Attaches oxygen set at 10-15 lpm. doi: 10.1161/ CIR.0000000000000902. Chest compressions should be started if the heart rate remains less than 60/min after at least 30 seconds of adequate PPV.1, Oxygen is essential for organ function; however, excess inspired oxygen during resuscitation may be harmful. 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)). The chest compression technique of using two thumbs, with the fingers encircling the chest and supporting the back, achieved better results in swine models compared with the technique of using two fingers, with a second hand supporting the back. 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. 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. Establishing ventilation is the most important step to correct low heart rate. The temperature of newly born babies should be maintained between 36.5C and 37.5C after birth through admission and stabilization. Initiate effective PPV for 30 seconds and reassess the heart rate. 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. It is reasonable to perform all resuscitation procedures, including endotracheal intubation, chest compressions, and insertion of intravenous lines with temperature-controlling interventions in place. Excessive peak inflation pressures are potentially harmful and should be avoided. Infants with unintentional hypothermia (temperature less than 36C) immediately after stabilization should be rewarmed to avoid complications associated with low body temperature (including increased mortality, brain injury, hypoglycemia, and respiratory distress). A 3:1 ratio of compressions to ventilation provided more ventilations than higher ratios in manikin studies. 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. In circumstances of altered or impaired transition, effective neonatal resuscitation reduces the risk of mortality and morbidity. The dosage interval for epinephrine is every 3 to 5 minutes if the heart rate remains less than 60/min, although an intravenous dose may be given as soon as umbilical access is obtained if response to endotracheal epinephrine has been inadequate. Limited observational studies suggest that tactile stimulation may improve respiratory effort. 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. Positive pressure ventilation should be delivered without delay to infants who are apneic, gasping, or have a heart rate below 100 beats per minute within the first 60 seconds of life despite initial resuscitation. Before giving PPV, the airway should be cleared by gently suctioning the mouth first and then the nose with a bulb syringe. Therapeutic hypothermia is recommended in infants born at 36 weeks' gestation or later with evolving moderate to severe hypoxic-ischemic encephalopathy. Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth. Electrocardiography detects the heart rate faster and more accurately than a pulse oximeter. 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 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. There should be ongoing evaluation of the baby for normal respiratory transition. A multicenter randomized trial showed that intrapartum suctioning of meconium does not reduce the risk of meconium aspiration syndrome. What is true about a pneumothorax in the newborn? Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent. Other important goals include establishment and maintenance of cardiovascular and temperature stability as well as the promotion of mother-infant bonding and breast feeding, recognizing that healthy babies transition naturally. Normal saline (0.9% sodium chloride) is the crystalloid fluid of choice. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. The heart rate should be verbalized for the team. Resuscitation of an infant with respiratory depression (term and preterm) in the delivery room (Figure 1) focuses on airway, breathing, circulation, and medications. 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. Newer methods of chest compression, using a sustained inflation that maintains lung inflation while providing chest compressions, are under investigation and cannot be recommended at this time outside research protocols.12,13. One observational study in newly born infants associated high tidal volumes during resuscitation with brain injury. Neonatal resuscitation teams may therefore benefit from ongoing booster training, briefing, and debriefing. Compresses correctly: Rate is correct. In preterm birth, there are also potential advantages from delaying cord clamping. 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. Each 2020 AHA Guidelines for CPR and ECC document was submitted for blinded peer review to 5 subject matter experts nominated by the AHA. Please see updates below from RQI Partners, the company that is providing the NRP Learning Platform TM and RQI for NRP. IV epinephrine every 3-5 minutes. 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. With growing enthusiasm for clinical studies in neonatology, elements of the Neonatal Resuscitation Algorithm continue to evolve as new evidence emerges. 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. In newborns born at 35 weeks' gestation or later, resuscitation starting with 21% oxygen reduces short-term mortality. Hypothermia (temperature less than 36C) should be prevented due to an increased risk of adverse outcomes. The same study demonstrated that the risk of death or prolonged admission increases 16% for every 30-second delay in initiating PPV. 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. 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. If heart rate after birth remains at less than 60/min despite adequate ventilation for at least 30 s, initiating chest compressions is reasonable. The current guidelines have focused on clinical activities described in the resuscitation algorithm, rather than on the most appropriate devices for each step. Provide chest compressions if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. During 5 minutec. 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. Heart rate assessment is best performed by auscultation. How deep should the catheter be inserted? 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. The Neonatal Resuscitation Algorithm remains unchanged from 2015 and is the organizing framework for major concepts that reflect the needs of the baby, the family, and the surrounding team of perinatal caregivers. NRP-certified nurses, nurse practitioners, and respiratory therapists have demonstrated the capacity to lead resuscitations.1113 However, it is recommended that an NRP-certified physician be present in the hospital when a high-risk delivery is anticipated.1113 One study provides an outline for physicians interested in developing a neonatal resuscitation team.14. Hyperthermia should be avoided.1,2,6, Delivery room temperature should be set at at least 78.8F (26C) for infants less than 28 weeks' gestation.6. All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and AHA Executive Committee. Metrics. When blood loss is suspected in a newly born infant who responds poorly to resuscitation (ventilation, chest compressions, and/or epinephrine), it may be reasonable to administer a volume expander without delay. 