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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Voicu S, Goury A, Lacoste-Palasset T, Malissin I, Fanet L, Souissi S, Busto J, Legros V, Sutterlin L, Naim G, M’Rad A, Pepin-Lehaleur A, Deye N, Mourvillier B, Mégarbane B. Dismal Survival in COVID-19 Patients Requiring ECMO as Rescue Therapy after Corticosteroid Failure. J Pers Med 2021; 11:jpm11111238. [PMID: 34834590 PMCID: PMC8622434 DOI: 10.3390/jpm11111238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/12/2021] [Accepted: 11/20/2021] [Indexed: 12/15/2022] Open
Abstract
(1) Background: COVID-19 may lead to refractory hypoxemia requiring venovenous extracorporeal membrane oxygenation (ECMO). Survival rate if ECMO is implemented as rescue therapy after corticosteroid failure is unknown. We aimed to investigate if ECMO implemented after failure of the full-recommended 10-day corticosteroid course can improve outcome. (2) Methods: We conducted a three-center cohort study including consecutive dexamethasone-treated COVID-19 patients requiring ECMO between 03/2020 and 05/2021. We compared survival at hospital discharge between patients implemented after (ECMO-after group) and before the end of the 10-day dexamethasone course (ECMO-before group). (3) Results: Forty patients (28M/12F; age, 57 years (51-62) (median (25th-75th percentiles)) were included, 28 (70%) in the ECMO-before and 12 (30%) in the ECMO-after group. In the ECMO-before group, 9/28 patients (32%) received the 6 mg/day dexamethasone regimen versus 12/12 (100%) in the ECMO-after group (p < 0.0001). The rest of the patients received an alternative dexamethasone regimen consisting of 20 mg/day during 5 days followed by 10 mg/day during 5 days. Patients in the ECMO-before group tended to be younger (57 years (51-59) versus 62 years (57-67), p = 0.053). In the ECMO-after group, no patient (0%) survived while 12 patients (43%) survived in the ECMO-before group (p = 0.007). (4) Conclusions: Survival is poor in COVID-19 patients requiring ECMO implemented after the full-recommended 10-day dexamethasone course. Since these patients may have developed a particularly severe presentation, new therapeutic strategies are urgently required.
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Affiliation(s)
- Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris-University, 75010 Paris, France; (S.V.); (T.L.-P.); (I.M.); (L.F.); (S.S.); (L.S.); (G.N.); (A.M.); (A.P.-L.); (N.D.)
| | - Antoine Goury
- Medical Critical Care Department, Robert Debré University Hospital, 51100 Reims, France; (A.G.); (J.B.); (B.M.)
| | - Thomas Lacoste-Palasset
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris-University, 75010 Paris, France; (S.V.); (T.L.-P.); (I.M.); (L.F.); (S.S.); (L.S.); (G.N.); (A.M.); (A.P.-L.); (N.D.)
| | - Isabelle Malissin
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris-University, 75010 Paris, France; (S.V.); (T.L.-P.); (I.M.); (L.F.); (S.S.); (L.S.); (G.N.); (A.M.); (A.P.-L.); (N.D.)
| | - Lucie Fanet
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris-University, 75010 Paris, France; (S.V.); (T.L.-P.); (I.M.); (L.F.); (S.S.); (L.S.); (G.N.); (A.M.); (A.P.-L.); (N.D.)
| | - Samar Souissi
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris-University, 75010 Paris, France; (S.V.); (T.L.-P.); (I.M.); (L.F.); (S.S.); (L.S.); (G.N.); (A.M.); (A.P.-L.); (N.D.)
| | - Julia Busto
- Medical Critical Care Department, Robert Debré University Hospital, 51100 Reims, France; (A.G.); (J.B.); (B.M.)
| | - Vincent Legros
- Surgical Critical Care Department, Maison Blanche University Hospital, 51100 Reims, France;
| | - Laetitia Sutterlin
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris-University, 75010 Paris, France; (S.V.); (T.L.-P.); (I.M.); (L.F.); (S.S.); (L.S.); (G.N.); (A.M.); (A.P.-L.); (N.D.)
| | - Giulia Naim
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris-University, 75010 Paris, France; (S.V.); (T.L.-P.); (I.M.); (L.F.); (S.S.); (L.S.); (G.N.); (A.M.); (A.P.-L.); (N.D.)
| | - Aymen M’Rad
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris-University, 75010 Paris, France; (S.V.); (T.L.-P.); (I.M.); (L.F.); (S.S.); (L.S.); (G.N.); (A.M.); (A.P.-L.); (N.D.)
| | - Adrien Pepin-Lehaleur
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris-University, 75010 Paris, France; (S.V.); (T.L.-P.); (I.M.); (L.F.); (S.S.); (L.S.); (G.N.); (A.M.); (A.P.-L.); (N.D.)
| | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris-University, 75010 Paris, France; (S.V.); (T.L.-P.); (I.M.); (L.F.); (S.S.); (L.S.); (G.N.); (A.M.); (A.P.-L.); (N.D.)
| | - Bruno Mourvillier
- Medical Critical Care Department, Robert Debré University Hospital, 51100 Reims, France; (A.G.); (J.B.); (B.M.)
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris-University, 75010 Paris, France; (S.V.); (T.L.-P.); (I.M.); (L.F.); (S.S.); (L.S.); (G.N.); (A.M.); (A.P.-L.); (N.D.)
- Correspondence: ; Tel.: +33-149958442
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