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Thanks to Kaitlyn Works, MD, and Corey Slovis, MD, for their excellent review of epinephrine in cardiac arrest. (“Use Epinephrine Judiciously in Cardiac Arrest,” EMN. 2020;42:6; https://bit.ly/2wMbIJc.)
Sometimes I will prolong what is clearly a futile code so that the family can enter the room prior to termination. This isn't an argument for epinephrine per se, just a reason to prolong an unsuccessful resuscitation attempt. The literature supports that this is an important cathartic practice that is beneficial in the long term for families.
I also wonder if there are organ donor benefits from the use of epinephrine? While it may not lead to a higher likelihood of functional discharge, if its use increases the availability of organ donation (from brain dead but living patients), there may be an argument for its continued use. Thoughts?
Bruce Nisbet, MD
Drs. Slovis and Works respond: Dr. Nisbet brings up two important considerations about epinephrine's ability to bring back the heart but not the brain. Allowing family to view the termination of a futile code is important. Prehospital care providers and in-hospital physicians should always consider whether it's right to have family present. Prolonging the code with repeat doses of epinephrine, however, may unintentionally prolong that patient's ICU stay or unnecessary and potentially dangerous emergency transport to the hospital. Once the resuscitation is known to be futile, our recommendation is to allow the family to see the resuscitation terminated in the right circumstances without additional doses of epinephrine.
Dr. Nisbet's second point is extremely cogent in this time of growing numbers of desperate patients awaiting an organ to survive. There is no question that status post-cardiac arrest patients can be organ or multiorgan donors. (Resuscitation. 2019;145:63.) In any arrest, consideration should include whether the patient could be an organ donor if we can get him back.
This scenario is usually an in-hospital arrest where death has been predicted and possible organ donation already discussed or a sudden death with a relatively short downtime. We fear that intentionally prolonging an out-of-hospital arrest whose downtime is unknown and then rushing the patient to the hospital with ongoing CPR is not something that should routinely be undertaken. The primary cause of death in EMS is motor vehicle crashes that are going to or coming from an emergency such as CPR in progress. Once an unwitnessed arrest has received CPR and two or three doses of epinephrine and remained pulseless, the likelihood he will regain a pulse or be a variable donor is minimal. (Resuscitation. 2019;138:316; https://bit.ly/34U1we2.)
Allowing the family to grieve during the resuscitation, considering organ donation, and valuing the entire team after termination are all important for every arrest and should be a focus of every team leader.