HS; NRCPR Investigators. The unadjusted 24-hour survival rate was again lower with high-dose epinephrine than with standard-dose epinephrine: only 1 of 27 patients in the former group was alive at 24 hours, as compared with 6 of 23 in the latter group. Statistical analyses were conducted with SAS version 9.4 (SAS Institute). Dieckmann
Peberdy
V, Bahr
The primary outcome was survival to hospital discharge. Ann Emerg Med 1991;20:22-26, 10. The Commission on Ethics in Research of the Children's Institute approved this prospective investigation.
EF, Pediatrics. We included index events only from hospitals with at least 6 months of reporting and at least 5 cases reported. We believe that this potential misclassification is likely undifferentiated and that, in most cases, this would lead to bias toward the null. The recording of the time of pulselessness and the first dose of epinephrine was done in whole minutes. Do practice guidelines augment drug utilisation review. Brown CG, Martin DR, Pepe PE, et al. Neither received any specific financial compensation for their role in the current study. The 5-minutes-or-less group (1325/1558 patients [85%]) had in-hospital survival to discharge of 33.1% (438/1325), compared with 21.0% (49/233) in the longer-than-5-minutes group (233/1558 patients [15%]). Results ), and the Department of Medicine, University of So Paulo School of Medicine (E.F.P. The median time to first epinephrine dose was 1 minute (IQR, 0-4; range, 0-20; mean [SD], 2.6 [3.4] minutes). JD, Howell A prospective investigation into the epidemiology of in-hospital pediatric cardiopulmonary resuscitation using the international Utstein reporting style. Kern KB, Hilwig RW, Rhee KH, Berg RA. Whether this association is true in the pediatric in-hospital cardiac arrest population remains unknown. Dieckmann RA, Vardis R. High-dose epinephrine in pediatric out-of-hospital cardiopulmonary arrest. Characteristics of the Population for Study of Timing of Epinephrine and Pediatric In-Hospital Nonshockable Cardiac Arrest, Table 2. For both primary and secondary outcomes, the RRs represent the RR for the outcome per minute increase in time to epinephrine. Twenty-two were assigned to high-dose epinephrine, and 16 to standard-dose epinephrine. Bethesda, MD 20894, Web Policies Crit Care Med 1993;21:678-686, 12. Lipman J, Wilson W, Kobilski S, et al. Peer-reviewed journal featuring in-depth articles to accelerate the transformation of health care delivery. Furthermore, attainment of an adequate sample size for assessment of that outcome would require a prolonged study period, thereby complicating the study with potentially different resuscitation strategies and protocols over time. Please enable it to take advantage of the complete set of features! CW. Among children with in-hospital cardiac arrest with an initial nonshockable rhythm who received epinephrine, delay in administration of epinephrine was associated with decreased chance of survival to hospital discharge, ROSC, 24-hour survival, and survival to hospital discharge with a favorable neurological outcome. The data are observational, and the possibility of unmeasured confounding remains. Demographic Characteristics of the Patients at the Time of Cardiac Arrest. Seven hundred forty patients did not receive epinephrine (Figure 1). Because data are used primarily at the local site for quality improvement, sites are granted a waiver of informed consent under the common rule. CPR denotes cardiopulmonary resuscitation, and ROSC return of spontaneous circulation. No adjustments were made for multiple testing, and, as such, our secondary end points should be considered exploratory. 2015;314(8):802810. The most effective and engaging way for clinicians to learn, improve their practice, and prepare for board exams. Pediatrics 2002;109:200-209, 25. JT, Criley Carpenter TC, Stenmark KR. To determine whether time to first epinephrine dose is associated with outcomes in pediatric in-hospital cardiac arrest. A number of limitations should be considered when interpreting the current study. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Fisher DG, Schwartz PH, Davis AL. Patient Flowchart for Study of Timing of Epinephrine and Pediatric In-Hospital Nonshockable Cardiac Arrest, Figure 2. Circulation 1984;69:822-835, 33. JJ. RA. RA, Nadkarni Drug interventions during the event, eTable 2. Exposure S. Medications in neonatal resuscitation: epinephrine and the search for better alternative strategies. Nakahara VM, 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]). I, Nadkarni Our findings do suggest, however, that there is room for improvement, with 15% of pediatric patients getting their first epinephrine dose more than 5 minutes after loss of pulse. All Rights Reserved. The primary outcome was survival to discharge from the hospital. J,
Case Records of the Massachusetts General Hospital, Monkeypox Virus Infection in Humans across 16 Countries AprilJune 2022, Protection Associated with Previous SARS-CoV-2 Infection in Nicaragua, Nirmatrelvir for Nonhospitalized Adults with Covid-19, Efficacy of Antibodies and Antiviral Drugs against Omicron BA.2.12.1, BA.4, and BA.5 Subvariants, Effectiveness of BNT162b2 Vaccine against Omicron in Children 5 to 11 Years of Age, Evidence for Step Therapy in Diabetic Macular Edema, Supplemental Vitamin D and Incident Fractures in Midlife and Older Adults, Case 23-2022: A 49-Year-Old Man with Hypoglycemia, Trial of Anti-BDCA2 Antibody Litifilimab for Cutaneous Lupus Erythematosus, Overall Survival with Brentuximab Vedotin in Stage III or IV Hodgkins Lymphoma, NEJM Catalyst Innovations in Care Delivery. 1. VM, Elliott Ornato Additional Contributions: We thank Francesca Montillo, MM, Emergency Department, Beth Israel Deaconess Medical Center, Boston, for editorial assistance and Valerie Teal, MS, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, for assisting with data acquisition. Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest. Importance (See Methods for definition of time to epinephrine.) S, Chan However, the AHA provides standardized reporting guidelines and training of all entry personnel to ensure accuracy of entered data. In addition, among the patients whose treatment involved no protocol violations and whose arrest had been precipitated by asphyxia, the 24-hour survival rate was lower with high-dose epinephrine: none of 8 such patients given the high dose survived at 24 hours, as compared with 6 of 13 patients given the standard dose (P=0.05). In addition, among patients with asphyxia-precipitated arrests and no protocol violations, the 24-hour survival rate was also lower in the high-dose epinephrine group: none of 8 patients in that group survived, as compared with 6 of 13 in the standard-dose group. Bookshelf G, Nallamothu C. Predictive indices of successful cardiac resuscitation after prolonged arrest and experimental cardiopulmonary resuscitation. The other eight involved children who had been assigned to standard-dose rescue therapy received high-dose epinephrine after their experimental vials had been emptied. Residents, nurses, and faculty members provided CPR according to American Heart Association guidelines, without interference from the observing research team. A randomized, blinded trial of high-dose epinephrine versus standard-dose epinephrine in a swine model of pediatric asphyxial cardiac arrest. Trends in survival after in-hospital cardiac arrest. Acta Anaesthesiol Scand 1991;35:253-256, 7. High-dose epinephrine in adult cardiac arrest. In-hospital pediatric cardiac arrest. emcrit resuscitation critical copd pneumonia patient Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. None of the patients in the high-dose group, as compared with four of those in the standard-dose group, survived to hospital discharge. Data abstractors were not blinded to the outcome of the patients, although they were unaware of the hypothesis of the current study. The doses in these 10 patients ranged from 0.002 to 0.06 mg per kilogram. These 362 patients had a very high rate of ROSC (94%) and a short median downtime (2 minutes [IQR, 1-5]), compared with the included cohort (64% ROSC and median downtime of 14 minutes [IQR, 6-28]). C, Thowsen RA, Alferness Crit Care Med 1993;21:111-117, 14. and transmitted securely.
