NRP-certified nurses, nurse practitioners, and respiratory therapists have demonstrated the capacity to lead resuscitations.1113 However, it is recommended that an NRP-certified physician be present in the hospital when a high-risk delivery is anticipated.1113 One study provides an outline for physicians interested in developing a neonatal resuscitation team.14. The practice test consists of 10 multiple-choice questions that adhere to the latest ILCOR standards. Title: Microsoft PowerPoint - CPS GR Final Author: JackieM Created Date: 9/10/2021 9:22:37 PM These guidelines apply primarily to the newly born baby who is transitioning from the fluid-filled womb to the air-filled room. The importance of skin-to-skin care in healthy babies is reinforced as a means of promoting parental bonding, breast feeding, and normothermia. Copyright 2011 by the American Academy of Family Physicians. Delayed umbilical cord clamping was recommended for both term and preterm neonates in 2015. Newly born infants who receive prolonged PPV or advanced resuscitation (eg, intubation, chest compressions epinephrine) should be closely monitored after stabilization in a neonatal intensive care unit or a monitored triage area because these infants are at risk for further deterioration. 1-800-AHA-USA-1 Heart rate is assessed initially by auscultation and/or palpation. The suggested ratio is 3 chest compressions synchronized to 1 inflation (with 30 inflations per minute and 90 compressions per minute) using the 2 thumbencircling hands technique for chest compressions. There should be ongoing evaluation of the baby for normal respiratory transition. A new Resuscitation Quality Improvement (RQI) program for NRP focused on PPV will be . Every birth should be attended by at least 1 person who can perform the initial steps of newborn resuscitation and initiate PPV, and whose only responsibility is the care of the newborn. Neonatal resuscitation program Your team is resuscitating a newborn whose heart rate remains less than 60 bpm despite effective PPV and 60 seconds of chest compressions. Various combinations of warming strategies (or bundles) may be reasonable to prevent hypothermia in very preterm babies. Each 2020 AHA Guidelines for CPR and ECC document was submitted for blinded peer review to 5 subject matter experts nominated by the AHA. A single-center RCT found that role confusion during simulated neonatal resuscitation was avoided and teamwork skills improved by conducting a team briefing. Noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation should be considered ethically equivalent. Two randomized trials and 1 quasi-randomized trial (very low quality) including 312 infants compared PPV with a T-piece (with PEEP) versus a self-inflating bag (no PEEP) and reported similar rates of death and chronic lung disease. Preterm and term newborns without good muscle tone or without breathing and crying should be brought to the radiant warmer for resuscitation. ECG provides the most rapid and accurate measurement of the newborns heart rate at birth and during resuscitation. Hypothermia after birth is common worldwide, with a higher incidence in babies of lower gestational age and birth weight. Other recommendations include confirming endotracheal tube placement using an exhaled carbon dioxide detector; using less than 100 percent oxygen and adequate thermal support to resuscitate preterm infants; and using therapeutic hypothermia for infants born at 36 weeks' gestation or later with moderate to severe hypoxic-ischemic encephalopathy. Ninety percent of infants transition safely, and it is up to the physician to assess risk factors, identify the nearly 10 percent of infants who need resuscitation, and respond appropriately. Tactile stimulation should be limited to drying an infant and rubbing the back and soles of the feet.21,22 There may be some benefit from repeated tactile stimulation in preterm babies during or after providing PPV, but this requires further study.23 If, at initial assessment, there is visible fluid obstructing the airway or a concern about obstructed breathing, the mouth and nose may be suctioned. Outside the delivery room, or if intravenous access is not feasible, the intraosseous route may be a reasonable alternative, determined by the local availability of equipment, training, and experience. If intravenous access is not feasible, it may be reasonable to use the intraosseous route. Umbilical venous catheterization is the recommended vascular access, although it has not been studied. In a randomized trial, the use of sodium bicarbonate in the delivery room did not improve survival or neurologic outcome. In newborns who do not require resuscitation, delaying cord clamping for more than 30 seconds reduces anemia, especially in preterm infants. Infants 36 weeks or greater estimated gestational age who receive advanced resuscitation should be examined for evidence of HIE to determine if they meet criteria for therapeutic hypothermia. Care (Updated May 2019)*, 2020 Advanced Cardiovascular Life Support (ACLS), 2020 Pediatric Advanced Life Support (PALS), 2015 Pediatric Emergency Assessment and Recognition, Conflicts of Interest and Ethics Policies, Advanced Cardiovascular Life Support (ACLS), CPR & First Aid in Youth Sports Training Kit, Resuscitation Quality Improvement Program (RQI), COVID-19 Resources for CPR & Resuscitation, Claiming Your AHA Continuing Education Credits, International Liaison Committee on Resuscitation. