Positive-pressure ventilation (PPV) remains the main intervention in neonatal resuscitation. 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. The most important priority for newborn survival is the establishment of adequate lung inflation and ventilation after birth. Adaptive trials, comparative effectiveness designs, and those using cluster randomization may be suitable for some questions, such as the best approach for MSAF in nonvigorous infants. 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. In one RCT and one observational study, there were no reports of technical difficulties with ECG monitoring during neonatal resuscitation, supporting its feasibility as a tool for monitoring heart rate during neonatal resuscitation. In preterm birth, there are also potential advantages from delaying cord clamping. Author disclosure: No relevant financial affiliations. Newly born infants who receive prolonged PPV or advanced resuscitation (intubation, chest compressions, or epinephrine) should be maintained in or transferred to an environment where close monitoring can be provided. ** 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: 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. Resuscitation of an infant with respiratory depression (term and preterm) in the delivery room (Figure 1) focuses on airway, breathing, circulation, and medications. Most changes are related to program administration and course facilitation. If a birth is at the lower limit of viability or involves a condition likely to result in early death or severe morbidity, noninitiation or limitation of neonatal resuscitation is reasonable after expert consultation and parental involvement in decision-making. 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. 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. Consider pneumothorax. After chest compressions are performed for at least 2 minutes When an alternative airway is inserted Immediately after epinephrine is administered Effective and timely resuscitation at birth could therefore improve neonatal outcomes further. 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. Effective team behaviors, such as anticipation, communication, briefing, equipment checks, and assignment of roles, result in improved team performance and neonatal outcome. Circulation. 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. There are long-standing worldwide recommendations for routine temperature management for the newborn. TALKAD S. RAGHUVEER, MD, AND AUSTIN J. COX, MD. Early skin-to-skin contact benefits healthy newborns who do not require resuscitation by promoting breastfeeding and temperature stability. Copyright 2021 by the American Academy of Family Physicians. However, if heart rate remains less than 60/min after ventilating with 100% oxygen (preferably through an endotracheal tube) and chest compressions, administration of epinephrine is indicated. Hyperlinked references are provided to facilitate quick access and review. Intrapartum suctioning is not recommended in infants born through meconium-stained amniotic fluid. Team debrieng. Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. 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. When vascular access is required in the newly born, the umbilical venous route is preferred. Delayed umbilical cord clamping was recommended for both term and preterm neonates in 2015. Once the heart rate increases to more than 60 bpm, chest compressions are stopped. Most babies will respond to this intervention. Teams and individuals who provide neonatal resuscitation are faced with many challenges with respect to the knowledge, skills, and behaviors needed to perform effectively. These guidelines apply primarily to the newly born baby who is transitioning from the fluid-filled womb to the air-filled room. Administration of epinephrine via a low-lying umbilical venous catheter provides the most rapid and reliable medication delivery. Monday - Friday: 7 a.m. 7 p.m. CT You administer 10 mL/kg of normal saline (based on the newborn's estimated weight). 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). Early cord clamping (within 30 seconds) may interfere with healthy transition because it leaves fetal blood in the placenta rather than filling the newborns circulating volume. Title: Microsoft PowerPoint - CPS GR Final Author: JackieM Created Date: 9/10/2021 9:22:37 PM In term and late preterm newborns (35 wk or more of gestation) receiving respiratory support at birth, 100% oxygen should not be used because it is associated with excess mortality. Appropriate resuscitation must be available for each of the more than 4 million infants born annually in the United States. Equipment checklists, role assignments, and team briefings improve resuscitation performance and outcomes. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. For infants born at less than 28 wk of gestation, cord milking is not recommended. minutes, and 80% at 5 minutes of life. 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. Noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation should be considered ethically equivalent. Positive-Pressure Ventilation (PPV) Readers are directed to the AHA website for the most recent guidance.12, The following sections briefly describe the process of evidence review and guideline development. Prevention of hyperthermia (temperature greater than 38C) is reasonable due to an increased risk of adverse outcomes. Part 2: Evidence Evaluation and Guidelines Development, Part 3: Adult Basic and Advanced Life Support, Part 4: Pediatric Basic and Advanced Life Support, Part 9: COVID-19 Interim Guidance for Healthcare Providers, Part 10: COVID-19 Interim Guidance for EMS, 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. 