In 2010 the International Liaison Committee
on Resuscitation (ILCOR) noted that despite the widespread use of adrenaline (epinephrine)
and other vasopressors during resuscitation in some countries, there was an
absence of high quality evidence to inform treatment recommendations about
their use. Some observational studies suggested either
no effect or potentially harmful effects on long-term survival and neurological
called for placebo-controlled trials to determine the safety and effectiveness
of these drugs in humans.
The European Resuscitation Council (ERC) therefore welcomes the
publication of the PARAMEDIC 2 study, a randomised controlled trial of
adrenaline compared to placebo in 8016 patients with out of hospital cardiac
arrest in the UK. The
trial provides high quality evidence about the effects of adrenaline on short
and long-term outcomes. The primary outcome of the study, survival to 30 days, was 3.2% in the adrenaline
group versus 2.4% in the placebo group (unadjusted odds ratio 1.390; 95% CI
1.062 to 1.819; P=0.017). At the time of hospital discharge, however, severe neurologic impairment had occurred in more of
the survivors in the adrenaline group than in the placebo group (39 of 126
patients [31.0%] vs. 16 of 90 patients [17.8%]).
The interpretation of these results will
require careful consideration by the ERC Advanced Life Support Science and
Education Committee (ALS SEC). The results of the PARAMEDIC 2 trial will also
be considered by ILCOR in its continuous evidence evaluation process. Any
changes in ILCOR treatment recommendations will be considered carefully by the
ERC ALS SEC in case an update to ERC Guidelines is required.
Professor Koen Monsieurs, ERC Vice chair
and Professor of Emergency Medicine at the University of Antwerp said:
“This is a landmark trial in resuscitation that
may prove very important to many patients. The trial compared adrenaline with
placebo in more than 8000 out of hospital cardiac arrest patients. The results
show that the use of adrenaline during resuscitation resulted in more survivors
at 30 days with adrenaline, but their neurologic function was worse than
survivors who received placebo. So it appears that with adrenaline we save more
hearts but not more brain. It would be very valuable to know how potential
victims of cardiac arrest (which is all of us) feel about this. The results of
this trial will now be analysed and discussed by ILCOR in view of all previous
evidence. The resulting ILCOR recommendation will be considered by the ERC, so
look out for an updated ERC guideline on adrenaline soon!”
The European Resuscitation Council was
formed in 1989 and “…aims to preserve human life by making high-quality
resuscitation available to all”. A network of 33 National Resuscitation
Councils (NRCs) represents the ERC at national level. Each NRC oversees
delivery of guidelines, resuscitation training and quality control in its
- Deakin CD, Morrison LJ,
Morley PT, et al. Part 8: Advanced life support: 2010 International Consensus
on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with
Treatment Recommendations. Resuscitation 2010;81 Suppl 1:e93-e174.
- Soar J, Callaway CW, Aibiki M, et al.
Part 4: Advanced life support: 2015 International Consensus on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science with Treatment
Recommendations. Resuscitation 2015;95:e71-120.
- Kleinman ME,
Perkins GD, Bhanji F, et al. ILCOR
Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. A Consensus Statement.
- Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, Regan S, Long J,
Slowther A, Pocock H, Black JJM, Moore F, Fothergill RT, Rees N, O’Shea L,
Docherty M, Gunson I, Han K, Charlton K, Finn J, Petrou S, Stallard N, Gates S,
and Lall R, for the PARAMEDIC2 Collaborators* A Randomized Trial of Epinephrine
in Out-of-Hospital Cardiac Arrest. NEJM 2018 E-publication www.nejm.org/doi/full/10.1056/NEJMoa1806842
- Soar J, Nolan
JP, Bottiger BW, et al. European
Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult
advanced life support. Resuscitation 2015;95:100-47.