1. science
2. medicine
3. pediatrics

NRP
™
Instructor Update
VOL 21 NO 1 sprin g / s u mme r 2 0 1 2
The Use of CPAP in a
Grunting Newborn
C
ontinuous positive airway pressure (CPAP) is often used
to provide respiratory support for preterm infants in the
intensive care nursery. As stated in the Textbook of Neonatal
Resuscitation, 6th Edition, page 275, “CPAP keeps the lungs
slightly inflated and is most helpful for preterm babies whose
lungs may be surfactant deficient and whose alveoli tend to
collapse at the end of each exhalation.” Lately, CPAP has also
been used in the delivery room in infants who have a normal
heart rate, but have persistent respiratory distress and/or
hypoxemia. The NRP 6th Edition does state that the use of
CPAP may be considered in the delivery room in a term or
preterm infant who has spontaneous breathing and a heart
rate over 100 beats/minute, but is also demonstrating labored
breathing with grunting and/or intercostal retractions or
persistent hypoxemia confirmed by oximetry.
There is no formal study-based evidence
to support or refute the use of CPAP in
the delivery room in the term baby with
respiratory distress.
The use of CPAP in the delivery room has been studied only in
infants born preterm. In these infants, CPAP reduced the need
for intubation and mechanical ventilation, and reduced the use
of artificial surfactant. However, one study on the use of CPAP
vs. intubation and ventilation did find an increased incidence of
early pneumothorax, possibly related to the pressure (8 cm H20)
delivered. There is no formal study-based evidence to support
or refute the use of CPAP in the delivery room in the term baby
with respiratory distress (AHA Guidelines, p. e1404), although
many neonatologists believe that it may be helpful. Thus, the
use of CPAP in the delivery room for the term infant with grunting
respirations must be considered on a case-by-case basis. Grunting
can be a normal short-term response to the rapid fluid shifts and
other changes that occur during the postnatal transition
period, and may resolve spontaneously as transition progresses.
However, if transition is delayed due to stress during delivery,
exposure of the fetus to anesthetic agents, or fetal lung fluid
retention, administration of CPAP for a brief period may lead to
significant improvement.
However, CPAP must be used judiciously. In the term infant with
normally expanded lungs, CPAP may not be beneficial and may
even cause overexpansion and pulmonary air leak. If the provider
decides to give a brief trial of face-mask CPAP in the delivery
room, he/she must keep in mind that CPAP can be delivered
only with a T-piece resuscitator or a flow-inflating bag equipped
with a pressure manometer. Currently available self-inflating bags
cannot deliver CPAP, even if a PEEP valve has been attached.
The provider should have the skill to administer safe and effective
CPAP, and resources to treat a pneumothorax should one occur
as a result of CPAP administration. If CPAP is provided, pulse
oximetry should be used to ensure appropriate concentration
of oxygen. Once CPAP has been administered, the baby should
be reassessed to determine whether the initial problems have
resolved or whether CPAP should be continued as part of postresuscitation care.
Note: The DVD that accompanies the Textbook of Neonatal
Resuscitation, 6th Edition includes brief resuscitation videos that
demonstrate how to administer CPAP with a flow-inflating bag and
T-piece resuscitator, and how to perform needle thoracentesis to
relieve a pneumothorax.
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NRP Acknowledgements
™
NRP Editors
John Kattwinkel, MD, FAAP
University of Virginia
Charlottesville, VA
In This Issue
1 The Use of CPAP in a
Grunting Newborn
Jeanette Zaichkin, RN, MN, NNP-BC
Seattle Children’s Hospital
Seattle, WA
2In This Issue/Acknowledgements
Prepare for NRP Resident
Training this Summer
NRP Steering Committee Liaisons
Khalid Aziz, MD, FRCPC, FAAP
Canadian Paediatric Society
Royal Alexandra Hospital
Edmonton, AB, Canada
4Combining the Integrated
Skills Station and Simulation
and Debriefing Component
Praveen Kumar, MD, FAAP
AAP Committee on Fetus and Newborn
Northwestern Memorial Hospital
Chicago, IL
3 Delayed Cord Clamping
NRP Online Course Caution
5NRP eBook Q&A
62012 NRP Current Issues Seminar
8 Vigorous and Cyanotic:
Start Free-flow Oxygen or
Wait for the Pulse Oximeter?
Welcome Dr Ades
10NRP Webinar: Sure Fire Strategies for
Creating an Engaging NRP Course:
Simulation Tips From the Experts
11NRP 6th Edition Online Exam
Access Information
NRP Instructor DVD
Completion Reminder
12NRP Research Grants Awarded
NRP Milestone
Changes to AARC Continuing
Education Credit
NRP Instructor DVD Thank You
Statements and opinions expressed in
this publication are those of the authors
and are not necessarily those of the
American Academy of Pediatrics or
American Heart Association.
Comments and questions are welcome
and should be directed to:
Jane E. McGowan, MD, FAAP
Editor, NRP Instructor Update
141 Northwest Point Blvd., PO Box 927
Elk Grove Village, IL 60009-0927
www.aap.org/nrp
© American Academy of Pediatrics/
American Heart Association, 2012
2
VOL 21 NO 1 sprin g / s u mme r 2 0 1 2
The Neonatal Resuscitation Program (NRP)
Steering Committee offers the NRP Instructor Update
to all AAP/AHA NRP Instructors.
