Low-Dose Epinephrine Boluses for Acute Hypotension in the PICU

Impact of resuscitation adjuncts on postintubation hypotension in patients with isolated traumatic brain injury

INTRODUCTION

Postintubation hypotension (PIH) is a risk factor of endotracheal intubation (ETI) after injury. For those with traumatic brain injury (TBI), one episode of hypotension can potentiate that injury. This study aimed to identify the resuscitation adjuncts that may decrease the incidence of PIH in this patient population.

METHODS

This is a 4-year (2019-2022) prospective observational study at a level I trauma center. Adult (18 years or older) patients with isolated TBI requiring ETI in the trauma bay were included. Blood pressures were measured 15 minutes preintubation and postintubation. Primary outcome was PIH, defined as a decrease in systolic blood pressure of ≥20% from baseline or to ≤80 mm Hg, or any decrease in mean arterial pressure to ≤60 mm Hg. Multivariable logistic regression was performed to identify the associations of preintubation vasopressor, hypertonic saline (HTS), packed red blood cell, and crystalloids on PIH incidence.

RESULTS

Of the 490 enrolled patients, 16% had mild (head AIS, ≤2), 35% had moderate (head AIS, 3-4), and 49% had severe TBI (head AIS, ≥5). The mean ± SD age was 42 ± 22 years, and 71% were male. The median ISS, head AIS, and Glasgow Coma Scale were 26 (19-38), 4 (3-5), and 6 (3-11), respectively. The mean ± SD systolic blood pressure 15 minutes preintubation and postintubation were 118 ± 46 and 106 ± 45, respectively. Before intubation, 31% received HTS; 10%, vasopressors; 20%, crystalloids; and 14%, at least 1 U of packed red blood cell (median, 2 [1-2] U). Overall, 304 patients (62%) developed PIH. On multivariable regression analysis, preintubation use of vasopressors and HTS was associated with significantly decreased odds of PIH independent of TBI severity, 0.310 (0.102-0.944, p = 0.039) and 0.393 (0.219-0.70, p = 0.002), respectively.

CONCLUSION

Nearly two thirds of isolated TBI patients developed PIH. Preintubation vasopressors and HTS are associated with a decreased incidence of PIH. Such adjuncts should be considered prior to ETI in patients with suspected TBI.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Airway Management of Critically Ill Pediatric Patients with Suspected or Proven Coronavirus Disease 2019 Infection: An Intensivist Point of View

Advanced airway management of critically ill children is crucial for novel coronavirus disease 2019 (COVID-19) management in the pediatric intensive care unit, whether due to shock and hemodynamic collapse or acute respiratory failure. In this article, intubation is challenging due to the particularities of children's physiology and the underlying disease's pathophysiology, especially when an airborne pathogen, like COVID-19, is present. Unfortunately, published recommendations and guidelines for COVID-19 in pediatrics do not address in-depth endotracheal intubation in acutely ill children. We discussed the caveats and pitfalls of intubation in critically ill children.

An integrated strategy to explore the potential role of melatonin against copper-induced adrenaline toxicity in rat cardiomyocytes: Insights into oxidative stress, inflammation, and apoptosis

AIMS

Circumstantial anxiety as well as chronic stress may stimulate the release of stress hormones including catecholamines. Adrenaline toxicity has been implicated in many cardiovascular conditions. Considering previous literature that suggests the oxidative potential of the adrenaline-copper entity, we have investigated its potential nocuous role in isolated adult rat cardiomyocytes, the underlying molecular mechanism, and its possible protection by melatonin.

MAIN METHODS

Given the mechanistic congruity of adrenaline-copper (AC) with the well-established H₂O₂-copper-ascorbate (HCA) system of free radical generation, we have used the latter as a representative model to study the cytotoxic nature of AC. We further investigated the cardioprotective efficacy of melatonin in both the stress models through scanning electron microscopy, immunofluorescence, flow cytometry, and western blot analysis.

