Normal saline (0.9% sodium chloride) is the crystalloid fluid of choice. Monday - Friday: 7 a.m. 7 p.m. CT When attempts at endotracheal intubation are unsuccessful, laryngeal mask airway (size 1) is an alternative for providing PPV in infants weighing more than 2 kg or in infants greater than 34 weeks' gestation.5,6,26, Neonatal resuscitation aims to restore tissue oxygen delivery before irreversible damage occurs. 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. A combination of chest compressions and ventilation resulted in better outcomes than ventilation or compressions alone in piglet studies. Comprehensive disclosure information for peer reviewers is listed in Appendix 2(link opens in new window). Appropriate and timely support should be provided to all involved. Epinephrine should be administered intravenously at 0.01 to 0.03 mg per kg or by endotracheal tube at 0.05 to 0.1 mg per kg. Glucose levels should be monitored as soon as practical after advanced resuscitation, with treatment as indicated. All Rights Reserved. Providing PPV at a rate of 40 to 60 inflations per minute is based on expert opinion. When appropriate, flow diagrams or additional tables are included. Oximetry and electrocardiography are important adjuncts in babies requiring resuscitation. 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. IV epinephrine every 3-5 minutes. Traditionally, 100 percent oxygen has been used to achieve a rapid increase in tissue oxygen in infants with respiratory depression. 1 Exhaled carbon dioxide detection is the recommended method of confirming endotracheal intubation. (Heart rate is 50/min.) During resuscitation of term and preterm newborns, the use of electrocardiography (ECG) for the rapid and accurate measurement of the newborns heart rate may be reasonable. Part 2: Evidence Evaluation and Guidelines Development, Part 3: Adult Basic and Advanced Life Support, Part 4: Pediatric Basic and Advanced Life Support, Part 9: COVID-19 Interim Guidance for Healthcare Providers, Part 10: COVID-19 Interim Guidance for EMS, 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. In other situations, clamping and cutting of the cord may also be deferred while respiratory, cardiovascular, and thermal transition is evaluated and initial steps are undertaken. Oximetry is used to target the natural range of oxygen saturation levels that occur in term babies. Routine suctioning, whether oral, nasal, oropharyngeal, or endotracheal, is not recommended because of a lack of benefit and risk of bradycardia. Cord milking in preterm infants should be avoided because of increased risk of intraventricular hemorrhage. Consequently, all newly born babies should be attended to by at least 1 person skilled and equipped to provide PPV. If there is a heart rate response: Continue uninterrupted ventilation until the infant begins to breathe adequately and the heart rate is above 100 min-1. When ECG heart rate is greater than 60/min, a palpable pulse and/or audible heart rate rules out pulseless electric activity.1721, The vast majority of newborns breathe spontaneously within 30 to 60 seconds after birth, sometimes after drying and tactile stimulation.1 Newborns who do not breathe within the first 60 seconds after birth or are persistently bradycardic (heart rate less than 100/min) despite appropriate initial actions (including tactile stimulation) may receive PPV at a rate of 40 to 60/min.2,3 The order of resuscitative procedures in newborns differs from pediatric and adult resuscitation algorithms. 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. Contact Us, Hours 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]. If the heart rate remains less than 60/min despite 60 seconds of chest compressions and adequate PPV, epinephrine should be administered, ideally via the intravenous route. For nonvigorous newborns delivered through MSAF who have evidence of airway obstruction during PPV, intubation and tracheal suction can be beneficial. increase in the newborn's heart rate is the most sensitive indicator of a successful response to resuscitation. One moderate quality RCT found higher rates of hyperthermia with exothermic mattresses. With growing enthusiasm for clinical studies in neonatology, elements of the Neonatal Resuscitation Algorithm continue to evolve as new evidence emerges. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. 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. For this reason, neonatal resuscitation should begin with PPV rather than with chest compressions.2,3 Delays in initiating ventilatory support in newly born infants increase the risk of death.1, The adequacy of ventilation is measured by a rise in heart rate and, less reliably, chest expansion. In newborns who do not require resuscitation, delaying cord clamping for more than 30 seconds reduces anemia, especially in preterm infants. Watch a recording of Innov8te NRP: An Introduction to the NRP 8th Edition: Three webinars hosted by RQI Partners to discuss changes to the 8 th edition NRP and the new RQI for NRP Posted 2/19/21. The heart rate response to chest compressions and medications should be monitored electrocardiographically. Hypothermia after birth is common worldwide, with a higher incidence in babies of lower gestational age and birth weight. In animal studies (very low quality), the use of alterative compression-to-inflation ratios to 3:1 (eg, 2:1, 4:1, 5:1, 9:3, 15:2, and continuous chest compressions with asynchronous PPV) are associated with similar times to ROSC and mortality rates. This content is owned by the AAFP. The benefit of 100% oxygen compared with 21% oxygen (air) or any other oxygen concentration for ventilation during chest compressions is uncertain. 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. For term and preterm infants who require resuscitation at birth, there is insufficient evidence to recommend early cord clamping versus delayed cord clamping. If the heart rate has not increased to 60/ min or more after optimizing ventilation and chest compressions, it may be reasonable to administer intravascular* epinephrine (0.01 to 0.03 mg/kg). Blood may be lost from the placenta into the mothers circulation, from the cord, or from the infant. Radiant warmers and other warming adjuncts are suggested for babies who require resuscitation at birth, especially very preterm and very low-birth-weight babies. Post-resuscitation care. Ventilation using a flow-inflating bag, self-inflating bag, or T-piece device can be effective. It may be reasonable to provide volume expansion with normal saline (0.9% sodium chloride) or blood at 10 to 20 mL/kg. 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. 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. For spontaneously breathing preterm infants who require respiratory support immediately after delivery, it is reasonable to use CPAP rather than intubation. 