What is the recommended dose of epinephrine (adrenaline) in neonatal resuscitation?

Epinephrine Dosing in Neonatal Resuscitation

The recommended dose of epinephrine in neonatal resuscitation is 0.01-0.03 mg/kg intravenously (IV) when heart rate remains below 60 beats per minute despite adequate ventilation and chest compressions; if IV access is unavailable, endotracheal administration at a higher dose of 0.05-0.1 mg/kg may be used while vascular access is being established. 1

Route of Administration and Dosing

Intravenous Administration (Preferred)

• Dose: 0.01-0.03 mg/kg 2, 1
• Concentration: 1:10,000 (0.1 mg/mL) 2
• Frequency: Repeat every 3-5 minutes if heart rate remains <60 bpm 1
• Higher IV doses (>0.03 mg/kg) are not recommended due to evidence of:
  • Exaggerated hypertension
  • Decreased myocardial function
  • Worse neurological outcomes
  • Increased postresuscitation mortality 2

Endotracheal Administration (Alternative)

• Dose: 0.05-0.1 mg/kg 2, 1
• Only to be used while IV access is being established 2, 1
• Less effective than IV administration at equivalent doses 2
• Higher doses are required endotracheally to achieve blood concentrations similar to IV administration 2

Clinical Decision Algorithm

1. Assess need for epinephrine

   • Only indicated when heart rate remains <60 beats per minute despite:
     • Adequate ventilation with 100% oxygen
     • Effective chest compressions 2, 1

2. Determine administration route

   • Attempt IV access (preferably umbilical venous catheter) first 2
   • If IV access cannot be rapidly established, proceed with endotracheal administration while continuing to establish IV access 2, 1

3. Administer appropriate dose

   • IV route: 0.01-0.03 mg/kg
   • Endotracheal route: 0.05-0.1 mg/kg 2, 1

4. Monitor response

   • Primary indicator: Increase in heart rate
   • If no response within 3-5 minutes, repeat dose 1

Important Considerations and Pitfalls

• Epinephrine should not be administered until adequate ventilation and chest compressions have been established 2
• Avoid delay in epinephrine administration once indicated 1
• Dosing errors are common during neonatal resuscitation 3
  • Consider preparing standardized doses:
    • IV: 0.02 mg/kg (0.2 mL/kg of 1:10,000 solution) in a 1 mL syringe
    • ET: 0.1 mg/kg (1 mL/kg of 1:10,000 solution) in a 5 mL syringe 3
• Despite widespread use, evidence supporting epinephrine in neonatal resuscitation is limited and largely extrapolated from pediatric and adult studies 4, 5
• The 2020 systematic review found very low certainty evidence comparing endotracheal versus IV administration, with no significant differences in survival outcomes 5

The current recommendations are maintained by international resuscitation committees despite limited evidence, based on the best available data and clinical experience 1. Proper preparation and administration of epinephrine at the recommended doses is crucial for optimizing outcomes in neonatal resuscitation.