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March 6, 1991, Vol 265, No. 9 >
ARTICLE | March 6, 1991

High-Dose Epinephrine During Resuscitation: Title and subTitle BreakA Word of Caution FREE

Joseph P. Ornato, MD
[+] Author Affiliations

Reprint requests to Medical College of Virginia, Box 525, Richmond, VA 23298 (Dr Ornato).


JAMA. 1991;265(9):1160-1161. doi:10.1001/jama.1991.03460090108042
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References

Many clinicians have begun to use high-dose epinephrine (HDE) rather than standard-dose epinephrine (SDE) during cardiopulmonary resuscitation.1-6 (HDE is usually defined as an intravenous bolus of >1 mg, often 0.2 mg/kg, and SDE is usually defined as a 0.5- to 1.0-mg intravenous bolus.) In animal models, HDE improves measurements of hemodynamics, enhances blood flow in the coronary and cerebral circulation during resuscitation, and brings a higher rate of return of spontaneous circulation than SDE.7-10 Anecdotal case reports2-6 and preliminary hemodynamic results in humans are consistent with the observations in animals,11 but no prospective, controlled study has yet proved that higher doses of epinephrine improve survival or other measures of outcome from cardiac arrest in humans.

Other clinicians and scientists have voiced a concern that HDE may be detrimental, especially during ischemia and ventricular fibrillation. Since a fibrillating heart consumes oxygen at a rapid rate,12-16 HDE

