Adrenaline for the pharmacological treatment of cardiac arrest… going, going, gone?

Is there a role for adrenaline during cardiopulmonary resuscitation?

“…These observations are consistent with other studies that link adrenaline with ventricular arrhythmias and increased post-ROSC myocardial dysfunction [27]. In human studies with patients with sepsis [28] or acute lung injury [29], b-agonist stimulation is similarly linked to cardiovascular instability and reduced survival [30]. A systematic review of b-blocker treatment in animal models of cardiac arrest found fewer shocks were required for defibrillation, myocardial oxygen demand was reduced and postresuscitation myocardial stability improved with fewer arrhythmias and improved survival [31 & ].…”

“…Appropriately powered placebo-controlled clinical trials of adrenaline in cardiac arrest are essential to determine whether patients benefit from being given this drug [30,42]. In the mean time, current guidelines dictate that most patients with cardiac arrest will continue to be given adrenaline.…”

Evaluation of pre-hospital administration of adrenaline (epinephrine) by emergency medical services for patients with out of hospital cardiac arrest in Japan: controlled propensity matched retrospective cohort study

“…Our study was sufficiently powered and successfully adjusted for time dependent severity of cardiac arrest, using sequential risk set matching with time dependent propensity scores (in other words, it adjusted for the varying duration of resuscitation procedures) 2. This way, for those who received adrenaline at a certain time point, their controls were selected from those who were, at that time point, still at risk for adrenaline use and had similar propensity scores (similar likelihood of receiving adrenaline) 17…”

“…The randomised controlled trials were underpowered. The observational studies could not adjust for time dependent imbalance of severity: timing of return of spontaneous circulation is a determinant of both outcome and treatment (those who rapidly respond to initial resuscitation procedures would have a higher chance of survival and a lower chance of being given of adrenaline) 26 11 12 A few registry based studies have focused on timing and shown favourable effects of early administration, but they did not adjust for the timing of return of spontaneous circulation 11…”

“…Evaluation of the effectiveness of the strategy of using pre-hospital adrenaline in improving long term outcomes in patients with out of hospital cardiac arrest would contribute to resolving the uncertainty about the role of adrenaline in pre-hospital resuscitation 2. We analysed a large scale national database in Japan, which provided sufficient power to detect any small effects, and used time dependent propensity score matching to adjust for the time dependent imbalance in patients inherent in observational studies.…”