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AHA AAP Guidelines Neonatal Resus | Cardiopulmonary Resuscitation | Childbirth

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International Guidelines for Neonatal Resuscitation: An Excerpt From the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science Contributors and Reviewers for the Neonatal Resuscitation Guidelines Pediatrics 2000;106;29DOI: 10.1542/peds.106.3.e29 This information is current as of September 26, 2005 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pedi
  DOI:10.1542/peds.106.3.e292000;106;29- Pediatrics Contributors and Reviewers for the Neonatal Resuscitation Guidelines Cardiovascular Care: International Consensus on ScienceGuidelines 2000for Cardiopulmonary Resuscitation and EmergencyInternational Guidelines for Neonatal Resuscitation: An Excerpt From theThis information is current as of September 26, 2005 http://www.pediatrics.org/cgi/content/full/106/3/e29located 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 © 2000 by the American Academy of Pediatrics. Alland trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk publication, it has been published continuously since 1948. PEDIATRICS is owned, published,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly by on September 26, 2005www.pediatrics.orgDownloaded from  International Guidelines for Neonatal Resuscitation: An Excerpt From theGuidelines 2000 for Cardiopulmonary Resuscitation and EmergencyCardiovascular Care: International Consensus on Science ABSTRACT. The International Guidelines 2000 Con-ference on Cardiopulmonary Resuscitation (CPR) andEmergency Cardiac Care (ECC) formulated new evi-denced-based recommendations for neonatal resuscita-tion. These guidelines comprehensively update the lastrecommendations, published in 1992 after the Fifth Na-tional Conference on CPR and ECC.As a result of the evidence evaluation process, signif-icant changes occurred in the recommended managementroutines for: ã Meconium-stained amniotic fluid: If the newly borninfant has absent or depressed respirations, heart rate < 100 beats per minute (bpm), or poor muscle tone, directtracheal suctioning should be performed to removemeconium from the airway. ã Preventing heat loss: Hyperthermia should beavoided. ã Oxygenation and ventilation: 100% oxygen is recom-mended for assisted ventilation; however, if supplemen-tal oxygen is unavailable, positive-pressure ventilationshould be initiated with room air. The laryngeal maskairway may serve as an effective alternative for establish-ing an airway if bag-mask ventilation is ineffective orattempts at intubation have failed. Exhaled CO 2 detec-tion can be useful in the secondary confirmation of en-dotracheal intubation. ã Chest compressions: Compressions should be admin-istered if the heart rate is absent or remains < 60 bpmdespite adequate assisted ventilation for 30 seconds. The2-thumb, encircling-hands method of chest compressionis preferred, with a depth of compression one third theanterior-posterior diameter of the chest and sufficient togenerate a palpable pulse. ã Medications, volume expansion, and vascular access:Epinephrine in a dose of 0.01–0.03 mg/kg (0.1–0.3 mL/kgof 1:10,000 solution) should be administered if the heartrate remains < 60 bpm after a minimum of 30 seconds ofadequate ventilation and chest compressions. Emergencyvolume expansion may be accomplished with an isotoniccrystalloid solution or O-negative red blood cells; albu-min-containing solutions are no longer the fluid ofchoice for initial volume expansion. Intraosseous accesscan serve as an alternative route for medications/volumeexpansion if umbilical or other direct venous access isnot readily available. ã Noninitiation and discontinuation of resuscitation:There are circumstances (relating to gestational age, birthweight, known underlying condition, lack of responseto interventions) in which noninitiation or discon-tinuation of resuscitation in the delivery room may beappropriate. Pediatrics 2000;106(3). URL: http://www.pediatrics.org/cgi/content/full/106/3/ e 29; neonatal resusci-tation. INTRODUCTORY FRAMEWORK FOR NEONATALRESUSCITATION GUIDELINES The Neonatal Resuscitation Guidelines present therecommendations of the International Guidelines2000 Conference on Cardiopulmonary Resuscitation(CPR) and Emergency Cardiovascular Care (ECC).The Guidelines 2000 Conference assembled interna-tional experts from many fields, including