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Successful cardiopulmonary resuscitation using high doses of epinephrine
International Journal of Cardiology, 33 (1991) 430-431 Q 1991 Elsevier Science Publishers B.V. All rights reserved 0167-5273/91/$03.50
430
CARD10 13612
Successful cardiopulmonary resuscitation using high doses of epinephrine Giovanni Cipolotti, Agostino Paccagnella and Giuseppe Simini 2 o Seroizio di Anestesia e Rianimazione, Ospedale “S. Maria dei Battuti”, Treoiso, Italy
(Received 28 December 1990; revision accepted 6 June 1991)
Cardiac arrest usually carries a bleak prognosis when occurring in patients who have undergone open heart surgery. We report two cases where cardiac arrest was not responsive to routine therapies. Doses of epinephrine 5-10 times higher than recommended were able to provide a resolution, and the patients were discharged in a normal neurological state. Key words: Epinephrine;
Cardiac arrest; Cardiopulmonary
Introduction The dose of epinephrine used routinely to treat cardiac arrest has recently been reviewed [1,2]. In this report we describe two patients in whom, because standard therapy using routine guidelines proved unsuccessful, epinephrine was administered in doses 5-10 times those currently recommended. The treatment proved successful in both cases. Case 1 A 64-year-old man (71 kg) affected by coronary arterial disease, myocardial infarction, hypertension, congestive heart failure and recurrent pulmonary
Correspondence to: Dr. G. Cipolotti, 2 Servizio Anestesia e
Rianimazione, viso, Italy.
Ospedale “S. Maria dei Battuti”, 31100 Tre-
resuscitation
edema underwent cardiac catheterization. This showed obstruction of the anterior interventricular coronary artery (85%) and a very large aneurysm in the anterior and lateral side of the left ventricle. After aortocoronary bypass grafting and aneurysmectomy, an intra-aortic balloon pump was inserted to help wean the patient from cardiopulmonary bypass. Inotropic drugs were continuously infused to maintain an acceptable cardiac rhythm and systemic arterial pressure. Because the hemodynamics improved during the few hours after surgery, drug dosages were decreased and use of the balloon pump was discontinued 24 hours later. Extubation was made after 6 hours. On the fourth post-operative day, the patient developed ventricular tachycardia followed by cardiac arrest. Cardiopulmonary resuscitation was attempted, and 0.01 mg/kg of epinephrine was infused. Ten minutes later, the monitor revealed ventricular fibrillation. Since this failed to respond to the given therapy, 5 and 10 mg of epinephrine were infused, producing sinus rhythm. The patient was discharged from hospital 8.5 days after surgery in a normal neurological state and he is now well three years after surgery.
431
Case 2 A 66-year-old man (66 kg) was affected by coronary arterial disease, myocardial infarction and stenosis of the left carotid artery. Cardiac catheterisation showed stenosis of the left main (40%), descending anterior interventricular (SO%), circumflex (30%), and right (90%) coronary arteries. Two aorto-coronary bypass grafts were inserted, and inotropic drugs were used for weaning from cardiopulmonary bypass. Six hours after surgery, the patient developed ventricular fibrillation, which responded to routine therapeutic schedules. Six hours later, the syndrome of low cardiac output occurred, and an intra-aortic balloon pump was inserted. Sixteen hours after surgery, a new episode of ventricular fibrillation was resolved by three defibrillations. Approximately 10 minutes later, a cardiac arrest was resolved by administering 1 and 5 mg epinephrine. Sinus rhythm and hemodynamic stability were obtained. After two hours, a new episode of cardiac arrest was successfully treated with a bolus of 10 mg epinephrine. The patient was extubated 36 hours after surgery, and the balloon pump was removed. Blood tests did not show any evidence of organ failure and, 25 days after surgery, he was discharged from hospital in a normal neurological state.
