This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. Neonatal resuscitation teams may therefore benefit from ongoing booster training, briefing, and debriefing. 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. 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. Intravenous epinephrine is preferred because. 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. Exothermic mattresses have been reported to cause local heat injury and hyperthermia.15, When babies are born in out-of-hospital, resource-limited, or remote settings, it may be reasonable to prevent hypothermia by using a clean food-grade plastic bag13 as an alternative to skin-to-skin contact.8. There was no difference in neonatal intubation performance after weekly booster practice for 4 weeks compared with daily booster practice for 4 consecutive days. 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. The current guidelines have focused on clinical activities described in the resuscitation algorithm, rather than on the most appropriate devices for each step. Teams and individuals who provide neonatal resuscitation are faced with many challenges with respect to the knowledge, skills, and behaviors needed to perform effectively. If intravenous access is not feasible, it may be reasonable to use the intraosseous route. Compared with term infants receiving early cord clamping, term infants receiving delayed cord clamping had increased hemoglobin concentration within the first 24 hours and increased ferritin concentration in the first 3 to 6 months in meta-analyses of 12 and 6 RCTs. 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. Author disclosure: No relevant financial affiliations. If the infant needs PPV, the recommended approach is to monitor the inflation pressure and to initiate PPV using a peak inspiratory pressure (PIP) of 20 cm H2O for the first few breaths; however, a PIP of 30 to 40 cm H2O (in some term infants) may be required at a rate of 40 to 60 breaths per minute.5,6 The best measure of adequate ventilation is prompt improvement in heart rate.24 Auscultation of the precordium is the primary means of assessing heart rate, but for infants requiring respiratory support, pulse oximetry is recommended.5,6 However, if the heart rate does not increase with mask PPV and there is no chest rise, ventilation should be optimized by implementing the following six steps: (1) adjust the mask to ensure a good seal; (2) reposition the airway by adjusting the position of the head; (3) suction the secretions in the mouth and nose; (4) open the mouth slightly and move the jaw forward; (5) increase the PIP enough to move the chest; and (6) consider an alternate airway (endotracheal intubation or laryngeal mask airway).5 PIP may be decreased when the heart rate increases to more than 60 bpm, and PPV may be discontinued once the heart rate is more than 100 bpm and there is spontaneous breathing. The goal should be to achieve oxygen saturation targets shown in Figure 1.5,6, When chest compressions are indicated, it is recommended to use a 3:1 ratio of compressions to ventilation.57, Chest compressions in infants should be delivered by using two thumbs, with the fingers encircling the chest and supporting the back, and should be centered over the lower one-third of the sternum.5,6, If the infant's heart rate is less than 60 bpm after adequate ventilation and chest compressions, epinephrine at 0.01 to 0.03 mg per kg (1:10,000 solution) should be given intravenously. Animal studies in newborn mammals show that heart rate decreases during asphyxia. 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. 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. After 30 seconds, Rescuer 2 evaluates heart rate. The 7th edition of the Textbook of Neonatal Resuscitation recommends 0.5-mL to 1-mL flush following IV epinephrine (0.01 to 0.03 mg/kg dose) via a low-lying UVC [6]. 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. Additional personnel are necessary if risk factors for complicated resuscitation are present. It is important to continue PPV and chest compressions while preparing to deliver medications. 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). Each of these resulted in a description of the literature that facilitated guideline development.1417, Each AHA writing group reviewed all relevant and current AHA guidelines for CPR and ECC1820 and all relevant 2020 ILCOR International Consensus on CPR and ECC Science With Treatment Recommendations evidence and recommendations21 to determine if current guidelines should be reaffirmed, revised, or retired, or if new recommendations were needed. 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. Historically, the repeat training has occurred every 2 years.69 However, adult, pediatric, and neonatal studies suggest that without practice, CPR knowledge and skills decay within 3 to 12 months1012 after training. 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. 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. If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route. Provide chest compressions if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. Newly born infants with abnormal glucose levels (both low and high) are at increased risk for brain injury and adverse outcomes after a hypoxic-ischemic insult. When feasible, well-designed multicenter randomized clinical trials are still optimal to generate the highest-quality evidence. When do chest compressions stop NRP? Current resuscitation guidelines recommend that epinephrine should be used if the newborn remains bradycardic with heart rate <60 bpm after 30 s of what appears to be effective ventilation with chest rise, followed by 30 s of coordinated chest compressions and ventilations (1, 8, 9). During an uncomplicated delivery, the newborn transitions from the low oxygen environment of the womb to room air (21% oxygen) and blood oxygen levels rise over several minutes. 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. A team or persons trained in neonatal resuscitation should be promptly available to provide resuscitation. Prevention of hyperthermia (temperature greater than 38C) is reasonable due to an increased risk of adverse outcomes. The following sections are worth special attention. In term and preterm newly born infants, it is reasonable to initiate PPV with an inspiratory time of 1 second or less. 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. 1-800-AHA-USA-1 Your team is caring for a term newborn whose heart rate is 50 bpm after receiving effective ventilation, chest compressions, and intravenous epinephrine administration. increase in the newborn's heart rate is the most sensitive indicator of a successful response to resuscitation. 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. 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 American Heart Association requests that this document be cited as follows: Aziz K, Lee HC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmolzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. Outside the delivery room, or if intravenous access is not feasible, the intraosseous route may be a reasonable alternative, determined by the local availability of equipment, training, and experience.
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