Myra H. Wyckoff

Part 11: Neonatal Resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

2010;126;e1319-e1344; originally published online Oct 18, 2010; Pediatrics COLLABORATORS CHAPTER Sithembiso Velaphi and on behalf of the NEONATAL RESUSCITATION Sam Richmond, Wendy M. Simon, Nalini Singhal, Edgardo Szyld, Masanori Tamura, Chameides, Jay P. Goldsmith, Ruth Guinsburg, Mary Fran Hazinski, Colin Morley, Jeffrey M. Perlman, Jonathan Wyllie, John Kattwinkel, Dianne L. Atkins, Leon Recommendations Resuscitation and Emergency Cardiovascular Care Science With Treatment Neonatal Resuscitation: 2010 International Consensus on Cardiopulmonary http://www.pediatrics.org/cgi/content/full/126/5/e1319 located on the World Wide Web at: The online version of this article, along with updated information and services, is rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Grove Village, Illinois, 60007. Copyright

Special Report—Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The following guidelines are an interpretation of the evidence presented in the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations 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 newborn and neonate are intended to apply to any infant during the initial hospitalization. The term newly born 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: ● Term gestation? ● 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:

Special Report - Neonatal resuscitation: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care

The following guidelines are an interpretation of the evidence presented in the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations 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 newborn and neonate are intended to apply to any infant during the initial hospitalization. The term newly born 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: 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 …

Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations.

### Newborn Transition The transition from intrauterine to extrauterine life that occurs at the time of birth requires timely anatomic and physiologic adjustments to achieve the conversion from placental gas exchange to pulmonary respiration. This transition is brought about by initiation of air breathing and cessation of the placental circulation. Air breathing initiates marked relaxation of pulmonary vascular resistance, with considerable increase in pulmonary blood flow and increased return of now-well-oxygenated blood to the left atrium and left ventricle, as well as increased left ventricular output. Removal of the low-resistance placental circuit will increase systemic vascular resistance and blood pressure and reduce right-to-left shunting across the ductus arteriosus. The systemic organs must equally and quickly adjust to the dramatic increase in blood pressure and oxygen exposure. Similarly, intrauterine thermostability must be replaced by neonatal thermoregulation with its inherent increase in oxygen consumption. Approximately 85% of babies born at term will initiate spontaneous respirations within 10 to 30 seconds of birth, an additional 10% will respond during drying and stimulation, approximately 3% will initiate respirations after positive-pressure ventilation (PPV), 2% will be intubated to support respiratory function, and 0.1% will require chest compressions and/or epinephrine to achieve this transition.1–3 Although the vast majority of newborn infants do not require intervention to make these transitional changes, the large number of births worldwide means that many infants require some assistance to achieve cardiorespiratory stability each year. Newly born infants who are breathing or crying and have good tone immediately after birth must be dried and kept warm so as to avoid hypothermia. These actions can be provided with the baby lying on the mother’s chest and should not require separation of mother and baby. This does not preclude the need for clinical assessment of the baby. …

Part 1: Executive summary: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care

Publication of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) marks 49 years since the first CPR guidelines were published in 1966 by an Ad Hoc Committee on Cardiopulmonary Resuscitation established by the National Academy of Sciences of the National Research Council.1 Since that time, periodic revisions to the Guidelines have been published by the AHA in 1974,2 1980,3 1986,4 1992,5 2000,6 2005,7 2010,8 and now 2015. The 2010 AHA Guidelines for CPR and ECC provided a comprehensive review of evidence-based recommendations for resuscitation, ECC, and first aid. The 2015 AHA Guidelines Update for CPR and ECC focuses on topics with significant new science or ongoing controversy, and so serves as an update to the 2010 AHA Guidelines for CPR and ECC rather than a complete revision of the Guidelines. The purpose of this Executive Summary is to provide an overview of the new or revised recommendations contained in the 2015 Guidelines Update. This document does not contain extensive reference citations; the reader is referred to Parts 3 through 9 for more detailed review of the scientific evidence and the recommendations on which they are based. There have been several changes to the organization of the 2015 Guidelines Update compared with 2010. “Part 4: Systems of Care and Continuous Quality Improvement” is an important new Part that focuses on the integrated structures and processes that are necessary to create systems of care for both in-hospital and out-of-hospital resuscitation capable of measuring and improving quality and patient outcomes. This Part replaces the “CPR Overview” Part of the 2010 Guidelines. Another new Part of the 2015 Guidelines Update is “Part 14: Education,” which focuses on evidence-based recommendations to facilitate widespread, consistent, efficient and effective implementation …