™
Editor
Jane E. McGowan, MD, FAAP
Managing Editors
Melissa Marx
Rachel Poulin, MPH
Wendy Marie Simon, MA, CAE
Contributor
Jeanette Zaichkin, RN, MN, NNP-BC
NRP Steering Committee
Jane E. McGowan, MD, FAAP, Cochair
Drexel University College of Medicine
Philadelphia, PA
Myra H. Wyckoff, MD, FAAP, Cochair
University of Texas Southwestern Medical Center
Dallas, TX
Anne Ades, MD, FAAP
The Children’s Hospital of Philadelphia
Philadelphia, PA
Christopher Colby, MD, FAAP
Mayo Clinic
Rochester, MN
Eric C. Eichenwald, MD, FAAP
University of Texas-Houston Medical School
Houston, TX
Kimberly D. Ernst, MD, MSMI, FAAP
University of Oklahoma Health Sciences Center
Oklahoma City, OK
Henry C. Lee, MD, FAAP
University of California-San Francisco
San Francisco, CA
Steven Ringer, MD, PhD, FAAP
Brigham & Women’s Hospital
Boston, MA
Patrick McNamara, MB, FRCPC
Canadian Paediatric Society
The Hospital for Sick Children
Toronto, ON, Canada
Jeffrey Perlman, MB, ChB, FAAP
ILCOR Science Director
Liaison AHA Pediatric Subcommittee
New York Presbyterian Hospital
New York, NY
Mildred Ramirez, MD, FACOG
American College of Obstetricians and Gynecologists
Baylor College of Medicine
Houston, TX
John Gallagher, RRT-NPS
American Association for Respiratory Care
Rainbow Babies & Children’s Hospital
Cleveland, OH
Linda McCarney, MSN, RN, NNP-BC, EMT-P
National Association of Neonatal Nurses
The Children’s Hospital in Denver
Aurora, CO
NRP Steering Committee Consultants
Louis P. Halamek, MD, FAAP
Stanford University
Palo Alto, CA
Jerry Short, PhD
University of Virginia
Charlottesville, VA
Gary M. Weiner, MD, FAAP
Saint Joseph Mercy Hospital
Ann Arbor, MI
AAP Staff Liaisons
Kristy Crilly
Nancy Gardner
Rory Hand, EdM
Jackie Hughes
Melissa Marx
Kirsten Nadler, MS
Rachel Poulin, MPH
Wendy Simon, MA, CAE
Delayed Cord Clamping
One issue studied by ILCOR pertained to the timing of cord
clamping after delivery. The ILCOR neonatal delegation agreed
that the literature supports delaying cord clamping for at least
one minute among babies who do not require resuscitation.
For term births, the time of delay reported in the literature ranged
from one minute up to the time that the cord stopped pulsating.
Benefits included an improved iron status during the first year
of life. However, infants with delayed cord clamping were more
likely to require phototherapy. Among preterm infants, the delay
ranged from 30 seconds to 3 minutes after delivery. Apparent
benefits included higher blood pressures during stabilization,
fewer transfusions, and perhaps a lower incidence
of intraventricular hemorrhages.
I
n November 2010, the International Liaison Committee on
Resuscitation (ILCOR) published its consensus statement
about the most recent resuscitation science (Circulation.
2010;122(suppl 2):S516 –S538). This document formed the
scientific foundation for the American Heart Association
(AHA) and American Academy of Pediatrics (AAP) guidelines.
The AHA/AAP guidelines were translated into practice through
the Neonatal Resuscitation Program (NRP) educational materials.
The AHA/AAP guidelines and NRP materials do not specifically
address the timing of cord clamping for babies requiring
resuscitation. That issue is still being studied and may be a
topic leading to a recommendation from the Consensus on
Science and Treatment Recommendations (CoSTR) 2015.
Providers should look to the upcoming AAP/American College
of Obstetricians and Gynecologists (ACOG) Guidelines for
Perinatal Care for further advice on cord clamping for healthy
babies. The 7th Edition is expected to be released in Fall 2012.
The ILCOR neonatal delegation agreed that the literature supports delaying cord
clamping for at least one minute among babies who do not require resuscitation.
Prepare for NRP™ Resident Training this Summer
Are you prepared to implement NRP 6th Edition training for residents who arrive at your hospital this summer? Ensure a smooth
transition by considering the following aspects of NRP training that may be different from last year’s course. Please visit the NRP
website and consult your Instructor Manual for Neonatal Resuscitation for additional course strategies.
1
esidents need to self-study the Textbook of Neonatal Resuscitation,
R
6th Edition and should not expect to learn the key points through
a slide/lecture program presented by an NRP instructor. If
NRP training is scheduled immediately upon their arrival at
the hospital, residents need access to a textbook and/or to the
DVD-ROM that accompanies the textbook prior to the scheduled
course date.
