Summary of "The new European resuscitation council guidelines on newborn resuscitation and support of the transition of infants at birth: An educational article"

This article reviews the 2021 European Resuscitation Council’s new guidelines on newborn resuscitation. Pediatric anesthesia professionals need to be up to date to provide the best care for premature and newborn infants.

The most important changes are as follows:

1. Delayed cord clamping (DCC) after at least 60 seconds in term neonates
   1. For term neonates, DCC will transfer approximately 30ml/kg of blood from the placenta
   2. For < 34 week premature infants, DCC decreases the need for inotropic support and transufusions, increases the lowest measured BP on 1^st day of life, but minimally improves survival
   3. Contraindications to DCC include placental abruption, cord prolapse, vasa previa, cord avulsion, or maternal hemorrhage
2. No routine suctioning or direct laryngoscopy of newborns delivered through meconium is recommended as these interventions may delay oxygenation.
   1. Systematic reviews/meta-analysis shows no benefit or change in the incidence of meconium aspiration syndrome
   2. Emphasis should be on ventilation initially by facemask in the first minute of life as respiratory support decreases NICU admission rates
3. Starting FiO₂ in preterm infants
   

   Age	FiO2
   < 28 weeks	30%
   28-32 weeks	21% to 30%
   > 32 weeks	21%
   increase to 100% only when chest compressions are needed

   1. 2019 meta-analysis and systematic review showed 27% reduction in short term mortality with room air vs 100% FiO2
4. Starting peak inspiratory pressure of 25 cm H₂O in preterm newborns of < 32 weeks gestation and 30 cm H₂O if > 32 weeks
5. Two thumb encircling technique for chest compressions
   1. This is associated with better rate and depth of compressions and less fatigue compared with the two-finger technique
6. Laryngeal mask airway (LMA) is an acceptable alternative airway
   1. Systematic review of 7 trials showed that the LMA had a higher success rate of ventilation and shorter “pink-up time” compared to face mask ventilation and less need for endotracheal intubation
7. Umbilical venous catheter access is optimal route of vascular access with intraosseous as an acceptable alternative in emergencies
   1. In newborn lambs, similar outcomes seen comparing intraosseous to intravenous adrenaline during resuscitation
   2. Intraosseous can have significant adverse events such as tibial fracture, osteomyelitis, compartment syndrome, and limb ischemia
8. Give adrenaline every 3-5 min if HR does not increase after ventilation and chest compressions
   1. Dose is 10-30 micrograms/kg if HR fails to increase to > 60 bpm despite ventilation and chest compressions
   2. If no other access is available, endotracheal adrenaline can be given at a dose of 50-100 micrograms/kg
   3. Systematic review showed no differences in endotracheal vs. intravenous adrenaline administration regarding hospital discharge, time to Return of Spontaneous Circulation (ROSC), proportion of newborns receiving additional adrenaline, and failure to achieve ROSC or death
9. Administer glucose in a prolonged resuscitation
   1. Recommend glucose (2.5 ml/kg of D10%) in prolonged resuscitation
   2. In post resuscitation, avoid hypoglycemia (<26-47 mg/dl) or hyperglycemia (>150 mg/dl)
10. Consider stopping the resuscitation if there is no response after 10 to 20 minutes of optimal resuscitation
    1. This is longer than previous guidelines of 10 min as outcomes are not always poor even if the HR remains undetectable at 10 min