History and physical examination findings suggestive of blood loss include a pale appearance, weak pulses, and persistent bradycardia (heart rate less than 60/min). Excessive peak inflation pressures are potentially harmful and should be avoided. Comprehensive disclosure information for peer reviewers is listed in Appendix 2(link opens in new window). Unauthorized use prohibited. 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. You're welcome to take the quiz as many times as you'd like. If the infant's heart rate is less than 100 bpm, PPV via face mask (not mask continuous positive airway pressure) is initiated at a rate of 40 to 60 breaths per minute to achieve and maintain a heart rate of more than 100 bpm.1,2,57 PPV can be administered via flow-inflating bag, self-inflating bag, or T-piece device.1,6 There is no major advantage of using one ventilatory device over another.23 Thus, each institution should standardize its equipment and train the neonatal resuscitation team appropriately. NRP Advanced may also be appropriate for health care professionals in smaller hospital facilities with fewer per- The reduced heart rate that occurs in this situation can be reversed with tactile stimulation. Medications are rarely needed in resuscitation of the newly born infant because low heart rate usually results from a very low oxygen level in the fetus or inadequate lung inflation after birth. For neonatal resuscitation providers, it may be reasonable to brief before delivery and debrief after neonatal resuscitation. Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. Epinephrine (adrenaline) is the only medication recommended by the International Liaison Committee On Resuscitation (ILCOR) during resuscitation in newborns with persistent bradycardia or . The impact of therapeutic hypothermia on infants less than 36 weeks gestational age with HIE is unclear and is a subject of ongoing research trials. When providing chest compressions to a newborn, it may be reasonable to choose the 2 thumbencircling hands technique over the 2-finger technique, as the 2 thumbencircling hands technique is associated with improved blood pressure and less provider fatigue. Noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation should be considered ethically equivalent. It is important to. However, it may be reasonable to increase inspired oxygen to 100% if there was no response to PPV with lower concentrations. The following sections are worth special attention. When providing chest compressions to a newborn, the 2 thumbencircling hands technique may have benefit over the 2-finger technique with respect to blood pressure generation and provider fatigue. Babies who have failed to respond to PPV and chest compressions require vascular access to infuse epinephrine and/or volume expanders. Rapid and effective response and performance are critical to good newborn outcomes. It is important to recognize that there are several significant gaps in knowledge relating to neonatal resuscitation. 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. If the heart rate remains less than 60/min despite these interventions, chest compressions can supply oxygenated blood to the brain until the heart rate rises. Animal studies in newborn mammals show that heart rate decreases during asphyxia. Each of these resulted in a description of the literature that facilitated guideline development.1417, Each AHA writing group reviewed all relevant and current AHA guidelines for CPR and ECC1820 and all relevant 2020 ILCOR International Consensus on CPR and ECC Science With Treatment Recommendations evidence and recommendations21 to determine if current guidelines should be reaffirmed, revised, or retired, or if new recommendations were needed. 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. The American Heart Association released minor updates to neonatal resuscitation recommendations with only minor changes to the previous algorithm (Figure 1). Ventilation using a flow-inflating bag, self-inflating bag, or T-piece device can be effective. 8 Assessment of Heart Rate During Neonatal Resuscitation 9 Ventilatory Support After Birth: PPV And Continuous Positive Airway Pressure 10 Oxygen Administration 11 Chest Compressions 12 Intravascular Access 13 Medications Epinephrine in Neonatal Resuscitation 14 Volume Replacement 15 Postresuscitation Care This guideline is designed for North American healthcare providers who are looking for an up-to-date summary for clinical care, as well as for those who are seeking more in-depth information on resuscitation science and gaps in current knowledge. However, the concepts in these guidelines may be applied to newborns during the neonatal period (birth to 28 days). In addition, accurate, fast, and continuous heart rate assessment is necessary for newborns in whom chest compressions are initiated. Limited observational studies suggest that tactile stimulation may improve respiratory effort. Positive pressure ventilation should be provided at 40 to 60 inflations per minute with peak inflation pressures up to 30 cm of water in term newborns and 20 to 25 cm of water in preterm infants. Plasma epinephrine concentrations at 1 min after epinephrine administration were not different. There is no evidence from randomized trials to support the use of volume resuscitation at delivery. It may be reasonable to use higher concentrations of oxygen during chest compressions. For newborns who are breathing, continuous positive airway pressure can help with labored breathing or persistent cyanosis. Important aspects of neonatal resuscitation are the hospital policy and planning that ensure necessary equipment and personnel are present before delivery.1 Anticipation and preparation are essential elements for successful resuscitation,18 and this requires timely and accurate communication between the obstetric team and the neonatal resuscitation team. In the resuscitation of an infant, initial oxygen concentration of 21 percent is recommended. Exothermic mattresses have been reported to cause local heat injury and hyperthermia.15, When babies are born in out-of-hospital, resource-limited, or remote settings, it may be reasonable to prevent hypothermia by using a clean food-grade plastic bag13 as an alternative to skin-to-skin contact.8. Saturday: 9 a.m. - 5 p.m. CT A multicenter, case-control study identified 10 perinatal risk factors that predict the need for advanced neonatal resuscitation. Prevention of hyperthermia (temperature greater than 38C) is reasonable due to an increased risk of adverse outcomes. You administer 10 mL/kg of normal saline (based on the newborn's estimated weight). 