Cumulative Epinephrine Doses Over 3 mg During ECPR Increase Risk of Unfavorable Neurologic Outcomes at Discharge

Photo Credit: Eugene Nekrasov

The following is a summary of “Cumulative epinephrine dose during cardiac arrest and neurologic outcome after extracorporeal cardiopulmonary resuscitation,” published in the June 2024 issue of Emergency Medicine by Garcia, et al.

Epinephrine is a crucial intervention during cardiac arrest, although its use without a specified maximum dose may lead to excessive alpha- and beta-adrenergic stimulation. The stimulation can increase aortic afterload unnecessarily, potentially exacerbating post-arrest myocardial dysfunction and contributing to cerebral microvascular insufficiency, particularly in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR).

The retrospective cohort study included adults aged 18 years and older who underwent ECPR at a major academic ECMO center between 2018 and 2022. Patients were categorized based on the amount of epinephrine administered during cardiac arrest into two groups: low (≤ 3 mg) and high (> 3 mg). The primary endpoint was the neurologic outcome at hospital discharge, assessed using the cerebral performance category (CPC) scale. Multivariable logistic regression was employed to evaluate the association between cumulative epinephrine dosage during arrest and neurologic outcomes.

Among the 51 ECPR cases analyzed, the median age of patients was 60 years, and 55% were male. The mean cumulative epinephrine dose administered during cardiac arrest was 6.2 mg, ranging from 0 to 24 mg. The study cohort comprised 18 patients in the low-dose (≤ 3 mg) group and 25 patients in the high-dose (> 3 mg) group. A favorable neurologic outcome at discharge was significantly more common in the low-dose group (55%) compared to the high-dose group (24%) (P = 0.025). After adjusting for age, patients who received higher doses of epinephrine (> 3 mg) during cardiac arrest were more likely to experience unfavorable neurologic outcomes at hospital discharge (odds ratio 4.6, 95% CI 1.3–18.0, P = 0.017).

In patients undergoing ECPR, cumulative epinephrine doses exceeding 3 mg during cardiac arrest were associated with an increased likelihood of unfavorable neurologic outcomes at hospital discharge, even after accounting for age. The findings underscored the need for further investigation into the optimal dosage and potential adverse effects of epinephrine administration during ECPR.

Reference: sciencedirect.com/science/article/abs/pii/S0735675724001244