3
esidents will need orientation to NRP 6th Edition course
R
procedures. This includes residents who completed an NRP 5th
Edition course as first year residents, and are now due for renewal
using the NRP 6th Edition practices. Page 240 of the Instructor
Manual for Neonatal Resuscitation has an orientation letter template
that you can customize for your course participants and provides
an explanation of the 6th Edition course and how to best prepare.
2
esidents must be able to access the NRP online examination
R
through HealthStream (www.healthstream.com), which may entail
the use of a different system than you used a year ago. Important
questions to ask as you prepare include: Can residents access the
online exam using the same system as other hospital employees?
Will the residency program require the HealthStream Express
website to access the examination? Will the program reimburse
individual exam purchases by residents?
4
he new course format, which focuses on simulation and
T
debriefing, may require a change from large group training
to several smaller sessions. Residents should self-study and
pass the online exam, then attend an in-person course where they
can practice skills, successfully complete the Integrated Skills
Station, and participate in simulation and debriefing exercises.
The ideal instructor-to-learner ratio is 1 instructor for 3 or 4 learners.
N RP I N S TRUCT OR UP DAT E
3
Combining the Integrated Skills Station and
Simulation/Debriefing Component
T
he Neonatal Resuscitation Program
6th Edition has 2 evaluation points:
the online examination and the Integrated
Skills Station (ISS). The purpose of the
ISS is to ensure that every member of the
team can perform all relevant technical
skills with correct technique and in
correct sequence. The ISS helps ensure
that learners will be able to perform
scenarios during the simulation/debriefing
component of the course without major
hands-on issues that require lengthy
discussion during debriefing. Learners
who need to debrief many issues around
technical skills miss the opportunity to
analyze and improve their teamwork and
communication skills. However, there may
be times when performing the ISS and
participating in a simulation exercise
may seem redundant, leading the
instructor to wonder if these
two components can be combined.
In fact, instructors do have some flexibility
in planning this part of the course.
Because every team has different skill
sets, instructors can use their own
judgment to best meet learners’ needs
instead of establishing a firm rule. An
inexperienced team of 3 or 4 people who
need practice perfecting technical skills
benefits from the repetition of everyone
completing an individual Integrated Skills
Station. On the other hand, the members
of a very experienced and expert team
may have already demonstrated their
technical skills during scenarios within
the Performance Skills Stations, and can
successfully move on to simulation where
communication and teamwork are the
topics of debriefing.
so that one instructor takes the same
team of 3-4 learners through all of the
Performance Skills Stations? If yes, and if
that instructor facilitates a scenario for a
team of 2 or 3 students that incorporates
all the previous skills stations (starting
with the Equipment Check) each time, the
instructor should already know everyone’s
capabilities when it’s time for the ISS. For
example, if each learner independently
performs relevant skills during a scenario
at the Medication Performance Skills
Station – beginning with Equipment
Check and ending with UVC placement
and administration of epinephrine – each
learner has accomplished the objectives
of the ISS. The instructor can then
decide if there is value in repeating
skills demonstrations by doing individual
ISS performances.
The best NRP instructors
will guarantee the quality
of the Provider course by
ensuring that learning
objectives takes precedence
over “getting through”
the course components and
With practice and experience, instructors
will find a balance that works best for each
set of learners. This may be different for
teams of learners within the same course.
The best NRP instructors will guarantee
the quality of the provider course by
ensuring that learning objectives takes
precedence over “getting through” the
course components and distributing NRP
cards. In the end, well-trained providers
mean better outcomes for all babies.
distributing NRP cards.
The Instructor Manual for Neonatal
Resuscitation states that expert instructors
may incorporate aspects of the ISS into
the simulation and debriefing component;
however, there is much to consider if a
decision is made to combine these two
components. Is the provider course built
NRP™ Online Course Caution
Over the past weeks, we have become aware of several
online companies that have been promoting online neonatal
resuscitation courses and recertification. While we have been
successful in having many of these companies remove or
considerably change the wording on their websites and in their
promotions, new sites do continue to pop up daily. As these new sites appear, we will
continue to take appropriate action to ensure that NRP is not being misrepresented.
™
Program
suscitation
Neonatal Re
and skills
al cognitive of the
ted the nation
lum
sfully comple e with the NRP curricu
ociation.
has succes
in accordanc ics/American Heart Ass
evaluations
iatr
Ped
Please note: Students must successf
demy of
ully complete lessons
American Aca
1-4 and lesson 9, to obtain an NRP™ provider
d Renewal
pletion Date
Course Com
At this time, we ask that you remain vigilant and notify your colleagues and constituents
about the existence of these sites, and remind them that the only way to obtain an
official AAP/AHA NRP course completion card is by completing the online examination
offered only through HealthStream, and completing in-person skills testing, simulation,
and debriefing under the guidance of an approved AAP/AHA NRP Instructor.
4
VOL 21 NO 1 sprin g / s u mme r 2 0 1 2
r
(NRP) Provide
Recommende
Date
Circle lessons NOT completed:
REQUIRED
Lesson 1: Overview & Principles of Resuscitation
Lesson
2: Initial Steps of Resuscitation
Signature
Lesson 3: Use of Resuscitation Devices
Instructor’s
for PPV
Lesson 4: Chest Compressions
Lesson 9: Ethics & Care at the End of Life
5
6
card.
