• Michael Wagner, Monika Olischar, Megan O'Reilly, Katharina Goeral, Angelika Berger, Po-Yin Cheung, and Georg M Schmölzer.
• Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Medical University of Vienna, Vienna, Austria.
• Pediatr Crit Care Me. 2018 Apr 1; 19 (4): 332-338.

ObjectiveDuring neonatal cardiopulmonary resuscitation, early establishment of vascular access is crucial. We aimed to review current evidence regarding different routes for the administration of medications during neonatal resuscitation.Data SourcesWe reviewed PubMed, EMBASE, and Google Scholar using MeSH terms "catheterization," "umbilical cord," "delivery room," "catecholamine," "resuscitation," "simulation," "newborn," "infant," "intraosseous," "umbilical vein catheter," "access," "intubation," and "endotracheal."Study SelectionArticles in all languages were included. Initially, we aimed to identify only neonatal studies and limited the search to randomized controlled trials.Data ExtractionDue to a lack of available studies, studies in children and adults, as well as animal studies and also nonrandomized studies were included.Data SynthesisNo randomized controlled trials comparing intraosseous access versus peripheral intravascular access versus umbilical venous catheter versus endotracheal tube versus laryngeal mask airway or any combination of these during neonatal resuscitation in the delivery room were identified. Endotracheal tube: endotracheal tube epinephrine administration should be limited to situations were no vascular access can be established. Laryngeal mask airway: animal studies suggest that a higher dose of epinephrine for endotracheal tube and laryngeal mask airway is required compared with IV administration, potentially increasing side effects. Umbilical venous catheter: European resuscitation guidelines propose the placement of a centrally positioned umbilical venous catheter during neonatal cardiopulmonary resuscitation; intraosseous access: case series reported successful and quick intraosseous access placement in newborn infants. Peripheral intravascular access: median time for peripheral intravascular access insertion was 4-5 minutes in previous studies.ConclusionsBased on animal studies, endotracheal tube administration of medications requires a higher dose than that by peripheral intravascular access or umbilical venous catheter. Epinephrine via laryngeal mask airway is feasible as a noninvasive alternative approach for drug delivery. Intraosseous access should be considered in situations with difficulty in establishing other access. Randomized controlled clinical trials in neonates are required to compare all access possibilities described above.

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