Bolus Epinephrine Dose-Readiness for Cardiac Arrest Prevention in Pediatric Cardiac ICUs: 2024 Survey of Units in the United States

Objective: To describe current practice in pediatric cardiac ICUs (CICUs) regarding use of bolus epinephrine in pre-arrest clinical scenarios; focusing on “epinephrine dose-readiness,” meaning having emergency medications available at a patients’ bedside. Setting: Academic and clinical CICUs in the United States. Design: Cross-sectional survey of medical directors from August to October 2024. Interventions: None. Measurements and Main Results: Forty-eight of 71 medical directors (68%) responded to the survey request. Of the respondents, 41 of 48 reported the practice of having bolus doses of epinephrine ready at patients’ bedsides. In 36 of 41 units, epinephrine doses were drawn up for high-risk patients only, whereas the other 5 of 41 units reported placing bolus doses of epinephrine at the bedside for all CICU patients, regardless of risk. Of these 5 units with bedside epinephrine for all patients, 4 units reported that this was done throughout the entirety of CICU admission. Most CICUs (33/41) with bedside epinephrine reported having patient-specific doses ready at bedside, whereas the other (8/41) CICUs with bedside epinephrine said that they had pre-filled epinephrine syringes that were not patient-specific. Regarding the dose of epinephrine boluses, 27 of 48 units reported having 1 µg/kg doses ready, which included 14 of 48 units that reported having both 10 µg/kg (cardiac arrest dose) and 1 µg/kg doses of epinephrine ready. On stratifying responses by CICU size (> 20 beds vs. those ≤ 20 beds) we identified a greater proportion reporting epinephrine dose-readiness for all patients throughout their CICU stay (31.6% vs. 4.8%; p = 0.025). Conclusions: In 48 U.S. CICUs in 2024, medical directors reported a range of practices in epinephrine dose-readiness for anticipation of patient clinical deterioration. Our findings expose a lack of standardization in practice, and there is a need to establish best practices with more research.