Newborn resuscitation program

NEWBORN
RESUSCITATION
PROGRAM
2015 AHA GUIDELINES
P G I B . A T A S

OVERVIEW
•10% of newborns require some assistance
to begin breathing at birth
•<1% require extensive resuscitative
measures

3 QUESTIONS TO ANSWER WITH
YES/NO
Term gestation?
Crying or breathing?
Good muscle tone?

YES!
Term gestation
 Crying or breathing
Good muscle tone
• baby does not need resuscitation
• should not be separated from the
mother.
• dry, place skin-to-skin with the
mother
• cover with dry linen to maintain
temperature
• Observe breathing, activity, and color

NO ?
Term gestation?
Crying or breathing?
Good muscle tone?
A. Initial steps in stabilization
(provide warmth, clear airway
if necessary, dry, stimulate)
B. Ventilation
C. Chest compressions
D. Administration of epinephrine
and/or volume expansion

60
• 60 seconds (“the Golden Minute”) are allotted for
completing the initial steps, reevaluating, and
beginning ventilation if required.

TO PROCEED OR NOT TO PROCEED?
• Respirations : apnea, gasping, or labored or unlabored
breathing)
• Heart rate : whether > or < 100
ointermittently auscultating the precordial pulse
opalpation of the umbilical pulse

O2 SAT
• Once positive pressure ventilation or supplementary oxygen
administration is begun, assessment should consist of
simultaneous evaluation of 3 vital characteristics:
1. heart rate
2. respirations
3. state of oxygenation

ANTICIPATION OF RESUSCITATION NEED
• At every delivery there should be at least 1 person whose
primary responsibility is the newly born.

Distribution of neonatal deaths by cause.
Among neonates, prematurity, perinatal complications, and sepsis are the
major causes of death.

UMBILICAL CORD MANAGEMENT
• 2015 ILCOR systematic review: DCC is associated with less
intraventricular hemorrhage (IVH) of any grade, higher blood pressure
and blood volume, less need for transfusion after birth, and less
necrotizing enterocolitis.
• DCC for longer than 30 seconds is reasonable for both term and
preterm infants who do not require resuscitation at birth.

UMBILICAL CORD MANAGEMENT
• There is insufficient evidence to recommend an approach to
cord clamping for infants who require resuscitation at birth
• We suggest against the routine use of cord milking for infants
born at less than 29 weeks of gestation

INITIAL STEPS
• provide warmth by placing the baby under a radiant heat
source
• position the head in a “sniffing” position to open the airway
• clear the airway if necessary with a bulb syringe or suction
catheter
• Dry
• stimulate breathing

TEMPERATURE CONTROL
Hypothermia is also associated with serious
morbidities, such as increased risk of IVH,19,26,39,50-
54 respiratory issues,15,19,21,50,55-
60hypoglycemia,15,44,60-64 and late-onset
sepsis.33,65

TEMPERATURE CONTROL
Very low-birth-weight (<1500 g) preterm babies are likely to become
hypothermic despite the use of traditional techniques for decreasing heat
loss.
additional warming techniques are recommended
• prewarming the delivery room to 26°C
• covering the baby in plastic wrapping (food or medical grade, heat-
resistant plastic)
• placing the baby on an exothermic mattress
• placing the baby under radiant heat

TEMPERATURE CONTROL
In resource-limited settings
• to maintain body temperature or prevent hypothermia during transition
(birth until 1 to 2 hours of life) in well newborn infants, it may be
reasonable to put them in a clean food-grade plastic bag up to the level
of the neck and swaddle them after drying. (Class IIb, LOE C-LD)
• Another option that may be reasonable is to nurse such newborns with
skin-to-skin contact or kangaroo mother care.

