The use of epinephrine in cases of ventricular fibrillation (VF) during cardiac arrest remains a contentious topic within the medical community. The current Advanced Cardiac Life Support (ACLS) guidelines endorse the administration of epinephrine as part of the resuscitation protocol, primarily due to its α-adrenergic receptor-stimulating properties, which can enhance coronary and cerebral perfusion pressures during cardiopulmonary resuscitation (CPR) (Goto et al., 2013; , Glover et al., 2012). However, emerging evidence suggests that the benefits of epinephrine may be overshadowed by potential adverse effects, leading to increased mortality and neurological impairment in some cases (Yamamoto et al., 2019; , Barnard et al., 2019).
Epinephrine's role in improving return of spontaneous circulation (ROSC) is well-documented, with studies indicating that its administration can lead to short-term survival benefits (Chiang et al., 2015). For instance, the PARAMEDIC-2 trial demonstrated a survival advantage at 30 days for patients receiving epinephrine compared to placebo, although it did not show a difference in neurological outcomes (Barnard et al., 2019). This raises critical questions about the long-term efficacy and safety of epinephrine, particularly in the context of VF, where the risk of myocardial dysfunction and arrhythmogenesis may be heightened (Yamamoto et al., 2019).
Moreover, the effectiveness of epinephrine in refractory VF is being challenged by alternative approaches, such as dual-sequential defibrillation and the use of antiarrhythmic agents like amiodarone. Studies have indicated that these methods may provide better outcomes in patients with refractory VF, suggesting a shift in focus from traditional epinephrine administration to more innovative strategies (Bignucolo et al., 2019; , Panchal et al., 2018). For example, research has shown that while epinephrine can increase perfusion pressures, it may also contribute to adverse hemodynamic effects, including increased myocardial oxygen demand and potential for arrhythmias, versus the use of intravenous fluids to create improved perfusion (Yamamoto et al., 2019; , Lee et al., 2021).
In summary, while epinephrine has been a cornerstone in the management of VF during cardiac arrest, its continued use is under scrutiny due to concerns about its long-term efficacy and safety. The medical community is increasingly considering alternative therapies that may offer improved outcomes without the associated risks of epinephrine. Therefore, further research is essential to establish clear guidelines on the use of epinephrine in this critical setting, balancing immediate resuscitation needs with long-term patient outcomes.
References:
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https://doi.org/10.1136/emermed-2018-208165
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