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• W4246459436 abstract "HomeCirculationVol. 102, No. suppl_1Part 11: Neonatal Resuscitation Free AccessOtherDownload EPUBAboutView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessOtherDownload EPUBPart 11: Neonatal Resuscitation Originally published22 Aug 2000https://doi.org/10.1161/circ.102.suppl_1.I-343Circulation. 2000;102:I-343–I-357Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 22, 2000: Previous Version of Record Major Guidelines ChangesThe Pediatric Working Group of the International Liaison Committee on Resuscitation (ILCOR) developed an advisory statement published in 1999. This statement listed the following principles of resuscitation of the newly born: Personnel capable of initiating resuscitation should attend every delivery. A minority (fewer than 10%) of newly born infants require active resuscitative interventions to establish a vigorous cry or regular respirations, maintain a heart rate >100 beats per minute (bpm), and achieve good color and tone.When meconium is observed in the amniotic fluid, deliver the head, and suction meconium from the hypopharynx on delivery of the head. If the newly born infant has absent or depressed respirations, heart rate <100 bpm, or poor muscle tone, carry out direct tracheal suctioning to remove meconium from the airway.Establishment of adequate ventilation should be of primary concern. Provide assisted ventilation with attention to oxygen delivery, inspiratory time, and effectiveness as judged by chest rise if stimulation does not achieve prompt onset of spontaneous respirations or the heart rate is <100 bpm.Provide chest compressions if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. 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.Administer epinephrine if the heart rate remains <60 bpm despite 30 seconds of effective assisted ventilation and circulation (chest compressions).At the Guidelines 2000 Conference, we made the following recommendations:TemperatureCerebral hypothermia; avoidance of perinatal hyperthermia —Avoid hyperthermia (Class III). —Although several recent animal and human studies have suggested that selective cerebral hypothermia may protect against brain injury in the asphyxiated infant, we cannot recommend routine implementation of this therapy until appropriate controlled human studies have been performed (Class Indeterminate).Oxygenation and VentilationRoom air versus 100% oxygen during positive-pressure ventilation —100% oxygen has been used traditionally for rapid reversal of hypoxia. Although biochemical and preliminary clinical evidence suggests that lower inspired oxygen concentrations may be useful in some settings, data is insufficient to justify a change from the recommendation that 100% oxygen be used if assisted ventilation is required. —If supplemental oxygen is unavailable and positive-pressure ventilation is required, use room air (Class Indeterminate).Laryngeal mask as an alternative method of establishing an airway —When used by appropriately trained providers, the laryngeal mask airway may be an effective alternative for establishing an airway during resuscitation of the newly born infant, particularly if bag-mask ventilation is ineffective or attempts at tracheal intubation have failed (Class Indeterminate).Confirmation of tracheal tube placement by exhaled CO2 detection —Exhaled CO2 detection can be useful in the secondary confirmation of tracheal intubation in the newly born, particularly when clinical assessment is equivocal (Class Indeterminate).Chest CompressionsPreferred technique for chest compressions —Two thumb–encircling hands chest compression is the preferred technique for chest compressions in newly born infants and older infants when size permits (Class IIb). —For chest compressions, we recommend a relative depth of compression (one third of the anterior-posterior diameter of the chest) rather than an absolute depth. Chest compressions should be sufficiently deep to generate a palpable pulse.Medications, Volume Expansion, and Vascular AccessEpinephrine dose —Administer epinephrine if the heart rate remains <60 bpm after a minimum of 30 seconds of adequate ventilation and chest compressions (Class I). —Epinephrine administration is particularly indicated in the presence of asystole.Choice of fluid for acute volume expansion —Emergency volume expansion may be accomplished by an isotonic crystalloid solution such as normal saline or Ringer’s lactate. O-negative red blood cells may be used if the need for blood replacement is anticipated before birth (Class IIb). —Albumin-containing solutions are no longer the fluid of choice for initial for initial volume expansion because their availability is limited, they introduce a risk of infectious disease, and an association with increased mortality has been observed.Alternative routes for vascular access —Intraosseous access can be used as an alternative route for medications/volume expansion