Association of Early Epinephrine with Hemodynamics and Outcome in Pediatric In-Hospital Cardiac Arrest: A Secondary Analysis of a Multi-center, Cluster-randomized Clinical Trial (ICU-RESUS).

Rationale: Delayed (> 5 minutes) epinephrine during pediatric in-hospital cardiac arrest (IHCA) is associated with worse outcomes. Epinephrine is nearly always given earlier, limiting 5 minutes as a quality target.

Objectives: To assess early epinephrine (≤2 minutes) on outcomes and hemodynamics during CPR in pediatric IHCA from pulseless non-shockable rhythms.

Methods: This study leveraged the database of ICU-RESUScitation project (NCT02837497). Primary exposure was time to epinephrine bolus: early versus >2 minutes. Primary outcome was survival to discharge. Secondary outcomes included return of spontaneous circulation (ROSC), survival with favorable neurologic outcome, change from baseline to discharge functional status scale (FSS), total FSS at discharge, new morbidity among survivors, and invasively measured blood pressure (BP) over the first 10 minutes of CPR.

Measurements and main results: Among 352 CPR events, median age was 1.0 (0.3, 8.0) year, 186 (53%) were male, an 185 (52.6%) had cardiac disease. Early epinephrine was administered in 273 (78%), and median time to administration was 1.0 (0.0, 2.0) minute. Survival to discharge was similar between patients who received early epinephrine versus those who did not. Early epinephrine was associated with higher ROSC, a change from baseline to discharge in FSS, lower total FSS scores at discharge, and lower rates of new morbidity compared to epinephrine >2 minutes. The probability of ROSC and survival to discharge with favorable neurologic outcome decreased for each minute of delay in epinephrine. There was no difference in the invasive BP targets during the first 10 minutes of CPR.

Conclusions: Early epinephrine was common, associated with higher ROSC and improved functional outcomes compared to epinephrine > 2 minutes in pediatric IHCA.