REFERENCES

1 +
Callaham M.  Epinephrine doses in cardiac arrest: is it time to outgrow the orthodoxy of ACLS? Ann Emerg Med. 1989;;18:1011-1012.
2 +
Koscove EM, Paradis NA.  Successful resuscitation from cardiac arrest using high-dose epinephrine therapy . JAMA. 1988;;259:3031-3034.
3 +
Goetting M, Paradis N.  High-dose epinephrine in refractory pediatric cardiac arrest . Crit Care Med. 1989;;17:1258-1262.
4 +
Martin D, Werman HA, Brown CG.  Four case studies: high-dose epinephrine in cardiac arrest . Ann Emerg Med. 1990;;19:322-326.
5 +
Paradis NA, Goetting MG, Rivers EP, Martin GB, Appleton TJ, Nowak RM.  High-dose epinephrine therapy and return of spontaneous circulation during human pseudo-electromechanical dissociation . Ann Emerg Med. 1990;;19:491-492. Abstract.
6 +
Sherman BW, Rutherford WF.  Resuscitation from cardiac arrest using high-dose epinephrine . JAMA. 1989;;261:989-990.
7 +
Brown CG, Werman HA, Davis EA, Hamlin R, Hobson J, Ashton JA.  Comparative effect of graded doses of epinephrine on regional brain blood flow during CPR in a swine model . Ann Emerg Med. 1986;;15:1138-1144.
8 +
Brown CG, Werman HA, Davis EA, Hobson J, Hamlin RL.  The effect of graded doses of epinephrine during cardiopulmonary resuscitation on regional myocardial blood flow in a swine model . Circulation. 1987;;75:491-497.
9 +
Kosnick JW, Jackson RE, Keats S, Tworek RM, Freeman SB.  Dose-related response of centrally administered epinephrine on the change in aortic diastolic pressure during closed-chest massage in dogs . Ann Emerg Med. 1985;;14:204-208.
10 +
Brunette DD, Jameson SJ.  Comparison of standard versus high-dose epinephrine in the resuscitation of cardiac arrest in dogs . Ann Emerg Med. 1990;;19:8-11.
11 +
Gonzalez ER, Ornato JP, Garnett AR, Levine R, Young DS, Racht EM.  Dose-dependent vasopressor response to epinephrine during CPR in humans . Ann Emerg Med. 1989;;18:920-926.
12 +
McKeever WP, Gregg DE, Canney PC.  Oxygen uptake of the nonworking left ventricle . Circ Res. 1958;;6:612-623.
13 +
Monroe RG, French G.  Ventricular pressure-volume relationships and oxygen consumption in fibrillation and arrest . Circ Res. 1960;;8:260-266.
14 +
Kohn RM.  Myocardial oxygen uptake during ventricular fibrillation and electro-mechanical dissociation . Am J Cardiol. 1963;;11:483-486.
15 +
Brown CG, Taylor RB, Werman HA, Luu T, Spittler G, Hamlin RL.  Effect of standard doses of epinephrine on myocardial oxygen delivery and utilization during cardiopulmonary resuscitation . Crit Care Med. 1988;;16:536-539.
16 +
Brown CG, Werman HA.  Adrenergic agonists during cardiopulmonary resuscitation . Resuscitation. 1990;;19:1-16.
17 +
Ditchey RV, Lindenfeld J.  Failure of epinephrine to improve the balance between myocardial oxygen supply and demand during closed-chest resuscitation in dogs . Circulation. 1988;;78:382-389.
18 +
Midei MG, Sugiura S, Maughan WI, Sagawa K, Weisfeldt ML, Guerci AD.  Preservation of ventricular function by treatment of ventricular fibrillation phenylephrine . J Am Coll Cardiol. 1990;;16:489-494.
19 +
Morady F, Nelson SD, Kou WH, et al.  Electrophysiologic effects of epinephrine in humans . J Am Coll Cardiol. 1988;;11:1235-1244.
20 +
Paradis NA, Martin GB, Rosenberg J, et al.  The effect of standard- and high-dose epinephrine on coronary perfusion pressure during prolonged cardiopulmonary resuscitation . JAMA. 1991;;265:1139-1144.
21 +
Callaham M, Barton CW, Kayser S.  Potential complications of high-dose epinephrine therapy in patients resuscitated from cardiac arrest . JAMA. 1991;;265:1117-1122.
22 +
Michael JR, Guerci AD, Koehler RC, et al.  Mechanisms by which epinephrine augments cerebral and myocardial perfusion during cardiopulmonary resuscitation in dogs . Circulation. 1984;;69:822-835.
23 +
Kern KB, Lancaster L, Goldman S, Ewy GA.  The effect of coronary artery lesions on the relationship between coronary perfusion pressure and myocardial blood flow during cardiopulmonary resuscitation in pigs . Am Heart J. 1990;;120:324-325.
24 +
Pearson JW, Redding JS.  Influence of peripheral vascular tone on cardiac resuscitation . Anesth Analg. 1976;;44:746-752.
25 +
Sanders AS, Ewy GA, Taft TV.  Prognostic and therapeutic importance of the aortic diastolic pressure in resuscitation from cardiac arrest . Crit Care Med. 1984;;12:871-873.
26 +
Niemann JT, Criley JM, Rosborough JP, Niskanen RA, Alferness C.  Predictive indices of successful cardiac resuscitation after prolonged arrest and experimental cardiopulmonary resuscitation . Ann Emerg Med. 1985;;14:521-528.
27 +
White RD.  Defining the pressure needs of the fibrillating heart during prolonged arrest: identification and application . Ann Emerg Med. 1985;;14:587-588.
28 +
Paradis NA, Martin GB, Rivers EP, et al.  Coronary perfusion pressure and return of spontaneous circulation in human cardiopulmonary resuscitation . JAMA. 1990;;263:1106-1113.
29 +
Keller RA, Forinash M.  EMS in the United States: a survey of providers in the 200 most populous cities . J Emerg Med Serv. 1990;;15:79-100.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Callaham M.  Epinephrine doses in cardiac arrest: is it time to outgrow the orthodoxy of ACLS? Ann Emerg Med. 1989;;18:1011-1012.
