[Which dosage concept for adrenaline is correct in cardiopulmonary resuscitation? A data analysis of preclinical resuscitations].
OBJECTIVE
Epinephrine is the drug of choice in cardiopulmonary resuscitation. Its dosage, however, is controversially discussed. The American Heart Association recommends for standard use in adults 1 mg epinephrine every 3-5 minutes, but classifies a medium dose, a high dose and a step-by-step escalating dosage concept as potentially useful alternatives. Aim of this study was to develop a rationale for the escalating dosage concept using an analysis of preclinical resuscitation data.


METHODS
Bonn city (141 km2, 310,000 residents, 52% female, 13.9% > 65 years) was served by a double-response system of two ALS-units (staffed by physicians) and four BLS-units (staffed by paramedics). All patients were included in this data analysis, which were cardiopulmonary resuscitated according to the AHA guidelines by the ALS-unit Bonn-North (66% of area and 240,000 residents) from 1989 to 1994. All relevant data were documented by the emergency physicians using preformed treatment sheets. Discharge rates were determined by reviewing the hospital records, and one-year survival data were collected by mail contact with the primary physicians. The correlations between duration of cardiac arrest, dosage of epinephrine and outcome were determined by regression analysis in patients older than 17 years suffering from unwitnessed and bystander-witnessed cardiac arrest. Statistical significance was assumed for p < 0.05.


RESULTS
Within 1989 to 1994 the ALS-team of Bonn-North resuscitated 685 cardiac arrest patients with presumed cardiac aetiology in 383 (56%) return of spontaneous circulation (ROSC) could be achieved. The epinephrine dosage required to achieve ROSC increased with prolongation of cardiac arrest interval (1989-1994; patients with ROSC selected, n = 263; r = 0.2276; p = 0.0002). Resuscitation success, however, decreased with increasing, dosage of epinephrine (1989-1992; n = 345; ROSC: r = -0.2643; p < 0.001; survival > 24 h: r = -0.3393; p < 0.001; discharge: r = -0.1677; p = 0.0018; survival > 1 year: r = -0.2685; p < 0.001).


CONCLUSIONS
Based on these data, we recommend an escalating epinephrine dosage concept, which facilitates titration of the drug to an effective level and meets the needs of the individual patient. This concept avoids overdosage in patients who had just collapsed shortly before initiation of CPR, attains higher levels of epinephrine in patients suffering from prolonged cardiac arrest, and takes into consideration that the effective epinephrine dose varies individually and increases with prolongation of the cardiac arrest interval.
Fischer
M
M
Klinik und Poliklinik für Anästhesiologie und Spezielle Intensivmedizin, Rheinische Friedrich-Wilhelms-Universität Bonn.
Fischer
N
N
Schüttler
J
J
D000293:Adolescent; D000328:Adult; D000368:Aged; D016887:Cardiopulmonary Resuscitation / Q000379:methods*; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D004632:Emergency Medical Services; D004837:Epinephrine / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D006323:Heart Arrest / Q000188:drug therapy* / Q000401:mortality; D006439:Hemodynamics / Q000187:drug effects; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D015996:Survival Rate; D016896:Treatment Outcome
D004837:Epinephrine
Welches Dosierungskonzept für Adrenalin ist bei kardiopulmonaler Reanimation das richtige? Eine Datenanalyse präklinischer Reanimationen.