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. Most newly born infants do not require immediate cord clamping or resuscitation and can be evaluated and monitored during skin-to-skin contact with their mothers after birth. These 2020 AHA neonatal resuscitation guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. 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 preterm infants who do not require resuscitation at birth, it is reasonable to delay cord clamping for longer than 30 seconds. Identification of risk factors for resuscitation may indicate the need for additional personnel and equipment. Rescuer 2 verbalizes the need for chest compressions. 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. 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. 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 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). Administration of epinephrine via a low-lying umbilical venous catheter provides the most rapid and reliable medication delivery. Although this flush volume may . 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. Routine oral, nasal, oropharyngeal, or endotracheal suctioning of newly born babies is not recommended. Ninety percent of infants transition safely, and it is up to the physician to assess risk factors, identify the nearly 10 percent of infants who need resuscitation, and respond appropriately. 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. Exhaled carbon dioxide detectors to confirm endotracheal tube placement. Metrics. Three out of seven (43%) and 12/15 (80%) lambs achieved ROSC after the rst dose of epinephrine with 1-mL and 2.5-mL ush respectively (p = 0.08). Please see updates below from RQI Partners, the company that is providing the NRP Learning Platform TM and RQI for NRP. 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. An important point is that ventilation has been shown to be the most effective measure in neonatal resuscitation Exothermic mattresses may be effective in preventing hypothermia in preterm babies. Most RCTs in well-resourced settings would routinely manage at-risk babies under a radiant warmer. 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. After birth, the baby should be dried and placed directly skin-to-skin with attention to warm coverings and maintenance of normal temperature. 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? Physicians who provide obstetric care should be aware of maternal-fetal risk factors1 and should assess the risk of respiratory depression with each delivery.19 The obstetric team should inform the neonatal resuscitation team of the risk status for each delivery and continue to focus on obstetric care. This is partly due to the challenges of performing large randomized controlled trials (RCTs) in the delivery room. 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). In a retrospective review, early hypoglycemia was a risk factor for brain injury in infants with acidemia requiring resuscitation. The neonatal epinephrine dose is 0.01 to 0.03 mg per kg (1:10,000 solution) given intravenously (via umbilical venous catheter).1,2,5,6 If there is any delay in securing venous access, epinephrine can be given via endotracheal tube at a higher dose of 0.05 to 0.10 mg per kg (1:10,000 solution), followed by intravenous dosing, if necessary, as soon as access is established.5, Naloxone is not recommended during neonatal resuscitation in the delivery room; infants with respiratory depression should be resuscitated with PPV.1,2,5,6 Volume expansion (using crystalloid or red blood cells) is recommended when blood loss is suspected (e.g., pale skin, poor perfusion, weak pulse) and when the infant's heart rate continues to be low despite effective resuscitation.5,6 Sodium bicarbonate is not recommended during neonatal resuscitation in the delivery room, because it does not improve survival or neurologic outcome.6,39, Approximately 7 to 20 percent of deliveries are complicated by meconium-stained amniotic fluid; these infants have a 2 to 9 percent risk of developing meconium aspiration syndrome.50 Oral and nasopharyngeal suction on the perineum is not recommended, because it has not been shown to reduce the risk of meconium aspiration syndrome.20 In the absence of randomized controlled trials, there is insufficient evidence to recommend changing the current practice of intubation and endotracheal suction in nonvigorous infants (as defined by decreased heart rate, respiratory effort, or muscle tone) born through meconium-stained amniotic fluid.1,2,5 However, if attempted intubation is prolonged or unsuccessful, and bradycardia is present, bag and mask ventilation is advised.5,6 Endotracheal suctioning of vigorous infants is not recommended.1,2,5,6, Withholding resuscitation and offering comfort care is appropriate (with parental consent) in certain infants, such as very premature infants (born at less than 23 weeks' gestation or weighing less than 400 g) and infants with anencephaly or trisomy 13 syndrome.5 If there is no detectable heart rate after 10 minutes of resuscitation, it is appropriate to consider discontinuing resuscitation.5,6, Intravenous glucose infusion should be started soon after resuscitation to avoid hypoglycemia.5,6 In addition, infants born at 36 weeks' gestation or later with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia, using studied protocols, within six hours at a facility with capabilities of multidisciplinary care and long-term follow-up.57. 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. In newborns born before 35 weeks' gestation, oxygen concentrations above 50% are no more effective than lower concentrations. You administer 10 mL/kg of normal saline (based on the newborn's estimated weight). 