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Hubble MW, Taylor S, Martin M, Houston S, Kaplan GR. Optimal weight-based epinephrine dosing for patients with a low likelihood of survival following out-of-hospital cardiac arrest. Ir J Med Sci 2024:10.1007/s11845-024-03797-0. [PMID: 39190288 DOI: 10.1007/s11845-024-03797-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 08/22/2024] [Indexed: 08/28/2024]
Abstract
INTRODUCTION Cardiac arrest patients presenting with non-shockable rhythms have a low probability of survival, and epinephrine is one of the few pharmaceutical options for this group. The recommended 1.0 mg adult dose is extrapolated from early animal studies and lacks adjustment for patient weight. Although several prior studies have investigated "low-" and "high-" dose epinephrine, none have identified a benefit to either strategy. AIMS To identify an optimal weight-based epinephrine dose for return-of-spontaneous-circulation (ROSC) after a single bolus among patients with low likelihood of survival. METHODS Included were adult patients who experienced a witnessed, non-traumatic out-of-hospital cardiac arrest prior to EMS arrival. Patients with shockable presenting rhythms or receiving bystander CPR were excluded. The AUROC was used to assess the predictive value of epinephrine dose (mg/kg) for ROSC following a single bolus. From the ROC curve, the optimal threshold dosage (OTD) was determined using the Youden Index. A logistic regression model calculated the adjusted odds ratio of OTD on ROSC. RESULTS A total of 2,463 patients met inclusion criteria, of which 190 (7.7%) attained ROSC after the first epinephrine administration. The dosage AUROC for ROSC was 0.603 (p < 0.01). As calculated by the Youden index, the OTD was 0.013 mg/kg. Patients receiving ≥ OTD were more likely to attain ROSC after a single epinephrine bolus (OR = 2.25,p < 0.001). CONCLUSIONS Among patients with a low likelihood of survival, the optimal dose of epinephrine for attaining ROSC with a single bolus of epinephrine was 0.013 mg/kg. These findings should inspire further investigation into optimal dosing strategies for epinephrine.
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Affiliation(s)
- Michael W Hubble
- Department of Emergency Medical Science, Wake Technical Community College, 2901 Holston Lane, Raleigh, NC, 27610, USA.
| | | | - Melisa Martin
- Department of EMS and Health Care Administration, Methodist University, Fayetteville, NC, USA
| | | | - Ginny R Kaplan
- Department of EMS and Health Care Administration, Methodist University, Fayetteville, NC, USA
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Brebner C, Asamoah-Boaheng M, Zaidel B, Yap J, Scheuermeyer F, Mok V, Hutton J, Meckler G, Schlamp R, Christenson J, Grunau B. The association of intravenous vs. humeral-intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests. Resuscitation 2024:110360. [PMID: 39154890 DOI: 10.1016/j.resuscitation.2024.110360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 07/16/2024] [Accepted: 08/11/2024] [Indexed: 08/20/2024]
Abstract
AIM While intravenous (IV) vascular access for out-of-hospital cardiac arrest (OHCA) resuscitation is standard, humeral-intraosseous (IO) access is commonly used, despite few supporting data. We investigated the association between IV vs. humeral-IO and outcomes. METHODS We utilized BC Cardiac Arrest Registry data, including adult OHCA where the first-attempted intra-arrest vascular access route performed by advanced life support (ALS)-trained paramedics was IV or humeral-IO. We fit a propensity-score adjusted model with inverse probability treatment weighting to estimate the association between IV vs. humeral-IO routes and favorable neurological outcomes (CPC 1-2) and survival at hospital discharge. We repeated models within subgroups defined by initial cardiac rhythm. RESULTS We included 2,112 cases; the first-attempted route was IV (n=1,575) or humeral-IO (n=537). Time intervals from ALS-paramedic on-scene arrival to vascular access (6.6 vs. 6.9 minutes) and epinephrine administration (9.0 vs. 9.3 minutes) were similar between IV and IO groups. Among IV and humeral-IO groups, 98 (6.2%) and 20 (3.7%) had favorable neurological outcomes. Compared to humeral-IO, an IV-first approach was associated with improved hospital-discharge favorable neurological outcomes (AOR 1.7; 95%CI 1.1-2.7) and survival (AOR 1.5; 95%CI 1.0-2.3). Among shockable rhythm cases, an IV-first approach was associated with improved favorable neurological outcomes (AOR 4.2; 95%CI 2.1-8.2), but not among non-shockable rhythm cases (AOR 0.73; 95%CI 0.39-1.4). CONCLUSION An IV-first approach, compared to humeral-IO, for intra-arrest resuscitation was associated with an improved odds of favorable neurological outcomes and survival to hospital discharge. This association was seen among an initial shockable rhythm, but not non-shockable rhythm, subgroups.