if umbilical or other direct venous access is not readily available (Class IIb).EthicsNoninitiation and discontinuation of resuscitation —There are circumstances (relating to gestational age, birth weight, known underlying condition, lack of response to interventions) in which noninitiation or discontinuation of resuscitation in the delivery room may be appropriate (Class IIb).IntroductionResuscitation of the newly born infant presents a different set of challenges than resuscitation of the adult or even the older infant or child. The transition from placental gas exchange in a liquid-filled intrauterine environment to spontaneous breathing of air requires dramatic physiological changes in the infant within the first minutes to hours after birth.Approximately 5% to 10% of the newly born population require some degree of active resuscitation at birth (eg, stimulation to breathe),1 and approximately 1% to 10% born in the hospital are reported to require assisted ventilation.2 More than 5 million neonatal deaths occur worldwide each year. It has been estimated that birth asphyxia accounts for 19% of these deaths, suggesting that the outcome might be improved for more than 1 million infants per year through implementation of simple resuscitative techniques.3 Although the need for resuscitation of the newly born infant often can be predicted, such circumstances may arise suddenly and may occur in facilities that do not routinely provide neonatal intensive care. Thus, it is essential that the knowledge and skills required for resuscitation be taught to all providers of neonatal care.With adequate anticipation, it is possible to optimize the delivery setting with appropriately prepared equipment and trained personnel who are capable of functioning as a team during neonatal resuscitation. At least 1 person skilled in initiating neonatal resuscitation should be present at every delivery. An additional skilled person capable of performing a complete resuscitation should be immediately available.Neonatal resuscitation can be divided into 4 categories of action: Basic steps, including rapid assessment and initial steps in stabilizationVentilation, including bag-mask or bag-tube ventilationChest compressionsAdministration of medications or fluidsTracheal intubation may be required during any of these steps. All newly born infants require rapid assessment, including examination for the presence of meconium in the amniotic fluid or on the skin; evaluation of breathing, muscle tone, and color; and classification of gestational age as term or preterm. Newly born infants with a normal rapid assessment require only routine care (warmth, clearing the airway, drying). All others receive the initial steps, including warmth, clearing the airway, drying, positioning, stimulation to initiate or improve respirations, and oxygen as necessary.Subsequent evaluation and intervention are based on a triad of characteristics: (1) respirations, (2) heart rate, and (3) color. Most newly born infants require only the basic steps, but for those who require further intervention, the most crucial action is establishment of adequate ventilation. Only a very small percentage will need chest compressions and medications.4Certain special circumstances have unique implications for resuscitation of the newly born infant. Care of the infant after resuscitation includes not only supportive care but also ongoing monitoring and appropriate diagnostic evaluation. In certain clinical circumstances, noninitiation or discontinuation of resuscitation in the delivery room may be appropriate. Finally, it is important to document resuscitation interventions and responses in order to understand an individual infant’s pathophysiology as well as to improve resuscitation performance and study resuscitation outcomes.5678BackgroundChanges in Neonatal Resuscitation Guidelines, 1992 to 2000The ILCOR Pediatric Working Group consists of representatives from the American Heart Association (AHA), European Resuscitation Council (ERC), Heart and Stroke Foundation of Canada (HSFC), Australian Resuscitation Council (ARC), New Zealand Resuscitation Council (NZRC), Resuscitation Council of Southern Africa (RCSA), and Council of Latin America for Resuscitation (CLAR). Members of the Neonatal Resuscitation Program (NRP) Steering Committee of the American Academy of Pediatrics (AAP) and representatives of the World Health Organization (WHO) joined the ILCOR Pediatric Working Group to extend existing advisory recommendations for pediatric and neonatal basic life support9 to comprehensive basic and advanced resuscitation for the newly born.10 Careful review of the guidelines of constituent organizations11121314151617 and current international literature formed the basis for the 1999 ILCOR advisory statement.10 We have included consensus recommendations from that statement at the beginning of this document.Using questions and controversies identified during the ILCOR process, the