- Epinephrine and Vascular Access
- Volume Expansion, Adjunctive Medications, and Glucose
Epinephrine and Vascular Access
Fewer than 1% of neonatal resuscitations require medications, but when they do, speed and accuracy of administration are directly linked to outcome. Epinephrine is the only drug used during active cardiac arrest. Volume expanders, naloxone, and dextrose have no role while compressions are running.
Indication for epinephrine
Epinephrine is indicated when the heart rate remains below 60 bpm despite a minimum of 30 seconds of effective coordinated chest compressions and ventilation via an advanced airway. The requirement for effective compressions and ventilation before medication is important, as epinephrine will not compensate for inadequate CPR. If PPV is not producing chest rise or compressions are not being performed correctly, those deficiencies must be corrected before epinephrine is expected to have effect.
Epinephrine dosing
Epinephrine is administered as a 1:10,000 solution (0.1 mg/mL). The intravenous and intraosseous dose differs from the endotracheal dose, reflecting differences in absorption and bioavailability (Table 12):
Route | Dose | Concentration | Notes |
|---|---|---|---|
| IV/IO (preferred) | 0.1–0.3 mL/kg | 1:10,000 (0.1 mg/mL) | Follow with 0.5–1 mL normal saline flush |
| Endotracheal (ET) | 0.5–1.0 mL/kg | 1:10,000 (0.1 mg/mL) | Only if IV/IO not immediately available; instill directly into ETT, follow with PPV breaths |
The IV/IO route is strongly preferred. Endotracheal epinephrine has unpredictable absorption and lower peak plasma concentrations than IV dosing. If the ET route is used due to delay in vascular access, IV/IO access should continue to be established and IV epinephrine given as soon as access is available.
Repeat dosing is administered every 3-5 minutes if the heart rate remains below 60 bpm. If multiple doses haven't moved the HR, stop and reassess: CPR quality, airway position, and whether there's a correctable cause.
Vascular access - umbilical venous catheter
The umbilical venous catheter (UVC) is the preferred route for vascular access during neonatal resuscitation. It can be inserted rapidly without interrupting compressions and provides reliable IV access.
The UVC is inserted 2-4 cm into the umbilical vein (the single large, thin-walled vessel at the 12 o'clock position on the cord cross-section) until blood return is confirmed, then flushed with 0.5 mL normal saline and secured. Do not advance past 4 cm without X-ray confirmation; deep insertion risks hepatic or portal vein placement.
The UVC should not be used for prolonged medication infusions in the resuscitation room without X-ray confirmation of placement.
Vascular access - intraosseous
Intraosseous access is the alternative when UVC insertion cannot be achieved or is delayed. Current guidelines maintain the IV-before-IO hierarchy but provide expanded guidance on IO technique and confirmation, reflecting increasing familiarity with IO access in the delivery room setting.
The proximal tibia is the standard IO insertion site in neonates. The needle is inserted 1–2 cm below the tibial tuberosity on the anteromedial surface. Correct placement is confirmed by the absence of resistance after penetrating the cortex, the needle standing upright without support, and free flow of a saline flush without subcutaneous infiltration. Drug doses and concentrations for IO administration are identical to IV.
Medically reviewed by: Kim Murray, RN, MS., Medical Educator
