# Post-Resuscitation Care in Neonatal Resuscitation -- AHA/AAP 2020

## Temperature Management

### Target Temperature Range

Maintain the newborn's temperature between 36.5 degrees C and 37.5 degrees C (97.7 degrees F to 99.5 degrees F) throughout resuscitation and post-resuscitation care (COR 1, LOE C-LD). Both hypothermia and hyperthermia are associated with increased morbidity and mortality, particularly in preterm and low birth weight infants.

### Warming Strategies

- **Radiant warmer:** Primary heat source during resuscitation and stabilization.
- **Preterm infants < 32 weeks:** Use polyethylene wrap or bag (food-grade, without drying) from neck down, in addition to radiant warmer and cap (COR 1, LOE B-NR). Additional warming adjuncts (thermal mattress, warm blankets) are reasonable (COR 2b, LOE B-NR).
- **Term infants:** Dry thoroughly, remove wet linens, and maintain skin-to-skin contact with parent when possible after stabilization.
- **Transport:** Use a prewarmed transport incubator. Monitor and maintain temperature during transfer.

### Prevention of Hyperthermia

Avoid iatrogenic hyperthermia (> 38.0 degrees C). Maternal fever during labor is independently associated with adverse neonatal outcomes. After resuscitation, monitor the newborn's temperature frequently and adjust warming interventions to avoid overheating.

## Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy (HIE)

### Indications

Therapeutic hypothermia should be offered to infants meeting ALL of the following criteria (COR 1, LOE B-R):

1. **Gestational age >= 36 weeks**
2. **Evidence of perinatal asphyxia** (at least one of the following):
   - Apgar score <= 5 at 10 minutes
   - Ongoing need for resuscitation (e.g., PPV) at 10 minutes of life
   - pH < 7.0 on cord blood or postnatal blood gas within 60 minutes of birth
   - Base deficit >= 16 mmol/L on cord blood or postnatal blood gas within 60 minutes of birth
3. **Moderate to severe encephalopathy** on clinical examination (altered level of consciousness, abnormal tone, abnormal reflexes, seizures)

### Protocol Parameters

| Parameter | Value |
|-----------|-------|
| **Target core temperature** | 33.5 degrees C +/- 0.5 degrees C (92.3 degrees F) |
| **Duration** | 72 hours |
| **Initiation** | Within 6 hours of birth |
| **Rewarming** | Slowly, at a rate of 0.5 degrees C per hour over approximately 6-8 hours |

### Critical Considerations

- Therapeutic hypothermia should be administered under a defined protocol at facilities with capabilities for multidisciplinary care, including continuous physiological monitoring and access to neurology.
- If a newborn meets criteria for therapeutic hypothermia but is born at a facility without cooling capabilities, passive cooling (turn off the radiant warmer, do not apply warming adjuncts) should be initiated during transport. Monitor rectal temperature to avoid uncontrolled hypothermia (< 33.0 degrees C).
- Therapeutic hypothermia has NOT been shown to be beneficial for preterm infants (< 36 weeks) and is not recommended in this population.
- Seizure management (phenobarbital is the first-line anticonvulsant) should be coordinated with the cooling protocol.

> **OpenMedicine Calculator:** `calculate_apgar` -- available via MCP for automated scoring. A 10-minute Apgar score <= 5 is one of the criteria for therapeutic hypothermia eligibility.

## Post-Resuscitation Monitoring

### Respiratory Monitoring

- Monitor respiratory rate, work of breathing, and oxygen saturation continuously.
- Maintain SpO2 within age-appropriate targets (85-95% for the first hours of life).
- Avoid hyperoxia (PaO2 > 100 mmHg), which may exacerbate reperfusion injury, particularly after asphyxia.
- Blood gas analysis (arterial or capillary) should be obtained to assess ventilation and acid-base status.

### Cardiovascular Monitoring

- Continuous heart rate monitoring via cardiac monitor.
- Blood pressure monitoring: hypotension is common after severe perinatal asphyxia. Treat with volume replacement (10 mL/kg normal saline) and/or inotropes (dopamine 5-20 mcg/kg/min as first-line) if mean arterial pressure is below gestational age-appropriate values.