neonatalresuscitation, to comprehensively update existingguidelines through a process of evidence evaluation.The Neonatal Resuscitation Program SteeringCommittee (American Academy of Pediatrics), thePediatric Working Group of the International LiaisonCommittee on Resuscitation (ILCOR), and the Pedi-atric Resuscitation Subcommittee of the EmergencyCardiovascular Care Committee (American HeartAssociation) worked together for 2 years in a system-atic process of evidence evaluation and formulationof new recommendations. In 1999 the PediatricWorking Group of ILCOR developed a consensusadvisory statement, “Resuscitation of the newly borninfant” ( Pediatrics 1999;103(4). http://www.pediatrics.org/cgi/content/full/103/4/e56). Using questionsand controversies identified during the consensusprocess, members of the participating organizationsworked with additional topic experts from variouscountries to assemble the most current scientific in-formation relating to neonatal resuscitation. A stan-dard worksheet template served as a framework foruniform evaluation of each selected topic. Articlespublished in peer-reviewed journals were assembledand analyzed individually for relevance to the pro-posed guideline change and the quality of the evi-dence presented. Strength of evidence was classifiedon the basis of the level of evidence, or study design(ie, randomized, controlled trials, prospective obser-vational studies, retrospective observational studies,case series, animal studies, extrapolations, and com-mon sense) and the quality of the methodology (pop-ulation, techniques, bias, confounders, etc). Integra-tion of evidence at many different levels and ofdifferent quality occurred through consensus discus-sions among experts and formal panel presentationand debate at the Evidence Evaluation Conference(American Heart Association, September 1999). Fromthe integration process emerged a class of recom-mendation for each proposed guideline, based on thelevel of evidence and critical assessment of the qual-ity of the studies, as well as the number of studies,consistency of conclusions, outcomes measured,and magnitude of benefit. The proposed guideline The Neonatal Resuscitation Guidelines, as presented here, constitute onlyone part of the International Guidelines 2000 for CPR and ECC. Full contentof the guidelines, including recommendations for adult, pediatric, andneonatal age groups at both basic and advanced life support levels, appearsin a supplement to Circulation (2000;102(suppl I):I-343–I-357).PEDIATRICS (ISSN 0031 4005). Copyright © 2000 by the American Acad-emy of Pediatrics/American Heart Association. http://www.pediatrics.org/cgi/content/full/106/3/ e 29PEDIATRICS Vol. 106 No. 3 September 2000 1 of 16 by on September 26, 2005www.pediatrics.orgDownloaded from  changes, as well as their class of recommendationand level of evidence were presented for final debateand ratification at the Guidelines 2000 Conference(February 2000).For each new or revised guideline, the class ofrecommendation, as well as the highest level of evi-dence (LOE) supporting the recommendation, ap-pears in the text. Table I provides a guide to theclinical interpretation of each class of recommenda-tion. Previous guideline recommendations not src-inally formulated through evidence-based review re-main in place unless there existed a lack of evidenceto confirm effectiveness, new evidence to suggestharm or ineffectiveness, or evidence that superiorapproaches had become available. Although the In-ternational Guidelines 2000 present the consensus ofexperts in the field of resuscitation, use of the guide-lines is not mandated or imposed upon an individualor organization. The guidelines represent the mosteffective practices for resuscitation of the newly borninfant, based upon current research, knowledge, andexperience. As such they are intended to serve as thefoundation for educational programs and national,regional, and local processes which establish stan-dards of practice. MAJOR GUIDELINES CHANGES The Pediatric Working Group of the InternationalLiaison Committee on Resuscitation (ILCOR) devel-oped an advisory statement published in 1999. Thisstatement listed the following principles of resusci-tation of the newly born:ã Personnel capable of initiating resuscitationshould attend every delivery. A minority (fewerthan 10%) of newly born infants require activeresuscitative interventions to establish a vigorouscry or regular respirations, maintain a heart rate  100 beats per minute (bpm), and achieve goodcolor and tone.