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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.
Highlights
Few clinical trials have provided evidence that epinephrine administration after out-of-hospital cardiac arrest (OHCA) improves long-term survival
Initial shockable rhythm was an independent contributing factor in both survival and Cerebral Performance Categories (CPC) score of 1 or 2 at one month after OHCA with the highest adjusted Odds ratio (OR) among variables
Prehospital epinephrine administration for OHCA patients with initial nonshockable rhythms was independently associated with achievement of pre-hospital return to spontaneous circulation (ROSC) and was associated with improved onemonth survival when epinephrine administration time was less than 20 minutes
Summary
Few clinical trials have provided evidence that epinephrine administration after out-of-hospital cardiac arrest (OHCA) improves long-term survival. We determined whether prehospital epinephrine administration would improve 1-month survival in OHCA patients. Epinephrine has been a cornerstone of cardiac resuscitation therapy and advanced cardiac life support since the 1960s [9]. The most recent advanced life support guidelines for the treatment of cardiac arrest due to ventricular fibrillation (VF) recommend the administration of either epinephrine or vasopressin as the first drug after defibrillation [13]. There is little evidence from clinical trials that epinephrine administration after OHCA improves long-term survival [6,14,15]. Increased myocardial dysfunction [16,17] and disturbed cerebral microcirculation [18] after epinephrine administration may contribute importantly to the poor long-term outcomes
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