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Esmolol does not affect circulation negatively during resuscitation

      Survival from out-of-hospital cardiac arrest increased from 7.9% to 12.0% between 2010 and 2016 [
      • Lloyd-Jones D.
      • et al.
      Heart disease and stroke statistics–2010 update: a report from the American Heart Association.
      ,
      • Mozaffarian D.
      • et al.
      Executive summary: heart disease and stroke statistics–2016 update: a report from the American heart association.
      ]. The explanation is likely multifactorial, although uniform guidelines have been shown to improve survival independently [
      • Sayre M.R.
      • et al.
      Impact of the 2005 American Heart Association cardiopulmonary resuscitation and emergency cardiovascular care guidelines on out-of-hospital cardiac arrest survival.
      ]. The 2015 International Liaison Committee on Resuscitation guidelines recommend administration of epinephrine during cardiac arrest [
      • Soar J.
      • et al.
      European resuscitation council guidelines for resuscitation 2015: section 3. Adult advanced life support.
      ] because of an increased rate of return of spontaneous circulation (ROSC) [
      • Jacobs I.G.
      • et al.
      Effect of adrenaline on survival in out-of-hospital cardiac arrest: a randomised double-blind placebo-controlled trial.
      ]. The increased rate of ROSC has been linked to the α receptor agonistic effect epinephrine [
      • Otto C.W.
      • Yakaitis R.W.
      • Blitt C.D.
      Mechanism of action of epinephrine in resuscitation from asphyxial arrest.
      ]. However, despite the increased rate of ROSC, no effect on survival is seen at hospital discharge [
      • Jacobs I.G.
      • et al.
      Effect of adrenaline on survival in out-of-hospital cardiac arrest: a randomised double-blind placebo-controlled trial.
      ]. The lack of long-term effect with epinephrine administration is thought to be mediated by post-ROSC myocardial dysfunction [
      • Tang W.
      • et al.
      Epinephrine increases the severity of postresuscitation myocardial dysfunction.
      ] secondary to ischemia [
      • Krause S.M.
      • Jacobus W.E.
      • Becker L.C.
      Alterations in cardiac sarcoplasmic reticulum calcium transport in the postischemic "stunned" myocardium.
      ]. Ischemia may result from an increase in myocardial oxygen demand induced by epinephrine's β1 receptor stimulation [
      • Ditchey R.V.
      • Lindenfeld J.
      Failure of epinephrine to improve the balance between myocardial oxygen supply and demand during closed-chest resuscitation in dogs.
      ].

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