International Guidelines for Neonatal Resuscitation: An Excerpt From the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science

The International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) formulated new evidenced-based recommendations for neonatal resuscitation. These guidelines comprehensively update the last recommendations, published in 1992 after the Fifth National Conference on CPR and ECC. As a result of the evidence evaluation process, significant changes occurred in the recommended management routines for: • Meconium-stained amniotic fluid: If the newly born infant has absent or depressed respirations, heart rate <100 beats per minute (bpm), or poor muscle tone, direct tracheal suctioning should be performed to remove meconium from the airway. • Preventing heat loss: Hyperthermia should be avoided. • Oxygenation and ventilation: 100% oxygen is recommended for assisted ventilation; however, if supplemental oxygen is unavailable, positive-pressure ventilation should be initiated with room air. The laryngeal mask airway may serve as an effective alternative for establishing an airway if bag-mask ventilation is ineffective or attempts at intubation have failed. Exhaled CO2 detection can be useful in the secondary confirmation of endotracheal intubation. • Chest compressions: Compressions should be administered if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. The 2-thumb, encircling-hands method of chest compression is preferred, with a depth of compression one third the anterior-posterior diameter of the chest and sufficient to generate a palpable pulse. • Medications, volume expansion, and vascular access: Epinephrine in a dose of 0.01–0.03 mg/kg (0.1–0.3 mL/kg of 1:10,000 solution) should be administered if the heart rate remains <60 bpm after a minimum of 30 seconds of adequate ventilation and chest compressions. Emergency volume expansion may be accomplished with an isotonic crystalloid solution or O-negative red blood cells; albumin-containing solutions are no longer the fluid of choice for initial volume expansion. Intraosseous access can serve as an alternative route for medications/volume expansion if umbilical or other direct venous access is not readily available. • Noninitiation and discontinuation of resuscitation: There are circumstances (relating to gestational age, birth weight, known underlying condition, lack of response to interventions) in which noninitiation or discontinuation of resuscitation in the delivery room may be appropriate. Pediatrics 2000;106(3). URL: http://www. pediatrics.org/cgi/content/full/106/3/e29; neonatal resuscitation. INTRODUCTORY FRAMEWORK FOR NEONATAL RESUSCITATION GUIDELINES The Neonatal Resuscitation Guidelines present the recommendations of the International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC). The Guidelines 2000 Conference assembled international experts from many fields, including neonatal resuscitation, to comprehensively update existing guidelines through a process of evidence evaluation. The Neonatal Resuscitation Program Steering Committee (American Academy of Pediatrics), the Pediatric Working Group of the International Liaison Committee on Resuscitation (ILCOR), and the Pediatric Resuscitation Subcommittee of the Emergency Cardiovascular Care Committee (American Heart Association) worked together for 2 years in a systematic process of evidence evaluation and formulation of new recommendations. In 1999 the Pediatric Working Group of ILCOR developed a consensus advisory statement, “Resuscitation of the newly born infant” (Pediatrics 1999;103(4). http://www.pediatrics. org/cgi/content/full/103/4/e56). Using questions and controversies identified during the consensus process, members of the participating organizations worked with additional topic experts from various countries to assemble the most current scientific information relating to neonatal resuscitation. A standard worksheet template served as a framework for uniform evaluation of each selected topic. Articles published in peer-reviewed journals were assembled and analyzed individually for relevance to the proposed guideline change and the quality of the evidence presented. Strength of evidence was classified on the basis of the level of evidence, or study design (ie, randomized, controlled trials, prospective observational studies, retrospective observational studies, case series, animal studies, extrapolations, and common sense) and the quality of the methodology (population, techniques, bias, confounders, etc). Integration of evidence at many different levels and of different quality occurred through consensus discussions among experts and formal panel presentation and debate at the Evidence Evaluation Conference (American Heart Association, September 1999). From the integration process emerged a class of recommendation for each proposed guideline, based on the level of evidence and critical assessment of the quality 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 only one part of the International Guidelines 2000 for CPR and ECC. Full content of the guidelines, including recommendations for adult, pediatric, and neonatal age groups at both basic and advanced life support levels, appears in a supplement to Circulation (2000;102(suppl I):I-343–I-357). PEDIATRICS (ISSN 0031 4005). Copyright © 2000 by the American Academy of Pediatrics/American Heart Association. http://www.pediatrics.org/cgi/content/full/106/3/e29 PEDIATRICS Vol. 106 No. 3 September 2000 1 of 16 by guest on October 29, 2017 http://pediatrics.aappublications.org/ Downloaded from changes, as well as their class of recommendation and level of evidence were presented for final debate and ratification at the Guidelines 2000 Conference (February 2000). For each new or revised guideline, the class of recommendation, as well as the highest level of evidence (LOE) supporting the recommendation, appears in the text. Table I provides a guide to the clinical interpretation of each class of recommendation. Previous guideline recommendations not originally formulated through evidence-based review remain in place unless there existed a lack of evidence to confirm effectiveness, new evidence to suggest harm or ineffectiveness, or evidence that superior approaches had become available. Although the International Guidelines 2000 present the consensus of experts in the field of resuscitation, use of the guidelines is not mandated or imposed upon an individual or organization. The guidelines represent the most effective practices for resuscitation of the newly born infant, based upon current research, knowledge, and experience. As such they are intended to serve as the foundation for educational programs and national, regional, and local processes which establish standards of practice. MAJOR GUIDELINES CHANGES The Pediatric Working Group of the International Liaison Committee on Resuscitation (ILCOR) developed an advisory statement published in 1999. This statement listed the following principles of resuscitation of the newly born: • Personnel capable of initiating resuscitation should attend every delivery. A minority (fewer than 10%) of newly born infants require active resuscitative interventions to establish a vigorous cry or regular respirations, maintain a heart rate .100 beats per minute (bpm), and achieve good color and tone. • When meconium is observed in the amniotic fluid, deliver the head, and suction meconium from the hypopharynx on delivery of the head. If the newly born infant has absent or depressed respirations, heart rate ,100 bpm, or poor muscle tone, carry out direct tracheal suctioning to remove meconium from the airway. • Establishment of adequate ventilation should be of primary concern. Provide assisted ventilation with attention to oxygen delivery, inspiratory time, and effectiveness as judged by chest rise if stimulation does not achieve prompt onset of spontaneous respirations or the heart rate is ,100 bpm. • Provide chest compressions if the heart rate is absent or remains ,60 bpm despite adequate assisted ventilation for 30 seconds. Coordinate chest compressions with ventilations at a ratio of 3:1 and a rate of 120 events per minute to achieve approximately 90 compressions and 30 breaths per minute. • Administer epinephrine if the heart rate remains ,60 bpm despite 30 seconds of effective assisted ventilation and circulation (chest compressions). At the Guidelines 2000 Conference, we made the following recommendations: