Abstract 102: Early Bolus Epinephrine Administration During Pediatric Cardiopulmonary Resuscitation for Bradycardia With Poor Perfusion

Abstract

Introduction: Though epinephrine is recommended during CPR for children with bradycardia with poor perfusion, a registry study identified an association between epinephrine administration and worse outcomes. Our objective was to use granular data from the ICU-RESUScitation (ICU-RESUS) trial, including markers of illness severity not available in registries, to further investigate epinephrine use in this population. We hypothesized that when controlling for patient characteristics, early epinephrine administration would be associated with superior outcomes in children receiving CPR for bradycardia with poor perfusion. Methods: Prespecified secondary analysis of ICU-RESUS, a multicenter cluster randomized trial of pediatric (<19 years) IHCA in 18 PICUs. Index events (October 2016 to March 2021) lasting 2 minutes with an initial rhythm of bradycardia with poor perfusion were included. Early administration of bolus epinephrine (first 2 minutes of CPR) was chosen as the exposure since pulselessness during CPR for bradycardia with poor perfusion develops at a median of 3 minutes. The association between early epinephrine and outcomes was evaluated with Poisson multivariable regression controlling for a priori pre-arrest characteristics including Pediatric Risk of Mortality (PRISM) score and vasoactive inotropic score (VIS). Results: Of 452 patients, 322 (71.2%) received early epinephrine. The early epinephrine group had higher PRISM and VIS and more frequently received calcium and sodium bicarbonate. On univariate analysis, the early epinephrine group had lower, but not statistically significantly, rates of survival to discharge (174/322 [54%] vs 82/130 [63%], p=0.093) and survival with favorable neurologic outcome (164/322 [51%] vs 75/130 [58%], p=0.212). In multivariable analysis, early epinephrine was not associated with survival to discharge (RR 0.97, 95% CI 0.82, 1.14) or survival with favorable neurologic outcome (RR 0.99, 95% CI 0.82, 1.18). Conclusion: In this cohort of pediatric IHCA with an initial rhythm of bradycardia with poor perfusion, early bolus epinephrine was not associated with outcomes when controlling for illness severity. Further work should focus on which patients with this rhythm benefit from epinephrine.