Epinephrine dosing interval and neurological outcome in out-of-hospital cardiac arrest

Perfusion ◽  
2021 ◽  
pp. 026765912110251
Author(s):  
Tatsuma Fukuda ◽  
Hirotsugu Kaneshima ◽  
Aya Matsudaira ◽  
Takumi Chinen ◽  
Hiroshi Sekiguchi ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Standard Dose ◽  
Population Based ◽  
Spontaneous Circulation ◽  
Time Interval ◽  
Epinephrine Administration ◽  
Dosing Interval ◽  
Using Data ◽  
Dosing Intervals ◽  
Hospital Cardiac Arrest

Objective: Current guidelines for cardiopulmonary resuscitation (CPR) recommend that standard-dose epinephrine be administered every 3–5 minutes during cardiac arrest. However, there is a knowledge gap regarding the optimal epinephrine dosing interval. This study aimed to examine the association between epinephrine dosing intervals and outcomes after out-of-hospital cardiac arrest (OHCA). Methods: This was a nationwide population-based observational study using data from a Japanese government-led registry of OHCA, including patients who experienced OHCA in Japan from 2011 to 2017. We defined the epinephrine dosing interval as the time interval between the first epinephrine administration and return of spontaneous circulation in the prehospital setting, divided by the total number of epinephrine doses. The primary outcome was 1-month neurologically favorable survival. Results: A total of 10,965 patients (mean (SD) age, 75.8 (14.3) years; 59.8% male) were included. The median epinephrine dosing interval was 3.5 minutes (IQR, 2.5–4.5; mean (SD), 3.6 (1.8)). Only approximately half of the patients received epinephrine administration with a standard dosing interval, as recommended in the current CPR guidelines. After multivariable adjustment, compared with the standard dosing interval, neither shorter nor longer epinephrine dosing intervals were associated with neurologically favorable survival after OHCA (Short vs Standard: adjusted OR 0.87 [95%CI 0.66–1.15]; and Long vs Standard: adjusted OR 1.08 [95%CI 0.76–1.55]). Similar associations were observed in propensity score-matched analyses. Conclusions: The epinephrine dosing interval was not associated with 1-month neurologically favorable survival after OHCA. Our findings do not deny the recommended epinephrine dosing interval in the current CPR guidelines.

Abstract 17573: Epinephrine Dosing Interval and Survival Outcomes During Pediatric In-hospital Cardiac Arrest

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Derek B Hoyme ◽  
Sonali S Patel ◽  
Ricardo A Samson ◽  
Tia T Raymond ◽  
Vinay M Nadkarni ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Hospital Discharge ◽  
Heart Association ◽  
Dose Interval ◽  
Coronary Perfusion ◽  
Epinephrine Administration ◽  
Dosing Interval ◽  
Vasoactive Medication ◽  
Dosing Intervals ◽  
Hospital Cardiac Arrest

Background: American Heart Association (AHA) guidelines recommend administration of epinephrine (epi) every 3 to 5 minutes during CPR to improve systemic blood pressure and coronary perfusion pressure. In adults with in-hospital cardiac arrest (IHCA), longer dosing intervals are associated with improved survival to hospital discharge. The purpose of this study is to investigate whether longer epi dosing intervals are associated with improved survival to hospital discharge after pediatric IHCA. Methods: A retrospective review of the AHA Get With The Guidelines-Resuscitation registry identified 1,260 pediatric IHCAs that met our inclusion criteria: index IHCA event; no vasoactive infusion in place or alternate vasoactive medication boluses; > 1 dose of epi administered; not located in delivery room, nursery, NICU or obstetrical units. For each arrest, an epi dosing interval was defined by dividing the duration of resuscitation after the first dose of epi by the total doses given. This was necessary as the database does not provide time of individual epi doses. For analysis, epi dosing intervals were categorized as 1 to <5 minutes/dose, 5 to <8 minutes/dose, and 8 to 10 minutes/dose. Multivariable logistic regression models were constructed controlling for age, gender, illness category, location of arrest, and arrest duration to evaluate the relationship of epi dosing intervals on survival to discharge. Odds ratios were calculated using the 1 to <5 minutes/dose interval as the reference. Results: Table 1 displays the descriptive characteristics of the patients and subsequent events. Adjusted odds ratio for survival to hospital discharge for dosing interval of 5 to <8 minutes was 1.454 (95% CI 1.014-2.084) and for 8 to 10 minutes was 1.945 (95% CI 1.094-3.459). Conclusions: Longer dosing intervals than those currently recommended by the AHA guidelines for epinephrine administration during pediatric IHCA are associated with improved survival to hospital discharge.

