What is the drug of choice for neonatal cardiac arrest?

Drug of Choice for Neonatal Cardiac Arrest

Epinephrine (adrenaline) is the drug of choice for neonatal cardiac arrest, administered intravenously at 0.01-0.03 mg/kg when the heart rate remains below 60 beats per minute despite adequate ventilation with 100% oxygen and chest compressions. 1

Route and Dosing Algorithm

First-Line: Intravenous/Intraosseous Administration

• Administer epinephrine 0.01-0.03 mg/kg IV/IO (using 1:10,000 concentration = 0.1 mg/mL) as soon as vascular access is established 1, 2
• The IV route is strongly preferred because it achieves higher peak plasma concentrations (470±250 ng/mL at 1 minute) compared to endotracheal administration (130±60 ng/mL at 5 minutes), and results in shorter time to return of spontaneous circulation (2 minutes vs 4.5 minutes) 1
• Repeat doses every 3-5 minutes if heart rate remains <60 bpm 1, 2

Alternative: Endotracheal Administration (Only While Obtaining Vascular Access)

• If IV/IO access is not yet available, administer a higher endotracheal dose of 0.05-0.1 mg/kg (using 1:10,000 concentration) 1, 2
• The higher endotracheal dose is necessary because endotracheal administration results in significantly lower blood concentrations and reduced efficacy compared to IV administration 1
• Do not delay attempts to establish vascular access while giving endotracheal epinephrine 1
• Once IV/IO access is obtained, give an intravascular dose immediately regardless of the interval after any endotracheal dose 1

Critical Dosing Considerations

Avoid High-Dose IV Epinephrine

• Do not exceed 0.03 mg/kg for IV administration 1, 2
• High-dose IV epinephrine (≥0.1 mg/kg) increases risk of post-resuscitation mortality, interferes with cerebral cortical blood flow and cardiac output, and causes exaggerated hypertension with decreased myocardial function 1, 2
• Evidence from pediatric studies shows increased mortality risk with high-dose IV epinephrine 1

Practical Preparation

• For endotracheal administration: prepare 0.1 mg/kg or 1 mL/kg of 1:10,000 epinephrine in a 5 mL syringe 3
• For IV administration: prepare 0.02 mg/kg or 0.2 mL/kg of 1:10,000 epinephrine in a 1 mL syringe, which accommodates birth weights from 500g to 5kg 3

When to Administer Epinephrine

Epinephrine is indicated only after the heart rate remains <60 bpm despite:

1. Adequate ventilation with 100% oxygen (usually requiring endotracheal intubation) 1
2. Chest compressions for at least 30 seconds 1, 4
3. Using a 3:1 compression-to-ventilation ratio (90 compressions and 30 breaths per minute) 1, 4

Important Pitfalls to Avoid

• Never administer epinephrine before establishing adequate ventilation - bradycardia in newborns is usually due to inadequate lung inflation or profound hypoxemia, and ventilation is the most effective resuscitation action 1, 4
• Two case series documented inappropriate early use of endotracheal epinephrine before airway and breathing were established 1
• Dosing errors are common when preparing epinephrine for neonatal resuscitation; use color-coded syringes and weight-based preparation to minimize errors 3

Evidence Quality and Guideline Consensus

The 2020 International Consensus on Cardiopulmonary Resuscitation provides the most recent evidence-based recommendations, though the certainty of evidence remains very low due to the rarity of neonatal cardiac arrest requiring epinephrine 1. The recommendations are consistent across the 2010 and 2020 guidelines, with refinement emphasizing the superiority of IV over endotracheal administration 1. No other medications (including vasopressin) have sufficient neonatal evidence to recommend as alternatives 5, 6.