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How Much Epinephrine Is Too Much in ECPR?

April 19, 2024

Written by Millie Cossé

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High-dose epinephrine (>3mg) was associated with unfavorable neurologic outcome when compared to low-dose epinephrine (≤3mg) after extracorporeal cardiopulmonary resuscitation.

Too much of a controversial thing is…a controversial thing
This retrospective cohort study included adults who received extracorporeal cardiopulmonary resuscitation (ECPR) at a single quaternary care center. 51 cases met inclusion criteria and were divided into high-dose (>3mg) and low-dose (≤3mg) epinephrine groups. Authors found that favorable neurologic outcome was significantly less in the high-dose epi group when compared to the low-dose epi group (24% vs. 55%, p=0.025).

While this may be due to the linear relationship between length of resuscitation and number of epinephrine doses, there is also physiologic plausibility that high-dose epinephrine is especially harmful in ECPR cases. Excessive alpha-adrenergic stimulation may lead to microvascular insufficiency and create technical problems with achieving adequate ECMO flow, while beta-adrenergic stimulation leads to increased myocardial oxygen demand and post-arrest myocardial dysfunction.

How will this change my practice?
This paper has several limitations, notably its small sample size, and should only be considered hypothesis generating. However, it contributes to a growing body of evidence that epinephrine may be helping us achieve more ROSC without any benefit in neurologic outcome.

Editor’s note: I agree with Millie. This seems like confounding by indication. It’s interesting that overdoing epinephrine has come up recently and in the Top Picks video series, which is why I wanted us to cover this article. ~Clay Smith

Cumulative epinephrine dose during cardiac arrest and neurologic outcome after extracorporeal cardiopulmonary resuscitation. Am J Emerg Med. 2024 Mar 15;80:61-66. doi: 10.1016/j.ajem.2024.03.013. Epub ahead of print. PMID: 38507848.

What are your thoughts?