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.

Abstract 18724: Coronary Angiography After Out-of-hospital Cardiac Arrest is Associated With Improved Neurologically Intact Survival

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Tasha Hanuschak ◽  
Steven Brooks ◽  
Laurie Morrison ◽  
Paul Peng ◽  
Cathy Zhan
Keyword(s):  
Cardiac Arrest ◽  
Coronary Angiography ◽  
Population Based ◽  
Spontaneous Circulation ◽  
Hospital Arrival ◽  
Hospital Size ◽  
Return Of Spontaneous Circulation ◽  
Randomized Controlled Studies ◽  
Neurologically Intact ◽  
Hospital Cardiac Arrest

Introduction: Evidence for the effectiveness of coronary angiography after out-of-hospital cardiac arrest (OHCA) is conflicting. Our objective was to evaluate the association between receiving coronary angiography within 72 hours of hospital arrival and survival with favorable neurologic outcome. Methods: This was a population-based retrospective cohort study of consecutive cases of adult OHCA transported to and treated at 28 hospitals in Southern Ontario between March 1, 2010 and December 31, 2014. We included patients with atraumatic OHCA, who achieved return of spontaneous circulation, and were alive 6 hours after hospital arrival. Multi-level logistic regression was used to measure the association between early coronary angiography and neurologically intact survival (Modified Rankin Score 0-2), while controlling for potential confounders and clustered data. We controlled for age, sex, initial cardiac rhythm, witness status, bystander resuscitation, EMS response time, prehospital return of spontaneous circulation, location of arrest, daytime presentation, neurologic status at hospital arrival, STEMI status, cardiac history, initiation of therapeutic hypothermia, hospital size and type, and hospital annual cardiac arrest volume. Results: During the period of study, 2678 consecutive OHCA patients met the inclusion criteria. The mean age was 66(±16), 31.7% were female, 54.1% had a bystander witnessed arrest, 35.2% received bystander CPR, 45.9% had a shockable initial rhythm, 30.1% had ST elevation on the first post arrest ECG, and 32.4% received coronary angiography. Receiving coronary angiography was strongly associated with neurologically intact survival (OR 2.30, CI95 1.69-3.15) and survival (OR 2.08, CI95 1.53-2.82). A similar association was observed in the subgroup of patients without STEMI (OR 3.24, CI95 2.16-4.87 and OR 2.66, CI95 1.78-3.99, respectively). Conclusions: Neurologically intact survival among post cardiac arrest patients may be improved with coronary angiography, particularly for patients without STEMI. This observation should be confirmed with future randomized controlled studies.

Abstract 18304: Are Prolonged Resuscitation Efforts Worthwhile? Patient Outcomes by Time to Restoration of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest Patients

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Kristian Kragholm ◽  
Monique Anderson ◽  
Carolina Malta Hansen ◽  
Phillip J. Schulte ◽  
Michael C. Kurz ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Neurological Outcome ◽  
Survival Rates ◽  
Spontaneous Circulation ◽  
Significant Survival ◽  
Bystander Cardiopulmonary Resuscitation ◽  
Bystander Cpr ◽  
Using Data ◽  
Favorable Neurological Outcome ◽  
Hospital Cardiac Arrest

