Route Of Epinephrine Administration Research Articles

Intracoronary epinephrine during cardiac resuscitation for patients undergoing percutaneous coronary intervention for acute myocardial infarction (iCPR study)

Abstract Background Despite significant progress in cardiopulmonary resuscitation (CPR), outcomes remain relatively poor. Epinephrine administration remains a cornerstone in the treatment of in-hospital cardiac arrest. Various routes of administration, including intravenous, intramuscular, intraosseous and endotracheal routes have been studied; however, the optimal route is debated. Purpose The purpose of this study was to compare patient outcomes following peripheral intravenous (IV), central IV, or arterial intracoronary (IC) epinephrine administration in patients undergoing CPR in the catheterization laboratory. Methods This was a prospective two-center pilot cohort study conducted in high-volume percutaneous coronary intervention (PCI) facilities in the republic of Lithuania. The study enrolled patients with acute myocardial infarction (AMI) who suffered a cardiac arrest in the cardiac catheterization laboratory during PCI. Cardiac resuscitation was performed according to the European Resuscitation Council Guidelines. Central IV was the first choice for epinephrine administration if it was available. However, in cases without central access, the route of epinephrine administration (peripheral IV or arterial IC) was at the discretion of the physician. The primary endpoint was the rate of return of spontaneous circulation (ROSC). We tested for overall differences in patient characteristics and outcomes between groups using Chi-Square (or Kruskal-Wallis) tests and used the Holm-Bonferroni adjustment (or Dunn's tests) for subsequent pairwise tests. We also performed logistic regression. Results There were 158 participants in this study, with 48 (30.4%), 50 (31.6%), and 60 (38.0%) receiving epinephrine via central IV, IC, and peripheral IV routes, respectively. The median age was 71 [61, 80] years and 56% of participants were men. Patient characteristics were similar across routes, except for age (higher for peripheral IV than IC), serum potassium (although no significant post-hoc differences), hemoglobin (lowest in peripheral route), and heart rhythm before CPR (higher rates of electromechanical dissociation in peripheral route). There were 111 (70%) patients who achieved the primary outcome of ROSC (Table 1). Peripheral IV administration was associated with 7-fold decreased odds of achieving ROSC (odds ratio = 0.14, 95% confidence interval = 0.05–0.36, p<0.0001) compared to central IV (no difference between central IV and IC; p=0.9343). By itself, adrenaline route yielded an area under the receiver operating characteristic curve of 0.73, indicating good predictive ability. Conclusion Epinephrine administration route was a significant predictor of ROSC for patients with AMI undergoing CPR in the catheterization laboratory. ROSC rates for patients who received epinephrine via IC or central IV were superior to those who received it via peripheral IV. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Baylor Health Care System Foundation (USA)National Interventional Cardiology Association (Lithuania)

Physicians Working At Different Clinical Settings: Can They Recognize and Manage Anaphylaxis?

Anaphylaxis is defined as a severe hypersensitivity reaction that can cause sudden onset and death. Therefore, it is vital that the diagnosis is made and the timely administration of epinephrine. In this study, it was aimed to determine the knowledge and attitudes of the physicians in Edirne city center regarding the diagnosis and treatment of anaphylaxis. The study was designed as cross sectional survey. Physicians were visited in their institutions. A written questionnaire was applied face-to-face and it included questions about diagnosis and management of anaphylaxis. A total of 347 physician agreed to participate in the study. 43.5% of the physicians did not read any literature, book chapters or guidelines about the diagnosis criteria. Only 16.7% of responders knew all sign and symptoms of anaphylaxis. Twenty eight percent of physicians knew that correct route and dose of epinephrine administration. Associated factors with the knowledge about correct dose and route of epinephrine administration were the number of encounters with anaphylaxis cases and presence of treatment scheme in the instutition; OR (95% CI) were 3.520 (1.879-6.593) and 1.961 (1.168-3.290) respectively. 45.5% of the responders knew that there are no absolute contraindications to administer epinephrine in the case of anaphylactic shock. The study revealed that, knowledge of physicians relating diagnosis, treatment and management of anaphylaxis is unsatisfactory in our city. We think that it would be beneficial to provide physicians with in-service training regarding the diagnosis and management of anaphylaxis.

