The Neonatal Resuscitation Program: Current Recommendations and a Look at the Future

The Neonatal Resuscitation Program (NRP) consists of an algorithm and curriculum to train healthcare professionals to facilitate newborn infants’ transition to extrauterine life and to provide a standardized approach to the care of infants who require more invasive support and resuscitation. This review discusses the most recent update of the NRP algorithm and recommended guidelines for the care of newly born infants. Current challenges in training and assessment as well as the importance of ergonomics in the optimization of human performance are discussed. Finally, it is recommended that in order to ensure high-performing resuscitation teams, members should be selected and retained based on objective performance criteria and frequent participation in realistic simulated clinical scenarios.     

The 2010 Guidelines on Neonatal Resuscitation (AHA, ERC, ILCOR): similarities and differences--what progress has been made since 2005?

In 2010, the American Heart Association (AHA), the European Resuscitation Council (ERC) and the International Liaison Committee on Resuscitation (ILCOR) issued new guidelines on newborn resuscitation. The new recommendations include: (1) pulse-oximetry for patient assessment during newborn resuscitation; (2) to start resuscitation of term infants with an FiO (2) of 0.21; (3) cardio-respiratory resuscitation with a 3:1 chest compression/inflation ratio for a heart rate <60 beats/min; (4) regarding infants born from meconium stained amniotic fluid: no recommendation is given to suction the upper airways at the perineum (when the head is born), but it is recommended to inspect the oropharynx and trachea for obstruction and suction the lower airway before inflations are given when the infant is depressed; (5) for birth asphyxia in term or near term infants, to induce hypothermia (33.5-34.5°C) within 6?h after birth. AHA, ERC and ILCOR used nearly identical literature for their evidence evaluation process. While the AHA and ILCOR guidelines are almost identical, the ERC guidelines differ slightly from the latter with regards to (i) promoting sustained inflations at birth, (ii) promoting a wider range in applied inflations during resuscitation, and (iii) to suction the airways in infants born from meconium stained amniotic fluid, before inflations are given.     

Summary of Japanese Neonatal Cardiopulmonary Resuscitation Guidelines 2015

The Japan Resuscitation Council joined the International Liaison Committee on Resuscitation (ILCOR) as a member of the Resuscitation Council of Asia in 2006. In 2007, the Japan Society of Perinatal and Neonatal Medicine (JSPNM), which is a member of an affiliated body, launched the Neonatal Cardiopulmonary Resuscitation (NCPR) program as an authorized project to ensure that all staff involved in perinatal and neonatal medicine can learn and practice neonatal cardiopulmonary resuscitation based on the Consensus on Science with Treatment Recommendations developed by ILCOR. The content of courses in the NCPR program is based on the NCPR guidelines. These guidelines are revised by the Japan Resuscitation Council according to the Consensus on Science with Treatment Recommendations, which is updated by ILCOR every 5 years. The latest updated edition in Japanese was published in 2016 and we translated these Japanese guidelines to English in 2018. Here, we introduce a summary of the NCPR guidelines 2015 in Japan. The NCPR 2015 algorithm has two flows, “lifesaving flow” and “stabilization of breathing flow” at the first branching point after the initial step of resuscitation.     

Neonatal resuscitation

At birth approximately 10 % of term or near-term neonates require initial stabilization maneuvers to establish a cry or regular breathing, maintain a heart rate greater than 100 beats per minute (bpm), and good color and muscular tone. About 1 % requires ventilation and very few infants receive chest compressions or medication. However, birth asphyxia is a worldwide problem and can lead to death or serious sequelae. Recently, the European Resuscitation Council (ERC) and the International Liaison Committee on Resuscitation (ILCOR) published new guidelines on resuscitation at birth. These guidelines review specific questions such as the use of air or 100 % oxygen in the delivery room, dose and routes of adrenaline delivery, the peripartum management of meconium-stained amniotic fluid, and temperature control. Assisted ventilation in preterm infants is briefly described. New devices to improve the care of newborn infants, such as the laryngeal mask airway or CO2 detectors to confirm tracheal tube placement, are also discussed. Significant changes have occurred in some practices and are included in this document.     