Neonatal Resuscitation Program Steering Committee (AAP), the Pediatric Working Group (ILCOR), and the Pediatric Resuscitation Subcommittee of the Emergency Cardiovascular Care Committee (AHA) carried out further evidence evaluation. At the Evidence Evaluation Conference and International Guidelines 2000 Conference on CPR and ECC, these groups and panels of international experts and participants developed additional recommendations. The International Guidelines 2000 recommendations form the basis of this document.Definition of “Newly Born,” “Neonate,” and “Infant”Although the guidelines for neonatal resuscitation focus on newly born infants, most of the principles are applicable throughout the neonatal period and early infancy. The term “newly born” refers specifically to the infant in the first minutes to hours after birth. The term “neonate” is generally defined as an infant during the first 28 days of life. Infancy includes the neonatal period and extends through 12 months of age.Unique Physiology of the Newly BornThe transition from fetal to extrauterine life is characterized by a series of unique physiological events: the lungs change from fluid-filled to air-filled, pulmonary blood flow increases dramatically, and intracardiac and extracardiac shunts (foramen ovale and ductus arteriosus) initially reverse direction and subsequently close. Such physiological considerations affect resuscitative interventions in the newly born.For initial lung expansion, fluid-filled alveoli may require higher ventilation pressures than are commonly used in rescue breathing during infancy.1819 Physical expansion of the lungs, with establishment of functional residual capacity and increase in alveolar oxygen tension, both mediate the critical decrease in pulmonary vascular resistance and result in an increase in pulmonary blood flow after birth. Failure to normalize pulmonary vascular resistance may result in persistence of right-to-left intracardiac and extracardiac shunts (persistent pulmonary hypertension). Failure to adequately expand alveolar spaces may result in intrapulmonary shunting of blood with resultant hypoxemia. In addition to disordered cardiopulmonary transition, disruption of the fetoplacental circulation also may render the newly born at risk for resuscitation because of acute blood loss.Developmental considerations at various gestational ages also influence pulmonary pathology and resuscitation physiology in the newly born. Surfactant deficiency in the premature infant alters lung compliance and resistance.20 Meconium passed into the amniotic fluid may be aspirated, leading to airway obstruction. Complications of meconium aspiration are particularly likely in infants small for gestational age and those born post term or with significant perinatal compromise.21Although certain physiological features are unique to the newly born, others pertain to infants throughout the neonatal period and into the first months of life. Severe illness due to a wide variety of conditions continues to manifest as disturbances in respiratory function (cyanosis, apnea, respiratory failure). Convalescing preterm infants with chronic lung disease often require significant ventilatory support regardless of the etiology of their need for resuscitation. Persistent pulmonary hypertension, persistent patency of the ductus arteriosus, and intracardiac shunts may produce symptoms during the neonatal period or even into infancy. Thus, many of the considerations and interventions that apply to the newly born may remain important for days, weeks, or months after birth.The point at which neonatal resuscitation guidelines should be replaced by pediatric resuscitation protocols varies for individual patients. Objective data is lacking on optimal compression-ventilation ratios by age and disease state. However, infants with acute or chronic lung disease may benefit from a lower compression-ventilation ratio well into infancy. For these infants, continued use of some aspects of the neonatal guidelines is reasonable. Conversely, a neonate with a cardiac arrhythmia resulting in poor perfusion requires use of protocols more fully detailed in pediatric advanced life support. Factors of age, pathophysiology, and caregiver training should be evaluated for each patient and the most appropriate resuscitation routines and care setting identified.Anticipation of Resuscitation NeedAnticipation, adequate preparation, accurate evaluation, and prompt initiation of support are the critical steps to successful neonatal resuscitation.CommunicationAppropriate preparation for an anticipated high-risk delivery requires communication between the person(s) caring for the mother and those responsible for resuscitation of the newly born. Communication among caregivers should include details of antepartum and intrapartum maternal medical conditions and treatment as well as specific indicators of fetal condition (fetal heart rate monitoring, lung maturity, ultrasonography). Table 