Acute Care Pediatric Nurse Practitioner Cincinnati Children's Hospital West Chester, Ohio, United States
Abstract:
Background: Early recognition of clinical deterioration in patients with congenital heart disease is imperative to prevent a cardiac arrest (CA) in the pediatric CICU. Bedside availability of dilute epinephrine increases efficiency of administration in cases of impending CA. Recently, dilute epinephrine availability at the bedside, in isolation or as part of a cardiac arrest prevention bundle, is associated with decreased CA rates. We sought to describe the use of dilute epinephrine to prevent CA in a single CICU, including evaluation of factors associated with CA rescue.
Methods: A single-center retrospective medical chart review of patients admitted to a pediatric cardiac intensive care unit in January 1, 2017 to December 31, 2018 who received at least one dose of a dilute epinephrine (1 mcg/kg), which per unit protocol, was kept at the bedside of all patients deemed to be high-risk for CA. Failure to rescue (FTR) was defined as those who received dilute epinephrine, but still proceeded to suffer a CA event or die after the event. Patient characteristics were compared between those rescued by dilute epinephrine and those with failure to rescue.
Results: 50 patients received dilute epinephrine in the study period; 32 patients were rescued, and 18 were not. Over half received >1 dose, which occurred more frequently in the FTR group. Patient demographics are shown in Table 1; the majority were postoperative neonatal cardiac surgical patients. Just over half, n=26, survived the hospital stay. Eleven (22%) FTR patients had CA and 10 patients with FTR were treated with ECMO. Compared to 69% survival in the rescue group, only 4/18 (22%) with FTR survived, p< 0.001. Hypotension was most common reason for administration among both groups. There was a trend toward rescue in patients with isolated bradycardia and trend toward FTR in patients with any hypotension. Vital signs 1 hour before, and at time dilute epinephrine administration are shown in Table 2; there was significant deterioration at time of dilute epinephrine administration, but no differences between rescue cohorts.
Conclusions: Bedside dilute epinephrine administration may have prevented 39 children from suffering CA during this study period. This data supports the use of bedside epinephrine to improve patient outcomes in high risk patients. Further work needs to be performed to determine what patient cohorts would benefit most from bedside epinephrine to prevent CA. Exploring more frequent vital sign measures in the time period prior to CA may help identify the optimal timing and thresholds to treat vital sign deterioration or administer dilute epinephrine to improve rescue rate. Key Words: Cardiac Arrest, Epinephrine, Hypotension
