Document Type
Article
Publication Date
7-16-2024
Abstract
BACKGROUND: Half of pediatric in-hospital cardiopulmonary resuscitation (CPR) events have an initial rhythm of non-pulseless bradycardia with poor perfusion. Our study objectives were to leverage granular data from the ICU-RESUScitation (ICU-RESUS) trial to: (1) determine the association of early epinephrine administration with survival outcomes in children receiving CPR for bradycardia with poor perfusion; and (2) describe the incidence and time course of the development of pulselessness.
METHODS: Prespecified secondary analysis of ICU-RESUS, a multicenter cluster randomized trial of children (< 19 years) receiving CPR in 18 intensive care units in the United States. Index events (October 2016-March 2021) lasting ≥ 2 min with a documented initial rhythm of bradycardia with poor perfusion were included. Associations between early epinephrine (first 2 min of CPR) and outcomes were evaluated with Poisson multivariable regression controlling for a priori pre-arrest characteristics. Among patients with arterial lines, intra-arrest blood pressure waveforms were reviewed to determine presence of a pulse during CPR interruptions. The temporal nature of progression to pulselessness was described and outcomes were compared between patients according to subsequent pulselessness status.
RESULTS: Of 452 eligible subjects, 322 (71%) received early epinephrine. The early epinephrine group had higher pre-arrest severity of illness and vasoactive-inotrope scores. Early epinephrine was not associated with survival to discharge (aRR 0.97, 95%CI 0.82, 1.14) or survival with favorable neurologic outcome (aRR 0.99, 95%CI 0.82, 1.18). Among 186 patients with invasive blood pressure waveforms, 118 (63%) had at least 1 period of pulselessness during the first 10 min of CPR; 86 (46%) by 2 min and 100 (54%) by 3 min. Sustained return of spontaneous circulation was highest after bradycardia with poor perfusion (84%) compared to bradycardia with poor perfusion progressing to pulselessness (43%) and bradycardia with poor perfusion progressing to pulselessness followed by return to bradycardia with poor perfusion (62%) (p < 0.001).
CONCLUSIONS: In this cohort of pediatric CPR events with an initial rhythm of bradycardia with poor perfusion, we failed to identify an association between early bolus epinephrine and outcomes when controlling for illness severity. Most children receiving CPR for bradycardia with poor perfusion developed subsequent pulselessness, 46% within 2 min of CPR onset.
Recommended Citation
O'Halloran, Amanda; Reeder, Ron; Berg, Robert; Ahmed, Tageldin; Bell, Michael; Bishop, Robert; Bochkoris, Matthew; Burns, Candice; Carcillo, Joseph; Carpenter, Todd; Dean, J. Michael; Diddle, J. Wesley; Federman, Myke; Fernandez, Richard; Fink, Ericka; Franzon, Deborah; Frazier, Aisha; Friess, Stuart; Graham, Kathryn; Hall, Mark; Hehir, David; Horvat, Christopher M; Huard, Leanna; Kienzle, Martha; Kilbaugh, Todd; Maa, Tensing; Manga, Arushi; McQuillen, Patrick; Meert, Kathleen; Mourani, Peter; Nadkarni, Vinay; Naim, Maryam; Notterman, Daniel; Pollack, Murray; Sapru, Anil; Schneiter, Carleen; Sharron, Matthew; Srivastava, Neeraj; Tilford, Bradley; Topjian, Alexis; Viteri, Shirley; Wessel, David; Wolfe, Heather; Yates, Andrew; Zuppa, Athena; Sutton, Robert; and Morgan, Ryan, "Early Bolus Epinephrine Administration During Pediatric Cardiopulmonary Resuscitation for Bradycardia with Poor Perfusion: An ICU-Resuscitation Study" (2024). Department of Pediatrics Faculty Papers. Paper 158.
https://jdc.jefferson.edu/pedsfp/158
Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.
PubMed ID
39010134
Language
English
Comments
This article is the author's final published version in Critical Care, Volume 28, Issue 1, 2024, Article number 242.
The published version is available at https://doi.org/10.1186/s13054-024-05018-7.
Copyright © The Author(s) 2024