In a meta-analysis of 8 RCTs involving 1344 term and late preterm infants with moderate-to-severe encephalopathy and evidence of intrapartum asphyxia, therapeutic hypothermia resulted in a significant reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age (odds ratio 0.75; 95% CI, 0.680.83). Term newborns with good muscle tone who are breathing or crying should be brought to their mother's chest routinely. Umbilical venous catheterization has been the accepted standard route in the delivery room for decades. 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). 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. This content is owned by the AAFP. Once the neonatal resuscitation team is summoned to the delivery room, it is important to obtain a pertinent history; assign roles to each team member; check that all equipment is available and functional,1 including a pulse oximeter and an air/oxygen blender6; optimize room temperature for the infant; and turn on the warmer, light, oxygen, and suction. A new Resuscitation Quality Improvement (RQI) program for NRP focused on PPV will be . In a retrospective study, volume infusion was given more often for slow response of bradycardia to resuscitation than for overt hypovolemia. In preterm birth, there are also potential advantages from delaying cord clamping. When Should I Check Heart Rate After Epinephrine All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and AHA Executive Committee. Providing PPV at a rate of 40 to 60 inflations per minute is based on expert opinion. 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. Another barrier is the difficulty in obtaining antenatal consent for clinical trials in the delivery room. Neonatal Resuscitation Program (NRP): Medications - Tom Wade MD A systematic review (low to moderate certainty) of 6 RCTs showed that early skin-to-skin contact promotes normothermia in healthy neonates. NRP courses are moving from the HealthStream platform to RQI. Team debrieng. A prospective study showed that the use of an exhaled carbon dioxide detector is useful to verify endotracheal intubation. Numerous nonrandomized quality improvement (very low to low certainty) studies support the use of warming adjunct bundles.. Updates to neonatal, pediatric resuscitation guidelines based on new Hypothermia at birth is associated with increased mortality in preterm infants. When intravenous access is not feasible, the intraosseous route may be considered. The newly born period extends from birth to the end of resuscitation and stabilization in the delivery area. If resuscitation is required, heart rate should be monitored by electrocardiography as early as possible. Neonatal Resuscitation: An Update | AAFP The benefit of 100% oxygen compared with 21% oxygen (air) or any other oxygen concentration for ventilation during chest compressions is uncertain. Ventilation should be optimized before starting chest compressions, possibly including endotracheal intubation. Additional personnel are necessary if risk factors for complicated resuscitation are present. These situations benefit from expert consultation, parental involvement in decision-making, and, if indicated, a palliative care plan.1,2,46. When chest compressions are initiated, an ECG should be used to confirm heart rate. 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). 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. During an uncomplicated delivery, the newborn transitions from the low oxygen environment of the womb to room air (21% oxygen) and blood oxygen levels rise over several minutes. One moderate quality RCT found higher rates of hyperthermia with exothermic mattresses. A randomized study showed similar success in providing effective ventilation using either laryngeal mask airway or endotracheal tube. Endotracheal suctioning for apparent airway obstruction with MSAF is based on expert opinion. In the resuscitation of an infant, initial oxygen concentration of 21 percent is recommended. Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth. 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. The airway is cleared (if necessary), and the infant is dried. Positive-Pressure Ventilation (PPV) 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. These 2020 AHA neonatal resuscitation guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. 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. TALKAD S. RAGHUVEER, MD, AND AUSTIN J. COX, MD. 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). Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. NRP 7th edition part 2 - Subjecto.com Compresses correctly: Rate is correct. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. 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. Prevention of hypothermia continues to be an important focus for neonatal resuscitation. Newly born infants who breathe spontaneously need to establish a functional residual capacity after birth.8 Some newly born infants experience respiratory distress, which manifests as labored breathing or persistent cyanosis. 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. In circumstances of altered or impaired transition, effective neonatal resuscitation reduces the risk of mortality and morbidity. 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. There are limited data comparing the different approaches to heart rate assessment during neonatal resuscitation on other neonatal outcomes. Equipment checklists, role assignments, and team briefings improve resuscitation performance and outcomes. 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. For every 30 seconds that ventilation is delayed, the risk of prolonged admission or death increases by 16%. 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. How to do NRP Skills Step by Step - Nurses Educational Opportunities 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. 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. A multicenter quality improvement study demonstrated high staff compliance with the use of a neonatal resuscitation bundle that included briefing and an equipment checklist. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. According to the Textbook of Neonatal Resuscitation, 8th edition, what volume of normal saline flush should you administer? The reduced heart rate that occurs in this situation can be reversed with tactile stimulation. 