RQI for NRP. If epinephrine is administered via endotracheal tube, a dose of 0.05 to 0.1 mg per kg (1:10,000 solution) is needed.1,2,57, Early volume expansion with crystalloid (10 mL per kg) or red blood cells is indicated for blood loss when the heart rate does not increase with resuscitation.5,6, Use of naloxone is not recommended as part of initial resuscitation of infants with respiratory depression in the delivery room.1,2,5,6, Very rarely, sodium bicarbonate may be useful after resuscitation.6, Term or near term infants with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia.57, Intravenous glucose infusion should be started soon after resuscitation to avoid hypoglycemia.5,6, It is recommended to cover preterm infants less than 28 weeks' gestation in polyethylene wrap after birth and place them under a radiant warmer. 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. The very limited observational evidence in human infants does not demonstrate greater efficacy of endotracheal or intravenous epinephrine; however, most babies received at least 1 intravenous dose before ROSC. 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. Administer epinephrine, preferably intravenously, if response to chest compressions is poor. A reasonable time frame for this change in goals of care is around 20 min after birth. In the resuscitation of an infant, initial oxygen concentration of 21 percent is recommended. The Neonatal Life Support Writing Group includes neonatal physicians and nurses with backgrounds in clinical medicine, education, research, and public health. For infants with a heart rate of 60 to < 100 beats/minute who have apnea, gasping, or ineffective respirations, positive pressure ventilation (PPV) using a mask is indicated. All Rights Reserved. For newborns who are breathing, continuous positive airway pressure can help with labored breathing or persistent cyanosis. RCTs and observational studies of warming adjuncts, alone and in combination, demonstrate reduced rates of hypothermia in very preterm and very low-birth-weight babies. There should be ongoing evaluation of the baby for normal respiratory transition. If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route. 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. 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. Excessive peak inflation pressures are potentially harmful and should be avoided. 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. monitored. 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). Exothermic mattresses may be effective in preventing hypothermia in preterm babies. 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. In a meta-analysis of 8 RCTs involving 1344 term and late preterm infants with moderate-to-severe encephalopathy and evidence of intrapartum asphyxia, therapeutic hypothermia resulted in a significant reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age (odds ratio 0.75; 95% CI, 0.680.83). 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). Please contact the American Heart Association at ECCEditorial@heart.org or 1-214-706-1886 to request a long description of . Exhaled carbon dioxide detectors to confirm endotracheal tube placement. The impact of therapeutic hypothermia on infants less than 36 weeks gestational age with HIE is unclear and is a subject of ongoing research trials. Intraosseous needles are reasonable, but local complications have been reported. 7272 Greenville Ave. 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. 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. This is partly due to the challenges of performing large randomized controlled trials (RCTs) in the delivery room. HR below 60/min? 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. Endotracheal intubation is indicated in very premature infants; for suctioning of nonvigorous infants born through meconium-stained amniotic fluid; and when bag and mask ventilation is necessary for more than two to three minutes, PPV via face mask does not increase heart rate, or chest compressions are needed. When anticipating a high-risk birth, a preresuscitation team briefing should be completed to identify potential interventions and assign roles and responsibilities. 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. For babies requiring vascular access at the time of delivery, the umbilical vein is the recommended route. In this review, we provide the current recommendations for use of epinephrine during neonatal . For infants requiring PPV at birth, there is currently insufficient evidence to recommend delayed cord clamping versus early cord clamping. Coordinate chest compressions with ventilations at a ratio of 3:1 and a rate of 120 events per minute to achieve approximately 90 compressions and 30 breaths per minute. ECG (3-lead) displays a reliable heart rate faster than pulse oximetry. Term newborns with good muscle tone who are breathing or crying should be brought to their mother's chest routinely. Use of CPAP for resuscitating term infants has not been studied. 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. When possible, healthy term babies should be managed skin-to-skin with their mothers. Copyright 2021 by the American Academy of Family Physicians. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion. Suctioning may be considered if PPV is required and the airway appears obstructed. 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. The baby could attempt to breathe and then endure primary apnea. The same study demonstrated that the risk of death or prolonged admission increases 16% for every 30-second delay in initiating PPV. One small manikin study (very low quality), compared the 2 thumbencircling hands technique and 2-finger technique during 60 seconds of uninterrupted chest compressions. Numerous nonrandomized quality improvement (very low to low certainty) studies support the use of warming adjunct bundles.. 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. NRP Advanced may also be appropriate for health care professionals in smaller hospital facilities with fewer per- There is a reduction of mortality and no evidence of harm in term infants resuscitated with 21 percent compared with 100 percent oxygen. Please see updates below from RQI Partners, the company that is providing the NRP Learning Platform TM and RQI for NRP. Rapid and effective response and performance are critical to good newborn outcomes. 