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Wolf J, Buckley GJ, Rozanski EA, Fletcher DJ, Boller M, Burkitt-Creedon JM, Weigand KA, Crews M, Fausak ED. 2024 RECOVER Guidelines: Advanced Life Support. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR. J Vet Emerg Crit Care (San Antonio) 2024; 34 Suppl 1:44-75. [PMID: 38924633 DOI: 10.1111/vec.13389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 04/25/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE To systematically review the evidence and devise clinical recommendations on advanced life support (ALS) in dogs and cats and to identify critical knowledge gaps. DESIGN Standardized, systematic evaluation of literature pertinent to ALS following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by Evidence Evaluators, and findings were reconciled by ALS Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk:benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization. SETTING Transdisciplinary, international collaboration in university, specialty, and emergency practice. RESULTS Seventeen questions pertaining to vascular access, vasopressors in shockable and nonshockable rhythms, anticholinergics, defibrillation, antiarrhythmics, and adjunct drug therapy as well as open-chest CPR were reviewed. Of the 33 treatment recommendations formulated, 6 recommendations addressed the management of patients with nonshockable arrest rhythms, 10 addressed shockable rhythms, and 6 provided guidance on open-chest CPR. We recommend against high-dose epinephrine even after prolonged CPR and suggest that atropine, when indicated, is used only once. In animals with a shockable rhythm in which initial defibrillation was unsuccessful, we recommend doubling the defibrillator dose once and suggest vasopressin (or epinephrine if vasopressin is not available), esmolol, lidocaine in dogs, and/or amiodarone in cats. CONCLUSIONS These updated RECOVER ALS guidelines clarify the approach to refractory shockable rhythms and prolonged CPR. Very low quality of evidence due to absence of clinical data in dogs and cats continues to compromise the certainty with which recommendations can be made.
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Affiliation(s)
- Jacob Wolf
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Elizabeth A Rozanski
- Department of Clinical Sciences, Tufts University School of Veterinary Medicine, North Grafton, Massachusetts, USA
| | - Daniel J Fletcher
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Manuel Boller
- VCA Canada Central Victoria Veterinary Hospital, Victoria, British Columbia, Canada
- Faculty of Veterinary Medicine, Department of Veterinary Clinical and Diagnostic Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jamie M Burkitt-Creedon
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Kelly A Weigand
- Cary Veterinary Medical Library, Auburn University, Auburn, Alabama, USA
- Flower-Sprecher Veterinary Library, Cornell University, Ithaca, New York, USA
| | - Molly Crews
- Department of Small Animal Clinical Sciences, Texas A&M University College of Veterinary Medicine & Biomedical Sciences, College Station, Texas, USA
| | - Erik D Fausak
- University Library, University of California, Davis, Davis, California, USA
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Okubo M, Komukai S, Izawa J, Chung S, Drennan IR, Grunau BE, Lupton JR, Ramgopal S, Rea TD, Callaway CW. Survival After Intra-Arrest Transport vs On-Scene Cardiopulmonary Resuscitation in Children. JAMA Netw Open 2024; 7:e2411641. [PMID: 38767920 PMCID: PMC11107299 DOI: 10.1001/jamanetworkopen.2024.11641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/28/2024] [Indexed: 05/22/2024] Open
Abstract
Importance For pediatric out-of-hospital cardiac arrest (OHCA), emergency medical services (EMS) may elect to transport to the hospital during active cardiopulmonary resuscitation (CPR) (ie, intra-arrest transport) or to continue on-scene CPR for the entirety of the resuscitative effort. The comparative effectiveness of these strategies is unclear. Objective To evaluate the association between intra-arrest transport compared with continued on-scene CPR and survival after pediatric OHCA, and to determine whether this association differs based on the timing of intra-arrest transport. Design, Setting, and Participants This cohort study included pediatric patients aged younger than 18 years with EMS-treated OHCA between December 1, 2005 and June 30, 2015. Data were collected from the Resuscitation Outcomes Consortium Epidemiologic Registry, a prospective 10-site OHCA registry in the US and Canada. Data analysis was performed from May 2022 to February 2024. Exposures Intra-arrest transport, defined as an initiation of transport prior to the return of spontaneous circulation, and the interval between EMS arrival and intra-arrest transport. Main Outcomes and Measures The primary outcome was survival to hospital discharge. Patients who underwent intra-arrest transport at any given minute after EMS arrival were compared with patients who were at risk of undergoing intra-arrest transport within the same minute using time-dependent propensity scores calculated from patient demographics, arrest characteristics, and EMS interventions. We examined subgroups based on age (<1 year vs ≥1 year). Results Of 2854 eligible pediatric patients (median [IQR] age, 1 [0-9] years); 1691 males [59.3%]) who experienced OHCA between December 2005 and June 2015, 1892 children (66.3%) were treated with intra-arrest transport and 962 children (33.7%) received continued on-scene CPR. The median (IQR) time between EMS arrival and intra-arrest transport was 15 (9-22) minutes. In the propensity score-matched cohort (3680 matched cases), there was no significant difference in survival to hospital discharge between the intra-arrest transport group and the continued on-scene CPR group (87 of 1840 patients [4.7%] vs 95 of 1840 patients [5.2%]; risk ratio [RR], 0.81 [95% CI, 0.59-1.10]). Survival to hospital discharge was not modified by the timing of intra-arrest transport (P value for the interaction between intra-arrest transport and time to matching = .10). Among patients aged younger than 1 year, intra-arrest transport was associated with lower survival to hospital discharge (RR, 0.52; 95% CI, 0.33-0.83) but there was no association for children aged 1 year or older (RR, 1.22; 95% CI, 0.77-1.93). Conclusions and Relevance In this cohort study of a North American OHCA registry, intra-arrest transport compared with continued on-scene CPR was not associated with survival to hospital discharge among children with OHCA. However, intra-arrest transport was associated with a lower likelihood of survival to hospital discharge among children aged younger than 1 year.
