Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. Rate is 40 - 60/min. It is important to recognize that there are several significant gaps in knowledge relating to neonatal resuscitation. Newly born infants who required advanced resuscitation are at significant risk of developing moderate-to-severe HIE. 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. The dose of epinephrine can be re-peated after 3-5 minutes if the initial dose is ineffective or can be repeated immediately if initial dose is given by endo-tracheal tube in the absence of an . 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. History and physical examination findings suggestive of blood loss include a pale appearance, weak pulses, and persistent bradycardia (heart rate less than 60/min). Radiant warmers and other warming adjuncts are suggested for babies who require resuscitation at birth, especially very preterm and very low-birth-weight babies. ** After completing the initial steps of providing warmth, positioning the infant in the sniffing position, clearing the airway and evaluate the infant's response with the following: There was no difference in Apgar scores or blood gas with naloxone compared with placebo. Before using epinephrine, tell your doctor if any past use of epinephrine injection caused an allergic reaction to get worse. Other important goals include establishment and maintenance of cardiovascular and temperature stability as well as the promotion of mother-infant bonding and breast feeding, recognizing that healthy babies transition naturally. The guidelines form the basis of the AAP/American Heart Association (AHA) Neonatal Resuscitation Program (NRP), 8th edition, which will be available in June 2021. It may be reasonable to use higher concentrations of oxygen during chest compressions. When blood loss is suspected in a newly born infant who responds poorly to resuscitation (ventilation, chest compressions, and/or epinephrine), it may be reasonable to administer a volume expander without delay. A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide. After chest compressions are performed for at least 2 minutes When an alternative airway is inserted Immediately after epinephrine is administered The baby could attempt to breathe and then endure primary apnea. Provide chest compressions if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. 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). For every 30 seconds that ventilation is delayed, the risk of prolonged admission or death increases by 16%. For newly born infants who are unintentionally hypothermic (temperature less than 36C) after resuscitation, it may be reasonable to rewarm either rapidly (0.5C/h) or slowly (less than 0.5C/h). 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. Both hands encircling chest Thumbs side by side or overlapping on lower half of . Establishing ventilation is the most important step to correct low heart rate. If the heart rate has not increased to 60/ min or more after optimizing ventilation and chest compressions, it may be reasonable to administer intravascular* epinephrine (0.01 to 0.03 mg/kg). For this reason, neonatal resuscitation should begin with PPV rather than with chest compressions.2,3 Delays in initiating ventilatory support in newly born infants increase the risk of death.1, The adequacy of ventilation is measured by a rise in heart rate and, less reliably, chest expansion. In the delivery room setting, the primary method of vascular access is umbilical venous catheterization. Term newborns with good muscle tone who are breathing or crying should be brought to their mother's chest routinely. All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and AHA Executive Committee. Copyright 2023 American Academy of Family Physicians. Epinephrine dosing may be repeated every three to five minutes if the heart rate remains less than 60 beats per minute. Rapid and effective response and performance are critical to good newborn outcomes. 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. 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. Initiate effective PPV for 30 seconds and reassess the heart rate. Appropriate and timely support should be provided to all involved. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion. On the basis of animal research, the progression from primary apnea to secondary apnea in newborns results in the cessation of respiratory activity before the onset of cardiac failure.4 This cycle of events differs from that of asphyxiated adults, who experience concurrent respiratory and cardiac failure. Wrapping, in addition to radiant heat, improves admission temperature of preterm infants. 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. High oxygen concentrations are recommended during chest compressions based on expert opinion. The AAP released the 8th edition of the Neonatal Resuscitation Program in June 2021. If the heart rate is less than 60 bpm, begin chest compressions. Therapeutic hypothermia is recommended in infants born at 36 weeks' gestation or later with evolving moderate to severe hypoxic-ischemic encephalopathy. 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. Rescuer 2 verbalizes the need for chest compressions. Intravenous epinephrine is preferred because. This content is owned by the AAFP. If the infant's heart rate is less than 60 beats per minute after adequate positive pressure ventilation and chest compressions, intravenous epinephrine at 0.01 to 0.03 mg per kg (1:10,000 solution) is recommended. 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. Suction should also be considered if there is evidence of airway obstruction during PPV, Direct laryngoscopy and endotracheal suctioning are not routinely required for babies born through MSAF but can be beneficial in babies who have evidence of airway obstruction while receiving PPV.7. How soon after administration of intravenous epinephrine should you pause compressions and assess the baby's heart rate?a. Team debrieng. 