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The physiologic response to epinephrine and pediatric cardiopulmonary resuscitation outcomes
Ryan W Morgan1, Robert A Berg2, Ron W Reeder3
1Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA. morganR1@chop.edu.
Insights
Epinephrine administration during pediatric cardiopulmonary resuscitation (CPR) increases diastolic blood pressure (DBP). A greater DBP increase in children undergoing CPR is associated with a higher likelihood of return of spontaneous circulation (ROSC).
Area of Science:
- Pediatric Critical Care Medicine
- Cardiology
- Emergency Medicine
Background:
- Epinephrine is administered during cardiopulmonary resuscitation (CPR) to enhance systemic vascular resistance and diastolic blood pressure (DBP), aiming to improve coronary perfusion and achieve return of spontaneous circulation (ROSC).
- The specific impact of DBP response to epinephrine during pediatric CPR on patient outcomes remains incompletely understood.
Purpose of the Study:
- To evaluate the association between the change in diastolic blood pressure (DBP) following epinephrine administration and the occurrence of return of spontaneous circulation (ROSC) in pediatric patients undergoing CPR.
Main Methods:
- A prospective, multicenter study involving 147 pediatric patients who received at least one minute of CPR and one dose of epinephrine.
- Invasive arterial blood pressure data was analyzed quantitatively, comparing mean DBP before and two minutes after epinephrine administration.
- Patients with a DBP increase of ≥5 mmHg were classified as 'responders'.
Main Results:
- Of 147 patients, 66 (45%) were responders, showing a mean DBP increase of 13.6 mmHg, while 81 (55%) were non-responders with a mean DBP decrease of -1.5 mmHg (p < 0.001).
- Epinephrine response, defined as a DBP increase, was significantly associated with ROSC (adjusted risk ratio [aRR] 1.60; p = 0.001).
- Higher DBP response thresholds (≥10 mmHg and ≥15 mmHg) were linked to increased survival to hospital discharge and favorable neurologic outcomes.
Conclusions:
- The change in diastolic blood pressure (DBP) after epinephrine administration during pediatric in-hospital CPR is a significant predictor of return of spontaneous circulation (ROSC).
- Monitoring DBP response to epinephrine may offer valuable prognostic information in pediatric CPR.
Background:
Epinephrine is provided during cardiopulmonary resuscitation (CPR) to increase systemic vascular resistance and generate higher diastolic blood pressure (DBP) to improve coronary perfusion and attain return of spontaneous circulation (ROSC). The DBP response to epinephrine during pediatric CPR and its association with outcomes have not been well described. Thus, the objective of this study was to measure the association between change in DBP after epinephrine administration during CPR and ROSC.
Methods:
This was a prospective multicenter study of children receiving ≥ 1 min of CPR with ≥ 1 dose of epinephrine and evaluable invasive arterial BP data in the 18 ICUs of the ICU-RESUS trial (NCT02837497). Blood pressure waveforms underwent compression-by-compression quantitative analysis. The mean DBP before first epinephrine dose was compared to mean DBP two minutes post-epinephrine. Patients with ≥ 5 mmHg increase in DBP were characterized as "responders."
Results:
Among 147 patients meeting inclusion criteria, 66 (45%) were characterized as responders and 81 (55%) were non-responders. The mean increase in DBP with epinephrine was 4.4 [- 1.9, 11.5] mmHg (responders: 13.6 [7.5, 29.3] mmHg versus non-responders: - 1.5 [- 5.0, 1.5] mmHg; p < 0.001). After controlling for a priori selected covariates, epinephrine response was associated with ROSC (aRR 1.60 [1.21, 2.12]; p = 0.001). Sensitivity analyses identified similar associations between DBP response thresholds of ≥ 10, 15, and 20 mmHg and ROSC; DBP responses of ≥ 10 and ≥ 15 mmHg were associated with higher aRR of survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category score of 1-3 or no worsening from baseline).
Conclusions:
The change in DBP following epinephrine administration during pediatric in-hospital CPR was associated with return of spontaneous circulation.
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