What is the best type of Intravenous (IV) access for Neonatal Resuscitation Program (NRP) and what are the alternative options?

Best IV Access for Neonatal Resuscitation

Umbilical venous catheterization is the primary and preferred method for vascular access during newborn resuscitation in the delivery room. 1

Primary Access: Umbilical Venous Catheter (UVC)

• The umbilical venous catheter should be your first-line approach for all neonatal resuscitations requiring vascular access in the delivery room. 1
• This recommendation is based on the 2020 International Consensus on Cardiopulmonary Resuscitation, which represents the most current guideline evidence available. 1
• UVC is the most commonly taught technique to neonatal providers and has the advantage of being readily accessible immediately after birth. 1
• The umbilical vein remains patent for several days after birth, making it a reliable option during the early neonatal period. 2

Practical Considerations for UVC

• UVC can be successfully established within a median of 5 minutes after birth in preterm infants. 3
• The catheter should be positioned centrally for optimal medication delivery, though up to 40% may be malpositioned without ultrasound guidance. 2
• Point-of-care ultrasound should be used when available to confirm proper tip location. 2
• An alternative rapid technique involves direct puncture of the umbilical vein through Wharton's jelly, which has been successfully used when traditional catheterization is difficult. 4

Alternative Access: Intraosseous (IO) Route

If umbilical venous access cannot be established or is not feasible, intraosseous access is the recommended alternative. 1

When to Consider IO Access

• Use IO access when UVC placement fails or is delayed beyond acceptable timeframes during active resuscitation. 1, 5
• IO access is particularly valuable in out-of-hospital settings where umbilical access may be more challenging. 1
• Consider IO access later in the NICU stay when the umbilical vein is no longer patent. 1

Critical Safety Warning About IO Access

• Be aware that serious complications have been reported with IO access in neonates, including tibial fractures, extravasation leading to compartment syndrome, and amputation. 1
• Despite these risks, IO access remains a reasonable alternative when umbilical access fails, as the priority is establishing vascular access during life-threatening resuscitation. 1
• The evidence supporting IO use in neonates is very limited—no case series or case reports of IO use specifically at delivery were identified in systematic reviews. 1

Setting-Specific Recommendations

In the Delivery Room

• First attempt: Umbilical venous catheterization 1
• Second attempt: Intraosseous access if UVC fails 1

Outside the Delivery Room

• Either umbilical venous access or IO route may be used based on local availability, training, and experience. 1
• The choice depends on whether the umbilical vein is still patent and provider expertise with each technique. 1

Other Access Routes: Not Recommended as Primary Options

Peripheral IV Access

• Peripheral IV catheters should not be the primary choice during active neonatal resuscitation requiring medications. 3, 5
• While peripheral IV access is feasible in preterm infants (successful in most cases on first attempt within 4-9 minutes), this timeframe is too long during critical resuscitation. 3, 5
• Peripheral access is appropriate for stable infants requiring IV fluids but not for emergency medication administration during CPR. 3

Endotracheal Route

• Endotracheal administration of medications should be limited to situations where no vascular access can be established. 5
• Animal studies demonstrate that significantly higher doses of epinephrine are required via endotracheal route compared to IV administration, potentially increasing side effects. 5
• This route is a last resort only when both UVC and IO access have failed. 5

Laryngeal Mask Airway (LMA)

• LMA for medication administration is not recommended as a primary route. 5
• Similar to endotracheal administration, higher doses are required with increased risk of adverse effects. 5

Evidence Quality and Limitations

The recommendations are based on weak evidence with very low certainty, as no randomized controlled trials, cohort studies, or case-control studies comparing these routes exist in neonatal resuscitation. 1, 5 However, the consensus strongly favors umbilical venous access based on clinical experience, provider familiarity, and public feedback from neonatal experts. 1