Delayed Epinephrine Linked To Worse Survival From In-Patient Cardiac Arrest Interview with:
Rohan Khera, MD

Cardiology Fellow, T32 Clinical-Investigator Pathway
UT Southwestern Medical Center
Dallas, TX What is the background for this study? What are the main findings?

Response: Nearly 200 thousand people have an in-hospital cardiac arrest in the US each year. Of these, the vast majority have a non-shockable initial rhythm – either pulseless electric activity (PEA) or asystole. The survival of this type of arrest remains poor at around 12-14%. Moreover, even after accounting for differences in case mix, there is a wide variation in survival across hospitals – and this serves as a potential avenue for targeting quality improvement strategies at poor performing hospitals.

Recent data suggest that a shorter time from the onset of cardiac arrest to the first dose of epinephrine is independently associated with higher survival. Against this background of wide hospital variation in cardiac arrest survival, and patient-level data suggesting an association between time to epinephrine and patient survival, we wanted to assess (A) if there were differences in time to epinephrine administration across hospitals, and (B) if a hospital’s rate of timely epinephrine use was associated with its cardiac arrest survival rate. Within Get With The Guidelines-Resuscitation, we identified nearly 104-thousand adult patients at 548 hospitals with an in-hospital cardiac arrest attributable to a non-shockable rhythms. delays to epinephrine,

We found that (a) proportion of cardiac arrests with delayed epinephrine markedly across hospitals, ranging from no arrests with delay (or 0%) to more than half of arrests at a hospital (54%).

There was an inverse correlation between a hospital’s rate of delayed epinephrine administration and its risk-standardized rate of survival to discharge and survival with functional recovery – compared to a low-performing hospitals, survival and recovery was 20% higher at hospitals that performed best on timely epinephrine use. What should readers take away from your report?

Response: Although current resuscitation guidelines recommend prompt delivery of epinephrine treatment to patients with in-hospital cardiac arrest attributable to asystole and pulseless electric activity, there is substantial practice variation across hospitals.

Our findings suggest that hospitals with low survival rates for these cardiac arrest rhythms may benefit from quality improvement efforts that include minimizing delays in epinephrine administration. What recommendations do you have for future research as a result of this study?

Response: Findings from our observational study suggest that we need future investigatios to (
1) Assess resuscitation practices that are associated with shorter times to epinephrine use, (2) prospectively evaluate if improvement of timely epinephrine use at low performing hospitals are associated with improved outcomes. Thank you for your contribution to the community.

Hospital Variation in Time to Epinephrine for Non-Shockable In-Hospital Cardiac Arrest
Rohan Khera, Paul S. Chan, Michael W. Donnino and Saket Girotra and for the American Heart Association’s Get With The Guidelines-Resuscitation Investigators
Circulation. 2016;CIRCULATIONAHA.116.025459
Originally published December 1, 2016

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on December 4, 2016 by Marie Benz MD FAAD