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. Use of CPAP for resuscitating term infants has not been studied. Clinical assessment of heart rate has been found to be both unreliable and inaccurate. In newly born infants who are gasping or apneic within 60 s after birth or who are persistently bradycardic (heart rate less than 100/min) despite appropriate initial actions (including tactile stimulation), PPV should be provided without delay. 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. Epinephrine use in the delivery room for resuscitation of the newborn is associated with significant morbidity and mortality. Rapid and effective response and performance are critical to good newborn outcomes. In a case series, endotracheal epinephrine (0.01 mg per kg) was less effective than intravenous epinephrine. However, it may be reasonable to increase inspired oxygen to 100% if there was no response to PPV with lower concentrations. A randomized trial showed that endotracheal suctioning of vigorous. 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. 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. High oxygen concentrations are recommended during chest compressions based on expert opinion. It may be reasonable to administer a volume expander to newly born infants with suspected hypovolemia, based on history and physical examination, who remain bradycardic (heart rate less than 60/min) despite ventilation, chest compressions, and epinephrine. Attaches oxygen set at 10-15 lpm. In addition, specific recommendations about the training of resuscitation providers and systems of care are provided in their respective guideline Parts.9,10. 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. 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. Pulse oximetry tended to underestimate the newborn's heart rate. 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. Flush the UVC with normal saline. Once return of spontaneous circulation (ROSC) is achieved, the supplemental oxygen concentration may be decreased to target a physiological level based on pulse oximetry to reduce the risks associated with hyperoxia.1,2. In preterm newly born infants, the routine use of sustained inflations to initiate resuscitation is potentially harmful and should not be performed. For every 30 seconds that ventilation is delayed, the risk of prolonged admission or death increases by 16%. 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. Approximately 10% of infants require help to begin breathing at birth, and 1% need intensive resuscitation. If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route. When possible, healthy term babies should be managed skin-to-skin with their mothers. 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. Each 2020 AHA Guidelines for CPR and ECC document was submitted for blinded peer review to 5 subject matter experts nominated by the AHA. Administer epinephrine, preferably intravenously, if response to chest compressions is poor. One moderate quality RCT found higher rates of hyperthermia with exothermic mattresses. The following sections are worth special attention. 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 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. Approximately 10% of newborns require assistance to breathe after birth.13,5,13 Newborn resuscitation requires training, preparation, and teamwork. Therapeutic hypothermia is provided under defined protocols similar to those used in published clinical trials and in facilities capable of multidisciplinary care and longitudinal follow-up. 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. Compared with preterm infants receiving early cord clamping, those receiving delayed cord clamping were less likely to receive medications for hypotension in a meta-analysis of 6 RCTs. How soon after administration of intravenous epinephrine should you pause compressions and assess the baby's heart rate?a. The potential benefit or harm of sustained inflations between 1 and 10 seconds is uncertain.2,29. When providing chest compressions in a newborn, it may be reasonable to repeatedly deliver 3 compressions followed by an inflation (3:1 ratio). Naloxone and sodium bicarbonate are rarely needed and are not recommended during neonatal resuscitation. For nonvigorous newborns delivered through MSAF who have evidence of airway obstruction during PPV, intubation and tracheal suction can be beneficial. Positive pressure ventilation should be provided at 40 to 60 inflations per minute with peak inflation pressures up to 30 cm of water in term newborns and 20 to 25 cm of water in preterm infants. Delayed cord clamping is associated with higher hematocrit after birth and better iron levels in infancy.921 While developmental outcomes have not been adequately assessed, iron deficiency is associated with impaired motor and cognitive development.2426 It is reasonable to delay cord clamping (longer than 30 seconds) in preterm babies because it reduces need for blood pressure support and transfusion and may improve survival.18, There are insufficient studies in babies requiring PPV before cord clamping to make a recommendation.22 Early cord clamping should be considered for cases when placental transfusion is unlikely to occur, such as maternal hemorrhage or hemodynamic instability, placental abruption, or placenta previa.27 There is no evidence of maternal harm from delayed cord clamping compared with early cord clamping.1012,2834 Cord milking is being studied as an alternative to delayed cord clamping but should be avoided in babies less than 28 weeks gestational age, because it is associated with brain injury.23, Temperature should be measured and recorded after birth and monitored as a measure of quality.1 The temperature of newly born babies should be maintained between 36.5C and 37.5C.2 Hypothermia (less than 36C) should be prevented as it is