Jun 8, 2026 · 28 min · 12 segments
Drs Dezfulian and Kienzle discuss the evidence for and against algorithmic epinephrine administration and identify ongoing knowledge gaps. Dr. Kienzle shares her provocative findings that earlier and…
Martha KinsleyGuestSo as we know, the PALS guidelines call for epinephrine to be dosed at a dose of 0.01 milligrams per kilo, maximizing at one milligram every three to five minutes.
And so epinephrine has been given in the past, maybe a little bit more frequently than what the guidelines say.
And so I think it's admirable that you guys decided to take a look at this and say, is this a good idea or a bad idea? So I guess to start with, why don't we give a little bit of background on epinephrine? Why do we give epinephrine for pediatric in-hospital cardiac arrest?
So the main proposed mechanism for epinephrine and cardiac arrest is through alpha receptor agonism, increased basal constriction, diastolic aortic blood pressure, and by virtue of that, increased coronary perfusion pressure, which increases the odds of ROSC.
In about half of pediatric arrest, though, that are due to bradycardia with poor perfusion, so kids with a beating heart, presumably there are beta effects on the myocardium, but I don't think we know whether that is good, bad, or somewhere in between.
And, you know, I guess that it begs the question of, you know, when we're talking about the dosing, is more epinephrine better? And personally, I think back to the New England Journal paper from 2004, where the first author was Perandi, but I believe Bob Berg, who's your former division chief, was the last author.
So basically a tenfold increase in epinephrine dosing within pediatric cardiac arrest.
And what they found was that although the ROSC was similar between the groups, the 24-hour survival was actually better in the lower, which is what we currently use as our standard dose of epinephrine.
The adjusted odds ratio in that study, I think, was 7.9. And when you look just at 24-hour survival, only one out of 34 of the children who had received high-dose epi actually survived, whereas 7 out of 34 of those with the lower or standard dose epinephrine survived.
So that then begs the question of what are the downsides of epi, because obviously more is not always better.
There are some animal studies and large animal models that suggest impaired cerebral blood flow at the microcirculatory level, even though at the macrocirculatory level, there's evidence that it in fact improves cerebral blood flow.
Additionally, there's arrhythmia risk with any high dose of catecholamines and then diastolic dysfunction as well.
There's some adult retrospective data that shows that higher epifrequency measured in milligrams per minute was associated with lower rates of survival with an odds ratio of 0.05, as well as lower odds of favorable neurologic outcome at discharge with an odds ratio of 0.02.
But despite that, some of their data suggests that higher doses may be sensible in heavier patients.
And heavier patients were defined as greater than 82 kilos in this study, which was a small minority of patients.
Because when they held milligrams per minute constant, the heavier patients did worse.
So that begs the question, were those patients underdosed? And that is of a specific interest to me.
So as we know, the PALS guidelines call for epinephrine to be dosed at a dose of 0.01 milligrams per kilo, maximizing at one milligram every three to five minutes.
And so epinephrine has been given in the past, maybe a little bit more frequently than what the guidelines say.
And so I think it's admirable that you guys decided to take a look at this and say, is this a good idea or a bad idea? So I guess to start with, why don't we give a little bit of background on epinephrine? Why do we give epinephrine for pediatric in-hospital cardiac arrest?
So the main proposed mechanism for epinephrine and cardiac arrest is through alpha receptor agonism, increased basal constriction, diastolic aortic blood pressure, and by virtue of that, increased coronary perfusion pressure, which increases the odds of ROSC.
In about half of pediatric arrest, though, that are due to bradycardia with poor perfusion, so kids with a beating heart, presumably there are beta effects on the myocardium, but I don't think we know whether that is good, bad, or somewhere in between.
And, you know, I guess that it begs the question of, you know, when we're talking about the dosing, is more epinephrine better? And personally, I think back to the New England Journal paper from 2004, where the first author was Perandi, but I believe Bob Berg, who's your former division chief, was the last author.
So basically a tenfold increase in epinephrine dosing within pediatric cardiac arrest.
And what they found was that although the ROSC was similar between the groups, the 24-hour survival was actually better in the lower, which is what we currently use as our standard dose of epinephrine.
The adjusted odds ratio in that study, I think, was 7.9. And when you look just at 24-hour survival, only one out of 34 of the children who had received high-dose epi actually survived, whereas 7 out of 34 of those with the lower or standard dose epinephrine survived.
So that then begs the question of what are the downsides of epi, because obviously more is not always better.
There are some animal studies and large animal models that suggest impaired cerebral blood flow at the microcirculatory level, even though at the macrocirculatory level, there's evidence that it in fact improves cerebral blood flow.
Additionally, there's arrhythmia risk with any high dose of catecholamines and then diastolic dysfunction as well.
There's some adult retrospective data that shows that higher epifrequency measured in milligrams per minute was associated with lower rates of survival with an odds ratio of 0.05, as well as lower odds of favorable neurologic outcome at discharge with an odds ratio of 0.02.
But despite that, some of their data suggests that higher doses may be sensible in heavier patients.
And heavier patients were defined as greater than 82 kilos in this study, which was a small minority of patients.
Because when they held milligrams per minute constant, the heavier patients did worse.
So that begs the question, were those patients underdosed? And that is of a specific interest to me.
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