New guidelines for newborn resuscitation

The new guidelines from the International Liaison Committee on Resuscitation and American Heart Association/American Academy of Pediatrics for newborn resuscitation underline that efficient ventilation is the key to a successful resuscitation of the newly born infant. Compared with the former guidelines published in 1999, the major changes are (i) less emphasis on using supplemental oxygen when initiating resuscitation, (ii) no need for routine intrapartum oropharyngeal and nasopharyngeal suctioning for vigorous infants born to mothers with meconium staining of amniotic fluid, (iii) occlusive wrapping of very low birth weight infants <28 weeks to reduce heat loss is recommended, (iv) preference for the intravenous versus endotracheal route for adrenaline and (v) more emphasis on parental autonomy at the threshold of viability. A number of gaps in newborn resuscitation have been identified and discussed. CONCLUSION: The new guidelines for newborn resuscitation are more evidence-based than previously ones. However, still there is a need for further research and modifications.     

Versorgung und Reanimation des Neugeborenen

Based on a rigorous scientific appraisal by the International Liaison Committee on Resuscitation (ILCOR), the European Resuscitation Council (ERC) issued and published new treatment recommendations for resuscitation in October 2010. These guidelines incorporate new scientific insights where appropriate. In areas for which evidence-based data are still lacking since the 2005 guidelines, the recommendations remain the same. The most notable change for newborn resuscitation is certainly the recommendation to use 21% oxygen at the beginning of newborn life support. The most important and often only necessary step in successful newborn resuscitation is ensuring adequate ventilation. In addition to the medical content the guidelines emphasize the importance of implementing the recommendations in daily practice through regular training not only to apply algorithms but also non-technical skills such as teamwork and communication. This article summarizes the new guidelines for the care of newborns in a concise and practical fashion.     

Use of oxygen for delivery room neonatal resuscitation in non-tertiary Australian and New Zealand hospitals: A survey of current practices, opinions and equipment

Background: Delivery room resuscitation of hypoxic newborn infants with pure or 100% oxygen causes oxidative toxicity and increases mortality. Current international resuscitation guidelines therefore recommend that oxygen be used judiciously. However, this requires staff education and special equipment that may not be available in non-tertiary maternity hospitals where the majority of births occur. Aim: To determine current attitudes, practices and available equipment for the use of air and blended oxygen for newborn delivery room resuscitation in non-tertiary maternity hospitals of Australia and New Zealand (ANZ). Methods: Structured questionnaires sent by mail and e-mail after personal phone contact. A total of 203 eligible hospitals in ANZ were identified. A second mailing was conducted a month later for non-responders. Responders: Final response rate was 64% (n= 130: 70% physicians, 30% midwives). The majority (121, 93%) of respondents were aware of Australian Resuscitation Council recommendations, but only one in five hospitals had the capacity to deliver blended oxygen and 38% used pulse oximeters at delivery. Only 24 (18.5%) hospitals had guidelines. Air would be used by 68 (57%) hospitals to resuscitate term infants compared to 35 (31%) for preterm infants. Most (111, 91%) advocated the use of blended oxygen despite the lack of facilities. Conclusion: Only one in five ANZ non-tertiary maternity hospitals had the capacity to resuscitate newborn infants with air or blended oxygen. Most are aware of current recommendations and agreed that the use of less oxygen would be beneficial for this purpose. Further study into the necessary infrastructure required to implement these guidelines are recommended.     

New Australian Neonatal Resuscitation Guidelines

New Australian Neonatal Resuscitation Guidelines highlight the recent advances in neonatal resuscitation. Resuscitation should start with air and only use oxygen if the infant does not respond. CPAP and PEEP should be considered for premature infants with meconium stained liquor. Sucking out the mouth and nose is not necessary. Infants less than 28 weeks gestation should be placed in a polyethylene bag or wrap to keep warm. Chest compressions, when required, remain at 3:1 inflation. The endotracheal tube position must be verified with a carbon dioxide detector.     

