Abstract 146: Association of Epinephrine Prior to Defibrillation with Survival in Patients with In-hospital Cardiac Arrest

Background: Prompt defibrillation is a first line treatment for in-hospital cardiac arrest (IHCA) due to a shockable rhythm, with epinephrine recommended only when defibrillation is ineffective. However, empirical data regarding epinephrine prior to first defibrillation for shockable IHCA and its association with survival are unavailable. Methods: Using 2000-2018 Get with the Guidelines Resuscitation data, we identified adults ( > 18 years) with an index IHCA due to an initial shockable rhythm. We conducted a time-dependent propensity-matched analysis to evaluate the association of epinephrine prior to first defibrillation with survival to discharge and acute resuscitation survival (i.e., return of spontaneous circulation for > 20 minutes). Results: Among 34,688 subjects, 10,057 (29.0%) received epinephrine before defibrillation. Median age was 67 years in both groups. Compared to defibrillation first, patients in the epinephrine first group were less likely to have myocardial infarction or heart failure, but more likely to have renal failure, sepsis and pneumonia, be located in an intensive care unit, and already receiving mechanical ventilation (P <0.001 for all). Treatment with epinephrine first was strongly associated with a delay in first defibrillation (median 3 min vs. 0 min; P <0.001). In propensity-matched analysis, epinephrine prior to defibrillation was associated with lower odds of survival to discharge (OR: 0.81, 95% CI 0.76 - 0.86) and acute resuscitation survival (OR: 0.79, 95% CI 0.74 - 0.84). Early epinephrine was associated with lower survival (OR: 0.87, 95% CI 0.78-0.97) and acute resuscitation survival (OR for acute resuscitation survival: 0.83, 95% CI 0.74-0.93) even in patients who received defibrillation within 2 minutes. Conclusions: Despite a strong emphasis on prompt defibrillation in current guidelines, nearly 1 in 3 patients with IHCA due to a shockable rhythm received epinephrine prior to first defibrillation. Epinephrine before defibrillation was associated with worse survival outcomes. Although delays in defibrillation were more common in the early epinephrine group, early epinephrine remained associated with worse outcomes even in patients who received prompt defibrillation.

Download Full-text

Epinephrine before defibrillation in patients with shockable in-hospital cardiac arrest: propensity matched analysis

BMJ ◽

10.1136/bmj-2021-066534 ◽

2021 ◽

pp. e066534

Author(s):

Erin Evans ◽

Morgan B Swanson ◽

Nicholas Mohr ◽

Nassar Boulos ◽

Mary Vaughan-Sarrazin ◽

...

Keyword(s):

Cardiac Arrest ◽

Cerebral Performance Category ◽

Spontaneous Circulation ◽

Sensitivity Analyses ◽

Shockable Rhythm ◽

History Of ◽

Independent Association ◽

Get With The Guidelines ◽

Current Guidelines ◽

Hospital Cardiac Arrest

Abstract Objective 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. Design Propensity matched analysis. Setting 2000-18 data from 497 hospitals participating in the American Heart Association’s Get With The Guidelines-Resuscitation registry. Participants Adults aged 18 and older with an index in-hospital cardiac arrest due to an initial shockable rhythm treated with defibrillation. Interventions Administration of epinephrine before first defibrillation. Main outcome measures 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 >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. Results Among 34 820 patients with an initial shockable rhythm, 9630 (27.6%) 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, pneumonia, and receive mechanical ventilation before in-hospital cardiac arrest (P<0.0001 for all). Treatment with epinephrine before defibrillation was strongly associated with delayed defibrillation (median 3 minutes v 0 minutes). In propensity matched analysis (9011 matched pairs), epinephrine before defibrillation was associated with lower odds of survival to discharge (25.2% v 29.9%; adjusted odds ratio 0.81, 95% confidence interval 0.74 to 0.88; P<0.001), favorable neurological survival (18.6% v 21.4%; 0.85, 0.76 to 0.92; P<0.001), and survival after acute resuscitation (64.4% v 69.4%; 0.76, 0.70 to 0.83; P<0.001). The above findings were consistent in a range of sensitivity analyses, including matching according to defibrillation time. Conclusions Contrary to current guidelines that prioritize immediate defibrillation for in-hospital cardiac arrest due to a shockable rhythm, more than one in four patients are treated with epinephrine before defibrillation, which is associated with worse survival.

