Neonatal Resuscitation Program (NRP): Medications

What follows is from the 2011 Textbook:*

“If resuscitation steps (particularly, effective PPV) are implemented in a skillful and timely manner, more than 99% of newborns requiring resuscitation will improve without the need for medications. Before administering medications in an intensive resuscitation, you should check the effectiveness of ventilation several times, . . . , chest compressions should be started and coodinated with ventilations and the oxygen concentration should be increased to 100%. With such poor cardiac output, the pulse oximeter usually will not give a reading. In most cases, you will chose to insert an endotracheal tube to ensure a stable airway and effective coordination of chest compressions and PPV if effective ventilation alone has not resulted in an increase in the baby’s heart rate.” (p 214)

“The most reliable route of administration of medications is the intravenous route.” And the way to accomplish is with emergency insertion of an umbilical vein catheter.* (p 215)

The DVD that comes with the 2011 Textbook has three outstanding Resuscitation Skills Videos relating to emergency umbilical venous catheterization: Preparing the Emergency UVC Catheter for Insertion, Placing an Emergency UVC, and Securing and Safeguarding the Emergency UVC.

A great brief (5 minute) online resource is The 3 x 3 Method for Placing Emergency Umbilical Venous Catheters (UVCs) is by Drs. Bryne and Strand from the Indiana University School of Medicine Department of Pediatrics and is available on YouTube titled Emergency UVC Placement. I have made a transcript of the narration of this video in my blog post Emergency Umbilical Vein Catheterization for Newborns—An Outstanding Video Resource and you can also watch the video on the blog post.  

Epinephrine in Neonatal Resuscitation

“Epinephrine is indicated when the heart rate remains below 60 beats per minute after you have given 30 seconds of effective assisted ventilation (preferably after endotracheal intubation) and at least another 45 to 60 seconds of coordinated chest compressions  and effective ventilation.” (p 219)

“Although epinephrine comes in 2 concetrations, only the 1:10,000 preparation should be used in neonatal resuscitation.” (p 219)

“The recommended intravenous dose in newborns is 0.1 to 0.3 mL/kg of a 1:10,000 solution (equal to 0.01 to 0.03 mg/kg). You will need to estimate the baby’s weight after birth.* (p 219)

You will draw up the 1:10,000 epinephrine solution in a 1-mL syringe for IV administration. Push rapidly your calculated dose. And then follow it by a 0.5 to 1 mL normal saline flush.* (p 220)

“Check the baby’s heart rate about 1 minute after administering epinephrine. . . . As you continue PPV with 100% oxygen and chest compressions, the heart rate should increase to more than 60 bpm within approximately 1 minute after you give epinephrine intravenously; . . . . The primary mechanism for epinephrine’s effect is that it increases vascular resistance and, therefore, systemic blood pressure, thus improving blood flow to the coronary arteries, resulting in improved contractility of the heart muscle.”* (p 221)

“If the heart rate does not increase to above about 60 bpm after the first dose of epinephrine, you can repeat the dose every 3 to 5 minutes.”* (p 221)

But the critical points both before and after you give your first dose of IV epinephrine is to make sure that you are delivering effective ventilations and effective chest compressions.* (p 221)

“If there is poor response to resuscitation, and the baby is pale or there is evidence of blood loss, you will want to consider the possibility of hypovolemia.”* (p 221)

“What should you do if the baby remains bradycardic after epinephrine administration, and there is strong suspicion of acute blood loss?”* (p 223)

“If the baby appears in shock and is not responding to resuscitation, administration of a volume expander may be indicated.” (p 223)

The recommended solution is 0.9% NaCl (normal saline) and the recommended dose is 10 mL/kg.* (p 223)

The recommended route of administration is the umbilical vein catheter and the recommended rate of adminstration is over 5-10 minutes.* (p 224)

“O Rh-negative packed red blood cells should be considered as part of the volume replacement when severe fetal anemia is documented or expected.” See the rest of this paragraph in the textbook for important caveats.*  (p 223)

“Volume expanders should not be routinely given during resuscitation in the absence of a history or indirect evidence of  acute blood loss.”* (p 223)


*Textbook of Neonatal Resuscitation, 6th ed. 2011, American Academy of Pediatrics and American Heart Association.

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