Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

The Association of Hospital Rate of Delayed Epinephrine Administration With Survival to Discharge for Pediatric Nonshockable In-Hospital Cardiac Arrest

Raymond, Tia T. MD1; Praestgaard, Amy2; Berg, Robert A. MD3; Nadkarni, Vinay M. MD4; Parshuram, Chris S. MB ChB, PhD5; for the American Heart Association’s Get With The Guidelines-Resuscitation Investigators

Pediatric Critical Care Medicine: May 2019 - Volume 20 - Issue 5 - p 405-416
doi: 10.1097/PCC.0000000000001863
Feature Articles

Objectives: To evaluate the variation of hospital rates of delayed epinephrine administration in pediatric patients with nonshockable in-hospital cardiac arrest, and the association of those rates with event, 24-hour, and overall survival to hospital discharge.

Design: A retrospective evaluation was performed. Delayed epinephrine was defined as greater than 5 minutes between the time the need for chest compressions was identified and epinephrine was administered. The main outcome was the association of hospital rate of delayed epinephrine administration with survival to hospital discharge. Secondary outcomes were event and 24-hour survival. Evaluation used hierarchical logistic regression and included 13 patient/event-level and seven hospital-level factors.

Setting: Hospitals with greater than 6 months data in the American Heart Association’s Get With the Guidelines—Resuscitation registry (2000–2016) and greater than or equal to five total pediatric cardiac arrests with nonshockable rhythm.

Patients: Children less than 18 years old with index nonshockable in-hospital cardiac arrest treated with greater than or equal to one epinephrine dose.

Interventions: None.

Measurements and Main Results: One-thousand four-hundred sixty-two patients at 69 hospitals were included: 218 patients (14.9%) had epinephrine delay rates ranging from 0% to 80% of events (median, 15.6%; interquartile range, 7–25%). The median and interquartile range of hospital level delay was 16% (7–25%). Patient/event-level predictors of delayed epinephrine were asystole (odds ratio, 1.54 [95% CI, 1.10–2.16]) and insertion of an endotracheal tube (odds ratio, 1.86 [95% CI, 1.27–2.73]). Hospital size less than 200 compared with greater than or equal to 500 beds (odds ratio, 3.07 [95% CI, 1.22–7.73]) and ICU location (odds ratio, 0.51 [95% CI, 0.36–0.74]) were associated with epinephrine delay rates. After adjustment, increasing quartiles of epinephrine delay were associated with lower patient and hospital-level return of spontaneous circulation (p = 0.019, p = 0.006) and 24-hour survival (p = 0.018, p = 0.002) respectively, but not survival to discharge (p = 0.20, p = 0.24).

Conclusions: Delayed epinephrine administration following pediatric nonshockable in-hospital cardiac arrest varies significantly between hospitals. Hospitals with higher rates of delayed epinephrine administration had worse patient- and hospital-level outcomes after adjusting for multiple patient- and hospital-level factors. Delayed epinephrine administration may directly contribute to increased mortality risk and/or may be a marker of unmeasured elements of hospital resuscitation performance.

1Division of Cardiac Critical Care, Department of Pediatrics, Medical City Children’s Hospital, Dallas, TX.

2Department of Biostatistics, University of Pennsylvania, Philadelphia, PA.

3Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

4Department of Anesthesiology, Critical Care and Pediatrics, Center for Simulation, Advanced Education and Innovation, Center for Resuscitation Science, The Children’s Hospital of Philadelphia, Philadelphia, PA.

5Division of Critical Care Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Members of the American Heart Association's Get With The Guidelines Resuscitation Investigators can be viewed in the Acknowledgments.

Supported, in part, by the Congenital Heart Surgical Unit at Medical City Children’s Hospital.

Dr. Praestgaard’s institution received funding from Medical City Children’s Hospital. Dr. Parshuram disclosed that he holds shares in a clinical decision support company in part owned by the Hospital for Sick Children, but no money has been paid to him. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail:

Copyright © 2019 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies