What is the resuscitation method for a newborn with no cry, no respiration, and no heartbeat at 8 minutes after birth?

From the Guidelines

For a newborn with no cry, no respiration, and no heartbeat at 8 minutes after birth, immediate comprehensive resuscitation is required following the Neonatal Resuscitation Program algorithm, with a 3:1 compression-to-ventilation ratio, as recommended by the most recent guidelines 1. The resuscitation method should begin with chest compressions at a rate of 90 compressions per minute coordinated with positive pressure ventilation.

• Establish vascular access via umbilical vein catheterization and administer epinephrine at 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) intravenously, as supported by previous guidelines 1.
• If no response, repeat epinephrine every 3-5 minutes while continuing chest compressions and ventilation.
• Consider volume expansion with 10 mL/kg of normal saline if blood loss is suspected.
• Assess for reversible causes such as pneumothorax or hypovolemia.
• Continuous monitoring of heart rate, oxygen saturation, and ECG is essential, as emphasized in various studies 1. This aggressive approach is necessary as the absence of heartbeat at 8 minutes indicates severe asphyxia, and rapid intervention is critical to prevent permanent neurological damage or death, with the goal of establishing effective circulation and oxygenation to vital organs, particularly the brain, which is extremely sensitive to hypoxic injury. It is also important to note that the decision to continue resuscitation efforts beyond 10 minutes of no heart rate is often complex and may be influenced by many factors, as discussed in previous guidelines 1.

From the Research

Resuscitation Method for Newborn with No Cry, No Respiration, and No Heartbeat

• The American Academy of Pediatrics and American Heart Association recommend a stepwise approach to neonatal resuscitation, starting with initial steps of providing warmth, drying, and stimulating the newborn, followed by positive pressure ventilation (PPV) if the baby is not breathing or is gasping 2.
• If the heart rate remains less than 60 beats per minute despite adequate ventilation, chest compressions should be initiated, and consideration should be given to the administration of epinephrine via an umbilical venous catheter 3.
• The effectiveness of ventilation and chest compressions during neonatal resuscitation is crucial, and the choice of respiratory device can impact the success of cardiopulmonary resuscitation (CPR) 4.
• A study comparing different ventilation devices during CPR found that a mechanical ventilator provided the best approach, especially in preterm infants prone to volutrauma 4.

Drug Administration

• The administration of drugs, such as epinephrine, is rarely indicated in newborn resuscitation but may be considered if the heart rate remains less than 60 beats per minute despite adequate ventilation and chest compressions 3.
• The optimal dose, order, and route of administration of drugs in neonatal resuscitation are still debated, and more research is needed to determine the best approach 3.
• A study on the effect of a larger flush volume on the bioavailability and efficacy of umbilical venous epinephrine during neonatal resuscitation found that a higher flush volume may be beneficial in achieving return of spontaneous circulation (ROSC) 5.

Outcome of Newborns with No Detectable Heart Rate

• Current resuscitation guidelines suggest that it is reasonable to consider stopping resuscitation if no heart rate has been detected for 10 minutes in a newborn baby from birth 6.
• However, a study on the outcome of babies with no detectable heart rate before 10 minutes of age found that some babies can survive with normal neurodevelopmental outcomes, especially if they are term babies 6.