Neonatal Resuscitation

Epinephrine Administration

For neonates requiring epinephrine, the American Academy of Pediatrics and the American Heart Association recommend an IV dose of 0.01-0.03 mg/kg, with a concentration of 1:10,000 (0.1 mg/mL), to be repeated every 3-5 minutes if heart rate remains <60 bpm 1, 2, 3, 4
Higher IV doses (>0.03 mg/kg) are not recommended due to evidence of exaggerated hypertension, decreased myocardial function, worse neurological outcomes, and increased postresuscitation mortality, as advised by the American Heart Association and the American Academy of Pediatrics 1, 2
Endotracheal administration requires higher doses (0.05-0.1 mg/kg) to achieve blood concentrations similar to IV administration, but may result in lower blood concentrations and be less effective than intravenous administration, according to the International Liaison Committee on Resuscitation (ILCOR) 1, 2
Epinephrine should only be administered when heart rate remains <60 beats per minute despite adequate ventilation with 100% oxygen and effective chest compressions, as recommended by the American Heart Association and the American Academy of Pediatrics 3, 4
The American Heart Association recommends attempting IV access first, and if IV access cannot be rapidly established, proceeding with endotracheal administration while continuing to establish IV access, with the primary indicator of response to epinephrine being an increase in heart rate, as emphasized by the International Liaison Committee on Resuscitation (ILCOR) 2, 3, 4

For neonates requiring continuous epinephrine infusion after volume resuscitation, the American Academy of Pediatrics recommends a dose of 0.1-1.0 μg/kg per minute, starting at the lowest dose and titrating to the desired clinical effect 5
The maximum dose of epinephrine infusion may be up to 5 μg/kg/min in severe cases, as recommended by the American Academy of Pediatrics 5
If extravasation occurs, the American Academy of Pediatrics suggests considering phentolamine (0.1-0.2 mg/kg up to 10 mg diluted in 10 mL of 0.9% sodium chloride) injected intradermally at the extravasation site 5

The American Heart Association recommends repeat doses of epinephrine every 3-5 minutes if heart rate remains <60/min 4
The American Heart Association advises against delaying epinephrine administration after failed ventilation and compressions, and recommends avoiding high intravenous doses (>0.03 mg/kg) as they may be harmful 2, 1
The International Liaison Committee on Resuscitation (ILCOR) emphasizes the importance of establishing intravenous access quickly, even after endotracheal administration, and monitoring the response to epinephrine 4

The recommendations for epinephrine administration in neonates are based on very low-certainty evidence, according to the American Heart Association 4
Despite the limitations of the evidence, the International Liaison Committee on Resuscitation (ILCOR) and the American Heart Association recommend prompt administration of epinephrine when indicated, following the recommended dosing as the current standard of care for neonatal resuscitation 2, 4