1 lists examples of the antepartum and intrapartum circumstances that place the newly born infant at risk.Preparation for DeliveryPersonnelPersonnel capable of initiating resuscitation should attend every delivery. At least 1 such person should be responsible solely for care of the infant. A person capable of carrying out a complete resuscitation should be immediately available for normal low-risk deliveries and in attendance for all deliveries considered high risk. More than 1 experienced person should attend an anticipated high-risk delivery. Resuscitation of a severely depressed newly born infant requires at least 2 persons, 1 to ventilate and intubate if necessary and another to monitor heart rate and perform chest compressions if required. A team of 3 or more persons with designated roles is highly desirable during an extensive resuscitation including medication administration. A separate team should be present for each infant of a multiple gestation. Each resuscitation team should have an identified leader, and all team members should have specifically defined roles.EquipmentAlthough the need for resuscitation at birth often can be predicted by risk factors, for many infants resuscitation cannot be anticipated.22 Therefore, a clean and warm environment with a complete inventory of resuscitation equipment and drugs should be maintained at hand and in fully operational condition wherever deliveries occur. Table 2 presents a list of suggested neonatal supplies, medications, and equipment.Standard precautions should be followed carefully in delivery areas, where exposure to blood and body fluids is likely. All fluids from patients should be treated as potentially infectious. Personnel should wear gloves and other appropriate protective barriers when handling newly born infants or contaminated equipment. Techniques involving mouth suction by the healthcare provider should not be used.EvaluationDetermination of the need for resuscitative efforts should begin immediately after birth and proceed throughout the resuscitation process. An initial complex of signs (meconium in the amniotic fluid or on the skin, cry or respirations, muscle tone, color, term or preterm gestation) should be evaluated rapidly and simultaneously by visual inspection. Actions are dictated by integrated evaluation rather than by evaluation of a single vital sign, followed by action on the result, and then evaluation of the next sign (sequential action). Evaluation and intervention for the newly born are often simultaneous processes, especially when >1 trained provider is present. To enhance educational retention, this process is often taught as a sequence of distinct steps. The appropriate response to abnormal findings also depends on the time elapsed since birth and how the infant has responded to previous resuscitative interventions.Response to Extrauterine EnvironmentMost newly born infants will respond to the stimulation of the extrauterine environment with strong inspiratory efforts, a vigorous cry, and movement of all extremities. If these responses are intact, color improves steadily from cyanotic or dusky to pink, and heart rate can be assumed to be adequate. The infant who responds vigorously to the extrauterine environment and who is term can remain with the mother to receive routine care (warmth, clearing the airway, drying). Indications for further assessment under a radiant warmer and possible intervention include Meconium in the amniotic fluid or on the skinAbsent or weak responsesPersistent cyanosisPreterm birthFurther assessment of the newly born infant is based on the triad of respiration, heart rate, and color.RespirationAfter initial respiratory efforts, the newly born infant should be able to establish regular respirations sufficient to improve color and maintain a heart rate >100 bpm. Gasping and apnea are signs that indicate the need for assisted ventilation.23Heart RateHeart rate is determined by listening to the precordium with a stethoscope or feeling pulsations at the base of the umbilical cord. Central and peripheral pulses in the neck and extremities are often difficult to feel in infants,2425 but the umbilical pulse is readily accessible in the newly born and permits assessment of heart rate without interruption of ventilation for auscultation. If pulsations cannot be felt at the base of the cord, auscultation of the precordium should be performed. Heart rate should be consistently >100 bpm in an uncompromised newly born infant. An increasing or decreasing heart rate also can provide evidence of improvement or deterioration.ColorAn uncompromised newly born infant will be able to maintain a pink color of the mucous membranes without supplemental oxygen. Central cyanosis is determined by examining the face, trunk, and mucous membranes. Acrocyanosis is usually a normal finding at birth and is not a reliable indicator of hypoxemia, but it may indicate other conditions, such as cold stress. Pallor