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

Abstract

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% 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 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.

Figure 1.. Patient Flowchart for Study of Timing of Epinephrine and Pediatric In-Hospital Nonshockable Cardiac Arrest

The database contained data on 15 959 pediatric in-hospital cardiac arrests. Of these, 1558 met all inclusion criteria and no exclusion criteria and were included in the analysis. ECMO indicates extracorporeal membrane oxygenation; ROSC, return of spontaneous circulation.

Figure 2.. Distribution of Time to Epinephrine in Pediatric In-Hospital Nonshockable Cardiac Arrest (N=1558)

The majority of the included patients received epinephrine early, with 37% receiving epinephrine within the first minute; 15% received the first dose of epinephrine more than 5 minutes after the cardiac arrest. (See Methods for definition of time to epinephrine.) No time point had zero observations.

Figure 3.. Time to Epinephrine and Survival to Hospital Discharge After Pediatric In-Hospital Nonshockable Cardiac Arrest (N=1558)

Longer time to epinephrine administration was associated with lower risk of survival to discharge in multivariable analysis (risk ratio per minute delay, 0.95 [95% CI, 0.93–0.98]; P < .001). Error bars indicate exact binomial 95% confidence intervals.