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Part 15: Neonatal Resuscitation
Part 15: Neonatal Resuscitation
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
John Kattwinkel, Jeffrey M. Perlman, Khalid Aziz, Christopher Colby, Karen Fairchild, John Gallagher, Mary Fran Hazinski, Louis P. Halamek, Praveen Kumar, George Little, Jane E. McGowan, Barbara Nightengale, Mildred M. Ramirez, Steven Ringer, Wendy M. Simon, Gary M. Weiner, Myra Wyckoff and Jeanette Zaichkin
Originally published2 Nov 2010https://doi.org/10.1161/CIRCULATIONAHA.110.971119Circulation. 2010;122:S909–S919
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The following guidelines are an interpretation of the evidence presented in the 1). They apply primarily to newly born infants undergoing transition from intrauterine to extrauterine life, but the recommendations are also applicable to neonates who have completed perinatal transition and require resuscitation during the first few weeks to months following birth. Practitioners who resuscitate infants at birth or at any time during the initial hospital admission should consider following these guidelines. For the purposes of these guidelines, the terms and are intended to apply to any infant during the initial hospitalization. The term is intended to apply specifically to an infant at the time of birth.
Approximately 10% of newborns require some assistance to begin breathing at birth. Less than 1% require extensive resuscitative measures.2,3 Although the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life, because of the large total number of births, a sizable number will require some degree of resuscitation.
Those newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following 3 characteristics:
Crying or breathing?
Good muscle tone?
If the answer to all 3 of these questions is “yes,” the baby does not need resuscitation and should not be separated from the mother. The baby should be dried, placed skin-to-skin with the mother, and covered with dry linen to maintain temperature. Observation of breathing, activity, and color should be ongoing.
If the answer to any of these assessment questions is “no,” the infant should receive one or more of the following 4 categories of action in sequence:
Initial steps in stabilization (provide warmth, clear airway if necessary, dry, stimulate)
Ventilation Chest compressions
Administration of epinephrine and/or volume expansion
Approximately 60 seconds (“the Golden Minute”) are allotted for completing the initial steps, reevaluating, and beginning ventilation if required (see Figure). The decision to progress beyond the initial steps is determined by simultaneous assessment of 2 vital characteristics: respirations (apnea, gasping, or labored or unlabored breathing) and heart rate (whether greater than or less than 100 beats per minute). Assessment of heart rate should be done by intermittently auscultating the precordial pulse. When a pulse is detectable, palpation of the umbilical pulse can also provide a rapid estimate of the pulse and is more accurate than palpation at other sites.4,5
Download figureDownload PowerPoint
A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures, but the device takes 1 to 2 minutes to apply, and it may not function during states of very poor cardiac output or perfusion. Once positive pressure ventilation or supplementary oxygen administration is begun, assessment should consist of simultaneous evaluation of 3 vital characteristics: heart rate, respirations, and the state of oxygenation, the latter optimally determined by a pulse oximeter as discussed under “Assessment of Oxygen Need and Administration of Oxygen” below. The most sensitive indicator of a successful response to each step is an increase in heart rate.
Anticipation of Resuscitation Need
Anticipation, adequate preparation, accurate evaluation, and prompt initiation of support are critical for successful neonatal resuscitation. At every delivery there should be at least 1 person whose primary responsibility is the newly born. This person must be capable of initiating resuscitation, including administration of positive-pressure ventilation and chest compressions. Either that person or someone else who is promptly available should have the skills required to perform a complete resuscitation, including endotracheal intubation and administration of medications.6 Several studies have demonstrated that a cesarean section performed under regional anesthesia at 37 to 39 weeks, without antenatally identified risk factors, versus a similar vaginal delivery performed at term, does not increase the risk of the baby requiring endotracheal intubation.7–10
With careful consideration of risk factors, the majority of newborns who will need resuscitation can be identified before birth. If the possible need for resuscitation is anticipated, additional skilled personnel should be recruited and the necessary equipment prepared. Identifiable risk factors and the necessary equipment for resuscitation are listed in the (American Academy of Pediatrics, ).11 If a preterm delivery (<37 weeks of gestation) is expected, special preparations will be required. Preterm babies have immature lungs that may be more difficult to ventilate and are also more vulnerable to injury by positive-pressure ventilation. Preterm babies also have immature blood vessels in the brain that are prone to hemorrhage; thin skin and a large surface area, which contribute to rapid heat loss; increased susceptibility to infection; and increased risk of hypovolemic shock related to small blood volume.