may be a sign of decreased cardiac output, severe anemia, hypovolemia, hypothermia, or acidosis.Techniques of ResuscitationThe techniques of neonatal resuscitation are discussed below and are outlined in the algorithm (see Figure).Basic StepsWarmthPreventing heat loss in the newly born is vital because cold stress can increase oxygen consumption and impede effective resuscitation.2627 Hyperthermia should be avoided, however, because it is associated with perinatal respiratory depression2829 (Class III, level of evidence [LOE] 3). Whenever possible, deliver the infant in a warm, draft-free area. Placing the infant under a radiant warmer, rapidly drying the skin, removing wet linen immediately, and wrapping the infant in prewarmed blankets will reduce heat loss. Another strategy for reducing heat loss is placing the dried infant skin-to-skin on the mother’s chest or abdomen to use her body as a heat source.Recent animal and human studies have suggested that selective (cerebral) hypothermia of the asphyxiated infant may protect against brain injury.303132 Although this is a promising area of research, we cannot recommend routine implementation until appropriate controlled studies in humans have been performed (Class Indeterminate, LOE 2).Clearing the AirwayThe infant’s airway is cleared by positioning of the infant and removal of secretions if needed.PositioningThe newly born infant should be placed supine or lying on its side, with the head in a neutral or slightly extended position. If respiratory efforts are present but not producing effective tidal ventilation, often the airway is obstructed; immediate efforts must be made to correct overextension or flexion or to remove secretions. A blanket or towel placed under the shoulders may be helpful in maintaining proper head position.SuctioningIf time permits, the person assisting delivery of the infant should suction the infant’s nose and mouth with a bulb syringe after delivery of the shoulders but before delivery of the chest. Healthy, vigorous, newly born infants generally do not require suctioning after delivery.33 Secretions may be wiped from the nose and mouth with gauze or a towel. If suctioning is necessary, clear secretions first from the mouth and then the nose with a bulb syringe or suction catheter (8F or 10F). Aggressive pharyngeal suction can cause laryngeal spasm and vagal bradycardia34 and delay the onset of spontaneous breathing. In the absence of meconium or blood, limit mechanical suction with a catheter in depth and duration. Negative pressure of the suction apparatus should not exceed 100 mm Hg (13.3 kPa or 136 cm H2O). If copious secretions are present, the infant’s head may be turned to the side, and suctioning may help clear the airway.Clearing the Airway of MeconiumApproximately 12% of deliveries are complicated by the presence of meconium in the amniotic fluid.35 When the amniotic fluid is meconium-stained, suction the mouth, pharynx, and nose as soon as the head is delivered (intrapartum suctioning) regardless of whether the meconium is thin or thick.36 Either a large-bore suction catheter (12F to 14F) or bulb syringe can be used.37 Thorough suctioning of the nose, mouth, and posterior pharynx before delivery of the body appears to decrease the risk of meconium-aspiration syndrome.36 Nevertheless, a significant number (20% to 30%) of meconium-stained infants will have meconium in the trachea despite such suctioning and in the absence of spontaneous respirations.3839 This suggests the occurrence of in utero aspiration and the need for tracheal suctioning after delivery in depressed infants.If the fluid contains meconium and the infant has absent or depressed respirations, decreased muscle tone, or heart rate <100 bpm, perform direct laryngoscopy immediately after birth for suctioning of residual meconium from the hypopharynx (under direct vision) and intubation/suction of the trachea.4041 There is evidence that tracheal suctioning of the vigorous infant with meconium-stained fluid does not improve outcome and may cause complications (Class I, LOE 1).4243 Warmth can be provided by a radiant heater; however, drying and stimulation generally should be delayed in such infants. Accomplish tracheal suctioning by applying suction directly to a tracheal tube as it is withdrawn from the airway. Repeat intubation and suctioning until little additional meconium is recovered or until the heart rate indicates that resuscitation must proceed without delay. If the infant’s heart rate or respiration is severely depressed, it may be necessary to institute positive-pressure ventilation despite the presence of some meconium in the airway. Suction catheters inserted through the tracheal tube may be too small to accomplish initial removal of particulate meconium; subsequent use of suction catheters inserted through a tracheal tube may be adequate to continue removal of meconium. Delay gastric suctioning to prevent aspiration of swallowed meconium until