Perkins G.D., Ji C., Deakin C.D. et al.
The New England Journal of Medicine 2018; 379(8): 711-21.. DOI: 10.1056/NEJMoa1806842
Aim Of Study
To determine whether the use of epinephrine is safe and effective in out of hospital cardiac arrests (OHCA).
Design
Randomized double-blind trial.
Methodology
Random assignment of drug packs to paramedics attending OHCA containing either epinephrine or 0.9% saline.
Primary Outcome
The rate of survival at 30 days.
Secondary Outcomes
- Survival until hospital admission
- Median length of stay in ITU
- Median length of hospital stay
- Survival until hospital discharge
- Favourable neurological outcome at hospital discharge
- Survival at 3 months
- Favourable neurological outcome at 3 months
Statistics
Primary analysis was carried out without adjustment in the modified intention-to-treat population. Survival outcomes were analysed using fixed-effect regression models with and without adjustments for a stated number of variables.
Results
Results for the primary outcome showed that in the epinephrine group 3.2% of patients were alive at 30 days in comparison with 2.4% in the placebo group. (unadjusted odds ratio for survival, 1.39; 95% confidence interval 1.06 to 1.82; P=0.02).
There was no evidence of significant difference between the epinephrine group and the placebo group in the proportion of patients who survived to hospital discharge with a favourable neurological outcome. However, severe neurological impairment was more common among survivors in the epinephrine group than the placebo group.
Conclusion
Epinephrine may be good at restarting hearts in cardiac arrest, but this may be at the cost of less favourable neurological outcomes in those that survive.
Limitations of Study
This trial only considered fixed dosing of 1mg epinephrine. The effects of variations in treatment received at hospital weren’t adjusted for in the outcomes.
Discussion from Journal Club Metting (? Change of practice)
With a number needed to treat (NNT) of 112 should we be focusing on more effective ways of improving survival in cardiac arrest such as earlier defibrillation (NNT 5) through training the public and defibrillator deployment.
Should there be a different, more detailed focus, on measuring neurological outcomes in our patients that reflect real world experience.
Summary by Dr A Street. Journal Club Meeting 16 May 2019.
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