Pediatrics Resident Physician UT Southwestern Medical Center University of Texas Southwestern Medical Center Dallas, Texas, United States
Background: The Neonatal Resuscitation Program (NRP) recommends an initial IV epinephrine dose of 0.01-0.03 mg/kg during neonatal CPR. However, there is little human data on what is the initial optimal epinephrine dose that is associated with improved survival.
Objective: To determine if a 0.02mg/kg initial dose of IV epinephrine is associated with decreased death in the DR compared to a 0.01mg/kg epinephrine dose in infants receiving IV epienphrine in the DR.
Design/Methods: In July 2014, Parkland Hospital implemented the use of 0.02mg/kg as an initial dose of IV epinephrine during neonatal CPR, a change from the previous use of 0.01mg/kg. Neonates born between 01/01/10 and 09/30/20 who received IV epinephrine in the DR were identified from the medical records and the Parkland neonatal resuscitation registry. Neonates were divided retrospectively into those who received an initial IV epinephrine dose of 0.01mg/kg (Epi0.01) and those who received an initial dose of 0.02mg/kg (Epi0.02). Baseline characteristics, resuscitation interventions and clinical outcomes were compared via fisher's exact test or rank sum test. Regression analysis was done to control for confounding.
Results: There were 22 infants in Epi0.01 and 35 infants in Epi0.02 groups. (Figure 1) Baseline characteristics were similar between both groups. (Table 1) Time before start of chest compressions was longer for EPI0.02 infants compared to EPI0.01. (Table 2A) Time to intubation, time to first epinephrine dose (any route), time to first IV epinephrine dose, total IV epinephrine dose and cumulative epinephrine dose were similar between both groups. Death in the DR was lower in EPI0.02 group compared to EPI0.01. [ 9 (26) vs 13 (59), p 0.025] After controlling for gestational age, asystole at the first HR assessment, and time to start CPR, death in the DR remained significantly lower in Epi0.02 group. (Table 2B) Time to return of spontaneous circulation, death within 48 hours, or death at discharge were similar between the two groups. A large number of survivors in both groups suffer from hypoglycemia, hypoxic ischemic encephalopathy, seizures, pulmonary hypertension and high systolic blood pressures within 4 hours after birth. (Table 3) Conclusion(s): The 0.02mg/kg initial dose of IV epinephrine during neonatal CPR in the DR was associated with lower death in the DR but death at discharge remained similar. Studies with larger sample size and with long-term outcomes in survivors are needed to further investigate the optimal initial dose of IV epinephrine.
Figure 1: Flow Diagram of Study Population
Table 1: Baseline Characteristics
Table 2A: Resuscitation Characteristics and Mortality
Table 2B: Multiple Logisitic Regression to Predict Death in the Delivery Room
Table 3: Clinical Outcomes in Survivors
Authors/Institutions: Jennifer Szotek, University of Texas Southwestern Medical Center, Dallas, Texas, United States; Angela C. Noltemeyer, University of Texas Southwestern Medical Center, Dallas, Texas, United States; Shalini Ramachandran, University of Texas Southwestern Medical Center, Dallas, Texas, United States; Myra Wyckoff, University of Texas Southwestern Medical Center, Dallas, Texas, United States; Vishal Kapadia, University of Texas Southwestern Medical Center, Dallas, Texas, United States
.jpg "Jennifer Szotek, MD photo")