ã When meconium is observed in the amniotic fluid,deliver the head, and suction meconium from thehypopharynx on delivery of the head. If the newly born infant has absent or depressed respirations,heart rate  100 bpm, or poor muscle tone, carryout direct tracheal suctioning to remove meco-nium from the airway.ã Establishment of adequate ventilation should be ofprimary concern. Provide assisted ventilation withattention to oxygen delivery, inspiratory time, andeffectiveness as judged by chest rise if stimulationdoes not achieve prompt onset of spontaneousrespirations or the heart rate is  100 bpm.ã Provide chest compressions if the heart rate isabsent or remains  60 bpm despite adequate as-sisted ventilation for 30 seconds. Coordinate chestcompressions with ventilations at a ratio of 3:1and a rate of 120 events per minute to achieveapproximately 90 compressions and 30 breaths perminute.ã Administer epinephrine if the heart rate remains  60 bpm despite 30 seconds of effective assistedventilation and circulation (chest compressions).At the Guidelines 2000 Conference, we made thefollowing recommendations: Temperature ã Cerebral hypothermia; avoidance of perinatalhyperthermia—Avoid hyperthermia (Class III).—Although several recent animal and humanstudies have suggested that selective cerebralhypothermia may protect against brain injury inthe asphyxiated infant, we cannot recommendroutine implementation of this therapy until ap-propriate controlled human studies have beenperformed (Class Indeterminate). Oxygenation and Ventilation ã Room air versus 100% oxygen during positive-pressure ventilation—100% oxygen has been used traditionally forrapid reversal of hypoxia. Although biochemi-cal and preliminary clinical evidence suggeststhat lower inspired oxygen concentrations may be useful in some settings, data is insufficient to justify a change from the recommendation that100% oxygen be used if assisted ventilation isrequired.—If supplemental oxygen is unavailable and pos-itive-pressure ventilation is required, use roomair (Class Indeterminate).ã Laryngeal mask as an alternative method of estab-lishing an airway—When used by appropriately trained providers,the laryngeal mask airway may be an effectivealternative for establishing an airway duringresuscitation of the newly born infant, particu-larly if bag-mask ventilation is ineffective orattempts at tracheal intubation have failed (ClassIndeterminate).ã Confirmation of tracheal tube placement by ex-haled CO 2 detection—Exhaled CO 2 detection can be useful in the sec-ondary confirmation of tracheal intubation inthe newly born, particularly when clinical as-sessment is equivocal (Class Indeterminate). Chest Compressions ã Preferred technique for chest compressions—Two thumb–encircling hands chest compres-sion is the preferred technique for chest com- TABLE I. ClinicalInterpretationofClassesofRecommendationsClass ofRecommendationInterpretationClass I Always acceptable, proven safe, definitelyusefulClass IIa Acceptable, safe, useful (standard of careor intervention of choice)Class IIb Acceptable, safe, useful (within thestandard of care or an optional oralternative intervention)ClassindeterminatePreliminary research stage with promisingresults but insufficient availableevidence to support a final class decisionClass III Unacceptable, no documented benefit, may be harmful 2 of 16 INTERNATIONAL GUIDELINESFOR NEONATALRESUSCITATION by on September 26, 2005www.pediatrics.orgDownloaded from  pressions in newly born infants and older in-fants when size permits (Class IIb).—For chest compressions, we recommend a rela-tive depth of compression (one third of the an-terior-posterior diameter of the chest) ratherthan an absolute depth. Chest compressionsshould be sufficiently deep to generate a palpa- ble pulse. Medications, Volume Expansion, and Vascular Access ã Epinephrine dose—Administer epinephrine if the heart rate remains  60 bpm after a minimum of 30 seconds ofadequate ventilation and chest compressions(Class I).—Epinephrine administration is particularly indi-cated in the presence of asystole.ã Choice of fluid for acute volume expansion—Emergency volume expansion may be accom-plished by an isotonic crystalloid solution suchas normal saline or Ringer’s lactate. O-negativered blood cells may be used if the need for bloodreplacement is anticipated before birth (ClassIIb).