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. The temperature of newly born babies should be maintained between 36.5C and 37.5C after birth through admission and stabilization. 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. Term newborns with good muscle tone who are breathing or crying should be brought to their mother's chest routinely. A reasonable time frame for this change in goals of care is around 20 min after birth. PPV remains the primary method for providing support for newborns who are apneic, bradycardic, or demonstrate inadequate respiratory effort. 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. You're welcome to take the quiz as many times as you'd like. In the delivery room setting, the primary method of vascular access is umbilical venous catheterization. High oxygen concentrations are recommended during chest compressions based on expert opinion. 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. Wrapping, in addition to radiant heat, improves admission temperature of preterm infants. History and physical examination findings suggestive of blood loss include a pale appearance, weak pulses, and persistent bradycardia (heart rate less than 60/min). When providing chest compressions with the 2 thumbencircling hands technique, the hands encircle the chest while the thumbs depress the sternum.1,2 The 2 thumbencircling hands technique can be performed from the side of the infant or from above the head of the newborn.1 Performing chest compressions with the 2 thumbencircling hands technique from above the head facilitates placement of an umbilical venous catheter. 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. The following sections are worth special attention. Author disclosure: No relevant financial affiliations. In resource-limited settings, it may be reasonable to place newly born babies in a clean food-grade plastic bag up to the level of the neck and swaddle them in order to prevent hypothermia. When providing chest compressions in a newborn, it may be reasonable to repeatedly deliver 3 compressions followed by an inflation (3:1 ratio). All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and AHA Executive Committee. Intra-arterial epinephrine is not recommended. diabetes. Intravenous epinephrine is preferred because. Delaying cord clamping for more than 30 seconds is reasonable for term and preterm infants who do not require resuscitation. 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). minutes, and 80% at 5 minutes of life. In observational studies in both preterm (less than 37 weeks) and low-birth-weight babies (less than 2500 g), the presence and degree of hypothermia after birth is strongly associated with increased neonatal mortality and morbidity. There is a history of acute blood loss around the time of delivery. Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth. Case series show small numbers of intact survivors after 20 minutes of no detectable heart rate. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient 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. Every birth should be attended by one person who is assigned, trained, and equipped to initiate resuscitation and deliver positive pressure ventilation. A multicenter randomized trial showed that intrapartum suctioning of meconium does not reduce the risk of meconium aspiration syndrome. Chest compressions are provided if there is a poor heart rate response to ventilation after appropriate ventilation corrective steps, which preferably include endotracheal intubation. Similarly, meta-analysis of 2 quasi-randomized trials showed no difference in moderate-to-severe neurodevelopmental impairment at 1 to 3 years of age. Newborn temperature should be maintained between 97.7F and 99.5F (36.5C and 37.5C), because mortality and morbidity increase with hypothermia, especially in preterm and low birth weight infants. When feasible, well-designed multicenter randomized clinical trials are still optimal to generate the highest-quality evidence. On the other hand, overestimation of heart rate when a newborn is bradycardic may delay necessary interventions. When the need for resuscitation is not anticipated, delays in assisting a newborn who is not breathing may increase the risk of death.1,5,13 Therefore, every birth should be attended by at least 1 person whose primary responsibility is the newborn and who is trained to begin PPV without delay.24, A risk assessment tool that evaluates risk factors present during pregnancy and labor can identify newborns likely to require advanced resuscitation; in these cases, a team with more advanced skills should be mobilized and present at delivery.5,7 In the absence of risk stratification, up to half of babies requiring PPV may not be identified before delivery.6,13, A standardized equipment checklist is a comprehensive list of critical supplies and equipment needed in a given clinical setting. The reduced heart rate that occurs in this situation can be reversed with tactile stimulation. 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. There was no difference in neonatal intubation performance after weekly booster practice for 4 weeks compared with daily booster practice for 4 consecutive days. For neonatal resuscitation providers, it may be reasonable to brief before delivery and debrief after neonatal resuscitation. Unauthorized use prohibited. The following knowledge gaps require further research: For all these gaps, it is important that we have information on outcomes considered critical or important by both healthcare providers and families of newborn infants. Prevention of hypothermia continues to be an important focus for neonatal resuscitation. 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.
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