Download Full-text

Abstract 12258: Out-of-hospital Cardiac Arrest With Initially Shockable Rhythm: What Are the Outcomes if No Shock is Given?

Circulation ◽

10.1161/circ.132.suppl_3.12258 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Yan Xiong ◽

Ahamed H Idris

Keyword(s):

Cardiac Arrest ◽

Hospital Discharge ◽

Spontaneous Circulation ◽

Shock Delivery ◽

Return Of Spontaneous Circulation ◽

Shockable Rhythm ◽

Multiple Variable ◽

Multiple Variable Regression ◽

Hospital Cardiac Arrest ◽

Resuscitation Attempt

Background: Prompt defibrillation is critical for termination of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in out-of-hospital cardiac arrest (OHCA). For ethical reasons, the real impact of not shocking OHCA patients with a shockable rhythm is unlikely to be investigated in clinical trials and thus remains unknown. Objectives: To describe demographics, pre-hospital characteristics, interventions, and outcomes in OHCA patients with an initially shockable rhythm who did and did not get shocked in the field in DFW ROC site. Methods: We included all non-traumatic OHCA cases ≥18 years old with VF or VT as first known rhythms, who were treated and transported to a hospital within the DFW ROC site between 2006 - 2011. We report return of spontaneous circulation (ROSC) in the field and survival to hospital discharge for victims with and without shock delivered in the field. Multiple variable regression analysis assessed the association between shock delivery and ROSC in the field as well as survival. Results: Included were 882 adult non-traumatic OHCA cases with VF or VT as first known rhythms; mean (±SD) age was 60 ± 15 years, 71% male, bystander witnessed 56%, bystander resuscitation attempt 43%, public arrest location 26%, EMS response time 4.7 ± 2.3 min, 26.9% (237) had ROSC in the field, 14.9% (131) survived to hospital discharge; 93.4% (824) of all patients were shocked, while 6.6% (58) were not shocked. Of the 6.6% (58) who were not shocked, 12.1% (7) achieved ROSC in the field and 8.6% (5) survived to hospital discharge. For those not shocked in the field, the unadjusted and adjusted odds ratios for ROSC were 0.354 (95% CI 0.158-0.791, p=0.011) and 0.189 (95% CI 0.039-0.911, p=0.038), respectively; and for survival to hospital discharge they were 0.522 (95% CI 0.205-1.331, p=0.173) and 0.498 (95% CI 0.088-2.810, p=0.430), respectively. Conclusions: In the DFW ROC site, 6.6% of OHCA victims with an initially shockable rhythm did not receive a shock, which was significantly associated with decreased ROSC in the field. More patients survived who were shocked in the field, but this difference was not significant after adjustment for Utstein variables.

Download Full-text

Improving Survival After In-Hospital Cardiac Arrest: The Australian Experience

American Journal of Critical Care ◽

10.4037/ajcc2007.16.3.240 ◽

2007 ◽

Vol 16 (3) ◽

pp. 240-247 ◽

Cited By ~ 32

Author(s):

Robyn Peters ◽

Mary Boyde

Keyword(s):

