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. Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent. A new Resuscitation Quality Improvement (RQI) program for NRP focused on PPV will be . However, the concepts in these guidelines may be applied to newborns during the neonatal period (birth to 28 days). Please contact the American Heart Association at ECCEditorial@heart.org or 1-214-706-1886 to request a long description of . Clinical assessment of heart rate has been found to be both unreliable and inaccurate. 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. 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. If resuscitation is required, electrocardiography should be used, especially with chest compressions. Term newborns with good muscle tone who are breathing or crying should be brought to their mother's chest routinely. Delayed umbilical cord clamping was recommended for both term and preterm neonates in 2015. Saturday: 9 a.m. - 5 p.m. CT Endotracheal suctioning may be useful in nonvigorous infants with respiratory depression born through meconium-stained amniotic fluid. 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. Chest compressions are a rare event in full-term newborns (approximately 0.1%) but are provided more frequently to preterm newborns.11When providing chest compressions to a newborn, it may be reasonable to deliver 3 compressions before or after each inflation: providing 30 inflations and 90 compressions per minute (3:1 ratio for 120 total events per minute). 1 minuteb. Test your knowledge with our free Neonatal Resuscitation Practice Test provided below in order to prepare you for our official online exam. According to the Textbook of Neonatal Resuscitation, 8th edition, what volume of normal saline flush should you administer? How soon after administration of intravenous epinephrine should you pause compressions and assess the baby's heart rate?a. Effective team behaviors, such as anticipation, communication, briefing, equipment checks, and assignment of roles, result in improved team performance and neonatal outcome. It may be possible to identify conditions in which withholding or discontinuation of resuscitative efforts may be reasonably considered by families and care providers. Positive-Pressure Ventilation (PPV) Suctioning may be considered for suspected airway obstruction. The heart rate should be verbalized for the team. Circulation. We thank Dr. Abhrajit Ganguly for assistance in manuscript preparation. 1. The temperature of newly born babies should be maintained between 36.5C and 37.5C after birth through admission and stabilization. When possible, healthy term babies should be managed skin-to-skin with their mothers. Given the evidence for ECG during initial steps of PPV, expert opinion is that ECG should be used when providing chest compressions. 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 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. If resuscitation is required, heart rate should be monitored by electrocardiography as early as possible. When feasible, well-designed multicenter randomized clinical trials are still optimal to generate the highest-quality evidence. The decision to continue or discontinue resuscitative efforts should be individualized and should be considered at about 20 minutes after birth. 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. A team or persons trained in neonatal resuscitation should be promptly available to provide resuscitation. Animal studies in newborn mammals show that heart rate decreases during asphyxia. 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. You administer 10 mL/kg of normal saline (based on the newborn's estimated weight). It is the expert opinion of national medical societies that conditions exist for which it is reasonable to not initiate resuscitation or to discontinue resuscitation once these conditions are identified. The AAP released the 8th edition of the Neonatal Resuscitation Program in June 2021. If it is possible to identify such conditions at or before birth, it is reasonable not to initiate resuscitative efforts. Dallas, TX 75231, Customer Service 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. Short, frequent practice (booster training) has been shown to improve neonatal resuscitation outcomes.5 Educational programs and perinatal facilities should develop strategies to ensure that individual and team training is frequent enough to sustain knowledge and skills. Ventilation should be optimized before starting chest compressions, possibly including endotracheal intubation. 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. Pulse oximetry tended to underestimate the newborn's heart rate. 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)). The heart rate response to chest compressions and medications should be monitored electrocardiographically. Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP. RQI for NRP. Evaluate respirations The three signs of effective resuscitation are: Heart rate Respirations Assessment of oxygenation (O2 Sat based on age in minutes) Baby can take up to ten minutes to reach an oxygen saturation of 90-95%. After birth, the baby should be dried and placed directly skin-to-skin with attention to warm coverings and maintenance of normal temperature. 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. 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. 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. 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. 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. In a prospective interventional clinical study, video-based debriefing of neonatal resuscitations was associated with improved preparation and adherence to the initial steps of the Neonatal Resuscitation Algorithm, improved quality of PPV, and improved team function and communication. NRP-certified nurses, nurse practitioners, and respiratory therapists have demonstrated the capacity to lead resuscitations.1113 However, it is recommended that an NRP-certified physician be present in the hospital when a high-risk delivery is anticipated.1113 One study provides an outline for physicians interested in developing a neonatal resuscitation team.14. 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). If the heart rate remains less than 60/min despite 30 seconds of adequate PPV, chest compressions should be provided. Hand position is correct. IV epinephrine every 3-5 minutes. For nonvigorous newborns (presenting with apnea or ineffective breathing effort) delivered through MSAF, routine laryngoscopy with or without tracheal suctioning is not recommended. Heart rate is assessed initially by auscultation and/or palpation. The recommended route is intravenous, with the intraosseous route being an alternative. 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. NRP Advanced may also be appropriate for health care professionals in smaller hospital facilities with fewer per- 7. It may be reasonable to provide volume expansion with normal saline (0.9% sodium chloride) or blood at 10 to 20 mL/kg. 2023 American Heart Association, Inc. All rights reserved. In a retrospective study, volume infusion was given more often for slow response of bradycardia to resuscitation than for overt hypovolemia. This guideline affirms the previous recommendations. 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. 