Epinephrine Dosing and Preparation in Pediatric and Neonatal Resuscitation
For neonatal resuscitation, administer intravenous/intraosseous epinephrine at 0.01-0.03 mg/kg (using 1:10,000 concentration) as the preferred route when heart rate remains <60 bpm despite adequate ventilation and chest compressions, with endotracheal administration at the higher dose of 0.05-0.1 mg/kg reserved only when IV/IO access is unavailable. 1, 2, 3
Intravenous/Intraosseous Route (Preferred)
The IV/IO route is strongly preferred because it achieves higher plasma concentrations more rapidly and results in shorter time to return of spontaneous circulation compared to endotracheal administration. 2, 4
Dosing Specifications:
- Dose range: 0.01-0.03 mg/kg 1, 2, 3
- Concentration: Use 1:10,000 solution (0.1 mg/mL) 2, 5
- Volume equivalent: 0.1-0.3 mL/kg of 1:10,000 solution 2
- Timing: Administer as soon as possible, ideally within 5 minutes of starting chest compressions 3
- Repeat dosing: Every 3-5 minutes if heart rate remains <60 bpm, using the same IV/IO dose 3, 4
Practical Preparation:
For IV administration, prepare an initial dose of 0.02 mg/kg (0.2 mL/kg of 1:10,000 solution) in a 1 mL syringe, as this middle-range dose enables use of a 1 mL syringe for birth weights from 500g to 5kg and minimizes preparation errors. 6 Color-coded syringes may decrease dosing errors. 6
Endotracheal Route (Only When IV/IO Unavailable)
Endotracheal epinephrine requires significantly higher doses (5-10 times the IV dose) due to lower bioavailability and achieves substantially lower blood concentrations. 1, 2
Dosing Specifications:
- Dose range: 0.05-0.1 mg/kg 1, 2
- Concentration: Use 1:10,000 solution (0.1 mg/mL) 2
- Volume equivalent: 0.5-1.0 mL/kg of 1:10,000 solution 2
Practical Preparation:
Prepare 0.1 mg/kg (1 mL/kg of 1:10,000 solution) in a 5 mL syringe for endotracheal administration based on animal data supporting this higher dose range. 6 Inject directly into the endotracheal tube and immediately continue ventilation. 7
Critical Timing Consideration:
Do not delay repeat IV/IO epinephrine while attempting endotracheal administration or other interventions, as time is critical for survival and neurologic outcomes. 4
Critical Safety Warnings
High-Dose Epinephrine is Harmful:
Intravenous doses >0.03 mg/kg cannot be recommended and may be harmful. 1, 2 Evidence from pediatric trials demonstrates increased risk of mortality with high-dose IV epinephrine (0.1 mg/kg), with no improvement in long-term survival. 1, 4 Animal studies show that IV epinephrine ≥0.1 mg/kg increases postresuscitation mortality and interferes with cerebral cortical blood flow and cardiac output. 1
Common Dosing Errors:
Dosing errors are extremely common when preparing epinephrine for neonatal resuscitation, with only 57% of doses prepared correctly in simulation studies. 8 The availability of two different epinephrine concentrations (1:1,000 and 1:10,000) significantly increases error risk—selecting the correct concentration was the only variable associated with correct dosing. 8
Avoid Premature Administration:
Inappropriate early use of endotracheal epinephrine before establishing adequate airway and breathing has been documented in case series. 1 Ensure effective ventilation and chest compressions are established first. 1, 3
Resuscitation Algorithm Context
Epinephrine is indicated only after adequate ventilation with 100% oxygen and chest compressions (using 3:1 compression-to-ventilation ratio) have failed to increase heart rate to ≥60 bpm. 1, 3, 4 Continue chest compressions and ventilation while administering epinephrine. 4
Flush Volume Considerations:
After UVC epinephrine administration, a 2.5 mL flush volume may be more effective than the standard 0.5-1.0 mL flush in achieving return of spontaneous circulation, though more clinical trials are needed. 9