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. In a retrospective study, volume infusion was given more often for slow response of bradycardia to resuscitation than for overt hypovolemia. Even healthy babies who breathe well after birth benefit from facilitation of normal transition, including appropriate cord management and thermal protection with skin-to-skin care. Rapid and effective response and performance are critical to good newborn outcomes. If the heart rate is less than 60 bpm, begin chest compressions. PEEP has been shown to maintain lung volume during PPV in animal studies, thus improving lung function and oxygenation.16 PEEP may be beneficial during neonatal resuscitation, but the evidence from human studies is limited. 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. Excessive chest wall movement should be avoided.2,6, In spontaneously breathing preterm infants with respiratory distress, either CPAP or endotracheal intubation with mechanical ventilation may be used.1,5,6, In preterm infants less than 32 weeks' gestation, an initial oxygen concentration of more than 21 percent (30 to 40 percent), but less than 100 percent should be used. A prospective study showed that the use of an exhaled carbon dioxide detector is useful to verify endotracheal intubation. Metrics. A nonrandomized trial showed that endotracheal suctioning did not decrease the incidence of meconium aspiration syndrome or mortality. 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. Several animal studies found that ventilation with high volumes caused lung injury, impaired gas exchange, and reduced lung compliance in immature animals. For nonvigorous newborns (presenting with apnea or ineffective breathing effort) delivered through MSAF, routine laryngoscopy with or without tracheal suctioning is not recommended. Wait 60 seconds and check the heart rate. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. . While vascular access is being obtained, it may be reasonable to administer endotracheal epinephrine at a larger dose (0.05 to 0.1 mg/kg). In term and late preterm newborns (35 wk or more of gestation) receiving respiratory support at birth, the initial use of 21% oxygen is reasonable. 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. Endotracheal suctioning for apparent airway obstruction with MSAF is based on expert opinion. Team debrieng. Noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation should be considered ethically equivalent. Limited observational studies suggest that tactile stimulation may improve respiratory effort. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. After chest compressions are performed for at least 2 minutes When an alternative airway is inserted Immediately after epinephrine is administered A newly born infant in shock from blood loss may respond poorly to the initial resuscitative efforts of ventilation, chest compressions, and/or epinephrine. Term newborns with good muscle tone who are breathing or crying should be brought to their mother's chest routinely. It is important to continue PPV and chest compressions while preparing to deliver medications. 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. Suctioning may be considered if PPV is required and the airway appears obstructed. If a baby does not begin breathing . Newborn resuscitation requires anticipation and preparation by providers who train individually and as teams. Ventilation should be optimized before starting chest compressions, with endotracheal intubation if possible. Available for purchase at https://shop.aap.org/textbook-of-neonatal-resuscitation-8th-edition-paperback/ (NOTE: This book features a full text reading experience. 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. Administration of epinephrine via a low-lying umbilical venous catheter provides the most rapid and reliable medication delivery. Provide chest compressions if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. 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. Currently, epinephrine is the only vasoactive drug recommended by the International Liaison Committee on Resuscitation (ILCOR) for neonates who remain severely bradycardic (heart rate <. Once the heart rate increases to more than 60 bpm, chest compressions are stopped. 1-800-AHA-USA-1 During chest compressions, an ECG should be used for the rapid and accurate assessment of heart rate. If the neonate's heart rate is less than 60 bpm after optimal ventilation for 30 seconds, the oxygen concentration should be increased to 100% with commencement of chest compressions. One observational study in newly born infants associated high tidal volumes during resuscitation with brain injury. Flush the UVC with normal saline. 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. Your team is caring for a term newborn whose heart rate is 50 bpm after receiving effective ventilation, chest compressions, and intravenous epinephrine administration. If the heart rate remains less than 60/min despite 30 seconds of adequate PPV, chest compressions should be provided. There was no difference in Apgar scores or blood gas with naloxone compared with placebo. National Center 3 minuted. 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. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. The dose of epinephrine can be re-peated after 3-5 minutes if the initial dose is ineffective or can be repeated immediately if initial dose is given by endo-tracheal tube in the absence of an intravenous access. One small manikin study (very low quality), compared the 2 thumbencircling hands technique and 2-finger technique during 60 seconds of uninterrupted chest compressions. It is reasonable to provide PPV at a rate of 40 to 60 inflations per minute. If skilled health care professionals are available, infants weighing less than 1 kg, 1 to 3 kg, and 3 kg or more can be intubated with 2.5-, 3-, and 3.5-mm endotracheal tubes, respectively. It may be possible to identify conditions in which withholding or discontinuation of resuscitative efforts may be reasonably considered by families and care providers. Clinical assessment of heart rate has been found to be both unreliable and inaccurate. A multicenter randomized trial showed that intrapartum suctioning of meconium does not reduce the risk of meconium aspiration syndrome. It is important to recognize that there are several significant gaps in knowledge relating to neonatal resuscitation. - 14446398 One RCT in resource-limited settings found that plastic coverings reduced the incidence of hypothermia, but they were not directly compared with uninterrupted skin-to-skin care.
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