ILCOR's new resuscitation guidelines in preterm and term infants: critical discussion and suggestions for implementation

Recommendations of the International Liaison Committee on Resuscitation (ILCOR) become updated every five years with changing evidence resulting in revised recommendations for clinical practice. New data exist concerning the adequate oxygen concentration to be used in the delivery room, the management of imminent meconium aspiration, ventilation strategies and the role of body temperature during and after resuscitation of preterm and term newborn infants. Only in some cases new evidence has led to clear-cut recommendations for or against specific interventions. Therefore the present publication cites the original ILCOR-recommendations and discusses these with regard to their practical implementation. The authors of the present work suggest to commence resuscitation independendly of gestational age with room air and adjust the inspiratory oxygen concentration thereafter on clinical grounds. The authors also advocate the retention of the presently performed intranatal suction procedure in cases of meconium-stained amniotic fluid and the use of therapeutic hypothermia following perinatal asphyxia in term newborns according to the protocol of one of the published randomized, controlled trials. Standard equipment for neonatal resuscitation should include pressure gauge for monitoring of inspiratory pressures, oxygen blender, and pulse oxymeter. The predominant majority of ILCOR-recommendations have only been cited and have been commented with respect to their practical implementation within the clinical context.     

Basic and advanced paediatric cardiopulmonary resuscitation - guidelines of the Australian and New Zealand Resuscitation Councils 2010

Guidelines for basic and advanced paediatric cardiopulmonary resuscitation (CPR) have been revised by Australian and New Zealand Resuscitation Councils. Changes encourage CPR out-of-hospital and aim to improve the quality of CPR in-hospital. Features of basic CPR include: omission of abdominal thrusts for foreign body airway obstruction; commencement with chest compression followed by ventilation in a ratio of 30:2 or compression-only CPR if the rescuer is unwilling/unable to give expired-air breathing when the victim is 'unresponsive and not breathing normally'. Use of automated external defibrillators is encouraged. Features of advanced CPR include: prevention of cardiac arrest by rapid response systems; restriction of pulse palpation to 10 s to diagnosis cardiac arrest; affirmation of 15:2 compression-ventilation ratio for children and for infants other than newly born; initial bag-mask ventilation before tracheal intubation; a single direct current shock of 4 J/kg for ventricular fibrillation (VF) and pulseless ventricular tachycardia followed by immediate resumption of CPR for 2 min without analysis of cardiac rhythm and avoidance of unnecessary interruption of continuous external cardiac compressions. Monitoring of exhaled carbon dioxide is recommended to detect non-tracheal intubation, assess quality of CPR, and to help match ventilation to reduced cardiac output. The intraosseous route is recommended if immediate intravenous access is impossible. Amiodarone is strongly favoured over lignocaine for refractory VF and adrenaline over atropine for severe bradycardia, asystole and pulseless electrical activity. Family presence at resuscitation is encouraged. Therapeutic hypothermia is acceptable after resuscitation to improve neurological outcome. Extracorporeal circulatory support for in-hospital cardiac arrest may be used in equipped centres.     

Resuscitation of the asphyxic newborn infant: new insight leads to new therapeutic possibilities

The basic mechanisms leading to cell death in birth asphyxia are becoming better known. Some of these are excitotoxicity, inflammation and oxidative stress. In the so-called therapeutic window - between the primary and secondary energy failure - modulation of these processes may be beneficial, reducing apoptosis and perhaps necrosis. In order to reduce oxidative stress, reoxygenation with low oxygen concentrations, even as low as room air, might be beneficial. Increased oxidative stress might have long-term effects on brain growth and development and there is evidence indicating that exposure to 100% oxygen after birth for only a few minutes might have long-term effects. New guidelines for newborn resuscitation have recently been published but more research is needed in this field, especially regarding resuscitation of preterm infants, where few data exist.     

