Inconsistencies in the guidelines: Use of adrenaline in paediatric cardiac arrest with hypothermia

Abstract

In light of questions raised about the resuscitation of two children with cardiac arrest after drowning admitted to our paediatric intensive care unit (PICU), we reviewed the current guidelines about the use of multiple doses of adrenaline in the presence of severe hypothermia (<30 °C). Drowning is the commonest cause of hypothermia in children. The Royal Society for the Prevention of Accidents (RoSPA) compilation of annual UK drowning statistics in 2002 showed 40 deaths amongst the under 15s (427 deaths for all ages). The most recent Advanced Life Support (ALS) guidelines (5th edition) for adults published by the Resuscitation Council (UK) recommend that adrenaline be withheld until the patient is warmed to 30 °C. This precaution is taken on the basis that there is reduced efficacy of drugs on a hypothermic circulation, and significant drug accumulation can occur due to reduced metabolism putting the patient at risk of a surge when re-warmed. Once the target temperature of 30 °C is reached, the dose intervals are doubled until the core temperature rises towards normal. For children the 2006 European Paediatric Life Support (EPLS) manual for use in the UK (Resuscitation Council (UK), 2nd edition) does not specify the withholding of adrenaline in the presence of hypothermia, whereas the European Resuscitation Council (ERC) 2006 English version (3rd edition) does. The 2006 Advanced Paediatric Life Support (APLS) manual by the Advanced Life Support Group (ALSG) in the UK does recommend the withholding of adrenaline until the patient is re-warmed to 30 °C, but prior editions did not. The EPLS (Resuscitation Council (UK), 2nd edition) and APLS manuals are widely used in the UK for paediatric resuscitation training yet differ in their recommendations. This was reflected in a telephone survey of resuscitation officers in 14 hospitals carried out in the East of England region by us, which showed that in 8 hospitals when faced with a paediatric cardiac arrest with severe hypothermia (<30 °C) they would give multiple doses of adrenaline, whereas in 6 hospitals they would not. In our opinion, the use of multiple doses of adrenaline during the resuscitation of children in the setting of cardiac arrest with severe hypothermia (<30 °C) may be harmful. With the reduced metabolism under these conditions there may be significant adrenaline accumulation in the circulation that when the patient is re-warmed the effect may be similar to that of having received high dose adrenaline. The administration of high dose adrenaline during cardiac arrest in paediatrics has shown no improvement in survival and a trend towards worse neurological outcomes, a point that is well discussed and referenced in the ERC guidelines published in 2005.1International Liaison Committee on ResuscitationPart 6. Paediatric basic and advanced life support.Resuscitation. 2005; 67: 271-291Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar We wonder whether the authors of the EPLS (Resuscitation Council (UK), 2nd edition) manual would care to comment on the absence of the specific guidance to withhold adrenaline in paediatric cardiac arrest with severe hypothermia, which is at odds with the ERC and ALSG paediatric manuals, as well as adult guidelines. None.