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. Effective team behaviors, such as anticipation, communication, briefing, equipment checks, and assignment of roles, result in improved team performance and neonatal outcome. The 2 thumbencircling hands technique achieved greater depth, less fatigue, and less variability with each compression compared with the 2-finger technique. Excessive peak inflation pressures are potentially harmful and should be avoided. This article has been copublished in Pediatrics. 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. Naloxone and sodium bicarbonate are rarely needed and are not recommended during neonatal resuscitation. TALKAD S. RAGHUVEER, MD, AND AUSTIN J. COX, MD. The current guideline, therefore, concludes with a summary of current gaps in neonatal research and some potential strategies to address these gaps. To perform neonatal resuscitation effectively, individual providers and teams need training in the required knowledge, skills, and behaviors. Administer epinephrine, preferably intravenously, if response to chest compressions is poor. High oxygen concentrations are recommended during chest compressions based on expert opinion. Although current guidelines recommend using 100% oxygen while providing chest compressions, no studies have confirmed a benefit of using 100% oxygen compared to any other oxygen concentration, including air (21%). The AAP released the 8th edition of the Neonatal Resuscitation Program in June 2021. 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. The use of radiant warmers, plastic bags and wraps (with a cap), increased room temperature, and warmed humidified inspired gases can be effective in preventing hypothermia in preterm babies in the delivery room. It is important to recognize that there are several significant gaps in knowledge relating to neonatal resuscitation. NRP Study Guide 7th Edition 2015 Guidelines of the American Academy of For infants requiring PPV at birth, there is currently insufficient evidence to recommend delayed cord clamping versus early cord clamping. On the other hand, overestimation of heart rate when a newborn is bradycardic may delay necessary interventions. Reduce the inflation pressure if the chest is moving well. For nonvigorous newborns (presenting with apnea or ineffective breathing effort) delivered through MSAF, routine laryngoscopy with or without tracheal suctioning is not recommended. For term and preterm infants who require resuscitation at birth, there is insufficient evidence to recommend early cord clamping versus delayed cord clamping. 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. Ventilation of the lungs results in a rapid increase in heart rate. The Neonatal Resuscitation Algorithm remains unchanged from 2015 and is the organizing framework for major concepts that reflect the needs of the baby, the family, and the surrounding team of perinatal caregivers. A brief introduction or short synopsis is provided to put the recommendations into context with important background information and overarching management or treatment concepts. With secondary apnea, the heart rate continues to drop, and blood pressure decreases as well. Before using epinephrine, tell your doctor if any past use of epinephrine injection caused an allergic reaction to get worse. You have administered epinephrine intravenously. 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. 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. 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. In resource-limited settings, it may be reasonable to place newly born babies in a clean food-grade plastic bag up to the level of the neck and swaddle them in order to prevent hypothermia. The neonatal epinephrine dose is 0.01 to 0.03 mg per kg (1:10,000 solution) given intravenously (via umbilical venous catheter).1,2,5,6 If there is any delay in securing venous access, epinephrine can be given via endotracheal tube at a higher dose of 0.05 to 0.10 mg per kg (1:10,000 solution), followed by intravenous dosing, if necessary, as soon as access is established.5, Naloxone is not recommended during neonatal resuscitation in the delivery room; infants with respiratory depression should be resuscitated with PPV.1,2,5,6 Volume expansion (using crystalloid or red blood cells) is recommended when blood loss is suspected (e.g., pale skin, poor perfusion, weak pulse) and when the infant's heart rate continues to be low despite effective resuscitation.5,6 Sodium bicarbonate is not recommended during neonatal resuscitation in the delivery room, because it does not improve survival or neurologic outcome.6,39, Approximately 7 to 20 percent of deliveries are complicated by meconium-stained amniotic fluid; these infants have a 2 to 9 percent risk of developing meconium aspiration syndrome.50 Oral and nasopharyngeal suction on the perineum is not recommended, because it has not been shown to reduce the risk of meconium aspiration syndrome.20 In the absence of randomized controlled trials, there is insufficient evidence to recommend changing the current practice of intubation and endotracheal suction in nonvigorous infants (as defined by decreased heart rate, respiratory effort, or muscle tone) born through meconium-stained amniotic fluid.1,2,5 However, if attempted intubation is prolonged or unsuccessful, and bradycardia is present, bag and mask ventilation is advised.5,6 Endotracheal suctioning of vigorous infants is not recommended.1,2,5,6, Withholding resuscitation and offering comfort care is appropriate (with parental consent) in certain infants, such as very premature infants (born at less than 23 weeks' gestation or weighing less than 400 g) and infants with anencephaly or trisomy 13 syndrome.5 If there is no detectable heart rate after 10 minutes of resuscitation, it is appropriate to consider discontinuing resuscitation.5,6, Intravenous glucose infusion should be started soon after resuscitation to avoid hypoglycemia.5,6 In addition, infants born at 36 weeks' gestation or later with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia, using studied protocols, within six hours at a facility with capabilities of multidisciplinary care and long-term follow-up.57. A meta-analysis of 3 RCTs (low certainty of evidence) and a further single RCT suggest that nonvigorous newborns delivered through MSAF have the same outcomes (survival, need for respiratory support, or neurodevelopment) whether they are suctioned before or after the initiation of PPV. The American Heart Association released minor updates to neonatal resuscitation recommendations with only minor changes to the previous algorithm (Figure 1). CPAP, a form of respiratory support, helps newly born infants keep their lungs open. 