Discussion In the cases described, cardiopulmonary resuscitation was performed according to recommendations in the literature [3], although the dose of epinephrine was higher than that usually recommended (0.5 to 1.0 mg every five minutes, about 0.007-0.014 mg/kg). In animal studies, a dose of epinephrine of 0.03-0.1 mg/kg [1,4] produced therapeutic success for 80-90% of cases. Furthermore, Brown et al. [2] found that a dose of 0.2 mg/kg epinephrine produced cerebral blood
flow higher than that produced with 0.02 mg/kg. Epinephrine in high doses is generally required to maintain high coronary and cerebral flow in animals
[5]. Although these experiments were performed in animals without coronary arterial disease, some authors [l] have shown that a dosage of epinephrine 5-10 times higher than that usually recommended would be effective for cardiopulmonary resuscitation. Because we have treated only two patients suffering arrest with epinephrine given in high doses, and because of the objective difficulty in analysing the effects of epinephrine in these very complex conditions, we cannot suggest conclusive therapeutic schedules. Koscove and Paradis [l], nonetheless, make two interesting observations. First, relatively poor results were obtained with recommended standard therapies. Second, epinephrine given in high doses seems to be the most efficient and the least harmful treatment. Consequently, we believe that epinephrine in a dose of 0.07-0.10 mg/kg/bolus should be administered whenever standard therapy proves inadequate and the expectation of life is poor. References Koscove EM, Paradis NA. Successful resuscitation from cardiac arrest using high-dose epinephrine therapy. J Am Med Assoc 1988;259:3031-3034. Brown CG, Werman HA, Davis EA, Hobson 3, Hamlin RL. The effects of graded doses of epinephrine on regional myocardial blood flow during cardiopulmonary resuscitation in swine. Circulation 1987;75:491-497. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). J Am Med Assoc 1986;255:2841-3044. Michael JR, Guerci AD, Koelher RC, et al. Mechanisms by which epinephrine augments cerebral and myocardial perfusion during cardiopulmonary resuscitation in dogs. Circulation 1984;69:822-835. Brunette DD, Jameson SJ. Comparison of standard vs. high-dose epinephrine in the resuscitation of Cardiac Arrest in Dogs. Ann Emerg Med 1990;19:8-13.
430
CARD10 13612
Successful cardiopulmonary resuscitation using high doses of epinephrine Giovanni Cipolotti, Agostino Paccagnella and Giuseppe Simini 2 o Seroizio di Anestesia e Rianimazione, Ospedale “S. Maria dei Battuti”, Treoiso, Italy
(Received 28 December 1990; revision accepted 6 June 1991)
Cardiac arrest usually carries a bleak prognosis when occurring in patients who have undergone open heart surgery. We report two cases where cardiac arrest was not responsive to routine therapies. Doses of epinephrine 5-10 times higher than recommended were able to provide a resolution, and the patients were discharged in a normal neurological state. Key words: Epinephrine;
Cardiac arrest; Cardiopulmonary
Introduction The dose of epinephrine used routinely to treat cardiac arrest has recently been reviewed [1,2]. In this report we describe two patients in whom, because standard therapy using routine guidelines proved unsuccessful, epinephrine was administered in doses 5-10 times those currently recommended. The treatment proved successful in both cases. Case 1 A 64-year-old man (71 kg) affected by coronary arterial disease, myocardial infarction, hypertension, congestive heart failure and recurrent pulmonary
Correspondence to: Dr. G. Cipolotti, 2 Servizio Anestesia e
Rianimazione, viso, Italy.
Ospedale “S. Maria dei Battuti”, 31100 Tre-
resuscitation
edema underwent cardiac catheterization. This showed obstruction of the anterior interventricular coronary artery (85%) and a very large aneurysm in the anterior and lateral side of the left ventricle. After aortocoronary bypass grafting and aneurysmectomy, an intra-aortic balloon pump was inserted to help wean the patient from cardiopulmonary bypass. Inotropic drugs were continuously infused to maintain an acceptable cardiac rhythm and systemic arterial pressure. Because the hemodynamics improved during the few hours after surgery, drug dosages were decreased and use of the balloon pump was discontinued 24 hours later. Extubation was made after 6 hours. On the fourth post-operative day, the patient developed ventricular tachycardia followed by cardiac arrest. Cardiopulmonary resuscitation was attempted, and 0.01 mg/kg of epinephrine was infused. Ten minutes later, the monitor revealed ventricular fibrillation. Since this failed to respond to the given therapy, 5 and 10 mg of epinephrine were infused, producing sinus rhythm. The patient was discharged from hospital 8.5 days after surgery in a normal neurological state and he is now well three years after surgery.