7
8
OPTIONAL
Lesson 5: Endotracheal Intubation & Laryngeal
Mask Airway
Lesson 6: Medications
Lesson 7: Special Considerations
Lesson 8: Resuscitation of Babies Born Preterm
The AAP may disclose personal information for
for such disclosure or for any actions taken in administrative purposes such as to verify participation or status and will have no liability
reliance on such information. This recognition
applicable state statutes and licensing acts. ©2011
is subject
American Academy of Pediatrics/American Heart to the provisions and limitations of
Association
Contact the AAP at 800/433-4000 x4797, or
visit our website at www.aap.org/nrp to
register for a renewal reminder e-mail.
NRP eBook Q&A
™
T
he NRP offers the option of purchasing many of its 6th
Edition materials in an electronic and interactive format.
The eBook is downloadable for offline viewing anytime. Users
can preview the variety of features of the eBook at ebooks.aap.org.
Below are some of the common questions that instructors have
about this new modality.
What is an eBook?
An eBook is an electronic version of a book. American
Academy of Pediatrics (AAP) eBooks allow users to read
publications on any screen with a browser that supports
Flash based systems. AAP eBooks have the look of print
books, with the entire layout, figures and images intact.
What are the technical requirements for AAP eBooks?
Online viewing:
Computer or device with Internet connection and
current web browser:
• Internet Explorer: Version 6.0 , 7.0, 8.0
• Firefox: Version 3.0 & up
• Opera: Version 9.0 & up
• Google Chrome: Version 2.0 & up
• Safari: Version 3.0 & up
For full functionality, Flash Version 9 & up is also required.
There is a limited HTML-based view for users and devices
without Flash, such as iPhone®.
Offline viewing:
• PC or Mac: Download iOffline from the My Bookshelf
page with Internet connection and current access
rights to title.
• iPad: Download AAP eBooks free app available
through iTunes®.
Once an eBook has been downloaded, it can be
viewed offline at any time.
What are the advantages of the
eBook over the print format?
• U
sers have the option to view a
page at a time or a 2-page spread,
and can zoom in for close study.
•T
he text is fully searchable, so users can easily
find specific terms
•U
sers have the ability to make personal notes,
bookmark, and highlight content.
•V
ideo content is integrated throughout the book
(for example, the NRP Textbook DVD content is
integrated throughout the eBook).
•U
sers can print a limited number of pages, one
page at a time.
• Individual eBooks will be updated when errata
are published.
• e Book purchasers will be among the first to see
new editions of books as they are released.
• If you subscribe to a collection or the full site, you
will automatically get new editions and titles as they
become available.
•Y
ou have the ability to read the book online, or
download it to a computer for off-line reading.
How do I purchase the eBook/what licensing
options are available?
AAP eBooks can be acquired in multiple ways.
Individuals can purchase individual titles for the life
of the edition through the site at ebooks.aap.org.
Institutions such as libraries, hospitals, and practices
can subscribe to the entire AAP eBook collection by
contacting [email protected].
*PLEASE NOTE: The Textbook of Neonatal Resuscitation,
6th Edition is not part of the AAP eBook Institutional
Collection and requires a separately ordered subscription.
Which NRP materials are available as an eBook?
he Textbook of Neonatal Resuscitation, 6th Edition is
T
available in both English and Spanish, and the Instructor
Manual for Neonatal Resuscitation is available in English.
Experience the Next-generation Virtual
Mobile Library! www.aapebooks.org
N RP I N S TRUCT OR UP DAT E
5
2012 NRP Current Issues Seminar
™
M
ark your calendars for Friday, October 19, 2012 and plan to
participate in the NRP Current Issues Seminar to be held in
conjunction with the 2012 American Academy of Pediatrics (AAP)
National Conference and Exhibition (NCE) in New Orleans. This
seminar will be appropriate for any NRP instructors or health care
professionals interested in neonatal resuscitation. This seminar will
focus on instructor development and skills for effective debriefing
and interactive learning. (Please note: This is NOT an NRP course.)
Consider staying to participate in the NCE! Your advance registration
to the full NCE includes admission to all general sessions, section
meetings, and committee events.
Plenary sessions include:
• Latest evidence on epinephrine and chest compressions
• Updates on the 7th Edition Guidelines for Perinatal Care
• L earn what it takes to effectively negotiate with your hospital
administration to get the support and equipment you need to teach
your NRP courses
Fax: 847/228-1281
Phone: 888/227-1770
Online: www.aap.org/nce
Breakout sessions include:
• NRP in Action – Case-based Interactive Discussion
• Be An Avatar – Hands-on Simulation (Space is Limited)
• Simulation and Debriefing in Your Classroom
Objectives:
After participation in this program, attendees should be able to:
•R
eview current evidence-based details regarding the use of
epinephrine and chest compressions
•O
utline and define the practical skills and effective techniques for
simulation and debriefing in your classroom
•D
efine practical methods to effectively communicate with hospital
administration regarding ethical, medical, and legal resources for
implementing the NRP
Don’t Wait! Register NOW!