KEY FINDINGS

Results show that melatonin significantly protects AC-treated cardiomyocytes from ROS-mediated membrane damage, disruption of mitochondrial membrane potential, antioxidant imbalance, and distortion of cellular morphology. Melatonin protects cardiomyocytes from inflammation by downregulating pro-inflammatory mediators viz., COX-2, NF-κB, TNF-α, and upregulating anti-inflammatory IL-10. Melatonin significantly ameliorated cardiomyocyte apoptosis in AC and HCA-treated cells as evidenced by decreased BAX/BCL-2 ratio and subsequent suppression of caspase-9 and caspase-3 levels. The isothermal calorimetric study revealed that melatonin inhibits the binding of adrenaline bitartrate with copper in solution, which fairly explains the rescue potential of melatonin against AC-mediated toxicity in cardiomyocytes.

SIGNIFICANCE

Findings suggest that the multipronged strategy of melatonin that includes its antioxidant, anti-inflammatory, anti-apoptotic, and overall cardioprotective ability may substantiate its potential therapeutic efficacy against adrenaline-copper-induced damage and death of adult rat cardiomyocytes.

Bolus Vasopressor Use for Air Medical Rapid Sequence Intubation: The Vasopressor Intravenous Push to Enhance Resuscitation Trial

BACKGROUND

Rapid sequence intubation (RSI) may compromise perfusion because of the use of sympatholytic medications as well as subsequent positive pressure ventilation. The use of bolus vasopressor agents may reverse hypotension and prevent arrest.

METHODS

This was a prospective, observational study enrolling air medical patients with critical peri-RSI hypotension (systolic blood pressure [SBP] < 90 mm Hg) to receive either arginine vasopressin (aVP), 2 U intravenously every 5 minutes, for trauma patients or phenylephrine (PE), 200 μg intravenously every 5 minutes, for nontrauma patients. The main outcome measures included an increase in SBP, a reversal of hypotension, and the occurrence of dysrhythmia or hypertension (SBP > 160 mm Hg) within 20 minutes of vasopressor administration.

RESULTS

A total of 523 patients (344 aVP and 179 PE) were enrolled over 2 years. An increase in SBP was observed in 326 aVP patients (95%), with reversal of hypotension in 272 patients (79%). An increase in SBP was observed in 171 PE patients (96%), with reversal of hypotension in 148 patients (83%). A low rate of rebound hypertension was observed for both aVP and PE patients.

CONCLUSION

Both aVP and PE appear to be safe and effective for treating critical hypotension in the peri-RSI period.

Peri-arrest bolus epinephrine practices amongst pediatric resuscitation experts

Aim

To describe current practices of peri-arrest bolus epinephrine use amongst pediatric resuscitation experts in a multinational survey.

Methods

A 9-question survey was developed and electronically distributed to pediatric critical care physicians who are site investigators for the Pediatric Resuscitation Quality Collaborative (pediRES-Q) network. Institutional demographics were collected through the American Hospital Association 2018 Annual Survey and linked to responses. Descriptive statistics were used to characterize closed-ended responses, and qualitative content analysis to analyze open-ended responses.

Results

Of the 63 collaborative members invited to participate, 49 (78%) responded, representing 35 institutions in 9 countries. Forty-six of the 49 respondents (94%) reported that they would consider using peri-arrest bolus epinephrine during critical situations in patients not requiring cardiopulmonary resuscitation. Initial dosing strategies ranged from 0.1mcg/kg to 10mcg/kg, with the most commonly reported initial dose of 1mcg/kg by 25 of the 37 (68%) respondents who answered this question. Three of the 49 (6%) participants indicated that they would generally avoid using peri-arrest bolus epinephrine, citing lack of evidence to support its use.

Conclusions

In this multinational survey of pediatric resuscitation experts, endorsement of peri-arrest bolus epinephrine use was nearly universal, though a few clinicians cited lack of evidence to support this practice. There was a 100-fold difference in the range of initial weight-based doses reported, as well as a minority of clinicians who reported using non-weight-based dosing. Further research is needed to determine best practices, standardization of initial dosing, clinical factors that may warrant dosing modifications and associations with clinically important outcomes.

