Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Dr. Ken Grauer on Killing Patients Just to Get a Temporary Pulse With Epinephrine – Part I


Dr. Grauer,

I love your ACLS 2nd edition and learned more about ACLS from your book than from any other source. You and Daniel Cavallaro did a great job of presenting the material in a way that encourages thinking and assessment. I think that your presentation of the rationale behind the possible treatments ahead of the 1992 ACLS was a great service to those who were able to read your book. I used it long after your third edition came out, because of the way you analyzed the treatments.

Dr. Grauer wrote a lot in two comments, in response to Killing Patients Just to Get a Temporary Pulse With Epinephrine, with only the abstract as a reference for the first comment. I will try to address a point, or two, at a time without distorting his meaning.

Observational studies are just that – observations – NOT proof. Based on observational studies done on large numbers of women we routinely treated with estrogen for many years – until controlled, prospective trials were done and showed the fallacy of that previously uniformly accepted observational dogma …

This is the primary difference in our views of the research.

I am not stating that we should use observational data to add an unexamined treatment.

No, I want much better evidence that any treatment works. It would not be good patient care to treat patients based only on observational data, but what we have to support the use of epinephrine in cardiac arrest epinephrine is not even as good as observational data.

An observational study showing a benefit from the use of epinephrine would be a tremendous contribution to the research supporting epinephrine in cardiac arrest, because there is no outcomes research supporting epinephrine in cardiac arrest. Nothing.

We have several studies showing harm from epinephrine, but no studies showing any benefit. 50 years of absolute failure to produce a single study showing improved outcomes with epinephrine. What is wrong with us?

We are treating patients based only on surrogate endpoints. Improved circulation in the laboratory and improved ROSC (Return Of Spontaneous Circulation).

Surrogate endpoints are only useful for generating hypotheses about possible outcomes studies. Surrogate endpoint studies are much lower quality than observational studies.

When surrogate endpoints are examined, they consistently fail to demonstrate improvement in outcomes.

We are not helping our patients if we do not pay attention to any studies that consistently show harm.

First, do no harm, is supposed to be an important consideration. No harm is impossible,[1] but we should minimize the potential harm.

After 50 years, where is any evidence of improved survival from epinephrine?

 

How useless is a drug, that after 50 years of use we cannot show ANY benefit?

 

The goal is not to produce a temporary pulse. The goal is to produce survivors.

 

Where are the survivors?

 

With epinephrine, 2,786 patients had ROSC.

Only 805 patients were alive one month later.

Why do almost all of the patients who get epinephrine die very quickly?

Only 205 patients had good brain function.

Why do almost all of the patients not killed by epinephrine end up with severe brain damage?

93% of the ROSC patients were dead or disabled with epinephrine.

More ROSC, but they don’t survive. All of the research has the same result.

If this is not the typical epinephrine response, then somebody needs to prove it.

We need to stop killing patients with epinephrine.

50 years of trust us, it works, means 50 years of killing patients just to get a quick pulse that often does not even last until the emergency department.

Footnotes:

[1] A piece of my mind: the harm of “first, do no harm”.
Shelton JD.
JAMA. 2000 Dec 6;284(21):2687-8. No abstract available.
PMID: 11105155 [PubMed – indexed for MEDLINE]

Much of the rest of the world operates on sensible risk/benefit principles and by embracing error. But medicine tries to operate on impossible zero-tolerance principles and by denying error. Paradoxically, the old concept leads to too much harm.

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Comments

  1. Thank you Rogue Medic – as I am truly touched by the picture of my 1992 Mosby ACLS book whose cover is torn by use …. I sincerely appreciate the kind words. THANK YOU also for providing me with the article and editorial in question, as well as additional pdf articles this morning.

    I respect your views that you state above. However, my opinion does differ from yours in a number of regards. After thorough review of the articles in question – I have expressed my views in ISSUE #10 of my ACLS Comments (https://www.kg-ekgpress.com/acls_comments-_issue_10/ ).

    I welcome feedback (ekgpress@mac.com)

    Thank you again Rogue Medic for this stimulating discussion, and for your receptivity to my views, even though they may differ with yours. Hopefully some day – that well done randomized controlled trial on use of Epinephrine in cardiac arrest will get done. Until then – the decision will have to be made on whether or not to continue using Epinephrine as we have up to now – Ken Grauer, MD