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Association of Early Epinephrine with Hemodynamics and Outcome in Pediatric In-Hospital Cardiac Arrest: A Secondary
Ashley Siems1, Maryam Y Naim1, Robert A Berg2
1Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC.
Insights
Early epinephrine administration in pediatric cardiac arrest improves survival and neurological outcomes. Prompt treatment within 2 minutes is linked to better results, including higher return of spontaneous circulation (ROSC) and reduced morbidity.
Area of Science:
- Pediatric Critical Care Medicine
- Emergency Medicine
- Cardiology
Background:
- Delayed epinephrine administration (>5 minutes) in pediatric in-hospital cardiac arrest (IHCA) is linked to adverse outcomes.
- Epinephrine is typically administered earlier, making 5 minutes an impractical quality benchmark.
- Early administration (≤2 minutes) is crucial for improving outcomes in pediatric IHCA.
Purpose of the Study:
- To evaluate the impact of early epinephrine administration (≤2 minutes) on survival and hemodynamic parameters during CPR in pediatric IHCA.
- To compare outcomes between early and delayed epinephrine administration in pediatric cardiac arrest patients with non-shockable rhythms.
Main Methods:
- Retrospective analysis of the ICU-RESUS project database (NCT02837497).
- Categorized CPR events based on time to epinephrine bolus: early (≤2 minutes) versus delayed (>2 minutes).
- Assessed primary outcome (survival to discharge) and secondary outcomes including ROSC, neurologic outcome, functional status, and blood pressure.
Main Results:
- Early epinephrine (≤2 minutes) was administered in 78% of 352 pediatric IHCA events.
- Early epinephrine was associated with higher rates of ROSC, improved functional status scores, and lower new morbidity.
- Survival to discharge was similar, but the probability of ROSC and favorable neurologic outcome decreased with each minute of epinephrine delay.
Conclusions:
- Early epinephrine administration is common in pediatric IHCA and associated with improved ROSC and functional outcomes.
- Prompt epinephrine delivery (≤2 minutes) is critical for enhancing survival and neurological recovery in pediatric cardiac arrest.
- While survival to discharge was similar, early administration positively impacts intermediate outcomes and reduces complications.
Abstract:
Rationale: Delayed (>5 minutes) epinephrine during pediatric in-hospital cardiac arrest (IHCA) is associated with worse outcomes. Epinephrine is nearly always given earlier, limiting 5 minutes as a quality target. Objectives: To assess early epinephrine administration (⩽2 minutes) on outcomes and hemodynamics during cardiopulmonary resuscitation (CPR) in pediatric IHCA from pulseless, nonshockable rhythms. Methods: This study leveraged the database of the ICU-RESUS (Intensive Care Unit Resuscitation) project (clinicaltrials.gov identifier NCT02837497). Primary exposure was the time to epinephrine bolus: early versus >2 minutes. Primary outcome was survival to discharge. Secondary outcomes included the return of spontaneous circulation (ROSC), survival with favorable neurologic outcome, change from baseline to discharge Functional Status Scale (FSS) score, total FSS score at discharge, new morbidity among survivors, and invasively measured blood pressure during the first 10 minutes of CPR. Results: Among 352 CPR events, median age was 1.0 (interquartile range [IQR], 0.3-8.0) year, 186 (53%) were male, and 185 (52.6%) had cardiac disease. Early epinephrine was administered in 273 (78%), and median time to administration was 1.0 (0.0-2.0) minute. Survival to discharge was similar between patients who received early epinephrine and those who did not. Early epinephrine administration was associated with higher ROSC, a change from baseline to discharge in FSS, lower total FSS scores at discharge, and lower rates of new morbidity compared with epinephrine administration at >2 minutes. The probability of ROSC and survival to discharge with favorable neurologic outcome decreased for each minute of delay in epinephrine administration. There was no difference in the invasive blood pressure targets during the first 10 minutes of CPR. Conclusions: Early epinephrine administration was common and was associated with higher ROSC and improved functional outcomes compared with epinephrine administration at >2 minutes in pediatric IHCA.
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