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.

中文翻译：

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小儿心肺复苏期间早期推注肾上腺素治疗灌注不良的心动过缓：一项 ICU 复苏研究


一半的儿科院内心肺复苏 (CPR) 事件的初始心律为非无脉性心动过缓且灌注不良。我们的研究目标是利用 ICU 复苏 (ICU-RESUS) 试验的详细数据来：(1) 确定早期肾上腺素给药与因灌注不良而接受心肺复苏的心动过缓儿童的生存结果之间的关系； (2) 描述无脉的发生率和时间进程。 ICU-RESUS 是一项针对在美国 18 个重症监护病房接受心肺复苏的儿童（< 19 岁）进行的多中心整群随机试验的预先指定二次分析。持续时间≥ 2 分钟且记录有心动过缓初始心律且灌注不良的指数事件（2016 年 10 月至 2021 年 3 月）也包括在内。早期肾上腺素（心肺复苏前 2 分钟）与结果之间的关联通过控制先验预逮捕特征的泊松多变量回归进行评估。在有动脉导管的患者中，检查逮捕期间的血压波形以确定心肺复苏中断期间是否存在脉搏。描述了进展为无脉的时间性质，并根据随后的无脉状态比较了患者之间的结果。在 452 名符合条件的受试者中，322 名（71%）接受了早期肾上腺素治疗。早期肾上腺素组的逮捕前疾病严重程度和血管活性正性肌力评分较高。早期肾上腺素与出院生存率（aRR 0.97，95%CI 0.82，1.14）或神经系统预后良好的生存率（aRR 0.99，95%CI 0.82，1.18）无关。在 186 名有创血压波形患者中，118 名 (63%) 在 CPR 的前 10 分钟内至少有 1 次无脉期； 2 分钟内 86 (46%)，3 分钟内 100 (54%)。 与灌注不良的心动过缓进展为无脉的心动过缓（43%）和灌注不良的心动过缓进展为无脉的心动过缓随后恢复为灌注不良的心动过缓（62%）相比，灌注不良的心动过缓后自主循环的持续恢复最高（84%）。 p < 0.001）。在这组以心动过缓伴灌注不良的儿童心肺复苏事件队列中，在控制疾病严重程度时，我们未能确定早期推注肾上腺素与结果之间的关联。大多数因心动过缓且灌注不良而接受 CPR 的儿童随后出现无脉，其中 46% 在 CPR 开始后 2 分钟内出现。