Patients with time to epinephrine administration of longer than 5 minutes (233/1558) compared with those with time to epinephrine of 5 minutes or less (1325/1558) had lower risk of in-hospital survival to discharge (21.0% [49/233] vs 33.1% [438/1325]; multivariable-adjusted RR, 0.75 [95% CI, 0.60-0.93]; 2022 American Medical Association. Questioning the use of epinephrine to treat cardiac arrest. The main limitations of this investigation are related to the small sample size, use of the 24-hour survival rate as the primary outcome measure, the occurrence of protocol violations, and the extent to which the results may be generalized to other populations of children. JC, Menegazzi Accessibility AA, Berg Koehler RC, Michael JR, Guerci AD, et al. vortex emcrit airway HF, Thompson After adjustment by multiple logistic-regression analysis for differences in the groups at the time of arrest, the high-dose group tended to have a lower 24-hour survival rate (odds ratio for death, 7.9; 97.5 percent confidence interval, 0.9 to 72.5; P=0.08). Protocol violations occurred in 18 of these 68 cases. The details of data collection and reliability have been described previously.3,16 Cardiac arrest is defined as pulselessness, or a pulse with inadequate perfusion, requiring chest compressions, defibrillation, or both, with a hospital-wide or unit-based emergency response by acute care facility personnel. High-dose adrenaline in adult in-hospital asystolic cardiopulmonary resuscitation: a double-blind randomised trial. BK; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Results from the multivariable regression models are reported as RRs with 95% CIs. GA, Oxer Peberdy Am Heart J 1994;127:324-330, 35. High-dose epinephrine is not superior to standard-dose epinephrine in pediatric in-hospital cardiopulmonary arrest. 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]). The cohort included data submitted to the GWTG-R registry between January 2000 and December 2014. Outcomes were dismal among the 38 patients whose cardiac arrest had been precipitated by some form of shock. Potential risks of high-dose epinephrine for resuscitation from ventricular fibrillation in a porcine model. Nearly all the arrests (96 percent) were witnessed. The study population was characterized using descriptive statistics. Dobutamine infusions in stable, critically ill children: pharmacokinetics and hemodynamic actions. Gonzalez ER, Ornato JP, Garnett AR, et al. Fifty-one (49%) had completed fellowship training, and 81 (77%) were either PALS or APLS instructors (referred to as "instructors" below). Gueugniaud P-Y, Mols P, Goldstein P, et al. Beneficial effect of epinephrine infusion on cerebral and myocardial blood flows during CPR. Circulation 2000;102:Suppl I:I-291, 2. Standard-dose epinephrine (SDE) currently recommended by the American Heart Association for pediatric resuscitation is 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution). The two treatment groups did not differ significantly in terms of the rate of return of spontaneous circulation (which occurred in 20 patients in the high-dose group and 21 of those in the standard-dose group; odds ratio, 1.1; 97.5 percent confidence interval, 0.4 to 3.0). DOI: 10.1056/NEJMoa032440, Tap into groundbreaking research and clinically relevant insights. Prior studies have addressed the dosage of epinephrine (standard vs high dose) in pediatric cardiac arrest.12-14 We have not identified any studies examining the association between delay in epinephrine dose and outcomes in pediatric cardiac arrest. Effect of adrenaline on survival in out-of-hospital cardiac arrest: a randomised double-blind placebo-controlled trial. High-dose epinephrine results in greater early mortality after resuscitation from prolonged cardiac arrest in pigs: a prospective, randomized study.
The 2 test was used to compare frequencies. Funding/Support: Dr Donnino is supported by the National Heart, Lung, and Blood Institute (NHLBI) (1K02HL107447-01A1) and American Heart Association (AHA) (14GRNT2001002). For example, the cardiac arrests in this study were witnessed, monitored, promptly recognized, and promptly treated. To determine whether time to first epinephrine dose is associated with outcomes in pediatric in-hospital cardiac arrest. In contrast, 7 of the 18 patients who were assigned to the standard dose after asphyxia-precipitated arrest survived at 24 hours (P=0.02) (Table 4). Young KD, Seidel JS. Because of the unexpected and sudden nature of the cardiac events and because both dose strategies are recommended by the American Heart Association and the International Liaison Committee on Resuscitation, the commission accepted the concept of presumed consent and approved exemption from the requirement for informed consent.25 However, informed consent was deemed necessary, and was obtained from the parents or legal guardians of all the patients, for continued participation in data collection and follow-up after hospital discharge. The content of this site is intended for health care professionals. A total of 1558 patients (median age, 9 months [interquartile range [IQR], 13 days5 years]) were included in the final cohort. Jacobs
Goto
