Dr. Laura Ortmann Discusses Study Published in Resuscitation
Dr. Laura Ortmann Discusses Study Published in Resuscitation
Laura Ortmann, MD, associate professor in UNMC’s division of Critical Care Medicine and Children’s director of Cardiac Critical Care, is the lead author of an article published recently in Resuscitation.* Titled, “Epinephrine dosing strategies during pediatric extracorporeal cardiopulmonary resuscitation reveal novel impacts on survival: A multicenter study utilizing time-stamped epinephrine dosing records,” the paper reports a retrospective study using data drawn from five pediatric hospitals. Dr. Ortmann fielded a few questions about the study for the Research Bulletin.
Considering that guidelines on the frequency of epinephrine dosing during CPR for a child in cardiac arrest seemed clear-cut, what led you to take a closer look at actual practices and outcomes?
The current guidelines published by the American Heart Association and taught in our Pediatric Advanced Life Support classes state that epinephrine should be given every three to five minutes during cardiac arrest with no limits. A number of years ago, I started looking at the literature to understand where this came from and was surprised to find there was no clinical evidence that giving epinephrine this often improved outcomes and didn’t cause harm. The recommendations were solely based on the medication’s half-life.
Sometimes children have cardiac arrests in the hospital, and we can’t get a pulse back. So, they are placed onto extracorporeal membranous oxygenation (ECPR). These resuscitations can last 60 minutes or more, and that’s a lot of epinephrine if you are giving it every three minutes. Epinephrine is a potent vasoconstrictor, so are we causing tissue damage and worsening outcomes by giving this much?
What was different about your methodology compared with previous published studies?
There are large national cardiac arrest databases that I’ve used for research in the past, but these only contain the total number of doses of epinephrine, not when they were given. We suspected that resuscitation leaders weren’t following the guidelines and were lengthening the time between doses as CPR progressed. By getting multiple centers to submit time-stamped dosing data, we were able to see that we were giving doses every three to five minutes for the first 10 minutes of the arrest but decreasing the doses after that. This also allowed us to discover that survivors and non-survivors received the same number of epinephrine doses early in the arrest, but after the first 10 minutes survivors received fewer doses. In fact, stopping epinephrine dosing altogether didn’t worsen outcomes.
How do your results challenge current understanding and the standard guidelines?
How to dose medications during ECPR has been a hot topic for many years in the pediatric cardiac intensive care world. As evidenced by our data, some centers have already transitioned away from following the guidelines and are stopping epinephrine dosing if the first two doses don’t result in a pulse. I believe that the trend away from frequent epinephrine dosing will continue. The AHA guidelines are updated every five years, and the work on the next set is just starting. We’ll see if they incorporate these results into their recommendations.
*Ortmann, L. A., Reeder, R. W., Raymond, T. T., Brunetti, M. A., Himebauch, A., Bhakta, R., Kempka, J., di Bari, S., & Lasa, J. J. (2023). Epinephrine dosing strategies during pediatric extracorporeal cardiopulmonary resuscitation reveal novel impacts on survival: A multicenter study utilizing time-stamped epinephrine dosing records. Resuscitation, 188, 109855.