Adaptive trials, comparative effectiveness designs, and those using cluster randomization may be suitable for some questions, such as the best approach for MSAF in nonvigorous infants. 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. Intravenous epinephrine is preferred because. The potential benefit or harm of sustained inflations between 1 and 10 seconds is uncertain.2,29. 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. Table 1. NRP Advanced is suited for health care professionals who serve as members of the resuscitation team in the delivery room or in other settings where complex neonatal resuscitation is required. Placing healthy newborn infants who do not require resuscitation skin-to-skin after birth can be effective in improving breastfeeding, temperature control and blood glucose stability. 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. Team training remains an important aspect of neonatal resuscitation, including anticipation, preparation, briefing, and debriefing. Consequently, all newly born babies should be attended to by at least 1 person skilled and equipped to provide PPV. Effective and timely resuscitation at birth could therefore improve neonatal outcomes further. "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) 1-800-AHA-USA-1 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. As mortality and severe morbidities decline with biomedical advancements and improvements in healthcare delivery, there is decreased ability to have adequate power for some clinical questions using traditional individual patient randomized trials. Breathing is stimulated by gently rubbing the infant's back. For babies requiring vascular access at the time of delivery, the umbilical vein is the recommended route. When should I check heart rate after epinephrine? A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. There is a reduction of mortality and no evidence of harm in term infants resuscitated with 21 percent compared with 100 percent oxygen. If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route. Most babies will respond to this intervention. 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. Hyperlinked references are provided to facilitate quick access and review. minutes, and 80% at 5 minutes of life. Ventilation should be optimized before starting chest compressions, possibly including endotracheal intubation. 7. For nonvigorous newborns delivered through MSAF who have evidence of airway obstruction during PPV, intubation and tracheal suction can be beneficial. 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. Intra-arterial epinephrine is not recommended. When intravenous access is not feasible, the intraosseous route may be considered. After 30 seconds, Rescuer 2 evaluates heart rate. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. 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. This article has been copublished in Pediatrics. 2020;142(suppl 2):S524S550. Metrics. The 2020 guidelines are organized into "knowledge chunks," grouped into discrete modules of information on specific topics or management issues.22 Each modular knowledge chunk includes a table of recommendations using standard AHA nomenclature of COR and LOE. The inability of newly born infants to establish and sustain adequate or spontaneous respiration contributes significantly to these early deaths and to the burden of adverse neurodevelopmental outcome among survivors. The 2015 Neonatal Resuscitation Algorithm and the major concepts based on sections of the algorithm continue to be relevant in 2020 (Figure(link opens in new window)(link opens in new window)). Limited observational studies suggest that tactile stimulation may improve respiratory effort. 7272 Greenville Ave. Please contact the American Heart Association at ECCEditorial@heart.org or 1-214-706-1886 to request a long description of . For infants requiring PPV at birth, there is currently insufficient evidence to recommend delayed cord clamping versus early cord clamping. Every birth should be attended by one person who is assigned, trained, and equipped to initiate resuscitation and deliver positive pressure ventilation. A team or persons trained in neonatal resuscitation should be promptly available at all deliveries to provide complete resuscitation, including endotracheal intubation and administration of medications. 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. If endotracheal epinephrine is given before vascular access is available and response is inadequate, it may be reasonable to give an intravascular* dose as soon as access is obtained, regardless of the interval. Exhaled carbon dioxide detectors can be used to confirm endotracheal tube placement in an infant. 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. Before using epinephrine, tell your doctor if any past use of epinephrine injection caused an allergic reaction to get worse. The heart rate should be verbalized for the team. To start, 21% to 30% oxygen should be used in these newborns, titrating up based on oxygen saturation. A combination of chest compressions and ventilation resulted in better outcomes than ventilation or compressions alone in piglet studies. Delaying cord clamping for more than 30 seconds is reasonable for term and preterm infants who do not require resuscitation. In preterm infants, delaying clamping reduces the need for vasopressors or transfusions. Clinical assessment of heart rate has been found to be both unreliable and inaccurate. There are long-standing worldwide recommendations for routine temperature management for the newborn. 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. Briefing has been defined as a discussion about an event that is yet to happen to prepare those who will be involved and thereby reduce the risk of failure or harm.4 Debriefing has been defined as a discussion of actions and thought processes after an event to promote reflective learning and improve clinical performance5 or a facilitated discussion of a clinical event focused on learning and performance improvement.6 Briefing and debriefing have been recommended for neonatal resuscitation training since 20107 and have been shown to improve a variety of educational and clinical outcomes in neonatal, pediatric, and adult simulation-based and clinical studies. When possible, healthy term babies should be managed skin-to-skin with their mothers. For neonatal resuscitation providers, it may be reasonable to brief before delivery and debrief after neonatal resuscitation. Various combinations of warming strategies (or bundles) may be reasonable to prevent hypothermia in very preterm babies. Wrapping, in addition to radiant heat, improves admission temperature of preterm infants. An important point is that ventilation has been shown to be the most effective measure in neonatal resuscitation When feasible, well-designed multicenter randomized clinical trials are still optimal to generate the highest-quality evidence. A multicenter, case-control study identified 10 perinatal risk factors that predict the need for advanced neonatal resuscitation. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. 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. 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. You have administered epinephrine intravenously. A large multicenter RCT found higher rates of intraventricular hemorrhage with cord milking in preterm babies born at less than 28 weeks gestational age. There were only minor changes to the NRP algorithm and recommended practices. Ventilation using a flow-inflating bag, self-inflating bag, or T-piece device can be effective. This content is owned by the AAFP. Team briefings promote effective teamwork and communication, and support patient safety.8,1012, During an uncomplicated term or late preterm birth, it may be reasonable to defer cord clamping until after the infant is placed on the mother and assessed for breathing and activity. 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. According to the Textbook of Neonatal Resuscitation, 8th edition, what volume of normal saline flush should you administer? 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. 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. The initiation of chest compressions in newborn babies with a heart rate less than 60/min is based on expert opinion because there are no clinical or physiological human studies addressing this question. 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 content is owned by the AAFP. When epinephrine is required, multiple doses are commonly needed. Endotracheal suctioning may be useful in nonvigorous infants with respiratory depression born through meconium-stained amniotic fluid. Most RCTs in well-resourced settings would routinely manage at-risk babies under a radiant warmer. Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth. 3 minuted. In a retrospective study, volume infusion was given more often for slow response of bradycardia to resuscitation than for overt hypovolemia. High oxygen concentrations are recommended during chest compressions based on expert opinion. Breathing: Assist breathing with PPV if baby apneic, gasping, or bradycardic. Intrapartum suctioning is not recommended in infants born through meconium-stained amniotic fluid. 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. These guidelines apply primarily to the newly born baby who is transitioning from the fluid-filled womb to the air-filled room. In newborns born before 35 weeks' gestation, oxygen concentrations above 50% are no more effective than lower concentrations. A systematic review (low to moderate certainty) of 6 RCTs showed that early skin-to-skin contact promotes normothermia in healthy neonates. Epinephrine dosing may be repeated every three to five minutes if the heart rate remains less than 60 beats per minute. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. 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. In the resuscitation of an infant, initial oxygen concentration of 21 percent is recommended. According to the Textbook of Neonatal Resuscitation, 8th edition algorithm, at what point during resuscitation is a cardiac monitor recommended to assess the baby's heart rate? For spontaneously breathing preterm infants who require respiratory support immediately after delivery, it is reasonable to use CPAP rather than intubation. The most important priority for newborn survival is the establishment of adequate lung inflation and ventilation after birth. 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. 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. To perform neonatal resuscitation effectively, individual providers and teams need training in the required knowledge, skills, and behaviors. See permissionsforcopyrightquestions and/or permission requests. Suctioning may be considered if PPV is required and the airway appears obstructed. 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. In a randomized trial, the use of mask CPAP compared with endotracheal intubation and mechanical ventilation in spontaneously breathing preterm infants decreased the risk of bronchopulmonary dysplasia or death, and decreased the use of surfactant, but increased the rate of pneumothorax. Preterm and term newborns without good muscle tone or without breathing and crying should be brought to the radiant warmer for resuscitation. 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. 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. It is reasonable to provide PPV at a rate of 40 to 60 inflations per minute. Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. Admission temperature should be routinely recorded. 1 Exhaled carbon dioxide detection is the recommended method of confirming endotracheal intubation. Approximately 10% of newborns require assistance to breathe after birth.13,5,13 Newborn resuscitation requires training, preparation, and teamwork. Positive-pressure ventilation (PPV) remains the main intervention in neonatal resuscitation. For nonvigorous newborns (presenting with apnea or ineffective breathing effort) delivered through MSAF, routine laryngoscopy with or without tracheal suctioning is not recommended. Umbilical venous catheterization has been the accepted standard route in the delivery room for decades. 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. 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. Newer methods of chest compression, using a sustained inflation that maintains lung inflation while providing chest compressions, are under investigation and cannot be recommended at this time outside research protocols.12,13. 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. In a case series, endotracheal epinephrine (0.01 mg per kg) was less effective than intravenous epinephrine. 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. A reasonable time frame for this change in goals of care is around 20 min after birth. When appropriate, flow diagrams or additional tables are included. 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. Hypothermia after birth is common worldwide, with a higher incidence in babies of lower gestational age and birth weight. Compresses correctly: Rate is correct. After chest compressions are performed for at least 2 minutes When an alternative airway is inserted Immediately after epinephrine is administered IV epinephrine every 3-5 minutes. How soon after administration of intravenous epinephrine should you pause compressions and assess the baby's heart rate?a. One moderate quality RCT found higher rates of hyperthermia with exothermic mattresses. Evidence for optimal dose, timing, and route of administration of epinephrine during neonatal resuscitation comes largely from extrapolated adult or animal literature. The International Liaison Committee on Resuscitation (ILCOR) Formula for Survival emphasizes 3 essential components for good resuscitation outcomes: guidelines based on sound resuscitation science, effective education of resuscitation providers, and implementation of effective and timely resuscitation.8 The 2020 neonatal guidelines contain recommendations, based on the best available resuscitation science, for the most impactful steps to perform in the birthing room and in the neonatal period. Comprehensive disclosure information for peer reviewers is listed in Appendix 2(link opens in new window). In term and late preterm newborns (35 wk or more of gestation) receiving respiratory support at birth, 100% oxygen should not be used because it is associated with excess mortality. Routine oral, nasal, oropharyngeal, or endotracheal suctioning of newly born babies is not recommended. 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. 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). When blood loss is known or suspected based on history and examination, and there is no response to epinephrine, volume expansion is indicated. Multiple clinical and simulation studies examining briefings or debriefings of resuscitation team performance have shown improved knowledge or skills.812. 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. The writing groups then drafted, reviewed, and approved recommendations, assigning to each a Level of Evidence (LOE; ie, quality) and Class of Recommendation (COR; ie, strength) (Table(link opens in new window)).11. Copyright 2023 American Academy of Family Physicians. You administer 10 mL/kg of normal saline (based on the newborn's estimated weight). For term infants who do not require resuscitation at birth, it may be reasonable to delay cord clamping for longer than 30 seconds. 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%). In babies who appear to have ineffective respiratory effort after birth, tactile stimulation is reasonable. 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. If the heart rate remains below 60 beats per minute despite 30 seconds of adequate positive pressure ventilation, chest compressions should be initiated with a two-thumb encircling technique at a 3:1 compression-to-ventilation ratio. On the other hand, overestimation of heart rate when a newborn is bradycardic may delay necessary interventions. 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. Before giving PPV, the airway should be cleared by gently suctioning the mouth first and then the nose with a bulb syringe. If heart rate after birth remains at less than 60/min despite adequate ventilation for at least 30 s, initiating chest compressions is reasonable. Randomized trials have shown that infants born at 36 weeks' gestation or later with moderate to severe hypoxic-ischemic encephalopathy who were cooled to 92.3F (33.5C) within six hours after birth had significantly lower mortality and less disability at 18 months compared with those not cooled. Wait 60 seconds and check the heart rate. Intraosseous needles are reasonable, but local complications have been reported. 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. All Rights Reserved. Intravenous epinephrine is preferred because plasma epinephrine levels increase much faster than with endotracheal administration. Heart rate assessment is best performed by auscultation. 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. Effective team behaviors, such as anticipation, communication, briefing, equipment checks, and assignment of roles, result in improved team performance and neonatal outcome. It is reasonable to perform all resuscitation procedures, including endotracheal intubation, chest compressions, and insertion of intravenous lines with temperature-controlling interventions in place. There is no evidence from randomized trials to support the use of volume resuscitation at delivery. RQI for NRP. It is important to recognize that there are several significant gaps in knowledge relating to neonatal resuscitation.
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