It may be reasonable to use higher concentrations of oxygen during chest compressions. 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]. 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. 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. 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. 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. A meta-analysis of 5 randomized and quasirandomized trials enrolling term and late preterm newborns showed no difference in rates of hypoxic-ischemic encephalopathy (HIE). 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. If resuscitation is required, heart rate should be monitored by electrocardiography as early as possible. 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. Hypothermia after birth is common worldwide, with a higher incidence in babies of lower gestational age and birth weight. monitored. To perform neonatal resuscitation effectively, individual providers and teams need training in the required knowledge, skills, and behaviors. 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. Updates to neonatal, pediatric resuscitation guidelines based on new 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. One observational study describes the initial pattern of breathing in term and preterm newly born infants to have an inspiratory time of around 0.3 seconds. If the heart rate remains less than 60/min despite 30 seconds of adequate PPV, chest compressions should be provided. One large retrospective review found that 0.04% of newborns received volume resuscitation in the delivery room, confirming that it is a relatively uncommon event. (PDF) Epinephrine in Neonatal Resuscitation - ResearchGate 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. 2023 American Heart Association, Inc. All rights reserved. Breakdowns in teamwork and communication can lead to perinatal death and injury.15 Team training in simulated resuscitations improves performance and has the potential to improve outcomes.16,17 Ultimately, being able to perform bag and mask ventilation and work in coordination with a team are important for effective neonatal resuscitation. Intravenous epinephrine is preferred because plasma epinephrine levels increase much faster than with endotracheal administration. 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. For babies requiring vascular access at the time of delivery, the umbilical vein is the recommended route. In preterm infants, delaying clamping reduces the need for vasopressors or transfusions. Prevention of hypothermia continues to be an important focus for neonatal resuscitation. A laboring woman received a narcotic medication for pain relief 1 hour before delivery.The baby does not have spontaneous respirations and does not improve with stimulation.Your first priority is to. See permissionsforcopyrightquestions and/or permission requests. No type of routine suctioning is helpful, even for nonvigorous newborns delivered through meconium-stained amniotic fluid. For nonvigorous newborns delivered through MSAF who have evidence of airway obstruction during PPV, intubation and tracheal suction can be beneficial. Currently, epinephrine is the only vasoactive drug recommended by the International Liaison Committee on Resuscitation (ILCOR) for neonates who remain severely bradycardic (heart rate <. Volunteers with recognized expertise in resuscitation are nominated by the writing group chair and selected by the AHA ECC Committee. Before giving PPV, the airway should be cleared by gently suctioning the mouth first and then the nose with a bulb syringe. Intravenous epinephrine is preferred because. 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. 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. 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. 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. 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. CPAP indicates continuous positive airway pressure; ECG, electrocardiographic; ETT, endotracheal tube; HR, heart rate; IV, intravenous; O2, oxygen; Spo2, oxygen saturation; and UVC, umbilical venous catheter. 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. The research community needs to address the paucity of educational studies that provide outcomes with a high level of certainty. 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. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. All Rights Reserved. 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. 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. Table 1 lists evidence and recommendations for interventions during neonatal resuscitation.1,2,57,2043, Intrapartum suctioning is not recommended with clear or meconium-stained amniotic fluid.1,2,5,6, Endotracheal suctioning of vigorous* infants is not recommended.1,2,5,6, Endotracheal suctioning of nonvigorous infants born through meconium-stained amniotic fluid may be useful.1,2,5, A self-inflating bag, flow-inflating bag, or T-piece device can be used to deliver positive pressure ventilation.1,6, Auscultation should be the primary means of assessing heart rate, and in infants needing respiratory support, the goal should be to check the heart rate by auscultation and by pulse oximetry.6, Initial PIP of 20 cm H2O may be effective, but a PIP of 30 to 40 cm H2O may be necessary in some infants to achieve or maintain a heart rate of more than 100 bpm.5, Ventilation rates of 40 to 60 breaths per minute are recommended.5,6, Use of an exhaled carbon dioxide detector in term and preterm infants is recommended to confirm endotracheal tube placement.5,6, Laryngeal mask airway should be considered if bag and mask ventilation is unsuccessful, and if endotracheal intubation is unsuccessful or not feasible.5,6, No evidence exists to support or refute the use of mask CPAP in term infants.2,5, PEEP should be used if suitable equipment is available, such as a flow-inflating bag or T-piece device.5, Delivery rooms should have a pulse oximeter readily available.57, A pulse oximeter is recommended when supplemental oxygen, positive pressure ventilation, or CPAP is used.57, Supplemental oxygen should be administered using an air/oxygen blender.57. Readers are directed to the AHA website for the most recent guidance.12, The following sections briefly describe the process of evidence review and guideline development. Depth is correct. 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. If there is ineffective breathing effort or apnea after birth, tactile stimulation may stimulate breathing. 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. One observational study in newly born infants associated high tidal volumes during resuscitation with brain injury. 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 effect of briefing and debriefing on longer-term and critical outcomes remains uncertain. This content is owned by the AAFP. One RCT (low certainty of evidence) suggests improved oxygenation after resuscitation in preterm babies who received repeated tactile stimulation. 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. 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. If a baby does not begin breathing . Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. Internal validity might be better addressed by clearly defined primary outcomes, appropriate sample sizes, relevant and timed interventions and controls, and time series analyses in implementation studies. Hypoglycemia is common in infants who have received advanced resuscitation and is associated with poorer outcomes.8 These infants should be monitored for hypoglycemia and treated appropriately. For nonvigorous newborns with meconium-stained fluid, endotracheal suctioning is indicated only if obstruction limits positive pressure ventilation, because suctioning does not improve outcomes. There were only minor changes to the NRP algorithm and recommended practices. 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 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. After 30 seconds, Rescuer 2 evaluates heart rate. A randomized study showed similar success in providing effective ventilation using either laryngeal mask airway or endotracheal tube. Optimal PEEP has not been determined, because all human studies used a PEEP level of 5 cm H2O.1822, It is reasonable to initiate PPV at a rate of 40 to 60/min to newly born infants who have ineffective breathing, are apneic, or are persistently bradycardic (heart rate less than 100/min) despite appropriate initial actions (including tactile stimulation).1, To match the natural breathing pattern of both term and preterm newborns, the inspiratory time while delivering PPV should be 1 second or less. Intra-arterial epinephrine is not recommended. 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. Neonatal Resuscitation - Pediatrics - MSD Manual Professional Edition IV epinephrine every 3-5 minutes. 8. 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. 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. 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 Epinephrine use in the delivery room for resuscitation of the newborn is associated with significant morbidity and mortality. However, the concepts in these guidelines may be applied to newborns during the neonatal period (birth to 28 days). Contact Us, Hours For newborns who are breathing, continuous positive airway pressure can help with labored breathing or persistent cyanosis. Hyperlinked references are provided to facilitate quick access and review. 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. Delayed cord clamping is associated with higher hematocrit after birth and better iron levels in infancy.921 While developmental outcomes have not been adequately assessed, iron deficiency is associated with impaired motor and cognitive development.2426 It is reasonable to delay cord clamping (longer than 30 seconds) in preterm babies because it reduces need for blood pressure support and transfusion and may improve survival.18, There are insufficient studies in babies requiring PPV before cord clamping to make a recommendation.22 Early cord clamping should be considered for cases when placental transfusion is unlikely to occur, such as maternal hemorrhage or hemodynamic instability, placental abruption, or placenta previa.27 There is no evidence of maternal harm from delayed cord clamping compared with early cord clamping.1012,2834 Cord milking is being studied as an alternative to delayed cord clamping but should be avoided in babies less than 28 weeks gestational age, because it is associated with brain injury.23, Temperature should be measured and recorded after birth and monitored as a measure of quality.1 The temperature of newly born babies should be maintained between 36.5C and 37.5C.2 Hypothermia (less than 36C) should be prevented as it is associated with increased neonatal mortality and morbidity, especially in very preterm (less than 33 weeks) and very low-birthweight babies (less than 1500 g), who are at increased risk for hypothermia.35,7 It is also reasonable to prevent hyperthermia as it may be associated with harm.4,6, Healthy babies should be skin-to-skin after birth.8 For preterm and low-birth-weight babies or babies requiring resuscitation, warming adjuncts (increased ambient temperature [greater than 23C], skin-to-skin care, radiant warmers, plastic wraps or bags, hats, blankets, exothermic mattresses, and warmed humidified inspired gases)10,11,14 individually or in combination may reduce the risk of hypothermia. If it is possible to identify such conditions at or before birth, it is reasonable not to initiate resuscitative efforts. 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. The frequency and format of booster training or refresher training that best supports retention of neonatal resuscitation knowledge, technical skills, and behavioral skills, The effects of briefing and debriefing on team performance, Optimal cord management strategies for various populations, including nonvigorous infants and those with congenital heart or lung disease, Optimal management of nonvigorous infants with MSAF, The most effective device(s) and interface(s) for providing PPV, Impact of routine use of the ECG during neonatal resuscitation on resuscitation, Feasibility and effectiveness of new technologies for rapid heart rate measurement (such as electric, ultrasonic, or optical devices), Optimal oxygen management during and after resuscitation, Novel techniques for effective delivery of CPR, such as chest compressions accompanied by sustained inflation, Optimal timing, dosing, dose interval, and delivery routes for epinephrine or other vasoactive drugs, including earlier use in very depressed newly born infants, Indications for volume expansion, as well as optimal dosing, timing, and type of volume, The management of pulseless electric activity, Management of the preterm newborn during and after resuscitation, Management of congenital anomalies of the heart and lungs during and after resuscitation, Resuscitation of newborns in the neonatal unit after the newly born period, Resuscitation of newborns in other settings up to 28 days of age, Optimal dose, route, and timing of surfactant in at-risk newborns, including less-invasive administration techniques, Indications for therapeutic hypothermia in babies with mild HIE and in those born at less than 36 weeks' gestational age, Adjunctive therapies to therapeutic hypothermia, Optimal rewarming strategy for newly born infants with unintentional hypothermia. 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. How soon after administration of intravenous epinephrine should you pause compressions and assess the baby's heart rate?a. 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. 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. Once the heart rate increases to more than 60 bpm, chest compressions are stopped. If the baby is apneic or has a heart rate less than 100 bpm Begin the initial steps Warm, dry and stimulate for 30 seconds
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