Around 5–10% of newborns require a degree of support to initiate and maintain a regular breathing rate immediately after birth, with approximately 1% of these needing extensive resuscitation measures, including medication management (Verklan et al, 2021). The updated Resuscitation Council UK guidelines (2021) contain detailed information about advanced neonatal life support that is specifically tailored to clinical practice in the UK.
While there are few major changes to the guidelines, there are updates in relation to neonatal vascular access for medications where the intraosseous route can be used if umbilical access is not possible. In addition, adrenalin/epinephrine initial and subsequent doses are now rationalised, and these can be repeated every 3–5 minutes in the absence of a response to the previous dose despite effective ventilation measures.
Neonatal resuscitation is a rapid response and high-pressure situation. Knowledge of the sequence of potential medications, the appropriate dosages and frequency, and routes of administration, is essential. The prescribing decision is informed by assessment of the neonate's heart rate, breathing, tone and time since birth with the medications detailed in Table 1 guiding management.
Table 1. Medications during neonatal resuscitation
| Medication | Indication | Routes of administration | Dosage |
|---|---|---|---|
| Adrenaline/epinephrine 1:10 000 adrenaline (100 μg in 1 mL) | Heart rate below 60 beats per minute despite effective ventilationSubsequent doses every 3–5 minutes if heart rate remains <60 min | Intravenous is preferred routeIntraosseous as alternative routeIntra-tracheal if no other route available | 20 μg/kg100 μg/kg |
| Glucose 10% solution | To reduce likelihood of hypoglycaemia in prolonged resuscitation | IntravenousIntraosseous | 250 mg/kg bolus (2.5 mL/kg of 10% glucose solution) |
| Volume replacement | With suspected blood loss or shock unresponsive to other resuscitative measures | IntravenousIntraosseous | 10 mL/kg group O Rh-negative blood10 mL/kg isotonic crystalloid |
| Sodium bicarbonate (4.2% solution) | May be considered to reverse intracardiac acidosis in prolonged resuscitation | Intravenous (slow injection)Intraosseous | 1–2 mmol/kg(2–4 mL of 4.2% sodium bicarbonate) |
Case scenario
Baby Yousaf is born at 32 weeks gestation, birth weight of 1200 g and noted acute blood loss at birth. After 1 minute of resuscitation the heart rate is 45 bpm with no spontaneous respiration. Medication route of administration is intra-tracheal.
QUESTION 1
What dosage of adrenaline/epinephrine should be administered?
QUESTION 2
There is noted blood loss at birth. What volume of replacement fluids should Yousaf be given?
QUESTION 3
Intravenous access is secured and heart rate remains at <60 bpm at 5 minutes. What repeat dosage of intravenous adrenaline/epinephrine should be given?
QUESTION 4
Active resuscitation continues at 9 minutes, heart rate <60 bpm. What dosages of glucose or sodium bicarbonate would be indicated?