Delayed Epinephrine Associated with Poor Pediatric Cardiac Arrest Outcomes

Time of Epinephrine to Survival
Time of Epinephrine to Survival
The benefits of epinephrine may depend on the time of administration.

A delay in the administration of the first epinephrine dose among children with in-hospital cardiac arrest who had an initial nonshockable rhythm was associated with poor outcomes, according to research published in the Journal of the American Medical Association.

Although epinephrine is currently recommended as a first-line pharmacological intervention for pediatric cardiac arrests, the recommendation is based on cardiac arrest outcomes in adults, as no randomized-controlled clinical trials have assessed the intervention in children. 

“There are notable differences between pediatric and adult cardiac arrest in etiology, epidemiology, and treatment, including that more children have a nonshockable rhythm,” wrote Lars W. Anderson, MD, of the department of emergency medicine at Beth Israel Deaconess Medical Center in Boston, Massachusetts, and colleagues.

They analyzed data from the Get With the Guidelines-Resuscitation registry, a quality improvement registry of US in-hospital cardiac arrests, to determine whether time to first epinephrine dose effected pediatric in-hospital cardiac arrest outcomes. The final cohort included 1,558 patients aged younger than 18 years who had an initial nonshockable rhythm, had received chest compressions, and had received at least 1 dose of epinephrine. 

The primary outcome was survival to hospital discharge. The researchers also assessed return of spontaneous circulation (ROSC), survival at 24 hours, and neurological outcomes as assessed on the Pediatric Cerebral Performance Category (PCPC) scale.

The average time to first epinephrine dose was 2.6 minutes (range 0-20 minutes), the researchers found. Overall, 37% of patients received epinephrine within the first minute after loss of pulse, but an additional 15% did not receive the drug until after 5 minutes.

Longer time to first epinephrine dose was associated with a lower risk of survival to discharge (multivariable-adjusted risk ratio [RR] per minute delay 0.95; 95% CI: 0.93-0.98). Patients with time to epinephrine administration of longer than 5 minutes (n=233) compared with those with time to epinephrine of 5 minutes or less (n=1325) 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).

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 outcomes (multivariable-adjusted RR per minute delay 0.95; 95%CI; 0.91-0.99).

“Because duration of CPR is associated with outcome and ROSC is a necessary first step to a meaningful recovery, the rationale for epinephrine administration as a time-sensitive intervention to improve long-term outcome becomes apparent,” the researchers wrote. 

The current findings were generally “in line with those previously reported for adults,” the researchers noted. “We found that a delay in epinephrine administration was associated with significantly decreased chance of good outcomes.”


  1. Andersen LW, Berg KM, Saindon BZ, Massaro JM et al. Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest. JAMA. 2015;doi:10.1001/jama.2015.9678.