Sequence of advanced airway management and epinephrine administration for paediatric patients with non-shockable out-of-hospital cardiac arrest.

BACKGROUND: Despite the frequent use of both advanced airway management (AAM) and epinephrine during resuscitation, no studies have evaluated the optimal sequencing of these interventions in paediatric out-of-hospital cardiac arrest (OHCA). We therefore aimed to investigate the association between the sequence of AAM and epinephrine administration and outcomes in paediatric patients with OHCA with non-shockable rhythms.

METHODS: This retrospective observational study analysed data from a multicentre OHCA registry in Japan from 2014 to 2022. We included paediatric patients (aged <18 years) with non-shockable OHCA who received AAM (endotracheal intubation or supraglottic airway device placement) and/or epinephrine administration. The primary outcome was 1-month survival, and the secondary outcomes were 1-month favourable neurological outcome (defined as a paediatric cerebral performance category of 1-3) and the return of spontaneous circulation (ROSC). Inverse probability of treatment weighting (IPTW) was applied based on propensity scores to address imbalances in patient characteristics.

RESULTS: Of the 952 paediatric patients with non-shockable OHCA (median age (IQR) 2 (0-14) years), 577 (61%) were male. Of these, 455 and 497 belonged to the AAM-first and epinephrine-first groups, respectively. After IPTW, all covariates were well balanced between the AAM-first and epinephrine-first groups (standardised mean difference ≤0.10). Compared with the epinephrine-first group, the AAM-first group showed similar 1-month survival (adjusted OR (aOR), 1.09; 95% CI 0.61 to 1.86), favourable neurological outcome at 1 month (aOR, 0.79; 95% CI 0.12 to 5.07) and ROSC (aOR, 0.98; 95% CI 0.72 to 1.35).

CONCLUSIONS: The sequence of AAM and epinephrine administration was not associated with 1-month survival, favourable neurological outcome at 1 month or ROSC in paediatric patients with non-shockable OHCA.