The physiologic response to epinephrine and pediatric cardiopulmonary resuscitation outcomes

Ryan W Morgan; Robert A Berg; Ron W Reeder; Todd C Carpenter; Deborah Franzon; Aisha H Frazier; Kathryn Graham; Kathleen L Meert; Vinay M Nadkarni; Maryam Y Naim; Bradley Tilford; Heather A Wolfe; Andrew R Yates; Robert M Sutton; ICU-RESUS and the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network Investigator Groups

doi:10.1186/s13054-023-04399-5

The physiologic response to epinephrine and pediatric cardiopulmonary resuscitation outcomes

Crit Care. 2023 Mar 13;27(1):105. doi: 10.1186/s13054-023-04399-5.

Authors

Ryan W Morgan¹, Robert A Berg², Ron W Reeder³, Todd C Carpenter⁴, Deborah Franzon⁵, Aisha H Frazier^{6

7}, Kathryn Graham², Kathleen L Meert⁸, Vinay M Nadkarni², Maryam Y Naim², Bradley Tilford⁸, Heather A Wolfe², Andrew R Yates⁹, Robert M Sutton²; ICU-RESUS and the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network Investigator Groups

Collaborators

ICU-RESUS and the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network Investigator Groups:
Tageldin Ahmed, Michael J Bell, Robert Bishop, Matthew Bochkoris, Candice Burns, Joseph A Carcillo, J Michael Dean, J Wesley Diddle, Myke Federman, Richard Fernandez, Ericka L Fink, Stuart H Friess, Mark Hall, David A Hehir, Christopher M Horvat, Leanna L Huard, Tensing Maa, Arushi Manga, Patrick S McQuillen, Peter M Mourani, Daniel Notterman, Murray M Pollack, Anil Sapru, Carleen Schneiter, Matthew P Sharron, Neeraj Srivastava, Sarah Tabbutt, Shirley Viteri, David Wessel, Andrew R Yates, Athena F Zuppa

Affiliations

¹ Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA. morganR1@chop.edu.
² Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA.
³ Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
⁴ Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.
⁵ Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA.
⁶ Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
⁷ Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
⁸ Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA.
⁹ Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA.

Abstract

Background: Epinephrine is provided during cardiopulmonary resuscitation (CPR) to increase systemic vascular resistance and generate higher diastolic blood pressure (DBP) to improve coronary perfusion and attain return of spontaneous circulation (ROSC). The DBP response to epinephrine during pediatric CPR and its association with outcomes have not been well described. Thus, the objective of this study was to measure the association between change in DBP after epinephrine administration during CPR and ROSC.

Methods: This was a prospective multicenter study of children receiving ≥ 1 min of CPR with ≥ 1 dose of epinephrine and evaluable invasive arterial BP data in the 18 ICUs of the ICU-RESUS trial (NCT02837497). Blood pressure waveforms underwent compression-by-compression quantitative analysis. The mean DBP before first epinephrine dose was compared to mean DBP two minutes post-epinephrine. Patients with ≥ 5 mmHg increase in DBP were characterized as "responders."

Results: Among 147 patients meeting inclusion criteria, 66 (45%) were characterized as responders and 81 (55%) were non-responders. The mean increase in DBP with epinephrine was 4.4 [- 1.9, 11.5] mmHg (responders: 13.6 [7.5, 29.3] mmHg versus non-responders: - 1.5 [- 5.0, 1.5] mmHg; p < 0.001). After controlling for a priori selected covariates, epinephrine response was associated with ROSC (aRR 1.60 [1.21, 2.12]; p = 0.001). Sensitivity analyses identified similar associations between DBP response thresholds of ≥ 10, 15, and 20 mmHg and ROSC; DBP responses of ≥ 10 and ≥ 15 mmHg were associated with higher aRR of survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category score of 1-3 or no worsening from baseline).

Conclusions: The change in DBP following epinephrine administration during pediatric in-hospital CPR was associated with return of spontaneous circulation.

Keywords: Adrenaline; Blood pressure; Cardiac arrest; Cardiopulmonary resuscitation; Epinephrine; Pediatrics.

Publication types

Multicenter Study

MeSH terms

Blood Pressure
Cardiopulmonary Resuscitation*
Child
Epinephrine / pharmacology
Epinephrine / therapeutic use
Heart Arrest* / drug therapy
Humans
Prospective Studies

Substances

Epinephrine

Abstract

Publication types

MeSH terms

Substances

Grants and funding