Resuscitation of the term and premature baby

Although most newly born babies establish normal respiration and circulation without help, up to 1−2% may require some resuscitation or stabilization. Babies who do not establish adequate regular normal breathing or who have a heart rate of less than 100 beats/min or other problems such as prematurity may require assistance. The differences in approach to the resuscitation of such babies originate in the physiology and pathophysiology of acute asphyxia at birth. However, management of airway and breathing remain the key features of resuscitation and where cardiac depression has occurred, this is nearly always due to hypoxia secondary to respiratory compromise. Therefore, most babies will respond within 2−3 min of effective aeration of the lungs and the need for intubation, chest compressions or drugs is rare. The International Liaison Committee on Resuscitation (ILCOR) evaluated evidence in 2000 and 2005 in order to provide guidelines for resuscitation: they will do so again for 2010. This evidence is limited in terms of both quantity and quality and controversies still exist. More research is needed to ensure that our future actions are based upon evidence rather than history. This article will review the recommended approach to resuscitation as well as some newer evidence.     

An advisory statement from the Pediatric Working Group of the International Liaison Committee on Resuscitation

The International Liaison Committee on Resuscitation (ILCOR), with representation from North America, Europe, Australia, New Zealand, Africa, and South America, was formed in 1992 to provide a forum for liaison between resuscitation organizations in the developed world. This consensus document on resuscitation extends previously published ILCOR advisory statements on resuscitation to address the unique and changing physiology of the newly born infant within the first few hours after birth and the techniques for providing advanced life support. After careful review of the international resuscitation literature and after discussion of key and controversial issues, consensus was reached on almost all aspects of neonatal resuscitation, and areas of controversy and high priority for additional research were delineated. Consensus on resuscitation for the newly born infant included the following principles: Common or controversial medications (epinephrine, volume expansion, naloxone, bicarbonate), special resuscitation circumstances affecting care of the newly born, continuing care of the newly born after resuscitation, and ethical considerations for initiation and discontinuation of resuscitation are discussed. There was agreement that insufficient data exist to recommend changes to current guidelines regarding the use of 21% versus 100% oxygen, neuroprotective interventions such as cerebral hypothermia, use of a laryngeal mask versus endotracheal tube, and use of high-dose epinephrine. Areas of controversy are identified, as is the need for additional research to improve the scientific justification of each component of current and future resuscitation guidelines.     

Besondere Notfallsituationen bei Früh- und Reifgeborenen

On the basis of the recommendations of the International Liaison Committee on Resuscitation (ILCOR 2005) and recent clinical trials, we recommend initiating the resuscitation of term and preterm infants with room air (certain exceptions apply) and adjusting the inspiratory oxygen concentration depending on the newborn’s clinical condition (“tailored oxygen resuscitation”). We continue to recommend, until further clinical data become available, intrapartum airway suctioning in cases of meconium-stained amniotic fluid, as well as the use of therapeutic hypothermia in asphyxic term and near-term newborn infants. Meconium aspiration, duct-dependent congenital heart disease, and respiratory distress syndrome require a particular problem-oriented approach in the operating and delivery room, during transport, and in the intensive care unit. The difficult airway, the management of meconium aspiration, critical congenital heart disease, and preterm newborn infants weighing less than 1500 g are discussed in detail.     

儿童心肺复苏术的研究状况和对比

心肺复苏指南自1974年制定以来,多次修订改进。2005年心肺复苏和心血管病急诊科学治疗建议国际会议的召开,对心肺复苏指南再次进行了修订,并利用循证程序就心肺复苏的治疗推荐方案达成了一致性意见。本文主要对心肺复苏的程序进行简略介绍,并对历年的心肺复苏指南作以简单比较。     

Creation and Validation of Tool to Assess Resident Competence in Neonatal Resuscitation

