Early bolus epinephrine administration during pediatric cardiopulmonary resuscitation for bradycardia with poor perfusion: an ICU-resuscitation study,Critical Care

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Early bolus epinephrine administration during pediatric cardiopulmonary resuscitation for bradycardia with poor perfusion: an ICU-resuscitation study
Critical Care ( IF 8.8 ) Pub Date : 2024-07-16 , DOI: 10.1186/s13054-024-05018-7
Amanda J O'Halloran ₁ , Ron W Reeder ₂ , Robert A Berg ₁ , Tageldin Ahmed ₃ , Michael J Bell ₄ , Robert Bishop ₅ , Matthew Bochkoris ₆ , Candice Burns ₇ , Joseph A Carcillo ₆ , Todd C Carpenter ₅ , J Michael Dean ₂ , J Wesley Diddle ₁ , Myke Federman ₈ , Richard Fernandez ₉ , Ericka L Fink ₆ , Deborah Franzon ₁₀ , Aisha H Frazier _{11,

12} , Stuart H Friess ₁₃ , Kathryn Graham ₁ , Mark Hall ₉ , David A Hehir ₁ , Christopher M Horvat ₆ , Leanna L Huard ₈ , Martha F Kienzle ₁ , Todd J Kilbaugh ₁ , Tensing Maa ₉ , Arushi Manga ₁₃ , Patrick S McQuillen ₁₀ , Kathleen L Meert ₃ , Peter M Mourani ₁₄ , Vinay M Nadkarni ₁ , Maryam Y Naim ₁ , Daniel Notterman ₁₅ , Murray M Pollack ₄ , Anil Sapru ₈ , Carleen Schneiter ₅ , Matthew P Sharron ₄ , Neeraj Srivastava ₈ , Bradley Tilford ₃ , Alexis A Topjian ₁ , Shirley Viteri ₁₆ , David Wessel ₄ , Heather A Wolfe ₁ , Andrew R Yates ₉ , Athena F Zuppa ₁ , Robert M Sutton ₁ , Ryan W Morgan ₁

Affiliation

Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA.
Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, D.C., DC, USA.
Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.
Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA.
Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA.
Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA.
Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA.
Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA.
Nemours Cardiac Center, Nemours Children's Health, Wilmington, DE, USA.
Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA.
Department of Molecular Biology, Princeton University, Princeton, NJ, USA.
Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, DE, USA.

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：

灌注不良心动过缓小儿心肺复苏期间早期推注肾上腺素：一项 ICU 复苏研究

一半的儿科院内心肺复苏（CPR）事件的初始节律为非无脉性心动过缓伴灌注不良。我们的研究目标是利用来自 ICU-RESUScitation （ICU-RESUS）试验的细化数据来：（1）确定早期肾上腺素给药与接受 CPR 治疗灌注不良心动过缓的儿童生存结果的相关性;（2）描述无脉发展的发生率和时间过程。ICU-RESUS 的预先指定二次分析，这是一项针对在美国 18 个重症监护病房接受 CPR 的儿童（< 19）的多中心整群随机试验。包括持续 ≥ 2 分钟的指数事件（2016 年 10 月至 2021 年 3 月），并记录了心动过缓伴灌注不良的初始心律。通过控制先验止搏前特征的泊松多变量回归评估早期肾上腺素（CPR 的前 2 分钟）与结果之间的关联。在有动脉导管的患者中，回顾了止搏内血压波形，以确定 CPR 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。早期肾上腺素组的心脏停搏前疾病严重程度和血管活性物质-正性肌力药评分较高。早期肾上腺素与出院生存率（aRR 0.97， 95%CI 0.82， 1.14）或神经系统结局良好的生存率（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;2 分钟时为 86 （46%），3 分钟时为 100 （54%）。灌注不良心动过缓后自主循环持续恢复最高（84%），与灌注不良的心动过缓进展为无脉（43%）和灌注不良的心动过缓进展为无脉性（62%）后返回灌注不良的心动过缓（62%）（p < 0.001）。在这组初始心律为心动过缓伴灌注不良的儿科 CPR 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局之间的关联。大多数因灌注不良的心动过缓接受 CPR 的儿童随后出现无脉，46% 在 CPR 发作后 2 分钟内出现。

更新日期：2024-07-16

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