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Affiliation(s)
- Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Junichi Izawa
- Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Okinawa, Japan
- Department of Preventive Services, Graduate School of Public Health, Kyoto University, Kyoto, Japan
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - SunHee Chung
- Department of Emergency Medicine, Oregon Health and Science University, Portland
| | - Ian R. Drennan
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brian E. Grunau
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joshua R. Lupton
- Department of Emergency Medicine, Oregon Health and Science University, Portland
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Thomas D. Rea
- Department of Medicine, University of Washington, Seattle
| | - Clifton W. Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Ishihara T, Sasaki R, Enomoto Y, Amagasa S, Yasuda M, Ohnishi S. Changes in pre- and in-hospital management and outcomes among children with out-of-hospital cardiac arrest between 2012 and 2017 in Kanto, Japan. Sci Rep 2023; 13:10092. [PMID: 37344630 DOI: 10.1038/s41598-023-37201-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/17/2023] [Indexed: 06/23/2023] Open
Abstract
Previously, the SOS-KANTO 2012 studies, conducted in the Kanto area of Japan, reported a summary of outcomes in patients with out-of-hospital cardiac arrest (OHCA). This sub-analysis of the SOS-KANTO study 2017 aimed to evaluate the neurological outcomes of paediatric OHCA patients, by comparing the SOS-KANTO 2012 and 2017 studies. All OHCA patients, aged < 18 years, who were transported to the participating hospitals by EMS personnel were included in both SOS-KANTO studies (2012 and 2017). The number of survival patients with favourable neurological outcomes (paediatric cerebral performance category 1 or 2) at 1 month did not improve between 2012 and 2017. There was no significant difference in achievement of pre-hospital return of spontaneous circulation (ROSC) [odds ratio (OR): 2.00, 95% confidence interval (95% CI): 0.50-7.99, p = 0.50] and favourable outcome at 1 month [OR: 0.67, 95% CI: 0.11-3.99, p = 1] between the two studies, matched by age, witnessed arrest, bystander CPR, aetiology of OHCA, and time from call to EMS arrival. Multivariable logistic regression showed no significant difference in the achievement of pre-hospital ROSC and favourable outcomes at 1 month between the two studies.
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Affiliation(s)
- Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Urayasu Hospital, Juntendo University, 2-1-1, Tomioka, Urayasu, Chiba, 279-0021, Japan.
| | - Ryuji Sasaki
- Division of Emergency and Transport Services, National Center for Child Health and Development, Tokyo, Japan
| | - Yuki Enomoto
- Department of Emergency and Critical Care Medicine, University of Tsukuba, Ibaragi, Japan
| | - Shunsuke Amagasa
- Division of Emergency and Transport Services, National Center for Child Health and Development, Tokyo, Japan
| | - Masato Yasuda
- Division of Emergency Medicine, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Shima Ohnishi
- Division of Emergency and Transport Services, National Center for Child Health and Development, Tokyo, Japan
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Ho AFW, Lee KY, Nur S, Fook SC, Pek PP, Tanaka H, Sang DS, Chow PIK, Tan BYQ, Lim SL, Ma MHM, Ryoo HW, Lin CH, Kuo CW, Kajino K, Ong MEH. Association between Conversion to Shockable Rhythms and Survival with Favorable Neurological Outcomes for Out-of-Hospital Cardiac Arrests. PREHOSP EMERG CARE 2023; 28:126-134. [PMID: 37171870 DOI: 10.1080/10903127.2023.2212039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/05/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND The initial cardiac rhythm in out-of-hospital cardiac arrest (OHCA) portends different prognoses and affects treatment decisions. Initial shockable rhythms are associated with good survival and neurological outcomes but there is conflicting evidence for those who initially present with non-shockable rhythms. The aim of this study is to evaluate if OHCA with conversion from non-shockable (i.e., asystole and pulseless electrical activity) rhythms to shockable rhythms compared to OHCA remaining in non-shockable rhythms is associated with better survival and neurological outcomes. METHOD OHCA cases from the Pan-Asian Resuscitation Outcomes Study registry in 13 countries between January 2009 and February 2018 were retrospectively analyzed. Cases with missing initial rhythms, age <18 years, presumed non-medical cause of arrest, and not conveyed by emergency medical services were excluded. Multivariable logistic regression analysis was performed to evaluate the relationship between initial and subsequent shockable rhythm, survival to discharge, and survival with favorable neurological outcomes (cerebral performance category 1 or 2). RESULTS Of the 116,387 cases included. 11,153 (9.6%) had initial shockable rhythms and 9,765 (8.4%) subsequently converted to shockable rhythms. Japan had the lowest proportion of OHCA patients with initial shockable rhythms (7.3%). For OHCA with initial shockable rhythm, the adjusted odds ratios (aOR) for survival and good neurological outcomes were 8.11 (95% confidence interval [CI] 7.62-8.63) and 15.4 (95%CI 14.1-16.8) respectively. For OHCA that converted from initial non-shockable to shockable rhythms, the aORs for survival and good neurological outcomes were 1.23 (95%CI 1.10-1.37) and 1.61 (95%CI 1.35-1.91) respectively. The aORs for survival and good neurological outcomes were 1.48 (95%CI 1.22-1.79) and 1.92 (95%CI 1.3 - 2.84) respectively for initial asystole, while the aOR for survival in initial pulseless electrical activity patients was 0.83 (95%CI 0.71-0.98). Prehospital adrenaline administration had the highest aOR (2.05, 95%CI 1.93-2.18) for conversion to shockable rhythm. CONCLUSION In this ambidirectional cohort study, conversion from non-shockable to shockable rhythm was associated with improved survival and neurologic outcomes compared to rhythms that continued to be non-shockable. Continued advanced resuscitation may be beneficial for OHCA with subsequent conversion to shockable rhythms.
