More Epinephrine Badness - Too Soon = Too Bad

Epinephrine given within 2 minutes of defibrillation of a shockable rhythm is not recommended by American Heart Association, and in this study of in-hospital arrest was associated with decreased ROSC, overall survival, and survival with good functional outcome.

BMJ. 2016 Apr 6;353:i1577. doi: 10.1136/bmj.i1577.

Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis.

Andersen LW1, Kurth T2, Chase M3, Berg KM4, Cocchi MN5, Callaway C6, Donnino MW7; American Heart Association’s Get With The Guidelines-Resuscitation Investigators.

Author information:

1Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Rosenberg Building, One Deaconess Road, Boston, MA 02215, USA Department of Anesthesiology, Aarhus University Hospital, Nørrebrogade 44, Bygn. 21, 1 Aarhus 8000, Denmark Research Center for Emergency Medicine, Aarhus University Hospital, Trøjborgvej 72-74, Bygn. 30, Aarhus 8200, Denmark.

2Institute of Public Health, Charité - Universitätsmedizin Berlin, Seestrasse 73, Berlin D-13347, Germany.

3Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Rosenberg Building, One Deaconess Road, Boston, MA 02215, USA.

4Department of Medicine, Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.

5Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Rosenberg Building, One Deaconess Road, Boston, MA 02215, USA Department of Anesthesia Critical Care, Division of Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.

6Department of Emergency Medicine, 400A Iroquois, 3600 Forbes Avenue, Pittsburgh, PA 15260, USA.

7Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Rosenberg Building, One Deaconess Road, Boston, MA 02215, USA Department of Medicine, Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA mdonnino@bidmc.harvard.edu.

 

Abstract

OBJECTIVES:

 To evaluate whether patients who experience cardiac arrest in hospital receive epinephrine (adrenaline) within the two minutes after the first defibrillation (contrary to American Heart Association guidelines) and to evaluate the association between early administration of epinephrine and outcomes in this population.

DESIGN:

 Prospective observational cohort study.

SETTING:

 Analysis of data from the Get With The Guidelines-Resuscitation registry, which includes data from more than 300 hospitals in the United States.

PARTICIPANTS:

 Adults in hospital who experienced cardiac arrest with an initial shockable rhythm, including patients who had a first defibrillation within two minutes of the cardiac arrest and who remained in a shockable rhythm after defibrillation.

INTERVENTION:

 Epinephrine given within two minutes after the first defibrillation.

MAIN OUTCOME MEASURES:

 Survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and survival to hospital discharge with a good functional outcome. A propensity score was calculated for the receipt of epinephrine within two minutes after the first defibrillation, based on multiple characteristics of patients, events, and hospitals. Patients who received epinephrine at either zero, one, or two minutes after the first defibrillation were then matched on the propensity score with patients who were "at risk" of receiving epinephrine within the same minute but who did not receive it.

RESULTS:

 2978  patients were matched on the propensity score, and the groups were well balanced. 1510 (51%) patients received epinephrine within two minutes after the first defibrillation, which is contrary to current American Heart Association guidelines. Epinephrine given within the first two minutes after the first defibrillation was associated with decreased odds of survival in the propensity score matched analysis (odds ratio 0.70, 95% confidence interval 0.59 to 0.82; P<0.001). Early epinephrine administration was also associated with a decreased odds of return of spontaneous circulation (0.71, 0.60 to 0.83; P<0.001) and good functional outcome (0.69, 0.58 to 0.83; P<0.001).

CONCLUSION:

 Half of patients with a persistent shockable rhythm received epinephrine within two minutes after the first defibrillation, contrary to current American Heart Association guidelines. The receipt of epinephrine within two minutes after the first defibrillation was associated with decreased odds of survival to hospital discharge as well as decreased odds of return of spontaneous circulation and survival to hospital discharge with a good functional outcome.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

PMCID: PMC4823528 Free PMC Article

PMID: 27053638 [PubMed - in process]