NRP Review: Part 2

🩺 NRP Review – Part 2: When PPV Isn’t Enough

NRP Review Part 2: Advanced Resuscitation

Welcome back to Lisa’s NICU Learning Nest! In last week’s NRP Review Part 1, we focused on initial steps of resuscitation—PPV, MRSOPA, and the importance of airway management. This week, we’re moving forward into advanced NRP, covering intubation, chest compressions, medications like epinephrine and fluid resuscitation, plus how to troubleshoot when things aren’t going as planned.

Intubation: A Critical Step in Advanced NRP

Before compressions or epinephrine, if your ventilation isn't working and you've optimized with MRSOPA, it's time to intubate. Here's what you need to know:

Indications for Intubation

• Ineffective PPV despite MRSOPA

• Prolonged need for PPV

• Chest compressions required

Supplies You’ll Need

• Laryngoscope with appropriate blade size (00 for micro-preemies, 0 or 1 for term)

• ETT (based on weight: <1 kg = 2.5; 1–2 kg = 3.0; >2 kg = 3.5)

• CO2 detector

• Suction setup (bulb and catheter)

• Tape or ETT holder

• T-piece resuscitator or bag-mask

• Stethoscope

Confirm placement:

• Rising HR

• CO2 detector color change (yellow = yes!)

• Bilateral breath sounds & visible chest rise

• Improvement in oxygenation

• Secure the tube and document ETT depth.

If HR is improving but CO2 doesn’t change, consider poor perfusion—keep ventilating and reassess.

Chest Compressions

• Indications: Initiate compressions if HR is <60 bpm despite 30 seconds of effective PPV, hopefully through an ETT.

• Technique:

  • Two-thumb encircling technique preferred.

  • Rate: 3 compressions to 1 breath (90 compressions, 30 breaths per minute).

  • Depth: One-third of the anterior-posterior chest diameter.

  • Reassess HR every 60 seconds to determine if compressions should continue.

***Don't forget: Always turn oxygen up to 100% (if you have not already)***

Epinephrine Administration

• Indications: HR remains <60 bpm despite 60 seconds of effective compressions + ventilation.

• New NRP Guidelines:

  • IV/UVC dose: 0.2 mL/kg

  • ETT dose: 1 mL/kg (higher dose due to poor absorption).

  • IV doses should be followed by 3 mL saline flush.

• Repeat dosing: Every 3-5 minutes if HR remains low.

Troubleshooting Epinephrine Administration

• If ETT epinephrine has been given and IV access is now available, administer IV epinephrine immediately and continue resuscitation.

Fluid Resuscitation & Additional Medications

• Indication: Suspected hypovolemia (pale, poor pulses, history of blood loss).

• Fluids:

  • Normal Saline 10 mL/kg IV push over 5-10 minutes.

  • Consider blood transfusion if risk factors for anemia or hypovolemia:

    • Placental abruption

    • Cord accident

    • Fetal-maternal hemorrhage

    • Severe anemia or hydrops

Duration of Resuscitation

• Consider discontinuing resuscitation after 20 minutes if:

  • No detectable heart rate despite effective resuscitation.

  • The baby is not responding to interventions.

  • Multidisciplinary team and family should be involved in decision-making.

Key Takeaways

1. PPV is the most important step in neonatal resuscitation—optimize it first.

2. MRSOPA should be done systematically while continuing PPV.

3. If a skilled provider is available, intubate before starting chest compressions.

4. Epinephrine dosing is now standardized – 0.2 mL/kg IV or 1 mL/kg ETT.

5. Normal Saline 10 mL/kg should be given rapidly when hypovolemia is suspected.

6. The documenter plays a crucial role in tracking events and times.

💬 Take-Home Message

When PPV isn’t enough, NRP steps must escalate quickly and efficiently. Mastering compressions, epinephrine timing/dosing, and understanding fluid and UVC protocols can truly make the difference in outcomes.

✨ Your knowledge and readiness save lives.

🖨️ Want a visual recap? Download our free NRP Algorithm flowchart under the Resources tab!

📺 Catch Part 1 of our NRP Review here for a refresher on setup, MRSOPA, and PPV troubleshooting.