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Affiliation(s)
- Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore
| | - Kai Yi Lee
- Physicians, Ministry of Health Holdings, Singapore
| | - Shahidah Nur
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | | | - Pin Pin Pek
- Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore
| | - Hideharu Tanaka
- Department of Emergency Medical Services System, Graduate School, Kokushikan University, Tokyo, Japan
- Research institute, Disaster prevention, EMS and rescue, Kokushikan University, Tokyo, Japan
| | - Do Shin Sang
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical, Research Institute, Seoul, Republic of Korea
| | - Patrick In-Ko Chow
- Department of Emergency Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | | | - Shir Lynn Lim
- Department of Cardiology, National University Heart Center, Singapore
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Douliou, Taiwan
| | - Hyun Wook Ryoo
- Department of Emergency Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Chih-Hao Lin
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chan-Wei Kuo
- Department of Emergency Medicine, Chang-Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Kentaro Kajino
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Health Services & Systems Research, Duke-NUS Medical School, Singapore
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Obara T, Yumoto T, Nojima T, Hongo T, Tsukahara K, Matsumoto N, Yorifuji T, Nakao A, Elmer J, Naito H. Association of Prehospital Physician Presence During Pediatric Out-of-Hospital Cardiac Arrest With Neurologic Outcomes. Pediatr Crit Care Med 2023; 24:e244-e252. [PMID: 36749942 DOI: 10.1097/pcc.0000000000003206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
OBJECTIVES To examine the association of prehospital physician presence with neurologic outcomes of pediatric patients with out-of-hospital cardiac arrest (OHCA). DESIGN Retrospective cohort study. SETTING Data from the Japanese Association for Acute Medicine-OHCA Registry. INTERVENTIONS None. PATIENTS Pediatric patients (age 17 yr old or younger) registered in the database between June 2014 and December 2019. MEASUREMENT AND MAIN RESULTS We used logistic regression models with stabilized inverse probability of treatment weighting (IPTW) to estimate the associated treatment effect of a prehospital physician with 1-month neurologically intact survival. Secondary outcomes included in-hospital return of spontaneous circulation (ROSC) and 1-month survival after OHCA. A total of 1,187 patients (276 in the physician presence group and 911 in the physician absence group) were included (median age 3 yr [interquartile range 0-14 yr]; 723 [61%] male). Comparison of the physician presence group, versus the physician absence, showed 1-month favorable neurologic outcomes of 8.3% (23/276) versus 3.6% (33/911). Physician presence was associated with greater odds of 1-month neurologically intact survival after stabilized IPTW adjustment (adjusted odds ratio [aOR] 1.98, 95% CI 1.08-3.66). We also found an association in the secondary outcome between physician presence, opposed to absence, and in-hospital ROSC (aOR 1.48, 95% CI 1.08-2.04). However, we failed to identify an association with 1-month survival (aOR 1.49, 95% CI 0.97-2.88). CONCLUSIONS Among pediatric patients with OHCA, prehospital physician presence, compared with absence, was associated almost two-fold greater odds of 1-month favorable neurologic outcomes.
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Affiliation(s)
- Takafumi Obara
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Tsuyoshi Nojima
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Takashi Hongo
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Kohei Tsukahara
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Naomi Matsumoto
- Department of Epidemiology, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Takashi Yorifuji
- Department of Epidemiology, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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Lockhart-Bouron M, Baert V, Leteurtre S, Hubert H, Recher M. Association between out-of-hospital cardiac arrest and survival in paediatric traumatic population: results from the French national registry. Eur J Emerg Med 2023; 30:186-192. [PMID: 37040661 DOI: 10.1097/mej.0000000000001024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
Trauma is an important cause of paediatric out-of-hospital cardiac arrest (OHCA) with a high mortality rate. The first aim of this study was to compare the survival rate at day 30 and at hospital discharge following paediatric traumatic and medical OHCA. The second aim was to compare the rates of return of spontaneous circulation and survival rates at hospital admission (Day 0). This multicentre comparative post-hoc study was conducted between July 2011 and February 2022 based on the French National Cardiac Arrest Registry data. All patients aged <18 years with OHCA were included in the study. Patients with traumatic aetiology were matched with those with medical aetiology using propensity score matching. Endpoint was the survival rate at day 30. There were 398 traumatic and 1061 medical OHCAs. Matching yielded 227 pairs. In non-adjusted comparisons, days 0 and 30 survival rates were lower in the traumatic aetiology group than in the medical aetiology group [19.1% vs. 24.0%, odds ratio (OR) 0.75, 95% confidence interval (CI) 0.56-0.99, and 2.0% vs. 4.5%, OR 0.43, 95% CI, 0.20-0.92, respectively]. In adjusted comparisons, day 30 survival rate was lower in the traumatic aetiology group than in the medical aetiology group (2.2% vs. 6.2%, OR 0.36, 95% CI, 0.13-0.99). In this post-hoc analysis, paediatric traumatic OHCA was associated with a lower survival rate than medical cardiac arrest.
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Affiliation(s)
- Marguerite Lockhart-Bouron
- Department of Pediatric Intensive Care, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Univ. Lille
| | - Valentine Baert
- Department of Pediatric Intensive Care, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Univ. Lille
- Department of French National Out-of-Hospital Cardiac Arrest Registry Research Group - Registre électronique des Arrêts Cardiaques, Lille, France
| | - Stéphane Leteurtre
- Department of Pediatric Intensive Care, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Univ. Lille
| | - Hervé Hubert
- Department of Pediatric Intensive Care, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Univ. Lille
- Department of French National Out-of-Hospital Cardiac Arrest Registry Research Group - Registre électronique des Arrêts Cardiaques, Lille, France
| | - Morgan Recher
- Department of Pediatric Intensive Care, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Univ. Lille
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Amoako J, Komukai S, Izawa J, Callaway CW, Okubo M. Evaluation of Use of Epinephrine and Time to First Dose and Outcomes in Pediatric Patients With Out-of-Hospital Cardiac Arrest. JAMA Netw Open 2023; 6:e235187. [PMID: 36976555 PMCID: PMC10051078 DOI: 10.1001/jamanetworkopen.2023.5187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 02/10/2023] [Indexed: 03/29/2023] Open
Abstract
Importance While epinephrine has been widely used in prehospital resuscitation for pediatric patients with out-of-hospital cardiac arrest (OHCA), the benefit and optimal timing of epinephrine administration have not been fully investigated. Objectives To evaluate the association between epinephrine administration and patient outcomes and to ascertain whether the timing of epinephrine administration was associated with patient outcomes after pediatric OHCA. Design, Setting, and Participants This cohort study included pediatric patients (<18 years) with OHCA treated by emergency medical services (EMS) from April 2011 to June 2015. Eligible patients were identified from the Resuscitation Outcomes Consortium Epidemiologic Registry, a prospective OHCA registry at 10 sites in the US and Canada. Data analysis was performed from May 2021 to January 2023. Exposures The main exposures were prehospital intravenous or intraosseous epinephrine administration and the interval between arrival of an advanced life support (ALS)-capable EMS clinician (ALS arrival) and the first administration of epinephrine. Main Outcomes and Measures The primary outcome was survival to hospital discharge. Patients who received epinephrine at any given minute after ALS arrival were matched with patients who were at risk of receiving epinephrine within the same minute using time-dependent propensity scores calculated from patient demographics, arrest characteristics, and EMS interventions. Results Of 1032 eligible individuals (median [IQR] age, 1 [0-10] years), 625 (60.6%) were male. 765 patients (74.1%) received epinephrine and 267 (25.9%) did not. The median (IQR) time interval between ALS arrival and epinephrine administration was 9 (6.2-12.1) minutes. In the propensity score-matched cohort (1432 patients), survival to hospital discharge was higher in the epinephrine group compared with the at-risk group (epinephrine: 45 of 716 [6.3%] vs at-risk: 29 of 716 [4.1%]; risk ratio, 2.09; 95% CI, 1.29-3.40). The timing of epinephrine administration was also not associated with survival to hospital discharge after ALS arrival (P for the interaction between epinephrine administration and time to matching = .34). Conclusions and Relevance In this study of pediatric patients with OHCA in the US and Canada, epinephrine administration was associated with survival to hospital discharge, while timing of the administration was not associated with survival.
