Revised: 6-22-10

Neonatal Resuscitation Program oxygen use guidelines.

In 2005, the International Liaison Committee on Resuscitation, (ILCOR) concluded that the benefit of 100% oxygen for initial newborn resuscitation was of "indeterminate value". Oxygen use for newborns was hotly debated at that time between practioners that felt oxygen was the most important tool for a newborn resuscitation, and others that warned against overuse of supplemenatal oxygen. Points of consensus around neonatal oxygen use were eventually built to include a broad latitude of viewpoints, but the new guidelines were published later than expected.

Standards published 2005 in Circulation stated:

“There are no studies comparing various concentrations of oxygen during resuscitation beyond the perinatal period. Use 100% oxygen during resuscitation. Monitor the patient’s oxygen level. When the patient is stable, wean the supplementary oxygen if the oxygen saturation is maintained."

ILCOR uses evidence-based review of resuscitation science in an effort to build consensus on best practices. The proceedings of the latest consensus meeting will be published in October 2010, and will provide the material for regional resuscitation organisations, including the NRP, to write their resuscitation guidelines.

Oxygen is the most frequently administered drug in the delivery room. As with any drug, there can be undesireable side effects of administration. Oxygen free radicals are known to cause brain injury in the newborn. For low birthweight and premature infants, prolonged oxygen administration can lead to chronic lung problems, blindness, and brain damage.

Asphyxia Can Begin Before Birth.

Placental insufficiency, cord compression, and abruptio placentae, are all classified as respiratory problems for the fetus, because these intrauterine conditions mean less oxygen is available for normal cellular respiration to occur. Babies can be in a hypoxic state previous to birth. This is an important factor to consider when initiating PPV.

By thirty seconds an uncompromised baby should have spontaneous breathing efforts. Blow-by oxygen will not stimulate respirations, and will not be an effective intervention for a baby who is not breathing after 30 seconds of stimulation. This seems an elementary fact to most of us, however, oxygen is the first thing many practioners habitually reach for, even when a baby is not breathing.

With or without supplemental oxygen, Positive Pressure Ventilation (PPV) is the most effective resuscitative action to take for an apneic baby. If the baby is not taking air, you must give air. In the absence of umbilical blood flow, and respirations, the circulatory system will soon collapse. The mechanical action of pushing breaths in forces fluid out to be absorbed by the circulatory system, and increases pulmonary blood flow so that oxygen will diffuse across the aveoli to be transported to the infant's tissues by hemoglobin. Without a change of pressure gradients in the lung tissue, fetal circulation persists, and without an oxygen source, disaster ensues. Room air does contain oxygen, (21%), and PPV with a self-inflating bag and mask does not require an oxygen source. Low-tech, but effective.

Worldwide, settings that have no access to pulse oximetry, or lack technology to run a cord gas, rely heavily on basic clinical observation like those outlined by the Neonatal Resuscitation Program. Is baby working hard to breathe? Is it maintaining color? Does it maintain good heart rate? Does it have good tone and flexed posture? Is there a strong cry?

In less developed countries room air is frequently used with bag and mask for resuscitation purposes. Since information and training have proceeded access to medical technology in some countries, outcomes suggest that availability of oxygen does not "make or break" the majority of successful resuscitations.

ILCOR will come together again in 2010, in an effort to share research, define best practice, and disseminate information about all aspects of adult, child, and infant CPR. Updated guidelines are expected, which will represent the scientific consensus of experts from a variety of countries, cultures and disciplines.

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The Value of Hands on Skill Training

We all do things out of habit, even when called to a newborn delivery. Be present to the situation, respond to your patient and team members, not just the flow diagram on the wall. Every 30 second interval counts in the first "golden hour" of life.

A new emphasis on skills practice, code scenarios, and effective resuscitation teams will eclipse the usual anxiety around the written portion of the NRP exam in 2011.

The paper test will be replaced completely by the online exam. The exam must be completed before one can qualify for the skills testing. Again, outcomes show that hands on practice translates into better skill sets, and kudos to NRP for recognizing this.

Expected Timeline:
Neonatal Resuscitation Program, 6th Edition

Fall 2010 Simulation-based learning NRP Instructor DVD to be available. The new teaching format emphasizes hands on skills, and problem solving using code scenarios.
October 1, 2010 Issues Seminar, San Francisco, CA.
October 18, 2010 Treatment Recomendations and AAP/AHA Guidelines for Emergency Cardiovascular Care of the Neonate to be released.
Spring 2011 New NRP education materials will be published.
January 1, 2012 NRP 6th Edition Implementation.