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Neonatal resuscitation with vasopressin instead of epinephrine: are we ready to challenge the status quo?

Pediatric Research volume 95, pages 1174–1176 (2024)Cite this article

Resuscitation following an acute deterioration remains one of the most challenging scenarios in neonatal intensive care, especially when there has been a loss of cardiac output. Fortunately, resuscitation is uncommon in neonates, but outcomes remain frustratingly poor. Over the last decade, there has been increasing research interest in how to best resuscitate neonates. Although resuscitation guidelines are a ubiquitous part of neonatal clinical care and training, the evidence to support many of the recommendations remains sparse, and becomes increasingly so as the level of resuscitative interventions escalate. Epinephrine is one such example. Epinephrine has been a staple of neonatal resuscitation for decades, but the rationale is more historical than evidence-based.1,2,3 Whilst recommended by the International Liaison Committee of Neonatal Resuscitation (ILCOR) for a heart rate persistently <60 beats/min despite effective positive pressure ventilation and chest compressions, there is an acknowledgement that evidence is generally indirect, limited and usually originated from adults, children or small animal studies.4 A recent systematic review of epinephrine in neonatal resuscitation highlighted the lack of data to support current practice.5 High-quality clinical trials in neonatal resuscitation are extremely difficult. The population is very small, hard to anticipate, consent is complex, and the interventions involve high levels of staff stress. In this context, the logical question when faced with the lack of evidence for epinephrine is not whether it is better than no epinephrine, but rather is epinephrine the right, or only, agent to use during resuscitation due to loss of cardiac output refractory to other interventions in neonates.

In this edition of Pediatric Research, Ramsie et al. address this question. They compare vasopressin and epinephrine in the resuscitation of asphyxiated neonatal piglets.6 Specifically, vasopressin at doses of 0.2, 0.4, or 0.8 IU/kg were compared against 0.02 mg/kg epinephrine (n = 8/group) on return of spontaneous circulation (ROSC) following asystolic cardiac arrest due to asphyxiation. The authors used their well-established intubated, sedated and anaesthetised neonatal piglet asphyxia model. They found there was no overall difference in the time to or incidence of ROSC between vasopressin doses and epinephrine. Interestingly, the median time to ROSC was slightly quicker (and potentially dose-related) in the vasopressin-treated piglets (122 s 0.8 IU/kg vasopressin vs 276 s epinephrine), but the ranges of ROSC were very large across all groups. Heart rate, arterial pressure, cerebral blood flow and brain oxygenation were higher in the recovery phase using vasopressin.

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Funding

The authors are supported by the Victorian Government Operational Infrastructure Support Program (Melbourne, Australia). DGT is supported by a National Health and Medical Research Council Leadership Level 1 Investigator Grant (Grant ID 2008212).

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Authors and Affiliations

  1. Department of Neonatology, Royal Children’s Hospital, Melbourne, VIC, Australia

    Anna Foth, David Stewart & David G. Tingay

  2. Neonatal Research, Murdoch Children’s Research Institute, Melbourne, VIC, Australia

    David Stewart & David G. Tingay

  3. Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia

    David G. Tingay

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  1. Anna Foth
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  2. David Stewart
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All authors contributed equally to the review of the original submission and structure of the Editorial, with agreed paragraph lead authors shared equally. All authors contributed to redrafting the manuscript.

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Correspondence to David G. Tingay.

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Foth, A., Stewart, D. & Tingay, D.G. Neonatal resuscitation with vasopressin instead of epinephrine: are we ready to challenge the status quo?. Pediatr Res 95, 1174–1176 (2024). https://doi.org/10.1038/s41390-023-02961-z

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