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2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

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2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Prepublication Release Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Khalid Aziz, MBBS, MA, MEd(IT), Chair; Henry C. Lee, MD, Vice Chair; Marilyn B. Escobedo, MD Amber V. Hoover, RN, MSN; Beena D. Kamath-Rayne, MD, MPH; Vishal S. Kapadia, MD, MSCS; David J. Magid, MD, MPH; Susan Niermeyer, MD, MPH; Georg M. Schmölzer, MD, PhD; Edgardo Szyld, MD, MSc Gary M. Weiner, MD; Myra H. Wyckoff, MD Nicole K. Yamada, MD, MS; Jeanette Zaichkin, RN, MN, NNP-BC DOI: 10.1542/peds.2020-038505E Journal: Pediatrics Article Type: Supplement Article Citation: Aziz K, Lee HC, Escobedo MB, et al. Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2020; doi: 10.1542/peds.2020-038505E This article has been copublished in Circulation. This is a prepublication version of an article that has undergone peer review and been accepted for publication but is not the final version of record. This paper may be cited using the DOI and date of access. This paper may contain information that has errors in facts, figures, and statements, and will be corrected in the final published version. The journal is providing an early version of this article to expedite access to this information. The American Academy of Pediatrics, the editors, and authors are not responsible for inaccurate information and data described in this version. ©2020 AmericanDownloaded Academy from www.aappublications.org/news of Pediatrics and American by guest on Heart October Association, 2, 2021 Inc. Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Khalid Aziz, MBBS, MA, MEd(IT), Chair; Henry C. Lee, MD, Vice Chair; Marilyn B. Escobedo, MD Amber V. Hoover, RN, MSN; Beena D. Kamath-Rayne, MD, MPH; Vishal S. Kapadia, MD, MSCS; David J. Magid, MD, MPH Susan Niermeyer, MD, MPH; Georg M. Schmölzer, MD, PhD; Edgardo Szyld, MD, MSc; Gary M. Weiner, MD; Myra H. Wyckoff, MD Nicole K. Yamada, MD, MS; Jeanette Zaichkin, RN, MN, NNP-BC TOP 10 TAKE-HOME MESSAGES FOR NEONATAL LIFE SUPPORT 1. Newborn resuscitation requires anticipation and preparation by providers who train individually and as teams. 2. Most newly born infants do not require immediate cord clamping or resusci- tation and can be evaluated and monitored during skin-to-skin contact with their mothers after birth. 3. Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth. 4. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. 5. Pulse oximetry is used to guide oxygen therapy and meet oxygen saturation goals. Key Words: AHA Scientific Statements 6. Chest compressions are provided if there is a poor heart rate response to cardiopulmonary resuscitation ventilation after appropriate ventilation corrective steps, which preferably neonatal resuscitation neonate ■ include endotracheal intubation. ©■ 2020 American Heart ◼Association, 7. The heart rate response to chest compressions and medications should be Inc., and American Academy of monitored electrocardiographically. Pediatrics This article has been copublished in 8. If the response to chest compressions is poor, it may be reasonable to provide Circulation. epinephrine, preferably via the intravenous route. 9. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion. 10. If all these steps of resuscitation are effectively completed and there is no heart rate response by 20 minutes, redirection of care should be discussed with the team and family. PREAMBLE It is estimated that approximately 10% of newly born infants need help to begin breathing at birth,1–3 and approximately 1% need intensive resuscitative measures to restore cardiorespiratory function.4,5 The neonatal mortality rate in the United States and Canada has fallen from almost 20 per 1000 live births6,7 in the 1960s to the current rate of approximately 4 per 1000 live births. The inability of newly born infants to establish and sustain adequate or spontaneous respiration contributes significantly to these early deaths and to the burden of adverse neurodevelop- mental outcome among survivors. Effective and timely resuscitation at birth could therefore improve neonatal outcomes further. Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. The International Liaison Commit- tee on Resuscitation (ILCOR) Formula for Survival emphasizes 3 essential components for good resuscitation outcomes: guidelines based on sound resuscitation science, Downloaded from www.aappublications.org/news by guest on October 2, 2021 effective education of resuscitation providers, and imple- for both vigorous and nonvigorous infants born with mentation of effective and timely resuscitation.8 The 2020 meconium-stained amniotic fluid (MSAF). This guide- neonatal guidelines contain recommendations, based on line reinforces initial steps and PPV as priorities. the best available resuscitation science, for the most im- It is important to recognize that there are several pactful steps to perform in the birthing room and in the significant gaps in knowledge relating to neonatal re- neonatal period. In addition, specific recommendations suscitation. Many current recommendations are based about the training of resuscitation providers and systems on weak evidence with a lack of well-designed human of care are provided in their respective guideline Parts.9,10 studies. This is partly due to the challenges of perform- ing large randomized controlled trials (RCTs) in the de- livery room. The current guideline, therefore, concludes INTRODUCTION with a summary of current gaps in neonatal research Scope of Guideline and some potential strategies to address these gaps. This guideline is designed for North American healthcare COVID-19 Guidance providers who are looking for an up-to-date summary for Together with other professional societies, the AHA has clinical care, as well as for those who are seeking more provided interim guidance for basic and advanced life sup- in-depth information on resuscitation science and gaps port in adults, children, and neonates with suspected or in current knowledge. The science of neonatal resuscita- confirmed coronavirus disease 2019 (COVID-19) infec- tion applies to newly born infants transitioning from the tion. Because evidence and guidance are evolving with the fluid-filled environment of the womb to the air-filled en- COVID-19 situation, this interim guidance is maintained vironment of the birthing room and to newborns in the separately from the ECC guidelines. Readers are directed 12 days after birth. In circumstances of altered or impaired to the AHA website for the most recent guidance. transition, effective neonatal resuscitation reduces the risk of mortality and morbidity. Even healthy babies who Evidence Evaluation and Guidelines breathe well after birth benefit from facilitation of normal Development transition, including appropriate cord management and thermal protection with skin-to-skin care. The following sections briefly describe the process of The 2015 Neonatal Resuscitation Algorithm and the evidence review and guideline development. See “Part major concepts based on sections of the algorithm con- 2: Evidence Evaluation and Guidelines Development” tinue to be relevant in 2020 (Figure). The following sec- for more details on this process.11 tions are worth special attention. • Positive-pressure ventilation (PPV) remains the Organization of the Writing Committee main intervention in neonatal resuscitation. While The Neonatal Life Support Writing Group includes neo- the science and practices surrounding monitoring natal physicians and nurses with backgrounds in clini- and other aspects of neonatal resuscitation con- cal medicine, education, research, and public health. tinue to evolve, the development of skills and prac- Volunteers with recognized expertise in resuscitation tice surrounding PPV should be emphasized. are nominated by the writing group chair and selected • Supplemental oxygen should be used judiciously, by the AHA ECC Committee. The AHA has rigorous guided by pulse oximetry. conflict of interest policies and procedures to minimize • Prevention of hypothermia continues to be an the risk of bias or improper influence during develop- important focus for neonatal resuscitation. The ment of the guidelines.13 Before appointment, writing importance of skin-to-skin care in healthy babies group members and peer reviewers disclosed all com- is reinforced as a means of promoting parental mercial relationships and other potential (including in- bonding, breast feeding, and normothermia. tellectual) conflicts. Disclosure information for writing • Team training remains an important aspect of group members is listed in Appendix 1. neonatal resuscitation, including anticipation, preparation, briefing, and debriefing. Rapid and effective response and performance are critical to Methodology and Evidence Review good newborn outcomes. These 2020 AHA neonatal resuscitation guidelines are • Delayed umbilical cord clamping was recommended based on the extensive evidence evaluation performed for both term and preterm neonates in 2015. This in conjunction with the ILCOR
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