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. Effective team behaviors, such as anticipation, communication, briefing, equipment checks, and assignment of roles, result in improved team performance and neonatal outcome. 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). The recommended route is intravenous, with the intraosseous route being an alternative. 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. Rate is 40 - 60/min. In preterm newborns (less than 35 wk of gestation) receiving respiratory support at birth, it may be reasonable to begin with 21% to 30% oxygen with subsequent oxygen titration based on pulse oximetry. Approximately 10% of newborns require assistance to breathe after birth.13,5,13 Newborn resuscitation requires training, preparation, and teamwork. Coordinate chest compressions with ventilations at a ratio of 3:1 and a rate of 120 events per minute to achieve approximately 90 compressions and 30 breaths per minute. 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. Two observational studies found an association between hyperthermia and increased morbidity and mortality in very preterm (moderate quality) and very low-birth-weight neonates (very low quality). A randomized trial showed that endotracheal suctioning of vigorous. 1-800-AHA-USA-1 Appropriate resuscitation must be available for each of the more than 4 million infants born annually in the United States. For infants requiring PPV at birth, there is currently insufficient evidence to recommend delayed cord clamping versus early cord clamping. Positive-pressure ventilation should be started in newborns who are gasping, apneic, or with a heart rate below 100 beats per minute by 60 seconds of life. See Part 2: Evidence Evaluation and Guidelines Development for more details on this process.11. Multiple clinical and simulation studies examining briefings or debriefings of resuscitation team performance have shown improved knowledge or skills.812. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. HR below 60/min? Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent. Closed on Sundays. Therefore, identifying a rapid and reliable method to measure the newborn's heart rate is critically important during neonatal resuscitation. If epinephrine is administered via endotracheal tube, a dose of 0.05 to 0.1 mg per kg (1:10,000 solution) is needed.1,2,57, Early volume expansion with crystalloid (10 mL per kg) or red blood cells is indicated for blood loss when the heart rate does not increase with resuscitation.5,6, Use of naloxone is not recommended as part of initial resuscitation of infants with respiratory depression in the delivery room.1,2,5,6, Very rarely, sodium bicarbonate may be useful after resuscitation.6, Term or near term infants with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia.57, Intravenous glucose infusion should be started soon after resuscitation to avoid hypoglycemia.5,6, It is recommended to cover preterm infants less than 28 weeks' gestation in polyethylene wrap after birth and place them under a radiant warmer. If resuscitation is required, electrocardiography should be used, especially with chest compressions. 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. There should be ongoing evaluation of the baby for normal respiratory transition. When intravenous access is not feasible, the intraosseous route may be considered. For infants with a heart rate of 60 to < 100 beats/minute who have apnea, gasping, or ineffective respirations, positive pressure ventilation (PPV) using a mask is indicated. CPAP, a form of respiratory support, helps newly born infants keep their lungs open. Approximately 10% of infants require help to begin breathing at birth, and 1% need intensive resuscitation. Chest compressions are provided if there is a poor heart rate response to ventilation after appropriate ventilation corrective steps, which preferably include endotracheal intubation. Exhaled carbon dioxide detectors can be used to confirm endotracheal tube placement in an infant. 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. doi: 10.1161/ CIR.0000000000000902. This article has been copublished in Pediatrics. It is reasonable to provide PPV at a rate of 40 to 60 inflations per minute. A multicenter quality improvement study demonstrated high staff compliance with the use of a neonatal resuscitation bundle that included briefing and an equipment checklist. If there is ineffective breathing effort or apnea after birth, tactile stimulation may stimulate breathing. 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. While there has been research to study the potential effectiveness of providing longer, sustained inflations, there may be potential harm in providing sustained inflations greater than 10 seconds for preterm newborns. June 2021 The NRP 8th Edition introduces a new educational methodology to better meet the needs of health care professionals who manage the newly born baby. 7. Suction should also be considered if there is evidence of airway obstruction during PPV, Direct laryngoscopy and endotracheal suctioning are not routinely required for babies born through MSAF but can be beneficial in babies who have evidence of airway obstruction while receiving PPV.7. Title: Microsoft PowerPoint - CPS GR Final Author: JackieM Created Date: 9/10/2021 9:22:37 PM 3 minuted. 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. 