Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry.
OBJECTIVE
To determine if earlier administration of epinephrine (adrenaline) in patients with non-shockable cardiac arrest rhythms is associated with increased return of spontaneous circulation, survival, and neurologically intact survival.


METHODS
Post hoc analysis of prospectively collected data in a large multicenter registry of in-hospital cardiac arrests (Get With The Guidelines-Resuscitation).


METHODS
We utilized the Get With The Guidelines-Resuscitation database (formerly National Registry of Cardiopulmonary Resuscitation, NRCPR). The database is sponsored by the American Heart Association (AHA) and contains prospective data from 570 American hospitals collected from 1 January 2000 to 19 November 2009.


METHODS
119,978 adults from 570 hospitals who had a cardiac arrest in hospital with asystole (55%) or pulseless electrical activity (45%) as the initial rhythm. Of these, 83,490 arrests were excluded because they took place in the emergency department, intensive care unit, or surgical or other specialty unit, 10,775 patients were excluded because of missing or incomplete data, 524 patients were excluded because they had a repeat cardiac arrest, and 85 patients were excluded as they received vasopressin before the first dose of epinephrine. The main study population therefore comprised 25,095 patients. The mean age was 72, and 57% were men.


METHODS
The primary outcome was survival to hospital discharge. Secondary outcomes included sustained return of spontaneous circulation, 24 hour survival, and survival with favorable neurologic status at hospital discharge.


RESULTS
25,095 adults had in-hospital cardiac arrest with non-shockable rhythms. Median time to administration of the first dose of epinephrine was 3 minutes (interquartile range 1-5 minutes). There was a stepwise decrease in survival with increasing interval of time to epinephrine (analyzed by three minute intervals): adjusted odds ratio 1.0 for 1-3 minutes (reference group); 0.91 (95% confidence interval 0.82 to 1.00; P=0.055) for 4-6 minutes; 0.74 (0.63 to 0.88; P<0.001) for 7-9 minutes; and 0.63 (0.52 to 0.76; P<0.001) for >9 minutes. A similar stepwise effect was observed across all outcome variables.


CONCLUSIONS
In patients with non-shockable cardiac arrest in hospital, earlier administration of epinephrine is associated with a higher probability of return of spontaneous circulation, survival in hospital, and neurologically intact survival.
Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, W/CC 2, MA, 02215, USA Department of Medicine, Division of Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA mdonnino@bidmc.harvard.edu.
Michael W
MW
Donnino
Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, W/CC 2, MA, 02215, USA.
Justin D
JD
Salciccioli
Center for Quality, University of Chicago Medicine, 850 E 58th Street, Chicago, IL, 60637, USA.
Michael D
MD
Howell
Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, W/CC 2, MA, 02215, USA Department of Anesthesia Critical Care, Division of Neurological/Trauma/Surgical Critical Care, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, MA, 02215, USA.
Michael N
MN
Cocchi
Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, W/CC 2, MA, 02215, USA.
Brandon
B
Giberson
Department of Medicine, Division of Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA.
Katherine
K
Berg
Department of Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, MA, 02215, USA.
Shiva
S
Gautam
Department of Emergency Medicine, University of Pittsburgh, 3600 Forbes Avenue, Iroquois Building, Suite 400A, Pittsburgh, PA, 15261, USA.
Clifton
C
Callaway
D000318:Adrenergic beta-Agonists / Q000008:administration & dosage*; D000368:Aged; D000369:Aged, 80 and over; D016887:Cardiopulmonary Resuscitation; D004554:Electric Countershock; D004837:Epinephrine / Q000008:administration & dosage*; D005260:Female; D006323:Heart Arrest / Q000401:mortality / Q000628:therapy*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012042:Registries; D012189:Retrospective Studies; D016019:Survival Analysis; D061665:Time-to-Treatment
D000318:Adrenergic beta-Agonists; D004837:Epinephrine