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Prehospital epinephrine use failed to improve outcomes in patients with out-of-hospital cardiac arrest
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Although associated with increased odds for return of spontaneous circulation, prehospital epinephrine use was associated with decreased chance of survival and did not improve functional outcomes at 1 month.
Researchers evaluated data from 417,188 patients with out-of-hospital cardiac arrest (mean age, 72 years) in Japan that occurred from 2005 to 2008. More than 13,000 patients were given epinephrine and matched with patients who were not given epinephrine.
Main outcome measures in this prospective, nonrandomized, observational propensity analysis included return of spontaneous circulation before arrival at the hospital; 1-month survival after cardiac arrest; survival with good or moderate cerebral performance (Cerebral Performance Category 1 or 2); and survival with no, mild or moderate neurological disability (Overall Performance Category 1 or 2).
Potential risks
Of patients who received epinephrine, 18.5% experienced return of spontaneous circulation before arriving at the hospital vs. 5.7% of patients who did not receive epinephrine (P<.001). Return of spontaneous circulation was observed in 18.3% of propensity-matched patients who received epinephrine and 10.5% who did not (P<.001).
According to study results, the 1-month survival rate was 5.4% in the epinephrine group vs. 4.7% in the non-epinephrine group. However, rate of survival with cerebral performance category 1 or 2 and overall performance category 1 or 2 was 1.4% in the epinephrine group when compared with 2.2% in the non-epinephrine group (all P<.001). Corresponding numbers were 5.1% and 1.3 in the propensity-matched epinephrine group vs. 7% and 3.1% in the propensity-matched non-epinephrine group, respectively.
Study results showed a positive association between prehospital epinephrine and return of spontaneous circulation before hospital arrival in both groups (adjusted OR=2.36; 95% CI, 2.22-2.5), as well as the propensity-matched group (adjusted OR=2.51; 95% CI, 2.24-2.8). However, negative associations were found between prehospital epinephrine and 1-month survival (adjusted OR=0.46; 95% CI, 0.42-0.51), cerebral performance category 1 or 2 (OR=0.31; 95% CI, 0.26-0.36) and overall performance category 1 or 2 (OR=0.32; 95% CI, 0.27-0.38) among all patients. This negative association with 1-month survival (OR=0.54; 95% CI, 0.43-0.68), cerebral performance category 1 or 2 (OR=0.21; 95% CI, 0.1-0.44) and overall performance category (OR=0.23; 95% CI, 0.11-0.45) was also observed among the propensity-matched patients.
Considerations for clinical practice
In an accompanying editorial, Clifton W. Callaway, MD, PhD, of the department of emergency medicine and pharmacology and the department of chemical biology at the University of Pittsburgh, wrote that these study results indicate that epinephrine may be more harmful than helpful to patients during cardiac arrest.
“Properly evaluating this traditional therapy now seems necessary and timely and should consist of a rigorously conducted and adequately powered clinical trial comparing epinephrine with placebo during cardiac arrest,” Callaway said. “While awaiting results of such a definitive trial, physicians and other practitioners involved in cardiac resuscitation must consider carefully whether continued use of epinephrine is justified.”
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Disclosure: The researchers report no relevant financial disclosures. Dr. Callaway received consulting fees or honoraria from Take Heart Austin, the Post Cardiac Arrest Symposium, the Sudden Cardiac Arrest Association and the Society for Critical Care Medicine, an equipment loan for laboratory studies from Medivance Inc. and royalties on patents related to defibrillation from Medtronic ERS.