Endotracheal Administered Epinephrine Is Effective in Return of Spontaneous Circulation Within a Pediatric Swine Hypovolemic Cardiac Arrest Model

Abstract

Objective: Early administration of epinephrine increases the incidence of return of spontaneous circulation (ROSC) and improves outcomes among pediatric cardiac arrest victims. Rapid endotracheal (ET) intubation can facilitate early administration of epinephrine to pediatric victims. To date, no studies have evaluated the use of ETepinephrine in a pediatric hypovolemic cardiac arrest model to determine the incidence of ROSC.Methods: This prospective, experimental study evaluated the pharmacokinetics and/or incidence of ROSC following ET administered epinephrine and compared it to these experimental groups: intravenous (IV) administered epinephrine, cardiopulmonary resuscitation only (CPR), and CPR + defibrillation (CPR + Defib).Results: Endotracheal administered epinephrine, at the Pediatric Advanced Life Support (PALS) recommended dose, was not significantly different than IV administered epinephrine in maximum plasma concentrations, time to maximum plasma concentration, area under the curve, or ROSC, or mean plasma concentrations at various time points (P > 0.05). The odds of ROSC in the ET group were 2.4 times greater than the IV group. The onset to ROSC in the ET group was significantly shorter than the IV group (P < 0.0001).Conclusions: These data support that ET epinephrine administration remains an alternative to IV administered epinephrine and faster at restoring ROSC among pediatric hypovolemic cardiac arrest victims in the acute setting when an endotracheal tube is present. Although further research is required to determine long-term outcomes of high-dose ET epinephrine administration, these data reinforce the therapeutic potential of ET administration of epinephrine to restore ROSC before IV access.

Cardiac Arrest – An interdisciplinary scoping review of preclinical literature from 2020

“…To compare the efficacy of epinephrine between differing routes of administration, Yauger et al used a hypovolemic pediatric swine model to compare intravenous with endotracheal administration of epinephrine. This study found that by using the guideline-recommended doses of epinephrine for each route, endotracheal administration led to more frequent ROSC and in a shorter timeframe [15]. This study provides an endorsement of the endotracheal route of administration but should be interpreted in a clinical context as the pigs studied were intubated before the time of arrest.…”

Effects of Endotracheal Epinephrine on Pharmacokinetics and Survival in a Swine Pediatric Cardiac Arrest Model

“…The time course of ET administered epinephrine was similar in the hypovolemic and normovolemic models. However, the time to maximum plasma concentration of IV administered epinephrine was greater in the hypovolemic model (111 ± 14 seconds) than in the normovolemic model 17 The delay in peak epinephrine concentration after IV administration in the hypovolemic model when compared with the normovolemic model may reflect poor circulation at the peripheral site of administration, that is, auricular vein.…”

“…We previously examined the pharmacokinetics of ET and IV administered epinephrine in a hypovolemic pediatric cardiac arrest model 17 . In comparison to the normovolemic model, the time courses of plasma epinephrine after ET and IV administration were similar in the hypovolemic model 17 .…”

“…We previously determined the incidence of ROSC and time to ROSC between ET and IV routes of epinephrine administration in a hypovolemic pediatric cardiac arrest model 17 . There was no significant difference in the incidence of ROSC between the ET and IV routes of epinephrine administration, indicating that ET administration of epinephrine is as effective as IV administration in achieving ROSC in hypovolemic pediatric cardiac arrest.…”

“…The investigators used the means and standard deviations of C max , T max , and plasma MC over time from similar pharmacokinetic studies and calculated a medium effect size of 0.6. 17,18 Using an alpha of 0.05, an effect size of 0.6, and a power of 0.80, it was determined a sample size of 8 was needed in the ET and IV groups. Power analysis was performed using G*Power 3.1 for Windows (Heinrich Heine University, Dusseldorf, Germany).…”