P1703Impact of prehospital epinephrine administration and quality of cardiopulmonary resuscitation on neurologically intact survival in out-of-hospital cardiac arrest patients with non-shockable rhythm

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
A Funada ◽  
Y Goto ◽  
H Okada ◽  
T Maeda ◽  
M Takamura
Keyword(s):  
Cardiac Arrest ◽  
Multivariate Logistic Regression Analysis ◽  
Multivariate Logistic Regression ◽  
High Quality ◽  
Epinephrine Administration ◽  
Hospital Arrival ◽  
Shockable Rhythm ◽  
Neurologically Intact ◽  
Hospital Cardiac Arrest

Abstract Background The effects of prehospital epinephrine administration in combination with the quality of cardiopulmonary resuscitation (CPR) on neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythm remains unclear. Purpose This study aimed to elucidate the effects of prehospital epinephrine administration in combination with the quality of CPR on neurologically intact survival in OHCA patients with non-shockable rhythm. Methods We analysed 118,732 adult OHCA patients with non-shockable rhythm from the All-Japan OHCA registry between 2011 and 2016 (29,989 emergency medical service [EMS]-witnessed arrests with EMS-initiated CPR [high-quality CPR] and 88,743 bystander-witnessed arrests with bystander-initiated CPR continued by EMS providers [low-quality CPR]). Patients who achieved prehospital return of spontaneous circulation without prehospital epinephrine administration were excluded. The primary outcome measure was 1-month neurologically intact survival (cerebral performance category 1 or 2; CPC 1–2). Time from collapse to prehospital epinephrine administration for patients with prehospital epinephrine administration, or to hospital arrival for patients without prehospital epinephrine administration was calculated and adjusted collectively in multivariate logistic regression analysis for 1-month CPC 1–2. Results Multivariate logistic regression analysis revealed that the time from collapse to prehospital epinephrine administration or to hospital arrival was negatively associated with 1-month CPC 1–2 (adjusted odds ratio [OR] 0.95 per 1-minute increment, 95% confidence interval [CI] 0.94–0.96). Compared with bystander-witnessed arrests without prehospital epinephrine administration, EMS-witnessed arrests with or without prehospital epinephrine administration were significantly associated with increased chances of 1-month CPC 1–2 (adjusted OR 2.04, 95% CI 1.50–2.75 and adjusted OR 1.97, 95% CI 1.57–2.48, respectively). Prehospital epinephrine administration was significantly associated with an increased chance of 1-month CPC 1–2 among bystander-witnessed arrests (adjusted OR 1.57, 95% CI 1.24–1.98), but not among EMS-witnessed arrests. EMS-witnessed arrests without prehospital epinephrine administration were significantly associated with an increased chance of 1-month CPC 1–2 compared with bystander-witnessed arrests with prehospital epinephrine administration (adjusted OR 1.26, 95% CI 1.01–1.56). Conclusions High-quality CPR is crucial for increasing neurologically intact survival in OHCA patients with non-shockable rhythm. The additional beneficial effects of prehospital epinephrine administration were observed only among OHCA patients with low-quality CPR.

5227Effects of witness status and time to cardiopulmonary resuscitation by emergency medical services on neurological outcomes in out-of-hospital cardiac arrest patients with non-shockable rhythm

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
A Funada ◽  
Y Goto ◽  
H Okada ◽  
T Maeda ◽  
M Takamura
Keyword(s):  
Logistic Regression ◽  
Cardiac Arrest ◽  
Regression Analysis ◽  
Cardiopulmonary Resuscitation ◽  
Multivariate Logistic Regression Analysis ◽  
Emergency Call ◽  
Multivariate Logistic Regression ◽  
Shockable Rhythm ◽  
Neurologically Intact ◽  
Hospital Cardiac Arrest