associated with increased neonatal mortality and morbidity, especially in very preterm (less than 33 weeks) and very low-birthweight babies (less than 1500 g), who are at increased risk for hypothermia.35,7 It is also reasonable to prevent hyperthermia as it may be associated with harm.4,6, Healthy babies should be skin-to-skin after birth.8 For preterm and low-birth-weight babies or babies requiring resuscitation, warming adjuncts (increased ambient temperature [greater than 23C], skin-to-skin care, radiant warmers, plastic wraps or bags, hats, blankets, exothermic mattresses, and warmed humidified inspired gases)10,11,14 individually or in combination may reduce the risk of hypothermia. Copyright 2023 American Academy of Family Physicians. Post-resuscitation care. Breathing: Assist breathing with PPV if baby apneic, gasping, or bradycardic. Routine oral, nasal, oropharyngeal, or endotracheal suctioning of newly born babies is not recommended. The heart rate should be re-checked after 1 minute of giving compressions and ventilations. Available for purchase at https://shop.aap.org/textbook-of-neonatal-resuscitation-8th-edition-paperback/ (NOTE: This book features a full text reading experience. The use of radiant warmers, plastic bags and wraps (with a cap), increased room temperature, and warmed humidified inspired gases can be effective in preventing hypothermia in preterm babies in the delivery room. 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. National Center . Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion. The AAP released the 8th edition of the Neonatal Resuscitation Program in June 2021. One RCT (low certainty of evidence) suggests improved oxygenation after resuscitation in preterm babies who received repeated tactile stimulation. NRP Advanced is suited for health care professionals who serve as members of the resuscitation team in the delivery room or in other settings where complex neonatal resuscitation is required. A multicenter randomized trial showed that intrapartum suctioning of meconium does not reduce the risk of meconium aspiration syndrome. Peer reviewer feedback was provided for guidelines in draft format and again in final format. monitored. 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 . Prevention of hypothermia continues to be an important focus for neonatal resuscitation. To start, 21% to 30% oxygen should be used in these newborns, titrating up based on oxygen saturation. A new Resuscitation Quality Improvement (RQI) program for NRP focused on PPV will be . For participants who have been trained in neonatal resuscitation, individual or team booster training should occur more frequently than every 2 yr at a frequency that supports retention of knowledge, skills, and behaviors. Suctioning may be considered if PPV is required and the airway appears obstructed. Oximetry and electrocardiography are important adjuncts in babies requiring resuscitation. Suctioning may be considered for suspected airway obstruction. There is a reduction of mortality and no evidence of harm in term infants resuscitated with 21 percent compared with 100 percent oxygen. One observational study compared neonatal outcomes before (historical cohort) and after implementation of ECG monitoring in the delivery room. 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. Animal studies in newborn mammals show that heart rate decreases during asphyxia. Limited observational studies suggest that tactile stimulation may improve respiratory effort. Various combinations of warming strategies (or bundles) may be reasonable to prevent hypothermia in very preterm babies. The primary objective of neonatal resuscitation is effective ventilation; an increase in heart rate indicates effective ventilation. Multiple clinical and simulation studies examining briefings or debriefings of resuscitation team performance have shown improved knowledge or skills.812. Tactile stimulation should be limited to drying an infant and rubbing the back and soles of the feet.21,22 There may be some benefit from repeated tactile stimulation in preterm babies during or after providing PPV, but this requires further study.23 If, at initial assessment, there is visible fluid obstructing the airway or a concern about obstructed breathing, the mouth and nose may be suctioned. When feasible, well-designed multicenter randomized clinical trials are still optimal to generate the highest-quality evidence. A large observational study found that delaying PPV increases risk of death and prolonged hospitalization. Numerous nonrandomized quality improvement (very low to low certainty) studies support the use of warming adjunct bundles.. 1 minuteb. 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. Heart rate is assessed initially by auscultation and/or palpation. Hypothermia after birth is common worldwide, with a higher incidence in babies of lower gestational age and birth weight. 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. If it is possible to identify such conditions at or before birth, it is reasonable not to initiate resuscitative efforts. Team briefings promote effective teamwork and communication, and support patient safety.8,1012, During an uncomplicated term or late preterm birth, it may be reasonable to defer cord clamping until after the infant is placed on the mother and assessed for breathing and activity. Contact Us, Hours Oximetry is used to target the natural range of oxygen saturation levels that occur in term babies. 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. After birth, the baby should be dried and placed directly skin-to-skin with attention to warm coverings and maintenance of normal temperature. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.
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nrp check heart rate after epinephrine