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. 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 effect of briefing and debriefing on longer-term and critical outcomes remains uncertain. The heart rate should be re-checked after 1 minute of giving compressions and ventilations. The dosage interval for epinephrine is every 3 to 5 minutes if the heart rate remains less than 60/min, although an intravenous dose may be given as soon as umbilical access is obtained if response to endotracheal epinephrine has been inadequate. Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP. 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. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. 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. There were only minor changes to the NRP algorithm and recommended practices. 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. Check the heart rate by counting the beats in 6 seconds and multiply by 10. If intravenous access is not feasible, it may be reasonable to use the intraosseous route. 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 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. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. During chest compressions, an ECG should be used for the rapid and accurate assessment of heart rate. Post-resuscitation care. A multicenter, case-control study identified 10 perinatal risk factors that predict the need for advanced neonatal resuscitation. The current guidelines have focused on clinical activities described in the resuscitation algorithm, rather than on the most appropriate devices for each step. Delaying cord clamping for more than 30 seconds is reasonable for term and preterm infants who do not require resuscitation. Additional personnel are necessary if risk factors for complicated resuscitation are present. The heart rate should be verbalized for the team. 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. Suctioning may be considered for suspected airway obstruction. 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. In the delivery room setting, the primary method of vascular access is umbilical venous catheterization. (Heart rate is 50/min.) Another barrier is the difficulty in obtaining antenatal consent for clinical trials in the delivery room. If all these steps of resuscitation are effectively completed and there is no heart rate response by 20 minutes, redirection of care should be discussed with the team and family. 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 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. The most important priority for newborn survival is the establishment of adequate lung inflation and ventilation after birth. If resuscitation is required, electrocardiography should be used, especially with chest compressions. Metrics. If heart rate after birth remains at less than 60/min despite adequate ventilation for at least 30 s, initiating chest compressions is reasonable. You administer 10 mL/kg of normal saline (based on the newborn's estimated weight). Hyperthermia should be avoided.1,2,6, Delivery room temperature should be set at at least 78.8F (26C) for infants less than 28 weeks' gestation.6. The potential benefit or harm of sustained inflations between 1 and 10 seconds is uncertain.2,29. These 2020 AHA neonatal resuscitation guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. Equipment checklists, role assignments, and team briefings improve resuscitation performance and outcomes. Positive pressure ventilation should be delivered without delay to infants who are apneic, gasping, or have a heart rate below 100 beats per minute within the first 60 seconds of life despite initial resuscitation. 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. Breathing is stimulated by gently rubbing the infant's back. Supplemental oxygen should be used judiciously, guided by pulse oximetry. 1 Exhaled carbon dioxide detection is the recommended method of confirming endotracheal intubation. 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. Newly born infants who breathe spontaneously need to establish a functional residual capacity after birth.8 Some newly born infants experience respiratory distress, which manifests as labored breathing or persistent cyanosis. An important point is that ventilation has been shown to be the most effective measure in neonatal resuscitation Many current recommendations are based on weak evidence with a lack of well-designed human studies. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. Delayed umbilical cord clamping was recommended for both term and preterm neonates in 2015. 1. Immediate, unlimited access to all AFP content, Immediate, unlimited access to this issue's content. Blood may be lost from the placenta into the mothers circulation, from the cord, or from the infant. Babies who have failed to respond to PPV and chest compressions require vascular access to infuse epinephrine and/or volume expanders. Approximately 10% of newborns require assistance to breathe after birth.13,5,13 Newborn resuscitation requires training, preparation, and teamwork. Heart rate assessment is best performed by auscultation. A nonrandomized trial showed that endotracheal suctioning did not decrease the incidence of meconium aspiration syndrome or mortality. In preterm newly born infants, the routine use of sustained inflations to initiate resuscitation is potentially harmful and should not be performed. Hand position is correct. An improvement in heart rate and establishment of breathing or crying are all signs of effective PPV. Consequently, all newly born babies should be attended to by at least 1 person skilled and equipped to provide PPV. Most babies will respond to this intervention. In the birth setting, a standardized checklist should be used before every birth to ensure that supplies and equipment for a complete resuscitation are present and functional.8,9,14,15, A predelivery team briefing should be completed to identify the leader, assign roles and responsibilities, and plan potential interventions. Resuscitation of an infant with respiratory depression (term and preterm) in the delivery room (Figure 1) focuses on airway, breathing, circulation, and medications. The importance of skin-to-skin care in healthy babies is reinforced as a means of promoting parental bonding, breast feeding, and normothermia.
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