To participate in the NRP Seminar, you must register for the
AAP National Conference and Exhibition. The NRP seminar fee
is an additional $75, which includes a luncheon. The 2012 NCE
of the AAP will be held October 20-23, at the Ernest N. Morial
Convention Center, New Orleans.
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VOL 21 NO 1 sprin g / s u mme r 2 0 1 2
Please note: The NCE exhibit floor does not open until
Saturday, October 20th.
Interested individuals can obtain AAP NCE registration materials in
one of three ways:
Registration opens the first week of June.
Registration Fees
Category
Advance Rate
(June 1-Sept 7)
Regular Rate
(Sept 8-Oct 23)
Additional
NRP
Seminar
Fee
AAP Members
Fellow
$530
$680
$75
One-day Fellow
$385
$385
$75
Nonmember
Physician
$735
$885
$75
One-day only
$450
$450
$75
Nonmembers
Nurses/Allied Health Professionals
Nurse
$320
$420
$75
Allied Health
Professional
$320
$420
$75
One-day only
$235
$235
$75
Going Green!
The 2012 NRP Current Issues Seminar utilizes an online syllabus, and participants will not be provided paper handouts. Participants are
encouraged to bring a laptop or print handouts in advance. Attendees will receive a web link to view the handouts two weeks prior to the
2012 NRP Current Issues Seminar, and upon registration at the NCE will receive a CD-ROM containing digital copies as well.
NRP Current Issues Seminar:
Friday, October 19th, 2012
7:00-8:30am
Registration
8:30-8:45am
Welcome
Kimberly Ernst, MD, MSMI, FAAP
Steven Ringer, MD, FAAP
Reflections on the NRP 25th Anniversary
8:45-9:15am
and 3 Million Trained
Bill Keenan, MD, FAAP
The 5 Ps for Success in Dealing With the
9:15-10:00am
Administration for Profitability and Liability:
How to Leverage What’s Important to Get
What’s Important
Jay Goldsmith, MD, FAAP
10:00-10:15am
NRP Research Grant Award Recipient #1
10:15-10:30am
Break
10:30-10:45am
NRP Research Grant Award Recipient #2
1:00-2:30pm
Concurrent Sessions Part 1
Breakout 1: Applied NRP or NRP in Action – Case Based Discussions with ARS
Steven Ringer, MD, FAAP
Breakout 2A: Be an Avatar – Hands-on
Simulation
Christopher Colby, MD, FAAP
Breakout 2B: Be an Avatar – Hands-on
Simulation
Myra Wyckoff, MD, FAAP
Breakout 3: Simulation and Debriefing
in Your Classroom
Jeanette Zaichkin, RN, MN, NNP-BC
2:30-2:45pm
Break
2:45-4:15pm
Repeat of Concurrent Sessions
4:15pm
Adjourn
4:15-4:45pm
ptional: Join the Faculty for a
O
Debriefing Session
10:45-11:15am
Pump Work: The “C” in CPR: Evidence on Epinephrine and Chest Compressions
Myra Wyckoff, MD, FAAP
11:15am-12:00pm The New Holy Writ for Lawyers
and Administrators
Lu-Ann Papile, MD, FAAP
12:00-1:00pm
Lunch
Seminar Credit
The American Academy of Pediatrics is accredited by the Accreditation
Council for Continuing Medical Education (ACCME) to provide continuing
medical education for physicians. This activity was planned and
implemented in accordance with the ACCME Essentials.
The AAP designates this educational activity for a maximum of 6.5
AMA PRA Category 1 Credits™. Physicians should only claim credit
commensurate with the extent of their participation in the activity.
This activity is acceptable for a maximum of 6.5 AAP credits. These credits
can be applied toward the AAP CME/CPD Award available to Fellows and
Candidate Members of the AAP.
The American Academy of Physician Assistants accepts AMA PRA
Category 1 Credit(s)™ from organizations accredited by the ACCME.
This program is approved for 6.5 NAPNAP contact hours which 0 contain
pharmacology (Rx) content per the National Association of Pediatric Nurse
Practitioners Continuing Education Guidelines.
Application has been made to the Illinois Nurses Association (INA) for
continuing education contact hours for nurses.
Application has been made to the American Association for
Respiratory Care (AARC) for continuing education contact hours
for respiratory therapists.
N RP I N S TRUCT OR UP DAT E
7
Vigorous and Cyanotic: Start Free-flow Oxygen or
Wait for the Pulse Oximeter?
H
ealthy newborns may take up to 10
minutes after birth to reach their
normal oxygen saturation of more than 90%,
and many healthy newborns appear slightly
cyanotic in the first minutes after birth. If the
newborn remains cyanotic, you should attach
a pulse oximeter and assess the need for
supplemental oxygen based on the preductal
measurement of oxygen saturation and the
newborn’s age in minutes.
wait another minute or two to administer
supplemental free-flow oxygen until the pulse
oximeter arrives and displays an oxygen
saturation reading? Is it okay for the provider
to start a low concentration of free-flow oxygen
and make corrections after pulse oximetry is
applied and functioning?
