The Neonatal Resuscitation Program (NRP) provides a standardized, evidence-based approach for managing newborns who struggle to transition from fetal to independent life. This protocol reserves the use of medications for the most severe cases of cardiorespiratory failure. Epinephrine, a potent vasoactive agent, is the primary medication administered during a neonatal code. It functions to stimulate the heart, constrict peripheral blood vessels, and improve blood flow to the heart and brain. The correct administration and precise dosing of this drug are governed by current American Academy of Pediatrics (AAP) and American Heart Association (AHA) guidelines for Neonatal Resuscitation.
Clinical Triggers for Epinephrine
Epinephrine is not a first-line intervention in neonatal resuscitation; its use represents a late stage in the established sequence of care. The initial and most foundational step is ensuring effective positive-pressure ventilation (PPV) to inflate the lungs, which is the most common cause of bradycardia in newborns. If the newborn’s heart rate remains below 100 beats per minute (bpm) despite 30 seconds of effective PPV, the resuscitation progresses.
The next step involves initiating chest compressions, coordinated with ventilation, if the heart rate is still below 60 bpm after 30 seconds of high-quality PPV. Chest compressions are delivered at a 3:1 ratio (three compressions for every one breath) and should continue for a full 60 seconds with an oxygen concentration of 100%. Only if the heart rate remains below 60 bpm after this combined 60 seconds of coordinated compressions and effective ventilation is epinephrine indicated.
Endotracheal Route Preparation and Dose
The administration of epinephrine via the endotracheal (ET) tube is considered a temporary measure while healthcare providers attempt to establish a more reliable vascular access. This route is less desirable because the absorption of the drug through the lungs is variable and less predictable. Despite this drawback, the ET route offers an immediate option when the newborn’s heart rate is critically low and vascular access is not yet secured.
The concentration of epinephrine used for this purpose is the standard 1:10,000 solution. The dose required for the ET route is significantly higher than the intravenous dose to compensate for the poor and delayed absorption through the pulmonary vasculature. The recommended weight-based dose range for endotracheal administration is 0.05 to 0.1 mg per kilogram (mg/kg) of body weight.
To ensure the drug reaches the absorption surface of the lungs, the epinephrine dose should be followed by a small volume of normal saline flush. The total volume administered, which includes the drug and the flush, must be delivered into the ET tube and followed by several positive-pressure breaths. This action helps to distribute the medication throughout the lung tissue, facilitating whatever limited systemic absorption is possible.
Intravenous Route Administration and Dose
The intravenous (IV) route is the preferred and definitive method for administering epinephrine during neonatal resuscitation due to its rapid and reliable delivery directly into the central circulation. Establishing prompt vascular access, typically through an umbilical venous catheter (UVC) or, alternatively, an intraosseous (IO) needle, is a high priority once the need for medication is identified. The drug concentration used for the IV route remains the standard 1:10,000 solution.
The correct weight-based dose for IV or IO administration is substantially lower than the ET dose, typically falling in the range of 0.01 to 0.03 mg/kg. For educational simplicity and to ensure prompt administration, a starting dose of 0.02 mg/kg is often taught and used as the initial IV dose. Once the dose is drawn up, it must be injected rapidly into the vascular access site.
The rapid injection is immediately followed by a normal saline flush to ensure the entire dose is pushed quickly from the catheter into the newborn’s central circulation. This flush ensures maximum drug bioavailability and minimizes the time to effect, which is crucial in a life-threatening scenario.
Assessing Response and Repeat Dosing Protocol
Following the administration of epinephrine, the care team must immediately assess the newborn’s heart rate and clinical status to determine the drug’s effectiveness. The expected monitoring interval for assessing the response is approximately one minute after the dose has been delivered and flushed into the circulation. A successful response is defined by an increase in the heart rate to above 60 bpm, signifying a return of adequate cardiac function.
If the heart rate remains below 60 bpm after the initial dose and one minute of continued chest compressions and ventilation, a repeat dose of epinephrine is indicated. Subsequent doses should be repeated every three to five minutes as long as the heart rate remains critically low. All subsequent doses should utilize the preferred IV or IO route if vascular access has been secured, even if the initial dose was given via the ET tube.
If the newborn remains bradycardic despite two or three adequate doses of epinephrine delivered via confirmed vascular access, the team must consider other potential underlying causes. In situations where the newborn has a history or physical signs suggesting acute blood loss or shock, volume expansion with crystalloid solution or blood may be considered. This addresses the possibility that the circulatory failure is due to severe hypovolemia rather than a purely cardiac issue.