Expert calls for standard epinephrine doses when treating children in cardiac arrest

Medical personnel attempting to resuscitate a child in cardiac arrest should abide by epinephrine dosing levels outlined in the Pediatric Advanced Life Support (PALS) guidelines rather than giving larger amounts of the drug, says a nationally recognized pediatrician from UT Southwestern Medical Center at Dallas.

In an editorial published in today's issue of The New England Journal of Medicine, Dr. George Lister, chairman of pediatrics at UT Southwestern, cautions against using excessive amounts of epinephrine in children.

"Contrary to the conventional wisdom, evidence has been accumulating that high-dose epinephrine is not beneficial and may even impair organ function and survival after the arrest," said Dr. Lister, who holds the Robert L. Moore Chair in Pediatrics. Epinephrine has been used for almost a century to increase the heart's ability to beat automatically and to redistribute the blood flow to vital organs such as the brain and the heart.

The standard dose of 0.01 milligrams per kilogram of body weight recommended in the PALS guidelines, published in 1986, may be the safest bet, he said. Limiting epinephrine doses to recommended levels also has the potential to reduce the rate of error because fewer formulations of the drug will need to be stocked in resuscitation boxes and carts.

Adhering to the guidelines in an emergency situation provides the best opportunity for a wide range of caregivers with highly variable experience to maximize the chances of success, Dr. Lister added.

Original research published in today's Journal by senior author Dr. Robert Berg of the University of Arizona College of Medicine shows that children who receive 10 times the recommended dose have initial recovery rates similar to children who receive the recommended dose. But children receiving the higher doses are more likely to die soon after the resuscitation.  

"All statistical caveats aside, the most intriguing aspect of these results is the possibility that a change in dose that may appear to be trivial can have such a detectable influence on the dismal survival rates after cardiac arrest," Dr. Lister said.

While epinephrine may increase blood flow during resuscitation, it also increases oxygen use by the heart and many other organs, which could contribute to subsequent injury to vital tissues.

Because children often suffer cardiac arrest from asphyxia rather than primary dysfunction of the heart, they offer a unique opportunity to understand the overall risks and benefits of epinephrine, he said.

Dr. J. Julio Pérez Fontán of Washington University School of Medicine co-wrote the editorial with Dr. Lister.