Planning and anticipating the need for pulse
oximetry is of utmost importance for avoiding
a situation where supplemental oxygen is
guided by unreliable visual assessment
only. Pulse oximetry should be immediately
available in all birth settings, and should be
applied whenever the use of oxygen can
be anticipated, and as soon as possible
after unanticipated supplemental oxygen is
administered to a newborn. The percentage of
oxygen given should be guided by saturations
that have been demonstrated by healthy
babies during the 10 minutes following their
birth (see diagram on page 9).
need for pulse oximetry is of
What If the vigorous newborn is judged to be
persistently cyanotic past the first couple of
minutes after birth and the pulse oximeter is
not within arm’s reach? Should the provider
Planning and anticipating the
utmost importance for avoiding
a situation where supplemental
oxygen is guided by unreliable
visual assessment only.
In the case described above, clinical
judgment and critical thinking skills are
valuable for making the best decision in the
context of the situation. In a low risk birth
setting, a pulse oximeter may need to be
brought from down the hall, but should be
immediately available and operational within
a very few minutes. If the baby has respiratory
distress, the provider may elect to administer
free-flow oxygen and even assist ventilation
while the pulse oximeter is en route and being
Welcome Dr Ades
Joining the NRP Steering Committee is
Anne Ades, MD, FAAP. Dr Ades is a Clinical
Assistant Professor of Pediatrics at the
University of Pennsylvania Perelman School
of Medicine. She takes over for Karen
Fairchild, MD, FAAP, Associate Professor
of Pediatrics at the University of Virginia
Health System in Charlottesville, VA.
Dr Ades commitment to NRP is driven by the belief that NRP not only
saves newborn lives, but can improve outcomes of at risk babies. She
feels that NRP provides a readily accessible framework for newborn
resuscitation that enables all providers of delivery room care instructed in
NRP to have common ground, and that the recommended team training
and simulation strategies will only enhance the care we provide.
When Dr Ades became an attending and took responsibility for teaching
NRP to providers of all levels and disciplines, she realized how much of
8
VOL 21 NO 1 sprin g / s u mme r 2 0 1 2
applied. Or, if the infant remains vigorous
it may be reasonable to delay the use of
supplemental oxygen until pulse oximetry is
available to guide management. In general,
cyanosis by itself is not a reliable indicator
for the need for supplemental oxygen. Once
supplemental oxygen is being administered,
you should monitor the baby’s SpO2 with an
oximeter, even if oxygen administration has
been discontinued by the time the oximeter
arrives. This will provide confirmation of the
baby’s oxygenation level, and allow you to
determine whether continued use of oxygen
would be beneficial.
Simulation and debriefing is ideal for helping
your learners practice critical thinking skills
in the case of the vigorous but cyanotic
newborn. Simulation provides a safe forum
for implementing decisions. Debriefing
allows providers to analyze the pros and
cons of each decision – and may point out
the need to improve systems to provide
more timely and efficient interventions
when necessary. Participation in simulated
resuscitation scenarios and debriefings of
team performance may allow providers to
make better, more confident decisions when
faced with similar situations during actual
clinical events.
a global impact NRP truly has on the way care is delivered to newborns.
As Dr Ades embarked on training a large group of nurses, RTs, and
physicians to care for newborns in a new unit using simulation and
NRP, her interest evolved in wanting to know how things worked behind
the scenes: how evidence was transitioned into guidelines and practice
recommendations and not just the clinical evidence, but also the evidence
behind the recommended teaching strategies.
Dr Ades is particularly interested in two major research areas related to
NRP. First, she is interested in research in how to optimize the care of
newborns in the delivery room using educational and quality assurance
approaches. Her other main area of research interest is in delivery room
management of neonates with congenital anomalies and developing
evidence-based guidelines for important aspects of their care that extends
beyond the current NRP algorithm.
The NRP and AAP are pleased to welcome Dr Ades and thank Dr Fairchild
for her efforts, commitment, and dedication to the mission of the NRP.
Birth
Yes—stay
with mother
Term gestation?
Breathing or crying?
Good tone?
Routine Care
• Provide warmth
• Clear airway if necessary
• Dry
• Ongoing evaluation
No
Warm, clear airway if necessary,
dry, stimulate
HR below 100 bpm,
gasping, or apnea?
30 sec
No
No
Clear airway
SPO2 monitoring
Consider CPAP
PPV,
SPO2 monitoring
3 min
4 min
70%-75%
75%-80%
5 min
10 min
80%-85%
85%-95%
Labored
breathing
or persistent
cyanosis?
Yes
Yes
Targeted Pre-ductal SpO2
After Birth
1 min
60%-65%
2 min
65%-70%
60 sec
The percentage of oxygen
given should be guided
by saturations that have
been demonstrated by
HR below 100 bpm?
healthy babies during
No
the 10 minutes following
their birth.
Yes
Take ventilation
corrective steps
No
Post-resuscitation
care
HR below 60 bpm?
Yes
Consider intubation
Chest compressions
Coordinate with PPV
Take ventilation
corrective steps
Intubate if
no chest rise!
HR below 60 bpm?
