The Neonatal Resuscitation Program (NRP) provides a structured approach for healthcare professionals attending to newborns at birth. Epinephrine is the primary drug used during advanced neonatal resuscitation when a newborn’s circulatory system fails to respond to initial efforts. This information is for educational purposes and should be used with official NRP certification and current guidelines.
Indications for Epinephrine in Neonatal Resuscitation
Epinephrine is reserved for newborns with severe and persistent bradycardia, an abnormally slow heart rate. Before considering this medication, the resuscitation team must complete several foundational steps. The process begins with at least 30 seconds of effective positive-pressure ventilation (PPV), confirmed by visible chest movement.
If the newborn’s heart rate remains below 60 beats per minute despite effective ventilation, the next step is to initiate high-quality chest compressions. These compressions are coordinated with PPV using 100% oxygen for another 60 seconds. Epinephrine is indicated only after these ventilation and circulation support measures fail to raise the heart rate above 60 beats per minute.
The underlying cause of severe bradycardia in newborns is typically profound hypoxemia and acidosis, which differs from the common causes of cardiac arrest in adults. Restoring lung aeration and providing effective ventilation are the most important actions in correcting this, which is why they are performed first.
Recommended Dosage and Concentration
The standard concentration of epinephrine (1 mg/mL or 1:1,000) must be diluted before administration to a concentration of 0.1 mg/mL, referred to as a 1:10,000 solution. This dilution is a safety measure to prevent administering an overly concentrated dose.
For intravenous (IV) or intraosseous (IO) administration, the recommended dose range is 0.01 to 0.03 mg per kilogram of the infant’s estimated body weight. The NRP suggests an initial dose of 0.02 mg/kg, which translates to a volume of 0.2 mL/kg of the 1:10,000 solution. For a newborn weighing 3 kilograms, an initial 0.02 mg/kg dose would be 0.06 mg, which is equal to 0.6 mL of the prepared solution.
An alternative route is through an endotracheal (ET) tube, though this method is less effective. If this route is used while vascular access is being established, the dose is higher to account for poor absorption from the lungs. The ET dose range is 0.05 to 0.1 mg/kg, which is equivalent to 0.5 to 1 mL/kg of the 1:10,000 solution.
Routes of Administration
The preferred route for administering epinephrine is intravenous (IV), as it delivers the medication directly into the central circulation for rapid effect. The most common access point in a newborn is the umbilical vein. A properly placed umbilical venous catheter (UVC) provides a reliable path for the drug to reach the heart and allows for 100% bioavailability.
When establishing IV access is difficult or delayed, the intraosseous (IO) route is the recommended alternative. This involves inserting a specialized needle into the bone marrow cavity, typically in the flat surface of the tibia. The bone marrow’s rich vascular network allows the medication to be absorbed into the systemic circulation almost as quickly as a direct IV injection.
The endotracheal (ET) route is no longer recommended as a primary option. Research has shown that drug absorption via this route is highly unreliable and unpredictable, and it does not provide the consistent results seen with IV or IO administration.
Administration Procedure and Post-Resuscitation Monitoring
When administering epinephrine through an IV or IO line, the dose should be given rapidly. It is immediately followed by a 0.5 to 1 mL flush of normal saline to propel the medication from the catheter into the central circulation.
After the initial dose, the resuscitation team continues coordinated chest compressions and ventilation. Approximately 60 seconds after the dose is given, the team should pause to reassess the newborn’s heart rate. If the heart rate remains below 60 beats per minute, a repeat dose of epinephrine may be administered every 3 to 5 minutes.
Once there is a return of spontaneous circulation and the heart rate is consistently above 60 bpm, the focus shifts to post-resuscitation care. The newborn requires continuous monitoring for potential side effects like hypertension and tachycardia. Close observation in a neonatal intensive care unit (NICU) is necessary to manage these effects and support the infant’s transition.