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. 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. Gaps in this domain, whether perceived or real, should be addressed at every stage in our research, educational, and clinical activities. Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP. 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. If skilled health care professionals are available, infants weighing less than 1 kg, 1 to 3 kg, and 3 kg or more can be intubated with 2.5-, 3-, and 3.5-mm endotracheal tubes, respectively. 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. 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. Delayed umbilical cord clamping was recommended for both term and preterm neonates in 2015. After birth, the baby should be dried and placed directly skin-to-skin with attention to warm coverings and maintenance of normal temperature. Premature animals exposed to brief high tidal volume ventilation (from high PIP) develop lung injury, impaired gas exchange, and decreased lung compliance. When should I check heart rate after epinephrine? 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. 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 Glucose levels should be monitored as soon as practical after advanced resuscitation, with treatment as indicated. Resuscitation of an infant with respiratory depression (term and preterm) in the delivery room (Figure 1) focuses on airway, breathing, circulation, and medications. On the other hand, overestimation of heart rate when a newborn is bradycardic may delay necessary interventions. A nonrandomized trial showed that endotracheal suctioning did not decrease the incidence of meconium aspiration syndrome or mortality. 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. Each 2020 AHA Guidelines for CPR and ECC document was submitted for blinded peer review to 5 subject matter experts nominated by the AHA. If the heart rate remains less than 60/min despite these interventions, chest compressions can supply oxygenated blood to the brain until the heart rate rises. Once the heart rate increases to more than 60 bpm, chest compressions are stopped. June 2021 The NRP 8th Edition introduces a new educational methodology to better meet the needs of health care professionals who manage the newly born baby. 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. For nonvigorous newborns delivered through MSAF who have evidence of airway obstruction during PPV, intubation and tracheal suction can be beneficial. 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. One small manikin study (very low quality), compared the 2 thumbencircling hands technique and 2-finger technique during 60 seconds of uninterrupted chest compressions. In a case series, endotracheal epinephrine (0.01 mg per kg) was less effective than intravenous epinephrine. 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? 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. Copyright 2021 by the American Academy of Family Physicians. There was no difference in neonatal intubation performance after weekly booster practice for 4 weeks compared with daily booster practice for 4 consecutive days. If intravenous access is not feasible, it may be reasonable to use the intraosseous route. Wait 60 seconds and check the heart rate. 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. These 2020 AHA neonatal resuscitation guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. 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. Aim for about 30 breaths min-1 with an inflation time of ~one second. The heart rate should be re- checked after 1 minute of giving compressions and ventilations. Epinephrine can cause increase in heart rate and blood pressure. Prevention of hyperthermia (temperature greater than 38C) is reasonable due to an increased risk of adverse outcomes. 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 circumstances of altered or impaired transition, effective neonatal resuscitation reduces the risk of mortality and morbidity. Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. The airway is cleared (if necessary), and the infant is dried. The newly born period extends from birth to the end of resuscitation and stabilization in the delivery area. Routine oral, nasal, oropharyngeal, or endotracheal suctioning of newly born babies is not recommended. This is partly due to the challenges of performing large randomized controlled trials (RCTs) in the delivery room. 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. Researchers studying these gaps may need to consider innovations in clinical trial design; examples include pragmatic study designs and novel consent processes. Stimulation may be provided to facilitate respiratory effort. While the science and practices surrounding monitoring and other aspects of neonatal resuscitation continue to evolve, the development of skills and practice surrounding PPV should be emphasized. The heart rate is reassessed,6 and if it continues to be less than 60 bpm, synchronized chest compressions and PPV are initiated in a 3:1 ratio (three compressions and one PPV).5,6 Chest compressions can be done using two thumbs, with fingers encircling the chest and supporting the back (preferred), or using two fingers, with a second hand supporting the back.5,6 Compressions should be delivered to the lower one-third of the sternum to a depth of approximately one-third of the anteroposterior diameter.5,6 The heart rate is reassessed at 45- to 60-second intervals, and chest compressions are stopped once the heart rate exceeds 60 bpm.5,6, Epinephrine is indicated if the infant's heart rate continues to be less than 60 bpm after 30 seconds of adequate PPV with 100 percent oxygen and chest compressions.

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