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Epinephrine Dosing Use During Extracorporeal Cardiopulmonary Resuscitation: Single-Center Retrospective Cohort
Nicholas M Kucher1, Alexandra M Marquez1, Anne-Marie Guerguerian1
1Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada.
Insights
Epinephrine dosing during pediatric cardiac arrest did not significantly increase afterload in patients requiring extracorporeal membrane oxygenation (ECMO). Further research is needed to confirm these findings on ECMO support and patient outcomes.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiovascular Research
- Extracorporeal Life Support
Background:
- Pediatric cardiac arrest guidelines recommend epinephrine administration.
- The effect of epinephrine on systemic afterload in patients on extracorporeal membrane oxygenation (ECMO) is not well understood.
Purpose of the Study:
- To investigate the association between epinephrine dosing and systemic afterload in pediatric patients undergoing ECMO during resuscitation.
- To evaluate the impact of epinephrine on ECMO support parameters.
Main Methods:
- Retrospective observational study of pediatric patients (0-18 years) requiring ECMO during resuscitation.
- Analyzed time from last epinephrine dose to ECMO initiation, cumulative dose, and arrest time.
- Assessed systemic afterload using mean arterial pressure and vasodilator use; ECMO support via pump flow and Vasoactive-Inotrope Score (VIS).
Main Results:
- A total of 69 events in 87 patients were analyzed.
- The median interval between the last epinephrine dose and ECMO initiation was 6 minutes.
- Shorter epinephrine-ECMO intervals correlated with increased vasodilator use (p=0.05) but not significantly with mean arterial pressure (p=0.06) or other ECMO support measures.
Conclusions:
- Limited evidence suggests epinephrine dosing during cardiac arrest is not associated with increased afterload post-ECMO cannulation.
- Further studies are required to validate these findings and assess clinical outcomes.
Objectives:
During pediatric cardiac arrest, contemporary guidelines recommend dosing epinephrine at regular intervals, including in patients requiring extracorporeal membrane oxygenation (ECMO). The impact of epinephrine-induced vasoconstriction on systemic afterload and venoarterial ECMO support is not well-defined.
Design:
Nested retrospective observational study within a single center. The primary exposure was time from last dose of epinephrine to initiation of ECMO flow; secondary exposures included cumulative epinephrine dose and arrest time. Systemic afterload was assessed by mean arterial pressure and use of systemic vasodilator therapy; ECMO pump flow and Vasoactive-Inotrope Score (VIS) were used as measures of ECMO support. Clearance of lactate was followed post-cannulation as a marker of systemic perfusion.
Setting:
PICU and cardiac ICU in a quaternary-care center.
Patients:
Patients 0-18 years old who required ECMO cannulation during resuscitation over the 6 years, 2014-2020. Patients were excluded if ECMO was initiated before cardiac arrest or if the resuscitation record was incomplete.
Interventions:
None.
Measurements And Main Results:
A total of 92 events in 87 patients, with 69 events having complete data for analysis. The median (interquartile range) of total epinephrine dosing was 65 mcg/kg (37-101 mcg/kg), with the last dose given 6 minutes (2-16 min) before the initiation of ECMO flows. Shorter interval between last epinephrine dose and ECMO initiation was associated with increased use of vasodilators within 6 hours of ECMO ( p = 0.05), but not with mean arterial pressure after 1 hour of support (estimate, -0.34; p = 0.06). No other associations were identified between epinephrine delivery and mean arterial blood pressure, vasodilator use, pump speed, VIS, or lactate clearance.
Conclusions:
There is limited evidence to support the idea that regular dosing of epinephrine during cardiac arrest is associated with increased in afterload after ECMO cannulation. Additional studies are needed to validate findings against ECMO flows and clinically relevant outcomes.
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