Abstract 341: Effect of Guideline Changes on Drug Administration in Pediatric In-Hospital Cardiac Arrest

Abstract

Introduction: Updates to PALS include modifications to recommendations and pictorial algorithms surrounding intra-arrest drug administration. These include: bicarbonate, which had been an option for prolonged arrests, was changed in 2010 to recommend against routine use; lidocaine was removed from the pictorial algorithm in 2010 and reintroduced in 2015, at which time the recommendation changed from it being 2 nd -line to being equivalent to amiodarone as 1 st line; and atropine for which text was added in 2010 stating there was insufficient evidence to support or refute routine use in pulseless cardiac arrest. Understanding the effects of these changes may be important in future guideline development. Hypotheses: We hypothesized that use of bicarbonate, lidocaine and atropine would decrease after 2010, and use of lidocaine would increase after 2015. Methods: Index pulseless IHCA in children ≤18 years of age in the GWTG-R pediatric database between 2001 and 2017 were included. We performed interrupted time series analyses using segmented linear regression with GEE for each medication. Atropine was analyzed post-hoc . Results: A total of 4,806 index cases (698 shockable, 4108 non-shockable) were included. After 2010, bicarbonate had no changes in the intercept (-3.1% (95% CI, -7.5, 1.3%; p = 0.17) or slope (0.7% (95% CI, -1.0, 2.3%; p = 0.41). For lidocaine in shockable arrests there was no change in the intercept (-7.7%, 95% CI, -21.6, 6.1%; p = 0.27) or slope (-2.7%, (95% CI, -7.2, 1.8%; p = 0.24) in 2010 nor in 2015 (intercept: -0.2%; 95% CI, -32.1, 31.8%; p = 0.99; slope: -3.6%; 95% CI; -7.8, 15.0%; p = 0.53). For atropine, there was a 9.3% downward step change in the intercept (95% CI, 3.3-15.2%; p < 0.01) for all arrests and 11.7% (95% CI, 5.3-18.2%; p < 0.001) for initial PEA/asystole. Conclusion: Recommendation changes in the PALS text correlated with decreased use of atropine but not bicarbonate. This is especially interesting considering atropine had not previously been part of the PALS cardiac arrest algorithm. However, this update coincides with the removal of atropine from the ACLS PEA/asystole algorithm in 2010, which may have influenced some providers. Lidocaine use was not affected by changes to the pictorial algorithm nor by changes in the text.