Delayed time to defibrillation after in-hospital cardiac arrest. PS. Berg RA, Donnerstein RL, Padbury JF. Epinephrine improves coronary and cerebral perfusion during CPR by directing the limited systemic blood flow to the coronary and cerebral circulations through its peripheral vasoconstrictive effects.31,32 A high dose of epinephrine increases coronary and cerebral perfusion during CPR more than does the standard dose.2-5,7 However, high doses, as compared with standard doses, also increase myocardial oxygen consumption and decrease cardiac output during CPR.33,34 Furthermore, high doses can result in a toxic hyperadrenergic state (manifested as severe tachycardia, severe hypertension, and ventricular arrhythmias) during the first few minutes after resuscitation.21,22,35 This state may be particularly dangerous for the stunned myocardium after resuscitation.36 Although we were unable to evaluate these physiological variables during the first few minutes after resuscitation in our patients, we speculate that the poor outcomes with high-dose epinephrine may be due in part to such adverse effects. H,
The data suggest that high-dose therapy may be worse than standard-dose therapy. LW, Saindon
Members of the pediatric intensive care and emergency medicine faculty were in the hospital 24 hours a day and were available to participate on the cardiac-resuscitation team. To assess the independent association between time to epinephrine administration during cardiac arrest resuscitation and survival to discharge, we applied a multivariable regression model with generalized estimating equations with an exchangeable (compound symmetry) correlation matrix to account for hospital clustering. We performed an analysis of data from the Get With the GuidelinesResuscitation registry. NA, Martin
Address reprint requests to Dr. Berg at Pediatrics/3302, 1501 N. Campbell Ave., P.O. Paradis NA, Martin GB, Rosenberg J, et al. N Engl J Med 1998;339:1595-1601, 18. In a previous investigation at the Children's Institute of the University of So Paulo School of Medicine, 61 percent of the cardiac arrests were precipitated by asphyxia, and 36 percent occurred in children who had received catecholamine infusions before the arrest.24 The Children's Institute is a 122-bed, tertiary-care children's hospital that admits more than 6000 patients each year. GM, Niermeyer
eFigure 1. During the 23-month investigation, cardiac arrests occurred in 185 children (Figure 1). The following variables were entered into the multivariable model: age group (neonate [<1 month], infant [1 month to <1 year], child [1-12 years], or adolescent [>12 years]), sex, year of the arrest (treated as a categorical variable with year 2000 as the reference), illness category (medical cardiac, medical noncardiac, surgical cardiac, surgical noncardiac, or newborn [ie, born this admission]), preexisting mechanical ventilation, whether the patient was monitored (presence of electrocardiography, pulse oximetry, and/or apnea monitor), whether the event was witnessed, location of arrest (intensive care unit [including postanesthesia care unit and the operating room], emergency department, floor without telemetry, floor with telemetry, or other), time of week (weekday [Monday 7 amFriday 11 pm] vs weekend [Friday 11 pmMonday 7 am]), time of day (day [7:00 am10:59 pm] vs night [11:00 pm6:59 am]), first documented pulseless rhythm (asystole vs pulseless electrical activity), and insertion or reinsertion of an airway during the event. Children who have more prolonged, untreated cardiac arrests, those who have undergone cardiac surgery, and those in ventricular fibrillation were underrepresented. JP,
Fiser
doi: 10.1542/peds.2006-0219. Propensity score analysis and multiple imputations, eTable 4. Comparison of standard and high-dose adrenaline in the resuscitation of asystole and electromechanical dissociation. Phenylephrine plus propranolol improves the balance between myocardial oxygen supply and demand during experimental cardiopulmonary resuscitation. Among children with asphyxia-precipitated cardiac arrest, high-dose epinephrine appears to be harmful. TJ, Andersen
For the analysis of neurological outcome, we included only patients who had these outcomes reported. et al; National Registry of Cardiopulmonary Resuscitation Investigators. Ortmann
JAMA 1992;268:2667-2672, 17. Chameides L, Hazinski MF. We performed an analysis of data from the Get With the GuidelinesResuscitation registry. Ann Emerg Med 1989;18:920-926, 6. J, Steen
We included US pediatric patients (age <18 years) with an in-hospital cardiac arrest and an initial nonshockable rhythm who received at least 1 dose of epinephrine. The quality of data across sites may therefore vary. We excluded a small number of patients based on missing values for covariates, time to epinephrine, or the outcomes, which might decrease the generalizability of our results. TM. Although some of these patients met other exclusion criteria, 362 patients were excluded solely on the basis of not having received epinephrine. After two mailings, 105 of 162 surveys (65%) were completed by members in practice.
On the basis of our previous experience, a two-year recruitment period was expected to yield approximately 70 patients for enrollment.24 In our previous study, the 24-hour survival rate after two standard doses of epinephrine was approximately 20 percent.24 In an earlier study based on historical controls, rescue therapy with high-dose epinephrine increased the 24-hour survival rate from 0 percent to approximately 50 percent.9 With 34 children in each group, the power to detect an improvement from 20 to 50 percent in the 24-hour survival rate (with a two-sided P value of 0.05) was 75 percent. 2022 American Medical Association. If time to CPR was negative (ie, the patient lost his or her pulse after initiation of CPR), a value of 0 minutes was imputed.