1 Exhaled carbon dioxide detection is the recommended method of confirming endotracheal intubation. Most changes are related to program administration and course facilitation. In a retrospective review, early hypoglycemia was a risk factor for brain injury in infants with acidemia requiring resuscitation. Uncrossmatched type O, Rh-negative blood (or crossmatched, if immediately available) is preferred when blood loss is substantial.4,5 An initial volume of 10 mL/kg over 5 to 10 minutes may be reasonable and may be repeated if there is inadequate response. Preterm and term newborns without good muscle tone or without breathing and crying should be brought to the radiant warmer for resuscitation. If all these steps of resuscitation are effectively completed and there is no heart rate response by 20 minutes, redirection of care should be discussed with the team and family. Compared with preterm infants receiving early cord clamping, those receiving delayed cord clamping were less likely to receive medications for hypotension in a meta-analysis of 6 RCTs. Newly born infants with abnormal glucose levels (both low and high) are at increased risk for brain injury and adverse outcomes after a hypoxic-ischemic insult. CPAP is helpful for preterm infants with breathing difficulty after birth or after resuscitation33 and may reduce the risk of bronchopulmonary dysplasia in very preterm infants when compared with endotracheal ventilation.3436 CPAP is also a less invasive form of respiratory support than intubation and PPV are. Heart rate assessment is best performed by auscultation. Provide chest compressions if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. Epinephrine can cause increase in heart rate and blood pressure. An important point is that ventilation has been shown to be the most effective measure in neonatal resuscitation Umbilical venous catheterization has been the accepted standard route in the delivery room for decades. In newborns who do not require resuscitation, delaying cord clamping for more than 30 seconds reduces anemia, especially in preterm infants. 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. While this research has led to substantial improvements in the Neonatal Resuscitation Algorithm, it has also highlighted that we still have more to learn to optimize resuscitation for both preterm and term infants. (Heart rate is 50/min.) In term infants, delaying clamping increases hematocrit and iron levels without increasing rates of phototherapy for hyperbilirubinemia, neonatal intensive care, or mortality. Neonatal resuscitation science has advanced significantly over the past 3 decades, with contributions by many researchers in laboratories, in the delivery room, and in other clinical settings. How soon after administration of intravenous epinephrine should you pause compressions and assess the baby's heart rate?a. These situations benefit from expert consultation, parental involvement in decision-making, and, if indicated, a palliative care plan.1,2,46. Historically, the repeat training has occurred every 2 years.69 However, adult, pediatric, and neonatal studies suggest that without practice, CPR knowledge and skills decay within 3 to 12 months1012 after training. Supplemental oxygen should be used judiciously, guided by pulse oximetry. The intravenous dose of epinephrine is 0.01 to 0.03 mg/kg, followed by a normal saline flush.4 If umbilical venous access has not yet been obtained, epinephrine may be given by the endotracheal route in a dose of 0.05 to 0.1 mg/kg. 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. 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. 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. Intrapartum suctioning is not recommended in infants born through meconium-stained amniotic fluid. The most important priority for newborn survival is the establishment of adequate lung inflation and ventilation after birth. High oxygen concentrations are recommended during chest compressions based on expert opinion. 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 heart rate after birth remains at less than 60/min despite adequate ventilation for at least 30 s, initiating chest compressions is reasonable. If a newborn's heart rate remains less than 60 bpm after PPV and chest compressions, you should NOT Just far enough to get blood return You catheterize the umbilical vein. We thank Dr. Abhrajit Ganguly for assistance in manuscript preparation. In addition, some conditions are so severe that the burdens of the illness and treatment greatly outweigh the likelihood of survival or a healthy outcome. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. 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. Initiate effective PPV for 30 seconds and reassess the heart rate. A 3:1 ratio of compressions to ventilation provided more ventilations than higher ratios in manikin studies. Consider pneumothorax. Peak inflation pressures of up to 30 cm H2O in term newborns and 20 to 25 cm H2O in preterm newborns are usually sufficient to inflate the lungs.57,9,1114 In some cases, however, higher inflation pressures are required.5,710 Peak inflation pressures or tidal volumes greater than what is required to increase heart rate and achieve chest expansion should be avoided.24,2628, The lungs of sick or preterm infants tend to collapse because of immaturity and surfactant deficiency.15 PEEP provides low-pressure inflation of the lungs during expiration. Early cord clamping (within 30 seconds) may interfere with healthy transition because it leaves fetal blood in the placenta rather than filling the newborns circulating volume. Several animal studies found that ventilation with high volumes caused lung injury, impaired gas exchange, and reduced lung compliance in immature animals. In newly born infants who are gasping or apneic within 60 s after birth or who are persistently bradycardic (heart rate less than 100/min) despite appropriate initial actions (including tactile stimulation), PPV should be provided without delay. Part 5: neonatal resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. 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. ECG provides the most rapid and accurate measurement of the newborns heart rate at birth and during resuscitation. Test your knowledge with our free Neonatal Resuscitation Practice Test provided below in order to prepare you for our official online exam. Birth 1 minute If HR remains <60 bpm, Consider hypovolemia. The American Heart Association requests that this document be cited as follows: Aziz K, Lee HC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmolzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion. Breathing: Assist breathing with PPV if baby apneic, gasping, or bradycardic. Endotracheal suctioning may be useful in nonvigorous infants with respiratory depression born through meconium-stained amniotic fluid. This can usually be achieved with a peak inflation pressure of 20 to 25 cm water (H. In newly born infants receiving PPV, it may be reasonable to provide positive end-expiratory pressure (PEEP). See permissionsforcopyrightquestions and/or permission requests. 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.