Neonatal resuscitation in the delivery room
The successful transition from intrauterine to extrauterine life is dependent upon significant physiologic changes that occur at birth. Although most newborns s
Neonatal resuscitation in the delivery room
Caraciolo J Fernandes, MD
Leonard E Weisman, MD
Laurie Wilkie, MD, MS
The successful transition from intrauterine to extrauterine life is dependent upon significant physiologic changes that occur at birth. Although most newborns successfully make this transition at delivery without requiring any special assistance, a small but significant number will require additional support, including resuscitation in the delivery room.
The indications and principles of neonatal resuscitation will be reviewed here. The physiological changes that occur in the transition from intrauterine to extrauterine life are discussed separately. (See "Physiologic transition from intrauterine to extrauterine life".)
ANTICIPATION OF RESUSCITATION NEED
Being prepared is the first and most important step in delivering effective neonatal resuscitation [1-3]. Most newborns in the United States are healthy and do not require additional special assistance, and the need for resuscitation is often not anticipated, even in tertiary birth centers [4,5]. However, in the United States, 10 percent of all newborns need some intervention, and 1 percent will require extensive resuscitative measures at delivery . As a result, at every birthing location, personnel who are adequately trained in neonatal resuscitation should be readily available to perform neonatal resuscitation whether or not problems are anticipated .
In all instances, at least one health care provider is assigned primary responsibility for the newborn infant . This person should have the necessary skills to evaluate the infant, and, if required, to initiate resuscitation procedures, such as positive pressure ventilation and chest compressions. In addition, either this person or another who is immediately available should have the requisite knowledge and skills to carry out a complete neonatal resuscitation, including endotracheal intubation and administration of medications.
Equipment needed for resuscitation should be available at every delivery area (table 1), and routinely checked to ensure the equipment is functioning properly [1,6].
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Asistan Hekim, Akademi Üyesi, Öğrenci
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Hasta veya Hastabakıcı
Literature review current through: Apr 2022. | This topic last updated: Apr 08, 2022.
Aziz K, Lee HC, Escobedo MB, et al. 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2020.
Aziz K, Lee HC, Escobedo MB, et al. Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S524.
Madar J, Roehr CC, Ainsworth S, et al. European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth. Resuscitation 2021; 161:291.
Mitchell A, Niday P, Boulton J, et al. A prospective clinical audit of neonatal resuscitation practices in Canada. Adv Neonatal Care 2002; 2:316.
Niles DE, Cines C, Insley E, et al. Incidence and characteristics of positive pressure ventilation delivered to newborns in a US tertiary academic hospital. Resuscitation 2017; 115:102.
American Academy of Pediatrics. Textbook of Neonatal Resuscitation, 7th ed, Weiner GM (Ed), American Academy of Pediatrics, 2016.
Jukkala AM, Henly SJ. Provider readiness for neonatal resuscitation in rural hospitals. J Obstet Gynecol Neonatal Nurs 2009; 38:443.
Patel D, Piotrowski ZH, Nelson MR, Sabich R. Effect of a statewide neonatal resuscitation training program on Apgar scores among high-risk neonates in Illinois. Pediatrics 2001; 107:648.
de Almeida MF, Guinsburg R, da Costa JO, et al. Resuscitative procedures at birth in late preterm infants. J Perinatol 2007; 27:761.
Endotracheal intubation 1.8.1. Indications for intubation
If the infant’s heart rate does not rise above 60 beats per minute with chest compressions and effective positive pressure ventilation in 100% oxygen, then advanced resuscitation interventions (including drug administration) are now indicated.
