Dataset Information

Weight-Based Versus Flat Dosing of Epinephrine During Cardiac Arrest in the PICU: A Multicenter Survey.

ABSTRACT:

Objectives

Pediatric Advanced Life Support (PALS) guidelines include weight-based epinephrine dosing recommendations of 0.01 mg/kg with a maximum of 1 mg, which corresponds to a weight of 100 kg. Actual practice patterns are unknown.

Design

Multicenter cross-sectional survey regarding institutional practices for the transition from weight-based to flat dosing of epinephrine during cardiopulmonary resuscitation in PICUs. Exploratory analyses compared epinephrine dosing practices with several institutional characteristics using Fisher exact test.

Setting

Internet-based survey.

Subjects

U.S. PICU representatives (one per institution) involved in resuscitation systems of care.

Interventions

None.

Measurements and main results

Of 137 institutions surveyed, 68 (50%) responded. Most responding institutions are freestanding children's hospitals or dedicated children's hospitals within combined adult/pediatric hospitals (67; 99%); 55 (81%) are academic and 41 (60%) have PICU fellowship programs. Among respondents, institutional roles include PICU medical director (13; 19%), resuscitation committee member (23; 34%), and attending physician with interest in resuscitation (21; 31%). When choosing between weight-based and flat dosing, 64 respondents (94%) report using patient weight, 23 (34%) patient age, and five (7%) patient pubertal stage. Among those reporting using weight, 28 (44%) switch at 50 to less than 60 kg, 17 (27%) at 60 to less than 80 kg, five (8%) at 80 to less than 100 kg, and eight (12%) at greater than or equal to 100 kg. Among those reporting using age, four (17%) switch at 14 to less than 16 years, five (22%) at 16 to less than 18, and six (26%) at greater than or equal to 18. Twenty-nine respondents (43%) report using ideal body weight when dosing epinephrine in obese patients. Using patient age in choosing epinephrine dosing is more common in institutions that require Advanced Cardiac Life Support (ACLS) certification for some/all code team responders compared with institutions that do not require ACLS certification (52% vs 22%; p = 0.02).

Conclusions

The majority of PICUs surveyed report epinephrine dosing practices that are inconsistent with PALS guidelines.

SUBMITTER: Kienzle MF

PROVIDER: S-EPMC9529772 | biostudies-literature | 2022 Oct

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Weight-Based Versus Flat Dosing of Epinephrine During Cardiac Arrest in the PICU: A Multicenter Survey.

Kienzle Martha F MF Morgan Ryan W RW Dewan Maya M Hebbar Kiran B KB Nadkarni Vinay M VM Srinivasan Vijay V Tegtmeyer Ken K Sutton Robert M RM Wolfe Heather A HA

Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 20220608 10

<h4>Objectives</h4>Pediatric Advanced Life Support (PALS) guidelines include weight-based epinephrine dosing recommendations of 0.01 mg/kg with a maximum of 1 mg, which corresponds to a weight of 100 kg. Actual practice patterns are unknown.<h4>Design</h4>Multicenter cross-sectional survey regarding institutional practices for the transition from weight-based to flat dosing of epinephrine during cardiopulmonary resuscitation in PICUs. Exploratory analyses compared epinephrine dosing practices wi ...[more]

PMID: 35678459

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Project description:ImportanceDelay 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.ObjectiveTo determine whether time to first epinephrine dose is associated with outcomes in pediatric in-hospital cardiac arrest.Design, setting and participantsWe 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.ExposureTime to epinephrine, defined as time in minutes from recognition of loss of pulse to the first dose of epinephrine.Main outcomes and measuresThe 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.ResultsAmong 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% CI, 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% CI, 0.96-0.99]), decreased risk of survival at 24 hours (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.95-0.99]), and decreased risk of survival with favorable neurological outcome (multivariable-adjusted RR per minute delay, 0.95 [95% CI, 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% CI, 0.60-0.93]; P = .01).Conclusions and relevanceAmong 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.

Project description:BackgroundFor patients with in-hospital cardiac arrests attributable to nonshockable rhythms, delays in epinephrine administration beyond 5 minutes is associated with worse survival. However, the extent of hospital variation in delayed epinephrine administration and its effect on hospital-level outcomes is unknown.MethodsWithin Get With The Guidelines-Resuscitation, we identified 103 932 adult patients (≥18 years) at 548 hospitals with an in-hospital cardiac arrest attributable to a nonshockable rhythm who received at least 1 dose of epinephrine between 2000 and 2014. We constructed 2-level hierarchical regression models to quantify hospital variation in rates of delayed epinephrine administration (>5 minutes) and its association with hospital rates of survival to discharge and survival with functional recovery.ResultsOverall, 13 213 (12.7%) patients had delays to epinephrine, and this rate varied markedly across hospitals (range, 0%-53.8%). The odds of delay in epinephrine administration were 58% higher at 1 randomly selected hospital in comparison with a similar patient at another randomly selected hospital (median odds ratio, 1.58; 95% confidence interval, 1.51-1.64). The median risk-standardized survival rate was 12.0% (range, 5.4%-31.9%), and the risk-standardized survival with functional recovery was 7.4% (range, 0.9%-30.8%). There was an inverse correlation between a hospital's rate of delayed epinephrine administration and its risk-standardized rate of survival to discharge (ρ=-0.22, P<0.0001) and survival with functional recovery (ρ=-0.14, P=0.001). In comparison with a median survival rate of 12.9% (interquartile range, 11.1%-15.4%) at hospitals in the lowest quartile of epinephrine delay, risk-standardized survival was 16% lower at hospitals in the quartile with the highest rate of epinephrine delays (10.8%; interquartile range, 9.7%-12.7%).ConclusionsDelays in epinephrine administration following in-hospital cardiac arrest are common and variy across hospitals. Hospitals with high rates of delayed epinephrine administration had lower rates of overall survival for in-hospital cardiac arrest attributable to nonshockable rhythm. Further studies are needed to determine whether improving hospital performance on time to epinephrine administration, especially at hospitals with poor performance on this metric, will lead to improved outcomes.