EF, Pediatrics. We included index events only from hospitals with at least 6 months of reporting and at least 5 cases reported. We believe that this potential misclassification is likely undifferentiated and that, in most cases, this would lead to bias toward the null. The recording of the time of pulselessness and the first dose of epinephrine was done in whole minutes. Do practice guidelines augment drug utilisation review. Brown CG, Martin DR, Pepe PE, et al. Neither received any specific financial compensation for their role in the current study. The 5-minutes-or-less group (1325/1558 patients [85%]) had in-hospital survival to discharge of 33.1% (438/1325), compared with 21.0% (49/233) in the longer-than-5-minutes group (233/1558 patients [15%]). Results ), and the Department of Medicine, University of So Paulo School of Medicine (E.F.P. The median time to first epinephrine dose was 1 minute (IQR, 0-4; range, 0-20; mean [SD], 2.6 [3.4] minutes). JD, Howell A prospective investigation into the epidemiology of in-hospital pediatric cardiopulmonary resuscitation using the international Utstein reporting style. Kern KB, Hilwig RW, Rhee KH, Berg RA. Whether this association is true in the pediatric in-hospital cardiac arrest population remains unknown. Dieckmann RA, Vardis R. High-dose epinephrine in pediatric out-of-hospital cardiopulmonary arrest. Characteristics of the Population for Study of Timing of Epinephrine and Pediatric In-Hospital Nonshockable Cardiac Arrest, Table 2. For both primary and secondary outcomes, the RRs represent the RR for the outcome per minute increase in time to epinephrine. Twenty-two were assigned to high-dose epinephrine, and 16 to standard-dose epinephrine. Bethesda, MD 20894, Web Policies Crit Care Med 1993;21:678-686, 12. Lipman J, Wilson W, Kobilski S, et al. Peer-reviewed journal featuring in-depth articles to accelerate the transformation of health care delivery. Furthermore, attainment of an adequate sample size for assessment of that outcome would require a prolonged study period, thereby complicating the study with potentially different resuscitation strategies and protocols over time. Please enable it to take advantage of the complete set of features! CW. Among children with in-hospital cardiac arrest with an initial nonshockable rhythm who received epinephrine, delay in administration of epinephrine was associated with decreased chance of survival to hospital discharge, ROSC, 24-hour survival, and survival to hospital discharge with a favorable neurological outcome. The data are observational, and the possibility of unmeasured confounding remains. Demographic Characteristics of the Patients at the Time of Cardiac Arrest. Seven hundred forty patients did not receive epinephrine (Figure 1). Because data are used primarily at the local site for quality improvement, sites are granted a waiver of informed consent under the common rule. CPR denotes cardiopulmonary resuscitation, and ROSC return of spontaneous circulation. No adjustments were made for multiple testing, and, as such, our secondary end points should be considered exploratory. 2015;314(8):802810. The most effective and engaging way for clinicians to learn, improve their practice, and prepare for board exams. Pediatrics 2002;109:200-209, 25. JT, Criley Carpenter TC, Stenmark KR. To determine whether time to first epinephrine dose is associated with outcomes in pediatric in-hospital cardiac arrest. A number of limitations should be considered when interpreting the current study. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Fisher DG, Schwartz PH, Davis AL. Patient Flowchart for Study of Timing of Epinephrine and Pediatric In-Hospital Nonshockable Cardiac Arrest, Figure 2. Circulation 1984;69:822-835, 33. JJ. RA. RA, Nadkarni Drug interventions during the event, eTable 2. Exposure S. Medications in neonatal resuscitation: epinephrine and the search for better alternative strategies. Nakahara VM, 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]). I, Nadkarni Our findings do suggest, however, that there is room for improvement, with 15% of pediatric patients getting their first epinephrine dose more than 5 minutes after loss of pulse. All Rights Reserved. The primary outcome was survival to discharge from the hospital. J,
