Epinephrine for the resuscitation of apparently stillborn or extremely bradycardic newborn infants

Abstract

Background: Epinephrine is a cardiac stimulant with complex effects on the heart and blood vessels. It has been used for decades in all age groups to treat cardiac arrest and bradycardia. Despite formal guidelines for the use of epinephrine in neonatal resuscitation, the evidence for these recommendations has not yet been rigorously scrutinised. While it is understood that this evidence is in large part derived from animal models and the adult human population, the contribution from work in the neonatal population remains unclear. In particular, it remains to be determined if any randomised studies in neonates have helped to establish if the administration of epinephrine in the context of apparent stillbirth or extreme bradycardia might influence mortality and morbidity. Objectives: To determine the effect of administration of epinephrine to apparently stillborn and extremely bradycardic newborns on mortality and morbidity. Secondary objectives included analysis of the effect of intravenous versus endotracheal administration epinephrine and high dose versus standard dose epinephrine on mortality and morbidity. Search methods: Searches were made of Medline from 1966 to August 2007, CINAHL (from 1982), Current Contents (from 1988), EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007). Bibliographies of conference proceedings were reviewed and unpublished studies were sought by hand searching the conference proceedings of the Society for Pediatric Research and the European Society for Pediatric Research from 1993 to 2007. This search was updated in November 2010. Selection criteria: Randomised and quasi-randomised controlled trials of newborns, both pre-term and term, receiving epinephrine for unexpected apparent stillbirth or extreme bradycardia. Data collection and analysis: No studies were found meeting the criteria for inclusion in this review. Main results: No studies were found meeting the criteria for inclusion in this review. Authors' conclusions: No randomised, controlled trials evaluating the administration of epinephrine to the apparently stillborn or extremely bradycardic newborn infant were found. Similarly, no randomised, controlled trials that addressed the issues of optimum dosage and route of administration of epinephrine were found. Current recommendations for the use of epinephrine in newborn infants are based only on evidence derived from animal models and the human adult literature. Randomised trials in neonates are urgently required to determine the role of epinephrine in this population.