Time to epinephrine treatment is associated with the risk of mortality in children who achieve sustained ROSC after traumatic out-of-hospital cardiac arrest

Abstract

Background The benefits of early epinephrine administration in pediatric with nontraumatic out-of-hospital cardiac arrest (OHCA) have been reported; however, the effects in pediatric cases of traumatic OHCA are unclear. Since the volume-related pharmacokinetics of early epinephrine may differ obviously with and without hemorrhagic shock (HS), beneficial or harmful effects of nonselective epinephrine stimulation (alpha and beta agonists) may also be enhanced with early administration. In this study, we aimed to analyze the therapeutic effect of early epinephrine administration in pediatric cases of HS and non-HS traumatic OHCA. Methods This was a multicenter retrospective study (2003–2014). Children (aged ≤ 19 years) who experienced traumatic OHCA and were administered epinephrine for resuscitation were included. Children were classified into the HS (blood loss > 30% of total body fluid) and non-HS groups. The demographics, outcomes, postresuscitation hemodynamics (the first hour) after the sustained return of spontaneous circulation (ROSC), and survival durations were analyzed and correlated with the time to epinephrine administration (early < 15, middle 15–30, late > 30 min) in the HS and non-HS groups. Cox regression analysis was used to adjust for risk factors of mortality. Results A total of 509 children were included. Most of them ( n = 348, 68.4%) had HS OHCA. Early epinephrine administration was implemented in 131 (25.7%) children. In both the HS and non-HS groups, early epinephrine administration was associated with achieving sustained ROSC (both p < 0.05) but was not related to survival or good neurological outcomes (without adjusting for confounding factors). However, early epinephrine administration in the HS group increased cardiac output but induced metabolic acidosis and decreased urine output during the initial postresuscitation period (all p < 0.05). After adjusting for confounding factors, early epinephrine administration was a risk factor of mortality in the HS group (HR 4.52, 95% CI 2.73–15.91). Conclusion Early epinephrine was significantly associated with achieving sustained ROSC in pediatric cases of HS and non-HS traumatic OHCA. For children with HS, early epinephrine administration was associated with both beneficial (increased cardiac output) and harmful effects (decreased urine output and metabolic acidosis) during the postresuscitation period. More importantly, early epinephrine was a risk factor associated with mortality in the HS group.

Effects of Endotracheal Administration of Epinephrine in Cardiac Arrest of Adult and Pediatric Swine

“…The difference in our study was that we used prospective, rigorously-design of pediatric swine ranging in age from an equivalent five to six years of age, whereas they used a retrospective design with individuals 19 years or younger (Lin et al, 2019). Our study also supports the findings of Manisterski et al who studied the efficacy of epinephrine in the ET route during cardiopulmonary resuscitation.…”

“…Another potential limitation was the study continued for only 30 minutes after ROSC. Dumas et al and Lin et al effects of epinephrine in long-term neurological survivability (Dumas et al, 2014;Lin et al, 2019).…”

“…We support the findings of Lin et al who used a retrospective analyses of both normovolemic and hypovolemic individuals aged 19 and younger. They found greater rates of ROSC with early administration epinephrine in both a normovolemic and hypovolemic (Lin et al, 2019).…”

The Impact of Emergency Interventions and Patient Characteristics on the Risk of Heart Failure in Patients with Nontraumatic OHCA

“…Some major risk factors, including unhealed underlying diseases, arrest-related hypoxia injury, and new-onset postresuscitation comorbidities, are considered to be responsible for this poor outcome [6][7][8]. Furthermore, new-onset postresuscitation comorbidities, which might interact with essential diseases or cause sickness independently, can be life-threatening and difficult to prevent [9][10][11][12][13][14].…”

“…erefore, we suspect that new-onset heart failure might be very predominant among OHCA survivors. Although a few animal studies have tried to identify the risk factors (including ischemia/reperfusion injury, systemic inflammatory response, and catecholamine surge) of postresuscitation heart failure in humans, this information has not been well addressed, and there is a lack of relevant long-term followup investigations [12,17,18]. Since some causes of this dysfunction (I/R injury, inflammatory response) might result in long-term impairment, we suspect that new-onset heart failure might be common in long-term survivors.…”