Part 13: Neonatal Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

The following guidelines are a summary of the evidence presented in the 2015 International Consensus on Cardiopulmo nary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR).1,2 Throughout the online version of this publication, live links are provided so the reader can connect directly to systematic reviews on the International Liaison Committee on Resuscitation (ILCOR) Scientific Evidence Evaluation and Review System (SEERS) website. These links are indicated by a combination of letters and numbers (eg, NRP 787). We encourage readers to use the links and review the evidence and appendices. These guidelines apply primarily to newly born infants transitioning from intrauterine to extrauterine life. The recommendations are also applicable to neonates who have completed newborn transition and require resuscitation during the first weeks after birth.3 Practitioners who resuscitate infants at birth or at any time during the initial hospitalization should consider following these guidelines. For purposes of these guidelines, the terms newborn and neonate apply to any infant during the initial hospitalization. The term newly born applies specifically to an infant at the time of birth.3 Immediately after birth, infants who are breathing and crying may undergo delayed cord clamping (see Umbilical Cord Management section). However, until more evidence is available, infants who are not breathing or crying should have the cord clamped (unless part of a delayed cord clamping research protocol), so that resuscitation measures can commence promptly. Approximately 10% of newborns require some assistance to begin breathing at birth. Less than 1% require extensive resuscitation measures,4 such as cardiac compressions and medications. Although most newly born infants successfully transition from intrauterine to extrauterine life without special help, because of the large total number of births, a significant number will require some degree of resuscitation.3 Newly born infants who do not …

The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: Neonatal resuscitation

APPROXIMATELY 10% OF newborns require some assistance to begin breathing at birth, and about 1% require extensive resuscitation. Although the vast majority of newborn infants do not require intervention to make the transition from intrauterine to extrauterine life, the large number of births worldwide means that many infants require some resuscitation. Newborn infants who are born at term, had clear amniotic fluid, and are breathing or crying and have good tone must be dried and kept warm but do not require resuscitation. All others need to be assessed for the need to receive 1 or more of the following actions in sequence:

Use and Efficacy of Endotracheal Versus Intravenous Epinephrine During Neonatal Cardiopulmonary Resuscitation in the Delivery Room

OBJECTIVE. Given the paucity of information regarding endotracheal epinephrine for newborn resuscitation, the objectives of this study were: (1) to determine the frequency of endotracheal epinephrine use in newborns in the delivery room, and (2) to determine whether the previously recommended dose of 0.01 to 0.03 mg/kg of endotracheal epinephrine is effective in establishing a return of spontaneous circulation. PATIENTS AND METHODS. A retrospective review was conducted for all neonates who received ≥1 dose of epinephrine in the delivery room between January 1999 and December 2004. Infants who received ≥1 dose of endotracheal epinephrine in the delivery room during resuscitation were included in the study population whether or not they survived to be admitted to the NICU. Exclusion criteria included lethal congenital anomalies, delivery outside the hospital, and missing medical charts. RESULTS. Of 93656 infants, 52 neonates (0.06%) received epinephrine in the delivery room, 5 of whom met exclusion criteria. Of the remaining 47 infants, 44 (94%) received the first dose via the endotracheal tube. Only 14 (32%) of 44 achieved return of spontaneous circulation after endotracheal tube administration of epinephrine. Of the 30 remaining infants, 23 (77%) had return of spontaneous circulation with intravenous epinephrine after initially failing endotracheal tube epinephrine. There were no differences in clinical characteristics between newborns who responded to endotracheal tube versus intravenous epinephrine except for a lower blood glucose on NICU admission (52 vs 113 mg%). CONCLUSIONS. Endotracheal epinephrine is frequently used when intensive resuscitation is required in the delivery room. The previously recommended endotracheal epinephrine dose of 0.01 to 0.03 mg/kg is often ineffective. Higher endotracheal doses will likely be needed to improve efficacy. A prospective study is needed to determine the best endotracheal epinephrine dosing regimen. Until such information is available, intravenous administration should be the preferred route of delivery.