Introduction: How long resuscitation attempts should be continued before termination of efforts is not clear in patients with out-of-hospital cardiac arrest (OHCA). We studied outcomes in patients with return of spontaneous circulation (ROSC) across quartiles of time from 9-1-1 call to ROSC. Hypothesis: Survival with favorable neurological outcome is seen in all time intervals from 9-1-1 call to ROSC. Methods: Using data from Resuscitation Outcomes Consortium (ROC) Prehospital Resuscitation clinical trials: IMpedance valve and an Early vs. Delayed analysis (PRIMED) available via National Institute of Health, patients with ROSC not witnessed by the emergency medical service (EMS) were identified and grouped by quartiles of time from 9-1-1 call to ROSC. We defined favorable neurological outcome as modified Rankin Scale (mRS) scores of ≤3. Results: Included were 3,431 OHCA patients with ROSC. Median time from 9-1-1 call to ROSC was 22.8 min (25%-75% 17 min–29.2 min); 953 (27.8%) survived to discharge (20.4% mRS ≤3). Significant survival and favorable neurological outcome were seen in each quartile (Figure). In patients who received bystander cardiopulmonary resuscitation (CPR), survival rates were 60.9%, 33.2%, 18.3% and 11.1% across quartiles of time to ROSC versus (vs.) 51.5%, 25.6%, 13.3% and 8.9% in patients without bystander CPR; corresponding rates of favorable neurological outcome were 50.7%, 23.8%, 12.2% and 9.1% vs. 40.1%, 16.6%, 8% and 4.8%. Correspondingly, survival rates in defibrillated patients were 70.1%, 45.9%, 25.5% and 16.4% vs. 36.3%, 9.5%, 6% and 3.4% in non-defibrillated patients; corresponding rates of favorable neurological outcome were 59.8%, 33.4%, 18.3% and 11.4% vs. 24.4%, 4.1%, 1.9% and 1.8%. Conclusions: Survival with favorable neurological outcome was seen in all quartiles of time to ROSC, even in cases without bystander CPR or shocks delivered. This suggests that EMS personnel should not terminate resuscitation efforts too early.

Abstract 152: Effect of the 2010 CPR Guidelines for Patients With Out-of-Hospital Cardiac Arrest Due to Non-Shockable Rhythm

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Tadashi Ashida ◽  
Tsukasa Yagi ◽  
Ken Nagao ◽  
Shigemasa Tani ◽  
Eizo Tachibana ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Neurological Outcome ◽  
Multivariable Analysis ◽  
Population Based ◽  
Spontaneous Circulation ◽  
Adult Patients ◽  
Shockable Rhythm ◽  
Class Iib ◽  
Favorable Neurological Outcome ◽  
Hospital Cardiac Arrest

Background: The 2010 guidelines have stressed that systematic post-cardiac arrest care after return of spontaneous circulation (ROSC) can improve the likelihood of patient survival with good neurological outcome. However, the 2010 guidelines showed that induced therapeutic hypothermia may be considered for comatose adult patients with ROSC after out-of-hospital cardiac arrest (OHCA) with an initial rhythm of non-shockable (Class IIb). It is unknown whether the post-cardiac arrest care for patients with non-shockable cardiac arrest contributed to favorable neurological outcome. The aim of the present study was to clarify the effects of the 2010 guidelines in patients with ROSC after cardiac arrest due to non-shockable rhythm, using the data of the All-Japan Utstein Registry, a prospective, nationwide, population-based registry of OHCA. Methods: From the data of this registry between 2005 and 2015, we included adult patients with ROSC after out-of-hospital non-shockable cardiac arrest due to cardiac etiology. Study patients were divided into three groups based on the different CPR guidelines; the era of the 2000 guidelines (2000G), the era of the 2005 guidelines (2005G), and the era of the 2010 guidelines (2010G). The endpoint was favorable neurological outcome at 30 days after OHCA. Results: The 31,204 patients who met the inclusion criteria comprised 25,045 with ROSC before arrival at the hospital and 6,259 with ROSC after hospital arrival without prehospital ROSC. Figure showed favorable neurological outcome at 30 days in the three groups. Moreover, multivariable analysis showed that the 2010 guidelines were an independent predictor of favorable neurological outcome at 30 days after OHCA, respectively (Figure). Conclusion: In the patients with ROSC after out-of-hospital non-shockable cardiac arrest, the 2010 guidelines were superior to the 2005 guidelines and the 2000 guidelines, in terms of neurological benefits.

Abstract 342: The Relationship Between Time Interval From Collapse to Return of Spontaneous Circulation After Out-of-Hospital Cardiac Arrest and Neurologically Intact Survival

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Ken Nagao ◽  
Yoshio Tahara ◽  
Hiroshi Nonogi ◽  
Naohiro Yonemoto ◽  
David F Gaieski ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Neurological Outcome ◽  
Spontaneous Circulation ◽  
Adult Patients ◽  
Time Interval ◽  
Return Of Spontaneous Circulation ◽  
Favorable Neurological Outcome ◽  
The Relationship ◽  
Neurologically Intact ◽  
Hospital Cardiac Arrest

