In this episode, I’ll discuss the impact of giving epinephrine before defibrillation to in-hospital cardiac arrest (IHCA) patients with shockable rhythms.
Knowing when a medication is the first-line treatment for a condition should be easy for pharmacists, as this is exactly what we spend our time on during training and professional development. But just like we expect a surgeon to know when medical therapy is indicated before surgery, pharmacists should also be aware of situations when medication use is not first-line. One such example is the need to give immediate defibrillation to patients in cardiac arrest who have a shockable rhythm, before the administration of epinephrine.
A group of authors recently published in Critical Care Medicine an observational cohort study looking at hospital variation in rates of epinephrine administration before defibrillation for shockable IHCA and its association with IHCA survival.
The AHA guidelines emphasize the need for prompt defibrillation of shockable rhythms for patients with IHCA and this study analyzed the Get With The Guidelines Resuscitation Registry data for over 500 hospitals and over 37,000 patients. The main outcome examined epinephrine administration before first defibrillation and its association with hospital-level rates of risk-adjusted survival.
When hospitals were organized in quartiles starting with the lowest rate of epinephrine before defibrillation in quartile 1, survival progressively decreased from 44.3% in the first quartile down to 40.3% in the fourth quartile.
The median hospital rate of epinephrine administration before defibrillation was 18.8% and there was significant variation between sites.
The authors concluded:
Administration of epinephrine before defibrillation in shockable IHCA is common and varies markedly across U.S. hospitals. Hospital rates of epinephrine administration before defibrillation were associated with a significant stepwise decrease in hospital rates of risk-adjusted survival. Efforts to prioritize immediate defibrillation for patients with shockable IHCA and avoid early epinephrine administration are urgently needed.
Pharmacists who participate in code response should be aware of the need to give prompt defibrillation and how its place in treatment is a higher priority than epinephrine. Efforts to determine your local hospital’s rate of epinephrine before defibrillation can help indicate whether educational efforts should be implemented for your code team.
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