Association of Early Epinephrine with Hemodynamics and Outcome in Pediatric In-Hospital Cardiac Arrest: A Secondary Analysis of a Multi-center, Cluster-randomized Clinical Trial (ICU-RESUS)

Ashley Siems, Children's National, Washington, District of Columbia, United States.
Maryam Y. Naim, Children's Hospital of Philadelphia, Philadelphia , Pennsylvania, United States; naim@chop.edu.
Robert A. Berg, Children's Hospital of Philadelphia an duNiversity of Pennsylvania, Anesthesiology, Philadelphia, Pennsylvania, United States.
Ron W. Reeder, University of Utah, Salt Lake City, Utah, United States.
Tageldin Ahmed, Children's Hospital of Michigan, Detroit, Michigan, United States.
Michael J. Bell, Children's National, Washington, District of Columbia, United States.
Robert Bishop, Arkansas Children's Hospital, Little Rock, Arkansas, United States.
Matthew Bochkoris, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States.
Candice Burns, Michigan State University, Grand Rapids, Missouri, United States.
Joseph A. Carcillo, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States.
Todd C. Carpenter, University of Colorado Denver, Pediatrics, Aurora, United States.
J Michael Dean, University of Utah School of Medicine, Department of Pediatrics, Salt Lake City, Utah, United States.
J Wesley Diddle, The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States.
Myke Federman, Mattel Children's Hospital UCLA Pediatric Critical Care, Los Angeles, California, United States.
Richard Fernandez, Children's National, Washington, District of Columbia, United States.
Ericka L. Fink, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, United States.
Deborah Franzon, UCSF Benioff Children's Hospital, Pediatrics, San Francisco, California, United States.
Aisha H. Frazier, Nemours/Alfred I. duPont Hospital for Children, Cardiac Center, Wilmington, Delaware, United States.
Stuart H. Friess, Washington University School of Medicine in Saint Louis, St Louis, Missouri, United States.
Kathryn Graham, The Children's Hospital of Philadelphia, Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States.
Mark Hall, Nationwide Children's Hospital, Columbus, United States.
Monica L. Harding, University of Utah, Salt Lake City, Utah, United States.
David A. Hehir, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.
Christopher M. Horvat, Children's Hospital of Pittsburgh of UPMC, Critical Care Medicine, Pittsburgh, Pennsylvania, United States.
Leanna L. Huard, University of California Los Angeles, Pediatrics, Los Angeles, California, United States.
Todd J. Kilbaugh, The Children's Hospital of Philadelphia, Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States.
Tensing Maa, Nationwide Children's Hospital, Department of Pediatrics , Columbus, Ohio, United States.
Arushi Manga, Washington University School of Medicine in Saint Louis, St Louis, Missouri, United States.
Patrick S. McQuillen, University of California San Francisco, San Francisco, California, United States.
Kathleen L. Meert, Children's Hospital of Michigan, Detroit, Michigan, United States.
Peter M. Mourani, University of Arkansas for Medical Sciences, Pediatrics, Critical Care Medicine, Little Rock, Arkansas, United States.
Vinay M. Nadkarni, CHOP, Philadelphia, Pennsylvania, United States.

Document Type

Journal Article

Publication Date

6-4-2025

Journal

Annals of the American Thoracic Society

DOI

10.1513/AnnalsATS.202408-825OC

Abstract

RATIONALE: Delayed (> 5 minutes) epinephrine during pediatric in-hospital cardiac arrest (IHCA) is associated with worse outcomes. Epinephrine is nearly always given earlier, limiting 5 minutes as a quality target. OBJECTIVES: To assess early epinephrine (≤2 minutes) on outcomes and hemodynamics during CPR in pediatric IHCA from pulseless non-shockable rhythms. METHODS: This study leveraged the database of ICU-RESUScitation project (NCT02837497). Primary exposure was time to epinephrine bolus: early versus >2 minutes. Primary outcome was survival to discharge. Secondary outcomes included return of spontaneous circulation (ROSC), survival with favorable neurologic outcome, change from baseline to discharge functional status scale (FSS), total FSS at discharge, new morbidity among survivors, and invasively measured blood pressure (BP) over the first 10 minutes of CPR. MEASUREMENTS AND MAIN RESULTS: Among 352 CPR events, median age was 1.0 (0.3, 8.0) year, 186 (53%) were male, an 185 (52.6%) had cardiac disease. Early epinephrine was administered in 273 (78%), and median time to administration was 1.0 (0.0, 2.0) minute. Survival to discharge was similar between patients who received early epinephrine versus those who did not. Early epinephrine was associated with higher ROSC, a change from baseline to discharge in FSS, lower total FSS scores at discharge, and lower rates of new morbidity compared to epinephrine >2 minutes. The probability of ROSC and survival to discharge with favorable neurologic outcome decreased for each minute of delay in epinephrine. There was no difference in the invasive BP targets during the first 10 minutes of CPR. CONCLUSIONS: Early epinephrine was common, associated with higher ROSC and improved functional outcomes compared to epinephrine > 2 minutes in pediatric IHCA.

Department

Pediatrics

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