High-dose epinephrine is not superior to standard-dose epinephrine in pediatric in-hospital cardiopulmonary arrest

Objective. To compare the efficacy of high-dose epinephrine (HDE) with that of standard-dose epinephrine (SDE) for resuscitation from in-hospital pediatric cardiopulmonary arrest (CPA). Design. Fifty-four-month retrospective study of all pediatric patients who had a CPA while hospitalized at a tertiary care children's hospital. Standard pediatric advanced life support techniques were used for all patients. Patients received HDE or SDE in accordance with physician orders and standard protocols at the time of CPA. Primary outcome measures were the return of spontaneous circulation (ROSC), the duration of survival after resuscitation, survival to hospital discharge, and Pediatric Overall Performance Category scores at the time of discharge. Results. During the study period, 51 patients met entry criteria and had a total of 58 CPAs. Twenty-one patients received HDE during resuscitation from 24 arrests, at a dose of 0.12 +/- 0.05 mg/kg (mean +/- SD); 30 patients received SDE during resuscitation from 34 arrests, at a dose of 0.01 +/- 0.01 mg/kg (mean +/- SD). The HDE and SDE groups were not significantly different in terms of gender, initial cardiac rhythm, location of CPA, primary diagnoses at the time of CPA, initial pH, or additional resuscitation medications received; the SDE group had a significant higher mean age, although the median ages were not different. Fourteen of 24 resuscitations using HDE resulted in ROSC (58%) with a mean time to ROSC of 19 minutes; 7 (29%) of 24 led to survival for 24 hours, and 6 (26%) of 23 patients survived to hospital discharge, all with moderate to severe neurologic and functional impairment. Twenty-four of 34 resuscitations using SDE resulted in ROSC (71%) with a mean time to ROSC of 12 minutes; 17 (50%) of 34 led to survival for 24 hours; and 7 (23%) of 30 patients survived to hospital discharge, 4 with mild to moderate neurologic impairment. No significant differences in rates of ROSC, survival rates, or Pediatric Overall Performance Category scores of survivors were found between the two groups. The mean time to ROSC was significantly longer in the HDE group. Conclusions. In this study, the use of HDE did not improve the rates of ROSC, short-term survival, or longterm survival after pediatric in-hospital CPA, nor did it improve overall outcome scores. Given the conflicting evidence surrounding possible detrimental effects of HDE use, a large, blinded, prospective trial of HDE use in this setting is necessary to clarify the appropriate role for HDE in pediatric resuscitation.