Case Records of the Massachusetts General Hospital, Monkeypox Virus Infection in Humans across 16 Countries AprilJune 2022, Protection Associated with Previous SARS-CoV-2 Infection in Nicaragua, Nirmatrelvir for Nonhospitalized Adults with Covid-19, Efficacy of Antibodies and Antiviral Drugs against Omicron BA.2.12.1, BA.4, and BA.5 Subvariants, Effectiveness of BNT162b2 Vaccine against Omicron in Children 5 to 11 Years of Age, Evidence for Step Therapy in Diabetic Macular Edema, Supplemental Vitamin D and Incident Fractures in Midlife and Older Adults, Case 23-2022: A 49-Year-Old Man with Hypoglycemia, Trial of Anti-BDCA2 Antibody Litifilimab for Cutaneous Lupus Erythematosus, Overall Survival with Brentuximab Vedotin in Stage III or IV Hodgkins Lymphoma, NEJM Catalyst Innovations in Care Delivery. 1. VM, Elliott Ornato Additional Contributions: We thank Francesca Montillo, MM, Emergency Department, Beth Israel Deaconess Medical Center, Boston, for editorial assistance and Valerie Teal, MS, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, for assisting with data acquisition. Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest. Importance (See Methods for definition of time to epinephrine.) S, Chan However, the AHA provides standardized reporting guidelines and training of all entry personnel to ensure accuracy of entered data. In addition, among the patients whose treatment involved no protocol violations and whose arrest had been precipitated by asphyxia, the 24-hour survival rate was lower with high-dose epinephrine: none of 8 such patients given the high dose survived at 24 hours, as compared with 6 of 13 patients given the standard dose (P=0.05). In addition, among patients with asphyxia-precipitated arrests and no protocol violations, the 24-hour survival rate was also lower in the high-dose epinephrine group: none of 8 patients in that group survived, as compared with 6 of 13 in the standard-dose group. Bookshelf G, Nallamothu C. Predictive indices of successful cardiac resuscitation after prolonged arrest and experimental cardiopulmonary resuscitation. The other eight involved children who had been assigned to standard-dose rescue therapy received high-dose epinephrine after their experimental vials had been emptied. Residents, nurses, and faculty members provided CPR according to American Heart Association guidelines, without interference from the observing research team. A randomized, blinded trial of high-dose epinephrine versus standard-dose epinephrine in a swine model of pediatric asphyxial cardiac arrest. Trends in survival after in-hospital cardiac arrest. Acta Anaesthesiol Scand 1991;35:253-256, 7. High-dose epinephrine in adult cardiac arrest. In-hospital pediatric cardiac arrest. emcrit resuscitation critical copd pneumonia patient Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. None of the patients in the high-dose group, as compared with four of those in the standard-dose group, survived to hospital discharge. Data abstractors were not blinded to the outcome of the patients, although they were unaware of the hypothesis of the current study. The doses in these 10 patients ranged from 0.002 to 0.06 mg per kilogram. These 362 patients had a very high rate of ROSC (94%) and a short median downtime (2 minutes [IQR, 1-5]), compared with the included cohort (64% ROSC and median downtime of 14 minutes [IQR, 6-28]). C, Thowsen RA, Alferness Crit Care Med 1993;21:111-117, 14. and transmitted securely.
