Early Epinephrine Improves the Stabilization of Initial Post-resuscitation Hemodynamics in Children With Non-shockable Out-of-Hospital Cardiac Arrest

Abstract

Background: In children with non-shockable out-of-hospital cardiac arrest, early epinephrine (EE) might help to establish the return of spontaneous circulation (ROSC) and be associated with survival. In the present study, we aimed to analyze the effects of EE on outcomes and post-resuscitation hemodynamics in children with non-shockable OHCA. Methods: This was a retrospective analysis of data from 216 children (<19 years) who had suffered non-traumatic and non-shockable OHCA and received epinephrine for resuscitation (Jan 1, 2006–Dec 31, 2014). Demographics, pre-/in-hospital information, and the time to the first dose of epinephrine were recorded. Early post-resuscitation hemodynamics (the first hour after sustained ROSC), survival and good neurological outcomes (Pediatric Cerebral Performance Category Scales 1 or 2) were analyzed by the time to epinephrine—classified as early (EE): <15 min, intermediate (IE): 15–30 min, or late (LE): >30 min. Results: Twenty-eight (13.0%) children survived to discharge, but only 17 (7.9%) had good neurological outcomes. In all, 41 (18.9%) children received EE; in comparison to IE and LE, this was significantly associated with tachycardia (73.9%) in the post-resuscitation period ( p < 0.05). Tachycardia (OR: 7.41, 95% CI: 1.96–29.31) and hypertension (OR: 6.03, 95% CI: 1.85–13.77) were significantly associated with EE after adjusting for confounding factors. EE was also significantly associated with better overall outcomes than ME and LE (any ROSC, sustained ROSC, survival to the intensive care unit, admission, survival to discharge and good neurological outcomes, all p < 0.05). Conclusions: EE helped to establish ROSC but was also associated with more tachycardia and hypertension in the early post-resuscitation period. In children with non-traumatic and non-shockable OHCA, EE was associated with a higher survival rate and better neurological outcomes than were ME and LE.

Executive Summary 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

“…Although epinephrine has been part of pediatric resuscitation for more than 50 years, there is little pediatric data about its effectiveness or the optimal initial dose or dose interval during resuscitation. The epinephrine SysRev identified evidence associating benefit with shorter time to initial epinephrine administration and improved outcomes in children with nonshockable rhythms and OHCA, 39 , 40 , 41 and a new treatment recommendation reflected this evidence. However, there remains insufficient evidence about the effect of time to initial epinephrine dose for OHCA with shockable rhythms.…”

“…The SysRev identified only observational (registry) data (including 1 large study reporting data from 26 755 children, 39 suggesting benefit associated with earlier rather than later initial epinephrine administration, especially for children with OHCA and nonshockable rhythms. 39 , 40 , 41 Because the 2 registry studies of epinephrine dose intervals in children with IHCA provided directly contradictory evidence, 42 , 43 the task force concluded that there was insufficient evidence to make a new recommendation about epinephrine dose interval.…”

Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

“…For the critical outcome of survival with good neurological outcome, we identified 2 observational studies of 725 pediatric patients 19 years or younger with traumatic (509 children) 110 and nontraumatic, nonshockable (216 children) 111 OHCA. These studies provided very-low-certainty evidence (downgraded for risk of bias, inconsistency, and imprecision), finding no benefit associated with a first dose of epinephrine less than 15 minutes compared with 15 minutes or more (RR, 3.94; 95% CI, 0.99-15.64; 80 more per 1000; 95% CI, from 0 fewer to 397 more).…”

“…For the critical outcome of survival to discharge, we identified 3 observational studies enrolling 27 480 children. These included emergency medical servicestreated children younger than 18 years with nonshockable arrest who did not experience ROSC within 10 minutes (26 755 children) 112 and children 19 years or younger with traumatic (509 children) 110 and nontraumatic, nonshockable (216 children) 111 OHCA. These studies provided very-low-certainty evidence (downgraded for risk of bias, inconsistency, and other considerations of large effect) of benefit associated with time to first epinephrine dose less than 15 minutes compared with 15 minutes or more (RR, 2.49; 95% CI, 1.30-4.77; 28 more per 1000; 95% CI, from 6 more to 70 more).…”

Pediatric Life Support

“…For the critical outcome of survival to discharge, we identified 3 observational studies enrolling 27 480 children. These included emergency medical services–treated children younger than 18 years with nonshockable arrest who did not experience ROSC within 10 minutes (26 755 children) 112 and children 19 years or younger with traumatic (509 children) 110 and nontraumatic, nonshockable (216 children) 111 OHCA. These studies provided very-low-certainty evidence (downgraded for risk of bias, inconsistency, and other considerations of large effect) of benefit associated with time to first epinephrine dose less than 15 minutes compared with 15 minutes or more (RR, 2.49; 95% CI, 1.30–4.77; 28 more per 1000; 95% CI, from 6 more to 70 more).…”