Acute Respiratory Failure With a Rare, Rapidly Progressing Pediatric Desmoid Tumor Anterior Mediastinal Mass

ABSTRACT

We present an unusual case of a 6-year-old boy who presented with the sudden presence of left neck mass and acute hypoxemic respiratory failure, whose subsequent imaging demonstrated a previously undiagnosed anterior mediastinal mass (AMM) extending into the left neck. Biopsy of the mass was consistent with a desmoid tumor, which is a rare cause of AMM in children. Desmoid tumors are locally aggressive, often invading and enveloping surrounding tissues, but overall slow growing. The sudden growth of the neck mass suggests a very aggressive desmoid tumor, causing an unexpected respiratory compromise. Anterior mediastinal masses may cause symptoms by compressing the heart, great vessels, and airways. However, the patient may adapt and develop compensatory mechanisms to counter the compressive effects. Emergency care of the patient with an AMM who presents with acute respiratory distress includes optimizing oxygenation through promoting a calm environment, oxygenating while minimizing positive end-expiratory pressure, maintaining the patient's compensatory mechanisms by minimizing sedation and muscle relaxation, positioning the patient to minimize compressive effects of the mass on the vital thorax structures, and early consultation with pediatric specialists to develop a shared-emergency treatment strategy and to secure an expedited disposition to the appropriate venue of care.

Efficacy of bolus-dose epinephrine to manage hypotension in the prehospital setting

PURPOSE

Hypotension in the Emergency Department (ED) and the prehospital setting has been associated with significant morbidity and mortality. Limited literature exists exploring the utilization of intravenous (IV) bolus-dose epinephrine (BDE) by Emergency Medical Services (EMS).

METHODS

A retrospective review evaluated patients transported to an academic medical center who had received IV BDE by a single urban EMS system from 2016 to 2020. The primary outcome was to assess the influence IV BDE had on systolic blood pressure (SBP). Secondary objectives were to assess changes in heart rate (HR), the impact of dose variability on SBP, and the incidence of severe hypertension (SBP > 220 mmHg).

RESULTS

A total of 55 patients who received 96 administrations of IV BDE were included in the analysis. The most common individual dose was 10 μg (76.0%) and 45.5% received multiple doses. The median weight-based dose of BDE was 0.14 μg/kg. A significant increase in SBP (median 14.0 mmHg) was noted among all patients following BDE administration compared with baseline (p < 0.001). No significant difference was found in HR following BDE compared with baseline (p = 0.375). Those that received a BDE dose >10 μg were noted to have a significantly greater rise in SBP than those that received 10 μg (30.0 mmHg vs. 11.0 mmHg; p = 0.022). Similarly, patients that received a dose ≥0.2 μg/kg had a significantly greater increase in SBP compared with those that received <0.2 μg/kg (30.0 mmHg vs. 10.0 mmHg; p = 0.048). There were no incidences of severe hypertension following therapy.

CONCLUSION

The utilization of IV BDE in the prehospital setting for acute hypotension resulted in a significant rise in SBP. A dose-response relationship was noted both in terms of a flat-based dose and a weight-based dose, with higher doses yielding a greater change in SBP. Additional investigations are necessary to further explore the most appropriate dose of this agent in this setting and its influence, if any, on clinical outcomes.

Reducing Cardiac Arrests in the PICU: Initiative to Improve Time to Administration of Prearrest Bolus Epinephrine in Patients With Cardiac Disease

OBJECTIVES

To evaluate the effectiveness of a quality-improvement initiative in reducing cardiac arrests in infants and children in the cardiac ICU.

DESIGN

Prospective observational before-after cohort study.

SETTING

Single pediatric cardiac ICU in the United Kingdom.

PATIENTS

All patients less than 18 years old admitted to the ICU.

INTERVENTION

Initial interdisciplinary training in cardiac arrest prevention followed by clinical practice change whereby patients with high-risk myocardium were identified on daily rounds. High-risk patients had bolus epinephrine preordered and prepared for immediate administration in the event of acute hypotension.

MEASUREMENTS AND MAIN RESULTS

Interrupted time series analysis was used to compare the cardiac arrest rate in the 18 months before and 4.5 years after implementation. Mean monthly cardiac arrest rate was 17.2 per 1,000 patient days before and 7.6 per 1,000 patient days after the initiative (56% decrease). Patient characteristics and ICU interventions were similar in the control and intervention periods. In the time series analysis, monthly cardiac arrest rate in the ICU decreased by 12.4 per 1,000 patient days (95% CI, -1.5 to -23.3; p = 0.03) immediately following the intervention, followed by a nonsignificant downward trend of 0.36 per 1,000 patient days per month (95% CI, -1.3 to 0.6; p = 0.44). Bolus epinephrine was administered during 110 hypotension events in 77 patients (eight administrations per 1,000 ICU days); responder rate was 77%. There were no significant changes in ICU and hospital mortality.