431
Case 2 A 66-year-old man (66 kg) was affected by coronary arterial disease, myocardial infarction and stenosis of the left carotid artery. Cardiac catheterisation showed stenosis of the left main (40%), descending anterior interventricular (SO%), circumflex (30%), and right (90%) coronary arteries. Two aorto-coronary bypass grafts were inserted, and inotropic drugs were used for weaning from cardiopulmonary bypass. Six hours after surgery, the patient developed ventricular fibrillation, which responded to routine therapeutic schedules. Six hours later, the syndrome of low cardiac output occurred, and an intra-aortic balloon pump was inserted. Sixteen hours after surgery, a new episode of ventricular fibrillation was resolved by three defibrillations. Approximately 10 minutes later, a cardiac arrest was resolved by administering 1 and 5 mg epinephrine. Sinus rhythm and hemodynamic stability were obtained. After two hours, a new episode of cardiac arrest was successfully treated with a bolus of 10 mg epinephrine. The patient was extubated 36 hours after surgery, and the balloon pump was removed. Blood tests did not show any evidence of organ failure and, 25 days after surgery, he was discharged from hospital in a normal neurological state.
Discussion In the cases described, cardiopulmonary resuscitation was performed according to recommendations in the literature [3], although the dose of epinephrine was higher than that usually recommended (0.5 to 1.0 mg every five minutes, about 0.007-0.014 mg/kg). In animal studies, a dose of epinephrine of 0.03-0.1 mg/kg [1,4] produced therapeutic success for 80-90% of cases. Furthermore, Brown et al. [2] found that a dose of 0.2 mg/kg epinephrine produced cerebral blood
flow higher than that produced with 0.02 mg/kg. Epinephrine in high doses is generally required to maintain high coronary and cerebral flow in animals
[5]. Although these experiments were performed in animals without coronary arterial disease, some authors [l] have shown that a dosage of epinephrine 5-10 times higher than that usually recommended would be effective for cardiopulmonary resuscitation. Because we have treated only two patients suffering arrest with epinephrine given in high doses, and because of the objective difficulty in analysing the effects of epinephrine in these very complex conditions, we cannot suggest conclusive therapeutic schedules. Koscove and Paradis [l], nonetheless, make two interesting observations. First, relatively poor results were obtained with recommended standard therapies. Second, epinephrine given in high doses seems to be the most efficient and the least harmful treatment. Consequently, we believe that epinephrine in a dose of 0.07-0.10 mg/kg/bolus should be administered whenever standard therapy proves inadequate and the expectation of life is poor. References Koscove EM, Paradis NA. Successful resuscitation from cardiac arrest using high-dose epinephrine therapy. J Am Med Assoc 1988;259:3031-3034. Brown CG, Werman HA, Davis EA, Hobson 3, Hamlin RL. The effects of graded doses of epinephrine on regional myocardial blood flow during cardiopulmonary resuscitation in swine. Circulation 1987;75:491-497. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). J Am Med Assoc 1986;255:2841-3044. Michael JR, Guerci AD, Koelher RC, et al. Mechanisms by which epinephrine augments cerebral and myocardial perfusion during cardiopulmonary resuscitation in dogs. Circulation 1984;69:822-835. Brunette DD, Jameson SJ. Comparison of standard vs. high-dose epinephrine in the resuscitation of Cardiac Arrest in Dogs. Ann Emerg Med 1990;19:8-13.