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. Alternative compression-to-ventilation ratios to 3:1, as well as asynchronous PPV (administration of inflations to a patient that are not coordinated with chest compressions), are routinely utilized outside the newborn period, but the preferred method in the newly born is 3:1 in synchrony. A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide. For nonvigorous newborns delivered through MSAF who have evidence of airway obstruction during PPV, intubation and tracheal suction can be beneficial. Additional personnel are necessary if risk factors for complicated resuscitation are present. It may be reasonable to administer further doses of epinephrine every 3 to 5 min, preferably intravascularly,* if the heart rate remains less than 60/ min. How soon after administration of intravenous epinephrine should you pause compressions and assess the baby's heart rate?a. It is recommended to increase oxygen concentration to 100 percent if the heart rate continues to be less than 60 bpm (despite effective positive pressure ventilation) and the infant needs chest compressions.57, Initial PIP of 20 to 25 cm H2O should be used; if the heart rate does not increase or chest wall movement is not seen, higher pressures can be used. For newly born infants who are unintentionally hypothermic (temperature less than 36C) after resuscitation, it may be reasonable to rewarm either rapidly (0.5C/h) or slowly (less than 0.5C/h). Hypoglycemia is common in infants who have received advanced resuscitation and is associated with poorer outcomes.8 These infants should be monitored for hypoglycemia and treated appropriately. For nonvigorous newborns with meconium-stained fluid, endotracheal suctioning is indicated only if obstruction limits positive pressure ventilation, because suctioning does not improve outcomes. Epinephrine dosing may be repeated every three to five minutes if the heart rate remains less than 60 beats per minute. Post-resuscitation care. Compresses correctly: Rate is correct. Very low-quality evidence from 2 nonrandomized studies and 1 randomized trial show that auscultation is not as accurate as ECG for heart rate assessment during newborn stabilization immediately after birth. The wet cloth beneath the infant is changed.5 Respiratory effort is assessed to see if the infant has apnea or gasping respiration, and the heart rate is counted by feeling the umbilical cord pulsations or by auscultating the heart for six seconds (e.g., heart rate of six in six seconds is 60 beats per minute [bpm]). In this review, we provide the current recommendations for use of epinephrine during neonatal . Together with other professional societies, the AHA has provided interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed coronavirus disease 2019 (COVID-19) infection. The chest compression technique of using two thumbs, with the fingers encircling the chest and supporting the back, achieved better results in swine models compared with the technique of using two fingers, with a second hand supporting the back. The goal should be to achieve oxygen saturation targets shown in Figure 1.5,6, When chest compressions are indicated, it is recommended to use a 3:1 ratio of compressions to ventilation.57, Chest compressions in infants should be delivered by using two thumbs, with the fingers encircling the chest and supporting the back, and should be centered over the lower one-third of the sternum.5,6, If the infant's heart rate is less than 60 bpm after adequate ventilation and chest compressions, epinephrine at 0.01 to 0.03 mg per kg (1:10,000 solution) should be given intravenously. A large observational study showed that most nonvigorous newly born infants respond to stimulation and PPV. It is the expert opinion of national medical societies that conditions exist for which it is reasonable to not initiate resuscitation or to discontinue resuscitation once these conditions are identified. Rescuer 2 verbalizes the need for chest compressions. Babies who have failed to respond to PPV and chest compressions require vascular access to infuse epinephrine and/or volume expanders. Breathing is stimulated by gently rubbing the infant's back. The science of neonatal resuscitation applies to newly born infants transitioning from the fluid-filled environment of the womb to the air-filled environment of the birthing room and to newborns in the days after birth. In observational studies in both preterm (less than 37 weeks) and low-birth-weight babies (less than 2500 g), the presence and degree of hypothermia after birth is strongly associated with increased neonatal mortality and morbidity. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. One RCT (low certainty of evidence) suggests improved oxygenation after resuscitation in preterm babies who received repeated tactile stimulation. Reviews in 2021 and later will address choice of devices and aids, including those required for ventilation (T-piece, self-inflating bag, flow-inflating bag), ventilation interface (face mask, laryngeal mask), suction (bulb syringe, meconium aspirator), monitoring (respiratory function monitors, heart rate monitoring, near infrared spectroscopy), feedback, and documentation. Babies who are breathing well and/or crying are cared for skin-to-skin with their mothers and should not need interventions such as routine tactile stimulation or suctioning, even if the amniotic fluid is meconium stained.7,19 Avoiding unnecessary suctioning helps prevent the risk of induced bradycardia as a result of suctioning of the airway. 7. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Ventilation using a flow-inflating bag, self-inflating bag, or T-piece device can be effective. If the infant's heart rate is less than 100 beats per minute and/or the infant has apnea or gasping respiration, positive pressure ventilation via face mask should be initiated with 21 percent oxygen (room air) or blended oxygen using a self-inflating bag, flow-inflating bag, or T-piece device while monitoring the inflation pressure. The heart rate is reassessed,6 and if it continues to be less than 60 bpm, synchronized chest compressions and PPV are initiated in a 3:1 ratio (three compressions and one PPV).5,6 Chest compressions can be done using two thumbs, with fingers encircling the chest and supporting the back (preferred), or using two fingers, with a second hand supporting the back.5,6 Compressions should be delivered to the lower one-third of the sternum to a depth of approximately one-third of the anteroposterior diameter.5,6 The heart rate is reassessed at 45- to 60-second intervals, and chest compressions are stopped once the heart rate exceeds 60 bpm.5,6, Epinephrine is indicated if the infant's heart rate continues to be less than 60 bpm after 30 seconds of adequate PPV with 100 percent oxygen and chest compressions. Therapeutic hypothermia is provided under defined protocols similar to those used in published clinical trials and in facilities capable of multidisciplinary care and longitudinal follow-up. On the other hand, overestimation of heart rate when a newborn is bradycardic may delay necessary interventions. . Positive-pressure ventilation (PPV) remains the main intervention in neonatal resuscitation. Variables to be considered may include whether the resuscitation was considered optimal, availability of advanced neonatal care (such as therapeutic hypothermia), specific circumstances before delivery, and wishes expressed by the family.3,6, Some babies are so sick or immature at birth that survival is unlikely, even if neonatal resuscitation and intensive care are provided. What is true about a pneumothorax in the newborn? The 7th edition of the Textbook of Neonatal Resuscitation recommends 0.5-mL to 1-mL flush following IV epinephrine (0.01 to 0.03 mg/kg dose) via a low-lying UVC [6]. When anticipating a high-risk birth, a preresuscitation team briefing should be completed to identify potential interventions and assign roles and responsibilities. If the infant's heart rate is less than 60 beats per minute after adequate positive pressure ventilation and chest compressions, intravenous epinephrine at 0.01 to 0.03 mg per kg (1:10,000 solution) is recommended. While the science and practices surrounding monitoring and other aspects of neonatal resuscitation continue to evolve, the development of skills and practice surrounding PPV should be emphasized. Auscultation of the precordium remains the preferred physical examination method for the initial assessment of the heart rate.9 Pulse oximetry and ECG remain important adjuncts to provide continuous heart rate assessment in babies needing resuscitation. When epinephrine is required, multiple doses are commonly needed. Positive-Pressure Ventilation (PPV) Table 1. If the infant's heart rate is less than 60 beats per minute after effective positive pressure ventilation, then chest compressions should be initiated with continued positive pressure ventilation (3:1 ratio of compressions to ventilation; 90 compressions and 30 breaths per minute). It is estimated that approximately 10% of newly born infants need help to begin breathing at birth,13 and approximately 