—Albumin-containing solutions are no longer thefluid of choice for initial volume expansion be-cause their availability is limited, they introducea risk of infectious disease, and an associationwith increased mortality has been observed.ã Alternative routes for vascular access—Intraosseous access can be used as an alternativeroute for medications/volume expansion if um- bilical or other direct venous access is notreadily available (Class IIb). Ethics ã Noninitiation and discontinuation of resuscitation—There are circumstances (relating to gestationalage, birth weight, known underlying condition,lack of response to interventions) in which non-initiation or discontinuation of resuscitation inthe delivery room may be appropriate (ClassIIb). INTRODUCTION Resuscitation of the newly born infant presents adifferent set of challenges than resuscitation of theadult or even the older infant or child. The transitionfrom placental gas exchange in a liquid-filled intra-uterine environment to spontaneous breathing of airrequires dramatic physiological changes in the infantwithin the first minutes to hours after birth.Approximately 5% to 10% of the newly born pop-ulation require some degree of active resuscitation at birth (eg, stimulation to breathe), 1 and approxi-mately 1% to 10% born in the hospital are reported torequire assisted ventilation. 2 More than 5 millionneonatal 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 yearthrough implementation of simple resuscitative tech-niques. 3 Although the need for resuscitation of thenewly born infant often can be predicted, such cir-cumstances may arise suddenly and may occur infacilities that do not routinely provide neonatal in-tensive care. Thus, it is essential that the knowledgeand skills required for resuscitation be taught to allproviders of neonatal care.With adequate anticipation, it is possible to opti-mize the delivery setting with appropriately pre-pared equipment and trained personnel who are ca-pable of functioning as a team during neonatalresuscitation. At least 1 person skilled in initiatingneonatal resuscitation should be present at everydelivery. An additional skilled person capable ofperforming a complete resuscitation should be im-mediately available.Neonatal resuscitation can be divided into 4 cate-gories of action:ã Basic steps, including rapid assessment and initialsteps in stabilizationã Ventilation, including bag-mask or bag-tube ven-tilationã Chest compressionsã Administration of medications or fluidsTracheal intubation may be required during any ofthese steps. All newly born infants require rapidassessment, including examination for the presenceof meconium in the amniotic fluid or on the skin;evaluation of breathing, muscle tone, and color; andclassification of gestational age as term or preterm.Newly born infants with a normal rapid assessmentrequire only routine care (warmth, clearing the air-way, drying). All others receive the initial steps,including warmth, clearing the airway, drying, posi-tioning, stimulation to initiate or improve respira-tions, and oxygen as necessary.Subsequent evaluation and intervention are basedon a triad of characteristics: (1) respirations, (2) heartrate, and (3) color. Most newly born infants requireonly the basic steps, but for those who requirefurther intervention, the most crucial action is estab-lishment of adequate ventilation. Only a very smallpercentage will need chest compressions andmedications. 4 Certain special circumstances have unique impli-cations for resuscitation of the newly born infant.Care of the infant after resuscitation includes notonly supportive care but also ongoing monitoringand appropriate diagnostic evaluation. In certainclinical circumstances, noninitiation or discontinua-tion of resuscitation in the delivery room may beappropriate. Finally, it is important to document re-suscitation interventions and responses in order tounderstand an individual infant’s pathophysiologyas well as to improve resuscitation performance andstudy resuscitation outcomes. 5–8 BACKGROUNDChanges in Neonatal Resuscitation Guidelines,1992 to 2000 The ILCOR Pediatric Working Group consists ofrepresentatives from the American Heart Associa-tion (AHA), European Resuscitation Council (ERC),Heart and Stroke Foundation of Canada (HSFC), http://www.pediatrics.org/cgi/content/full/106/3/ e 29 3 of 16 by on September 26, 2005www.pediatrics.orgDownloaded from
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