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. Prevention of hypothermia continues to be an important focus for neonatal resuscitation. 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. The immediate care of newly born babies involves an initial assessment of gestation, breathing, and tone. Neonatal Resuscitation Pre Test Example Quiz & Answers - HCP Certifications A combination of chest compressions and ventilation resulted in better outcomes than ventilation or compressions alone in piglet studies. For newborns who are breathing, continuous positive airway pressure can help with labored breathing or persistent cyanosis. 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). The American Heart Association released minor updates to neonatal resuscitation recommendations with only minor changes to the previous algorithm (Figure 1). Hand position is correct. When providing chest compressions in a newborn, it may be reasonable to repeatedly deliver 3 compressions followed by an inflation (3:1 ratio). Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Babies who have failed to respond to PPV and chest compressions require vascular access to infuse epinephrine and/or volume expanders. In circumstances of altered or impaired transition, effective neonatal resuscitation reduces the risk of mortality and morbidity. In a randomized controlled simulation study, medical students who underwent booster training retained improved neonatal intubation skills over a 6-week period compared with medical students who did not receive booster training. You administer 10 mL/kg of normal saline (based on the newborn's estimated weight). 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. Copyright 2023 American Academy of Family Physicians. Evidence for optimal dose, timing, and route of administration of epinephrine during neonatal resuscitation comes largely from extrapolated adult or animal literature. Suctioning may be considered for suspected airway obstruction. 7272 Greenville Ave. Other recommendations include confirming endotracheal tube placement using an exhaled carbon dioxide detector; using less than 100 percent oxygen and adequate thermal support to resuscitate preterm infants; and using therapeutic hypothermia for infants born at 36 weeks' gestation or later with moderate to severe hypoxic-ischemic encephalopathy. In babies who appear to have ineffective respiratory effort after birth, tactile stimulation is reasonable. Hyperlinked references are provided to facilitate quick access and review. In animal studies (very low quality), the use of alterative compression-to-inflation ratios to 3:1 (eg, 2:1, 4:1, 5:1, 9:3, 15:2, and continuous chest compressions with asynchronous PPV) are associated with similar times to ROSC and mortality rates. 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. For neonatal resuscitation providers, it may be reasonable to brief before delivery and debrief after neonatal resuscitation. Expert neonatal and bioethical committees have agreed that, in certain clinical conditions, it is reasonable not to initiate or to discontinue life-sustaining efforts while continuing to provide supportive care for babies and families.1,2,4, If the heart rate remains undetectable and all steps of resuscitation have been completed, it may be reasonable to redirect goals of care. 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. 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. Team training remains an important aspect of neonatal resuscitation, including anticipation, preparation, briefing, and debriefing. Consequently, all newly born babies should be attended to by at least 1 person skilled and equipped to provide PPV. Effective team behaviors, such as anticipation, communication, briefing, equipment checks, and assignment of roles, result in improved team performance and neonatal outcome. For term and preterm infants who require resuscitation at birth, there is insufficient evidence to recommend early cord clamping versus delayed cord clamping. In term and late preterm newborns (35 wk or more of gestation) receiving respiratory support at birth, the initial use of 21% oxygen is reasonable. 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. NRP 7th edition part 2 - Subjecto.com 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. Identification of risk factors for resuscitation may indicate the need for additional personnel and equipment. Providing PPV at a rate of 40 to 60 inflations per minute is based on expert opinion. You have administered epinephrine intravenously. There should be ongoing evaluation of the baby for normal respiratory transition. 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. Provide chest compressions if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. 1-800-242-8721 Rate is 40 - 60/min. 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. In newly born babies receiving resuscitation, if there is no heart rate and all the steps of resuscitation have been performed, cessation of resuscitation efforts should be discussed with the team and the family. Unauthorized use prohibited. In small hospitals, a nonphysician neonatal resuscitation team is one way of providing in-house coverage at all hours. 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. When feasible, well-designed multicenter randomized clinical trials are still optimal to generate the highest-quality evidence. Every healthy newly born baby should have a trained and equipped person assigned to facilitate transition. 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 . 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. Normal saline (0.9% sodium chloride) is the crystalloid fluid of choice. 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. When should i check heart rate after epinephrine? It is recommended to begin resuscitation with 21 percent oxygen, and increase the concentration of oxygen (using an air/oxygen blender) if oxygen saturation is low57 (see Figure 1). The airway is cleared (if necessary), and the infant is dried. 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. Preterm and term newborns without good muscle tone or without breathing and crying should be brought to the radiant warmer for resuscitation. Resuscitation of an infant with respiratory depression (term and preterm) in the delivery room (Figure 1) focuses on airway, breathing, circulation, and medications. 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. 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. When should you check heart rate in neonatal resuscitation? 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 wet cloth beneath the infant is changed.5 Respiratory effort is assessed to see if the infant has apnea or gasping respiration, and the heart rate is counted by feeling the umbilical cord pulsations or by auscultating the heart for six seconds (e.g., heart rate of six in six seconds is 60 beats per minute [bpm]). Neonatal Resuscitation: An Update | AAFP 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. To start, 21% to 30% oxygen should be used in these newborns, titrating up based on oxygen saturation. 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. Although this flush volume may . Attaches oxygen set at 10-15 lpm. . Administer epinephrine, preferably intravenously, if response to chest compressions is poor. The heart rate response to chest compressions and medications should be monitored electrocardiographically. Reviews in 2021 and later will address choice of devices and aids, including those required for ventilation (T-piece, self-inflating bag, flow-inflating bag), ventilation interface (face mask, laryngeal mask), suction (bulb syringe, meconium aspirator), monitoring (respiratory function monitors, heart rate monitoring, near infrared spectroscopy), feedback, and documentation. 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)). All Rights Reserved. There is a reduction of mortality and no evidence of harm in term infants resuscitated with 21 percent compared with 100 percent oxygen. The usefulness of positive end-expiratory pressure during PPV for term infant resuscitation has not been studied.6 A recent study showed that use of mask continuous positive airway pressure for resuscitation and treatment of respiratory distress syndrome in spontaneously breathing preterm infants reduced the need for intubation and subsequent mechanical ventilation without increasing the risk of bronchopulmonary dysplasia or death.29 In a preterm infant needing PPV, a PIP of 20 to 25 cm H2O may be adequate to increase heart rate while avoiding a higher PIP to prevent injury to preterm lungs, and positive end-expiratory pressure may be beneficial if suitable equipment is available.6. The International Liaison Committee on Resuscitation (ILCOR) Formula for Survival emphasizes 3 essential components for good resuscitation outcomes: guidelines based on sound resuscitation science, effective education of resuscitation providers, and implementation of effective and timely resuscitation.8 The 2020 neonatal guidelines contain recommendations, based on the best available resuscitation science, for the most impactful steps to perform in the birthing room and in the neonatal period. Volunteers with recognized expertise in resuscitation are nominated by the writing group chair and selected by the AHA ECC Committee. Neonatal Resuscitation: Updated Guidelines from the American Heart This article has been copublished in Pediatrics. A brief introduction or short synopsis is provided to put the recommendations into context with important background information and overarching management or treatment concepts. 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. Recommendation-specific text clarifies the rationale and key study data supporting the recommendations. Early skin-to-skin contact benefits healthy newborns who do not require resuscitation by promoting breastfeeding and temperature stability. During 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. 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 None of these studies evaluate outcomes of resuscitation that extends beyond 20 minutes of age, by which time the likelihood of intact survival was very low. Birth 1 minute If HR remains <60 bpm, Consider hypovolemia. 7. 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. While this research has led to substantial improvements in the Neonatal Resuscitation Algorithm, it has also highlighted that we still have more to learn to optimize resuscitation for both preterm and term infants. Comprehensive disclosure information for writing group members is listed in Appendix 1(link opens in new window). 1 minuteb. 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. The heart rate should be re-checked after 1 minute of giving compressions and ventilations. No type of routine suctioning is helpful, even for nonvigorous newborns delivered through meconium-stained amniotic fluid. Rapid and effective response and performance are critical to good newborn outcomes. Case series in preterm infants have found that most preterm infants can be resuscitated using PPV inflation pressures in the range of 20 to 25 cm H. An observational study including 1962 infants between 23 and 33 weeks gestational age reported lower rates of mortality and chronic lung disease when giving PPV with PEEP versus no PEEP. During resuscitation, supplemental oxygen may be provided to prevent harm from inadequate oxygen supply to tissues (hypoxemia).4 However, overexposure to oxygen (hyperoxia) may be associated with harm.5, Term and late preterm newborns have lower shortterm mortality when respiratory support during resuscitation is started with 21% oxygen (air) versus 100% oxygen.1 No difference was found in neurodevelopmental outcome of survivors.1 During resuscitation, pulse oximetry may be used to monitor oxygen saturation levels found in healthy term infants after vaginal birth at sea level.3, In more preterm newborns, there were no differences in mortality or other important outcomes when respiratory support was started with low (50% or less) versus high (greater than 50%) oxygen concentrations.2 Given the potential for harm from hyperoxia, it may be reasonable to start with 21% to 30% oxygen.