Abstract Background Data on the effects of witness status and time from an emergency call to initiation of cardiopulmonary resuscitation (CPR) by emergency medical service (EMS) providers on neurological outcome in out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythm according to the first documented rhythm are limited. Purpose We aimed to determine the effects of witness status and time from an emergency call to CPR initiation by EMS providers on neurologically intact survival in OHCA patients according to the type of non-shockable rhythm (pulseless electrical activity [PEA] and asystole). Methods We analysed the records of 583,431 adult OHCA patients with non-shockable rhythm (191,905 bystander-witnessed arrest and 391,526 unwitnessed arrest). Data were derived from the prospectively recorded All-Japan OHCA registry between 2011 and 2016. Call to EMS-CPR interval was defined as the time from an emergency call to CPR initiation by EMS providers. The primary outcome was 1-month neurologically intact survival (cerebral performance category 1 or 2; CPC 1–2) and secondary outcome was presence of PEA. Results The rates of 1-month CPC 1–2 were 1.21% (2,326/191,905) for bystander-witnessed arrest and 0.24% (959/391,526) for unwitnessed arrest. When divided into 4 groups based on witness status and initial documented rhythm, these rates were 2.42% (1,869/77,190) for bystander-witnessed arrest with PEA (group A), 0.40% (457/114,715) for bystander-witnessed arrest with asystole (group B), 1.51% (679/44,926) for unwitnessed arrest with PEA (group C) and 0.08% (280/346,600) for unwitnessed arrest with asystole (group D). Multivariate logistic regression analysis revealed each 1-min delay of Call to EMS-CPR interval to be significantly associated with decreased chances of 1-month CPC 1–2 for groups A, B and D (adjusted odds ratio [OR]: 0.95, 0.91 and 0.96, respectively; 95% confidence interval [CI]: 0.93–0.96, 0.88–0.94 and 0.93–0.99, respectively). However, for group C, there was no significant relationship between these variables (adjusted OR: 1.00; 95% CI: 0.98–1.02). The proportion of PEA was 40.2% (77,190/191,905) for bystander-witnessed arrest and 11.5% (44,926/391,526) for unwitnessed arrest. Multivariate logistic regression analysis revealed that, as Call to EMS-CPR interval lengthened (per 1-min delay), the number of OHCA patients with PEA decreased for bystander-witnessed arrest (adjusted OR: 0.94; 95% CI: 0.93–0.94) and for unwitnessed arrest (adjusted OR: 0.96; 95% CI: 0.96–0.97). Conclusions The 1-month CPC 1–2 rate differed by witness status and initial documented rhythm in OHCA patients with non-shockable rhythm. Shortening of Call to EMS-CPR interval is crucial for improving 1-month CPC 1–2 rate and sustaining PEA, particularly in bystander-witnessed arrest.

Abstract 169: Association Between Time to First Administration of Epinephrine After Defibrillation and Outcome in Out-Of-Hospital Cardiac Arrest Patients With Shockable Rhythm

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Shoji Kawakami ◽  
Yoshio Tahara ◽  
Teruo Noguchi ◽  
Satoshi Yasuda ◽  
Naohiro W Yonemoto ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Neurological Outcome ◽  
Cerebral Performance Category ◽  
Multivariate Logistic Regression Analysis ◽  
Population Based ◽  
Emergency Medical Service Personnel ◽  
Epinephrine Administration ◽  
Shockable Rhythm ◽  
Favorable Neurological Outcome ◽  
Hospital Cardiac Arrest

Introduction: In out-of-hospital cardiac arrest (OHCA) patients during shockable rhythm, the epinephrine administration after second defibrillation is recommended by the 2015 ILCOR/CoSTR guidelines. However, there is insufficient evidence regarding the proper timing of epinephrine administration particularly in relation to defibrillation. Hypothesis: The timing of epinephrine after first defibrillation (D-E interval) was associated with clinical outcome in OHCA patients. Methods: Between 2011 and 2016, we enrolled 753,025 OHCA patients from nationwide prospective population-based registry in Japan. Following exclusion criteria, a total of 1,559 patients with witnessed by bystanders and shockable rhythm on the initial electrocardiogram who administrated epinephrine after defibrillation by emergency medical service personnel and obtained return of spontaneous circulation in prehospital setting were eligible for the study. We evaluated the association between D-E interval and favorable neurological outcome (cerebral performance category: 1 or 2) at 30 days. To evaluate predictor for better neurological outcome, study patients were categorized as every 2 minutes up to 20 minutes, and more than 20 minutes. Results: Patients with favorable neurological outcome were 22% (N=348). Patients with favorable neurological outcome had a shorter D-E interval than those with non-favorable neurological outcome (7.9±4.1vs 10.2±5.3 min, p<0.001). Multivariate logistic regression analysis showed that D-E interval at more than 10 minutes, when D-E interval at 2 to 3 minutes as defined reference, was a significant predictor for non-favorable neurological outcome ( Table ). Conclusion: Delayed epinephrine administration after first defibrillation (D-E interval >10 minutes) was significantly associated with non-favorable neurological outcome.