Patients with time to epinephrine administration of longer than 5 minutes (233/1558) compared with those with time to epinephrine of 5 minutes or less (1325/1558) had lower risk of in-hospital survival to discharge (21.0% [49/233] vs 33.1% [438/1325]; multivariable-adjusted RR, 0.75 [95% CI, 0.60-0.93]; 2022 American Medical Association. Questioning the use of epinephrine to treat cardiac arrest. The main limitations of this investigation are related to the small sample size, use of the 24-hour survival rate as the primary outcome measure, the occurrence of protocol violations, and the extent to which the results may be generalized to other populations of children. JC, Menegazzi Accessibility AA, Berg Koehler RC, Michael JR, Guerci AD, et al. vortex emcrit airway HF, Thompson After adjustment by multiple logistic-regression analysis for differences in the groups at the time of arrest, the high-dose group tended to have a lower 24-hour survival rate (odds ratio for death, 7.9; 97.5 percent confidence interval, 0.9 to 72.5; P=0.08). Protocol violations occurred in 18 of these 68 cases. The details of data collection and reliability have been described previously.3,16 Cardiac arrest is defined as pulselessness, or a pulse with inadequate perfusion, requiring chest compressions, defibrillation, or both, with a hospital-wide or unit-based emergency response by acute care facility personnel. High-dose adrenaline in adult in-hospital asystolic cardiopulmonary resuscitation: a double-blind randomised trial. BK; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Results from the multivariable regression models are reported as RRs with 95% CIs. GA, Oxer Peberdy Am Heart J 1994;127:324-330, 35. High-dose epinephrine is not superior to standard-dose epinephrine in pediatric in-hospital cardiopulmonary arrest. 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]). The cohort included data submitted to the GWTG-R registry between January 2000 and December 2014. Outcomes were dismal among the 38 patients whose cardiac arrest had been precipitated by some form of shock. Potential risks of high-dose epinephrine for resuscitation from ventricular fibrillation in a porcine model. Nearly all the arrests (96 percent) were witnessed. The study population was characterized using descriptive statistics. Dobutamine infusions in stable, critically ill children: pharmacokinetics and hemodynamic actions. Gonzalez ER, Ornato JP, Garnett AR, et al. Fifty-one (49%) had completed fellowship training, and 81 (77%) were either PALS or APLS instructors (referred to as "instructors" below). Gueugniaud P-Y, Mols P, Goldstein P, et al. Beneficial effect of epinephrine infusion on cerebral and myocardial blood flows during CPR. Circulation 2000;102:Suppl I:I-291, 2. Standard-dose epinephrine (SDE) currently recommended by the American Heart Association for pediatric resuscitation is 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution). The two treatment groups did not differ significantly in terms of the rate of return of spontaneous circulation (which occurred in 20 patients in the high-dose group and 21 of those in the standard-dose group; odds ratio, 1.1; 97.5 percent confidence interval, 0.4 to 3.0). DOI: 10.1056/NEJMoa032440, Tap into groundbreaking research and clinically relevant insights. Prior studies have addressed the dosage of epinephrine (standard vs high dose) in pediatric cardiac arrest.12-14 We have not identified any studies examining the association between delay in epinephrine dose and outcomes in pediatric cardiac arrest. Effect of adrenaline on survival in out-of-hospital cardiac arrest: a randomised double-blind placebo-controlled trial. High-dose epinephrine results in greater early mortality after resuscitation from prolonged cardiac arrest in pigs: a prospective, randomized study.
The 2 test was used to compare frequencies. Funding/Support: Dr Donnino is supported by the National Heart, Lung, and Blood Institute (NHLBI) (1K02HL107447-01A1) and American Heart Association (AHA) (14GRNT2001002). For example, the cardiac arrests in this study were witnessed, monitored, promptly recognized, and promptly treated. To determine whether time to first epinephrine dose is associated with outcomes in pediatric in-hospital cardiac arrest. In contrast, 7 of the 18 patients who were assigned to the standard dose after asphyxia-precipitated arrest survived at 24 hours (P=0.02) (Table 4). Young KD, Seidel JS. Because of the unexpected and sudden nature of the cardiac events and because both dose strategies are recommended by the American Heart Association and the International Liaison Committee on Resuscitation, the commission accepted the concept of presumed consent and approved exemption from the requirement for informed consent.25 However, informed consent was deemed necessary, and was obtained from the parents or legal guardians of all the patients, for continued participation in data collection and follow-up after hospital discharge. The content of this site is intended for health care professionals. A total of 1558 patients (median age, 9 months [interquartile range [IQR], 13 days5 years]) were included in the final cohort. Jacobs
Goto