Background: Early cardiopulmonary resuscitation (CPR) and early defibrillation are critical to survival from out-of-hospital cardiac arrest (OHCA). However, few studies have investigated the relationship between time interval from collapse to return of spontaneous circulation (ROSC) and neurologically intact survival. Methods: From the All-Japan OHCA Utstein Registry between 2005 and 2015, we enrolled adult patients achieving prehospital ROSC after witnessed OHCA, inclusive of arrest after emergency medical service responder arrival. The study patients were divided into two groups according to initial cardiac arrest rhythm (shockable versus non-shockable). The collapse-to-ROSC interval was calculated as the time interval from collapse to first achievement of prehospital ROSC. The primary endpoint was 30-day favorable neurological outcome after OHCA. Results: A total of 69,208 adult patients achieving prehospital ROSC after witnessed OHCA were enrolled; 23,017(33.3%) the shockable arrest group and 46,191 (66.7%) the non-shockable arrest group. The shockable arrest group compared with the non-shockable arrest group had significantly shorter collapse-to-ROSC interval (16±10 min vs. 20±13 min, P<0.001) and significantly higher frequency of the favorable neurological outcome (54.9% vs. 15.3%, P<0.001). Frequencies of the favorable neurological outcome after shockable OHCA decreased to 1.2% to 1.5% with every minute that the collapse-to-ROSC interval was delayed (78% at 1 minute of collapse, 68% at 10 minutes, 44% at 20 minutes, 34% at 30 minutes, 16% at 40 minutes, 4% at 50 minutes and 0% at 60 minutes, respectively, P<0.001), and those after non-shockable OHCA decreased to 0.8% to 1.8% with every minute that the collapse-to-ROSC interval was delayed (40% at 1 minute of collapse, 26% at 10 minutes, 11% at 20 minutes, 5% at 30 minutes, 2% at 40 minutes, 0% at 50 minutes and 0% at 60 minutes, respectively, P<0.001). Conclusions: Termination of the collapse-to-ROSC interval to achieve neurologically intact survival after witnessed OHCA was 50 minutes or longer irrespective of initial cardiac arrest rhythm (shockable versus non-shockable), although the neurologically intact survival rate was difference between the two groups.

Abstract 20: Intraosseous vs. Intravenously Administered Advanced Life Support Drugs in Patients With Out-of-Hospital Cardiac Arrest: Insights From the Resuscitation Outcomes Consortium Continuous Chest Compression Trial

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Purav Mody ◽  
Siobhan Brown ◽  
Rohan Khera ◽  
Ambarish Pandey ◽  
Colby Ayers ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Chest Compression ◽  
Life Support ◽  
Advanced Life Support ◽  
Spontaneous Circulation ◽  
Neurological Function ◽  
Access Route ◽  
Epinephrine Administration ◽  
Bystander Cpr ◽  
Hospital Cardiac Arrest

Background: There is an urgent need to identify strategies which improve outcomes for out-of-hospital cardiac arrest (OHCA). Determining the optimal access route to deliver medications during resuscitation from OHCA may be one such strategy. Methods: Using data from the Continuous Chest compression trial between 2011 and 2016, we examined rates of sustained return of spontaneous circulation (ROSC) i.e. ROSC on ER arrival, survival to discharge and survival with favorable neurological function (modified Rankin scale ≤3) among patients with attempted IV and IO access. Results: Among 19,731 patients with available access information, IO or IV access was attempted in 3,068 (15.5%) and 16,663 (84.5%) patients, respectively and was successful in 2,975 (97%) and 15,485 (92%) of these patients. Overall, patients with attempted IO access were younger, more likely female, received less bystander CPR, had lower proportions of shockable and witnessed arrests, marginally faster times to access and to epinephrine administration, and less frequently received therapeutic hypothermia and coronary angiography as compared with patients with IV access ( Table ) . Unadjusted rates of sustained ROSC, discharge survival and survival with favorable neurological function were significantly lower in patients with attempted IO access ( Table) . After adjustment for age, sex, initial rhythm, bystander CPR, public location, witnessed status, EMS response time and trial cluster, attempted IO access was associated with lower sustained ROSC rates (OR 0.79, 95% CI 0.71-0.89, p<0.001) but not with discharge survival (OR 0.88, 95% CI 0.71-1.08, p=0.21) or survival with favorable neurological function (OR 0.86, 95% CI 0.67-1.1, p=0.26). Conclusions: Among patients with OHCA, intraosseous access was attempted in 1 in 7 OHCA patients and associated with worse ROSC rates but no difference in survival. Further studies are necessary to elucidate the optimal access route among OHCA patients.

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