International Consensus On Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (Costr)
International Consensus On Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (Costr)
International Consensus On Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (Costr)
INTERNATIONAL CONSENSUS ON
CARDIOPULMONARY RESUSCITATION AND
EMERGENCY CARDIOVASCULAR CARE SCIENCE
WITH TREATMENT RECOMMENDATIONS (COSTR)
FOR NEONATAL LIFE SUPPORT
o Postresuscitation Care
1. Rewarming of hypothermic newborns (NLS 858: EvUp)
2. Induced hypothermia in settings with limited resources (NLS 734: EvUp)
3. Postresuscitation glucose management (NLS 607: EvUp)
TOPICS NOT REVIEWED IN 2020
Term umbilical cord management (NLS 1551-SysRev in process)
CPAP versus increased oxygen for term infants in the delivery room (NLS
1579)
Optimal peak inspiratory pressure (New)
Oxygen saturation target percentiles (NLS 1580)
Use of feedback CPR devices for neonatal cardiac arrest (NLS 862)
AND
PREPARATION
1.PREDICTION OF NEED OF RESPIRATORY SUPPORT IN DELIVERY
ROOM
When an infant without antenatally identified risk factors is
delivered at term by cesarean delivery under regional
anesthesia, a provider capable of performing assisted
ventilation should be present at the delivery. It is not
necessary for a provider skilled in neonatal intubation to be
present at that delivery.
2.EFFECT OF BRIEFING/DEBRIEFING
FOLLOWING RESUSCITATION
Population: Among healthcare professionals involved in the
resuscitation or simulated resuscitation of a neonate
Intervention: Does briefing/debriefing
Twenty-five studies across 15 comparison groups met the inclusion criteria, categorised as: barriers to heat loss (18 studies);
external heat sources (3 studies); and combinations of interventions (4 studies).
Evidence of moderate quality shows that use of plastic wraps or bags compared with routine care led to higher temperatures on
admission to NICUs with less hypothermia, particularly for extremely preterm infants. Thermal mattresses and SSC also reduced
hypothermia risk when compared with routine care, but findings are based on two or fewer small studies. Caution must be taken
to avoid iatrogenic hyperthermia, particularly when multiple interventions are used simultaneously. Limited evidence suggests
benefit and no evidence of harm for most short-term morbidity outcomes known to be associated with hypothermia, including
major brain injury, bronchopulmonary dysplasia, retinopathy of prematurity, necrotising enterocolitis, and nosocomial infection
Preterm infants of less than 32 weeks’ gestation under radiant warmers in the hospital
delivery room, using a combination of interventions that may include environmental
temperature 23°C to 25°C, warm blankets, plastic wrapping without drying, cap, and
thermal mattress to reduce hypothermia (temperature less than 36.0°C) on admission
to NICU.
Study design: RCTs and nonrandomized studies (non-RCTs, interrupted times series,
controlled before-and-after studies, cohort studies) were eligible for inclusion
Time frame: All years and languages were included if there was an English abstract;
unpublished studies (eg, conference abstracts, trial protocols) were excluded.
3 RCTs and 1 observational study identified which compared use of “suction clear
amniotic fluid” with “no suction or wipe” in “premature, near term and term infant
population” in 1545 patients .
Serious consequences such as
irritation to mucous membranes & increased risk for iatrogenic infection {Gungor 2006},
bradycardia & apnea {Cordero 1971},
hypoxemia and arterial oxygen desaturation {Carrasco 1997; Gungor 2005,; Kohlhauser 2000}
hypercapnea {Skov 1992}
impaired cerebral blood flow regulation {Van Bel 1988; Perlman 1983}
increased intracranial pressure {Fisher 1982}, and development of subsequent neonatal brain injury
{Kaiser 2008}.
Trevisanuto, Daniele et al. “Tracheal suctioning of meconium at birth for non-vigorous infants: a systematic review
and meta-analysis.” Resuscitation vol. 149 (2020
For nonvigorous newborn infants delivered through meconium-
stained amniotic fluid, routine immediate direct laryngoscopy
with or without tracheal suctioning not recommended.
Meconium-stained amniotic fluid remains a significant risk
factor for receiving advanced resuscitation in the delivery room.
Rarely, an infant may require intubation and tracheal suctioning
to relieve airway obstruction.
PHYSIOLOGICAL MONITORING
AND
FEEDBACK DEVICES
1.HEART RATE MONITORING DURING
NEONATAL RESUSCITATION
Population: Newborns requiring resuscitation
Intervention: ECG monitoring
Outcomes:
Secondary Outcomes:
Death in the delivery room (critical); death within first 48 hours (critical); death at the latest follow-up
(critical)
Long term neurodevelopmental (ND) or behavioral or education outcomes at >18 months corrected age,
using validated assessment tool(s) (critical)
Use of mechanical ventilation during hospitalization (important)
Air leaks reported individually or as a composite outcome, at any time during initial hospitalization
(important)
BPD, defined as use of supplemental oxygen at 28 days of age; need for supplemental oxygen at 36
weeks of gestational age for infants born at or before 32 weeks of gestation (latest reported outcome)
(critical)
Intraventricular hemorrhage, grade 3 or 4 (critical)
For term or late preterms receiving PPV for bradycardia or ineffective respirations at
birth, it is not possible to recommend any specific duration for initial inflations due to
the very low confidence in effect estimates.