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Affiliation(s)
- Jeffrey Amoako
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Junichi Izawa
- Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Okinawa, Japan
| | - Clifton W. Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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8
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Andersen HB, Andersen M, Andelius TCK, Pedersen MV, Løfgren B, Pedersen M, Ringgaard S, Kyng KJ, Henriksen TB. Epinephrine vs placebo in neonatal resuscitation: ROSC and brain MRS/MRI in term piglets. Pediatr Res 2023; 93:511-519. [PMID: 35681089 DOI: 10.1038/s41390-022-02126-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 05/01/2022] [Accepted: 05/17/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND We aimed to investigate the effect of epinephrine vs placebo on return of spontaneous circulation (ROSC) and brain magnetic resonance spectroscopy and imaging (MRS/MRI) in newborn piglets with hypoxic cardiac arrest (CA). METHODS Twenty-five piglets underwent hypoxia induced by endotracheal tube clamping until CA. The animals were randomized to CPR + intravenous epinephrine or CPR + placebo (normal saline). The primary outcome was ROSC, and secondary outcomes included time-to-ROSC, brain MRS/MRI, and composite endpoint of death or severe brain MRS/MRI abnormality. RESULTS ROSC was more frequent in animals treated with epinephrine than placebo; 10/13 vs 4/12, RR = 2.31 (95% CI: 1.09-5.77). We found no difference in time-to-ROSC (120 (113-211) vs 153 (116-503) seconds, p = 0.7) or 6-h survival (7/13 vs 3/12, p = 0.2). Among survivors, there was no difference between groups in brain MRS/MRI. We found no difference in the composite endpoint of death or severe brain MRS/MRI abnormality; RR = 0.7 (95% CI: 0.37-1.19). CONCLUSIONS Resuscitation with epinephrine compared to placebo improved ROSC frequency after hypoxic CA in newborn piglets. We found no difference in time-to-ROSC or the composite endpoint of death or severe brain MRS/MRI abnormality. IMPACT In a newborn piglet model of hypoxic cardiac arrest, resuscitation with epinephrine compared to placebo improved the rate of return of spontaneous circulation and more than doubled the 6-h survival. Brain MRS/MRI biomarkers were used to evaluate the effect of epinephrine vs placebo. We found no difference between groups in the composite endpoint of death or severe brain MRS/MRI abnormality. This study adds to the limited evidence regarding the effect and safety of epinephrine; the lack of high-quality evidence from randomized clinical trials was highlighted in the latest ILCOR 2020 guidelines, and newborn animal studies were specifically requested.
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Affiliation(s)
- Hannah B Andersen
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Mads Andersen
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Ted C K Andelius
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mette V Pedersen
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Bo Løfgren
- Research Center for Emergency, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Michael Pedersen
- Comparative Medicine Lab, Aarhus University Hospital, Aarhus, Denmark
| | | | - Kasper J Kyng
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Tine B Henriksen
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Matsuyama T, Ohta B, Kiyohara K, Kitamura T. Intra-arrest partial carbon dioxide level and favorable neurological outcome after out-of-hospital cardiac arrest: a nationwide multicenter observational study in Japan (the JAAM-OHCA registry). EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:14-21. [PMID: 36447370 DOI: 10.1093/ehjacc/zuac152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/14/2022] [Accepted: 11/29/2022] [Indexed: 12/05/2022]
Abstract
AIMS Little is known about whether guideline-recommended ventilation during cardiopulmonary resuscitation results in optimal partial carbon dioxide (pCO2) levels or favorable outcomes. This study aimed to evaluate the association between intra-arrest pCO2 level and the outcome after out-of-hospital cardiac arrest (OHCA). METHODS AND RESULTS We performed a secondary analysis of a multicenter observational study, including adult patients with OHCA who did not achieve a return of spontaneous circulation (ROSC) upon hospital arrival and whose blood gas analysis was performed before the ROSC between June 2014 and December 2017. The patients were categorized into four quartiles based on their intra-arrest carbon dioxide levels: Quartile 1 (<66.0 mmHg), Quartile 2 (66.1-87.2 mmHg), Quartile 3 (87.3-113.5 mmHg), and Quartile 4 (≥113.6 mmHg). The primary outcome was 1-month survival with favorable neurological outcomes defined as cerebral performance Category 1 or 2. Multivariate logistic regression analysis was used to evaluate the association between pCO2 and favorable neurological outcomes. During the study period, 20 913 patients were eligible for the analysis. The proportion of favorable neurological outcomes was 1.8% (90/5133), 0.7% (35/5232), 0.4% (19/5263), and 0.2% (9/5285) in Quartiles 1-4, respectively. Multivariable logistic regression analysis demonstrated that the probability of favorable neurological outcome decreased with increased intra-arrest carbon dioxide levels (i.e. Q1 vs. Q4, adjusted odds ratio 0.25, 95% confidence interval 0.16-0.55, P for trend <0.001). CONCLUSION Lower intra-arrest pCO2 levels were associated with a favorable neurological outcome.