Abstract 9502: Prehospital Variables Associated With Neurologically Intact Survival in Elderly Survivors After Out-of-Hospital Cardiac Arrest: Evidence from a Japanese Nationwide Population-based Cohort Study

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Akira Funada ◽  
Yoshikazu Goto ◽  
Masayuki Takamura
Keyword(s):  
Cardiac Arrest ◽  
Service Providers ◽  
Recursive Partitioning ◽  
Age Groups ◽  
Cerebral Performance Category ◽  
Multivariate Logistic Regression Analysis ◽  
Population Based ◽  
Shockable Rhythm ◽  
Neurologically Intact ◽  
Hospital Cardiac Arrest

Introduction: Prehospital variables associated with neurologically intact survival in elderly survivors after out-of-hospital cardiac arrest (OHCA) are unclear and could differ according to age. Methods: We evaluated 6,349 elderly patients with OHCA (age ≥ 65 years) of cardiac origin who achieved prehospital return of spontaneous circulation (ROSC) and survived for at least 1-month after OHCA. Data were obtained from the prospectively recorded All-Japan Utstein Registry between 2011 and 2016. Patients witnessed by emergency medical service providers were excluded. The primary outcome was 1-month neurologically intact survival, defined as a cerebral performance category (CPC) score of 1-2. Patients were divided into three groups by age (65-74, 75-89, or ≥ 90 years). The time from call receipt to ROSC was calculated. Results: The rates of 1-month CPC 1-2 in patients aged 65-74, 75-89, and ≥ 90 years were 66.5% (2,079/3,125), 52.9% (1,557/2,943), and 42.7% (120/281), respectively (p for trend < 0.001). In multivariate logistic regression analysis, initial shockable rhythm and witnessed arrest were significantly associated with 1-month CPC 1-2 for all age groups (Table). However, the presence of bystander cardiopulmonary resuscitation (CPR) was significantly associated with 1-month CPC 1-2 only for patients aged 65-74 years. Time from call receipt to ROSC was not associated with 1-month CPC 1-2 for patients aged ≥ 90 years. In recursive partitioning analysis, the best single predictor for 1-month CPC 1-2 was initial shockable rhythm for all age groups. The next predictor for patients aged 65-74 years with initial shockable rhythm was the presence of bystander CPR, whereas the witnessed arrest was the next predictor for patients aged 65-74 years with initial non-shockable rhythm and other age groups regardless of the initial rhythm. Conclusions: Prehospital variables associated with neurologically intact survival in elderly survivors after OHCA varied with age.

Abstract 176: Effects of the Presence of Emergency Medical Service Physician on Neurologically Intact Survival After an Out-of-Hospital Cardiac Arrest: A Nationwide Population-Based Observational Study

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Akira Funada ◽  
Yoshikazu Goto ◽  
Hayato Tada ◽  
Masaya Shimojima ◽  
Hirofumi Okada ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Large Scale ◽  
Cerebral Performance Category ◽  
Multivariate Logistic Regression Analysis ◽  
Population Based ◽  
P Values ◽  
Hospital Arrival ◽  
Emergency Medical ◽  
Neurologically Intact ◽  
Hospital Cardiac Arrest

Introduction: Previous observational studies have suggested that prehospital emergency medical services (EMS) physician-guided cardiopulmonary resuscitation (CPR) is associated with improved survival after an out-of-hospital cardiac arrest (OHCA) when compared with paramedic-guided CPR. Hypothesis: EMS physician-guided CPR for OHCA is associated with improved 1-month neurologically intact survival compared with paramedic-guided CPR, from the 2010 guideline updates onward. Methods: The study included 613,251 Japanese adults (aged ≥18 years) from a prospectively recorded nationwide Utstein-style database who had OHCA between 2011 and 2015. The patients were divided into two groups on the basis of the presence of a physician during CPR before hospital arrival: EMS physician- (n=19,551, 3.2%) and paramedic-guided CPR groups (n=593,700, 96.8%). The study end-points were 1-month and neurologically intact survivals, defined as Cerebral Performance Category scores of 1 or 2 (CPC 1-2). Results: Proportions of crude 1-month survival and CPC 1-2 in the EMS physician-guided CPR group were significantly higher than those in paramedic-guided CPR group: 10.9% (2138/19,551) vs. 4.8% (28,448/593,700) for 1-month survival and 5.7% (1114/19,551) vs. 2.5% (14,859/593,700) for 1-month CPC 1-2, both p-values <0.0001. Multivariate logistic regression analysis showed that EMS physician-guided CPR was associated with increased adjusted odds ratios (aORs) for 1-month favorable outcomes: 1.70; 95% confidence interval [CI], 1.61-1.79 for 1-month survival; and 1.51; 95% CI, 1.46-1.62 for 1-month CPC 1-2. In the propensity-matched cohort, EMS physician-guided CPR also showed more favorable outcomes 1 month after OHCA than did paramedic-guided CPR: 11.6% (1931/16,612) vs. 7.9% (1310/16,612) for 1-month survival and 6.0% (996/16,612) vs. 4.6% (766/16,612) for 1-month CPC 1-2, both p-values <0.0001 (aOR, 1.68; 95% CI, 1.55-1.82 for survival; and 1.45; 95% CI, 1.30-1.62 for CPC 1-2. Conclusions: This large-scale registry-based study in Japan shows that EMS physician-guided CPR in OHCA before hospital arrival is associated with improved 1-month neurologically intact survival compared with paramedic-guided CPR.

