115 - Nebulized Racemic Epinephrine: Dosing Efficacy of 0.5 mL vs 1.0 mL in Croup

Publication Number: 115.5963

Thuy Bui, Children's Healthcare of Atlanta, Pediatric Emergency Medicine Associates, Atlanta, GA, United States; John Cheng, Children's Healthcare of Atlanta, Atlanta, GA, United States; Aziza Mustefa, Children's Healthcare of Atlanta, Denver, CO, United States; Ruijin Geng, Morehouse School of Medicine, Marietta, GA, United States; Scott Gillespie, Emory University School of Medicine, Atlanta, GA, United States

Background: Viral croup is a common cause of upper respiratory infections in children, and it is
estimated that 1.5% - 6% of children require hospitalization (1-2). While there is general
agreement on the management of croup, there is little evidence to guide the dosing of racemic
epinephrine (RE).

Objective: The purpose of this study is to understand the impact of RE dosing (0.25mL, 0.5mL,
and 1.0mL) on patient outcomes.

Design/Methods: This study was a retrospective record review of patients
diagnosed with croup, who were seen in the Emergency Department (ED) at Children’s
Healthcare of Atlanta hospitals (CHOA) from January 1, 2012 – December 31, 2017. Primary
outcomes for the study were ED length of stay (minutes), hospital admission, ED return visit
rate, need for repeated dose of RE, and change in vital signs after dose. Standard
demographic data was also obtained. Independent variables included repeat RE doses (≤0.5
mL and 1.0mL), season of admission, and time of admission to the ED. A Cochran-Mantel-
Haenszel test was performed comparing RE doses (0.25mL, 0.5ml and 1.0ml) to all outcomes.
Logistic regression was performed to calculate the effect of demographic data on the primary outcomes.

Results: A total of 2,185 patient charts were reviewed and considered eligible for the study.
1,259 patients received a first dose of RE of ≤0.5mL. 926 patients received a first dose of RE of
1.0mL. There was no difference in rates of hospital admission between these groups (39.63%
RE dose ≤0.5mL vs 41.36% RE dose 1.0mL, p = 0.416). There was a trend towards patients in
the 1.0mL group requiring a second dose of RE, but this did not reach statistical significance
(26.85% RE dose ≤0.5mL vs 30.24% RE dose 1.0mL, p = 0.82). There were higher rates of
return to the ED in the ≤0.5mL dose group (7.15% RE dose ≤0.5mL vs 4.64% RE dose 1.0mL, p<br>= 0.016). Overall length of stay was 11 minutes longer (155.31 minutes) for the ≤0.5mL RE dose
group as compared to the 1.0mL dose group (144.56 minutes, p = 0.0009). There was no
significant difference in vital sign change over time when comparing the ≤0.5mL RE group to
the 1.0mL RE group.

Conclusion(s): Higher doses of RE can be used as nebulized treatments without significant
change in vital signs, and are associated with a shorter ED length of stay, reduced ED return rate,
and no change in likelihood of hospital admission.

References (abstract background)
(1) R. Zoorob, M. Sidani, J. Murray, Croup: an overview, Am. Fam. Physician 83 (2011) 1067–1073
PubMed PMID: 21534520.

(2) R.J. Rosychuk, T.P. Klassen, D. Metes, D.C. Voaklander, A. Senthilselvan, B.H. Rowe, Croup
presentations to emergency departments in Alberta, Canada: a large population-based study,
Pediatr. Pulmonol. 45 (2010) 83–91 https://doi.org/ 10.1002/ppul.21162.