Part 7: Neonatal resuscitation

### Newborn Transition The transition from intrauterine to extrauterine life that occurs at the time of birth requires timely anatomic and physiologic adjustments to achieve the conversion from placental gas exchange to pulmonary respiration. This transition is brought about by initiation of air breathing and cessation of the placental circulation. Air breathing initiates marked relaxation of pulmonary vascular resistance, with considerable increase in pulmonary blood flow and increased return of now-well-oxygenated blood to the left atrium and left ventricle, as well as increased left ventricular output. Removal of the low-resistance placental circuit will increase systemic vascular resistance and blood pressure and reduce right-to-left shunting across the ductus arteriosus. The systemic organs must equally and quickly adjust to the dramatic increase in blood pressure and oxygen exposure. Similarly, intrauterine thermostability must be replaced by neonatal thermoregulation with its inherent increase in oxygen consumption. Approximately 85% of babies born at term will initiate spontaneous respirations within 10 to 30 seconds of birth, an additional 10% will respond during drying and stimulation, approximately 3% will initiate respirations after positive-pressure ventilation (PPV), 2% will be intubated to support respiratory function, and 0.1% will require chest compressions and/or epinephrine to achieve this transition.1–3 Although the vast majority of newborn infants do not require intervention to make these transitional changes, the large number of births worldwide means that many infants require some assistance to achieve cardiorespiratory stability each year. Newly born infants who are breathing or crying and have good tone immediately after birth must be dried and kept warm so as to avoid hypothermia. These actions can be provided with the baby lying on the mother’s chest and should not require separation of mother and baby. This does not preclude the need for clinical assessment of the baby. …

Resuscitation of Preterm Neonates With Limited Versus High Oxygen Strategy

OBJECTIVE: To determine whether a limited oxygen strategy (LOX) versus a high oxygen strategy (HOX) during delivery room resuscitation decreases oxidative stress in preterm neonates. METHODS: A randomized trial of neonates of 24 to 34 weeks’ gestational age (GA) who received resuscitation was performed. LOX neonates received room air as the initial resuscitation gas, and fraction of inspired oxygen (Fio2) was adjusted by 10% every 30 seconds to achieve target preductal oxygen saturations (Spo2) as described by the 2010 Neonatal Resuscitation Program guidelines. HOX neonates received 100% O2 as initial resuscitation gas, and Fio2 was adjusted by 10% to keep preductal Spo2 at 85% to 94%. Total hydroperoxide (TH), biological antioxidant potential (BAP), and the oxidative balance ratio (BAP/TH) were analyzed in cord blood and the first hour of life. Secondary outcomes included delivery room interventions, respiratory support on NICU admission, and short-term morbidities. RESULTS: Forty-four LOX (GA: 30 ± 3 weeks; birth weight: 1678 ± 634 g) and 44 HOX (GA: 30 ± 3 weeks; birth weight: 1463 ± 606 g) neonates were included. LOX decreased integrated excess oxygen (∑Fio2 × time [min]) in the delivery room compared with HOX (401 ± 151 vs 662 ± 249; P < .01). At 1 hour of life, BAP/TH was 60% higher for LOX versus HOX neonates (13 [9–16] vs 8 [6–9]) µM/U.CARR, P < .01). LOX decreased ventilator days (3 [0–64] vs 8 [0–96]; P < .05) and reduced the incidence of bronchopulmonary dysplasia (7% vs 25%; P < .05). CONCLUSIONS: LOX is feasible and results in less oxygen exposure, lower oxidative stress, and decreased respiratory morbidities and thus is a reasonable alternative for resuscitation of preterm neonates in the delivery room.