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Neonatal resuscitation 2015 aha guidelines update for cpr
- 1. Neonatal Resuscitation 2015AHA Guidelines Update for CPR www.pediatrics.org/cgi/doi/10.1542/peds.2015-3373G doi:10.1542/peds.2015-3373G What's new?
- 3. Steps of resuscitation: 1.Initial steps in stabilization. 2. Ventilate and oxygenate-O2 administration and monitoring,PPV,PEEP,advanced airways. 3. Initiate chest compressions. 4. Administer epinephrine and/or volume. 5. Witholding and discontinuation of resuscitation.
- 5. TOPIC NRP 2010NRP 2015 LOE COMMENTS Positive pressure ventilation •No mention about SIP •PEEP admisnitered in resuscitation of prterm. •Routine application of sustained infaltion pressure>5 sec not recommended. •PPV when administered to Preterm,use of PEEP- 5cm is suggested. Class 2b Class 2b •3 RCT, 2 cohort studies demonstrated a benefit of SIP for reducing need for mechanical ventilation,no benefit was found for reduction of mortality, BPD, or air leak. •PPV delivered with flow infalting,self infalting bag or T piece resucitator. •Needs additition of PEEP valve to self infalting bag • 2 RCT suggested that addition of PEEP during delivery room resuscitation of preterm newborns resulted in no improvement in mortality.
- 6. TOPIC NRP 2010NRP 2015 LOE COMMENTS Positive pressure ventilation •No mention about monitors and exhaled CO2 in face mask ventilation. •A laryngeal mask should be considered during resuscitation if facemask ventilation is unsuccessful and tracheal intubation is unsuccessful or •Use and effectivness of respiratory mechanics monitors and exhaled CO2 monitors not established. •A laryngeal mask is recommended during resuscitation of term and preterm newborns at 34 weeks or more of gestation when tracheal intubation is unsuccessful or is not feasible Class 2b Class 2b •Prevent excessive pressures and tidal volume and exhaled CO2 monitors may help assess that actual gas exchange is occurring during face-mask PPV attempts- effictivness not established •Use of the laryngeal mask has not been evaluated during chest compressions or for administration of emergency medications
- 7. TOPIC NRP 2010NRP 2015 LOE COMMENTS Positive pressure ventilation Spontaneously breathing preterm infants who have respiratory distress may be supported with CPAP or with intubation and mechanical ventilation. CPAP: Spontaneously breathing preterm infants with respiratory distress may be supported with CPAP initially rather than routine intubation for administering PPV . Class 2b 3 RCT enrolling 2548 preterms- Starting CPAP resulted in decreased rate of intubation in the delivery room, decreased duration of ventilation with reduction of death and BPD, and no significant increase in air leak or severe IVH.
- 8. TOPIC NRP 2010NRP 2015 LOE COMMENTS O2 in Preterm infants •Recommended that whether born at term or preterm, should be an oxygen saturation value in the interquartile range of preductal saturations. •<35 wks GA begin resuscitation with low O2{21%-30%} •Titrate according to preductal SpO2. •Initiating resuscitation of preterm newborns with high oxygen (65% or greater) is not recommended Class 1,LOE B-R Class III Meta-analysis of 7 RCT-initiation with high oxygen (65% or greater) and low oxygen (21- 30%) showed no improvement in survival to hospital discharge with the use of high oxygen.
- 9. TOPIC NRP 2010NRP 2015 LOE COMMENTS O2 in term infants Initiating resuscitation with air or a blended oxygen and titrating the oxygen concentration to achieve an SpO2 in the target range as described above using pulse oximetry . Initiate resuscitation with air (21% ) Supplementary oxygen may be administered and titrated to achieve a preductal oxygen saturation approximating the interquartile range measured in healthy term infants after vaginal birth at sea leve
- 10. • PPV-Flow infalting,selfinfalting or T piece resuscitator. • When administeringPPV for preterm provide PEEP of 5cm . • Initiate PPV in room air for Term and Fio2 21-30% for preterm infants. • LMA can be used >34 wk GA infant when intubation is not successful. • CPAP rather than routine intubation for spontaneously breathing preterm infants with respiratory distress
- 11. TOPIC NRP 2010NRP 2015 LOE COMMENTS Chest compression Indicated for a heart rate that is <60 per minute despite adequate ventilation with supplementary oxygen for 30 seconds. Compressions should be delivered on the lower third of the sternum to a depth of approximately one third of the A-P diameter of the chest . If the heart rate is less than 60/min despite adequate ventilation (via endotracheal tube if possible), chest compressions are indicated Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior- posterior diameter of the chest. Class 2b No change in recommendation
- 12. TOPIC NRP 2010NRP 2015 LOE COMMENTS Chest compression •The 2 thumb– encircling hands technique is recommended for performing chest compressions in newly born infants . • The 2-finger technique may be preferable when access to the umbilicus is required during insertion of an umbilical catheter. 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 2-thumb technique can be continued from the head of the bed while the umbilicus is accessed for insertion of an umbilical catheter, the 2-finger technique is no longer needed. Class 2b