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Affiliation(s)
- Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kaji-cho 465, Kamigyo-ku, Kyoto 6028566, Japan
| | - Bon Ohta
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kaji-cho 465, Kamigyo-ku, Kyoto 6028566, Japan
| | - Kosuke Kiyohara
- Department of Food Science, Otsuma Women's University, Sanban-cho 12, Chiyoda-ku, Tokyo 1028357, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Services, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Yamada-Oka 2-2, Suita, Osaka 5650871, Japan
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10
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Irvine R, Doan T, Bosley E, Colbeck M, Bowles KA. Paediatric Out-of-Hospital Cardiac Arrests: An Epidemiological Study. PREHOSP EMERG CARE 2022:1-10. [PMID: 35771687 DOI: 10.1080/10903127.2022.2096159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Objective: To identify the epidemiological patterns of paediatric out-of-hospital cardiac arrests (OHCA) in Queensland, Australia and to investigate associations between patient variables and prehospital outcome.Methods: Included were paediatric (>4 days - 18 years) OHCA patients attended by paramedics in the state of Queensland (Australia) between January 2009 and December 2019. Patient and arrest characteristics were described. Factors associated with return of spontaneous circulation (ROSC) on hospital arrival were investigated.Results: A total of 1612 paediatric patients were included; 611 were deceased prior to paramedic arrival and 1001 received resuscitation attempts by paramedics. Approximately one quarter (26.8%) of resuscitation-attempted patients achieved ROSC on hospital arrival. Most arrests (49.7%) were due to medical causes. Arrests due to trauma had the lowest rate of ROSC on hospital arrival (9.6%), whereas those due to drug overdose had the highest rate (40%). Patients in rural areas had a lower rate of ROSC on hospital arrival than those in metropolitan areas (20.7% vs 32.5%, p < 0.001). The median response interval to all OHCA patients was 8 minutes. Trauma was considerably more prevalent in rural areas than in metropolitan areas, while all other aetiologies were comparable. Older paediatric age groups had higher rates of ROSC on hospital arrival than infants, particularly early adolescents (39.4% vs. 14.9%, p = 0.001). Aetiology, age, bystander witness, shockable initial rhythm, and geographic locality factors were independently associated with ROSC on hospital arrival.Conclusions: Approximately a quarter of paediatric prehospital OHCA achieved ROSC on hospital arrival. Prehospital outcome differs according to patient cohort and is associated with diverse patient demographic variables.
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Affiliation(s)
- Rachel Irvine
- Department of Paramedicine, Monash University, Victoria, Australia
| | - Tan Doan
- Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Emma Bosley
- Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Marc Colbeck
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Banyo, Queensland, Australia
| | - Kelly-Ann Bowles
- Department of Paramedicine, Monash University, Victoria, Australia
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11
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Matsuyama T, Ohta B, Kiyohara K, Kitamura T. Cardiopulmonary resuscitation duration and favorable neurological outcome after out-of-hospital cardiac arrest: a nationwide multicenter observational study in Japan (the JAAM-OHCA registry). Crit Care 2022; 26:120. [PMID: 35501884 PMCID: PMC9059367 DOI: 10.1186/s13054-022-03994-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/26/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE We aimed to assess the association between cardiopulmonary resuscitation (CPR duration) and outcomes after OHCA. METHODS This secondary analysis of a prospective, multicenter, observational study included adult non-traumatic OHCA patients aged ≥ 18 years between June 2014 and December 2017. CPR duration was defined as the time from professional CPR initiation to the time of return of spontaneous circulation or termination of resuscitation. The primary outcome was 1-month survival, with favorable neurological outcomes defined by cerebral performance category 1 or 2. We performed multivariable logistic regression analysis to investigate the association between CPR duration and favorable neurological outcomes. We also investigated the association between CPR duration and favorable neurological outcomes stratified by case features, including the first documented cardiac rhythm, witnessed status, and presence of bystander CPR. RESULTS A total of 23,803 patients were included in this analysis. Multivariable logistic regression analysis demonstrated that the probability of favorable neurological outcomes decreased with CPR duration (i.e., 20.8% [226/1084] in the ≤ 20 min group versus 0.0% [0/708] in the 91-120 min group, P for trend < 0.001). Furthermore, the impact of CPR duration differed depending on the presence of case features; those with shockable, witnessed arrest, and bystander CPR were more likely to achieve favorable neurological outcomes after prolonged CPR duration > 30 min. CONCLUSION The probability of favorable neurological outcome rapidly decreased within a few minutes of CPR duration. But, the impact of CPR duration may be influenced by each patient's clinical feature.
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Affiliation(s)
- Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Bon Ohta
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kosuke Kiyohara
- Department of Food Science, Otsuma Women's University, Tokyo, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Services, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
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12
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McKenzie K, Cameron S, Odoardi N, Gray K, Miller MR, Tijssen JA. Evaluation of Local Pediatric Out-of-Hospital Cardiac Arrest and Emergency Services Response. Front Pediatr 2022; 10:826294. [PMID: 35273929 PMCID: PMC8901601 DOI: 10.3389/fped.2022.826294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background Survival after pediatric out-of-hospital cardiac arrest is poor. Paramedic services provide critical interventions that impact survival outcomes. We aimed to describe local pediatric out-of-hospital cardiac arrest (POHCA) events and evaluate the impact of the paramedic service response to POHCA. Methods The Canadian Resuscitation Outcomes Consortium and corresponding ambulance call records were used to evaluate deviations from best practice by paramedics for patients aged 1 day to <18 years who had an atraumatic out-of-hospital cardiac arrest between 2012 and 2020 in Middlesex-London County. Deviations were any departure from protocol as defined by Middlesex-London Paramedic Services. Results Fifty-one patients were included in this study. All POHCA events had at least one deviation, with a total of 188 deviations for the study cohort. Return of spontaneous circulation (ROSC) was achieved in 35.3% of patients and 5.8% survived to hospital discharge. All survivors developed a new, severe neurological impairment. Medication deviations were most common (n = 40, 21.3%) followed by process timing (n = 38, 20.2%), vascular access (n = 27, 14.4%), and airway (n = 27, 14.4%). A delay in vascular access was the most common deviation (n = 25, 49.0%). The median (IQR) time to epinephrine administration was 8.6 (5.90-10.95) min from paramedic arrival. Cardiac arrests occurring in public settings had more deviations than private settings (p = 0.04). ROSC was higher in events with a deviation in any circulation category (p = 0.03). Conclusion Patient and arrest characteristics were similar to other POHCA studies. This cohort exhibited high rates of ROSC and bystander cardiopulmonary resuscitation but low survival to hospital discharge. The study was underpowered for its primary outcome of survival. The total deviations scored was low relative to the total number of tasks in a resuscitation. Epinephrine was frequently administered outside of the recommended timeframe, highlighting an important quality improvement opportunity.
