Early bolus epinephrine administration during pediatric cardiopulmonary resuscitation for bradycardia with poor perfusion: an ICU-resuscitation study.
Bradycardia
Cardiopulmonary resuscitation
Epinephrine
Heart arrest
Hemodynamics
Pediatric intensive care units
Journal
Critical care (London, England)
ISSN: 1466-609X
Titre abrégé: Crit Care
Pays: England
ID NLM: 9801902
Informations de publication
Date de publication:
16 Jul 2024
16 Jul 2024
Historique:
received:
27
04
2024
accepted:
04
07
2024
medline:
16
7
2024
pubmed:
16
7
2024
entrez:
15
7
2024
Statut:
epublish
Résumé
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. 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. 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). 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.
Sections du résumé
BACKGROUND
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
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
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
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.
Identifiants
pubmed: 39010134
doi: 10.1186/s13054-024-05018-7
pii: 10.1186/s13054-024-05018-7
doi:
Substances chimiques
Epinephrine
YKH834O4BH
Types de publication
Journal Article
Multicenter Study
Randomized Controlled Trial
Langues
eng
Sous-ensembles de citation
IM
Pagination
242Subventions
Organisme : National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development
ID : U01HD049934
Organisme : National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development
ID : UG1HD049981
Organisme : National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development
ID : UG1HD049983
Organisme : National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development
ID : UG1HD050096
Organisme : National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development
ID : UG1HD063108
Organisme : National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development
ID : UG1HD083166
Organisme : National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development
ID : UG1HD083170
Organisme : National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development
ID : UG1HD083171
Organisme : NHLBI NIH HHS
ID : R01HL131544
Pays : United States
Organisme : NHLBI NIH HHS
ID : R01HL147616
Pays : United States
Organisme : NHLBI NIH HHS
ID : K23HL148541
Pays : United States
Informations de copyright
© 2024. The Author(s).
Références
Berg RA, Nadkarni VM, Clark AE, Moler F, Meert K, Harrison RE, et al. Incidence and outcomes of cardiopulmonary resuscitation in pediatric intensive care units. Crit Care Med. 2016;44(4):798–808.
doi: 10.1097/CCM.0000000000001484
pubmed: 26646466
pmcid: 4809365
Walsh CK, Krongrad E. Terminal cardiac electrical activity in pediatric patients. Am J Cardiol. 1983;51(3):557–61.
doi: 10.1016/S0002-9149(83)80096-4
pubmed: 6823870
Topjian AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL, et al. Part 4: pediatric basic and advanced life support: 2020 american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142(16_suppl_2):S469–523. https://doi.org/10.1161/CIR.0000000000000901 .
doi: 10.1161/CIR.0000000000000901
pubmed: 33081526
Van De Voorde P, Turner NM, Djakow J, De Lucas N, Martinez-Mejias A, Biarent D, et al. European resuscitation council guidelines 2021: paediatric life support. Resuscitation. 2021;161:327–87.
doi: 10.1016/j.resuscitation.2021.02.015
pubmed: 33773830
Donoghue A, Berg RA, Hazinski MF, Praestgaard AH, Roberts K, Nadkarni VM, et al. Cardiopulmonary resuscitation for bradycardia with poor perfusion versus pulseless cardiac arrest. Pediatrics. 2009;124(6):1541–8.
doi: 10.1542/peds.2009-0727
pubmed: 19917587
Khera R, Tang Y, Girotra S, Nadkarni VM, Link MS, Raymond TT, et al. Pulselessness after initiation of cardiopulmonary resuscitation for bradycardia in hospitalized children: prevalence, predictors of survival, and implications for hospital profiling. Circulation. 2019;140(5):370–8.
doi: 10.1161/CIRCULATIONAHA.118.039048
pubmed: 31006260
pmcid: 6663562
Morgan RW, Reeder RW, Meert KL, Telford R, Yates AR, Berger JT, et al. Survival and hemodynamics during pediatric cardiopulmonary resuscitation for bradycardia and poor perfusion versus pulseless cardiac arrest. Crit Care Med. 2020;48(6):881–9.
doi: 10.1097/CCM.0000000000004308
pubmed: 32301844
pmcid: 7895327
Holmberg MJ, Ross CE, Yankama T, Roberts JS, Andersen LW. Epinephrine in children receiving cardiopulmonary resuscitation for bradycardia with poor perfusion. Resuscitation. 2020;149:180–90.
doi: 10.1016/j.resuscitation.2019.12.032
pubmed: 31926260
Andersen LW, Berg KM, Saindon BZ, Massaro JM, Raymond TT, Berg RA, et al. Time to epinephrine and survival after pediatric in-hospital cardiac arrest. JAMA. 2015;314(8):802–10.
