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

  • Catherine E. Ross
    Correspondence
    Corresponding author at: 333 Longwood Avenue, Division of Medicine Critical Care, Boston, MA, 02115, USA.
    Affiliations
    Division of Medicine Critical Care, Department of Medicine, Boston Children’s Hospital and Harvard Medical School, 333 Longwood Avenue, Boston, MA, 02115, USA
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  • Lisa A. Asaro
    Affiliations
    Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, 333 Longwood Avenue, Boston, MA, 02115, USA
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  • David Wypij
    Affiliations
    Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, 333 Longwood Avenue, Boston, MA, 02115, USA

    Department of Biostatistics, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, USA
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  • Conor C. Holland
    Affiliations
    Etiometry Platform™, Etiometry Inc, 119 Braintree Street, Suite 210, Allston, MA, 02134, USA
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  • Michael W. Donnino
    Affiliations
    Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 359 Brookline Avenue, Boston, MA, 02115, USA

    Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 359 Brookline Avenue, Boston, MA, 02115, USA
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  • Monica E. Kleinman
    Affiliations
    Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
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      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.

      Abbreviations:

      IHCA (in-hospital cardiac arrest), ICU (intensive care unit), BDE (bolus dilute epinephrine), ECMO (extracorporeal membrane oxygenation), BCH (Boston Children’s Hospital), SBP (systolic blood pressure), MAP (mean arterial pressure), DBP (diastolic blood pressure), HR (heart rate)

      Keywords

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      References

        • Girotra S.
        • Spertus J.A.
        • Li Y.
        • Berg R.A.
        • Nadkarni V.M.
        • Chan P.S.
        Survival trends in pediatric in-hospital cardiac arrests: an analysis from get with the guidelines-resuscitation.
        Circ Cardiovasc Qual Outcomes. 2013; 6: 42-49
        • de Caen A.R.
        • Berg M.D.
        • Chameides L.
        • Gooden C.K.
        • Hickey R.W.
        • Scott H.F.
        • et al.
        Part 12: Pediatric advanced life support: 2015 american heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.
        Circulation. 2015; 132: S526-42
        • Berg R.A.
        • Sutton R.M.
        • Holubkov R.
        • Nicholson C.E.
        • Dean J.M.
        • Harrison R.
        • et al.
        Ratio of picu versus ward cardiopulmonary resuscitation events is increasing.
        Crit Care Med. 2013; 41: 2292-2297
        • Nadkarni V.M.
        • Larkin G.L.
        • Peberdy M.A.
        • Carey S.M.
        • Kaye W.
        • Mancini M.E.
        • et al.
        First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults.
        JAMA. 2006; 295: 50-57
        • Selde W.
        Push dose epinephrine: a temporizing measure for drugs that have the side-effect of hypotension.
        Jems. 2014; 39: 62-63
        • Weingart S.
        Push-dose pressors for immediate blood pressure control.
        Clin Exp Emerg Med. 2015; 2: 131-132
        • Cole J.B.
        Bolus-dose vasopressors in the emergency department: first, do no harm; second, more evidence is needed.
        Ann Emerg Med. 2018; 71: 93-95
        • Holden D.
        • Ramich J.
        • Timm E.
        • Pauze D.
        • Lesar T.
        Safety considerations and guideline-based safe use recommendations for bolus-dose vasopressors in the emergency department.
        Ann Emerg Med. 2018; 71: 83-92
        • Doherty A.
        • Ohashi Y.
        • Downey K.
        • Carvalho J.C.
        Phenylephrine infusion versus bolus regimens during cesarean delivery under spinal anesthesia: a double-blind randomized clinical trial to assess hemodynamic changes.
        Anesth Analg. 2012; 115: 1343-1350
        • Siddik-Sayyid S.M.
        • Taha S.K.
        • Kanazi G.E.
        • Aouad M.T.
        A randomized controlled trial of variable rate phenylephrine infusion with rescue phenylephrine boluses versus rescue boluses alone on physician interventions during spinal anesthesia for elective cesarean delivery.
        Anesth Analg. 2014; 118: 611-618
        • Mohta M.
        • Harisinghani P.
        • Sethi A.K.
        • Agarwal D.
        Effect of different phenylephrine bolus doses for treatment of hypotension during spinal anaesthesia in patients undergoing elective caesarean section.
        Anaesth Intensive Care. 2015; 43: 74-80
        • Panchal A.R.
        • Satyanarayan A.
        • Bahadir J.D.
        • Hays D.
        • Mosier J.
        Efficacy of bolus-dose phenylephrine for peri-intubation hypotension.
        J Emerg Med. 2015; 49: 488-494
        • Schwartz M.B.
        • Ferreira J.A.
        • Aaronson P.M.
        The impact of push-dose phenylephrine use on subsequent preload expansion in the ed setting.
        Am J Emerg Med. 2016; 34: 2419-2422
        • Gottlieb M.
        Bolus dose of epinephrine for refractory post-arrest hypotension.
        Cjem. 2017; : 1-5
        • Reiter P.D.
        • Roth J.
        • Wathen B.
        • LaVelle J.
        • Ridall L.A.
        Low-dose epinephrine boluses for acute hypotension in the picu.
        Pediatr Crit Care Med. 2018;
      1. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 10: Pediatric advanced life support. The american heart association in collaboration with the international liaison committee on resuscitation.
        Circulation. 2000; 102: I291-I342
      2. Report of the second task force on blood pressure control in children—1987.
        Pediatrics. 1987; 79: 1-25
        • Acquisto N.M.
        • Bodkin R.P.
        • Johnstone C.
        Medication errors with push dose pressors in the emergency department and intensive care units.
        Am J Emerg Med. 2017; 35: 1964-1965