Neonatal Resuscitation Program, 8th edition- Algorithm
The most important and effective action in neonatal resuscitation is ventilation of the baby’s lungs.
Antenatal counseling
Ventilation Corrective Steps (MR.SOPA)
Team briefing and equipment check
When a MR.SOPA step results in chest movement, ventilate
for 30 seconds and reassess heart rate.
Birth
Chest movement?
Yes! PPV X 30 secs
Infant stays with mother for routine No! Do S and O step
Term gestation? care: Warm and maintain normal
Good tone? Yes
temperature, dry, stimulate, position Mask Reposition
Give 5
breaths
Breathing or crying? airway, clear secretions if needed. adjustment head
Ongoing evaluation
No
Warm and maintain normal Chest movement?
1 minute
Yes! PPV X 30 secs
temperature, dry, stimulate, position No! Do P step next
airway, clear secretions if needed
Suction Open Give 5
Mouth and nose mouth breaths
Apnea or gasping? No Labored breathing or
HR below 100/min? persistent cyanosis? Chest movement?
Yes! PPV X 30 secs
No! Alternative airway
Yes Yes
Pressure increase* Give 5 Alternative
breaths airway
PPV Position airway, suction if needed
Spo2 monitor. *Increase pressure incrementally by 5 to 10 cm H2O. The maximum
Spo2 monitor.
Oxygen as needed. recommended pressure is 40 cm H2O in term baby.
Consider ECG monitor
Consider CPAP.
Sudden Deterioration After Intubation
No The DOPE mnemonic
HR below 100/min?
Yes D Displaced endotracheal tube
Check chest movement O Obstructed endotracheal tube
Ventilation corrective steps if needed Post-resuscitation
ETT or laryngeal mask if needed care Team debriefing P Pneumothorax
ECG monitor
E Equipment failure
No
HR below 60/min?
Endotracheal Intubation
Yes Total Oxygen Saturation Table GA Depth of Insertion ET Tube Size
(weeks) at Lips (cm) (ID, mm)
ETT or laryngeal mask. 1 min 60% - 65%
Chest compressions Coordinate 23-24 5.5 Size 2.5
2 min 65% - 70%
with PPV- 100% Oxygen. < 1 kg or < 28 weeks
ECG monitor Consider 3 min 70% - 75% 25-26 6.0
Emergency UVC
4 min 75% - 80% 27-29 6.5 Size 3.0
1-2 kg or 28-34 weeks
No 5 min 80% – 85% 30-32 7.0
HR below 60/min?
10 min 85% - 95% 33-34 7.5 Size 3.5
Yes
Initial oxygen concentration for PPV > 2kg or > 34 weeks
35-37 8.0
IV epinephrine every 3-5 minutes. ≥ 35 weeks’ GA 21% oxygen
If HR persistently below 60/min 38-40 8.5
Consider hypovolemia < 35 weeks’ GA 21% - 30%
Consider pneumothorax oxygen 41-43 9.0 3.5-4.0
Neonatal Code Medications
Drug Dose* 0.5 kg 1 kg 2 kg 3 kg 4 kg Administration
Epinephrine 0.02 mg/kg IV Dose: IV Dose: IV Dose: IV Dose: IV Dose: IV/IO rapid push
IV/IO 0.01 mg 0.02 mg 0.04 mg 0.06 mg 0.08 mg Flush with 3 mL NS
Concentration: Equal to Repeat every 3-5 minutes if heart rate
0.1 mg/mL 0.2 mL/kg Volume: Volume: Volume: Volume: Volume: less than 60 bpm
1 mg/10 mL 0.1 mL 0.2 mL 0.4 mL 0.6 mL 0.8 mL
Epinephrine ETT 0.1 mg/kg ETT Dose: IV Dose: IV Dose: IV Dose: IV Dose: May administer while vascular access
0.1 mg/mL 0.05 mg 0. 1 mg 0.2 mg 0.3 mg 0.4 mg Is being established
1 mg/10 mL Equal to ETT rapid push
1 mL/kg Volume: Volume: Volume: Volume: Volume: No need for flush. Provide PPV
0.5 mL 1 mL 2 mL 3 mL 4 mL breaths
To distribute into lungs.
Normal Saline IV 10 mL/kg 5 mL IV 10 mL IV 20 mL IV 30 mL IV 40 mL IV Give over 5-10 min
0.9% NaCl
*The recommended dose range for intravenous or intraosseous administration is 0.01 to 0.03 mg/kg (equal to 0.1 to 0.3 mL/kg).
The recommended dose range for endotracheal administration is 0.05 to 0.1 mg/kg (equal to 0.5 to 1 mL/kg).
Neonatal Resuscitation Program, 8th edition- Algorithm
The most important and effective action in neonatal resuscitation is ventilation of the baby’s lungs.
Antenatal counseling
Team briefing and equipment check
Birth
Infant stays with mother for routine
Term gestation? Yes care: Warm and maintain normal
Good tone? temperature, dry, stimulate,
Breathing or crying? position airway, clear secretions if
needed. Ongoing evaluation
No
Warm and maintain normal temperature,
1 minute
dry, stimulate, position airway, clear
secretions if needed
Apnea or gasping? No Labored breathing or
HR below 100/min? persistent cyanosis?
Yes Yes
PPV Position airway, suction if needed
Spo2 monitor. Spo2 monitor.
Consider ECG monitor Oxygen as needed.
Consider CPAP.
No
HR below 100/min?
Yes
Check chest movement
Ventilation corrective steps if needed Post-resuscitation care
ETT or laryngeal mask if needed Team debriefing
ECG monitor
No
HR below 60/min?
Yes
ETT or laryngeal mask. Total Oxygen Saturation Table
Chest compressions Coordinate
1 min 60% - 65%
with PPV- 100% Oxygen.
ECG monitor Consider 2 min 65% - 70%
Emergency UVC
3 min 70% - 75%
4 min 75% - 80%
No
HR below 60/min? 5 min 80% – 85%
10 min 85% - 95%
Yes
Initial oxygen concentration for
PPV
IV epinephrine every 3-5 minutes.
≥ 35 weeks’ GA 21% oxygen
If HR persistently below 60/min
Consider hypovolemia < 35 weeks’ GA 21% - 30%
Consider pneumothorax oxygen
