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PARAMEDIC2: Epinephrine increases rate of 30-day survival in cardiac arrest
Patients with out-of-hospital cardiac arrest treated with epinephrine were more likely to survive at 30 days compared with those treated with placebo, according to a study published in The New England Journal of Medicine.
Analysis of survival, neurologic outcome
Gavin D. Perkins, MD, professor of critical care medicine and director of the clinical trial unit at University of Warwick Medical School in the United Kingdom, and colleagues analyzed data from 8,014 patients with out-of-hospital cardiac arrest who were provided life support from five ambulance services in the United Kingdom. Patients were excluded if they were pregnant, had cardiac arrest from asthma or anaphylaxis, younger than 16 years or were administered epinephrine before paramedics arrived.
If initial attempts with defibrillation and CPR were unsuccessful, patients were assigned parenteral epinephrine (n = 4,015; mean age, 70 years; 65% men) or saline placebo (n = 3,999; mean age, 70 years; 65% men).
The primary outcome of interest was rate of survival at 30 days. Secondary outcomes of interest included lengths of stay in the hospital and ICU, rate of survival until hospital admission, neurologic outcomes at hospital discharge and at 3 months, and the rate of survival at hospital discharge and at 3 months.
At 30 days, 3.2% of the epinephrine group and 2.4% of the placebo group were alive (OR = 1.39; 95% CI, 1.06-1.82).
The rate of patients who survived until hospital discharge with a favorable neurologic outcome did not significantly differ between patients assigned epinephrine and those assigned placebo (2.2% vs. 1.9%, respectively; OR = 1.18; 95% CI, 0.86-1.61). More patients assigned epinephrine had severe neurologic impairment compared with the placebo group (31% vs. 17.8%).
‘Burdens of treatment are high’
“Clinical decision-making must balance the burdens and benefits of treatment,” Perkins and colleagues wrote. “The burdens of treatment are high in cardiac arrest, since resuscitation is an invasive procedure with substantial risks of complications. If resuscitation is initially successful, most patients require continuation of life-sustaining therapies in the ICU for several days.”
In a related editorial, Clifton W. Callaway, MD, PhD, tenured professor of emergency medicine, executive vice chair of emergency medicine and professor of emergency medicine research at University of Pittsburgh Medical Center, and Michael W. Donnino, MD, associate professor of medicine at Beth Israel Deaconess Medical Center, wrote: “Despite having a powerful effect on restoring spontaneous circulation after out-of-hospital cardiac arrest, epinephrine produced only a small absolute increase in survival with no increase in favorable functional recovery as compared with placebo. We now must ponder whether additional treatments after a return of spontaneous circulation could improve functional recovery, whether drug use should differ on the basis of cardiac rhythm and whether lower doses of epinephrine would be superior to higher doses among patients with out-of-hospital cardiac arrest.” – by Darlene Dobkowski
Disclosures: Perkins reports no relevant financial disclosures. Callaway reports he received nonfinancial support from the American Heart Association, personal fees from UpToDate and volunteers for the AHA. Donnino reports he volunteers for the AHA and is a vice chair of an AHA writing group. Please see the study for all other authors’ relevant financial disclosures.