### Metabolic Monitoring

- **Blood glucose:** Monitor blood glucose within 1 hour after resuscitation and maintain > 40-50 mg/dL. Hypoglycemia after asphyxia exacerbates brain injury. Treat with IV dextrose 10% at 2 mL/kg bolus, followed by continuous dextrose infusion (glucose infusion rate 4-8 mg/kg/min).
- **Electrolytes:** Monitor serum sodium, potassium, calcium, and magnesium. Hyponatremia, hypocalcemia, and hypomagnesemia are common after asphyxia.
- **Metabolic acidosis:** Address underlying cause. Sodium bicarbonate may be considered cautiously for severe metabolic acidosis (pH < 7.0) only after adequate ventilation is established.

### Renal Monitoring

- Monitor urine output (normal > 1 mL/kg/hr). Oliguria may indicate acute tubular necrosis secondary to perinatal asphyxia.
- Monitor serum creatinine and electrolytes.

### Neurological Assessment

- Serial neurological examinations to assess for encephalopathy.
- EEG monitoring should be considered for infants at risk for seizures (e.g., those meeting HIE criteria).
- Early neurology consultation for infants with signs of encephalopathy.

## Withholding and Discontinuing Resuscitation

### Withholding Resuscitation

It may be reasonable to not initiate resuscitation when the condition is associated with almost certain early death and when high morbidity is likely among the rare survivors. Examples include:

- Confirmed gestational age < 22 weeks (unless local guidelines support resuscitation at this gestational age and the family has been counseled)
- Birth weight < 400 g
- Anencephaly
- Confirmed lethal chromosomal or genetic abnormalities (e.g., trisomy 13, trisomy 18 -- with family counseling)

Shared decision-making with the family is essential before delivery whenever possible (COR 1, LOE C-EO).

### Discontinuing Resuscitation

- If the heart rate remains undetectable (Apgar 0) despite 10 minutes of adequate resuscitation, it is reasonable to consider discontinuing resuscitation efforts (COR 2b, LOE C-LD).
- A reasonable time frame to change the goals of care from resuscitation to comfort care is around 20 minutes after birth if there has been no return of spontaneous circulation despite adequate resuscitation (COR 2b, LOE C-LD).
- Failure to achieve return of spontaneous circulation after 10-20 minutes of intensive resuscitation is associated with a high risk of mortality and a high risk of moderate to severe neurodevelopmental impairment among survivors.
- Individual circumstances (gestational age, presumed etiology, availability of therapeutic hypothermia, parental wishes) should guide the decision to continue or discontinue.

## Apgar Score in the Context of Resuscitation

The Apgar score is assigned at 1 and 5 minutes of life, and then every 5 minutes thereafter if the 5-minute score is < 7, up to 20 minutes.

### Key Points

- The Apgar score describes the condition of the newborn at specific time points and the response to resuscitation.
- The Apgar score should NOT drive resuscitation decisions. Heart rate is the primary indicator guiding resuscitation.
- An Apgar score of 0 at 10 minutes is a strong predictor of mortality and morbidity in late preterm and term infants.
- A persistently low Apgar score (< 5 at 5 and 10 minutes) should prompt consideration for therapeutic hypothermia evaluation.

## Debriefing

Team debriefing after neonatal resuscitation is recommended to improve performance, identify system issues, and support provider well-being (COR 2a, LOE C-LD).

## Limitations

- Criteria for therapeutic hypothermia were derived from specific clinical trials (NICHD, CoolCap, TOBY) with strict inclusion/exclusion criteria; application to borderline cases requires clinical judgment.
- The 20-minute cutoff for discontinuation of resuscitation is based on observational data and expert consensus, not randomized trials.
- Post-resuscitation management protocols (glucose targets, blood pressure thresholds) are based on limited neonatal-specific evidence and may vary by institution.
- Prognostication based on Apgar scores alone is unreliable; additional diagnostic tools (MRI, EEG, biomarkers) are necessary for comprehensive neurological outcome prediction.
