Each 2020 AHA Guidelines for CPR and ECC document was submitted for blinded peer review to 5 subject matter experts nominated by the AHA. Resuscitation of an infant with respiratory depression (term and preterm) in the delivery room (Figure 1) focuses on airway, breathing, circulation, and medications. The heart rate should be re-checked after 1 minute of giving compressions and ventilations. Pulse oximetry tended to underestimate the newborn's heart rate. 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. A multicenter, case-control study identified 10 perinatal risk factors that predict the need for advanced neonatal resuscitation. 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. 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. 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. 7. 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. What is true about a pneumothorax in the newborn? This is partly due to the challenges of performing large randomized controlled trials (RCTs) in the delivery room. In small hospitals, a nonphysician neonatal resuscitation team is one way of providing in-house coverage at all hours. Before using epinephrine, tell your doctor if any past use of epinephrine injection caused an allergic reaction to get worse. The initiation of chest compressions in newborn babies with a heart rate less than 60/min is based on expert opinion because there are no clinical or physiological human studies addressing this question. A systematic review (low to moderate certainty) of 6 RCTs showed that early skin-to-skin contact promotes normothermia in healthy neonates. Hyperlinked references are provided to facilitate quick access and review. Gaps in this domain, whether perceived or real, should be addressed at every stage in our research, educational, and clinical activities. High-quality observational studies of large populations may also add to the evidence. In preterm infants, delaying clamping reduces the need for vasopressors or transfusions. increase in the newborn's heart rate is the most sensitive indicator of a successful response to resuscitation. The heart rate should be re- checked after 1 minute of giving compressions and ventilations. 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. Oximetry is used to target the natural range of oxygen saturation levels that occur in term babies. During chest compressions, an ECG should be used for the rapid and accurate assessment of heart rate. Stimulation may be provided to facilitate respiratory effort. 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. Test your knowledge with our free Neonatal Resuscitation Practice Test provided below in order to prepare you for our official online exam. Most babies will respond to this intervention. 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. Peer reviewer feedback was provided for guidelines in draft format and again in final format. If resuscitation is required, electrocardiography should be used, especially with chest compressions. "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) Median time to ROSC and cumulative epinephrine dose required were not different. 1-800-AHA-USA-1 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)). 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. There was no difference in Apgar scores or blood gas with naloxone compared with placebo. A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide. Most newly born infants do not require immediate cord clamping or resuscitation and can be evaluated and monitored during skin-to-skin contact with their mothers after birth. Intravenous epinephrine is preferred because. The benefit of 100% oxygen compared with 21% oxygen (air) or any other oxygen concentration for ventilation during chest compressions is uncertain. Evidence suggests that warming can be done rapidly (0.5C/h) or slowly (less than 0.5C/h) with no significant difference in outcomes.1519 Caution should be taken to avoid overheating. See Part 2: Evidence Evaluation and Guidelines Development for more details on this process.11. In a case series, endotracheal epinephrine (0.01 mg per kg) was less effective than intravenous epinephrine. Care (Updated May 2019)*, 2020 Advanced Cardiovascular Life Support (ACLS), 2020 Pediatric Advanced Life Support (PALS), 2015 Pediatric Emergency Assessment and Recognition, Conflicts of Interest and Ethics Policies, Advanced Cardiovascular Life Support (ACLS), CPR & First Aid in Youth Sports Training Kit, Resuscitation Quality Improvement Program (RQI), COVID-19 Resources for CPR & Resuscitation, Claiming Your AHA Continuing Education Credits, International Liaison Committee on Resuscitation. 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. Before appointment, all peer reviewers were required to disclose relationships with industry and any other potential conflicts of interest, and all disclosures were reviewed by AHA staff. 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. 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. 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. 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).
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