1% need intensive resuscitative measures to restore cardiorespiratory function.4,5 The neonatal mortality rate in the United States and Canada has fallen from almost 20 per 1000 live births 6,7 in the 1960s to the current rate of approximately 4 per 1000 live births. These situations benefit from expert consultation, parental involvement in decision-making, and, if indicated, a palliative care plan.1,2,46. Once the heart rate increases to more than 60 bpm, chest compressions are stopped. - 14446398 Newly born infants who receive prolonged PPV or advanced resuscitation (intubation, chest compressions, or epinephrine) should be maintained in or transferred to an environment where close monitoring can be provided. Intrapartum suctioning is not recommended in infants born through meconium-stained amniotic fluid. Median time to ROSC and cumulative epinephrine dose required were not different. In preterm birth, there are also potential advantages from delaying cord clamping. When the heart rate increases to more than 100 bpm, PPV may be discontinued if there is effective respiratory effort.5 Oxygen is decreased and discontinued once the infant's oxygen saturation meets the targeted levels (Figure 1).5, If there is no heartbeat after 10 minutes of adequate resuscitative efforts, the team can cease further resuscitation.1,5,6 A member of the team should keep the family informed during the resuscitation process. Case series in preterm infants have found that most preterm infants can be resuscitated using PPV inflation pressures in the range of 20 to 25 cm H. An observational study including 1962 infants between 23 and 33 weeks gestational age reported lower rates of mortality and chronic lung disease when giving PPV with PEEP versus no PEEP. Expert neonatal and bioethical committees have agreed that, in certain clinical conditions, it is reasonable not to initiate or to discontinue life-sustaining efforts while continuing to provide supportive care for babies and families.1,2,4, If the heart rate remains undetectable and all steps of resuscitation have been completed, it may be reasonable to redirect goals of care. In the resuscitation of an infant, initial oxygen concentration of 21 percent is recommended. Preterm infants less than 32 weeks' gestation are more likely to develop hyperoxemia with the initial use of 100 percent oxygen, and develop hypoxemia with 21 percent oxygen compared with an initial concentration of 30 or 90 percent oxygen. IV epinephrine every 3-5 minutes. The usefulness of positive end-expiratory pressure during PPV for term infant resuscitation has not been studied.6 A recent study showed that use of mask continuous positive airway pressure for resuscitation and treatment of respiratory distress syndrome in spontaneously breathing preterm infants reduced the need for intubation and subsequent mechanical ventilation without increasing the risk of bronchopulmonary dysplasia or death.29 In a preterm infant needing PPV, a PIP of 20 to 25 cm H2O may be adequate to increase heart rate while avoiding a higher PIP to prevent injury to preterm lungs, and positive end-expiratory pressure may be beneficial if suitable equipment is available.6. Newborn temperature should be maintained between 97.7F and 99.5F (36.5C and 37.5C), because mortality and morbidity increase with hypothermia, especially in preterm and low birth weight infants. Chest compressions are provided if there is a poor heart rate response to ventilation after appropriate ventilation corrective steps, which preferably include endotracheal intubation. Once return of spontaneous circulation (ROSC) is achieved, the supplemental oxygen concentration may be decreased to target a physiological level based on pulse oximetry to reduce the risks associated with hyperoxia.1,2. It may be possible to identify conditions in which withholding or discontinuation of resuscitative efforts may be reasonably considered by families and care providers. Equipment checklists, role assignments, and team briefings improve resuscitation performance and outcomes. One observational study compared neonatal outcomes before (historical cohort) and after implementation of ECG monitoring in the delivery room. In preterm infants younger than 30 weeks' gestation, continuous positive airway pressure instead of intubation reduces bronchopulmonary dysplasia or death with a number needed to treat of 25. A combination of chest compressions and ventilation resulted in better outcomes than ventilation or compressions alone in piglet studies. Current resuscitation guidelines recommend that epinephrine should be used if the newborn remains bradycardic with heart rate <60 bpm after 30 s of what appears to be effective ventilation with chest rise, followed by 30 s of coordinated chest compressions and ventilations (1, 8, 9). Intra-arterial epinephrine is not recommended. Pulse oximetry is used to guide oxygen therapy and meet oxygen saturation goals. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Blood may be lost from the placenta into the mothers circulation, from the cord, or from the infant. A nonrandomized trial showed that endotracheal suctioning did not decrease the incidence of meconium aspiration syndrome or mortality. Chest compressions should be started if the heart rate remains less than 60/min after at least 30 seconds of adequate PPV.1, Oxygen is essential for organ function; however, excess inspired oxygen during resuscitation may be harmful. After birth, the baby should be dried and placed directly skin-to-skin with attention to warm coverings and maintenance of normal temperature. For newborns who are breathing, continuous positive airway pressure can help with labored breathing or persistent cyanosis. Breakdowns in teamwork and communication can lead to perinatal death and injury.15 Team training in simulated resuscitations improves performance and has the potential to improve outcomes.16,17 Ultimately, being able to perform bag and mask ventilation and work in coordination with a team are important for effective neonatal resuscitation. All Rights Reserved. In newborns born before 35 weeks' gestation, oxygen concentrations above 50% are no more effective than lower concentrations. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. Endotracheal suctioning may be useful in nonvigorous infants with respiratory depression born through meconium-stained amniotic fluid. Tactile stimulation is reasonable in newborns with ineffective respiratory effort, but should be limited to drying the infant and rubbing the back and the soles of the feet. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion. increase in the newborn's heart rate is the most sensitive indicator of a successful response to resuscitation. Resuscitation of an infant with respiratory depression (term and preterm) in the delivery room (Figure 1) focuses on airway, breathing, circulation, and medications. It is important to. This content is owned by the AAFP. The 2 thumbencircling hands technique achieved greater depth, less fatigue, and less variability with each compression compared with the 2-finger technique. Hyperlinked references are provided to facilitate quick access and review. 5 minutec. "Epinephrine is indicated when the heart rate remains below 60 beats per minute after you have given 30 seconds of effective assisted ventilation (preferably after endotracheal intubation) and at least another 45 to 60 seconds of coordinated chest compressions and effective ventilation." (p 219) Hyperthermia should be avoided.1,2,6, Delivery room temperature should be set at at least 78.8F (26C) for infants less than 28 weeks' gestation.6. A meta-analysis (very low quality) of 8 animal studies (n=323 animals) that compared air with 100% oxygen during chest compressions showed equivocal results. Oximetry and electrocardiography are important adjuncts in babies requiring resuscitation. It may be reasonable to administer a volume expander to newly born infants with suspected hypovolemia, based on history and physical examination, who remain bradycardic (heart rate less than 60/min) despite ventilation, chest compressions, and epinephrine. The dose of Epinephrine via the UVC is 0.1 mg/kg - 0.5 mg/kg It may be easier for you to use 0.1 mg/kg for the UVC access.. For an infant weighing 1 kg the dose becomes 0.1 ml. Finally, we wish to reinforce the importance of addressing the values and preferences of our key stakeholders, the families and teams who are involved in the process of resuscitation. In babies who appear to have ineffective respiratory effort after birth, tactile stimulation is reasonable. The exhaled carbon dioxide detector changes from purple to yellow with endotracheal intubation, and a negative result suggests esophageal intubation.5,6,25 Clinical indicators of endotracheal intubation, such as condensation in the tube, chest wall movement, or presence of bilateral equal breath sounds, have not been well studied. There is a reduction of mortality and no evidence of harm in term infants resuscitated with 21 percent compared with 100 percent oxygen. The heart rate should be re-checked after 1 minute of giving compressions and ventilations. Initiate effective PPV for 30 seconds and reassess the heart rate. In a randomized controlled simulation study, medical students who underwent booster training retained improved neonatal intubation skills over a 6-week period compared with medical students who did not receive booster training. Rapid evaluation: this evaluation determines if the baby can stay wit the mother for routine care or should be moved to the radiant warmer Airway: The initial steps open the airway and support spontaneous respirations. 