What are the most common drugs used in neonatal resuscitation, and when are they indicated?
Drugs are rarely used in neonatal resuscitation, as most problems are improved by addressing airway, breathing, and circulation. Bradycardia in the newborn is usually due to inadequate lung inflation and hypoxemia, so adequate ventilation is most important.
Epinephrine is recommended when the heart rate remains below 60 beats per minute despite adequate ventilation with 100% oxygen and chest compressions for 30 seconds. Evidence from neonatal models shows increased diastolic and mean arterial pressures in response to epinephrine. The current recommended dose for epinephrine during neonatal resuscitation is 0.01 to 0.03 mg/kg of 1:10,000 concentration (0.1-0.3 mL/kg). High-dose epinephrine is not recommended for neonates because of the rare incidence of ventricular fibrillation and the theoretical risk of a hypertensive response, which could result in intraventricular hemorrhage. Use the intravenous route.
Atropine is a parasympathetic drug that decreases vagal tone and is not recommended in neonatal resuscitation. Bradycardia in the neonate is usually caused by hypoxia, and therefore atropine is unlikely to be beneficial.
Naloxone is a narcotic antagonist and is not indicated in the initial resuscitation of the newly born.
Volume expanders such as crystalloids (normal saline or Ringer’s lactate) and colloids (blood) are indicated for signs of hypovolemia. Signs of hypovolemia in the neonate include pallor, weak pulses, and poor response to resuscitative efforts. The dose for volume expanders is 10 mL/kg, with reassessment after each dose. Isotonic crystalloids are the first choice among volume expanders. Red blood cells (O negative) are indicated in situations of large blood loss.
Aronson PL, Alessandrini EA: Neonatal resuscitation. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 6th ed. Philadelphia, Lippincott Williams & Wilkins, 2010.
Barber CA, Wyckoff MH: Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics 2006;118:1028-1034.