Beyond ACLS: Is It Time to Abandon Epinephrine in Out-Of-Hospital Cardiac Arrest?

11 Mar
March 11, 2015

epinephrineEpinephrine is widely used and recommended by Advanced Cardiovascular Life Support (ACLS) in out-of-hospital cardiac arrest (OHCA), but its effectiveness in neurologic outcomes has never been truly established.  To verify effectiveness of epinephrine confounders, such as patients, CPR quality, CPR by bystanders, time from call to arrival at scene or hospital, and much much more, must be controlled for in a trial. This type of study is not easily performed due to ACLS being the current standard of care.

What Studies Have Evaluated the Effectiveness of Epinephrine in Out-Of-Hospital Cardiac Arrest?

  1. Holmberg M et al. Resus 2002 (12104107) : Use of epinephrine in OHCA was an independent predictor of increased mortality.
  2. Ong MEH et al. Ann Emerg Med 2007 (17509730) : Use of epinephrine in OHCA was not associated with mortality benefit.
  3. Olasveengen TM et al. JAMA 2009 (19934423) : Use of epinephrine in OHCA was associated with increased Return of Spontaneous Circulation (ROSC) but was not associated with mortality benefit.
  4. Jacobs IG et al. Resus 2011 (21745533) : Use of epinephrine in OHCA was associated with increased Return of Spontaneous Circulation (ROSC) but was not associated with mortality benefit.

Is There a Larger Study Looking at the Use of Epinephrine in OHCA? (22436956)

What did they do:

  • Prospective, Non-Randomized, Observational Propensity Analysis
  • 417,188 OHCA Cases in Japan

Outcomes:

  • ROSC
  • 1 Month Survival
  • Survival with Good or Moderate Cerebral Performance Category (CPC) 1 or 2
  • Survival with No, Mild, or Moderate Neurologic Disability (Overall Performance Category = OPC) 1 or 2

Results:

Epinephrine in OHCA (Non-Propensity Matched)

OutcomesEpinephrineNo Epinephrine
ROSC18.5%5.7%
1 Month Survival5.4%4.7%
CPC 1 or 21.4%2.2%
OPC 1 or 21.4%2.2%

Epinephrine in OHCA (Propensity Matched)

OutcomesEpinephrineNo Epinephrine
ROSC18.3%10.5%
1 Month Survival5.1%7.0%
CPC 1 or 21.3%3.1%
OPC 1 or 21.3%3.1%

Screen Shot 2015-03-10 at 10.48.38 PM

Limitations:

  • This was an observational study.  In other words use of epinephrine was not randomized which can cause a selection bias of what patients got epinephrine and which ones didn’t
  • Data on in-hospital CPR quality was not included in this study and could be a confounding factor into neurologic outcome and survival not taken into account.
  • There is no standard regimen for OHCA once the patients made it to the hospital (i.e. Induced therapeutic hypothermia, cardiac catheterization, and/or use of vasopressin)
  • The number of epinephrine doses received once in the hospital were not recorded

Conclusion of Study: In Japan, the use of epinephrine in OHCA increases the chance of ROSC, but does not increase survival with good neurologic outcomes at one month.

What is considered a “good” Cerebral Performance Category (CPC)?

Cerebral Performance Category (CPC)

A “good” outcome would be the ability to perform basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring or a CPC score of 2 or less.

wp-bottom-line-banner-copy1

Clinical Bottom Line: ACLS is still the standard care in OHCA, which means we still give epinephrine, but the ACLS algorithm should be readdressed and our focus should instead focus on high quality, uninterrupted CPR and early defibrillation.

Screen Shot 2015-02-27 at 4.49.35 PM

Bibliography

The following two tabs change content below.

Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of R.E.B.E.L. EM
Tags: , , ,
7 replies
  1. John Wood says:

    Hi

    Are you aware of the Paramedic2 trial trying to answer this question in the UK?
    http://www2.warwick.ac.uk/fac/med/research/hscience/ctu/trials/critical/paramedic2/
    Hopefully it will generate some useful evidence.

    Best wishes

    John

    Reply
    • Salim Rezaie says:

      Hello John,
      Yes I have heard of the PARAMEDIC2 Trial and anxiously awaiting the results. The Japanese study above is over 400,000 patients with OHCA and although not a true RCT, its hard to ignore the results. I am interested to see what this new study shows. Appreciate you reading and the link.

      Salim

      Reply
  2. Jeff Poland says:

    Good article, but it goes even deeper than that. Decreases in neuro outcomes are prevalent and associated with epinephrine administration, and there is validity to that in the form of basic science – Take a look at Ristagno’s 2009 paper in Critical Care Medicine – http://journals.lww.com/ccmjournal/Abstract/2009/04000/Epinephrine_reduces_cerebral_perfusion_during.34.aspx.

    He even did a handy head-to-head, so to speak, comparison of equipressor doses of epinephrine and vasopressin. http://journals.lww.com/ccmjournal/Abstract/2007/09000/Effects_of_epinephrine_and_vasopressin_on_cerebral.19.aspx

    Reply
    • Salim Rezaie says:

      Hey Jeff,
      100% agree…can’t wait for the Paramedic 2 trial to get published which is going to randomize to epi vs no epi…appreciate u reading and leaving the links for others to look at.
      Salim

      Reply

Trackbacks & Pingbacks

  1. […] without a very lengthy explanation. Epinephrine in cardiac arrest was already covered on REBEL EM (Is It Time to Abandon Epinephrine in Out-Of-Hospital Cardiac Arrest?). I will often  hang an epi drip at 0.5 mcg/kg/min instead of having team members distracted by […]

  2. […] the state of evidence for the use of epinephrine in out-of-hospital cardiac arrest? REBEL EM reviews the literature. […]

  3. […] I wrote a post on the use of epinephrine in out-of-hospital cardiac arrest (OHCA) and this triggered some interesting discussion on twitter. Are we at a point that we can just stop […]

Leave a Reply

Want to join the discussion?
Feel free to contribute!

Leave a Reply

Your email address will not be published. Required fields are marked *

Time limit is exhausted. Please reload CAPTCHA.

Optimization WordPress Plugins & Solutions by W3 EDGE