Neonatal resuscitation drugs should be stocked in any area in which neonates are resuscitated, including each delivery and

stabilization area, as well as the emergency room. Personnel should be familiar with neonatal medications, concentrations, dosages, and routes of administration. Drugs currently recommended include epinephrine (1:10,000) and isotonic sodium chloride solution (0.9%) as an intra-vascular volume expansion agent.

EPINEPHRINE (ADRENALINE)
Action Sympathomimetic catecholamine Acts directly on alpha and beta receptors Exerts positive ionotropic and chronotropic effect on the heart (Increases strength & rate of cardiac contractions) and relaxes the bronchial smooth muscles Causes peripheral vasoconstriction Increases systemic blood pressure Indication in newborn Treatment of cardiac arrest It is indicated when HR remains < 60 after 30 sec of effective PPV and another 30 sec of coordinated chest compressions and ventilation The only exception to this rule may be in infants who are born without a detectable pulse or heart rate. Severe bradycardia Dosage Intravenous Dose is 0.01 to 0.03 mg/kg per dose (0.1 0.3ml/kg dose of 1:10,000 solution) May repeat every 3-5 min upto 2-3 times Higher intravenous doses are not recommended, and the post-resuscitation hypertension could put premature infants at risk for intraventricular hemorrhage Endotracheal If vascular access cannot be obtained dose should be increased to 3 times that of the intravenous dose (0.03-0.05mg/kg: 1in 10,000 dil) Ensure that the small volume is not deposited on the endotracheal tube connector or in the lumen of the tube. The administration of epinephrine may be followed with 0.5-1 mL of saline to ensure that the drug is delivered to the lung, where it is absorbed and delivered to the heart. Administration of a higher dose (0.05 to 0.1 mg/kg) through the endotracheal tube may be considered, but the safety and efficacy of this practice have not been evaluated (AHA 2010,circulation). Preparation Available concentration 1:1000 Dilute it 10 times to make it 1:10,000 1ml of 1:1000 with 9 ml of water for injection 1:1000 solution means 1ml=1mg (or 0.1ml=0.1mg) 1:10,000 solution means 1ml=0.1mg (or 0.1 ml=0.01mg)

Drug interactions Adrenaline is incompatible with aminophyline, ampicillin, phenobarbitone and sodium bicarbonate. Compatible with normal saline and dextrose solutions Onset of effect Intravenous: immediate If an umbilical venous catheter is used for medication administration, the catheter should be inserted only until blood flow is obtained, usually 3-5 cm. Because the dosing recommendations for epinephrine have included the endotracheal route of administration, the need for emergent placement of umbilical venous catheters has been reduced markedly in the delivery room. Adverse effects Tachycardia Cold extremities Hypertension Necrosis (locally by repeated injections) Decreased renal and splanchnic blood flow Expected response After 30 seconds of administration and continued PPV and CC, HR should increase to > 60 bpm. If no response repeat the dose every 3-5 minutes, repeat doses should preferably be give IV. In case of no response, recheck effectiveness of ventilation and chest compression. Consider Endotracheal intubation, Epinephrine delivery. Also, consider possibility of hypovolemia or severe metabolic acidosis

SODIUM BICARBONATE Action

It may be helpful to correct metabolic acidosis that result from the build up of lactic acid. Severe acidosis causes poor myocardial contraction and blood vessel constriction in the lung, thus decreasing the oxygenation. Sodabicarb releases bicarbonate ions in the body and raises the blood ph. Sodium bicarbonate had previously been recommended in the delivery room to reverse the effects of metabolic acidosis related to hypoxia and asphyxia. However, recent studies show that 0.9% saline provides better cardiac and blood pressure support to correct both the acidosis and the underlying etiology of the metabolic acidosis. Use of sodium bicarbonate in the delivery room has been associated with an increased incidence of intraventricular hemorrhage in very low birthweight infants. Data are insufficient to recommend the routine use of bicarbonate in neonatal resuscitations.

Indication
Sodium bicarbonate, however, may be useful in prolonged arrest after adequate ventilation is established. (when sodium bicarbonate is mixed with acid carbon dioxide is formed.so lungs must be adequately ventilated to remove co2.)

Dosage

A dose of 2 mEq/kg may be intravenously administered. 1-2 ml of 7.5% sodabicarb dilutes with equal amount of distilled water, IV over 3 minutes.( @ <1 mEq/min). Should be given in large vein from which there is good blood return since it is caustic and hypertonic. Never given through ET tube due to the same reason. The subsequent doses are calculated on the basis of arterial pH ideally. But, if they are not available 0.5 mEq/kg can be given every 10 min.

Contra indication
Alkalosis Hypocalcaemia Inadequate ventilation If sodium bicarbonate is used in the face of a persistent respiratory acidosis and elevated pCO2, the acidosis is not corrected. Inj.Soda bicarb 7.5 % solution provides 0.9 mEq/ml of sodium bicarbonate Never in ET route Should be diluted with equal amount of distilled water of double volume of dextrose 5% Bolus administration in preterm babies may result in intra-ventricular haemorrhage

Points to remember

Drug interactions
Incompatible with calcium, cefotaxime, dopamine, dobutamine, magnesium sulphate and atropine

NALOXONE
Administration of naloxone is not recommended as part of initial resuscitative efforts in the delivery room for newborns with respiratory depression. Heart rate and oxygenation should be restored by supporting ventilation (AHA 2010) Mechanism of action Competitive antagonist at opioid receptors. Both endogenous and exogenous opioids are antagonised. Reverses all effects of opioids like respiratory depression, analgesia, papillary constriction, delayed gastric emptying, dysphonia, coma and convulsions. Multiple doses may be necessary due to their short duration of action Onset of effect- IV or ET 1-2 min Dose and route- 0.1 mg /kg /dose as IV bolus/ET/IM /SC, May repeat after 2-3 min, if no response. Available as 0.4 mg/ml Indications Continued Neonatal respiratory depression after positive pressure ventilation has restored a normal heart rate and colour ( due to obstetric analgesia) A history of maternal narcotic administration within past 4 hrs Adverse effects Do not give naloxone to newborn of a mother who is suspected of having addiction to narcotics or is on methadone maintenance. This may result in newborn having seizure

Narcotic withdrawal syndrome may be precipitated in newborn with chronic dependence Abrupt reversal results in vomiting, diaphoresis, tachycardia, hypertension and tremors

VOLUME EXPANDERS
Volume expansion should be considered when blood loss is known or suspected (pale skin, poor perfusion, weak pulse) and the babys heart rate has not responded adequately to other resuscitative measures. In general, the neonatal heart responds well to the increase in preload at the atrial level caused by the volume expansion. Hypovolemia may be masked in a newborn infant because of the significant peripheral vasoconstriction caused by the elevated catecholamines following delivery. Systolic blood pressure also may be elevated falsely with pain. Recommended solutions Isotonic crystalloid Normal Saline Ringer Lactate Colloids 5% albumin, Plasmanate O-negative blood cross-matched with mothers blood (When blood loss is known, restoring the critical oxygen-carrying capacity is essential.) Dose 10ml/kg, Route Umbilical vein/peripheral vein Rate of administration over 5-10 minutes. In premature babies: Rapid boluses may induce ICH

References

www.emedicine.com AAP 2005,Neonatal Resuscitation Manual Drug therapy in paediatrics AHA NRP guidelines 2010
http://www.uihealthcare.com/depts/med/pediatrics/iowaneonatologyhandbook/pulmonary/medicatio ns.html http://pediatrics.aappublications.org/content/126/5/e1400.full