Neonatal nurses must have the knowledge and skill to actively resuscitate ill neonates along with an interdisciplinary team.

Hi there!

Have you ever been in a neonatal code? Maybe you have been in a critical delivery or a code situation when a baby decompensated in the NICU. There are several medications we administer in a code to support the baby's systems and resuscitate cardiopulmonary function. Let's talk about them!

Epinephrine: 🚨💉

Epinephrine is a lifesaver when adequate ventilation, oxygenation, and chest compressions fail to increase the heart rate above 60. Epinephrine can be administered via two routes: Endotracheal and Intravenous/Intraosseous. Though the IV route is the preferred route...

A concentration of 0.1mg/mL of Epinephrine is used in neonates. Epinephrine doses are 0.1mg/kg (1mL/kg) via the endotracheal route. The endotracheal route is less effective than the IV route but can be helpful when we are still trying to establish IV access.

Epinephrine is administered intravenously at a dose of 0.02 mg/kg (0.2mL/kg). After the dose be sure to flush with 3mL of Normal Saline for adequate delivery. 

Here's a safety tip I always like to give my students: IV epinephrine should only be drawn up in a 1 mL syringe. If anyone ever hands you "IV epi" and it's in a 3mL or a 5mL (!!) syringe you should question it. Similarly, endotracheal epi should be drawn up in a 3 or 5-mL syringe (depending on how big your baby is). 

Be aware the language of 1:10,000 concentration is no longer used due to the FDA requiring this change in 2017 to prevent medication errors. I'm so glad, cause the 1:10,000 vs 1:1,000 thing always confused me.

Epinephrine should be repeated every 3-5 minutes if necessary. In cases where the HR remains <60 despite epinephrine administration, volume expanders like normal saline should be given to address hypovolemia contributing to cardiovascular collapse. The dose for volume expanders is 10mL/kg given over 5-10 minutes. Watch closely for improved HR, peripheral perfusion, and neurologic status, and be cautious of signs of fluid. Signs of fluid overload include hepatomegaly or rales/crackles on auscultation.

Blood Glucose Measurement and Treatment 🩸🍬

During resuscitation, prompt measurement of blood glucose is essential, as glucose serves as the primary metabolic substrate for the heart and brain. If hypoglycemia is detected, a bolus dose of 2mL/kg of Dextrose 10% (D10) IV should be given.

Ensure the continuous IV infusion provides a GIR (glucose infusion rate) of 5-6 mg/kg/min to maintain euglycemia (aka normal glucose levels).

Do not give D25 or D50 concentrations of Dextrose! This is a common RNC-style question that I see, particularly if you are resuscitating a newborn outside the NICU (like an Emergency Department). These concentrations will cause glucose levels to spike and subsequently fall, so don't fall for that tricky question on the certification exam.

Sodium Bicarbonate (NaHCO3)⚠️🧪

NaHCO3 is no longer part of the NRP algorithm because CO2 is produced when NaHCO3 is mixed with acid in the blood. This causes worsening acidosis in neonates with impaired ventilation. With that said there are times in neonatal resuscitation (outside the delivery room) where NaHCO3 is indicated. 

NaHCO3 is used for the treatment of life-threatening hyperkalemia. It helps move potassium into the cells, decreasing potassium levels. Rapid correction of metabolic acidosis with NaHCO3 must be avoided, as it can lead to complications such as IVH, hyperosmolality, metabolic alkalosis, hypernatremia, hypokalemia, and hypocalcemia. Routine use in cardiac arrest is not recommended. The use of sodium bicarbonate is controversial and each individual patient must be evaluated for potential risks and benefits. 

Calcium Administration: 💊🦴

Calcium is given to prevent cardiac arrhythmias by stabilizing the cell membrane of the myocardium. Calcium may be given during cardiac arrest in the presence of hyperkalemia or hypocalcemia.

Calcium chloride is more bioavailable but must be given through central venous access to prevent tissue damage. The dose is 20mg/kg or 0.2mL/kg.

Calcium gluconate is less irritating and can be administered peripherally, although central administration is preferred. The dose for calcium gluconate is 100mg/kg or 1mL/kg, given via slow IV push during resuscitation.

Atropine for AV Block or Bradycardia 🌿💓

Atropine is indicated for primary AV block or bradycardia unresponsive to airway support, oxygenation, and epinephrine. Administer at a dose of 0.02mg/kg IV.

Be aware that low doses of atropine may cause paradoxical bradycardia due to its central actions, as it acts as a competitive antagonist of acetylcholine.

Adenosine for Symptomatic SVT 💗🏃‍♂️

Adenosine is the first-line pharmacotherapy for symptomatic supraventricular tachycardia (SVT) after unsuccessful vagal maneuvers. Administer at a dose of 0.05-0.1mg/kg via rapid IV push as close to the heart as possible, immediately followed by a saline flush. The reason adenosine must be given rapidly is due to its half-life of <10 seconds and because it is metabolized as it comes into contact with red blood cells. 

It's important to note that adenosine should only be given by providers familiar with ECG readings. Giving adenosine to patients with Wolff-Parkinson-White syndrome can result in atrial and ventricular fibrillation. Adenosine is not effective in treating atrial flutter or atrial fibrillation. 

Prior to giving adenosine have the defibrillator at the bedside, ideally with pads on the baby. Obtain an EKG strip during adenosine administration to assist with determining the etiology of the SVT. If adenosine is unsuccessful after 2-3 doses synchronized cardioversion should be considered. 

In neonatal emergencies, swift and informed action is crucial. I hope that this information equips you with the knowledge needed to address critical situations with confidence and care. 

Have a wonderful day!

Amanda