The administration of drugs requires that the infant has intravenous access or an endotracheal tube in-situ. The indications for endotracheal intubation and umbilical vessel catheterisation are discussed below.
The skills of intubation and umbilical vessel catheterisation are considered to be advanced resuscitation interventions. The opportunity to practice and apply these skills is offered to participants undertaking the Advanced Resuscitation Program.
There is no “set” or correct time to decide to intubate a newborn infant during a resuscitation, although there are several circumstances in which intubation is indicated if a person with the professional expertise to perform this procedure is available. These are:
Mask ventilation (with a T- piece device, bag or laryngeal mask) is difficult or does not result in the infant’s heart rate increasing to above 100 bpm and the newborn has not made adequate breathing efforts
The infant is born without a detectable heart rate
Intubation under specific circumstances
The infant born through meconium stained amniotic fluid who is not vigorous at birth may be intubated and receive brief tracheal suctioning if a person with the expertise to perform this procedure is available.
The preterm infant born in a tertiary centre may be given CPAP from birth via a mask and/or nasal prongs or intubated soon after birth so that surfactant can be administered
See Resuscitation in Special Circumstances for more information
Equipment for endotracheal intubation
A full set of intubation equipment should be available in all areas of hospitals where babies are born
At all high risk births, this equipment should be set up ready for use and a person with the expertise to intubate should be present at the birth
Click here for a list of the recommended equipment for endotracheal intubation
Endotracheal size and lengthWeight in gramsGestation in weeksTube size: Internal diameter in mmDepth of insertion from upper lip in cm< 1000 < 28 2.5 6.5 – 71000 – 2000 28 – 34 3.0 7 – 82000 – 3000 34 – 38 3.0 or 3.5 8 -9> 3000 > 38 3.5 or 4.0 < 9
The endotracheal tube diameter can also be calculated using the infant’s gestational age in weeks divided by 10.
Click here to access the Neonatal Worksheet, which will calculate the correct size endotracheal tube and depth of insertion for a given gestational age and birth weight.
Estimating the depth of insertion of the endotracheal tube
The “rule of 6” can be used as an estimate as to where the endotracheal tube should be tied.“Rule of 6” Length at which the tube should be tied at the lips or nares in cmOral intubation Infant’s weight in kg plus 6 cm = length at the lipNasal intubation Infant’s (weight in kg x 1.5) plus 6 cm = length at the nares
Oral versus nasal intubation
Oral intubation is recommended in an emergency situation as it is easier and quicker than nasal intubation in most instances.
Nasal intubation should only be attempted by personnel experienced in and proficient at nasal intubation.
Verification of endotracheal tube position
ANZCOR state: An end tidal CO2 detector attached to the outside end of the endotracheal tube is recommended for verification of correct tube placement in neonates who have spontaneous circulation. (Guideline 13.5, 2016)
Positive detection of exhaled CO2 via a colorimetric carbon dioxide detector (e.g. Pedi-Cap™ CO2 detector or similar) attached between the end of the endotracheal tube and the manual ventilation device confirms tracheal intubation.
Pedi-Cap™ CO2 detector (1kg – 15kg Pediatric)
You may wish to view the Pedi-Cap CO2 detector presentation on the NeoResus web site.
Other clinical signs that indicate successful tracheal intubationThe infant’s heart rate rises quickly to above 100 bpm with positive pressure ventilation via the endotracheal tube.
The endotracheal tube is visualized passing through the vocal cords.
Breath sounds are heard in both axillae with a stethoscope
This can be misleading in a preterm infant as sound is easily transmitted. Sound heard over the anterior portion of the chest can be coming from the stomach or oesophagus
Breath sounds should be absent or decreased over the stomach
In certain circumstances, such as a pneumothorax or congenital diaphragmatic hernia, there may be asymmetrical breath sounds
Vapour (mist) is seen on the inside of the endotracheal tube during exhalation
N.B. The presence of misting inside the endotracheal tube has not been systematically evaluated in neonates (ILCOR, 2006)