CONCLUSIONS

Implementation of the initiative led to a significant, sustained reduction in ICU cardiac arrest rate.

Adverse prognostic factors for rescuing patients with acute myocardial infarction–induced cardiac arrest receiving percutaneous coronary intervention under extracorporeal membrane oxygenation

Background:

Acute myocardial infarction–induced cardiac arrest has high mortality rate.

Objective:

To investigate the risk factors of extracorporeal membrane oxygenation combined with percutaneous coronary intervention in rescuing acute myocardial infarction–induced cardiac arrest.

Methods:

Forty-three eligible patients were assigned into death and survival groups. Their general clinical data, treatment outcomes, and various indicators 24, 48, and 72 h after extracorporeal membrane oxygenation implantation were compared. The factors affecting clinical outcomes were determined by multivariate logistic regression analysis. A nomogram prediction model was constructed and validated.

Results:

After removing extracorporeal membrane oxygenation device, 19 patients recovered and 24 died (mortality rate: 55.81%). The two groups had different conventional cardiopulmonary resuscitation duration, number of diseased vessels, distribution of culprit vessel, time from cardiac arrest to extracorporeal membrane oxygenation implantation, length of stay in critical care unit, and mean arterial pressure 24 and 48 h after extracorporeal membrane oxygenation implantation ( p < 0.05). Left anterior descending as the culprit vessel, number of diseased vessels, conventional cardiopulmonary resuscitation duration, time from cardiac arrest to extracorporeal membrane oxygenation implantation, and mean arterial pressure 48 h after extracorporeal membrane oxygenation resuscitation were independent risk factors for death. The predicted mortality rate was 72.6%, and the actual concordance index (C-index) was 0.869. Such indices after internal and external validations were 0.861 and 0.848, respectively, suggesting a good concordance.

Conclusion:

Left anterior descending as the culprit vessel, number of diseased vessels, conventional cardiopulmonary resuscitation duration, time from cardiac arrest to extracorporeal membrane oxygenation implantation, and mean arterial pressure 48 h after extracorporeal membrane oxygenation resuscitation are independent risk factors for patients with acute myocardial infarction–induced cardiac arrest undergoing extracorporeal membrane oxygenation combined with percutaneous coronary intervention.

Prehospital Efficacy and Adverse Events Associated with Bolus Dose Epinephrine in Hypotensive Patients During Ground-Based EMS Transport

BACKGROUND

The utility and efficacy of bolus dose vasopressors in hemodynamically unstable patients is well-established in the fields of general anesthesia and obstetrics. However, in the prehospital setting, minimal evidence for bolus dose vasopressor use exists and is primarily limited to critical care transport use. Hypotensive episodes, whether traumatic, peri-intubation-related, or septic, increase patient mortality. The purpose of this study is to assess the efficacy and adverse events associated with prehospital bolus dose epinephrine use in non-cardiac arrest, hypotensive patients treated by a single, high-volume, ground-based Emergency Medical Services (EMS) agency.

METHODS

This is a retrospective, observational study of all non-cardiac arrest EMS patients treated for hypotension using bolus dose epinephrine from September 12, 2018 through September 12, 2019. Inclusion criteria for treatment with bolus dose epinephrine required a systolic blood pressure (SBP) measurement <90mmHg. A dose of 20mcg every two minutes, as needed, was allowed per protocol. The primary data source was the EMS electronic medical record.

RESULTS

Forty-two patients were treated under the protocol with a median (IQR) initial SBP immediately prior to treatment of 78mmHg (65-86) and a median (IQR) initial mean arterial pressure (MAP) of 58mmHg (50-66). The post-bolus SBP and MAP increased to 93mmHg (75-111) and 69mmHg (59-83), respectively. The two most common patient presentations requiring protocol use were altered mental status (55%) and respiratory failure (31%). Over one-half of the patients treated required both advanced airway management (62%) and multiple bolus doses of vasopressor support (55%). A single episode of transient severe hypertension (SBP>180mmHg) occurred, but there were no episodes of unstable tachyarrhythmia or cardiac arrest while en route or upon arrival to the receiving hospitals.