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. Your team is caring for a term newborn whose heart rate is 50 bpm after receiving effective ventilation, chest compressions, and intravenous epinephrine administration. 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. 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. 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. 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. Before giving PPV, the airway should be cleared by gently suctioning the mouth first and then the nose with a bulb syringe. 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. 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. 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 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. During resuscitation, a baby is responding to positive-pressure ventilation with a rapidly increasing heart rate. Rapid and effective response and performance are critical to good newborn outcomes. 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. Target Oxygen Saturation Table Initial oxygen concentration for PPV 1 min 60%-65% 2 min 65%-70% 3 min 70%-75% 4 min 75%-80% 5 min 80%-85% 10 min 85%-95% 35 weeks' GA 21% oxygen The studies were too heterogeneous to be amenable to meta-analysis. 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. All Rights Reserved. Therapeutic hypothermia is recommended in infants born at 36 weeks' gestation or later with evolving moderate to severe hypoxic-ischemic encephalopathy. 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. 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. It is reasonable to perform all resuscitation procedures, including endotracheal intubation, chest compressions, and insertion of intravenous lines with temperature-controlling interventions in place. 2020;142(suppl 2):S524S550. If a baby does not begin breathing . A single-center RCT found that role confusion during simulated neonatal resuscitation was avoided and teamwork skills improved by conducting a team briefing. It is estimated that approximately 10% of newly born infants need help to begin breathing at birth,13 and approximately 1% need intensive resuscitative measures to restore cardiorespiratory function.4,5 The neonatal mortality rate in the United States and Canada has fallen from almost 20 per 1000 live births 6,7 in the 1960s to the current rate of approximately 4 per 1000 live births. 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. Team training remains an important aspect of neonatal resuscitation, including anticipation, preparation, briefing, and debriefing. Please see updates below from RQI Partners, the company that is providing the NRP Learning Platform TM and RQI for NRP. The Neonatal Resuscitation Program, which was initiated in 1987 to identify infants at risk of needing resuscitation and provide high-quality resuscitation, underwent major updates in 2006 and 2010. 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. increase in the newborn's heart rate is the most sensitive indicator of a successful response to resuscitation. Teams and individuals who provide neonatal resuscitation are faced with many challenges with respect to the knowledge, skills, and behaviors needed to perform effectively. 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. If there is ineffective breathing effort or apnea after birth, tactile stimulation may stimulate breathing. When blood loss is known or suspected based on history and examination, and there is no response to epinephrine, volume expansion is indicated. Breathing is stimulated by gently rubbing the infant's back. Every healthy newly born baby should have a trained and equipped person assigned to facilitate transition. For infants born at less than 28 wk of gestation, cord milking is not recommended. A reasonable time frame for this change in goals of care is around 20 min after birth. Normal saline (0.9% sodium chloride) is the crystalloid fluid of choice. If you have a certificate code, then you can manually verify a certificate by entering the code here. It is important to continue PPV and chest compressions while preparing to deliver medications. The potential benefit or harm of sustained inflations between 1 and 10 seconds is uncertain.2,29. Consider pneumothorax. 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. 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. No studies have examined PEEP vs. no PEEP when positive pressure ventilation is used after birth. Many current recommendations are based on weak evidence with a lack of well-designed human studies. Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. Part 5: neonatal resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. 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). Immediate, unlimited access to all AFP content, Immediate, unlimited access to this issue's content. 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. Ventilation should be optimized before starting chest compressions, with endotracheal intubation if possible. A large multicenter RCT found higher rates of intraventricular hemorrhage with cord milking in preterm babies born at less than 28 weeks gestational age. Comprehensive disclosure information for peer reviewers is listed in Appendix 2(link opens in new window). Supplemental oxygen should be used judiciously, guided by pulse oximetry. The practice test consists of 10 multiple-choice questions that adhere to the latest ILCOR standards. Tell your doctor if you have ever had: heart disease or high blood pressure; asthma; Parkinson's disease; depression or mental illness; a thyroid disorder; or. In preterm newly born infants, the routine use of sustained inflations to initiate resuscitation is potentially harmful and should not be performed. HR below 60/min? Approximately 10% of newborns require assistance to breathe after birth.13,5,13 Newborn resuscitation requires training, preparation, and teamwork. When chest compressions are initiated, an ECG should be used to confirm heart rate. 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. 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. If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route. If the baby is bradycardic (HR <60 per minute) after 90 seconds of resuscitation with a lower concentration of oxygen, oxygen concentration should be increased to 100% until recovery of a normal heart rate (Class IIb, LOE B). Plasma epinephrine concentrations at 1 min after epinephrine administration were not different. Reduce the inflation pressure if the chest is moving well. With growing enthusiasm for clinical studies in neonatology, elements of the Neonatal Resuscitation Algorithm continue to evolve as new evidence emerges. (if you are using the 0.1 mg/kg dose.) When vascular access is required in the newly born, the umbilical venous route is preferred. In newborns who do not require resuscitation, delaying cord clamping for more than 30 seconds reduces anemia, especially in preterm infants. 0.5 mL 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. The heart rate should be re-checked after 1 minute of giving compressions and ventilations. 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. After birth, the newborn's heart rate is used to assess the effectiveness of spontaneous respiratory effort, the need for interventions, and the response to interventions.
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