Physiologic response to pre-arrest bolus dilute epinephrine in the pediatric intensive care unit

Abstract

Aim: To quantify the physiologic effects of pre-arrest bolus dilute epinephrine in the pediatric intensive care unit.

Methods: Patients <18 years old and ≥37 weeks gestation who received an intravenous bolus of dilute epinephrine (10 mcg/mL) in the pediatric intensive care units at our institution from January 2011 to March 2017 were retrospectively identified. Patients were excluded if doses exceeded 20 mcg/kg, or under the following circumstances: orders limiting resuscitation, extracorporeal membrane oxygenation, active chest compressions, simultaneous administration of other blood pressure-altering interventions or documented normotension prior to epinephrine. The primary outcome was change in systolic blood pressure within 5 min of epinephrine. Patients were categorized as non-responders if the change in systolic blood pressure was ≤10 mmHg.

Results: One hundred forty-four patients were analyzed. The median index dose was 0.7 mcg/kg (IQR, 0.3-2.0), and the mean increase in systolic blood pressure was 31 mmHg (95% CI, 25-36; P < 0.001). Thirty-nine (27%) patients were classified as non-responders. Compared to responders, non-responders had higher rates of cardiac arrest or extracorporeal membrane oxygenation within 6 h (26% vs 10%; relative risk, 2.69; 95% CI, 1.21-5.97; P = 0.03), and had higher in-hospital mortality (51% vs 21%; relative risk, 2.45; 95% CI, 1.51-3.96; P < 0.001).

Conclusions: In the majority of pre-arrest pediatric patients, bolus dilute epinephrine resulted in an increase in systolic blood pressure, and lack of blood pressure response was associated with poor outcomes. Optimal dosing of dilute epinephrine remains unclear.

Keywords: Acute hypotension; Bolus-dose pressors; Epinephrine; Pediatric cardiac arrest.

Conflict of interest statement

Conflicts of interest

None.

Copyright © 2018 Elsevier B.V. All rights reserved.

Figures

Fig. 1.

Charted vital sign data before and after index administration of BDE by responder status. Each point represents the mean with the SD represented by the bars.

Fig. 2.

Overlay graph of T3 invasive SBP data with respect to BDE administration. The hashed vertical line represents the recorded administration of the index BDE, set to time = 0. The bolded line represents the mean of all patients, and the shaded area represents ± 1 SD. Callout values were calculated from the population mean for the baseline, nadir, peak and plateau.

Fig. 3.

Overlay graph of T3 continuous electrocardiogram HR data with respect to BDE administration. The hashed vertical line represents the recorded administration of the index BDE, set to time = 0. The bolded line represents the mean of all patients, and the shaded area represents ± 1 SD. Callout values were calculated from the population mean for the baseline, nadir, peak and plateau.