Time to Epinephrine and Pediatric Cardiac Arrest

Study Questions:

What is the association of time to first epinephrine dose and outcomes after pediatric in-hospital cardiac arrest?

Methods:

The investigators performed an analysis of data from the Get With the Guidelines–Resuscitation registry. They included US pediatric patients (ages <18 years) with an in-hospital cardiac arrest and an initial nonshockable rhythm who received at least one dose of epinephrine. A total of 1,558 patients (median age, 9 months; interquartile range [IQR], 13 days–5 years) were included in the final cohort. Time to epinephrine, defined as time in minutes from recognition of loss of pulse to the first dose of epinephrine, was measured. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC), survival at 24 hours, and neurological outcome. A favorable neurological outcome was defined as a score of 1-2 on the Pediatric Cerebral Performance Category scale.

Results:

Among the 1,558 patients, 487 (31.3%) survived to hospital discharge. The median time to first epinephrine dose was 1 minute (IQR, 0-4; range, 0-20; mean [SD], 2.6 [3.4] minutes). Longer time to epinephrine administration was associated with lower risk of survival to discharge in multivariable analysis (multivariable-adjusted risk ratio [RR] per minute delay, 0.95; 95% confidence interval [CI], 0.93-0.98). Longer time to epinephrine administration was also associated with decreased risk of ROSC (multivariable-adjusted RR per minute delay, 0.97; 95% CI, 0.96-0.99), decreased risk of survival at 24 hours (multivariable-adjusted RR per minute delay, 0.97; 95% CI, 0.95-0.99), and decreased risk of survival with favorable neurological outcome (multivariable-adjusted RR per minute delay, 0.95; 95% CI, 0.91-0.99). Patients with time to epinephrine administration of longer than 5 minutes (233/1,558) compared with those with time to epinephrine of 5 minutes or less (1,325/1,558) had lower risk of in-hospital survival to discharge (21.0% [49/233] vs. 33.1% [438/1,325]; multivariable-adjusted RR, 0.75; 95% CI, 0.60-0.93; p = 0.01).

Conclusions:

The authors concluded that among children with in-hospital cardiac arrest with an initial nonshockable rhythm who received epinephrine, delay in administration of epinephrine was associated with a decreased chance of survival to hospital discharge.

Perspective:

This multicenter cohort study of in-hospital pediatric cardiac arrest reports that delay in administration of epinephrine was associated with a decreased chance of ROSC, 24-hour survival, survival to hospital discharge, and survival to hospital discharge with a favorable neurological outcome among patients with an initial nonshockable rhythm. These associations remained when accounting for multiple predetermined potentially confounding patient, event, and hospital characteristics and in multiple different sensitivity analyses. The observational design of the study precludes ascertainment of causality, but the strong association with outcomes suggests that early epinephrine is beneficial in pediatric cardiac arrest. A randomized trial would be difficult to do since clinicians may lack equipoise to delay epinephrine therapy.

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD & Pediatrics and Arrhythmias, CHD & Pediatrics and Quality Improvement

Keywords: Arrhythmias, Cardiac, Epinephrine, Heart Arrest, Heart Defects, Congenital, Pediatrics, Resuscitation, Risk, Survival


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