TEMPERATURE CONTROL
Temperature of newly born nonasphyxiated
infants be maintained between 36.5°C and 37.5°C
after birth through admission and stabilization

CLEARING THE AIRWAY
When Amniotic Fluid Is Clear
• Suctioning of the nasopharynx can create bradycardia during
resuscitation
• Suctioning of the trachea in intubated babies receiving mechanical
ventilation in the neonatal intensive care unit (NICU) can be associated
with deterioration of pulmonary compliance and oxygenation and
reduction in cerebral blood flow velocity when performed routinely (ie,
in the absence of obvious nasal or oral secretions).

CLEARING THE AIRWAY
• Suctioning in the presence of secretions can decrease respiratory
resistance

CLEARING THE AIRWAY
Therefore it is recommended that suctioning immediately following birth
(including suctioning with a bulb syringe) should be reserved for babies
who have obvious obstruction to spontaneous breathing or who require
positive-pressure ventilation (PPV).

CLEARING THE AIRWAY
When Meconium is Present
• Aspiration of meconium before delivery, during birth, or during
resuscitation can cause severe meconium aspiration syndrome (MAS)
• Suctioning of the oropharynx before delivery of the shoulders is of no
value
• Elective and routine endotracheal intubation and direct suctioning of
the trachea is of no value in performing this procedure in babies who
were vigorous at birth.

CLEARING THE AIRWAY
There is insufficient evidence to recommend a change in the
current practice of performing endotracheal suctioning of
nonvigorous babies with meconium-stained amniotic fluid

CLEARING THE AIRWAY
• if the infant born through MSAF presents with poor muscle tone and
inadequate breathing efforts, the initial steps of resuscitation should be
completed under the radiant warmer.
• PPV should be initiated if the infant is not breathing or the heart rate
<100/min after the initial steps are completed.
• Routine intubation for tracheal suction in this setting is not suggested

CLEARING THE AIRWAY
meconium-stained amniotic fluid
depressed respirations
depressed muscle tone
and/or has a heart rate < 100 bpm

direct suctioning of the trachea soon after
delivery is indicated before many respirations
have occurred to reduce the chances of the baby
developing meconium aspiration syndrome
Meconium aspirator

ASSESSMENT OF HEART RATE
• Immediately after birth, assessment of the newborn’s heart rate is used
to evaluate the effectiveness of spontaneous respiratory effort and
determine the need for subsequent interventions.
• During resuscitation, an increase in the newborn’s heart rate is
considered the most sensitive indicator of a successful response to each
intervention

ASSESSMENT OF HEART RATE
• During resuscitation of term and preterm newborns, the use of 3-lead
ECG for the rapid and accurate measurement of the newborn’s heart
rate may be reasonable. (Class IIb, LOE C-LD)
• use of ECG does not replace the need for pulse oximetry to evaluate the
newborn’s oxygenation.

ASSESSMENT OF OXYGEN NEED AND
ADMINISTRATION OF OXYGEN
• Blood oxygen levels in uncompromised babies generally do
not reach extrauterine values until approximately 10 minutes
following birth.
• Oxyhemoglobin saturation may normally remain in the 70% to
80% range for several minutes following birth.

ASSESSMENT OF OXYGEN NEED AND
• It is recommended that oximetry be used when
resuscitation can be anticipated, when PPV is
administered, when central cyanosis persists beyond
the first 5 to 10 minutes of life, or when supplementary
oxygen is administered.

• initiate resuscitation with air (21% oxygen at sea
level).
• If blended oxygen is not available, resuscitation
should be initiated with air. (Class IIb, LOE B)
Two meta-analyses of several randomized controlled trials comparing
neonatal resuscitation initiated with room air versus 100% oxygen showed

• Resuscitation of preterm newborns <35 weeks of
gestation should be initiated with low oxygen (21% -
30%)
• Initiating resuscitation of preterm newborns with high
oxygen (65% or greater) is NOT recommended.

POSITIVE PRESSURE VENTILATION
• apneic or gasping
• heart rate <100 per minute after administering the initial steps

start PPV

Initial Breaths and Assisted Ventilation
• Primary measure of adequate initial ventilation: prompt improvement in
heart rate
• Chest wall movement should be assessed if heart rate does not improve
• Initial inflation pressure: 20 cm H2O; but ≥30 to 40 cm H2O may be
required in some term babies without spontaneous ventilation (Class IIb,
LOE C).
• assisted ventilation should be delivered at 40 - 60 breaths/minute to
achieve or HR >100 per minute (Class IIb, LOE C).

