UMEM Educational Pearls

Title: Extending the Epinephrine Dosing Interval in Cardiac Arrest

Category: Pharmacology & Therapeutics

Keywords: epinephrine, cardiac arrest (PubMed Search)

Posted: 2/25/2014 by Bryan Hayes, PharmD (Updated: 3/1/2014)
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Background

The ACLS recommendation for epinephrine dosing in most cardiac arrest cases is 1 mg every 3-5 minutes. This dosing interval is largely based on expert opinion.

Primary Outcome

A new study reviewed 21,000 in-hospital cardiac arrest (IHCA) cases from the Get With the Guidelines-Resuscitation registry. The authors sought to examine the association between epinephrine dosing period and survival to hospital discharge in adults with an IHCA.

Methods

Epinephrine average dosing period was defined as the time between the first epinephrine dose and the resuscitation endpoint, divided by the total number of epinephrine doses received subsequent to the first dose.

What they found

Compared to the recommended 3-5 minute dosing period, survival to hospital discharge was significantly higher in patients with more time between doses:

For 6 to <7 min/dose, adjusted OR, 1.41 (95%CI: 1.12, 1.78)
For 7 to <8 min/dose, adjusted OR, 1.30 (95%CI: 1.02, 1.65)
For 8 to <9 min/dose, adjusted OR, 1.79 (95%CI: 1.38, 2.32)
For 9 to<10 min/dose, adjusted OR, 2.17 (95%CI: 1.62, 2.92)

This pattern was consistent for both shockable and non-shockable cardiac arrest rhythms.

Application to Clinical Practice

This study only included in-hospital cardiac arrests.
The data was retrospectively reviewed from a registry of prospectively collected data.
This is certainly an interesting finding that needs to be explored further.
Given that epinephrine in cardiac arrest has never been proven to work (and may cause harm), it's not too suprising that giving less of a potentially harmful drug portends better outcomes.

References

Warren SA, et al. Adrenaline (epinephrine) dosing period and survival after in-hospital cardiac arrest: A retrospective review of prospectively collected data. Resuscitation 2014;85(3):350-8. [PMID 24252225]

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