Epinephrine Dosing for Teenagers: Use PediCrisis!
Myron Yaster MD, Jayant Deshpande MD, and Justin L. Lockman MD MD MSEd
“Life-threatening, critical events in the operating room are managed in a fast-paced, high-distraction atmosphere, often with little time to think or deliberate about treatment options. Success often depends on implementing a team approach with well-rehearsed, systematic, evidence-based assessment and management protocols within the first moments of presentation”.[1] Yet, because life-threatening crises are rare and human performance can be compromised under stressful conditions[2], “even expert clinicians may omit or delay key actions, with detrimental effects on patient morbidity and mortality.”[1] Cognitive aids, including emergency manuals and checklists, have been recommended as a means to address the failure of healthcare providers to adhere to evidence-based standards of treatment during crisis situations.
It turns out that our friends and colleagues in the PICU vary widely in how they administer epinephrine during CPR. If only they had our PediCrisis 2.0 app, which not only has the correct PALS dosing, it takes advantage of the calculator within the phone to calculate weight-based dosing!
And not wishing to be a broken record: If you haven’t downloaded SPA’s PediCrisis 2.0 app, please do it now! It’s available for free in the Apple App Store or Google Play Store.
https://apps.apple.com/us/app/pedi-crisis-2-0/id1409734476
https://play.google.com/store/search?q=pedi%20crisis&c=apps&hl=en_US&gl=US
Myron Yaster MD
Original article
Martha F Kienzle, Ryan W Morgan, Maya Dewan, Kiran B Hebbar, Vinay M Nadkarni, Vijay Srinivasan, Ken Tegtmeyer, Robert M Sutton, Heather A Wolfe. Weight-Based Versus Flat Dosing of Epinephrine During Cardiac Arrest in the PICU: A Multicenter Survey. Pediatr Crit Care Med. 2022 Oct 1;23(10):e451-e455. doi: 10.1097/PCC.0000000000003012. PMID: 35678459
This report presents the results of a survey of pediatric critical care physicians at American children’s hospitals with knowledge of their hospital’s resuscitation systems (e.g., PICU medical director and resuscitation committee leader/member). “Current PALS guidelines, which apply until age 18, suggest an epinephrine dose of 0.01 mg/kg (weight-based dosing) to a maximum (adult) dose of 1 mg (flat dosing). Unlike other emergency medications that reach adult dosing at smaller doses, a child would have to weigh 100 kg or more to receive flat dosing. Thus, clinicians may administer flat doses of epinephrine to pediatric patients under variable circumstances. The objective of this study was to characterize institutional practices in the transition from weight-based to flat epinephrine dosing during CPR in U.S. PICUs.”[3]
The good news is that Kienzle et al. got a very impressive 50% response rate to their survey. The bad news is that “Survey respondents reported considerable institutional practice variation in the transition from weight-based to flat epinephrine dosing during CPR in PICUs. The majority of PICUs surveyed report epinephrine dosing practices that are inconsistent with PALS guidelines.”[3]
Why does this matter? Let’s take a 50 kg patient as an example. The weight-based dose (0.01 mg/kg) would be 0.5 mg…the adult dose would be the maximum, flat epinephrine dose of 1 mg – double the weight based dose! “This could potentially cause differing effects on coronary perfusion pressure, myocardial oxygen demand, and cerebral blood flow and, thereby, outcomes.”[3]. We understand that critical care physicians often deviate intentionally from guidelines because guidelines are there to help not to constrain. Sometimes in the care of children with complex problems, there is good reason to deviate from guidelines. This is not one of those times! We are talking about institutional practices, not expert judgment.
This issue is hardly unique to epinephrine and CPR. Indeed, it arises frequently in many situations for deciding drug dosing in our practices. Let’s take pediatric pain management. Adult analgesic medication doses are never weight-based but are flat dosed. This makes pharmacokinetic measurements incomprehensible when trying to figure out equivalent pediatric dosing. It also causes real issues with your pharmacist who will insist upon maximum doses of morphine or methadone (e.g., 5 mg) even in children/adolescents weighing 100+ kg! Of course, we haven’t even addressed the question of actual weight vs. ideal body weight vs. lean body mass vs. body surface area vs. allometry in drug dosing.
How you deal with the issue of weight-based dosing for epinephrine in your practice. During emergencies including CPR, if you use the PediCrisis 2.0 app all of your doses will be weight-based and follow AHA guidelines. Let us know your thoughts with a reader response.
References
1. Clebone, A., et al., Development and Usability Testing of the Society for Pediatric Anesthesia Pedi Crisis Mobile Application. Anesth Analg, 2019. 129(6): p. 1635-1644.
2. Hales, B.M. and P.J. Pronovost, The checklist--a tool for error management and performance improvement. J.Crit Care., 2006. 21(3): p. 231-2re35.
3. Kienzle, M.F., et al., Weight-Based Versus Flat Dosing of Epinephrine During Cardiac Arrest in the PICU: A Multicenter Survey. Pediatr Crit Care Med, 2022. 23(10): p. e451-e455.