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Weight-Based Versus Flat Dosing of Epinephrine During Cardiac Arrest in the PICU: A Multicenter Survey
Martha F Kienzle1, Ryan W Morgan1, Maya Dewan2
1Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Insights
Pediatric Advanced Life Support (PALS) guidelines recommend weight-based epinephrine dosing, but most surveyed Pediatric Intensive Care Units (PICUs) use inconsistent practices. Actual epinephrine dosing in PICUs deviates from PALS recommendations, impacting resuscitation protocols.
Area of Science:
- Pediatric Critical Care Medicine
- Resuscitation Science
- Pharmacology
Background:
- Pediatric Advanced Life Support (PALS) guidelines recommend weight-based epinephrine dosing (0.01 mg/kg, max 1 mg) for cardiopulmonary resuscitation.
- Actual clinical practice patterns regarding epinephrine dosing in Pediatric Intensive Care Units (PICUs) are not well-established.
- Understanding current dosing practices is crucial for optimizing resuscitation outcomes in critically ill children.
Purpose of the Study:
- To investigate current institutional practices for epinephrine dosing during cardiopulmonary resuscitation in U.S. PICUs.
- To determine the extent to which PICUs adhere to or deviate from PALS weight-based dosing recommendations.
- To explore factors influencing the transition from weight-based to flat-dosing strategies for epinephrine.
Main Methods:
- A multicenter, cross-sectional survey was conducted among U.S. PICU representatives.
- The survey focused on institutional policies for epinephrine dosing during resuscitation.
- Exploratory analyses examined the association between dosing practices and institutional characteristics using Fisher exact test.
Main Results:
- Of 137 surveyed institutions, 68 (50%) responded, predominantly academic children's hospitals with PICU fellowship programs.
- Most respondents (94%) use patient weight for epinephrine dosing, but the weight threshold for switching to flat dosing varies significantly.
- A notable proportion of institutions (43%) use ideal body weight for obese patients, and age-based dosing is more common in institutions requiring Advanced Cardiac Life Support (ACLS) certification (p=0.02).
Conclusions:
- The majority of surveyed PICUs report epinephrine dosing practices inconsistent with current PALS guidelines.
- Significant variability exists in how PICUs implement epinephrine dosing, particularly regarding weight-based calculations and the transition to flat dosing.
- Further research is needed to standardize epinephrine dosing protocols and ensure adherence to evidence-based guidelines for improved patient outcomes.
Objectives:
Pediatric Advanced Life Support (PALS) guidelines include weight-based epinephrine dosing recommendations of 0.01 mg/kg with a maximum of 1 mg, which corresponds to a weight of 100 kg. Actual practice patterns are unknown.
Design:
Multicenter cross-sectional survey regarding institutional practices for the transition from weight-based to flat dosing of epinephrine during cardiopulmonary resuscitation in PICUs. Exploratory analyses compared epinephrine dosing practices with several institutional characteristics using Fisher exact test.
Setting:
Internet-based survey.
Subjects:
U.S. PICU representatives (one per institution) involved in resuscitation systems of care.
Interventions:
None.
Measurements And Main Results:
Of 137 institutions surveyed, 68 (50%) responded. Most responding institutions are freestanding children's hospitals or dedicated children's hospitals within combined adult/pediatric hospitals (67; 99%); 55 (81%) are academic and 41 (60%) have PICU fellowship programs. Among respondents, institutional roles include PICU medical director (13; 19%), resuscitation committee member (23; 34%), and attending physician with interest in resuscitation (21; 31%). When choosing between weight-based and flat dosing, 64 respondents (94%) report using patient weight, 23 (34%) patient age, and five (7%) patient pubertal stage. Among those reporting using weight, 28 (44%) switch at 50 to less than 60 kg, 17 (27%) at 60 to less than 80 kg, five (8%) at 80 to less than 100 kg, and eight (12%) at greater than or equal to 100 kg. Among those reporting using age, four (17%) switch at 14 to less than 16 years, five (22%) at 16 to less than 18, and six (26%) at greater than or equal to 18. Twenty-nine respondents (43%) report using ideal body weight when dosing epinephrine in obese patients. Using patient age in choosing epinephrine dosing is more common in institutions that require Advanced Cardiac Life Support (ACLS) certification for some/all code team responders compared with institutions that do not require ACLS certification (52% vs 22%; p = 0.02).
Conclusions:
The majority of PICUs surveyed report epinephrine dosing practices that are inconsistent with PALS guidelines.
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