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Epinephrine Use and Survival among OHCA Patients
Although epinephrine is often used in cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA), the effectiveness of epinephrine use before hospital arrival has not been established. For ethical reasons, a randomized, controlled evaluation of the effectiveness of epinephrine, which would control the effects of covariates, cannot be performed, and several studies addressing some aspects of this problem were inconsistent and did not establish the effectiveness of epinephrine use in CPR.
The investigators, from several organizations in Japan, wished to evaluate the association between epinephrine use before hospital arrival and short- and long-term mortality among patients with cardiac arrest. This study [JAMA. 2012;307(11):1161-1168] was a prospective, nonrandomized, observational propensity analysis of data from a sample of 417,088 OHCAs between 2005 and 2008 in Japan in which patients ≥18 years of age had an OHCA before the arrival of emergency medical services (EMS) personnel, received treatment from EMS personnel on the scene, and were subsequently taken to the hospital.
Main outcome measures were return of spontaneous circulation before hospital arrival, survival at 1 month after cardiac arrest, survival with good or moderate cerebral performance (Cerebral Performance Category [CPC] 1 or 2), and survival with no, mild, or moderate neurological disability (Overall Performance Category [OPC] 1 or 2).
Mean age of the OHCA patients was 72 years. Of these patients, 15,030 were given epinephrine before arrival at hospital, and 402,158 were not given epinephrine. The number of OHCA cases who received epinephrine increased over the study period from 190 in 2005 to 8124 in 2008, whereas the number of OHCA cases who did not receive epinephrine remained at the same level (P<.001).
Return of spontaneous circulation (ROSC) before hospital arrival was observed in 2786 of the patients (18.5%) in the epinephrine group and 23,042 of the patients (5.7%) in the group that did not receive epinephrine (P<.001). ROSC was observed in 2446 (18.3%) and 1400 (10.5%) of 13,401 propensity-matched patients, respectively (P<.001).
In the total sample, the numbers of patients with 1-month survival and survival with CPC 1 or 2 and OPC 1 or 2, respectively, were 805 (5.4%), 205 (1.4%), and 211 (1.4%) with epinephrine and 18,906 (4.7%), 8903 (2.2%), and 8831 (2.2%) without epinephrine (all P<.001). Corresponding numbers in propensity-matched patients were 687 (5.1%), 173 (1.3%), and 178 (1.3%) with epinephrine and 944 (7.0%), 413 (3.1%), and 410 (3.1%) without epinephrine (all P<.001).
In all patients, a positive association was observed between prehospital epinephrine and ROSC before hospital arrival (adjusted odds ratio [OR], 2.36; 95% confidence interval [CI], 2.22-2.50; P<.001). In propensity-matched patients, a positive association was also observed (adjusted OR, 2.51; 95% CI, 2.24-2.80; P<.001). In contrast, among all patients, negative associations were observed between prehospital epinephrine and long-term outcome measures (adjusted ORs: 1-month survival, 0.46 [95% CI, 0.42-0.51]; CPC 1-2, 0.31 [95% CI, 0.26-0.36]; and OPC 1-2, 0.32 [95% CI, 0.27-0.38]; all P<.001). Similar negative associations were observed among propensity-matched patients (adjusted ORs: 1-month survival, 0.54 [95% CI, 0.43-0.68]; CPC 1-2, 0.21 [95% CI, 0.10-0.44]; and OPC 1-2, 0.23 [95% CI, 0.11-0.45]; all P<.001).
The investigators said that their analysis showed that intravenous epinephrineadministration before hospital arrival was independently associated with increased chance of ROSC before hospital arrival but reduced survival and good functional outcome 1 month after the event.