2 +
Koscove EM, Paradis NA.  Successful resuscitation from cardiac arrest using high-dose epinephrine therapy . JAMA. 1988;;259:3031-3034.
3 +
Goetting M, Paradis N.  High-dose epinephrine in refractory pediatric cardiac arrest . Crit Care Med. 1989;;17:1258-1262.
4 +
Martin D, Werman HA, Brown CG.  Four case studies: high-dose epinephrine in cardiac arrest . Ann Emerg Med. 1990;;19:322-326.
5 +
Paradis NA, Goetting MG, Rivers EP, Martin GB, Appleton TJ, Nowak RM.  High-dose epinephrine therapy and return of spontaneous circulation during human pseudo-electromechanical dissociation . Ann Emerg Med. 1990;;19:491-492. Abstract.
6 +
Sherman BW, Rutherford WF.  Resuscitation from cardiac arrest using high-dose epinephrine . JAMA. 1989;;261:989-990.
7 +
Brown CG, Werman HA, Davis EA, Hamlin R, Hobson J, Ashton JA.  Comparative effect of graded doses of epinephrine on regional brain blood flow during CPR in a swine model . Ann Emerg Med. 1986;;15:1138-1144.
8 +
Brown CG, Werman HA, Davis EA, Hobson J, Hamlin RL.  The effect of graded doses of epinephrine during cardiopulmonary resuscitation on regional myocardial blood flow in a swine model . Circulation. 1987;;75:491-497.
9 +
Kosnick JW, Jackson RE, Keats S, Tworek RM, Freeman SB.  Dose-related response of centrally administered epinephrine on the change in aortic diastolic pressure during closed-chest massage in dogs . Ann Emerg Med. 1985;;14:204-208.
10 +
Brunette DD, Jameson SJ.  Comparison of standard versus high-dose epinephrine in the resuscitation of cardiac arrest in dogs . Ann Emerg Med. 1990;;19:8-11.
11 +
Gonzalez ER, Ornato JP, Garnett AR, Levine R, Young DS, Racht EM.  Dose-dependent vasopressor response to epinephrine during CPR in humans . Ann Emerg Med. 1989;;18:920-926.
12 +
McKeever WP, Gregg DE, Canney PC.  Oxygen uptake of the nonworking left ventricle . Circ Res. 1958;;6:612-623.
13 +
Monroe RG, French G.  Ventricular pressure-volume relationships and oxygen consumption in fibrillation and arrest . Circ Res. 1960;;8:260-266.
14 +
Kohn RM.  Myocardial oxygen uptake during ventricular fibrillation and electro-mechanical dissociation . Am J Cardiol. 1963;;11:483-486.
15 +
Brown CG, Taylor RB, Werman HA, Luu T, Spittler G, Hamlin RL.  Effect of standard doses of epinephrine on myocardial oxygen delivery and utilization during cardiopulmonary resuscitation . Crit Care Med. 1988;;16:536-539.
16 +
Brown CG, Werman HA.  Adrenergic agonists during cardiopulmonary resuscitation . Resuscitation. 1990;;19:1-16.
17 +
Ditchey RV, Lindenfeld J.  Failure of epinephrine to improve the balance between myocardial oxygen supply and demand during closed-chest resuscitation in dogs . Circulation. 1988;;78:382-389.
18 +
Midei MG, Sugiura S, Maughan WI, Sagawa K, Weisfeldt ML, Guerci AD.  Preservation of ventricular function by treatment of ventricular fibrillation phenylephrine . J Am Coll Cardiol. 1990;;16:489-494.
19 +
Morady F, Nelson SD, Kou WH, et al.  Electrophysiologic effects of epinephrine in humans . J Am Coll Cardiol. 1988;;11:1235-1244.
20 +
Paradis NA, Martin GB, Rosenberg J, et al.  The effect of standard- and high-dose epinephrine on coronary perfusion pressure during prolonged cardiopulmonary resuscitation . JAMA. 1991;;265:1139-1144.
21 +
Callaham M, Barton CW, Kayser S.  Potential complications of high-dose epinephrine therapy in patients resuscitated from cardiac arrest . JAMA. 1991;;265:1117-1122.
22 +
Michael JR, Guerci AD, Koehler RC, et al.  Mechanisms by which epinephrine augments cerebral and myocardial perfusion during cardiopulmonary resuscitation in dogs . Circulation. 1984;;69:822-835.
23 +
Kern KB, Lancaster L, Goldman S, Ewy GA.  The effect of coronary artery lesions on the relationship between coronary perfusion pressure and myocardial blood flow during cardiopulmonary resuscitation in pigs . Am Heart J. 1990;;120:324-325.
24 +
Pearson JW, Redding JS.  Influence of peripheral vascular tone on cardiac resuscitation . Anesth Analg. 1976;;44:746-752.
25 +
Sanders AS, Ewy GA, Taft TV.  Prognostic and therapeutic importance of the aortic diastolic pressure in resuscitation from cardiac arrest . Crit Care Med. 1984;;12:871-873.
26 +
Niemann JT, Criley JM, Rosborough JP, Niskanen RA, Alferness C.  Predictive indices of successful cardiac resuscitation after prolonged arrest and experimental cardiopulmonary resuscitation . Ann Emerg Med. 1985;;14:521-528.
27 +
White RD.  Defining the pressure needs of the fibrillating heart during prolonged arrest: identification and application . Ann Emerg Med. 1985;;14:587-588.
28 +
Paradis NA, Martin GB, Rivers EP, et al.  Coronary perfusion pressure and return of spontaneous circulation in human cardiopulmonary resuscitation . JAMA. 1990;;263:1106-1113.
29 +
Keller RA, Forinash M.  EMS in the United States: a survey of providers in the 200 most populous cities . J Emerg Med Serv. 1990;;15:79-100.

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