- 13. TOPIC NRP 2010NRP 2015 LOE COMMENTS Chest compression Same 3:1 where 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 2b
- 14. TOPIC NRP 2010NRP 2015 LOE COMMENTS Chest compression If the baby is bradycardic (HR <60 per minute) after 90 seconds of resuscitation with a lower concentration of oxygen, O2 concentration should be increased to 100% until recovery of a normal heart rate . •Endorses increasing the oxygen concentration to 100% whenever chest compressions are Provided •Supplementary oxygen concentration should be weaned as soon as the heart rate recovers Class 2b Class 1 Animal evidence show no advantage to 100% oxygen during CPR. By the time resuscitation of a newborn infant has reached the stage of chest compressions, efforts to achieve return of spontaneous circulation using effective ventilation with low concentration oxygen should have been attempted
- 15. TOPIC NRP 2010NRP 2015 LOE COMMENTS Chest compression •HR used for assesment of ROSC. •Current measure for determining successful progress in neonatal resuscitation is to assess the heart rate response. Class 2b • ET CO2 monitoring and pulse oximetry, useful techniques to determine return of spontaneous circulation occurs. •In asystolic/ bradycardic neonates, routine use of any device such as ETCO2 monitors or pulse oximeters for detection of ROSC, is not recommended as their usefulness for this purpose in neonates has not been well Established.
- 16. • Chest compressionif HR<60 despite adequate ventilation. • Compression delivered over lower third of sternum. • Compression to ventilation ratio of 3:1. • 2 thumb and 2 finger technique. • 2 finger technique no longer recommended. • Use 100% O2 whenever compressions are administered. • Assesment of HR is best measure to assess progress, use of ET CO2 and oximetry not routinely recommended.
- 17. TOPIC NRP 2010NRP 2015 LOE COMMENTS Induced Therapeutic Hypothermia Resource- Limited Areas Should be administered under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinar y care and longitudinal follow-up Use of therapeutic hypothermia in resource limited settings may be considered and offered under clearly defined protocols . Class 2b
- 18. TOPIC NRP 2010NRP 2015 LOE COMMENTS Guidelines for Withholding and Discontinuing •Not indicated- almost certain death and unaccepatable high morbidity. •Nearly always indicated-High rate of survival and acceptable morbidity. •Borderline- survival borderline and morbidity is relatively high,parental desires should be supported. •For GA<25 wks,consider accuracy of GA, the presence or absence of chorioamnionitis, and the level of care available . •Decision to be influenced by region- specific guidelines. No new data have Been published that would justify a change to these guidelines as published in 2010.
- 19. TOPIC NRP 2010NRP 2015 LOE COMMENTS Guidelines for Withholding and Discontinuing In a newly born baby with no detectable heart rate, it is appropriate to consider stopping resuscitation if the heart rate remains undetectable for 10 minutes . Infants with an Apgar score of 0 after 10 minutes of resuscitation, if the heart rate remain undetectable, it may be reasonable to stop assisted ventilations. Class 2b Decision to continue or discontinue resuscitative efforts must be individualized- etiology,GA, associated complications, role of hypothermia .
- 20. TOPIC NRP 2010NRP 2015 LOE COMMENTS Provider training: 2010 Guidelines suggested that simulation should become a standard component in neonatal resuscitation training Suggested that neonatal resuscitation task training occur more frequently than the current 2-year interval.
- 21. TOPIC NRP 2010NRP 2015 LOE COMMENTS Instructor training: None Instructors be trained using timely, objective structured, and individually targeted verbal and/or written feedback .
- 22. Unchanged Recommendations: TOPIC RECOMMENDATION Temperaturecontrol Resuscitation should be performed with temperature-controlling interventions. Clearing the airway when amniotic fluid is clear Routine suctioning is not recommended Assessment of need of oxygen therapy and monitoring of oxygen therapy Oximetry should be used to monitor if any neonate needs PPV, with persistent central cyanosis persists and with the use of supplementary oxygen. Initial breaths and assisted ventilation An initial inflation pressure of 20 cm water is adequate; some term babies may require up to ≥30 to 40 cm water. Rate of giving PPV- 40 to 60 per minute.
- 23. Unchanged Recommendations: TOPIC RECOMMENDATIONS Endotrachealtube placement Exhaled CO2 detection is most reliable. Chest compressions Coordinated chest compressions and PPV should be done if heart rate<60 per minute after establishing effective ventilation Epinephrine IV dose - 0.01 to 0.03 mg/kg of 1:10 000 epinephrine. For an endotracheal route - 0.05 to 0.1 mg/kg Volume Expansion Volume expansion when blood loss is known/suspected.Dose - 10 mL/kg of isotonic crystalloid solution or blood, may be repeated.
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