Abstract 165: Hospital Variation in Time to Administration of Epinephrine After Cardiac Arrest With Initial Non-shockable Rhythm

2016 ◽  
Vol 9 (suppl_2) ◽  
Author(s):  
Rohan Khera ◽  
Paul S Chan ◽  
Michael W Donnino ◽  
Saket Girotra ◽  
Keyword(s):  
Cardiac Arrest ◽  
Survival Rate ◽  
Inverse Correlation ◽  
Poor Performance ◽  
Patient Characteristics ◽  
Hospital Performance ◽  
Epinephrine Administration ◽  
Shockable Rhythm ◽  
Hospital Variation ◽  
Hospital Cardiac Arrest

Background: For patients with in-hospital cardiac arrests due to non-shockable rhythms, delays in epinephrine administration beyond 5 minutes is associated with worse survival. However, the extent of hospital variation in delayed epinephrine administration and its impact on hospital-level outcomes is unknown. Methods: Within Get with the Guidelines-Resuscitation, we identified 103,932 adult patients (>18 years) at 548 hospitals with an in-hospital cardiac arrest due to a non-shockable rhythm who received at least 1 dose of epinephrine between 2000 to 2014. We constructed two-level hierarchical regression models to quantify hospital variation in rates of delayed epinephrine administration (>5 minutes) and its association with hospital rates of survival to discharge. Results: Among the 548 hospitals, there was substantial variation in rates of delayed epinephrine administration (median 13.5%, range: 0%- 53.8%). The odds of delay in epinephrine administration were 61% higher at one randomly selected hospital compared to a similar patient at another randomly selected hospitals (median odds ratio [OR] 1.61; 95% C.I. 1.54 - 1.67). After adjusting for patient characteristics, the median risk-standardized survival rate for non-shockable in-hospital cardiac arrests was 12.1% and varied significantly across hospitals (range: 5.2% to 30.9%). There was an inverse correlation between a hospital’s rate of delayed epinephrine administration and its risk-standardized survival rate for cardiac arrests due to non-shockable rhythm (ρ= -0.23, P<0.0001). Compared to hospitals in the best quartile, risk-standardized survival was 17.4% lower at hospitals in the worst quartile of delayed epinephrine administration (13.8% vs. 11.4%, P<0.0001, Figure). Conclusions: Although delays in epinephrine administration following in-hospital cardiac arrest are common, there is substantial hospital variation in rates of delayed epinephrine administration. Hospitals with high rates of delayed epinephrine administration were found to have lower rates of risk-adjusted survival. Further studies are needed to determine if improving hospital performance on time to epinephrine administration, especially at hospitals with poor performance on this metric will lead to improvement in outcomes.

Abstract 264: The Association of Chest Compression Fraction and Clinical Outcomes from Shockable Out-of-Hospital Cardiac Arrest During the Resuscitation Outcomes Consortium Primed Trial

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Sheldon Cheskes ◽  
Robert H Schmicker ◽  
Tom Rea ◽  
Judy Powell ◽  
Ian R Drennan ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Clinical Outcomes ◽  
Chest Compression ◽  
Reference Group ◽  
Secondary Analysis ◽  
Process Data ◽  
Shockable Rhythm ◽  
The Relationship ◽  
Neurologically Intact ◽  
Hospital Cardiac Arrest