initial resuscitation is complete. Meconium-stained infants who develop apnea or respiratory distress should receive tracheal suctioning before positive-pressure ventilation, even if they are initially vigorous.Tactile StimulationDrying and suctioning produce enough stimulation to initiate effective respirations in most newly born infants. If an infant fails to establish spontaneous and effective respirations after drying with a towel or gentle rubbing of the back, flicking the soles of the feet may initiate spontaneous respirations. Avoid more vigorous methods of stimulation. Tactile stimulation may initiate spontaneous respirations in newly born infants who are experiencing primary apnea. If these efforts do not result in prompt onset of effective ventilation, discontinue them because the infant is in secondary apnea and positive-pressure ventilation will be required.23Oxygen AdministrationHypoxia is nearly always present in a newly born infant who requires resuscitation. Therefore, if cyanosis, bradycardia, or other signs of distress are noted in a breathing newborn during stabilization, administration of 100% oxygen is indicated while determining the need for additional intervention. Free-flow oxygen can be delivered through a face mask and flow-inflating bag, an oxygen mask, or a hand cupped around oxygen tubing. The oxygen source should deliver at least 5 L/min, and the oxygen should be held close to the face to maximize the inhaled concentration. Many self-inflating bags will not passively deliver sufficient oxygen flow (ie, when not being squeezed). The goal of supplemental oxygen use should be normoxia; sufficient oxygen should be administered to achieve pink color in the mucous membranes. If cyanosis returns when supplemental oxygen is withdrawn, post-resuscitation care should include monitoring of administered oxygen concentration and arterial oxygen saturation.VentilationMost newly born infants who require positive-pressure ventilation can be adequately ventilated with a bag and mask. Indications for positive-pressure ventilation include apnea or gasping respirations, heart rate <100 bpm, and persistent central cyanosis despite 100% oxygen.Although the pressure required for establishment of air breathing is variable and unpredictable, higher inflation pressures (30 to 40 cm H2O or higher) and longer inflation times may be required for the first several breaths than for subsequent breaths.1819 Visible chest expansion is a more reliable sign of appropriate inflation pressures than any specific manometer reading. The assisted ventilation rate should be 40 to 60 breaths per minute (30 breaths per minute when chest compressions are also being delivered). Signs of adequate ventilation include bilateral expansion of the lungs, as assessed by chest wall movement and breath sounds, and improvement in heart rate and color. If ventilation is inadequate, check the seal between mask and face, clear any airway obstruction (adjust head position, clear secretions, open the infant’s mouth), and finally increase inflation pressure. Prolonged bag-mask ventilation may produce gastric inflation; this should be relieved by insertion of an 8F orogastric tube that is aspirated with a syringe and left open to air. If such maneuvers do not result in adequate ventilation, endotracheal intubation should follow.After 30 seconds of adequate ventilation with 100% oxygen, spontaneous breathing and heart rate should be checked. If spontaneous respirations are present and the heart rate is ≥100 bpm, positive-pressure ventilation may be gradually reduced and discontinued. Gentle tactile stimulation may help maintain and improve spontaneous respirations while free-flow oxygen is administered. If spontaneous respirations are inadequate or if heart rate remains below 100 bpm, assisted ventilation must continue with bag and mask or tracheal tube. If the heart rate is <60 bpm, continue assisted ventilation, begin chest compressions, and consider endotracheal intubation.The key to successful neonatal resuscitation is establishment of adequate ventilation. Reversal of hypoxia, acidosis, and bradycardia depends on adequate inflation of fluid-filled lungs with air or oxygen.4445 Although 100% oxygen has been used traditionally for rapid reversal of hypoxia, there is biochemical evidence and preliminary clinical evidence to argue for resuscitation with lower oxygen concentrations.464748 Current clinical data, however, is insufficient to justify adopting this as routine practice. If assisted ventilation is required, deliver 100% oxygen by positive-pressure ventilation. If supplemental oxygen is unavailable, initiate resuscitation of the newly born infant with positive-pressure" @default.
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• W4246459436 date "2000-08-22" @default.
• W4246459436 modified "2023-09-26" @default.
• W4246459436 title "Part 11: Neonatal Resuscitation" @default.
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