End-Expiratory Pressure
• A flow-inflating or self-inflating resuscitation bag or T-piece resuscitator are
appropriate devices to use for PPV.

End-Expiratory Pressure
• Flow-inflating or self-inflating resuscitation bag or T-piece resuscitator
are appropriate devices to use for PPV.
• In 2015, the Neonatal Resuscitation ILCOR and Guidelines Task Forces
repeated their 2010 recommendation that, when PPV is administered to
preterm newborns, approximately 5 cm H2O PEEP is suggested. (Class IIb,
LOE B-R)

Endotracheal Tube Placement
• indicated when bag-mask ventilation is ineffective or prolonged, when
chest compressions are performed, or for special circumstances such as
congenital diaphragmatic hernia.
• Exhaled CO2 detection is the recommended method of confirmation of
endotracheal tube placement. (Class IIa, LOE B)
• Clinical assessment such as chest movement, presence of equal breath
sounds bilaterally, and condensation in the endotracheal tube are
additional indicators of correct endotracheal tube placement.

Endotracheal Tube Placement

Continuous Positive Airway Pressure (CPAP) NRP 590
• Starting CPAP resulted in decreased rate of intubation in the delivery
room, decreased duration of mechanical ventilation with potential
benefit of reduction of death and/or bronchopulmonary dysplasia, and
no significant increase in air leak or severe IVH.
• Spontaneously breathing preterm infants with respiratory
distress may be supported with CPAP initially rather than
routine intubation for administering PPV. (Class IIb, LOE B-R)

CHEST COMPRESSIONS
• heart rate <60 per minute despite adequate ventilation

start chest compressíons

CHEST COMPRESSIONS
• Because the 2-thumb technique generates higher
blood pressures and coronary perfusion pressure with
less rescuer fatigue, the 2 thumb–encircling hands
technique is suggested as the preferred method.178-192
(Class IIb, LOE C-LD)

CHEST COMPRESSIONS
• Compressions and ventilations be coordinated to
avoid simultaneous delivery.
• Chest should be allowed to re-expand fully during
relaxation, but the rescuer’s thumbs should not leave
the chest.

CHEST COMPRESSIONS
• 3:1 ratio of compressions to ventilation, with 90
compressions and 30 breaths to achieve approximately
120 events per minute to maximize ventilation at an
achievable rate.193-198 (Class IIa, LOE C-LD)
• Thus each event will be allotted approximately 1/2 second,
with exhalation occurring during the first compression after
each ventilation. (Class IIb, LOE C)

CHEST COMPRESSIONS
• 3:1 compression-to-ventilation ratio is used for
neonatal resuscitation where compromise of gas
exchange is nearly always the primary cause of
cardiovascular collapse, but rescuers may consider
using higher ratios (eg, 15:2) if the arrest is believed to
be of cardiac origin. (Class IIb, LOE C-EO)

CHEST COMPRESSIONS
• Respirations, heart rate, and oxygenation should be reassessed
periodically, and coordinated chest compressions and ventilations
should continue until the spontaneous heart rate is ≥60 per minute.
(Class IIb, LOE C)
• The Neonatal Guidelines Writing Group endorses increasing the oxygen
concentration to 100% whenever chest compressions are provided
• To reduce the risks of complications associated with hyperoxia the
supplementary oxygen concentration should be weaned as soon as the
heart rate recovers. (Class I, LOE C-LD).