Yes
IV epinephrine
Consider:
• Hypovolemia
• Pneumothorax
N RP I N S TRUCT OR UP DAT E
9
NRP Webinar
™
Sure Fire Strategies for Creating an Engaging
NRP Course: Simulation Tips From the Experts
Times Will be the Same for all Webinars
1:00-2:30pm Eastern • 12:00-1:30pm Central
11:00am-12:30pm Mountain • 10:00-11:30am Pacific
J
oin other NRP instructors as members of the NRP Steering
Committee discuss strategies for success to create an
engaging learning environment using a simulation-based NRP
course curriculum.
The NRP Steering Committee is presenting this event to
instructors via a streaming webinar. An unlimited number of
participants can listen at each site with only one registration fee.
(Note: Continuing Education Credit for more than five attendees
requires an additional fee.)
This unique and informative program is being offered on two
different dates to give as many instructors as possible the
opportunity to participate in this timely program. You will be
able to ask questions of the faculty during the question-andanswer sessions and participate in audience polling with either
immediate access to the results or immediate feedback.
Program Objectives
After participation in this program, participants should be able to:
• Discuss strategies for organizing and implementing a
simulation-based NRP Provider Course curriculum
• Review components of the 6th Edition NRP Provider Course
and how to use them
• Identify strategies for creating an engaging learning environment
through use of simulation and debriefing
Faculty
Myra Wyckoff, MD, FAAP
Jeanette Zaichkin, RN, MN, NNP-BC
Interactive and Fast-Paced
The faculty’s interaction with the listener will make this program
valuable, and you can ask questions wherever you are – this
feature is very much like participating in a talk radio program.
Webinar Credit
The American Academy of Pediatrics is accredited by the Accreditation
Council for Continuing Medical Education (ACCME) to provide
continuing medical education for physicians. This activity was planned
and implemented in accordance with the ACCME Essentials.
10
September 26 &
September 27, 2012
Convenient and Time-Saving
Webinars allow you to avoid traffic and parking challenges – there
is no travel time or expense at all. Participants can call from a
hospital, office, home, or anywhere there is a telephone. With the
site license pricing, registrants can invite other participants to join
in, discuss these important issues, and save money. Each session
lasts 90 minutes. If you’re not able to attend, you may purchase
access to an On Demand streaming archive of the presentation.
What You Will Need
For video & audio: An Internet connection is required to view
the visual information – no special hardware is needed – a
dial-up connection will work fine. You’ll be able to watch the
presentation while the speakers annotate their slides. To allow a
group to view the presentation, consider using a large monitor
or a projection unit.
For audio only: A phone is all that’s needed, but a speakerphone
is required for the audio if several people want to “attend”
the program.
What We Will Send You
Several days before the webinar(s), registrants will receive:
• Instructions on how to attend this webinar, including a toll-free
number, course code, and PIN numbers to access the program.
•E
ither a URL to obtain the handouts via e-mail or a hard copy
of the materials via FedEx. Registrants will need to duplicate the
materials for others attending the webinar at their location.
•A
link to a roster form and evaluations to be completed and
returned for credit verification.
Registration
Registration is easy – and with the program being offered on
two different dates, we hope more NRP instructors will be able
to access this valuable information and participate. To register,
you can either call the KRM Customer Service Line with your
credit card information at 800/775-7654 or register online at
www.krm.com/aap.
This program is approved for 1.5 NAPNAP contact hours which
0 contain pharmacology (Rx) content per the National Association
of Pediatric Nurse Practitioners Continuing Education Guidelines.
The AAP designates this educational activity for a maximum of 1.5
AMA PRA Category 1 Credits™. Physicians should only claim credit
commensurate with the extent of their participation in the activity.
This activity has been submitted to Illinois Nurses Association Approver
Unit for approval to award 1.5 contact hours. Illinois Nurses Association
is accredited as an approver of continuing nursing education by the
American Nurses Credentialing Center’s Commission on Accreditation.
This activity is acceptable for a maximum of 1.5 AAP credits. These
credits can be applied toward the AAP CME/CPD Award available to
Fellows and Candidate Members of the AAP.
Application has been made to the American Association for
Respiratory Care (AARC) for 1.5 continuing education contact
hours for respiratory therapists.
The American Academy of Physician Assistants accepts AMA PRA
Category 1 Credit(s)™ from organizations accredited by the ACCME.
To receive credit, registrants will be required to complete and return an
evaluation form to verify participation.
VOL 21 NO 1 sprin g / s u mme r 2 0 1 2
CK HER
E
C
LI
NRP 6th Edition Online
Exam Access Information
™
EX
A M I N AT
IO
Cl
N
NR
T
he NRP has partnered with
HealthStream to host the online
examination. HealthStream offers
four types of access to the NRP
Online Examination, 6th Edition.
The access type you use depends
on what your facility/employer
has provided. Please note that
NRP instructors are eligible
NE
O N LI
for complimentary access to the
examination once annually, provided
instructor status has been maintained.
