Epinephrine in pediatric cardiorespiratory arrest: when and how much?

Faria, João Carlos Pina; Victorino, Camila Augusta; Sato, Monica Akemi

doi:10.31744/einstein_journal/2020RW5055

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REVIEW • Einstein (São Paulo) 18 • 2020 • https://doi.org/10.31744/einstein_journal/2020RW5055 copy

Epinephrine in pediatric cardiorespiratory arrest: when and how much?

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ABSTRACT

The objective of the present study was to assess the efficacy of different doses, times for infusion of the first dose, intervals of administration of subsequent doses, and number of epinephrine doses in the survival of children and adolescents who went into cardiorespiratory arrest. It is a review study with data from the PubMed^Ⓡ/MEDLINE^Ⓡdatabase. The search was for articles published from January 1^st, 2000 to February 10, 2019, with a sample of patients aged under 18 years, published in English, Portuguese and Spanish. We found 222 articles, of which 16 met the inclusion criteria of the study. The first dose should be given as soon as possible. The standard dose (0.01mg/kg) has a better outcome when compared to the higher dose (0.1mg/kg). There is an iⓇverse relation between the number of epinephrine doses and survival. The interval currently recommended between doses has lower survival when compared to larger intervals. The dosage recommended by the American Heart Association presents a better outcome for survival, but the interval between doses and the maximum number of doses should be better assessed.

Heart arrest; Out-of-hospital cardiac arrest; Child; Adolescent; Epinephrine/administration & dosage; Survival

Reference	Type of study	Type of cardiorespiratory arrest	Number of events	Objective	Conclusion
Fukuda et al.⁽⁵⁾	Observational	Out-of-hospital	225	Assess time to first epinephrine dose and survival	The shorter the time to first epinephrine dose, the higher the survival
Andersen et al.⁽¹³⁾	Observational	In-hospital	1,558	Assess time to first epinephrine dose with survival and neurological prognosis	The shorter the time to first epinephrine dose, the higher the survival, and the better the neurological prognosis
Lin et al.⁽¹⁴⁾	Observational	Out-of-hospital trauma	388	Assess time to first epinephrine dose with survival and neurological prognosis	Early treatment with epinephrine may not provide benefits in cases of trauma
Hoyme et al.⁽¹⁵⁾	Observational	In-hospital	1,630	Assess different intervals between doses of epinephrine and survival	Administration intervals longer than those currently recommended present higher survival
Meert et al.⁽¹⁶⁾	Observational	Out-of-hospital	295	Assess management during cardiorespiratory arrest with survival and neurological prognosis	The higher the number of doses of epinephrine, the lower the survival, and the worse the neurological prognosis
Moler et al.⁽¹⁷⁾	Observational	Out-of-hospital	138	Assess different managements to treat cardiorespiratory arrest and survival	The higher the number of doses of epinephrine, the lower the survival
de Mos et al.⁽¹⁸⁾	Observational	In-hospital	91	Assess different managements to treat cardiorespiratory arrest and survival	The higher the number of doses of epinephrine, the lower the survival
Young et al.⁽¹⁹⁾	Observational	Out-of-hospital	601	Describe epidemiological characteristics, survival rates and neurological outcomes	The higher the number of doses of epinephrine, the lower the survival, and the worse the neurological prognosis
Checchia et al.⁽²⁰⁾	Observational	Out-of-hospital	24	Determine if the measurement of heart troponin I in children in cardiorespiratory arrest outside the hospital anticipates the severity of the myocardial lesion	The higher the number of doses of epinephrine, the lower the survival
Donoghue et al.⁽²¹⁾	Observational	In-hospital not trauma	16,834 (16,245 adults and 537 children)	Compare results of cardiopulmonary resuscitation for pediatric patients and adults, and identify factors associated with differences in results between children and adults	More epinephrine was used in children In the multivariate analysis, age did not present association regarding survival
Enright et al.⁽²²⁾	Observational	Out-of-hospital during physical exercise	9	Determine if long-term survival is influenced by specific resuscitation interventions	Children who went into cardiorespiratory arrest during physical exercise present mainly non-shockable rhythms, and epinephrine, in this scenario, may be harmful
Tibballs et al.⁽²³⁾	Observational	In-hospital	111	Assess the impact of different factors in prognosis of cardiorespiratory arrest in children	Doses of epinephrine above 0.015mg/kg present lower survival
Perondi et al.⁽²⁴⁾	Randomized	In-hospital	68	Compare efficacy between standard dose and high dose of epinephrine in hospital pediatric cardiorespiratory arrest	Data suggest that treatment with high doses may be worse than treatment with standard dose
Guay et al.⁽²⁵⁾	Observational	In-hospital	203	Assess efficacy of advanced life support interventions in pediatric cardiorespiratory arrest	For epinephrine administered by the intravenous route, the standard dose of 0.01mg/kg seems appropriate as an initial dose
Patterson et al.⁽²⁶⁾	Randomized	Out-of-hospital	230	Assess if a high dose of epinephrine used during out-of-hospital cardiorespiratory arrest refractory to pre-hospital interventions improves return of spontaneous circulation, survival and neurological prognosis	A high-dose of epinephrine does not improve or decrease return of spontaneous circulation, survival and neurological prognosis in comparison with standard dose in out-of-hospital cardiorespiratory arrest
Rodríguez Núñez et al.⁽²⁷⁾	Observational	Intra and out-of-hospital	92	Assess the impact on survival of epinephrine (intravenous or intraosseous) in high-dose in comparison to standard dose in children in cardiorespiratory arrest	There was no difference in the two groups regarding return of spontaneous circulation, total resuscitation time, neurological status at the end of the episode and survival to hospital discharge and in 1-year follow-up

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[1] Corresponding author: João Carlos Pina Faria Avenida Lauro Gomes, 2.000 Vila Sacadura Cabral Zip code: 09060-870 − Santo André, SP, Brazil Phone: (55 11) 4993-5400 E-mail: jocapf79@gmail.com