7F access &eing o&tained
3. Hive ra$idly I as quic%ly as $ossi&le.
4. Recommended 7F dose) 4.1+4.* mL>%g o" 1)14(444 solution $er um&ilical vein in a 1+
mL syringe. Bollow 7F administration o" e$ine$hrine with 4.- I 1 mL @ush o" normal
saline.
5. Recommended intratracheal dose( 0,@ B 1 mCD.g o" 1)14(444 solution $er
endotracheal tu&e in a *+1 mL syringe.
6. Chec% the new&orn heart rate a&out 1 minute a"ter administering e$ine$hrine
8longer i" given endotracheally9. ,$ine$hrine dose may &e re$eated every *+-
minutes.
29. Thera$eutic hy$othermia "ollowing $erinatal as$hy/ia should &e
1. =sed only "or &a&ies J *1 wee%s. gestation and who meet $reviously de5ned
criteria "or this thera$y
2. 7nitiated &e"ore 1 hours a"ter &irth
3. =sed only &y centers with s$ecialiAed $rograms equi$$ed to $rovide the thera$y
30. To hel$ %ee$ the $reterm &a&y warm(
1. Increase the tem#erature of the deliver' room and the area where the
%a%' will %e resuscitated to a##ro0imatel' 2@EC to 2EC *FFE7)FGE7+
2. =se $olyethylene $lastic wra$ "or &a&ies delivered at less than 9 wee%s. gestation
8or K wee%s and less9. =se a sheet o" $lastic "ood wra$( a "ood+grade 1+gallon
$lastic &ag( or a commercially availa&le sheet o" $olyethylene $lastic.
3. Place a $orta&le warming $ad under layers o" towels on the resuscitation ta&le.
NRP 2011: Raising the Bar for Providers and
Instructors) Revised ->?>11 Page ? o"
Information for NRP Instructors
1. Eealth6tream is the vendor "or the 1
th
edition NRP online e/amination. The "ee "or the e/am
varies de$ending on how many e/ams are $urchased and how the e/amination is accessed.
7" your institution uses Eealth6tream as its Learning Management 6ystem( your learners may
receive the e/amination in the same way other hos$ital learning $rograms are o&tained. 7"
your institution is not a Eealth6tream client( you may $urchase online e/aminations in small
or large volume $urchases. Eealth6tream will set u$ a we&site "or your use. 7ndividuals may
also $urchase an online e/amination with a $ersonal credit card. Bor more in"ormation( visit
www.aa$.org>nr$ and clic% on 0nline ,/amination.
2. 6imulation training is de$endent on good methodology( not technology' there"ore(
so$histicated electronic simulators are not necessary.
3. NRP 7nstructor Maintenance Requirements 8includes Regional Trainers9
1. ,ach current NRP instructor must own a $ersonal co$y o" the NRP Instructor %&%: 'n
Interactive (oo for )aciitation of *i"uation+based ,earning and com$lete the $ost+
3F3 education activity &y Lanuary 1( 41. Hour 8I8 is licensed to one com#uter
and cannot %e used on multi#le devices a"ter launching the $rogram. Launch it
on the com$uter where it will &e viewedM
2. ,ach instructor must teach or co+teach at least courses in the years "or which
their instructor card is valid.
3. <eginning in Lanuary 41*( every NRP instructor must ta%e the online e/amination
8Lessons 1 through 99 $rior to their instructor status renewal date. <eginning in
s$ring 411( every instructor may ta%e the online e/amination once>calendar year i"
desired at no charge' however( continuing education credit may &e awarded only
once every two years.
4. NRP 7nstructor eligi&ility
1. 0nly registered nurses 8including NNPs( CNMs( etc9( $hysicians 8M3 or 309(
res$iratory thera$ists( and $hysician assistants are eligi&le to &ecome NRP
instructors. There are no e/ce$tions and no waivers. Pro"essionals who &ecame NRP
instructors &y waiver in the $ast will maintain their instructor status as long as
maintenance requirements are met.
2. NRP instructor candidates are required to meet $rerequisites $rior to their NRP
7nstructor Course. 7nstructor candidates must have current NRP $rovider status
8Lessons 1 through 99( $roduce a
letter o" recommendation and su$$ort "rom their manager>hos$ital administrator(
$ass the 1
th
edition online e/amination in the *4 days &e"ore their 7nstructor
Course 8Lessons 1 through 99( watch the NRP 7nstructor 3F3 and com$lete the
$ost+3F3 education activity( and ta%e the 7nstructor 6el"+#ssessment( which is
included in the NRP 7nstructor Manual.
NRP 2011: Raising the Bar for Providers and
Instructors) Revised ->?>11 Page @ o"
NRP
th
Adition 7low 8iagram
NRP 2011: Raising the Bar for Providers and Instructors) Revised ->?>11 Page o"