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Epinephrine Before Defibrillation in Children With Initially Shockable In-Hospital Cardiac Arrest
Morgan B Swanson1, Javier J Lasa2, Paul S Chan3
1Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA.
Insights
Nearly half of pediatric cardiac arrests with shockable rhythms received epinephrine before or during defibrillation. This timing was not significantly linked to survival or neurological outcomes, despite initial lower survival rates.
Area of Science:
- Pediatric Emergency Medicine
- Cardiology
- Critical Care Medicine
Background:
- Current guidelines recommend epinephrine administration after the first defibrillation attempt for pediatric in-hospital cardiac arrest (IHCA) with a shockable rhythm.
- However, the actual practice and its impact on outcomes are not well-established.
Purpose of the Study:
- To assess the prevalence of epinephrine administration before or during the same minute as defibrillation in pediatric IHCA.
- To determine the association of this timing with clinical outcomes, including survival and neurological function.
Main Methods:
- Retrospective cohort study utilizing data from the American Heart Association's Get With the Guidelines-Resuscitation Registry (2000-2020).
- Included children (<18 years) with IHCA, initial shockable rhythm (ventricular fibrillation/pulseless ventricular tachycardia), and at least one defibrillation.
- Propensity-score matching was employed for confounding adjustment.
Main Results:
- Nearly half (47%) of pediatric IHCA cases received epinephrine before or during the same minute as defibrillation.
- Unadjusted analyses showed lower survival, return of spontaneous circulation (ROSC), and favorable neurologic outcomes in this group.
- Adjusted analyses, however, revealed no statistically significant association between this epinephrine timing and hospital survival, ROSC, or favorable neurologic outcome.
Conclusions:
- A significant proportion of pediatric IHCA with shockable rhythms receive epinephrine earlier than recommended by current guidelines.
- The early administration of epinephrine was not statistically associated with adverse or improved clinical outcomes after adjusting for confounders.
Objective:
Assess prevalence of epinephrine before or during the same minute as defibrillation and association with clinical outcomes in pediatric in-hospital cardiac arrest (IHCA).
Design:
Retrospective cohort study.
Setting:
We used 2000-2020 data from the American Heart Association's Get With the Guidelines-Resuscitation Registry.
Patients:
Children (< 18 yr) with index IHCA with an initial shockable rhythm of ventricular fibrillation or pulseless ventricular tachycardia and at least one defibrillation attempt.
Interventions:
None.
Measurements And Main Results:
The primary exposure was epinephrine administration before or during the same minute as defibrillation. Study outcomes were survival to hospital discharge (primary outcome), return of spontaneous circulation (ROSC) for greater than or equal to 20 min, and survival with favorable neurologic outcome. Propensity-score matching was used for confounding adjustment. Among 492 pediatric IHCA index events with an initial shockable rhythm, median age was 7 years and 351 (71%) were in the ICU. Overall, 232 (47%) children received either epinephrine before defibrillation (29%) or during the same minute as defibrillation (18%). In unadjusted analyses, proportions of survival to hospital discharge (37.1% vs. 51.2%), ROSC (74.6% vs. 84.6%), and survival with favorable neurologic outcome (22.1% vs. 40.4%) were lower in the epinephrine before or during the same minute as defibrillation group. However, in adjusted analyses using propensity score matching with exact matching on time to defibrillation category, epinephrine before or during the same minute as defibrillation was not associated with hospital survival (odds ratio [OR] 0.84, 0.46-1.56), ROSC (OR 0.97, 0.48-1.96), or favorable neurologic outcome (OR 0.52, 0.27-1.00).
Conclusions:
Contrary to current guidelines, nearly 50% of pediatric IHCA due to an initial shockable rhythm receive epinephrine before, or during the same minute, as first defibrillation. Although survival outcomes were numerically lower in epinephrine before defibrillation group, the association was not statistically significant.
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