What is the recommended dose of adrenaline (epinephrine) for neonatal care?

Adrenaline (Epinephrine) Dosing for Neonatal Resuscitation

For neonatal resuscitation, intravenous epinephrine should be administered at a dose of 0.01 to 0.03 mg/kg when heart rate remains below 60 beats per minute despite adequate ventilation and chest compressions; if intravenous access is unavailable, endotracheal administration at a higher dose of 0.05 to 0.1 mg/kg may be used while vascular access is being established. 1

Indications for Epinephrine Use

Epinephrine administration is indicated when:

• Heart rate remains below 60 beats per minute despite:
  • Adequate ventilation with 100% oxygen
  • Effective chest compressions for at least 30 seconds

Route of Administration and Dosing

Primary Route: Intravenous (IV)

• Dose: 0.01-0.03 mg/kg
• Concentration: 1:10,000 (0.1 mg/mL)
• Administration: Via umbilical venous catheter (preferred vascular access)
• Interval: Repeat every 3-5 minutes if heart rate remains <60 bpm 1

Alternative Route: Endotracheal (ET)

• Dose: 0.05-0.1 mg/kg (higher dose required)
• Concentration: 1:10,000 (0.1 mg/mL)
• Administration: Only while vascular access is being established
• Note: ET administration results in lower blood concentrations and may be less effective than IV administration 1

Practical Preparation Recommendations

For IV administration:

• Prepare 0.02 mg/kg (0.2 mL/kg of 1:10,000 solution) in a 1 mL syringe 2
• This dose works well for infants from 500g to 5kg

For ET administration:

• Prepare 0.1 mg/kg (1 mL/kg of 1:10,000 solution) in a 5 mL syringe 2

Important Considerations and Cautions

• Do not delay: Administer as soon as indicated after failed ventilation and compressions
• Avoid high IV doses: Higher IV doses (>0.03 mg/kg) are not recommended and may be harmful 1
• Establish IV access quickly: Even after ET administration, obtain IV access for subsequent doses 1
• Monitor response: The primary indicator of improved ventilation and circulation is an increase in heart rate

Evidence Quality and Limitations

The evidence supporting these recommendations is of very low certainty, primarily due to:

• Lack of controlled clinical trials in neonates
• Reliance on animal studies and extrapolation from pediatric data
• Small observational studies with risk of bias 1, 3

Despite these limitations, the International Liaison Committee on Resuscitation (ILCOR) maintains these recommendations based on the best available evidence and clinical experience.

Common Pitfalls to Avoid

1. Premature administration: Ensure adequate ventilation and chest compressions before considering epinephrine
2. Dosing errors: Use appropriate concentration (1:10,000) and calculate dose carefully
3. Delayed vascular access: Have a plan for rapid umbilical venous catheter placement
4. Excessive dosing: Higher IV doses may increase mortality and interfere with cerebral blood flow 1
5. Relying solely on ET route: Continue efforts to establish IV access even after ET administration

The evidence suggests that while epinephrine improves return of spontaneous circulation, its effects on long-term survival and neurological outcomes remain uncertain, particularly in asphyxiated or preterm infants 4. Nevertheless, when indicated, prompt administration following the recommended dosing is the current standard of care for neonatal resuscitation.