title: Is epinephrine during cardiac arrest associated with worse outcomes in resuscitated patients?
abstract: BACKGROUND
  Although epinephrine is essential for successful return of spontaneous circulation (ROSC), the influence of this drug on recovery during the post-cardiac arrest phase is debatable.
  
  
  OBJECTIVE
  This study sought to investigate the relationship between pre-hospital use of epinephrine and functional survival among patients with out-of-hospital cardiac arrest (OHCA) who achieved successful ROSC.
  
  
  METHODS
  We included all patients with OHCA who achieved successful ROSC admitted to a cardiac arrest center from January 2000 to August 2012. Use of epinephrine was coded as yes/no and by dose (none, 1 mg, 2 to 5 mg, >5 mg). A favorable discharge outcome was coded using a Cerebral Performance Category 1 or 2. Analyses incorporated multivariable logistic regression, propensity scoring, and matching methods.
  
  
  RESULTS
  Of the 1,556 eligible patients, 1,134 (73%) received epinephrine; 194 (17%) of these patients had a good outcome versus 255 of 422 patients (63%) in the nontreated group (p < 0.001). This adverse association of epinephrine was observed regardless of length of resuscitation or in-hospital interventions performed. Compared with patients who did not receive epinephrine, the adjusted odds ratio of intact survival was 0.48 (95% confidence interval [CI]: 0.27 to 0.84) for 1 mg of epinephrine, 0.30 (95% CI: 0.20 to 0.47) for 2 to 5 mg of epinephrine, and 0.23 (95% CI: 0.14 to 0.37) for >5 mg of epinephrine. Delayed administration of epinephrine was associated with worse outcome.
  
  
  CONCLUSIONS
  In this large cohort of patients who achieved ROSC, pre-hospital use of epinephrine was consistently associated with a lower chance of survival, an association that showed a dose effect and persisted despite post-resuscitation interventions. These findings suggest that additional studies to determine if and how epinephrine may provide long-term functional survival benefit are needed.
authors.affiliation: INSERM U970, Parisian Cardiovascular Research Center, Paris Descartes University, Paris, France; Emergency Department, Cochin-Hotel-Dieu Hospital, APHP, Paris Descartes University, Paris, France. Electronic address: florence.dumas@cch.aphp.fr.
authors.forename: Florence
authors.initials: F
authors.lastname: Dumas
authors.affiliation: INSERM U970, Parisian Cardiovascular Research Center, Paris Descartes University, Paris, France; Medical Intensive Care Unit, Cochin Hospital, APHP, Paris Descartes University, Paris, France.
authors.forename: Wulfran
authors.initials: W
authors.lastname: Bougouin
authors.affiliation: INSERM U970, Parisian Cardiovascular Research Center, Paris Descartes University, Paris, France; Medical Intensive Care Unit, Cochin Hospital, APHP, Paris Descartes University, Paris, France.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Geri
authors.affiliation: INSERM U970, Parisian Cardiovascular Research Center, Paris Descartes University, Paris, France; Emergency Medical Services, SAMU 75, Necker Hospital, APHP, Paris, France.
authors.forename: Lionel
authors.initials: L
authors.lastname: Lamhaut
authors.affiliation: Medical Intensive Care Unit, Cochin Hospital, APHP, Paris Descartes University, Paris, France.
authors.forename: Adrien
authors.initials: A
authors.lastname: Bougle
authors.affiliation: Medical Intensive Care Unit, Cochin Hospital, APHP, Paris Descartes University, Paris, France.
authors.forename: Fabrice
authors.initials: F
authors.lastname: Daviaud
authors.affiliation: Medical Intensive Care Unit, Cochin Hospital, APHP, Paris Descartes University, Paris, France.
authors.forename: Tristan
authors.initials: T
authors.lastname: Morichau-Beauchant
authors.affiliation: Department of Cardiology, Cochin Hospital, APHP, Paris Descartes University, Paris, France.
authors.forename: Julien
authors.initials: J
authors.lastname: Rosencher
authors.affiliation: INSERM U970, Parisian Cardiovascular Research Center, Paris Descartes University, Paris, France.
authors.forename: Eloi
authors.initials: E
authors.lastname: Marijon
authors.affiliation: Emergency Medical Services, SAMU 75, Necker Hospital, APHP, Paris, France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Carli
authors.affiliation: INSERM U970, Parisian Cardiovascular Research Center, Paris Descartes University, Paris, France.
authors.forename: Xavier
authors.initials: X
authors.lastname: Jouven
authors.affiliation: Emergency Medical Services, Division of Public Health for Seattle and King County, University of Washington, Seattle, Washington.
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Rea
authors.affiliation: INSERM U970, Parisian Cardiovascular Research Center, Paris Descartes University, Paris, France; Medical Intensive Care Unit, Cochin Hospital, APHP, Paris Descartes University, Paris, France.
authors.forename: Alain
authors.initials: A
authors.lastname: Cariou
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016887:Cardiopulmonary Resuscitation / Q000009:adverse effects / Q000379:methods*; D015331:Cohort Studies; D004837:Epinephrine / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D058687:Out-of-Hospital Cardiac Arrest / Q000175:diagnosis* / Q000188:drug therapy* / Q000401:mortality; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome
chemical_list: D004837:Epinephrine
keywords: cardiac arrest; hypothermia; percutaneous coronary intervention