298 - Comparison of 2 different initial doses of intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room.

Publication Number: 298.4249

Arun Prasath, UT Southwestern Medical Center, Dallas, TX, United States; Jennifer Healy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Myra H. Wyckoff, UT Southwestern, Dallas, TX, United States; Vishal Kapadia, University of Texas Southwestern Medical School, Dallas, TX, United States

Background: The 8th edition Neonatal Resuscitation Program (NRP) recommends an initial intravenous (IV) epinephrine dose of 0.02mg/kg during neonatal cardiopulmonary resuscitation (CPR), a change from 7th edition which suggested a dosing range from 0.01 -0.03mg/kg. Although animal studies suggest higher IV epinephrine dose may be more effective. The human data for ideal epinephrine dose for neonatal CPR remains an important knowledge gap.

Objective: To determine if an initial 0.02mg/kg dose of IV epinephrine is associated with increased survival in the delivery room (DR) compared to an initial 0.01mg/kg dose in infants receiving IV epinephrine in the delivery room (DR).

Design/Methods: Retrospective cohort study from a single, urban, academic center with approximately 14 ,000 births/year. In July 2014, Parkland Hospital increased the initial IV epinephrine dose for neonatal CPR from 0.01 mg/kg to 0.02 mg/kg due to local data suggesting that 0.01mg/kg IV epinephrine frequently failed to achieve ROSC. All newborn infants who received epinephrine via IV as initial dose or following initial endotracheal dosing in the DR from 01/01/2010 to 08/31/2024 were included. Newborn infants with major congenital anomalies were excluded. Group EPI0.01 received 0.01mg/kg as first IV epinephrine dose. Group EPI0.02 received 0.02mg/kg as first IV epinephrine dose. The primary outcome was mortality in the DR. Baseline characteristics, resuscitation interventions and clinical outcomes were compared via fisher’s exact test or rank sum test.

Results: There were 22 infants in EPI0.01 and 68 infants in EPI0.02 groups. (Figure 1). Maternal and Neonatal baseline characteristics were similar between groups (Table 1). Time to intubation, time to chest compressions, time to first epinephrine dose (any route), time to first IV epinephrine dose, total IV epinephrine dose and cumulative epinephrine dose were similar between both groups (Table 1). Death in the DR was similar in EPI0.01 group compared to EPI0.02 [ 9 (26) vs 17 (25), p 0.2]. Time to return of spontaneous circulation, and death prior to discharge were similar between the two groups. A large number of survivors in both groups suffer from hypoglycemia, hypoxic ischemic encephalopathy, seizures and pulmonary hypertension. (Table 2)

Conclusion(s): The 0.02mg/kg initial dose of IV epinephrine during neonatal CPR in the DR was not associated with improved survival in DR. Infants who survive after neonatal DR CPR have high morbidity and mortality. Studies with larger sample size and with long-term outcomes in survivors are needed to further investigate the optimal initial dose of IV epinephrine.

Figure 1: Flow diagram of study population
Figure 1: Flow diagram of study population


Table 1: Maternal and Neonatal Characteristics of Newborn Infants Receiving Cardiopulmonary Resuscitation and Epinephrine at Birth


Table 2: NICU outcomes for Newborn Infants who Received Cardiopulmonary Resuscitation with Epinephrine in the DR