Epinephrine delay decreases survival for children with in-hospital, nonshockable cardiac arrest

Among children with in-hospital cardiac arrest with an initial nonshockable heart rhythm who received epinephrine (adrenaline), delay in administration of epinephrine was associated with a decreased chance of 24-hour survival and survival to hospital discharge, according to a study in the August 25 issue of JAMA.

Approximately 16,000 children in the United States have a cardiac arrest each year, predominantly in a hospital setting. Epinephrine is recommended by both the American Heart Association and the European Resuscitation Council in pediatric cardiac arrest. Delay in administration of the first epinephrine dose is associated with decreased survival among adults after in-hospital, nonshockable (pulseless electrical activity or asystole) cardiac arrest. Whether this association is the same for children has not been known, according to background information in the article.

Michael W. Donnino, M.D., of Beth Israel Deaconess Medical Center, Boston, and colleagues examined whether time to first epinephrine dose is associated with improved clinical outcomes in pediatric in-hospital cardiac arrest. The researchers performed an analysis of data from the Get With the Guidelines-Resuscitation registry and included U.S. pediatric patients (age <18 years) with an in-hospital cardiac arrest and an initial nonshockable rhythm who received at least 1 dose of epinephrine.

A total of 1,558 patients (median age, 9 months) were included in the final analysis. Among these patients, 487 (31 percent) survived to hospital discharge. The median time to first epinephrine dose was 1 minute. Delay in administration of epinephrine was associated with a decreased chance of return of spontaneous circulation (ROSC), 24-hour survival, survival to hospital discharge, and survival to hospital discharge with a favorable neurological outcome. These associations remained when accounting for multiple patient, event, and hospital characteristics.

Patients with time to epinephrine administration of longer than 5 minutes (233/1,558) compared with those with time to epinephrine of 5 minutes or less (1,325/1,558) had lower likelihood of in-hospital survival to discharge (21 percent vs 33.1 percent).

"Although the observational design precludes ascertainment of causality, the strong association with outcomes suggests that early epinephrine may be beneficial in pediatric cardiac arrest," the authors write.

Editorial: Pediatric Pulseless Arrest with "Nonshockable" Rhythm

"The study by Andersen et al reinforces that pediatric patients with in-hospital cardiac arrest and nonshockable rhythms have poor overall prognosis: less than one-third survive to hospital discharge, and survival with favorable neurocognitive outcome was even lower, at best 17 percent, even when epinephrine was given within first 5 minutes of resuscitation," write Robert C. Tasker, M.B.B.S., M.D., and Adrienne G. Randolph, M.D., M.Sc., of Boston Children's Hospital, in an accompanying editorial.

"Given there will never be a randomized clinical trial and that epinephrine is listed in the pediatric advanced life support guidelines as the next step after CPR for nonshockable rhythms, 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 AHA Class I strength of recommendation. The data support what is currently recommended and show some benefit in the first 5 minutes. It is not known if epinephrine should be given within 2 minutes, as a good number of patients did not receive the drug at all and had ROSC in that time."

Source: The JAMA Network Journals