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  3. Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis
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Research

Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i1577 (Published 06 April 2016) Cite this as: BMJ 2016;353:i1577
  1. Lars W Andersen, research fellow1 2 3,
  2. Tobias Kurth, professor of public health and epidemiology4,
  3. Maureen Chase, assistant professor1,
  4. Katherine M Berg, instructor of medicine5,
  5. Michael N Cocchi, director of critical care quality1 6,
  6. Clifton Callaway, professor of emergency medicine7,
  7. Michael W Donnino, director of center for resuscitation science1 5
  8. for the American Heart Association’s Get With The Guidelines-Resuscitation Investigators
  1. 1Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Rosenberg Building, One Deaconess Road, Boston, MA 02215, USA
  2. 2Department of Anesthesiology, Aarhus University Hospital, Nørrebrogade 44, Bygn. 21, 1 Aarhus 8000, Denmark
  3. 3Research Center for Emergency Medicine, Aarhus University Hospital, Trøjborgvej 72-74, Bygn. 30, Aarhus 8200, Denmark
  4. 4Institute of Public Health, Charité – Universitätsmedizin Berlin, Seestrasse 73, Berlin D-13347, Germany
  5. 5Department of Medicine, Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
  6. 6Department of Anesthesia Critical Care, Division of Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
  7. 7Department of Emergency Medicine, 400A Iroquois, 3600 Forbes Avenue, Pittsburgh, PA 15260, USA
  1. Correspondence to: M Donnino, Beth Israel Deaconess Medical Center, One Deaconess Road, W/CC 2, Boston, MA 02215, USA mdonnino{at}bidmc.harvard.edu
  • Accepted 24 February 2016

Abstract

Objectives To evaluate whether patients who experience cardiac arrest in hospital receive epinephrine (adrenaline) within the two minutes after the first defibrillation (contrary to American Heart Association guidelines) and to evaluate the association between early administration of epinephrine and outcomes in this population.

Design Prospective observational cohort study.

Setting Analysis of data from the Get With The Guidelines-Resuscitation registry, which includes data from more than 300 hospitals in the United States.

Participants Adults in hospital who experienced cardiac arrest with an initial shockable rhythm, including patients who had a first defibrillation within two minutes of the cardiac arrest and who remained in a shockable rhythm after defibrillation.

Intervention Epinephrine given within two minutes after the first defibrillation.

Main outcome measures Survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and survival to hospital discharge with a good functional outcome. A propensity score was calculated for the receipt of epinephrine within two minutes after the first defibrillation, based on multiple characteristics of patients, events, and hospitals. Patients who received epinephrine at either zero, one, or two minutes after the first defibrillation were then matched on the propensity score with patients who were “at risk” of receiving epinephrine within the same minute but who did not receive it.

Results 2978patients were matched on the propensity score, and the groups were well balanced. 1510 (51%) patients received epinephrine within two minutes after the first defibrillation, which is contrary to current American Heart Association guidelines. Epinephrine given within the first two minutes after the first defibrillation was associated with decreased odds of survival in the propensity score matched analysis (odds ratio 0.70, 95% confidence interval 0.59 to 0.82; P<0.001). Early epinephrine administration was also associated with a decreased odds of return of spontaneous circulation (0.71, 0.60 to 0.83; P<0.001) and good functional outcome (0.69, 0.58 to 0.83; P<0.001).

Conclusion Half of patients with a persistent shockable rhythm received epinephrine within two minutes after the first defibrillation, contrary to current American Heart Association guidelines. The receipt of epinephrine within two minutes after the first defibrillation was associated with decreased odds of survival to hospital discharge as well as decreased odds of return of spontaneous circulation and survival to hospital discharge with a good functional outcome.

Footnotes

  • Get with the Guidelines-Resuscitation Investigators

    MWD, Paul S Chan (Saint Luke’s Mid America Heart Institute), Steven M Bradley (VA Eastern Colorado Healthcare System), Girotra Saket (University of Iowa Carver College of Medicine), Monique L Anderson (Duke Clinical Research Institute), Matthew M Churpek (University of Chicago), Ahamed H Idris (University of Texas Southwestern Medical Center), Dana P Edelson (University of Chicago), Robert T Faillace (Geisinger Healthcare System), Romergryko Geocadin (Johns Hopkins University School of Medicine), Raina Merchant (University of Pennsylvania School of Medicine), Vincent N Mosesso Jr (University of Pittsburgh School of Medicine), Joseph P Ornato and Mary Ann Peberdy (Virginia Commonwealth University), Sarah M Perman (University of Colorado, School of Medicine), Mindy Smyth (retired).

  • Contributors: LWA and MWD were responsible for study concept and design, acquisition of data, and drafting of the manuscript. LWA and TK performed the statistical analysis. All authors interpreted the data, critically revised the manuscript for important intellectual content and approved the final version for submission. All authors agree to be accountable for all aspects of the work. LWA and MWD are guarantors.

  • Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the submitted work; no financial relationships except as noted below with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. MWD is a paid consultant for the American Heart Association.

  • Ethical approval: All participating hospitals in the Get With The Guidelines-Resuscitation registry are required to comply with local regulatory guidelines. Because data are used primarily at the local site for quality improvement, sites are granted a waiver of informed consent under the common rule.

  • Transparency: The lead author affirms that this manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant) have been explained.

  • Data sharing: No additional data available.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/.

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