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. In a small number of newborns (n=2) with indwelling catheters, the 2 thumbencircling hands technique generated higher systolic and mean blood pressures compared with the 2-finger technique. During resuscitation, a baby is responding to positive-pressure ventilation with a rapidly increasing heart rate. Given the evidence for ECG during initial steps of PPV, expert opinion is that ECG should be used when providing chest compressions. Neonatal Resuscitation - Pediatrics - MSD Manual Professional Edition Exhaled carbon dioxide detectors to confirm endotracheal tube placement. Before appointment, all peer reviewers were required to disclose relationships with industry and any other potential conflicts of interest, and all disclosures were reviewed by AHA staff. Before every birth, a standardized equipment checklist should be used to ensure the presence and function of supplies and equipment necessary for a complete resuscitation. Therapeutic hypothermia is recommended in infants born at 36 weeks' gestation or later with evolving moderate to severe hypoxic-ischemic encephalopathy. Administration of epinephrine via a low-lying umbilical venous catheter provides the most rapid and reliable medication delivery. 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. Newly born infants born at 36 wk or more estimated gestational age with evolving moderate-to-severe HIE should be offered therapeutic hypothermia under clearly defined protocols. 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 heart rate should be re-checked after 1 minute of giving compressions and ventilations. Copyright 2023 American Academy of Family Physicians. The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines.13 Before appointment, writing group members and peer reviewers disclosed all commercial relationships and other potential (including intellectual) conflicts. NRP Study Guide 7th Edition 2015 Guidelines of the American Academy of There was no difference in neonatal intubation performance after weekly booster practice for 4 weeks compared with daily booster practice for 4 consecutive days. 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. Because evidence and guidance are evolving with the COVID-19 situation, this interim guidance is maintained separately from the ECC guidelines. Epinephrine use in the delivery room for resuscitation of the newborn is associated with significant morbidity and mortality. Use of CPAP for resuscitating term infants has not been studied. Team training remains an important aspect of neonatal resuscitation, including anticipation, preparation, briefing, and debriefing. 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. Positive end-expiratory pressure of up to 5 cm of water may be used to maintain lung volumes based on low-quality evidence of reduced mortality in preterm infants. With the symptoms of The dose of epinephrine is .5-1ml/kg by ETT or .1-.3ml/kg in the concentration of 1:10,000 (0.1mg/ml), which is to be followed by 0.5-1ml flush of normal saline. The following sections are worth special attention. Post-resuscitation care. Hypothermia (temperature less than 36C) should be prevented due to an increased risk of adverse outcomes. The immediate care of newly born babies involves an initial assessment of gestation, breathing, and tone. Before using epinephrine, tell your doctor if any past use of epinephrine injection caused an allergic reaction to get worse. Randomized controlled studies and observational studies in settings where therapeutic hypothermia is available (with very low certainty of evidence) describe variable rates of survival without moderate-to-severe disability in babies who achieve ROSC after 10 minutes or more despite continued resuscitation. Clinical assessment of heart rate by auscultation or palpation may be unreliable and inaccurate.14 Compared to ECG, pulse oximetry is both slower in detecting the heart rate and tends to be inaccurate during the first few minutes after birth.5,6,1012 Underestimation of heart rate can lead to potentially unnecessary interventions. Positive-pressure ventilation (PPV) remains the main intervention in neonatal resuscitation. Effective and timely resuscitation at birth could therefore improve neonatal outcomes further. 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. In newborns born at 35 weeks' gestation or later, resuscitation starting with 21% oxygen reduces short-term mortality. Heart rate is assessed initially by auscultation and/or palpation. HR below 60/min? After an uncomplicated term or late preterm birth, it is reasonable to delay cord clamping until after the baby is placed on the mother, dried, and assessed for breathing, tone, and activity. 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. Pulse oximetry with oxygen targeting is recommended in this population.3, Most newborns who are apneic or have ineffective breathing at birth will respond to initial steps of newborn resuscitation (positioning to open the airway, clearing secretions, drying, and tactile stimulation) or to effective PPV with a rise in heart rate and improved breathing. Approximately 10% of infants require help to begin breathing at birth, and 1% need intensive resuscitation. In term and preterm newly born infants, it is reasonable to initiate PPV with an inspiratory time of 1 second or less. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. Supplemental oxygen should be used judiciously, guided by pulse oximetry. However, free radicals are generated when successful resuscitation results in reperfusion and restoration of oxygen delivery to organs.44 Use of 100 percent oxygen may increase the load of oxygen free radicals, which can potentially lead to end-organ damage. 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. Researchers studying these gaps may need to consider innovations in clinical trial design; examples include pragmatic study designs and novel consent processes. Limited observational studies suggest that tactile stimulation may improve respiratory effort. 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 with meconium-stained fluid, endotracheal suctioning is indicated only if obstruction limits positive pressure ventilation, because suctioning does not improve outcomes. 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. When blood loss is known or suspected based on history and examination, and there is no response to epinephrine, volume expansion is indicated.

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