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High-dose epinephrine in pediatric out-of-hospital cardiopulmonary arrest
1Department of Emergency Services, San Francisco General Hospital, CA 94110, USA.
Insights
High-dose epinephrine (HDE) did not improve survival or neurologic outcomes in pediatric out-of-hospital cardiopulmonary arrest (CPA) compared to standard-dose epinephrine (SDE). Further research is needed to determine optimal treatment strategies for pediatric CPA.
Area of Science:
- Pediatric Emergency Medicine
- Cardiology
- Critical Care
Background:
- Out-of-hospital pediatric cardiopulmonary arrest (CPA) has a dismal survival rate.
- Epinephrine is a critical medication used in advanced cardiac life support protocols.
- The optimal dose of epinephrine for pediatric CPA remains uncertain.
Purpose of the Study:
- To compare the efficacy of high-dose epinephrine (HDE) versus standard-dose epinephrine (SDE) in treating pediatric out-of-hospital CPA.
- To evaluate the impact of different epinephrine doses on return of spontaneous circulation (ROSC), survival, and neurologic outcomes.
Main Methods:
- Retrospective cohort study of 65 children younger than 18 years with nontraumatic out-of-hospital CPA.
- Paramedics administered HDE (>0.1 mg/kg), SDE (<0.1 mg/kg), or no epinephrine (NE).
- Outcomes assessed included ROSC, return of organized electrical rhythm (ROER), hospital admission, survival, and neurologic outcome (Pediatric Cerebral Performance Category - PCPC score).
Main Results:
- No statistically significant difference in ROER, ROSC, hospital admission, survival, or neurologic outcomes between HDE and SDE groups.
- Only two children (3%) survived to hospital discharge, one in the HDE group (with severe neurologic impairment) and one in the SDE group (neurologically intact).
- The majority of patients (83%) presented with asystole.
Conclusions:
- HDE does not appear to offer improved outcomes compared to SDE for out-of-hospital pediatric CPA.
- A large, blinded prospective clinical trial is necessary to definitively assess epinephrine efficacy and safety in pediatric CPA.
- Standardized reporting using modified Utstein criteria is crucial for future pediatric CPA research.
Objective:
To compare the efficacy of high-dose epinephrine (HDE) and standard-dose epinephrine (SDE) for out-of-hospital treatment of pediatric cardiopulmonary arrest (CPA).
Design:
Forty-eight-month retrospective cohort study.
Setting:
Prehospital emergency medical services (EMS) system of a large metropolitan region.
Patients:
All children younger than 18 years of age, who suffered nontraumatic CPA, did not meet local EMS criteria for death in the field, and were treated by paramedics according to EMS pediatric CPA protocols.
Interventions:
Paramedics administered HDE (> 0.1 mg/kg), SDE (< 0.1 mg/kg), or no epinephrine (NE), based on base hospital physician order and availability of access for drug delivery. Protocols permitted either HDE or SDE. The drug was given through an endotracheal tube, intraosseous line, or intravenous line.
Main Outcome Measures:
Return of spontaneous circulation (ROSC) and return of an organized electrical rhythm (ROER) in the ambulance and emergency department, hospital admission, hospital discharge, and short- and long-term neurologic outcome by pediatric cerebral performance category (PCPC) score.
Results:
During the study period, 65 children met inclusion criteria and underwent attempted out-of-hospital resuscitation. Forty patients (62%) received HDE (mean dose +/- SD, 0.19 +/- 0.06 mg/kg); 13 patients (20%) received SDE (mean dose +/- SD, 0.02 +/- 0.02 mg/kg); and 12 patients (18%) received NE. The HDE and SDE groups were statistically different only in epinephrine dose but not in age, gender, proportion of asystolic presenting rhythms, success of endotracheal tube intubation or intraosseous line insertion, rate of ROSC, rate of ROER, survival, or proportion of sudden infant death syndrome final diagnoses. Fifty-four children (83%) presented in asystole, 5 (8%) had pulseless electrical activity (PEA), and 6 (9%) had ventricular fibrillation (VF). None presented with either supraventricular tachycardia or ventricular tachycardia. Thirty-nine patients receiving HDE had asystole or VF as presenting rhythms, 4 (10%) had ROER, and 1 had ROSC. The single child receiving HDE presenting with PEA did not have ROSC. Ten patients receiving SDE had asystole or VF, 2 (20%) had ROER, and none had ROSC. There were 3 children receiving SDE who had PEA, and 1 had ROSC. Eleven patients receiving NE had asystole or VF, and none had ROER. One child receiving NE had PEA and ROSC. Altogether, 1 patient receiving HDE, 1 receiving SDE, and 1 receiving NE had ROSC in the field, which continued in the emergency department; all 3 were admitted to the hospital. Two children (3%), 1 receiving HDE and 1 receiving SDE, survived to hospital discharge. The survivor receiving HDE had spastic quadriplegia and profound neurologic handicaps at discharge, with a PCPC score of 4 (severe disability with daily living milestones below the 10th percentile and excessive dependence on others for provision of activities of daily living); at a 1-year follow-up, she had a PCPC score of 4. The survivor receiving SDE was neurologically healthy at discharge; at discharge and at follow-up at age 1 year, she had a PCPC score of 1 (age-appropriate level of functioning and developmentally appropriate).
Conclusions:
HDE does not seem to improve the rates of ROER and ROSC, hospital admission, survival, or neurologic outcome when compared with SDE for treatment of out-of-hospital pediatric CPA. A large, blinded prospective clinical trial testing different epinephrine doses is necessary to determine drug efficacy and safety. Future pediatric CPA studies must standardize reporting of core data elements, using the adult Utstein criteria modified for pediatrics, to allow valid treatment comparisons. Overall, survival in out-of-hospital pediatric CPA is dismal.(ABSTRACT TRUNCATED)