Effects of prehospital epinephrine during out-of-hospital cardiac arrest with initial non-shockable rhythm: an observational cohort study

Abstract

IntroductionFew clinical trials have provided evidence that epinephrine administration after out-of-hospital cardiac arrest (OHCA) improves long-term survival. Here we determined whether prehospital epinephrine administration would improve 1-month survival in OHCA patients.MethodsWe analyzed the data of 209,577 OHCA patients; the data were prospectively collected in a nationwide Utstein-style Japanese database between 2009 and 2010. Patients were divided into the initial shockable rhythm (n = 15,492) and initial non-shockable rhythm (n = 194,085) cohorts. The endpoints were prehospital return of spontaneous circulation (ROSC), 1-month survival, and 1-month favorable neurological outcomes (cerebral performance category scale, category 1 or 2) after OHCA. We defined epinephrine administration time as the time from the start of cardiopulmonary resuscitation (CPR) by emergency medical services personnel to the first epinephrine administration.ResultsIn the initial shockable rhythm cohort, the ratios of prehospital ROSC, 1-month survival, and 1-month favorable neurological outcomes in the non-epinephrine group were significantly higher than those in the epinephrine group (27.7% vs. 22.8%, 27.0% vs. 15.4%, and 18.6% vs. 7.0%, respectively; all P < 0.001). However, in the initial non-shockable rhythm cohort, the ratios of prehospital ROSC and 1-month survival in the epinephrine group were significantly higher than those in the non-epinephrine group (18.7% vs. 3.0% and 3.9% vs. 2.2%, respectively; all P < 0.001) and there was no significant difference between the epinephrine and non-epinephrine groups for 1-month favorable neurological outcomes (P = 0.62). Prehospital epinephrine administration for OHCA patients with initial non-shockable rhythms was independently associated with prehospital ROSC (adjusted odds ratio [aOR], 8.83, 6.18, 4.32; 95% confidence interval [CI], 8.01-9.73, 5.82-6.56, 3.98-4.69; for epinephrine administration times ≤9 min, 10-19 min, and ≥20 min, respectively), with improved 1-month survival when epinephrine administration time was <20 min (aOR, 1.78, 1.29; 95% CI, 1.50-2.10, 1.17-1.43; for epinephrine administration times ≤9 min and 10-19 min, respectively), and with deteriorated 1-month favorable neurological outcomes (aOR, 0.63, 0.49; 95% CI, 0.48-0.80, 0.32-0.71; for epinephrine administration times 10-19 min and ≥20 min, respectively).ConclusionsPrehospital epinephrine administration for OHCA patients with initial nonshockable rhythms was independently associated with achievement of prehospital ROSC and had association with improved 1-month survival when epinephrine administration time was <20 min.

Part 4: Advanced Life Support

“…Goto 131 showed no significant difference in 1-month survival for shockable rhythms, but improved 1-month survival for shockable rhythms with epinephrine at less than 9 minutes (OR, 0.95; 95% CI, 0.77-1. 16 and OR, 1.78; 95% CI, 1.5-2.1).…”

“…Another study 131 showed an association with improved ROSC for epinephrine given at less than 9 minutes after arrest versus none (for nonshockable rhythms: OR, 8.83; 95% CI, 8.01-9.73; for shockable rhythms: OR, 1.45; 95% CI, 1.20-1.75). A third study 134 showed an association with improved ROSC for early epinephrine versus late (more or less than 10 minutes after EMS call): OR, 1.78 (95% CI, 1.15-2.74).…”

“…For the critical outcome of neurologically favorable survival at hospital discharge (assessed with CPC 1 or 2), there was very-low-quality evidence (downgraded for risk of bias, inconsistency, indirectness, and imprecision) from 4 observational studies [130][131][132][133] involving more than 262 556 OHCAs, showing variable benefit from early administration of epinephrine. One study of 1556 OHCAs who had achieved ROSC 130 demonstrated an association between the administration of epinephrine and worse CPC, but shorter times of administration were associated with less negative effects: adjusted OR of 0.54 (95% CI, 0.32-0.91) for good CPC with epinephrine at less than 9 minutes versus no prehospital epinephrine, and adjusted OR of 0.17 (95% CI, 0.09-0.34) for epinephrine at more than 22 minutes.…”

“…For the important outcome of ROSC, there was very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 4 observational studies 127,131,134,135 of more than 210 000 OHCAs showing an association with improved outcome and early administration of adrenaline. One study 135 showed increased ROSC for patients receiving the first vasopressor dose early (less than 10 versus more than 10 minutes after EMS call): OR, 1.91 (95% CI, 1.01-3.63).…”

“…Another study enrolling 3161 subjects 132 showed an association with improved 1-month neurologic outcome in VF/pVT OHCA with early epinephrine (at 10 minutes or less from EMS call to administration) compared with no S104 Circulation For the critical outcome of survival to hospital discharge after OHCA, there was very-low-quality evidence (downgraded for risk of bias, inconsistency, indirectness, and imprecision), from 4 observational studies 127,131,133,134 enrolling more than 420 000 OHCAs that showed variable effect from early administration of adrenaline. Goto 131 showed no significant difference in 1-month survival for shockable rhythms, but improved 1-month survival for shockable rhythms with epinephrine at less than 9 minutes (OR, 0.95; 95% CI, 0.77-1.…”