MEDICATIONS
• Drugs are rarely indicated in resuscitation of the newly born
infant.
• Bradycardia in the newborn infant is usually the result of
inadequate lung inflation or profound hypoxemia, and
establishing adequate ventilation is the most important step
to correct it.
• If the heart rate remains less than 60/min despite adequate
ventilation with 100% oxygen (preferably through an
endotracheal tube) and chest compressions, administration of
epinephrine or volume, or both, is indicated

MEDICATIONS
Epinephrine
• Intravenous administration of epinephrine may be considered
at a dose of 0.01 to 0.03 mg/kg of 1:10 000 epinephrine.
• If endotracheal administration is attempted while intravenous
access is being established, higher dosing at 0.05 to 0.1
mg/kg may be reasonable. Epinephrine is recommended to
be administered IV. (Class IIb, LOE C)
• Given the lack of supportive data for endotracheal
epinephrine, the IV route should be used as soon as venous
access is established. (Class IIb, LOE C)

MEDICATIONS
Volume expansion
• Volume expansion should be considered when blood
loss is known or suspected (pale skin, poor perfusion,
weak pulse) and the infant’s heart rate has not
responded adequately to other resuscitative
measures.216 (Class IIb, LOE C)

MEDICATIONS
Volume expansion
• Isotonic crystalloid solution or blood may be useful for
volume expansion in the delivery room. (Class IIb, LOE C)
• Recommended dose: 10 mL/kg, which may need to be
repeated.
• When resuscitating premature infants, care should be taken to
avoid giving volume expanders rapidly, because rapid
infusions of large volumes have been associated with IVH.
(Class IIb, LOE C)

POST RESUSCITATION CARE
Glucose
• Lower glucose levels were associated with an
increased risk for brain injury, while increased glucose
levels may be protective.
• Intravenous glucose infusion should be considered as
soon as practical after resuscitation, with the goal of
avoiding hypoglycemia.

Induced therapeutic hypothermia
• It is recommended that infants born at >36 weeks of
gestation with evolving moderate-to-severe hypoxic-ischemic
encephalopathy should be offered therapeutic hypothermia
under clearly defined protocols similar to those used in
published clinical trials and in facilities with the capabilities for
multidisciplinary care and longitudinal follow-up.7,8 (Class IIa,
LOE A).

Induced therapeutic hypothermia
• Evidence suggests that use of therapeutic hypothermia in
resource-limited settings (ie, lack of qualified staff, inadequate
equipment, etc) may be considered and offered under clearly
defined protocols similar to those used in published clinical
trials and in facilities with the capabilities for multidisciplinary
care and longitudinal follow-up.217-220 (Class IIb, LOE-B-R)

WITHHOLDING
• conditions associated with high mortality and poor outcome
(Class IIb, LOE C)
• If gestation, birth weight, or congenital anomalies are
associated with almost certain early death and when
unacceptably high morbidity is likely among the rare
survivors, resuscitation is not indicated (Class IIb, LOE C)

WITHHOLDING
• counseling a family at gestations below 25 weeks: consider
variables such as perceived accuracy of gestational age
assignment, the presence or absence of chorioamnionitis, and
the level of care available for location of delivery.
• decisions about appropriateness of resuscitation below 25
weeks of gestation will be influenced by region-specific
guidelines.

WITHHOLDING
Discontinuation
• AS: 0 @ 10 minutes: strong predictor of mortality and
morbidity in late preterm and term infants.
• AS: 0 after 10 minutes of resuscitation: HR undetectable, it
may be reasonable to stop assisted ventilation; decision must
be individualized
• Variables to be considered: whether the resuscitation was
considered optimal; availability of advanced neonatal care,
such as therapeutic hypothermia; specific circumstances
before delivery (eg, known timing of the insult); and wishes
expressed by the family.229-234 (Class IIb, LOE C-LD)

RESOURCES
• http://reader.aappublications.org/nrp-neonatal-resuscitation-textbook-6th-edition-english-
version/149
• http://circ.ahajournals.org/content/122/18_suppl_3/S909.full.pdf+html
• https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-13-neonatal-
resuscitation/
• Peliowski-Davidovich… A. Hypothermia for newborns with hypoxic ischemic encephalopathy.
Paediatrics & child … [Internet]. 2012. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3276531/

Newborn resuscitation program

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