Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest

Andersen, Lars W.; Berg, Katherine M.; Saindon, Brian Z.; Massaro, Joseph M.; Raymond, Tia T.; Berg, Robert A.; Nadkarni, Vinay M.; Donnino, Michael W.
August 2015
JAMA: Journal of the American Medical Association;8/25/2015, Vol. 314 Issue 8, p802
Academic Journal
IMPORTANCE Delay in administration of the first epinephrine dose is associated with decreased survival among adults after in-hospital, nonshockable cardiac arrest. Whether this association is true in the pediatric in-hospital cardiac arrest population remains unknown. OBJECTIVE To determine whether time to first epinephrine dose is associated with outcomes in pediatric in-hospital cardiac arrest. DESIGN, SETTING. AND PARTICIPANTS We performed an analysis of data from the Get With the Guidelines-Resuscitation registry. 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. A total of 1558 patients (median age, 9 months [interquartile range [IQR], 13 days-5 years]) were included in the final cohort. EXPOSURE Time to epinephrine, defined as time in minutes from recognition of loss of pulse to the first dose of epinephrine. MAIN OUTCOMES AND MEASURES The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC), survival at 24 hours, and neurological outcome. A favorable neurological outcome was defined as a score of 1 to 2 on the Pediatric Cerebral Performance Category scale. RESULTS Among the 1558 patients, 487 (31.3%) survived to hospital discharge. The median time to first epinephrine dose was 1 minute (IQR, 0-4; range, 0-20; mean [SD], 2.6 [3.4] minutes). Longer time to epinephrine administration was associated with lower risk of survival to discharge in multivariable analysis (multivariable-adjusted risk ratio [RR] per minute delay, 0.95 [95% Cl, 0.93-0.98]). Longer time to epinephrine administration was also associated with decreased risk of ROSC (multivariable-adjusted RR per minute delay, 0.97 [95% Cl, 0.96-0.99]), decreased risk of survival at 24 hours (multivariable-adjusted RR per minute delay, 0.97 [95% Cl, 0.95-0.99]), and decreased risk of survival with favorable neurological outcome (multivariable-adjusted RR per minute delay, 0.95 [95% Cl, 0.91-0.99]). 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% Cl, 0.60-0.93]; P = .01). CONCLUSIONS AND RELEVANCE 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.


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