CONCLUSION

These preliminary data suggest that the administration of bolus dose epinephrine may be effective at rapidly augmenting hypotension in the prehospital setting with a minimal incidence of adverse events. Paramedic use of bolus dose epinephrine successfully increased SBP and MAP without clinically significant side effects. Prospective studies with larger sample sizes are needed to further investigate the effects of prehospital bolus dose epinephrine on patient morbidity and mortality.

Human Errors and Adverse Hemodynamic Events Related to "Push Dose Pressors" in the Emergency Department

BACKGROUND

Though the use of small bolus doses of vasopressors, termed "push dose pressors," has become common in emergency medicine, data examining this practice are scant. Push dose pressors frequently involve bedside dilution, which may result in errors and adverse events. The objective of this study was to assess for instances of human error and adverse hemodynamic events during push dose pressor use in the emergency department.

METHODS

This was a structured chart and video review of all patients age ≥ 16 years undergoing resuscitation and receiving push dose pressors from a single center from January 2010 to November 2017. Push dose pressors were defined as intended intravenous boluses of phenylephrine (any dose) or epinephrine (≤ 100 mcg).

RESULTS

A total of 249 patients were analyzed. Median age was 60 years (range, 16-97), 58% were male, 49% survived to discharge. Median initial epinephrine dose was 20 mcg (n = 139, IQR 10-100, range 1-100); median phenylephrine dose was 100 mcg (n = 110, IQR 100-100, range 25-10,000). Adverse hemodynamic events occurred in 98 patients (39%); 30 in the phenylephrine group (27%; 95% CI, 19-36%), and 68 in the epinephrine group (50%; 95% CI, 41-58%). Human errors were observed in 47 patients (19%), including 7 patients (3%) experiencing dosing errors (all overdoses; range, 2.5- to 100-fold) and 43 patients (17%) with a documentation error. Only one dosing error occurred when a pharmacist was present.

CONCLUSIONS

Human errors and adverse hemodynamic events were common with the use of push dose pressors in the emergency department. Adverse hemodynamic events were more common than in previous studies. Future research should determine if push dose pressors improve outcomes and if so, how to safely implement them into practice.

Bolus Dose Epinephrine Improves Blood Pressure but is Associated with Increased Mortality in Critical Care Transport

Objective: Hypotension in the prehospital environment is common and linked to dose-dependent mortality. Bolus dose epinephrine (BDE) may reverse hypotension. We tested if BDE use to treat profound hypotension is associated with 24-hour survival. Methods: We performed a retrospective case-cohort study of critical care transport patients with systolic blood pressure (SBP) <70 mmHg from January 2011 to January 2017. To account for baseline differences between treated and untreated patients, we used nearest neighbor matching to estimate the average treatment effect of BDE on 24-hour survival. Included covariates were age, gender, shock type (cardiogenic, distributive, obstructive or hypovolemic), weight, type of service, vitals (heart rate, SBP and diastolic blood pressure, respiratory rate, oxygen saturation, end-tidal carbon dioxide, and Glasgow Coma Scale score) at the time of the first hypotensive episode, as well as pretreatment characteristics including cardiopulmonary resuscitation, defibrillation, transcutaneous pacing, needle thoracostomy, vasopressors, intubation, or arrhythmias. After statistical analysis, we assessed for residual bias by selecting random matched patient records and asking 2 blinded physicians to rate overall illness severity on a Likert scale. We compared perceived illness severity between cases and matched controls using a rank-sum test. Results: There were 6,992 patients transported with SBP <70 mmHg at least once and 4,374 meet inclusion criteria. Of the 1,620 patients transported after protocol implementation, 574 (35%) received BDE. Overall 24-hour survival, survival to discharge and 30-day survival were 80, 57, and 54%, respectively. Survival at 24 hours differed between the BDE group (66%) and controls (82%). These differences persisted at both discharge and 30 days. Administration of BDE was associated with increased post-treatment SBP. BDE treated patients were also more likely to receive cardiopulmonary resuscitation and vasopressors after treatment than untreated hypotensive patients, but there was no association with tachydysrhythmias requiring defibrillation. Conclusions: Bolus dose epinephrine increases blood pressure in the prehospital setting. Despite robust efforts to control for confounding, BDE remained associated with increased mortality in this observational cohort. This association may be due to unmeasured confounding and a randomized controlled trial is necessary to establish a causal relationship between bolus dose vasopressors and mortality.

Push Dose Epinephrine Use in the Management of Hypotension During Critical Care Transport

Introduction: Hypotension is a critical event during the transport of critically ill patients. Push dose vasopressor use, though widely adopted by anesthesiologists, has only recently found use in the field of emergency medicine and may have utility in the management of out-of-hospital hypotension. This study aimed to characterize the hemodynamic effects and adverse events that occur following push dose epinephrine (PDE) administration by critical care transport (CCT) providers to correct documented hypotension. Methods: We performed a retrospective observational study of patients transported by a regional critical care transport service and who received PDE during transport to correct documented hypotension. Per protocol, 10-20 µg of 1:100,000 epinephrine was given intravenously every 2 min until: (1) the systolic blood pressure (SBP) was at least 90 mmHg, or (2) the mean arterial pressure (MAP) was 65 mmHg or greater. All patients were over 18 years of age and were transported between January 1, 2015 and December 31, 2016. Primary outcomes of interest were the primary diagnoses associated with PDE use, hemodynamic outcomes of the intervention, and adverse events. Results: During the study period 100 doses of push dose epinephrine were given during the transport of 58 patients. Of these, 94 (94.0%) were found to be appropriately dosed and indicated per protocol. The most common diagnoses associated with PDE use were: post-cardiac arrest (n = 24), sepsis (n = 9), altered mental status (n = 7), and cardiogenic shock (n = 3). The median increase in MAP across all doses was 13.0 (5.0-34.0) mmHg, and the heart rate increase was 2.0 (-1.0-9.3) beats per minute. Hypotension was resolved in 55 of 94 instances (58.5%). A single episode of transient extreme hypertension occurred after one PDE dose and did not result in patient harm. Conclusions: Push dose epinephrine may be an effective method of temporarily resolving hypotension during the CCT of critically ill patients. In the cases where PDE was administered, there was close adherence to the established protocol and adverse events were found to be rare directly following PDE administration. Further research is needed to validate these findings, establish optimal dosing, and evaluate use in non-CCT prehospital settings.

Physiologic response to pre-arrest bolus dilute epinephrine in the pediatric intensive care unit

AIM

To quantify the physiologic effects of pre-arrest bolus dilute epinephrine in the pediatric intensive care unit.

METHODS

Patients <18 years old and ≥37 weeks gestation who received an intravenous bolus of dilute epinephrine (10 mcg/mL) in the pediatric intensive care units at our institution from January 2011 to March 2017 were retrospectively identified. Patients were excluded if doses exceeded 20 mcg/kg, or under the following circumstances: orders limiting resuscitation, extracorporeal membrane oxygenation, active chest compressions, simultaneous administration of other blood pressure-altering interventions or documented normotension prior to epinephrine. The primary outcome was change in systolic blood pressure within 5 min of epinephrine. Patients were categorized as non-responders if the change in systolic blood pressure was ≤10 mmHg.

RESULTS

One hundred forty-four patients were analyzed. The median index dose was 0.7 mcg/kg (IQR, 0.3-2.0), and the mean increase in systolic blood pressure was 31 mmHg (95% CI, 25-36; P < 0.001). Thirty-nine (27%) patients were classified as non-responders. Compared to responders, non-responders had higher rates of cardiac arrest or extracorporeal membrane oxygenation within 6 h (26% vs 10%; relative risk, 2.69; 95% CI, 1.21-5.97; P = 0.03), and had higher in-hospital mortality (51% vs 21%; relative risk, 2.45; 95% CI, 1.51-3.96; P < 0.001).

CONCLUSIONS

In the majority of pre-arrest pediatric patients, bolus dilute epinephrine resulted in an increase in systolic blood pressure, and lack of blood pressure response was associated with poor outcomes. Optimal dosing of dilute epinephrine remains unclear.