INTRODUCTION: The role of chest compression fraction (CCF) in resuscitation of shockable out-of-hospital cardiac arrest (OHCA) is uncertain. We evaluated the relationship between CCF and clinical outcomes in a secondary analysis of the Resuscitation Outcomes Consortium (ROC) PRIMED trial. METHODS: We included OHCA patients from the ROC PRIMED trial who suffered cardiac arrest prior to EMS arrival, presented with a shockable rhythm, and had cardiopulmonary resuscitation (CPR) process data for at least one shock. We used multivariable logistic regression adjusting for Utstein variables, CPR metrics of compression rate and perishock pause, and ROC site to determine the relationship between CCF and survival to hospital discharge, return of spontaneous circulation (ROSC), and neurologically intact survival defined with Modified Rankin Score (MRS) ≤ 3. Due to potential confounding between CCF and cases that achieved early ROSC, we also performed an analysis restricted to patients without ROSC in the first 10 minutes of EMS resuscitation. RESULTS: Among the 2,558 eligible patients, median (IQR) age was 65 (54, 76) years, 76.9% were male, and mean (SD) CCF was 0.70 (0.15). Compared to the reference group (CCF < 0.60), the odds ratio (OR) for survival was 0.57 (95%CI: 0.42, 0.78) for CCF 0.60-0.79 and 0.32 (95%CI: 0.22, 0.48) for CCF ≥0.80. Results were similar for outcomes of ROSC and neurologically intact survival. Conversely, when restricted to the cohort who did not achieve ROSC during the first 10 minutes (n=1,660), the relationship between CCF and survival was no longer significant. Compared to the reference group (CCF < 0.60), the OR for survival was 0.85 (95 %CI: 0.58, 1.26) for CCF 0.60-0.79 and OR 0.87 (95%CI: 0.58, 1.36) for CCF ≥0.80. CONCLUSIONS: In this observational cohort study of OHCA patients presenting in a shockable rhythm, CCF when adjusted for Utstein predictors, CPR metrics and ROC site was paradoxically associated with lower odds of survival. The relationship between CCF and clinical outcomes was null in a sensitivity analysis restricted to patients without ROSC in the first 10 minutes. CCF is a complex measure and taken by itself may not be a consistent predictor of clinical outcome.

Abstract 44: Time to Epinephrine Impacts Mortality Following Pediatric In-Hospital Nonshockable Cardiac Arrest

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Lars W Andersen ◽  
Katherine Berg ◽  
Brian Z Saindon ◽  
Joseph M Massaro ◽  
Tia T Raymond ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Hospital Discharge ◽  
Neurological Outcome ◽  
Spontaneous Circulation ◽  
National Registry ◽  
Epinephrine Administration ◽  
Negatively Associated ◽  
Logistic Regression Models ◽  
Shockable Rhythm ◽  
Hospital Cardiac Arrest

Background: Delay in administration of the first epinephrine dose has been shown to be associated with a lower chance of good outcome in adult, in-hospital, non-shockable cardiac arrest. Whether this association is true in pediatric in-hospital non-shockable cardiac arrest remains unknown. Methods: We utilized the Get With the Guidelines - Resuscitation national registry to identify pediatric patients (age < 18 years) with an in-hospital cardiac arrest between 2000 and 2010. We included patients with an initial non-shockable rhythm who received at least one dose of epinephrine. To assess the association between time to epinephrine administration and survival to discharge we used multivariate logistic regression models with adjustment for multiple predetermined variables including age, gender, illness category, pre-existing mechanical ventilation, monitored, witnessed, location, time of the day/week, year of arrest, insertion of an airway, initial rhythm, time to initiation of cardiopulmonary resuscitation, hospital type and hospital teaching status. Secondary outcomes included return of spontaneous circulation (ROSC) and neurological outcome. Results: 1,131 patients were included. Median age was 9 months (quartiles: 21 days - 6 years) and 46% were female. Overall survival to hospital discharge was 29%. Longer time to epinephrine was negatively associated with survival to discharge in multivariate analysis (OR: 0.94 [95%CI: 0.90 - 0.98], per minute delay). Longer time to epinephrine was negatively associated with ROSC (OR: 0.93 [95%CI: 0.90 - 0.97], per minute delay) but was not statistically significantly associated with survival with good neurological outcome (OR: 0.95 [95%CI: 0.89 - 1.03], per minute delay). Conclusions: Delay in administration of epinephrine during pediatric in-hospital cardiac arrest with a non-shockable rhythm is associated with a lower chance of ROSC and lower survival to hospital discharge.

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