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Javaudin F, Bougouin W, Fanet L, Diehl JL, Jost D, Beganton F, Empana JP, Jouven X, Adnet F, Lamhaut L, Lascarrou JB, Cariou A, Dumas F. Cumulative dose of epinephrine and mode of death after non-shockable out-of-hospital cardiac arrest: a registry-based study. Crit Care 2023; 27:496. [PMID: 38124126 PMCID: PMC10734153 DOI: 10.1186/s13054-023-04776-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Epinephrine increases the chances of return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA), especially when the initial rhythm is non-shockable. However, this drug could also worsen the post-resuscitation syndrome (PRS). We assessed the association between epinephrine use during cardiopulmonary resuscitation (CPR) and subsequent intensive care unit (ICU) mortality in patients with ROSC after non-shockable OHCA. METHODS We used data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (capturing OHCA data located in the Greater Paris area, France) between May 2011 and December 2021. All adults with ROSC after medical, cardiac and non-cardiac causes, non-shockable OHCA admitted to an ICU were included. The mode of death in the ICU was categorized as cardiocirculatory, neurological, or other. RESULTS Of the 2,792 patients analyzed, there were 242 (8.7%) survivors at hospital discharge, 1,004 (35.9%) deaths from cardiocirculatory causes, 1,233 (44.2%) deaths from neurological causes, and 313 (11.2%) deaths from other etiologies. The cardiocirculatory death group received more epinephrine (4.6 ± 3.8 mg versus 1.7 ± 2.8 mg, 3.2 ± 2.6 mg, and 3.5 ± 3.6 mg for survivors, neurological deaths, and other deaths, respectively; p < 0.001). The proportion of cardiocirculatory death increased linearly (R2 = 0.92, p < 0.001) with cumulative epinephrine doses during CPR (17.7% in subjects who did not receive epinephrine and 62.5% in those who received > 10 mg). In multivariable analysis, a cumulative dose of epinephrine was strongly associated with cardiocirculatory death (adjusted odds ratio of 3.45, 95% CI [2.01-5.92] for 1 mg of epinephrine; 12.28, 95% CI [7.52-20.06] for 2-5 mg; and 23.71, 95% CI [11.02-50.97] for > 5 mg; reference 0 mg; population reference: alive at hospital discharge), even after adjustment on duration of resuscitation. The other modes of death (neurological and other causes) were also associated with epinephrine use, but to a lesser extent. CONCLUSIONS In non-shockable OHCA with ROSC, the dose of epinephrine used during CPR is strongly associated with early cardiocirculatory death. Further clinical studies aimed at limiting the dose of epinephrine during CPR seem warranted. Moreover, strategies for the prevention and management of PRS should take this dose of epinephrine into consideration for future trials.
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Affiliation(s)
- François Javaudin
- Paris Sudden Death Expertise Center, 75015, Paris, France.
- Emergency Department, Nantes University Hospital, 44000, Nantes, France.
- SAMU, 1 Quai Moncousu, 44093, Nantes Cedex1, France.
| | - Wulfran Bougouin
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Medical Intensive Care Unit, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300, Massy, France
- AfterROSC Network, Paris, France
| | - Lucie Fanet
- Paris Sudden Death Expertise Center, 75015, Paris, France
| | - Jean-Luc Diehl
- Medical Intensive Care Unit, AP-HP, European Georges Pompidou Hospital, 75015, Paris, France
- Innovative Therapies in Hemostasis, INSERM 1140, Université Paris Cité, 75006, Paris, France
| | - Daniel Jost
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- BSPP (Paris Fire-Brigade Emergency-Medicine Department), 1 Place Jules Renard, 75017, Paris, France
| | - Frankie Beganton
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
| | - Jean-Philippe Empana
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
| | - Xavier Jouven
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Cardiology Department, AP-HP, European Georges Pompidou Hospital, 75015, Paris, France
| | - Frédéric Adnet
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- SAMU de Paris, Necker University Hospital, Assistance Publique-Hôpitaux de Paris, 75015, Paris, France
| | - Lionel Lamhaut
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- SAMU de Paris, Necker University Hospital, Assistance Publique-Hôpitaux de Paris, 75015, Paris, France
| | - Jean-Baptiste Lascarrou
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- AfterROSC Network, Paris, France
- Medecine Intensive Reanimation, Nantes University Hospital, 44000, Nantes, France
| | - Alain Cariou
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- AfterROSC Network, Paris, France
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, 75014, Paris, France
| | - Florence Dumas
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Emergency Department, AP-HP, Cochin-Hotel-Dieu Hospital, 75014, Paris, France
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