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Affiliation(s)
- Kate McKenzie
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Saoirse Cameron
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Natalya Odoardi
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Katelyn Gray
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Michael R. Miller
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Health Research Institute, Lawson Health Research Institute, London, ON, Canada
| | - Janice A. Tijssen
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Health Research Institute, Lawson Health Research Institute, London, ON, Canada
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13
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Recher M, Canon V, Lockhart M, Lafrance M, Hubert H, Leteurtre S. High dose of epinephrine does not improve survival of children with out-of-hospital cardiac arrest: Results from the French National Cardiac Arrest Registry. Front Pediatr 2022; 10:978742. [PMID: 36275073 PMCID: PMC9583001 DOI: 10.3389/fped.2022.978742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The pediatric resuscitation guidelines recommend the use of 0. 01 mg kg-1 epinephrine during a cardiac arrest; an epinephrine dose higher than that is not recommended. The first aim of this study was to determine the administration rate of high epinephrine dose during pediatric out-of-hospital cardiac arrest. The second aim was to compare the survival status in patients who received high or standard doses of epinephrine. METHODS This was a multicenter comparative post-hoc study conducted between January 2011 and July 2021 based on the French National Cardiac Arrest Registry data. All prepubescent (boys < 12 years old, girls < 10 years old) victims of an out-of-hospital cardiac arrest were included. To compare survival status and control bias, patients who received a high epinephrine dose were matched with those who received a standard epinephrine dose using propensity score matching. RESULTS The analysis included 755 patients; 400 (53%) received a high dose and 355 (47%) received a standard dose of epinephrine. The median dose (mg kg-1) per bolus was higher in the high-dose group than that in the standard dose group (0.04 vs. 0.01 mg kg-1, P < 0.001). Before matching, there was no between-group difference in the 30-day survival rate or survival status at hospital discharge. Matching yielded 288 pairs; there was no between-group difference in the 30-day survival rate or survival at hospital discharge (High dose, n = 5; standard dose, n = 12; Odds ratios: 2.40, 95% confidence interval: 0.85-6.81). Only 2 patients in the standard dose group had a good neurological outcome. CONCLUSION More than 50% of the patients did not receive the recommended epinephrine dose during resuscitation. There was no association between patients receiving a high dose or standard dose of epinephrine with the 30-day survival or survival status at hospital discharge. Collaboration across multiple cardiac arrest registries is needed to study the application of pediatric guidelines.
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Affiliation(s)
- Morgan Recher
- Pediatric Intensive Care Unit, CHU Lille, Lille, France.,ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Univ. Lille, CHU Lille, Lille, France
| | - Valentine Canon
- ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Univ. Lille, CHU Lille, Lille, France.,French National Out-of-Hospital Cardiac Arrest Registry Research Group - Registre électronique des Arrêts Cardiaques, Lille, France
| | - Marguerite Lockhart
- Pediatric Intensive Care Unit, CHU Lille, Lille, France.,ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Univ. Lille, CHU Lille, Lille, France
| | - Martin Lafrance
- ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Univ. Lille, CHU Lille, Lille, France.,French National Out-of-Hospital Cardiac Arrest Registry Research Group - Registre électronique des Arrêts Cardiaques, Lille, France
| | - Hervé Hubert
- ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Univ. Lille, CHU Lille, Lille, France.,French National Out-of-Hospital Cardiac Arrest Registry Research Group - Registre électronique des Arrêts Cardiaques, Lille, France
| | - Stéphane Leteurtre
- Pediatric Intensive Care Unit, CHU Lille, Lille, France.,ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Univ. Lille, CHU Lille, Lille, France
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14
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Okubo M, Komukai S, Callaway CW, Izawa J. Association of Timing of Epinephrine Administration With Outcomes in Adults With Out-of-Hospital Cardiac Arrest. JAMA Netw Open 2021; 4:e2120176. [PMID: 34374770 PMCID: PMC8356068 DOI: 10.1001/jamanetworkopen.2021.20176] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
IMPORTANCE Administration of epinephrine has been found to be associated with an increased chance of survival after out-of-hospital cardiac arrest (OHCA), but the optimal timing of administration has not been fully investigated. OBJECTIVE To ascertain whether there is an association between timing of epinephrine administration and patient outcomes after OHCA. DESIGN, SETTING, AND PARTICIPANTS This cohort study included adults 18 years or older with OHCA treated by emergency medical services (EMS) personnel from April 1, 2011, to June 30, 2015. Initial cardiac rhythm was stratified as either initially shockable (ventricular defibrillation or pulseless ventricular tachycardia) or nonshockable (pulseless electrical activity or asystole). Eligible individuals were identified from among publicly available, deidentified patient-level data from the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registry, a prospective registry of adults with EMS-treated, nontraumatic OHCA with 10 sites in North America. Data analysis was conducted from May 2019 to April 2021. EXPOSURES Interval between advanced life support (ALS)-trained EMS personnel arrival at the scene and the first prehospital intravenous or intraosseous administration of epinephrine. MAIN OUTCOMES AND MEASURES The primary outcome was survival to hospital discharge. In each cohort of initial cardiac rhythms, patients who received epinephrine at any period (minutes) after EMS arrival at the scene were matched with patients who were at risk of receiving epinephrine within the same period using time-dependent propensity scores calculated from patient demographic characteristics, arrest characteristics, and EMS interventions. RESULTS Of 41 079 eligible individuals (median [interquartile range] age, 67 [55-79] years), 26 579 (64.7%) were men. A total of 10 088 individuals (24.6%) initially had shockable cardiac rhythms, and 30 991 (75.4%) had nonshockable rhythms. Those who received epinephrine included 8223 patients (81.5%) with shockable cardiac rhythms and 27 901 (90.0%) with nonshockable rhythms. In the shockable cardiac rhythm cohort, the risk ratio (RR) for receipt of epinephrine with survival to hospital discharge was highest between 0 and 5 minutes after EMS arrival (1.12; 95% CI, 0.99-1.26) across the categorized timing of the administration of epinephrine by 5-minute intervals after EMS arrival; however, that finding was not statistically significant. Treating the timing of epinephrine administration as a continuous variable, the RR for survival to hospital discharge decreased 5.5% (95% CI, 3.4%-7.5%; P < .001 for the interaction between epinephrine administration and time to matching) per minute after EMS arrival. In the nonshockable cardiac rhythm cohort, the RR for the association of receipt of epinephrine with survival to hospital discharge was the highest between 0 and 5 minutes (1.28; 95% CI, 0.95-1.72), although not statistically significant, and decreased 4.4% (95% CI, 0.8%-7.9%; P for interaction = .02) per minute after EMS arrival. CONCLUSIONS AND RELEVANCE Among adults with OHCA, survival to hospital discharge differed across the timing of epinephrine administration and decreased with delayed administration for both shockable and nonshockable rhythms.