1 Exhaled carbon dioxide detection is the recommended method of confirming endotracheal intubation. There is no evidence from randomized trials to support the use of volume resuscitation at delivery. Among the most important changes are to not intervene with endotracheal suctioning in vigorous infants born through meconium-stained amniotic fluid (although endotracheal suctioning may be appropriate in nonvigorous infants); to provide positive pressure ventilation with one of three devices when necessary; to begin resuscitation of term infants using room air or blended oxygen; and to have a pulse oximeter readily available in the delivery room. High oxygen concentrations are recommended during chest compressions based on expert opinion. If the infant needs PPV, the recommended approach is to monitor the inflation pressure and to initiate PPV using a peak inspiratory pressure (PIP) of 20 cm H2O for the first few breaths; however, a PIP of 30 to 40 cm H2O (in some term infants) may be required at a rate of 40 to 60 breaths per minute.5,6 The best measure of adequate ventilation is prompt improvement in heart rate.24 Auscultation of the precordium is the primary means of assessing heart rate, but for infants requiring respiratory support, pulse oximetry is recommended.5,6 However, if the heart rate does not increase with mask PPV and there is no chest rise, ventilation should be optimized by implementing the following six steps: (1) adjust the mask to ensure a good seal; (2) reposition the airway by adjusting the position of the head; (3) suction the secretions in the mouth and nose; (4) open the mouth slightly and move the jaw forward; (5) increase the PIP enough to move the chest; and (6) consider an alternate airway (endotracheal intubation or laryngeal mask airway).5 PIP may be decreased when the heart rate increases to more than 60 bpm, and PPV may be discontinued once the heart rate is more than 100 bpm and there is spontaneous breathing. For infants born at less than 28 wk of gestation, cord milking is not recommended. In one RCT and one observational study, there were no reports of technical difficulties with ECG monitoring during neonatal resuscitation, supporting its feasibility as a tool for monitoring heart rate during neonatal resuscitation. If the heart rate is less than 60 bpm, begin chest compressions. One observational study in newly born infants associated high tidal volumes during resuscitation with brain injury. In newly born infants who require PPV, it is reasonable to use peak inflation pressure to inflate the lung and achieve a rise in heart rate. For term and preterm infants who require resuscitation at birth, there is insufficient evidence to recommend early cord clamping versus delayed cord clamping. 1. This content is owned by the AAFP. Saturday: 9 a.m. - 5 p.m. CT For infants requiring PPV at birth, there is currently insufficient evidence to recommend delayed cord clamping versus early cord clamping. Ventilation of the lungs results in a rapid increase in heart rate. Comprehensive disclosure information for writing group members is listed in Appendix 1(link opens in new window). It is important to recognize that there are several significant gaps in knowledge relating to neonatal resuscitation. minutes, and 80% at 5 minutes of life. 8. Table 1 lists evidence and recommendations for interventions during neonatal resuscitation.1,2,57,2043, Intrapartum suctioning is not recommended with clear or meconium-stained amniotic fluid.1,2,5,6, Endotracheal suctioning of vigorous* infants is not recommended.1,2,5,6, Endotracheal suctioning of nonvigorous infants born through meconium-stained amniotic fluid may be useful.1,2,5, A self-inflating bag, flow-inflating bag, or T-piece device can be used to deliver positive pressure ventilation.1,6, Auscultation should be the primary means of assessing heart rate, and in infants needing respiratory support, the goal should be to check the heart rate by auscultation and by pulse oximetry.6, Initial PIP of 20 cm H2O may be effective, but a PIP of 30 to 40 cm H2O may be necessary in some infants to achieve or maintain a heart rate of more than 100 bpm.5, Ventilation rates of 40 to 60 breaths per minute are recommended.5,6, Use of an exhaled carbon dioxide detector in term and preterm infants is recommended to confirm endotracheal tube placement.5,6, Laryngeal mask airway should be considered if bag and mask ventilation is unsuccessful, and if endotracheal intubation is unsuccessful or not feasible.5,6, No evidence exists to support or refute the use of mask CPAP in term infants.2,5, PEEP should be used if suitable equipment is available, such as a flow-inflating bag or T-piece device.5, Delivery rooms should have a pulse oximeter readily available.57, A pulse oximeter is recommended when supplemental oxygen, positive pressure ventilation, or CPAP is used.57, Supplemental oxygen should be administered using an air/oxygen blender.57.
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