BackgroundThe American Board of Pediatrics requires that pediatricians be able to initiate stabilization of a newborn. After residency, 45% of general pediatricians routinely attend deliveries. However, there is no standard approach or tool to measure resident proficiency in newborn resuscitation across training programs. In a national survey, we found a large variability in faculty assessment of the amount of supervision trainees need for various resuscitation scenarios. Objective documentation of trainee performance would permit competency-based decisions on the level of supervision required and facilitate feedback on trainee performance.MethodsA simplified tool was created following the Neonatal Resuscitation Program (NRP) algorithm, with emphasis on communication, leadership, knowledge of equipment, and initial stabilization. To achieve content validity, the tool was evaluated by the NRP steering committee. To assess internal structure of the tool, we filmed 10 simulated resuscitation scenarios, 9 of which contained errors. Experienced resuscitation team members used the tool to assess performance of the team leader in the videos. To evaluate the response process, the tool was used to assess experienced resuscitators in real time at academic and non-academic sites.ResultsThe NRP steering committee approved the tool, providing evidence of content validity. Performance of the team leader in the simulated videos was assessed by 16 evaluators using the tool. There was an intraclass coefficient of 0.86, showing excellent agreement. There was no statistical difference in scores between 102 resuscitations led by experienced resuscitators at academic and nonacademic hospitals (P = .98), which demonstrates generalizability.ConclusionsThe tool we have developed to assess performance in initiating newborn resuscitation shows evidence of construct validity based on assessment of content and internal structure (interobserver agreement, response processes, and generalizability).     

Free-flow oxygen delivery to newly born infants

Resuscitation guidelines recommend administration of free-flow oxygen to newly born infants who breathe but remain cyanosed. Self-inflating resuscitation bags are described as unreliable for this purpose. We measured oxygen concentrations >or=80% delivered through a 240 mL Laerdal self-inflating resuscitation bag and from 5 mm tubing inside a cupped hand.     

Neue Behandlungskonzepte in der pädiatrischen Notfallversorgung

Technological innovations and the advent of standardized training formats, including high technology simulation laboratories have recently improved and facilitated pediatric emergency management. The proof of concept, actual impact and effectiveness of these changes have been evaluated in animal models, analysis of case series and skill improvement testing after training. In one of the most significant advances, efficient intraosseous vascular access can be established in less than 1 min using an electrical hand-held drill. Pediatric respiratory insufficiency can usually be managed with respiratory support via a face mask and bag; however, in patients with a difficult airway, laryngeal masks are an extremely useful device for airway management which can be trained with relative ease. Intubation is suitable only for physicians with relevant expertise. Additional escalation strategies for respiratory support include non-invasive ventilation prior to intubation. The current guidelines of the European Resuscitation Council recommend a chest compression-ventilation ratio of 15:2 which will result in improved coronary perfusion and higher training efficiency. Pharmacological resuscitation with adrenalin should only be performed using standard dosage via intravenous or intraosseous access. Hypothermia for neuroprotection after successful resuscitation of children has been shown to be effective for term newborn infants but currently no general recommendations for the pediatric population are possible. In the absence of an intravenous access, nasal administration of drugs results in rapid resorption and can be used for anticonvulsive treatment or even for analgesia/sedation. Crucial for successful treatment of pediatric septic shock is early and aggressive intravenous fluid resuscitation (up to 60 ml/kg) using chrystalloid solutions, so-called early goal directed therapy. Point-of-care ultrasound meanwhile significantly contributes to improved results for in-hospital pedriatric emergency management. In this paper, recommendations of pediatric and emergency societies are provided, the current literature is discussed and personal experience is reported in selected topics.     

The National Movement of Neonatal Resuscitation in India

Summary Birth asphyxia is an important cause of preventable neonatal morbidity and mortality in developing countries. Of the 26 million births each year in India, 4-6 per cent of neonates fail to establish spontaneous breathing at birth. These babies can be helped, if healthcare professionals present at the time of birth are skilled in the art of neonatal resuscitation. Since the introduction of the Neonatal Resuscitation Programme (NRP) by the American Academy of Pediatrics and American Heart Association, organized training programmes for instructors and providers have been launched in India, under the aegis of the National Neonatology Forum (NNF) since 1990. The initial goal was to train the trainers and provide them with the necessary equipment. The NNF created a national faculty of 150 pediatricians and nurses for NRP by conducting certification courses in various regions of the country. The certified faculty members in turn trained 12,000 healthcare professionals in various parts of India over the following 2 years. Simultaneously, in several teaching institutions, NRP was introduced into the curricula of medical and nursing students. This programme provides a uniform, systematic and action-oriented approach to the resuscitation of the newborn. Prospective evaluation of the resuscitation programme in teaching hospitals has revealed the use of rational resuscitation practices and a significant decline in asphyxia-related deaths.