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Epinephrine delay worsens survival odds of children with in-hospital, nonshockable cardiac arrest
Children with in-hospital cardiac arrest and an initial unshockable rhythm who had a delay in epinephrine administration had a decreased chance of survival, according to new findings published in JAMA.
According to Lars W. Andersen, MD, of the department of emergency medicine at Beth Israel Deaconess Medical Center in Boston, and colleagues, delay in administration of epinephrine is known to be linked with decreased survival in adults with in-hospital cardiac arrest and an initial unshockable rhythm, but the association was unknown for children.
Anderson and colleagues analyzed data from the Get With the Guidelines–Resuscitation registry. Their cohort included 1,558 patients aged younger than 18 years who received at least one dose of epinephrine after having in-hospital cardiac arrest with an initial unshockable rhythm.
They defined time to epinephrine as the time in minutes from loss of pulse to initial epinephrine dose. Survival to hospital discharge was the primary outcome. Other outcomes of interest included return of spontaneous circulation, 24-hour survival and favorable neurological outcome, defined as a Pediatric Cerebral Performance Category scale score of 1 to 2.
The rate of survival to hospital discharge was 31.3% and the median time to first dose of epinephrine was 1 minute (interquartile range, 0-4; range, 0-20; mean, 2.6 (standard deviation, 3.4), the researchers found.
The researchers determined that increased time to administration of epinephrine was linked with lower risk for survival to hospital discharge (adjusted risk ratio [aRR] per minute delay = 0.95; 95% CI, 0.93-0.98).
They also found that longer time to administration of epinephrine was associated with lower risk for return of spontaneous circulation (aRR per minute delay = 0.97; 95% CI, 0.96-0.99), lower risk for 24-hour survival (aRR per minute delay = 0.97; 95% CI, 0.95-0.99) and lower risk for survival with favorable neurological outcome (aRR per minute delay = 0.95; 95% CI, 0.91-0.99).
Only 21% of those who had epinephrine administered after more than 5 minutes survived to discharge, compared with 33.1% of those who had it administered within 5 minutes (aRR = 0.75; 95% CI, 0.6-0.93), according to the researchers.
“Although the observational design precludes ascertainment of causality, the strong association with outcomes suggests that early epinephrine may be beneficial in pediatric cardiac arrest,” Andersen and colleagues wrote.
In an invited commentary, Robert C. Tasker, MBBS, MD, and Adrienne G. Randolph, MD, MSc, both from Boston Children’s Hospital and Harvard Medical School, noted that in the present study, almost all arrests were witnessed and most were in a pediatric ICU, OR or postanesthesia care unit setting, so “it is unclear whether the associations reported merely reflect other factors, such as the circumstances of cardiac arrest; the presence of an airway and intravenous access; the quality of chest compressions; and the what, where and when of resuscitation performed.”
They concluded that “these new data provide fairly strong evidence that following the guidelines with regards to epinephrine dosing and timing is best practice, with this study likely providing an [American Heart Association] Class I strength of recommendation.” – by Erik Swain
Disclosure: One researcher reports being a paid consultant for the AHA. The other researchers, Tasker and Randolph report no relevant financial disclosures.