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Affiliation(s)
- Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Clifton W. Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Junichi Izawa
- Department of Internal Medicine, Okinawa Prefectural Yaeyama Hospital, Okinawa, Japan
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Wakabayashi Y, Eitoku M, Suganuma N. Characterization and selection of Japanese electronic health record databases used as data sources for non-interventional observational studies. BMC Med Inform Decis Mak 2021; 21:167. [PMID: 34022876 PMCID: PMC8140583 DOI: 10.1186/s12911-021-01526-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/10/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Interventional studies are the fundamental method for obtaining answers to clinical questions. However, these studies are sometimes difficult to conduct because of insufficient financial or human resources or the rarity of the disease in question. One means of addressing these issues is to conduct a non-interventional observational study using electronic health record (EHR) databases as the data source, although how best to evaluate the suitability of an EHR database when planning a study remains to be clarified. The aim of the present study is to identify and characterize the data sources that have been used for conducting non-interventional observational studies in Japan and propose a flow diagram to help researchers determine the most appropriate EHR database for their study goals. METHODS We compiled a list of published articles reporting observational studies conducted in Japan by searching PubMed for relevant articles published in the last 3 years and by searching database providers' publication lists related to studies using their databases. For each article, we reviewed the abstract and/or full text to obtain information about data source, target disease or therapeutic area, number of patients, and study design (prospective or retrospective). We then characterized the identified EHR databases. RESULTS In Japan, non-interventional observational studies have been mostly conducted using data stored locally at individual medical institutions (663/1511) or collected from several collaborating medical institutions (315/1511). Whereas the studies conducted with large-scale integrated databases (330/1511) were mostly retrospective (73.6%), 27.5% of the single-center studies, 47.6% of the multi-center studies, and 73.7% of the post-marketing surveillance studies, identified in the present study, were conducted prospectively. We used our findings to develop an assessment flow diagram to assist researchers in evaluating and choosing the most suitable EHR database for their study goals. CONCLUSIONS Our analysis revealed that the non-interventional observational studies were conducted using data stored local at individual medical institutions or collected from collaborating medical institutions in Japan. Disease registries, disease databases, and large-scale databases would enable researchers to conduct studies with large sample sizes to provide robust data from which strong inferences could be drawn.
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Affiliation(s)
- Yumi Wakabayashi
- Integrated Center for Advanced Medical Technologies, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan.
| | - Masamitsu Eitoku
- Department of Environmental Medicine, Kochi Medical School, Kochi University, Kochi, Japan
| | - Narufumi Suganuma
- Department of Environmental Medicine, Kochi Medical School, Kochi University, Kochi, Japan
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Kiyohara K, Okubo M, Komukai S, Izawa J, Gibo K, Matsuyama T, Kiguchi T, Iwami T, Kitamura T. Association Between Resuscitative Time on the Scene and Survival After Pediatric Out-of-Hospital Cardiac Arrest. Circ Rep 2021; 3:211-216. [PMID: 33842726 PMCID: PMC8024189 DOI: 10.1253/circrep.cr-21-0021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background:
The optimal timing for transporting pediatric patients with out-of-hospital cardiac arrest (OHCA) who do not achieve return of spontaneous circulation (ROSC) is unclear. Therefore, we assessed the association between resuscitation time on the scene and 1-month survival. Methods and Results:
Data from the All-Japan Utstein Registry from 2013 through 2015 for 3,756 pediatric OHCA patients (age <18 years) who did not achieve ROSC prior to departing the scene were analyzed. Overall, the proportion of 1-month survival for on-scene resuscitation time <5, 5–9, 10–14, and ≥15 min was 13.6% (104/767), 10.2% (170/1,666), 8.6% (75/870), and 4.0% (18/453), respectively. Among specific age groups, the proportion of 1-month survival for on-scene resuscitation time of <5, 5–9, 10–14, and ≥15 min was 12.6% (54/429), 8.7% (59/680), 8.6% (23/267), and 6.8% (8/118), respectively, for patients aged 0 years; 16.4% (38/232), 11.0% (52/473), 11.9% (23/194), and 7.1% (6/85), respectively, for those aged 1–7 years; and 11.3% (12/106), 11.5% (59/513), 7.1% (29/409), and 1.6% (4/250), respectively, for those aged 8–17 years. Conclusions:
Longer on-scene resuscitation was associated with decreased chance of 1-month survival among pediatric OHCA patients without ROSC. For patients aged <8 years, earlier departure from the scene, within 5 min, may increase the chances of 1-month survival. Conversely, for patients aged ≥8 years, continuing on-scene resuscitation for up to 10 min would be reasonable.