Here
ick
P
u I
f Your Employer is an Existing HealthStream Customer,
you will access the course through the same HealthStream
platform that is used to deliver your other online learning
materials. Contact your HealthStream administrator for
additional details.
u I
f Your Employer is a New HealthStream Customer,
you may utilize HealthStream Express to access and
complete the NRP Exam. Your administrator will contact
you with information about how you should access
HealthStream Express.
u I
f Your Employer uses Another Learning Management
System, you may be given the course via your primary
LMS. In this case, the course is delivered via a system
called HealthStream Connect.
u I
f You are an Individual Purchaser, you will access the
exam by creating an account and purchasing the exam
with a credit card.
An online examination user guide containing full access information is now available on the NRP website at www.aap.org/nrp.
If you have any questions or concerns, you may contact your HealthStream administrator or HealthStream Customer Support
at 1-800-521-0574, selection #7 or email [email protected].
NRP™ Instructor DVD Completion Reminder
As a reminder, those participating in your future instructor courses are required to purchase and
complete the NRP Instructor DVD: An Interactive Tool for Facilitation of Simulation-based Learning.
The DVD can be purchased from the AAP Bookstore at www.aap.org/bookstore.
Instructors that did not complete the DVD by March 16, 2012 need to retake the standard length NRP
Provider Course and Hospital-based Instructor Course (which includes successfully completing the NRP
Instructor DVD) under the guidance of an active Regional Trainer, in order to reinstate instructor status.
Please know that your status as an NRP Provider will remain in effect until your original NRP Instructor
renewal/expiration date.
Beginning January 1, 2013, instructors will be required to complete and pass all 9 lessons of the online
examination every 2 years based on renewal date. Instructors may take the online examination once
per year, free of charge. If you fail the online examination, you will be required to retake it and will be
responsible for covering any costs incurred for retaking the exam. Continuing education credit will only
be offered once every 2 years.
N RP I N S TRUCT OR UP DAT E
11
NRP Research
Grants Awarded
™
Congratulations to the
following individuals
who received 2011
NRP Grant Awards
I NS
T
RS
lations!
Congratu R U C T O
C
LI
C H ERE
Research K
Grant Awards:
NRP Milestone
™
For over two decades, the Neonatal Resuscitation Program (NRP) has set the standard
and served as an international example for training in resuscitation of the newborn.
The program reached a significant training milestone on February 8, 2012 when the
3,000,000th provider trained within the United States was recorded. Congratulations to
Regional Trainer Beverly McInnis from Richmond, Virginia for submitting the roster that
included provider 3,000,000.
The NRP will continue to evolve, both in process and content, to meet the needs
of healthcare professionals who care for newborns. The NRP Steering Committee
expresses its sincere thanks to you, our dedicated instructors, who brought us to this
training milestone. We hope you will continue to be with us as we move towards
4 million and beyond.
Satyan Lakshminrusimha, MD, FAAP
State University of New York at Buffalo
“Tracheal Suctioning in ‘Spontaneous’ Meconium
Aspiration in Non-vigorous Asphyxiated Lambs.”
C
E
PR
S
Henry Lee, MD, FAAP
The Regents
E the University of
I Dof
O V San R
California,
Francisco
“A Multi-center State Collaborative Project
to Improve Delivery Room Management in
Neonatal Resuscitation.”
LI
CK HER
Young Investigator
Awards:
Melissa Carmen, MD
State University of New York at Buffalo
“The Use of Pulse Oximetry in the Assessment
of Effective Chest Compressions During
Neonatal Resuscitation.”
AMINA
O
TI
N
Cl
Heather Morein French, MD, FAAP
Drexel University
Here College of Medicine
k
c
“Variability
i in Delivery Room Management of
Infants With Congenital Anomalies.”
Congratulations to our research grant awardees!
EX
The Fall/Winter issue of the NRP Instructor Update
will include information about the 2013 NRP
E
NR
IN
Research
and Young Investigator
PGrant
O N LProgram
Award opportunities.
Changes to AARC Continuing Education Credit
The American Academy for Respiratory Care (AARC) has transitioned to a new online
accreditation system. As part of this change, effective January 1, 2012, a learner must
complete all 9 lessons of the NRP Online Examination in order to receive continuing
education credit from the AARC. Partial credit from AARC is no longer available.
Please note that your certificate for completing only a portion of the NRP Online
Examination is still valid for proof of Allied Health credit. This may be sufficient to meet
your continuing education requirements, depending upon individual state requirements.
If you have any questions about this change please contact [email protected].
Thank You for Completing the NRP™ Instructor DVD!
Thank you for completing the NRP Instructor DVD: An Interactive Tool for the Facilitation of Simulation-based Learning
prior to the March 16, 2012 deadline. Due to the exceedingly high volume of learners completing the DVD before the
approaching deadline, the internal Academy servers were overloaded at times resulting in outages and generating errors
for our users. We regret the inconvenience to our valued customers, and appreciate your patience and understanding
during this time period. Despite the implementation challenges, we have received positive feedback about the DVD
content and we are grateful learners feel it is a valuable tool for the transition to simulation.
We encourage you to revisit the DVD from time-to-time. The lessons will become more helpful after you have experience
with debriefing in your courses.
Have questions? Contact the AAP Life Support staff at [email protected].
12
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