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. In term and preterm newly born infants, it is reasonable to initiate PPV with an inspiratory time of 1 second or less. Supplemental oxygen should be used judiciously, guided by pulse oximetry. 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. 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. 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. Please contact the American Heart Association at ECCEditorial@heart.org or 1-214-706-1886 to request a long description of . 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. 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). Approximately 10% of newborns require assistance to breathe after birth.13,5,13 Newborn resuscitation requires training, preparation, and teamwork. An important point is that ventilation has been shown to be the most effective measure in neonatal resuscitation Plasma epinephrine concentrations at 1 min after epinephrine administration were not different. Every healthy newly born baby should have a trained and equipped person assigned to facilitate transition. 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. The Neonatal Life Support Writing Group includes neonatal physicians and nurses with backgrounds in clinical medicine, education, research, and public health. A combination of chest compressions and ventilation resulted in better outcomes than ventilation or compressions alone in piglet studies. Stimulation may be provided to facilitate respiratory effort. After birth, the newborn's heart rate is used to assess the effectiveness of spontaneous respiratory effort, the need for interventions, and the response to interventions. Babies who have failed to respond to PPV and chest compressions require vascular access to infuse epinephrine and/or volume expanders. Wrapping, in addition to radiant heat, improves admission temperature of preterm infants. 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. If epinephrine is administered via endotracheal tube, a dose of 0.05 to 0.1 mg per kg (1:10,000 solution) is needed.1,2,57, Early volume expansion with crystalloid (10 mL per kg) or red blood cells is indicated for blood loss when the heart rate does not increase with resuscitation.5,6, Use of naloxone is not recommended as part of initial resuscitation of infants with respiratory depression in the delivery room.1,2,5,6, Very rarely, sodium bicarbonate may be useful after resuscitation.6, Term or near term infants with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia.57, Intravenous glucose infusion should be started soon after resuscitation to avoid hypoglycemia.5,6, It is recommended to cover preterm infants less than 28 weeks' gestation in polyethylene wrap after birth and place them under a radiant warmer. For neonatal resuscitation providers, it may be reasonable to brief before delivery and debrief after neonatal resuscitation. Delayed umbilical cord clamping was recommended for both term and preterm neonates in 2015. 8. Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. In this review, we provide the current recommendations for use of epinephrine during neonatal . The updated guidelines also provide indications for chest compressions and for the use of intravenous epinephrine, which is the preferred route of administration, and recommend not to use sodium bicarbonate or naloxone during resuscitation. Epinephrine use in the delivery room for resuscitation of the newborn is associated with significant morbidity and mortality. For infants requiring PPV at birth, there is currently insufficient evidence to recommend delayed cord clamping versus early cord clamping. 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]). These guidelines apply primarily to the newly born baby who is transitioning from the fluid-filled womb to the air-filled room. It may be reasonable to use higher concentrations of oxygen during chest compressions. Several animal studies found that ventilation with high volumes caused lung injury, impaired gas exchange, and reduced lung compliance in immature animals. Gaps in this domain, whether perceived or real, should be addressed at every stage in our research, educational, and clinical activities. Most changes are related to program administration and course facilitation. 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. RQI for NRP. For every 30 seconds that ventilation is delayed, the risk of prolonged admission or death increases by 16%. Infants 36 weeks or greater estimated gestational age who receive advanced resuscitation should be examined for evidence of HIE to determine if they meet criteria for therapeutic hypothermia. Before every birth, a standardized risk factors assessment tool should be used to assess perinatal risk and assemble a qualified team on the basis of that risk. Evaluate respirations The three signs of effective resuscitation are: Heart rate Respirations Assessment of oxygenation (O2 Sat based on age in minutes) Baby can take up to ten minutes to reach an oxygen saturation of 90-95%. In a retrospective review, early hypoglycemia was a risk factor for brain injury in infants with acidemia requiring resuscitation. Suctioning may be considered if PPV is required and the airway appears obstructed. For term and preterm infants who require resuscitation at birth, there is insufficient evidence to recommend early cord clamping versus delayed cord clamping. For infants with a heart rate of 60 to < 100 beats/minute who have apnea, gasping, or ineffective respirations, positive pressure ventilation (PPV) using a mask is indicated. It is important to. A large observational study found that delaying PPV increases risk of death and prolonged hospitalization. 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. There were only minor changes to the NRP algorithm and recommended practices. If the infant's heart rate is less than 60 beats per minute after adequate positive pressure ventilation and chest compressions, intravenous epinephrine at 0.01 to 0.03 mg per kg (1:10,000 solution) is recommended. If the neonate's heart rate is less than 60 bpm after optimal ventilation for 30 seconds, the oxygen concentration should be increased to 100% with commencement of chest compressions. Optimal PEEP has not been determined, because all human studies used a PEEP level of 5 cm H2O.1822, It is reasonable to initiate PPV at a rate of 40 to 60/min to newly born infants who have ineffective breathing, are apneic, or are persistently bradycardic (heart rate less than 100/min) despite appropriate initial actions (including tactile stimulation).1, To match the natural breathing pattern of both term and preterm newborns, the inspiratory time while delivering PPV should be 1 second or less.