Category: Neonatal Resuscitation

Neonatal Resuscitation Guideline - Epinephrine

Question#: 557

Question:

Under Neonatal Resus the guidelines to give Epi via ETT state to use 1:10,000 Epi at 0.1mg/kg. Is there a reason why it suggests using 1:10,000 epi instead of 1:1000 epi via ETT route. It seems like we will drown these kids in fluid down the tube (ie. a 4kg neonate would get 4mL of 1:10,000 Epi down the tube every 4 min vs 0.4mL if it were 1:1000). If I look at the medical cardiac arrest directive, the suggested ETT administration for epi is 1:1000 and NOT 1:10,000 for those greater than 30 days old. Furthermore, PediStat suggests using 1:1000 Epi via the ETT and only using 1:10,000 Epi for IV/IO.

Answer:

1:10,000 epinephrine is the preferred choice for endotracheal administration in neonatal resuscitation (if no IV/IO is available) as it provides a dilution of the epinephrine and is able to account for loss of fluid in endotracheal tube and non-ventilatory sections of the tracheobronchial tree. Furthermore, as no dilution is required, there is less risk of making a medication error.

1:1,000 epinephrine is an acceptable option but the medication needs to be diluted with 3 - 5 ml of normal saline, creating more opportunities for medication error.

Undiluted 1:1,1000 epinephrine (0.4 ml for a 4 kg patient) will be ineffective as a significant loss of medication will occur in the syringe, endotracheal tube and bronchial tree, leaving very little for absorption.

References 
* Ralston, M.E., 2020. Primary drugs in pediatric resuscitation. UpToDate, accessed 01-Dec-2021.
* Fernandes, C.J., Neonatal resuscitation in the delivery room. UpToDate, accessed 01-Dec-2021.

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