Cardiac Arrest ◽

Life Support ◽

Survival Rates ◽

Spontaneous Circulation ◽

High Rate ◽

Hospital Data ◽

Return Of Spontaneous Circulation ◽

Shockable Rhythm ◽

Resuscitation Training ◽

Hospital Cardiac Arrest

Background Survival rates after in-hospital cardiac arrest have not improved markedly despite improvements in technology and resuscitation training. Objectives To investigate clinical variables that influence return of spontaneous circulation and survival to discharge after in-hospital cardiac arrest. Methods An Utstein-style resuscitation template was implemented in a 750-bed hospital. Data on 158 events were collected from January 2004 through November 2004. Significant variables were analyzed by using a multiple logistic regression model. Results Of the 158 events, 128 were confirmed cardiac arrests. Return of spontaneous circulation occurred in 69 cases (54%), and the patient survived to discharge in 41 (32%). An initial shockable rhythm was present in 42 cases (33%), with a return of spontaneous circulation in 32 (76%) and survival to discharge in 24 (57%). An initial nonshockable rhythm was present in the remaining 86 cases (67%), with a return of spontaneous circulation in 37 (43%) and survival to discharge in 17 (20%). Witnessed or monitored arrests (P=.006), time to arrival of the cardiac arrest team (P=.002), afternoon shift (P=.02), and initial shockable rhythm (P=.005) were independently associated with return of spontaneous circulation. Location of patient in a critical care area (P=.002), initial shockable rhythm (P<.001), and length of resuscitation (P=.02) were independently associated with survival to hospital discharge. Conclusions The high rate of survival to discharge after cardiac arrest is attributed to extensive education and the incorporation of semiautomatic external defibrillators into basic life support management.

Download Full-text

Abstract 206: Cardiopulmonary Resuscitation Process Measures Associated With Return of Spontaneous Circulation in Non-Shockable Out-of-Hospital Cardiac Arrest

Circulation ◽

10.1161/circ.138.suppl_2.206 ◽

2018 ◽

Vol 138 (Suppl_2) ◽

Author(s):

Jose M Juarez ◽

Allison C Koller ◽

Robert H Schmicker ◽

Seo Young Park ◽

David D Salcido ◽

...

Keyword(s):

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Chest Compression ◽

Duty Cycle ◽

Spontaneous Circulation ◽

Research Network ◽

Process Measures ◽

Return Of Spontaneous Circulation ◽

Shockable Rhythm ◽

Hospital Cardiac Arrest

Purpose: Survival rates after non-shockable out-of-hospital cardiac arrest (OHCA) remain low despite advances in resuscitation. Cardiopulmonary resuscitation (CPR) process measures may inform treatment strategies. We hypothesized that CPR process measures would be associated with return of spontaneous circulation (ROSC) and patient electrocardiogram (ECG) transitions. Methods: We obtained defibrillator monitor data for emergency medical service (EMS)-treated non-shockable OHCA from the Resuscitation Outcomes Consortium (ROC), an OHCA research network (U.S./Canada). We extracted ECG data from EMS defibrillator files and parsed cases into compression-free analyzable segments using custom MATLAB software. Two data abstractors classified segment rhythms as PEA, asystole, ventricular fibrillation (VF), pulseless ventricular tachycardia (PVT), or ROSC. We calculated CPR process measures (average rate, depth, duration, leaning proportion, chest compression fraction, and duty cycle) for CPR bouts preceding every ECG segment. We used mixed effects models controlling for subject to test associations between individual CPR process measures and the bout-level outcomes ROSC and shockable rhythm. Results: We analyzed 1893 cases consisting of 7981 CPR bouts. Case initial rhythms were asystole (68.2%), PEA (24.9%), or NSA-AED (6.9%). Segment rhythm classifications were asystole (78.1%), PEA (20.4%), ROSC (5.5%), VF (1.4%), and PVT (0.07%). Regression model results are shown in Table 1. Chest compression fraction was most strongly associated with ROSC and shockable rhythm. Depth was also associated with shockable rhythm. Leaning proportion and duty cycle were not associated with either outcome. Conclusions: In cases of non-shockable OHCA, CPR quality measures were associated with ROSC and transition to a shockable rhythm at the bout level.

Download Full-text

Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out‐of‐Hospital Cardiac Arrest: A Systematic Review and Meta‐Analysis

Journal of the American Heart Association ◽

10.1161/jaha.121.023806 ◽

2021 ◽

Author(s):

Jun Wei Yeo ◽

Zi Hui Celeste Ng ◽

Amelia Xin Chun Goh ◽

Jocelyn Fangjiao Gao ◽

Nan Liu ◽

...

Keyword(s):

Cardiac Arrest ◽

Meta Analysis ◽

High Volume ◽

Spontaneous Circulation ◽

Sensitivity Analyses ◽

Return Of Spontaneous Circulation ◽

Shockable Rhythm ◽

Interhospital Transfer ◽

The Impact ◽

Hospital Cardiac Arrest

Background The role of cardiac arrest centers (CACs) in out‐of‐hospital cardiac arrest care systems is continuously evolving. Interpretation of existing literature is limited by heterogeneity in CAC characteristics and types of patients transported to CACs. This study assesses the impact of CACs on survival in out‐of‐hospital cardiac arrest according to varying definitions of CAC and prespecified subgroups. Methods and Results Electronic databases were searched from inception to March 9, 2021 for relevant studies. Centers were considered CACs if self‐declared by study authors and capable of relevant interventions. Main outcomes were survival and neurologically favorable survival at hospital discharge or 30 days. Meta‐analyses were performed for adjusted odds ratio (aOR) and crude odds ratios. Thirty‐six studies were analyzed. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR, 1.85 [95% CI, 1.52–2.26]), even when including high‐volume centers (aOR, 1.50 [95% CI, 1.18–1.91]) or including improved‐care centers (aOR, 2.13 [95% CI, 1.75–2.59]) as CACs. Survival significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59–2.32]), even when including high‐volume centers (aOR, 1.74 [95% CI, 1.38–2.18]) or when including improved‐care centers (aOR, 1.97 [95% CI, 1.71–2.26]) as CACs. The treatment effect was more pronounced among patients with shockable rhythm ( P =0.006) and without prehospital return of spontaneous circulation ( P =0.005). Conclusions were robust to sensitivity analyses, with no publication bias detected. Conclusions Care at CACs was associated with improved survival and neurological outcomes for patients with nontraumatic out‐of‐hospital cardiac arrest regardless of varying CAC definitions. Patients with shockable rhythms and those without prehospital return of spontaneous circulation benefited more from CACs. Evidence for bypassing hospitals or interhospital transfer remains inconclusive.

Download Full-text

Abstract 124: Chest Compression Pause Duration is Associated with Worse Survival Outcomes Following Pediatric In-hospital Cardiac Arrest

Circulation ◽

10.1161/circ.142.suppl_4.124 ◽

2020 ◽

Vol 142 (Suppl_4) ◽

Author(s):

Kasper Glerup Lauridsen ◽

Ryan W Morgan ◽

Robert A Berg ◽

Dana E Niles ◽

Monica E Kleinman ◽

...

Keyword(s):

Cardiac Arrest ◽

Hospital Discharge ◽

Neurological Outcome ◽

Pause Duration ◽

Spontaneous Circulation ◽

Survival Outcomes ◽

Lower Odds ◽

Return Of Spontaneous Circulation ◽

Favorable Neurological Outcome ◽

Hospital Cardiac Arrest

Introduction: The association between chest compression (CC) pause duration and pediatric in-hospital cardiac arrest (IHCA) survival outcomes is unknown. We hypothesized that longer maximum CC pause durations are associated with worse survival and neurological outcomes. Methods: Cohort study of all index pediatric IHCAs (<18 years of age) ≥1 min in the Pediatric Resuscitation Quality (PediRES-Q) Network from July 2015 through December 2019. We used multivariate logistic regression with mixed effects and robust standard errors to analyze association of 5-sec increments of longest CC pause duration with survival and neurologic outcomes. Favorable neurological outcome was defined as Pediatric Cerebral Performance Category (PCPC) at discharge ≤3 or no change from baseline. Results: We identified 371 index IHCAs: median [Q1,Q3] age 2.6 [0.6,9.4] years, female 46%, shockable rhythm 13%, CPR duration 23 [9,47] min. Median length of the longest pause was 17 [8,27] sec. Each 5 sec increase in longest CC pause duration was associated with 6% lower odds for survival with favorable neurological outcome, even after adjusting for age, defibrillation, intubation, extracorporeal CPR, illness category, hypotension as etiology for arrest, CC depth, and clustering by site (aOR 0.94 [95% CI:0.88-0.99], p=0.04). Analyses controlling for the same factors demonstrated an association of longest pause duration with lower odds for survival to hospital discharge (aOR 0.94 [95% CI: 0.90-0.99, p=0.02) and return of spontaneous circulation (aOR 0.91 [(95% CI: 0.86-0.96], p=0.001). Conclusions: Longest CC pause duration is associated with favorable neurological outcome, survival to hospital discharge, and return of spontaneous circulation following pediatric IHCA, even when controlling for known confounders and clustering by site. Each 5 sec. increment in longest CC pause duration was associated with 6% lower odds for survival with favorable neurological outcome.

Download Full-text