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. 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. 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). 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. Unauthorized use prohibited. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. For neonatal resuscitation providers, it may be reasonable to brief before delivery and debrief after neonatal resuscitation. The airway is cleared (if necessary), and the infant is dried. The same study demonstrated that the risk of death or prolonged admission increases 16% for every 30-second delay in initiating PPV. Breathing is stimulated by gently rubbing the infant's back. Every birth should be attended by one person who is assigned, trained, and equipped to initiate resuscitation and deliver positive pressure ventilation. Use of CPAP for resuscitating term infants has not been studied. The updated guidelines also provide indications for chest compressions and for the use of intravenous epinephrine, which is the preferred route of administration, and recommend not to use sodium bicarbonate or naloxone during resuscitation. 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. 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. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. See permissionsforcopyrightquestions and/or permission requests. 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. Team debrieng. 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. Routine oral, nasal, oropharyngeal, or endotracheal suctioning of newly born babies is not recommended. When blood loss is known or suspected based on history and examination, and there is no response to epinephrine, volume expansion is indicated. Providing PPV at a rate of 40 to 60 inflations per minute is based on expert opinion. When feasible, well-designed multicenter randomized clinical trials are still optimal to generate the highest-quality evidence. Supplemental oxygen: 100 vs. 21 percent (room air). 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. 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. Recent clinical trials have shown that infants resuscitated with 21 percent oxygen compared with 100 percent oxygen had significantly lower mortality (at one week and one month) and were able to establish regular respiration in a shorter time; the rates of encephalopathy and cerebral palsy were similar in the two groups.4549 The 2010 NRP guidelines recommend starting resuscitation of term infants with 21 percent oxygen or blended oxygen and increasing the concentration of oxygen (using an air/oxygen blender) if oxygen saturation (measured using a pulse oximeter) is lower than recommended targets (Figure 1).5 Oxygen concentration should be increased to 100 percent if the heart rate is less than 60 bpm despite effective ventilation, and when chest compressions are necessary.57, If the infant's heart rate is less than 60 bpm, the delivery of PPV is optimized and applied for 30 seconds. When blood loss is suspected in a newly born infant who responds poorly to resuscitation (ventilation, chest compressions, and/or epinephrine), it may be reasonable to administer a volume expander without delay. Prevention of hyperthermia (temperature greater than 38C) is reasonable due to an increased risk of adverse outcomes. In term and preterm newly born infants, it is reasonable to initiate PPV with an inspiratory time of 1 second or less. For term infants who do not require resuscitation at birth, it may be reasonable to delay cord clamping for longer than 30 seconds. Before every birth, a standardized risk factors assessment tool should be used to assess perinatal risk and assemble a qualified team on the basis of that risk. During resuscitation, supplemental oxygen may be provided to prevent harm from inadequate oxygen supply to tissues (hypoxemia).4 However, overexposure to oxygen (hyperoxia) may be associated with harm.5, Term and late preterm newborns have lower shortterm mortality when respiratory support during resuscitation is started with 21% oxygen (air) versus 100% oxygen.1 No difference was found in neurodevelopmental outcome of survivors.1 During resuscitation, pulse oximetry may be used to monitor oxygen saturation levels found in healthy term infants after vaginal birth at sea level.3, In more preterm newborns, there were no differences in mortality or other important outcomes when respiratory support was started with low (50% or less) versus high (greater than 50%) oxygen concentrations.2 Given the potential for harm from hyperoxia, it may be reasonable to start with 21% to 30% oxygen. Hypothermia after birth is common worldwide, with a higher incidence in babies of lower gestational age and birth weight. For nonvigorous newborns delivered through MSAF who have evidence of airway obstruction during PPV, intubation and tracheal suction can be beneficial. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. Copyright 2021 by the American Academy of Family Physicians. Delaying cord clamping for more than 30 seconds is reasonable for term and preterm infants who do not require resuscitation. Case series show small numbers of intact survivors after 20 minutes of no detectable heart rate. Initiate effective PPV for 30 seconds and reassess the heart rate.
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nrp check heart rate after epinephrine