Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest

Akihito Hagihara, Manabu Hasegawa, Takeru Abe, Takashi Nagata, Yoshifumi Wakata, Shogo Miyazaki
JAMA: the Journal of the American Medical Association 2012 March 21, 307 (11): 1161-8

CONTEXT: Epinephrine is widely used in cardiopulmonary resuscitation for out-of-hospital cardiac arrest (OHCA). However, the effectiveness of epinephrine use before hospital arrival has not been established.

OBJECTIVE: To evaluate the association between epinephrine use before hospital arrival and short- and long-term mortality in patients with cardiac arrest.

DESIGN, SETTING, AND PARTICIPANTS: Prospective, nonrandomized, observational propensity analysis of data from 417 188 OHCAs occurring in 2005-2008 in Japan in which patients aged 18 years or older had an OHCA before arrival of emergency medical service (EMS) personnel, were treated by EMS personnel, and were transported to the hospital.

MAIN OUTCOME MEASURES: 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).

RESULTS: Return of spontaneous circulation before hospital arrival was observed in 2786 of 15,030 patients (18.5%) in the epinephrine group and 23,042 of 402,158 patients (5.7%) in the no-epinephrine group (P < .001); it 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 return of spontaneous circulation before hospital arrival (adjusted odds ratio [OR], 2.36; 95% 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).

CONCLUSION: Among patients with OHCA in Japan, use of prehospital epinephrine was significantly associated with increased chance of return of spontaneous circulation before hospital arrival but decreased chance of survival and good functional outcomes 1 month after the event.

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