The effect of high-dose intramuscular epinephrine on the recovery of spontaneous circulation in an asphyxia\u2010induced cardiac arrest rat model

BackgroundObtaining vascular access can be challenging during resuscitation following cardiac arrest, and it is particularly difficult and time-consuming in paediatric patients. We aimed to compare the efficacy of high-dose intramuscular (IM) versus intravascular (IV) epinephrine administration with regard to the return of spontaneous circulation (ROSC) in an asphyxia-induced cardiac arrest rat model.Methods Forty-five male Sprague-Dawley rats were used for these experiments. Cardiac arrest was induced by asphyxia, and defined as a decline in mean arterial pressure (MAP) to 20 mmHg. After asphyxia-induced cardiac arrest, the rats were randomly allocated into one of 3 groups (control saline group, IV epinephrine group, and IM epinephrine group). After 540 s of cardiac arrest, cardiopulmonary resuscitation was performed, and IV saline (0.01 cc/kg), IV (0.01 mg/kg, 1:100,000) epinephrine or IM (0.05 mg/kg, 1:100,000) epinephrine was administered. ROSC was defined as the achievement of an MAP above 40 mmHg for more than 1 minute. Rates of ROSC, haemodynamics, and arterial blood gas analysis were serially observed.ResultsThe ROSC rate (61.5%) of the IM epinephrine group was less than that in the IV epinephrine group (100%) but was higher than that of the control saline group (15.4%) (log-rank test). There were no differences in MAP between the two groups, but HR in the IM epinephrine group (beta coefficient = 1.02) decreased to a lesser extent than that in the IV epinephrine group with time.ConclusionsIM epinephrine induced better ROSC rates compared to the control saline group in asphyxia-induced cardiac arrest, but not compared to IV epinephrine. The IM route of epinephrine administration may be a promising option in an asphyxia-induced cardiac arrest.

Abstract 126: Intravenous Versus Intraosseous Epinephrine Administration for Pediatric Patients with Out-of-hospital Cardiac Arrest

Introduction: The 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation recommend intravenous (IV) or intraosseous (IO) epinephrine administration for pediatric patients with out-of-hospital cardiac arrest (OHCA). However, it is unknown whether the route of epinephrine administration affects patient outcomes. Our objective was to evaluate the association between the route of epinephrine administration and survival. Methods: We conducted a secondary analysis of the Resuscitation Outcomes Consortium Epistry, a prospective multicenter OHCA registry from 2011 through 2015 in North America. We included pediatric patients (≤18 years) with OHCA for whom emergency medical services (EMS) providers attempted resuscitation and administered epinephrine via IV or IO. We excluded patients who received endotracheal epinephrine, received both IV and IO epinephrine, received IV epinephrine with failed IO access, and received IO epinephrine with failed IV access. The primary outcome was survival to hospital discharge. We used multivariable logistic regression and adjusted for age, sex, initial rhythm, location of arrest, witness status, receiving layperson cardiopulmonary resuscitation, 9-1-1 call to EMS arrival, and advanced airway management. We also conducted a propensity score matching analysis with the same covariates. Results: Of the eligible 831 pediatric patients with OHCA, 226 (27.2%) received IV epinephrine and 605 (72.8%) IO epinephrine. Median interval between 9-1-1 call and epinephrine administration was 16.4 minutes (interquartile range [IQR] 12.9-21.0) in IV group and 16.2 minutes (IQR 12.8-20.0) in IO group. In the logistic regression model, the adjusted odds ratio (OR) of the IO group for survival to hospital discharge was 0.99 (95% confidence interval [CI] 0.41-2.40), compared with the IV group. Similarly, in the propensity score analysis, 218 patients underwent matching with good balance (standardized differences <0.25 for all covariates) and the OR of the IO group for survival to hospital discharge was 1.00 (95% CI 0.38-2.62). Conclusions: We observed no significant difference in survival to hospital between pediatric patients with OHCA who received epinephrine via IV and IO routes.

Medical knowledge on managing anaphylaxis in northeastern brazil

Results No pharmacological actions, pharmacological measures, and knowledge of biphasic anaphylaxis reaction were approached. As non-pharmacological measures, maintenance of respiratory tract was cited by 48 physicians, whereas attention to hydration, intravenous access and patient positioning were cited by 12 doctors. As pharmacological measure, adrenaline was mentioned in 48 questionnaires as the primary drug, nine physicians reported corticosteroids as primary drug and three physicians cited antihistamine. As a route of epinephrine administration, they were mentioned: subcutaneous (39,6%), intravenous (22,9%), intramuscular (29,2%) and 8,3% did not know. About the local administration of epinephrine: 70,8% did not answer, 10,4% cited the forearm, 6,3% cited the abdomen and 12,5% cited the thigh. About patients with beta-blockers and refractory to treat anaphylaxis, an indication of glucagon to control framework was cited by four doctors. Approximately 83% of respondents were unaware of the biphasic reaction of anaphylaxis and 16% mentioned that meet only 12% described it correctly.