2. PEEP VERSUS NO PEEP
PEEP for the initial ventilation of premature newborn infants
during delivery room resuscitation is recommended.
Welsford, Michelle et al. “Initial Oxygen Use for Preterm Newborn Resuscitation: A Systematic Review With
Meta-analysis.” Pediatrics vol. 143,1 (2019)
Results for All Preterm Newborns <35 Results for All Preterm Newborns ≤28
Weeks Gestation Weeks Gestation
Welsford, Michelle et al. “Room Air for Initiating Term Newborn Resuscitation: A Systematic Review With Meta-
analysis.” Pediatrics vol. 143,1 (2019)
o For preterm newborn (<35 weeks’ gestation) who receive respiratory support at birth,
starting with a lower oxygen concentration (21% to 30%) rather than higher initial
oxygen concentration (60% to 100%) recommended.
Subsequent titration of oxygen concentration using pulse oximetry is advised
o For newborn infants at ≥35 weeks gestation receiving respiratory support at birth, start
with 21% oxygen (air).
CIRCULATORY SUPPORT
1. CPR RATIOS FOR NEONATAL RESUSCITATION
o 4 neonatal manikin, various animal studies {Li 2015 14; Boldingh 2016 3202; Boldingh
2016 910; Dellimore 2017 1255}
o found no advantage over 3:1 CPR ratio: though a small pilot trial of 9
preterm newborns reported faster time to ROSC.
Isayama, Tetsuya et al. “The Route, Dose, and Interval of Epinephrine for Neonatal Resuscitation: A Systematic
Review.” Pediatrics vol. 146,4 (2020):
administration of intravascular epinephrine (adrenaline) (0.01–0.03 mg/kg)
If intravascular access not yet available, administer endotracheal epinephrine
at a larger dose (0.05–0.1 mg/kg)
administer further doses of epinephrine every 3 to 5 minutes, preferably
intravascularly
If response to ET epinephrine inadequate, an intravascular dose be given as
soon as vascular access is obtained, regardless of the interval after any initial ET
dose
2.INTRAOSSEOUS VERSUS UMBILICAL VEIN
FOR EMERGENCY ACCESS
Granfeldt A, Avis SR, Lind PC, Holmberg MJ, Kleinman M, Maconochie I, Hsu CH, Fernanda de Almeida M, Wang
TL, Neumar RW, Andersen LW. Intravenous vs. intraosseous administration of drugs during cardiac arrest: A
systematic review.
Lee NH, Nam SK, Lee J, Jun YH. Clinical impact of admission hypothermia in very low birth weight infants :
results from Korean Neonatal Network. Korean Journal of Pediatrics. 2019 .
All ELBWIs with hypothermia (temp <36.0°C) on NICU
admission with Rewarming rate (≥0.5°C/h rapid group; <0.5°C/h
slow group)
no significant differences between rapid or slow rewarming rate
and major neonatal outcomes.
higher rewarming rate was associated with a reduced incidence
of respiratory distress syndrome.
Rech Morassutti F, Cavallin F, Zaramella P, et al. Association of Rewarming Rate on Neonatal Outcomes in
Extremely Low Birth Weight Infants with Hypothermia. The Journal of Pediatrics. 2015
o admission hypothermia has significant effect on mortality and
hence to be post resucitation warm care is a must.
recommendation for either rapid (>0.5°C/h) or slow
rewarming (≤0.5°C/h) of unintentionally hypothermic newborn
infants (temperature < 36°C) at hospital admission would be
speculative.
2. INDUCED HYPOTHERMIA IN SETTINGS WITH LIMITED
RESOURCES
Pauliah, Shreela S et al. “Therapeutic hypothermia for neonatal encephalopathy in low- and middle-income countries:
a systematic review and meta-analysis.” PloS one vol. 8,3 (2013)
newborn infants at term or near-term with evolving moderate-
to-severe HIE in low-income countries and/or other settings with
limited resources may be treated with therapeutic hypothermia
Shah R, Harding J, Brown J, McKinlay C: Neonatal Glycaemia and Neurodevelopmental Outcomes:A Systematic
Review and Meta-Analysis. Neonatology 2019
neonatal hypoglycaemia is associated with 2-3 fold increased
risk of specific cognitive deficits in early childhood (2–5 yrs),
including visual-motor impairment and executive dysfunction,
and general cognitive impairment and literacy and numeracy
problems in later childhood (6–11 yrs)
Intravenous glucose infusion should be considered as soon as
practical after resuscitation, with the goal of avoiding
hypoglycemia.
TAKE-HOME MESSAGES FOR NEONATAL LIFE SUPPORT
Newborn resuscitation requires anticipation and preparation by
providers who train individually and as teams.
Most newly born infants do not require immediate cord clamping
or resuscitation and can be evaluated and monitored during skin-
to-skin contact with their mothers after birth.
Inflation and ventilation of the lungs are the priority in newly
born infants who need support after birth.
A rise in heart rate is the most important indicator of effective
ventilation and response to resuscitative interventions.
Pulse oximetry is used to guide oxygen therapy and meet oxygen
saturation goals.
Chest compressions are provided if there is a poor heart rate
response to ventilation after appropriate ventilation corrective
steps, which preferably include endotracheal intubation.
The HR response to chest compressions and medications should
be monitored electrocardiographically.