title: Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest.
abstract: OBJECTIVE
  Delay in administration of the first epinephrine dose is associated with decreased survival among adults after in-hospital, nonshockable cardiac arrest. Whether this association is true in the pediatric in-hospital cardiac arrest population remains unknown.
  
  
  OBJECTIVE
  To determine whether time to first epinephrine dose is associated with outcomes in pediatric in-hospital cardiac arrest.
  
  
  METHODS
  We performed an analysis of data from the Get With the Guidelines-Resuscitation registry. We included US pediatric patients (age <18 years) with an in-hospital cardiac arrest and an initial nonshockable rhythm who received at least 1 dose of epinephrine. A total of 1558 patients (median age, 9 months [interquartile range [IQR], 13 days-5 years]) were included in the final cohort.
  
  
  METHODS
  Time to epinephrine, defined as time in minutes from recognition of loss of pulse to the first dose of epinephrine.
  
  
  METHODS
  The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC), survival at 24 hours, and neurological outcome. A favorable neurological outcome was defined as a score of 1 to 2 on the Pediatric Cerebral Performance Category scale.
  
  
  RESULTS
  Among the 1558 patients, 487 (31.3%) survived to hospital discharge. The median time to first epinephrine dose was 1 minute (IQR, 0-4; range, 0-20; mean [SD], 2.6 [3.4] minutes). Longer time to epinephrine administration was associated with lower risk of survival to discharge in multivariable analysis (multivariable-adjusted risk ratio [RR] per minute delay, 0.95 [95% CI, 0.93-0.98]). Longer time to epinephrine administration was also associated with decreased risk of ROSC (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.96-0.99]), decreased risk of survival at 24 hours (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.95-0.99]), and decreased risk of survival with favorable neurological outcome (multivariable-adjusted RR per minute delay, 0.95 [95% CI, 0.91-0.99]). Patients with time to epinephrine administration of longer than 5 minutes (233/1558) compared with those with time to epinephrine of 5 minutes or less (1325/1558) had lower risk of in-hospital survival to discharge (21.0% [49/233] vs 33.1% [438/1325]; multivariable-adjusted RR, 0.75 [95% CI, 0.60-0.93]; P = .01).
  
  
  CONCLUSIONS
  Among children with in-hospital cardiac arrest with an initial nonshockable rhythm who received epinephrine, delay in administration of epinephrine was associated with decreased chance of survival to hospital discharge, ROSC, 24-hour survival, and survival to hospital discharge with a favorable neurological outcome.
authors: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts2Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark.
authors: Lars W
authors: LW
authors: Andersen
authors: Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors: Katherine M
authors: KM
authors: Berg
authors: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors: Brian Z
authors: BZ
authors: Saindon
authors: Harvard Clinical Research Institute, Boston, Massachusetts5Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts.
authors: Joseph M
authors: JM
authors: Massaro
authors: Division of Cardiac Critical Care, Department of Pediatrics, Medical City Children's Hospital, Dallas, Texas.
authors: Tia T
authors: TT
authors: Raymond
authors: Department of Anesthesiology, Critical Care and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia.
authors: Robert A
authors: RA
authors: Berg
authors: Department of Anesthesiology, Critical Care and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia.
authors: Vinay M
authors: VM
authors: Nadkarni
authors: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts3Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors: Michael W
authors: MW
authors: Donnino
mesh_terms: D000293:Adolescent; D000316:Adrenergic alpha-Agonists / Q000008:administration & dosage / Q000627:therapeutic use*; D000318:Adrenergic beta-Agonists / Q000008:administration & dosage / Q000627:therapeutic use*; D000465:Algorithms; D001775:Blood Circulation; D002648:Child; D002673:Child, Hospitalized; D002675:Child, Preschool; D015331:Cohort Studies; D004837:Epinephrine / Q000008:administration & dosage / Q000627:therapeutic use*; D005260:Female; D006323:Heart Arrest / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D012042:Registries; D012306:Risk; D061665:Time-to-Treatment
chemical_list: D000316:Adrenergic alpha-Agonists; D000318:Adrenergic beta-Agonists; D004837:Epinephrine