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Affiliation(s)
- Kosuke Kiyohara
- Department of Food Science, Faculty of Home Economics, Otsuma Women's University Tokyo Japan
| | - Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine Pittsburgh, PA USA
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine Osaka Japan
| | - Junichi Izawa
- Department of Internal Medicine, Okinawa Prefectural Yaeyama Hospital Okinawa Japan
| | - Koichiro Gibo
- Department of Emergency Medicine, Okinawa Prefectural Chubu Hospital Okinawa Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine Kyoto Japan
| | | | - Taku Iwami
- Kyoto University Health Service Kyoto Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine Osaka Japan
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Cheng FJ, Wu WT, Hung SC, Ho YN, Tsai MT, Chiu IM, Wu KH. Pre-hospital Prognostic Factors of Out-of-Hospital Cardiac Arrest: The Difference Between Pediatric and Adult. Front Pediatr 2021; 9:723327. [PMID: 34746054 PMCID: PMC8567010 DOI: 10.3389/fped.2021.723327] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/13/2021] [Indexed: 01/07/2023] Open
Abstract
The prognosis of out-of-hospital cardiac arrest (OHCA) is very poor. Although several pre-hospital factors are associated with survival, the different association of pre-hospital factors with OHCA outcomes in pediatric and adult groups remain unclear. To assess the association of pre-hospital factors with OHCA outcomes among pediatric and adult groups, a retrospective observational study was conducted using the emergency medical service (EMS) database in Kaohsiung from January 2015 to December 2019. Pre-hospital factors, underlying diseases, and OHCA outcomes were collected for the pediatric (Age ≤ 20) and adult groups. Kaplan-Meier type plots and multivariable logistic regression were used to analyze the association between pre-hospital factors and outcomes. In total, 7,461 OHCAs were analyzed. After adjusting for EMS response time, bystander CPR, attended by EMT-P, witness, and pre-hospital defibrillation, we found that age [odds ratio (OR) = 0.877, 95% confidence interval (CI): 0.764-0.990, p = 0.033], public location (OR = 7.681, 95% CI: 1.975-33.428, p = 0.003), and advanced airway management (AAM) (OR = 8.952; 95% CI, 1.414-66.081; p = 0.02) were significantly associated with survival till hospital discharge in pediatric OHCAs. The results of Kaplan-Meier type plots with log-rank test showed a significant difference between the pediatric and adult groups in survival for 2 h (p < 0.001), 24 h (p < 0.001), hospital discharge (p < 0.001), and favorable neurologic outcome (p < 0.001). AAM was associated with improved survival for 2 h (p = 0.015), 24 h (p = 0.023), and neurologic outcome (p = 0.018) only in the pediatric group. There were variations in prognostic factors between pediatric and adult patients with OHCA. The prognosis of the pediatric group was better than that of the adult group. Furthermore, AAM was independently associated with outcomes in pediatric patients, but not in adult patients. Age and public location of OHCA were independently associated with survival till hospital discharge in both pediatric and adult patients.
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Affiliation(s)
- Fu-Jen Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Wei-Ting Wu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Shih-Chiang Hung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Yu-Ni Ho
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Ming-Ta Tsai
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Kuan-Han Wu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan
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Mavroudis CD, Ko TS, Morgan RW, Volk LE, Landis WP, Smood B, Xiao R, Hefti M, Boorady TW, Marquez A, Karlsson M, Licht DJ, Nadkarni VM, Berg RA, Sutton RM, Kilbaugh TJ. Epinephrine's effects on cerebrovascular and systemic hemodynamics during cardiopulmonary resuscitation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:583. [PMID: 32993753 PMCID: PMC7522922 DOI: 10.1186/s13054-020-03297-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 09/17/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite controversies, epinephrine remains a mainstay of cardiopulmonary resuscitation (CPR). Recent animal studies have suggested that epinephrine may decrease cerebral blood flow (CBF) and cerebral oxygenation, possibly potentiating neurological injury during CPR. We investigated the cerebrovascular effects of intravenous epinephrine in a swine model of pediatric in-hospital cardiac arrest. The primary objectives of this study were to determine if (1) epinephrine doses have a significant acute effect on CBF and cerebral tissue oxygenation during CPR and (2) if the effect of each subsequent dose of epinephrine differs significantly from that of the first. METHODS One-month-old piglets (n = 20) underwent asphyxia for 7 min, ventricular fibrillation, and CPR for 10-20 min. Epinephrine (20 mcg/kg) was administered at 2, 6, 10, 14, and 18 min of CPR. Invasive (laser Doppler, brain tissue oxygen tension [PbtO2]) and noninvasive (diffuse correlation spectroscopy and diffuse optical spectroscopy) measurements of CBF and cerebral tissue oxygenation were simultaneously recorded. Effects of subsequent epinephrine doses were compared to the first. RESULTS With the first epinephrine dose during CPR, CBF and cerebral tissue oxygenation increased by > 10%, as measured by each of the invasive and noninvasive measures (p < 0.001). The effects of epinephrine on CBF and cerebral tissue oxygenation decreased with subsequent doses. By the fifth dose of epinephrine, there were no demonstrable increases in CBF of cerebral tissue oxygenation. Invasive and noninvasive CBF measurements were highly correlated during asphyxia (slope effect 1.3, p < 0.001) and CPR (slope effect 0.20, p < 0.001). CONCLUSIONS This model suggests that epinephrine increases CBF and cerebral tissue oxygenation, but that effects wane following the third dose. Noninvasive measurements of neurological health parameters hold promise for developing and directing resuscitation strategies.
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Affiliation(s)
- Constantine D Mavroudis
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA. .,Division of Cardiovascular Surgery, The University of Pennsylvania, Philadelphia, PA, USA.
| | - Tiffany S Ko
- Department of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lindsay E Volk
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Benjamin Smood
- Division of Cardiovascular Surgery, The University of Pennsylvania, Philadelphia, PA, USA
| | - Rui Xiao
- Department of Pediatrics, Division of Biostatistics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marco Hefti
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Timothy W Boorady
- Department of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexandra Marquez
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Daniel J Licht
- Department of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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de Caen A, Moylan A, Maconochie IK. Epinephrine for Pediatric Out-of-Hospital Cardiac Arrest. J Am Coll Cardiol 2020; 75:205-206. [DOI: 10.1016/j.jacc.2019.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 10/28/2019] [Indexed: 11/26/2022]
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