doi: 10.1001/jama.2015.9678
pubmed: 26305650
pmcid: 6191294
Moule P. Checking the carotid pulse: diagnostic accuracy in students of the healthcare professions. Resuscitation. 2000;44(3):195–201.
doi: 10.1016/S0300-9572(00)00139-8
pubmed: 10825620
Tibballs J, Russell P. Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation. 2009;80(1):61–4.
doi: 10.1016/j.resuscitation.2008.10.002
pubmed: 18992985
Sutton RM, Wolfe HA, Reeder RW, Ahmed T, Bishop R, Bochkoris M, et al. Effect of physiologic point-of-care cardiopulmonary resuscitation training on survival with favorable neurologic outcome in cardiac arrest in pediatric ICUs: a randomized clinical trial. JAMA. 2022;327(10):934.
doi: 10.1001/jama.2022.1738
pubmed: 35258533
pmcid: 8905390
Reeder RW, Girling A, Wolfe H, Holubkov R, Berg RA, Naim MY, et al. Improving outcomes after pediatric cardiac arrest—the ICU-resuscitation project: study protocol for a randomized controlled trial. Trials. 2018;3(19):213.
doi: 10.1186/s13063-018-2590-y
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–7.
doi: 10.1016/S0140-6736(07)61602-X
Nolan JP, Berg RA, Andersen LW, Bhanji F, Chan PS, Donnino MW, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the utstein resuscitation registry template for in-hospital cardiac arrest: a consensus report from a task force of the international Liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia). Circulation. 2019;140(18):e746–57. https://doi.org/10.1161/CIR.0000000000000710 .
doi: 10.1161/CIR.0000000000000710
pubmed: 31522544
Fiser DH, Long N, Roberson PK, Hefley G, Zolten K, Brodie-Fowler M. Relationship of pediatric overall performance category and pediatric cerebral performance category scores at pediatric intensive care unit discharge with outcome measures collected at hospital discharge and 1- and 6-month follow-up assessments. Crit Care Med. 2000;28(7):2616–20.
doi: 10.1097/00003246-200007000-00072
pubmed: 10921604
Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated pediatric risk of mortality score. Crit Care Med. 1996;24(5):743–52.
doi: 10.1097/00003246-199605000-00004
pubmed: 8706448
Gaies MG, Gurney JG, Yen AH, Napoli ML, Gajarski RJ, Ohye RG, et al. Vasoactive-inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med. 2010;11(2):234–8.
doi: 10.1097/PCC.0b013e3181b806fc
pubmed: 19794327
McIntosh AM, Tong S, Deakyne SJ, Davidson JA, Scott HF. Validation of the vasoactive-inotropic score in pediatric sepsis*. Pediatr Crit Care Med. 2017;18(8):750–7.
doi: 10.1097/PCC.0000000000001191
pubmed: 28486385
pmcid: 5548505
Morgan RW, Berg RA, Reeder RW, Carpenter TC, Franzon D, Frazier AH, et al. The physiologic response to epinephrine and pediatric cardiopulmonary resuscitation outcomes. Crit Care. 2023;13(27):105.
doi: 10.1186/s13054-023-04399-5
Matos RI, Watson RS, Nadkarni VM, Huang HH, Berg RA, Meaney PA, et al. Duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests. Circulation. 2013;127(4):442–51.
doi: 10.1161/CIRCULATIONAHA.112.125625
pubmed: 23339874
Shimoda-Sakano TM, Paiva EF, Schvartsman C, Reis AG. Factors associated with survival and neurologic outcome after in-hospital cardiac arrest in children: a cohort study. Resusc Plus. 2023;13:100354.
doi: 10.1016/j.resplu.2022.100354
pubmed: 36686327
pmcid: 9852640
Del Castillo J, López-Herce J, Cañadas S, Matamoros M, Rodríguez-Núnez A, Rodríguez-Calvo A, et al. Cardiac arrest and resuscitation in the pediatric intensive care unit: a prospective multicenter multinational study. Resuscitation. 2014;85(10):1380–6.
doi: 10.1016/j.resuscitation.2014.06.024
pubmed: 25008138
Berg RA, Sutton RM, Holubkov R, Nicholson CE, Dean JM, Harrison R, et al. Ratio of pediatric ICU versus ward cardiopulmonary resuscitation events is increasing. Crit Care Med. 2013;41(10):2292–7.
doi: 10.1097/CCM.0b013e31828cf0c0
pubmed: 23921270
pmcid: 3783604