Are We Giving Epinephrine Too Frequently?

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Current PALS (and ACLS) algorithms recommend repeat epinephrine doses q3-5 minutes.  This study suggested that this is too frequent.  If doses were spaced 8-10 minutes apart, pediatric inpatients had significantly better survival.

Why does this matter?
If this study is correct, it means we need to nearly double the time interval between epinephrine doses in pediatric arrest.

Not so fast...
This was a large retrospective registry study of 1630 children with in-hospital cardiac arrest that examined the time interval between epinephrine doses and survival to discharge.  When compared with epinephrine given every 1-5 minutes, odds of survival to discharge was 164% greater, OR 2.64 (95% CI 1.53-4.55), when it was given every 8-10 minutes.  Interestingly, the statistically unadjusted results showed that less frequent dosing was worse.  But after multivariable logistic regression to adjust for factors known to adversely impact survival ("age, gender, illness category, location of arrest, event duration, time to first epinephrine dose, and whether the arrest occurred at night"), less frequent dosing proved better.  There was a lot of statistical manipulation needed to get these results.  The retrospective design also makes confounding more likely.  Perhaps there was some other factor associated with less frequent epinephrine dosing that made the prognosis better for these children.  We can't be sure with this data, but the time-interval groups were fairly well matched as far as severity, cause of arrest, etc.  This study will probably result in a change in practice for me.

Epinephrine dosing interval and survival outcomes during pediatric in-hospital cardiac arrest.Resuscitation. 2017 Aug;117:18-23. doi: 10.1016/j.resuscitation.2017.05.023. Epub 2017 May 25.

Peer reviewed by Thomas Davis, MD.