Delayed time to defibrillation after in-hospital cardiac arrest. PS. Berg RA, Donnerstein RL, Padbury JF. Epinephrine improves coronary and cerebral perfusion during CPR by directing the limited systemic blood flow to the coronary and cerebral circulations through its peripheral vasoconstrictive effects.31,32 A high dose of epinephrine increases coronary and cerebral perfusion during CPR more than does the standard dose.2-5,7 However, high doses, as compared with standard doses, also increase myocardial oxygen consumption and decrease cardiac output during CPR.33,34 Furthermore, high doses can result in a toxic hyperadrenergic state (manifested as severe tachycardia, severe hypertension, and ventricular arrhythmias) during the first few minutes after resuscitation.21,22,35 This state may be particularly dangerous for the stunned myocardium after resuscitation.36 Although we were unable to evaluate these physiological variables during the first few minutes after resuscitation in our patients, we speculate that the poor outcomes with high-dose epinephrine may be due in part to such adverse effects. H,
The data suggest that high-dose therapy may be worse than standard-dose therapy. LW, Saindon
Members of the pediatric intensive care and emergency medicine faculty were in the hospital 24 hours a day and were available to participate on the cardiac-resuscitation team. To assess the independent association between time to epinephrine administration during cardiac arrest resuscitation and survival to discharge, we applied a multivariable regression model with generalized estimating equations with an exchangeable (compound symmetry) correlation matrix to account for hospital clustering. We performed an analysis of data from the Get With the GuidelinesResuscitation registry. NA, Martin
Address reprint requests to Dr. Berg at Pediatrics/3302, 1501 N. Campbell Ave., P.O. Paradis NA, Martin GB, Rosenberg J, et al. N Engl J Med 1998;339:1595-1601, 18. In a previous investigation at the Children's Institute of the University of So Paulo School of Medicine, 61 percent of the cardiac arrests were precipitated by asphyxia, and 36 percent occurred in children who had received catecholamine infusions before the arrest.24 The Children's Institute is a 122-bed, tertiary-care children's hospital that admits more than 6000 patients each year. GM, Niermeyer
eFigure 1. During the 23-month investigation, cardiac arrests occurred in 185 children (Figure 1). The following variables were entered into the multivariable model: age group (neonate [<1 month], infant [1 month to <1 year], child [1-12 years], or adolescent [>12 years]), sex, year of the arrest (treated as a categorical variable with year 2000 as the reference), illness category (medical cardiac, medical noncardiac, surgical cardiac, surgical noncardiac, or newborn [ie, born this admission]), preexisting mechanical ventilation, whether the patient was monitored (presence of electrocardiography, pulse oximetry, and/or apnea monitor), whether the event was witnessed, location of arrest (intensive care unit [including postanesthesia care unit and the operating room], emergency department, floor without telemetry, floor with telemetry, or other), time of week (weekday [Monday 7 amFriday 11 pm] vs weekend [Friday 11 pmMonday 7 am]), time of day (day [7:00 am10:59 pm] vs night [11:00 pm6:59 am]), first documented pulseless rhythm (asystole vs pulseless electrical activity), and insertion or reinsertion of an airway during the event. Children who have more prolonged, untreated cardiac arrests, those who have undergone cardiac surgery, and those in ventricular fibrillation were underrepresented. JP,
Fiser
doi: 10.1542/peds.2006-0219. Propensity score analysis and multiple imputations, eTable 4. Comparison of standard and high-dose adrenaline in the resuscitation of asystole and electromechanical dissociation. Phenylephrine plus propranolol improves the balance between myocardial oxygen supply and demand during experimental cardiopulmonary resuscitation. Among children with asphyxia-precipitated cardiac arrest, high-dose epinephrine appears to be harmful. TJ, Andersen
For the analysis of neurological outcome, we included only patients who had these outcomes reported. et al; National Registry of Cardiopulmonary Resuscitation Investigators. Ortmann
JAMA 1992;268:2667-2672, 17. Chameides L, Hazinski MF. We performed an analysis of data from the Get With the GuidelinesResuscitation registry. Ann Emerg Med 1989;18:920-926, 6. J, Steen
We included US pediatric patients (age <18 years) with an in-hospital cardiac arrest and an initial nonshockable rhythm who received at least 1 dose of epinephrine. The quality of data across sites may therefore vary. We excluded a small number of patients based on missing values for covariates, time to epinephrine, or the outcomes, which might decrease the generalizability of our results. TM. Although some of these patients met other exclusion criteria, 362 patients were excluded solely on the basis of not having received epinephrine. After two mailings, 105 of 162 surveys (65%) were completed by members in practice. On the basis of our previous experience, a two-year recruitment period was expected to yield approximately 70 patients for enrollment.24 In our previous study, the 24-hour survival rate after two standard doses of epinephrine was approximately 20 percent.24 In an earlier study based on historical controls, rescue therapy with high-dose epinephrine increased the 24-hour survival rate from 0 percent to approximately 50 percent.9 With 34 children in each group, the power to detect an improvement from 20 to 50 percent in the 24-hour survival rate (with a two-sided P value of 0.05) was 75 percent. 2022 American Medical Association. If time to CPR was negative (ie, the patient lost his or her pulse after initiation of CPR), a value of 0 minutes was imputed.