Project description:ImportanceWhile epinephrine and advanced airway management (AAM) (supraglottic airway insertion and endotracheal intubation) are commonly used for out-of-hospital cardiac arrest (OHCA), the optimal sequence of these interventions remains unclear.ObjectiveTo evaluate the association of the sequence of epinephrine administration and AAM with patient outcomes after OHCA.Design, setting, and participantsThis cohort study analyzed the nationwide, population-based OHCA registry in Japan and included adults (aged ≥18 years) with OHCA for whom emergency medical services personnel administered epinephrine and/or placed an advanced airway between January 1, 2014, and December 31, 2019. The data analysis was performed between October 1, 2022, and May 12, 2023.ExposureThe sequence of intravenous epinephrine administration and AAM.Main outcomes and measuresThe primary outcome was 1-month survival. Secondary outcomes were 1-month survival with favorable functional status and prehospital return of spontaneous circulation. To control imbalances in measured patient demographics, cardiac arrest characteristics, and bystander and prehospital interventions, propensity scores and inverse probability of treatment weighting (IPTW) were performed for shockable and nonshockable initial rhythm subcohorts.ResultsOf 259 237 eligible patients (median [IQR] age, 79 [69-86] years), 152 289 (58.7%) were male. A total of 21 592 patients (8.3%) had an initial shockable rhythm, and 237 645 (91.7%) had an initial nonshockable rhythm. Using IPTW, all covariates between the epinephrine-first and AAM-first groups were well balanced, with all standardized mean differences less than 0.100. After IPTW, the epinephrine-first group had a higher likelihood of 1-month survival for both shockable (odds ratio [OR], 1.19; 95% CI, 1.09-1.30) and nonshockable (OR, 1.28; 95% CI, 1.19-1.37) rhythms compared with the AAM-first group. For the secondary outcomes, the epinephrine-first group experienced an increased likelihood of favorable functional status and prehospital return of spontaneous circulation for both shockable and nonshockable rhythms compared with the AAM-first group.Conclusions and relevanceThese findings suggest that for patients with OHCA, administration of epinephrine before placement of an advanced airway may be the optimal treatment sequence for improved patient outcomes.

Project description:ObjectiveTo determine the use of epinephrine (adrenaline) before defibrillation for treatment of in-hospital cardiac arrest due to a ventricular arrhythmia and examine its association with patient survival.DesignPropensity matched analysis.Setting2000-18 data from 497 hospitals participating in the American Heart Association’s Get With The Guidelines-Resuscitation registry.ParticipantsAdults aged 18 and older with an index in-hospital cardiac arrest due to an initial shockable rhythm treated with defibrillation.InterventionsAdministration of epinephrine before first defibrillation.Main outcome measuresSurvival to discharge; favorable neurological survival, defined as survival to discharge with none, mild, or moderate neurological disability measured using cerebral performance category scores; and survival after acute resuscitation (that is, return of spontaneous circulation for >20 minutes). A time dependent, propensity matched analysis was performed to adjust for confounding due to indication and evaluate the independent association of epinephrine before defibrillation with study outcomes.ResultsAmong 34 820 patients with an initial shockable rhythm, 7054 (20.3%) were treated with epinephrine before defibrillation, contrary to current guidelines. In comparison with participants treated with defibrillation first, participants receiving epinephrine first were less likely to have a history of myocardial infarction or heart failure, but more likely to have renal failure, sepsis, respiratory insufficiency, and receive mechanical ventilation before in-hospital cardiac arrest (standardized differences >10% for all). Treatment with epinephrine before defibrillation was strongly associated with delayed defibrillation (median 4 minutes v 0 minutes). In propensity matched analysis (6569 matched pairs), epinephrine before defibrillation was associated with lower odds of survival to discharge (22.4% v 29.7%; adjusted odds ratio 0.69; 95% confidence interval 0.64 to 0.74; P<0.001), favorable neurological survival (15.8% v 21.6%; 0.68; 0.61 to 0.76; P<0.001) and survival after acute resuscitation (61.7% v 69.5%; 0.73; 0.67 to 0.79; P<0.001). The above findings were consistent in a range of sensitivity analyses, including matching according to defibrillation time.ConclusionsContrary to current guidelines that prioritize immediate defibrillation for in-hospital cardiac arrest due to a shockable rhythm, one in five patients are treated with epinephrine before defibrillation. Use of epinephrine before defibrillation was associated with worse survival outcomes.

Dataset Information

Weight-Based Versus Flat Dosing of Epinephrine During Cardiac Arrest in the PICU: A Multicenter Survey.

Objectives

Design

Setting

Subjects

Interventions

Measurements and main results

Conclusions

Publications

Weight-Based Versus Flat Dosing of Epinephrine During Cardiac Arrest in the PICU: A Multicenter Survey.

Similar Datasets

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