The practice test consists of 10 multiple-choice questions that adhere to the latest ILCOR standards. The exhaled carbon dioxide detector changes from purple to yellow with endotracheal intubation, and a negative result suggests esophageal intubation.5,6,25 Clinical indicators of endotracheal intubation, such as condensation in the tube, chest wall movement, or presence of bilateral equal breath sounds, have not been well studied. Teams and individuals who provide neonatal resuscitation are faced with many challenges with respect to the knowledge, skills, and behaviors needed to perform effectively. Consequently, all newly born babies should be attended to by at least 1 person skilled and equipped to provide PPV. Hand position is correct. Reduce the inflation pressure if the chest is moving well. Hypothermia after birth is common worldwide, with a higher incidence in babies of lower gestational age and birth weight. A systematic review (low to moderate certainty) of 6 RCTs showed that early skin-to-skin contact promotes normothermia in healthy neonates. During A multicenter, case-control study identified 10 perinatal risk factors that predict the need for advanced neonatal resuscitation. 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. 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. "Epinephrine is indicated when the heart rate remains below 60 beats per minute after you have given 30 seconds of effective assisted ventilation (preferably after endotracheal intubation) and at least another 45 to 60 seconds of coordinated chest compressions and effective ventilation." (p 219) 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. The recommended route is intravenous, with the intraosseous route being an alternative. 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. See permissionsforcopyrightquestions and/or permission requests. Provide chest compressions if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. 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. Higher doses (0.05 to 0.1 mg per kg) of endotracheal epinephrine are needed to achieve an increase in blood epinephrine concentration. 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. Cord milking in preterm infants should be avoided because of increased risk of intraventricular hemorrhage. 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. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion. 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. Term newborns with good muscle tone who are breathing or crying should be brought to their mother's chest routinely. 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. Clinical assessment of heart rate has been found to be both unreliable and inaccurate. Recommendation-specific text clarifies the rationale and key study data supporting the recommendations. Please contact the American Heart Association at ECCEditorial@heart.org or 1-214-706-1886 to request a long description of . Hypothermia (temperature less than 36C) should be prevented due to an increased risk of adverse outcomes. Exothermic mattresses may be effective in preventing hypothermia in preterm babies. Delaying cord clamping for more than 30 seconds is reasonable for term and preterm infants who do not require resuscitation. Umbilical venous catheterization has been the accepted standard route in the delivery room for decades. Part 5: neonatal resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Before every birth, a standardized equipment checklist should be used to ensure the presence and function of supplies and equipment necessary for a complete resuscitation. Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent. Uncrossmatched type O, Rh-negative blood (or crossmatched, if immediately available) is preferred when blood loss is substantial.4,5 An initial volume of 10 mL/kg over 5 to 10 minutes may be reasonable and may be repeated if there is inadequate response. 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 In a case series, endotracheal epinephrine (0.01 mg per kg) was less effective than intravenous epinephrine. Electrocardiography detects the heart rate faster and more accurately than a pulse oximeter. If intravenous access is not feasible, it may be reasonable to use the intraosseous route. Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth. 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. 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. Supplemental oxygen: 100 vs. 21 percent (room air). You administer 10 mL/kg of normal saline (based on the newborn's estimated weight). IV epinephrine If HR persistently below 60/min Consider hypovolemia Consider pneumothorax HR below 60/min? If the infant's heart rate is less than 100 beats per minute and/or the infant has apnea or gasping respiration, positive pressure ventilation via face mask should be initiated with 21 percent oxygen (room air) or blended oxygen using a self-inflating bag, flow-inflating bag, or T-piece device while monitoring the inflation pressure. Median time to ROSC and cumulative epinephrine dose required were not different. 2020;142(suppl 2):S524S550. diabetes. Check the heart rate by counting the beats in 6 seconds and multiply by 10. Rescuer 2 verbalizes the need for chest compressions. 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. 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. In addition, specific recommendations about the training of resuscitation providers and systems of care are provided in their respective guideline Parts.9,10. Immediate, unlimited access to all AFP content, Immediate, unlimited access to this issue's content. increase in the newborn's heart rate is the most sensitive indicator of a successful response to resuscitation. Ventilation should be optimized before starting chest compressions, possibly including endotracheal intubation. Intra-arterial epinephrine is not recommended. 2023 American Heart Association, Inc. All rights reserved. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. Title: Microsoft PowerPoint - CPS GR Final Author: JackieM Created Date: 9/10/2021 9:22:37 PM 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. Recent clinical trials have shown that infants resuscitated with 21 percent oxygen compared with 100 percent oxygen had significantly lower mortality (at one week and one month) and were able to establish regular respiration in a shorter time; the rates of encephalopathy and cerebral palsy were similar in the two groups.4549 The 2010 NRP guidelines recommend starting resuscitation of term infants with 21 percent oxygen or blended oxygen and increasing the concentration of oxygen (using an air/oxygen blender) if oxygen saturation (measured using a pulse oximeter) is lower than recommended targets (Figure 1).5 Oxygen concentration should be increased to 100 percent if the heart rate is less than 60 bpm despite effective ventilation, and when chest compressions are necessary.57, If the infant's heart rate is less than 60 bpm, the delivery of PPV is optimized and applied for 30 seconds. There should be ongoing evaluation of the baby for normal respiratory transition. Prevention of hyperthermia (temperature greater than 38C) is reasonable due to an increased risk of adverse outcomes. Studies of newly born animals showed that PEEP facilitates lung aeration and accumulation of functional residual capacity, prevents distal airway collapse, increases lung surface area and compliance, decreases expiratory resistance, conserves surfactant, and reduces hyaline membrane formation, alveolar collapse, and the expression of proinflammatory mediators. Copyright 2011 by the American Academy of Family Physicians. 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. Suctioning may be considered for suspected airway obstruction. Important aspects of neonatal resuscitation are the hospital policy and planning that ensure necessary equipment and personnel are present before delivery.1 Anticipation and preparation are essential elements for successful resuscitation,18 and this requires timely and accurate communication between the obstetric team and the neonatal resuscitation team. Once the heart rate increases to more than 60 bpm, chest compressions are stopped. Volunteers with recognized expertise in resuscitation are nominated by the writing group chair and selected by the AHA ECC Committee. One RCT (low certainty of evidence) suggests improved oxygenation after resuscitation in preterm babies who received repeated tactile stimulation. 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. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Heart rate is assessed initially by auscultation and/or palpation. The studies were too heterogeneous to be amenable to meta-analysis. Newborn resuscitation requires anticipation and preparation by providers who train individually and as teams. For neonatal resuscitation providers, it may be reasonable to brief before delivery and debrief after neonatal resuscitation. Administration of epinephrine via a low-lying umbilical venous catheter provides the most rapid and reliable medication delivery.