Impact of epinephrine administration route on resuscitation outcomes

Abstract

AIMS: In this study, we sought to determine how effective intravenous (IV) epinephrine is when administered peripherally, centrally, and intracoronarily (IC).

METHODS AND RESULTS: Patients with acute myocardial infarction who experienced cardiac arrest in the cardiac catheterization lab during percutaneous coronary intervention were included in a prospective, two-center pilot cohort study (trial registration number NCT05253937). The European Resuscitation Council's (ERC) Guidelines were followed during cardiac resuscitation. It is preferred to administer epinephrine through the subclavian vein or internal jugular vein, which was primed for use when available. The treating physician chose how to deliver epinephrine during cardiac arrest (peripheral IV catheter or IC catheter). We contrasted the results of patients who got epinephrine centrally, peripherally, or intravenously. Each arm consisted of 158 participants, 48 (30.4%), 50 (31.6%), and 60 (38.0%), respectively. The primary endpoint was (the rate of) return of spontaneous circulation (ROSC). In-hospital stent thrombosis was the secondary endpoint, and survival-to-discharge with favorable neurologic status (cerebral performance category score 1–2) was the tertiary endpoint. Additionally, ROSC odds were lower by 5% each year as patient age increased, and 2.5 times lower for patients who had VF rather than EMD prior to CPR. There was a lower likelihood of returning to spontaneous circulation with peripheral IV epinephrine administration as opposed to central IV and IC, (ROSC, odds ratio = 0.14, 95% confidence interval = 0.05-0.36, p< 0.0001). No significant difference regarding the primary endpoint was observed between the central IV and central IC administration routes (p = 0.9343). Furthermore, regarding the secondary endpoints, IC route was significantly more likely to cause stent thrombosis than peripheral IV (IC vs. peripheral IV OR = 4.6, 95% CI = 1.5–14.3, p = 0.0094, and IC vs. central IV OR = 6.0, 95% CI = 1.9–19.2, p = 0.0025). Finally, the study tertiary endpoint revealed that the neurologic outcomes following ROSC were better when central IV and IC routes were utilized to administer epinephrine.

CONCLUSION: The administration of epinephrine centrally and through the IC route results in better outcomes. However, the risk of stent thrombosis gets higher with IC administration of epinephrine which highlights the need for further investigation of the impact of IC epinephrine injection on thrombosis.