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Epinephrine administration in non-shockable out-of-hospital cardiac arrest

  • R. Jouffroy
    Correspondence
    Corresponding author.
    Affiliations
    Department of Anesthesia & Critical Care – SAMU, Assistance Publique - Hôpitaux de Paris, Hôpital Necker - Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris, France
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  • A. Saade
    Affiliations
    Department of Anesthesia & Critical Care – SAMU, Assistance Publique - Hôpitaux de Paris, Hôpital Necker - Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris, France
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  • P. Alexandre
    Affiliations
    Department of Anesthesia & Critical Care – SAMU, Assistance Publique - Hôpitaux de Paris, Hôpital Necker - Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris, France
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  • P. Philippe
    Affiliations
    Department of Anesthesia & Critical Care – SAMU, Assistance Publique - Hôpitaux de Paris, Hôpital Necker - Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris, France
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  • P. Carli
    Affiliations
    Department of Anesthesia & Critical Care – SAMU, Assistance Publique - Hôpitaux de Paris, Hôpital Necker - Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris, France
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  • B. Vivien
    Affiliations
    Department of Anesthesia & Critical Care – SAMU, Assistance Publique - Hôpitaux de Paris, Hôpital Necker - Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris, France
    Search for articles by this author

      Abstract

      Background

      Epinephrine is recommended for the treatment of non-shockable out of hospital cardiac arrest (OHCA) to obtain return of spontaneous circulation (ROSC). Epinephrine efficiency and safety remain under debate.

      Objective

      We propose to describe the association between the cumulative dose of epinephrine and the failure of ROSC during the first 30 min of advanced life support (ALS).

      Methodology

      A retrospective observational cohort study using the Paris SAMU 75 registry including all non-traumatic OHCA. All OHCA receiving epinephrine during the first 30 min of ALS were enrolled. Cumulative epinephrine dose given during ALS to ROSC was retrieved from medical reports.

      Results

      Among 1532 patients with OHCA, 776 (51%) had initial non-shockable rhythm. Fifty-four patients were excluded for missing data.
      The mean value of cumulative dose of epinephrine was 10 ± 4 mg in patients who failed to achieve ROSC (ROSC−) and 4 ± 3 mg (p = 0.04) for those who achieved ROSC.
      ROC curve analysis indicated a cut-off point of 7 mg total cumulative epinephrine associated with ROSC− (AUC = 0.89 [0.86–0.92]).
      Using propensity score analysis including age, sex and no-flow duration, association with ROSC− only remained significant for epinephrine > 7 mg (p ≤10–3, OR [CI95] = 1.53 [1.42–1.65]).

      Conclusion

      An association between total cumulative epinephrine dose administered during OHCA resuscitation and ROSC− was reported with a threshold of 7 mg, best identifying patients with refractory OHCA. We suggest using this threshold in this context to guide the termination of ALS and early decide on the implementation of extracorporeal life support or organ harvesting in the first 30 min of ALS.
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