Epinephrine in Anaphylaxis: Higher Risk of Cardiovascular Complications and Overdose After Administration of Intravenous Bolus Epinephrine Compared with Intramuscular Epinephrine

Epinephrine is the drug of choice for the management of anaphylaxis, and fatal anaphylaxis is associated with delayed epinephrine administration. Data on adverse cardiovascular (CV) complications and epinephrine overdose are limited. To compare rates of CV adverse events and epinephrine overdoses associated with anaphylaxis management between various routes of epinephrine administration among patients with anaphylaxis in the emergency department. This was an observational cohort study from April 2008 to July 2012. Patients in the emergency department who met diagnostic criteria for anaphylaxis were included. We collected demographics; route of epinephrine administration; trigger; overdose; and adverse CV events, including arrhythmia, cardiac ischemia, stroke, angina, and hypertension. The study cohort included 573 patients, of whom, 301 (57.6%) received at least 1 dose of epinephrine. A total of 362 doses of epinephrine were administered to 301 patients: 67.7% intramuscular (IM) autoinjector, 19.6% IM injection, 8.3% subcutaneous injection, 3.3% intravenous (IV) bolus, and 1.1% IV continuous infusion. There were 8 CV adverse events and 4 overdoses with 8 different patients. All the overdoses occurred when epinephrine was administered IV bolus. Adverse CV events were associated with 3 of 30 doses of IV bolus epinephrine compared with 4 of 316 doses of IM epinephrine (10% vs 1.3%; odds ratio 8.7 [95% CI, 1.8-40.7], P = .006). Similarly, overdose occurred with 4 of 30 doses of IV bolus epinephrine compared with 0 of 316 doses of IM epinephrine (13.3% vs 0%; odds ratio 61.3 [95% CI, 7.5 to infinity], P < .001). The risk of overdose and adverse CV events is significantly higher with IV bolus epinephrine administration. Analysis of the data supports the safety of IM epinephrine and a need for extreme caution and further education about IV bolus epinephrine in anaphylaxis.

Do epinephrine auto-injectors have an unsuitable needle length for young children?

Background Epinephrine delivered by an auto-injector to the anterolateral aspect of the thigh is the standard of care for the emergency treatment of anaphylaxis. For most pediatric patients in Canada, the EpipenJr is prescribed, which has a needle length of 12.7mm. The route of epinephrine administration affects its onset of action, and intramuscular delivery is recommended for rapid absorption. If epinephrine is injected subcutaneously, the absorption will be slower. Conversely, if it is injected into the bone, the absorption will be unpredictable. There are no published clinical studies assessing whether the needle length of the EpipenJr is adequate to deliver epinephrine intramuscularly in pediatric patients at risk of anaphylaxis.

Level of knowledge about anaphylaxis among health care providers

Level of knowledge about anaphylaxis was evaluated in health care providers by using a self-administered questionnaire. A total of 1172 participants responded to the survey, and previously half of them had met a case with anaphylaxis with a highest rate in primary and a lowest rate in tertiary care (p= 0.005). 84.7% of participants answered the questions about the symptoms of anaphylaxis correctly. Although 62.6% of the group knew correctly anaphylaxis treatment steps, 44.7% of them agreed to administer epinephrine if they suspected of a subject with anaphylaxis. One third of the group indicated appropriate route of epinephrine administration. 85.2% of participants agreed to refer the patient to allergy clinic despite 33.7% of the group were unaware of where the nearest allergy clinic was. Only 20.3% of the respondents have heard about epinephrine auto-injector. Anaphylaxis was often diagnosed and managed inadequately, regardless of practice location, employment status and speciality in north-eastern Turkey.

Comparison of standard versus high-dose epinephrine in the resuscitation of cardiac arrest in dogs

A prospective, randomized, blinded study was conducted to evaluate the efficacy of standard compared with high-dose epinephrine in cardiac arrest in dogs. Twenty-five mongrel dogs were anesthetized and monitored by central venous catheter, intra-arterial catheter, and ECG. A left lateral thoracotomy was performed, and the proximal left anterior descending artery was ligated. After ten minutes of myocardial ischemia, ventricular fibrillation was obtained by application of 6-V AC. Mechanical ventilation was stopped. Total arrest time was ten minutes. All animals were randomized into one of five resuscitation protocols; each protocol was identical except for the dose and route of epinephrine administration. Group 1 animals comprised the control group and received normal saline. Group 2 and 3 animals received epinephrine in doses of 0.014 mg/kg by central venous and intracardiac injection, respectively. Group 4 and 5 animals received epinephrine in doses of 0.071 mg/kg by central venous and intracardiac injection, respectively. None of the dogs receiving normal saline had a return of spontaneous circulation, defined as a spontaneous systolic blood pressure of more than 50 mm Hg. Nine of the ten animals from groups 2 and 3 and all of the ten animals from groups 4 and 5 had a return of spontaneous circulation. However, animals receiving the standard dose of epinephrine had a significantly longer resuscitation time compared with the high-dose group (P = .05) and required more doses of epinephrine for successful resuscitation than did animals receiving high doses (P less than .02).(ABSTRACT TRUNCATED AT 250 WORDS)