{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T16:23:51Z","timestamp":1791476631252,"version":"4.3.4"},"reference-count":37,"publisher":"BMJ","license":[{"start":{"date-parts":[[2021,11,10]],"date-time":"2021-11-10T00:00:00Z","timestamp":1636502400000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000016","name":"U.S. Department of Health and Human Services","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000016","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100009633","name":"Eunice Kennedy Shriver National Institute of Child Health and Human Development","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100009633","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ"],"accepted":{"date-parts":[[2021,10,18]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To determine the use of epinephrine (adrenaline) before defibrillation for treatment of in-hospital cardiac arrest due to a ventricular arrhythmia and examine its association with patient survival.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Propensity matched analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>2000-18 data from 497 hospitals participating in the American Heart Association\u2019s Get With The Guidelines-Resuscitation registry.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Adults aged 18 and older with an index in-hospital cardiac arrest due to an initial shockable rhythm treated with defibrillation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Interventions<\/jats:title>\n                    <jats:p>Administration of epinephrine before first defibrillation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main outcome measures<\/jats:title>\n                    <jats:p>Survival to discharge; favorable neurological survival, defined as survival to discharge with none, mild, or moderate neurological disability measured using cerebral performance category scores; and survival after acute resuscitation (that is, return of spontaneous circulation for &gt;20 minutes). A time dependent, propensity matched analysis was performed to adjust for confounding due to indication and evaluate the independent association of epinephrine before defibrillation with study outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Among 34\u2009820 patients with an initial shockable rhythm, 7054 (20.3%) were treated with epinephrine before defibrillation, contrary to current guidelines. In comparison with participants treated with defibrillation first, participants receiving epinephrine first were less likely to have a history of myocardial infarction or heart failure, but more likely to have renal failure, sepsis, respiratory insufficiency, and receive mechanical ventilation before in-hospital cardiac arrest (standardized differences &gt;10% for all). Treatment with epinephrine before defibrillation was strongly associated with delayed defibrillation (median 4 minutes\n                      <jats:italic>v<\/jats:italic>\n                      0 minutes). In propensity matched analysis (6569 matched pairs), epinephrine before defibrillation was associated with lower odds of survival to discharge (22.4%\n                      <jats:italic>v<\/jats:italic>\n                      29.7%; adjusted odds ratio 0.69; 95% confidence interval 0.64 to 0.74; P&lt;0.001), favorable neurological survival (15.8%\n                      <jats:italic>v<\/jats:italic>\n                      21.6%; 0.68; 0.61 to 0.76; P&lt;0.001) and survival after acute resuscitation (61.7%\n                      <jats:italic>v<\/jats:italic>\n                      69.5%; 0.73; 0.67 to 0.79; P&lt;0.001). The above findings were consistent in a range of sensitivity analyses, including matching according to defibrillation time.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Contrary to current guidelines that prioritize immediate defibrillation for in-hospital cardiac arrest due to a shockable rhythm, one in five patients are treated with epinephrine before defibrillation. Use of epinephrine before defibrillation was associated with worse survival outcomes.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmj-2021-066534","type":"journal-article","created":{"date-parts":[[2021,11,10]],"date-time":"2021-11-10T06:45:14Z","timestamp":1636526714000},"page":"e066534","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":36,"title":["Epinephrine before defibrillation in patients with shockable in-hospital cardiac arrest: propensity matched analysis"],"prefix":"10.1136","volume":"375","author":[{"given":"Erin","family":"Evans","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Morgan B","family":"Swanson","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA"},{"name":"Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicholas","family":"Mohr","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nassar","family":"Boulos","sequence":"additional","affiliation":[{"name":"Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mary","family":"Vaughan-Sarrazin","sequence":"additional","affiliation":[{"name":"Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA"},{"name":"Centre for Access Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Centre, Iowa City, IA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul S","family":"Chan","sequence":"additional","affiliation":[{"name":"Saint Luke\u2019s Mid America Heart and Vascular Institute, University of Missouri-Kansas, Kansas City, MO, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4784-4513","authenticated-orcid":false,"given":"Saket","family":"Girotra","sequence":"additional","affiliation":[{"name":"Centre for Access Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Centre, Iowa City, IA, USA"},{"name":"Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2021,11,10]]},"reference":[{"key":"2025110101374373000_375.nov10_3.e066534.1","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCOUTCOMES.119.005580"},{"key":"2025110101374373000_375.nov10_3.e066534.2","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2020.10403"},{"key":"2025110101374373000_375.nov10_3.e066534.3","doi-asserted-by":"publisher","DOI":"10.1161\/CIR.0000000000000916"},{"key":"2025110101374373000_375.nov10_3.e066534.4","unstructured":"American Heart Association. 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