The Next Chapter in the High-Dose Epinephrine Story: Unfavorable Neurologic Outcomes?

Editorials15 September 1998The Next Chapter in the High-Dose Epinephrine Story: Unfavorable Neurologic Outcomes?Richard O. Cummins, MD, MPH and Mary Fran Hazinski, RN, MSNRichard O. Cummins, MD, MPHUniversity of Washington; Seattle, WA 98195Vanderbilt University; Nashville, TN 37212Search for more papers by this author and Mary Fran Hazinski, RN, MSNUniversity of Washington; Seattle, WA 98195Vanderbilt University; Nashville, TN 37212Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-129-6-199809150-00014 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The standard dose of epinephrine used in cardiopulmonary resuscitation, 1 mg given intravenously every 5 minutes, originated from landmark studies by Redding and Pearson in the 1960s [1, 2]. They studied the effects of 1 mg of epinephrine given to dogs weighing 10 kg and established that epinephrine played a critical role in improving blood flow to the heart and brain during cardiopulmonary resuscitation and in restoring spontaneous circulation. The original American Heart Association (AHA) resuscitation recommendations adopted the 1-mg dose for all patients without adjusting for the obvious weight differences between 10-kg dogs and 70-kg humans. In addition, cardiac ...References1. Redding J, Pearson J. Adrenaline in cardiac resuscitation. Am Heart J. 1963; 66:210-4. Google Scholar2. Redding J, Pearson J. Evaluation of drugs for cardiac resuscitation. Anesthesiology. 1963; 66:203-7. Google Scholar3. Beck C, Rand HI. Cardiac arrest during anesthesia and surgery. JAMA. 1949; 141:1230-3. Google Scholar4. Brown CG, Taylor RB, Werman HA, Luu T, Spittler G, Hamlin RL. Effect of standard doses of epinephrine on myocardial oxygen delivery and utilization during cardiopulmonary resuscitation. Crit Care Med. 1988; 16:536-9. Google Scholar5. Brown CG, Werman HA, Davis EA, Hamlin R, Hobson J, Ashton JA. Comparative effect of graded doses of epinephrine on regional brain blood flow during CPR in a swine model. Ann Emerg Med. 1986; 15:1138-44. Google Scholar6. Brown CG, Werman HA, Davis EA, Hobson J, Hamlin RL. The effects of graded doses of epinephrine on regional myocardial blood flow during cardiopulmonary resuscitation in swine. Circulation. 1987; 75:491-7. Google Scholar7. Brown CG, Martin DR, Pepe PE, Stueven H, Cummins RO, Gonzalez E, et al. A comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. The Multicenter High-Dose Epinephrine Study Group. N Engl J Med. 1992; 327:1051-5. Google Scholar8. Callaham ML, Madsen CD, Barton CD, Saunders CE, Pointer JA. A randomized clinical trial of high-dose epinephrine and noradrenaline vs. standard dose epinephrine in prehospital cardiac arrest. JAMA. 1992; 268:2667-72. Google Scholar9. Lindner KH, Ahnefeld FW, Prengel AW. Comparison of standard and high-dose adrenaline in the resuscitation of asystole and electromechanical dissociation. Acta Anaesthesiol Scand. 1991; 35:253-6. Google Scholar10. Steill IG, Hebert PC, Weitzman BW, Wells GA, Raman S, Stark RM, et al. High-dose epinephrine in adult cardiac arrest. N Engl J Med. 1992; 327:1045-50. Google Scholar11. Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Part 1. Introduction. JAMA. 1992; 268:2171-83. Google Scholar12. Behringer W, Kittler H, Sterz F, Domanovits H, Schoerkhuber W, Holzer M, et al. Cumulative epinephrine dose during cardiopulmonary resuscitation and neurologic outcome. Ann Intern Med. 1998; 129:450-6. Google Scholar13. Cummins RO, Hazinski MF, Kerber RE, Kudenchuk P, Becker L, Nichol G, et al. Low-energy biphasic waveform defibrillation: evidence-based review applied to emergency cardiovascular care guidelines: a statement for healthcare professionals from the American Heart Association Committee on Emergency Cardiovascular Care and the Subcommittees on Basic Life Support, Advanced Cardiac Life Support, and Pediatric Resuscitation. Circulation. 1998; 97:1654-67. Google Scholar14. Cummins RO, Chamberlain DA, Abramson NS, Allen M, Baskett PJ, Becker L, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Circulation. 1991; 84:960-75. Google Scholar15. Rivers EP, Wortsman J, Rady MY, Blake HC, McGeorge FT, Buderer NM. The effect of total cumulative epinephrine dose administered during human CPR on hemodynamic, oxygen transport and utilization variables in the postresuscitation period. Chest. 1994; 5:1499-507. Google Scholar16. Tang W, Weil MH, Sun S, Noc M, Yang L, Gazmuri RJ. Epinephrine increases the severity of postresuscitation myocardial dysfunction. Circulation. 1995; 92:3089-93. Google Scholar17. Choux C, Gueugniaud PY, Barbieux A, Pham E, Lae C, Dubien PY, et al. Standard doses versus repeated high doses of epinephrine in cardiac arrest outside the hospital. Resuscitation. 1995; 29:3-9. Google Scholar18. Woodhouse SP, Cox S, Boyd P, Case C, Weber M. High dose and standard dose adrenaline do not alter survival, compared with placebo in cardiac arrest. Resuscitation. 1995; 30:243-9. Google Scholar19. Herlitz J, Ekstrom L, Wennerblom B, Axelsson A, Bang A, Holmberg S. Adrenaline in out-of-hospital ventricular fibrillation. Does it make any difference? Resuscitation. 1995; 29:195-201. Google Scholar Author, Article, and Disclosure InformationAuthors: Richard O. Cummins, MD, MPH; Mary Fran Hazinski, RN, MSNAffiliations: University of Washington; Seattle, WA 98195Vanderbilt University; Nashville, TN 37212Corresponding Author: Richard O. Cummins, MD, MPH, University of Washington, 1959 NE Pacific, Seattle, WA 98195.Current Author Addresses: Dr. Cummins: University of Washington, 1959 NE Pacific, Seattle, WA 98195. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoCumulative Epinephrine Dose during Cardiopulmonary Resuscitation and Neurologic Outcome Wilhelm Behringer , Harald Kittler , Fritz Sterz , Hans Domanovits , Waltraud Schoerkhuber , Michael Holzer , Marcus Mullner , and Anton N. Laggner Metrics Cited byImpact of epinephrine administration frequency in out-of-hospital cardiac arrest patients: a retrospective analysis in a tertiary hospital settingAdrenaline (epinephrine) dosing period and survival after in-hospital cardiac arrest: A retrospective review of prospectively collected dataImportant Changes in the ACLS 2000 Guidelines for the Management of Cardiac ArrestANTIDYSRHYTHMICSHigh dose versus standard dose epinephrine in cardiac arrest — a meta-analysisEpinephrine and outcome of cardiac arrestEpinephrine and Outcome after Cardiac ArrestFritz Sterz, MD, Wilhelm Behringer, MD, and Harald Kittler, MD 15 September 1998Volume 129, Issue 6Page: 501-502KeywordsBlood flowBrainCardiopulmonary resuscitationClinical trial reportingClinical trialsCohort studiesEpinephrineHeartProspective studiesResuscitation ePublished: 15 August 2000 Issue Published: 15 September 1998 Copyright & PermissionsCopyright © 1998 by American College of Physicians. 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