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Affiliation(s)
- Callahan Brebner
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Michael Asamoah-Boaheng
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C
| | - Bianca Zaidel
- Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Justin Yap
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada
| | - Frank Scheuermeyer
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C
| | - Valerie Mok
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Jacob Hutton
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; British Columbia Emergency Health Services, British Columbia, Canada
| | - Garth Meckler
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada
| | - Robert Schlamp
- British Columbia Emergency Health Services, British Columbia, Canada
| | - Jim Christenson
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C
| | - Brian Grunau
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C; British Columbia Emergency Health Services, British Columbia, Canada
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Palatinus HN, Johnson MA, Wang HE, Hoareau GL, Youngquist ST. Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest. Resuscitation 2024; 201:110266. [PMID: 38857847 DOI: 10.1016/j.resuscitation.2024.110266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/20/2024] [Accepted: 06/04/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Early administration of adrenaline is associated with improved survival after out-of-hospital cardiac arrest (OHCA). Delays in vascular access may impact the timely delivery of adrenaline. Novel methods for administering adrenaline before vascular access may enhance survival. The objective of this study was to determine whether an initial intramuscular (IM) adrenaline dose followed by standard IV/IO adrenaline is associated with improved survival after OHCA. METHODS STUDY DESIGN We conducted a before-and-after study of the implementation of an early, first-dose IM adrenaline EMS protocol for adult OHCAs. The pre-intervention period took place between January 2010 and October 2019. The post-intervention period was between November 2019 and May 2024. SETTING Single-center urban, two-tiered EMS agency. PARTICIPANTS Adult, nontraumatic OHCA meeting criteria for adrenaline use. INTERVENTION Single dose (5 mg) IM adrenaline. All other care, including subsequent IV or IO adrenaline, followed international guidelines. MAIN OUTCOMES AND MEASURES The primary outcome was survival to hospital discharge. Secondary outcomes were time from EMS arrival to the first dose of adrenaline, survival to hospital admission, and favorable neurologic function at discharge. RESULTS Among 1405 OHCAs, 420 (29.9%) received IM adrenaline and 985 (70.1%) received usual care. Fifty-two patients received the first dose of adrenaline through the IV or IO route within the post-intervention period and were included in the standard care group analysis. Age was younger and bystander CPR was higher in the IM adrenaline group. All other characteristics were similar between IM and standard care cohorts. Time to adrenaline administration was faster for the IM cohort [(median 4.3 min (IQR 3.0-6.0) vs. 7.8 min (IQR 5.8-10.4)]. Compared with standard care, IM adrenaline was associated with improved survival to hospital admission (37.1% vs. 31.6%; aOR 1.37, 95% CI 1.06-1.77), hospital survival (11.0% vs 7.0%; aOR 1.73, 95% CI 1.10-2.71) and favorable neurologic status at hospital discharge (9.8% vs 6.2%; aOR 1.72, 95% CI 1.07-2.76). CONCLUSION In this single-center before-and-after implementation study, an initial IM dose of adrenaline as an adjunct to standard care was associated with improved survival to hospital admission, survival to hospital discharge, and functional survival. A randomized controlled trial is needed to fully assess the potential benefit of IM adrenaline delivery in OHCA.
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Affiliation(s)
- Helen N Palatinus
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States.
| | - M Austin Johnson
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Henry E Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, United States
| | - Guillaume L Hoareau
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States; Nora Eccles-Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, United States
| | - Scott T Youngquist
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States; Salt Lake City Fire Department, Salt Lake City, UT, United States
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Park SY, Choi B, Kim SH. Impact of intravenous accessibility and prehospital epinephrine use on survival outcomes of adult nontraumatic out-of-hospital cardiac arrest patients. BMC Emerg Med 2024; 24:79. [PMID: 38710999 DOI: 10.1186/s12873-024-00998-9] [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: 01/05/2024] [Accepted: 05/02/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND This study compared out-of-hospital cardiac arrest (OHCA) patient outcomes based on intravenous (IV) access and prehospital epinephrine use. METHODS A retrospective study in Ulsan, South Korea, from January 2017 to December 2022, analyzed adult nontraumatic OHCA cases. Patients were grouped: Group 1 (no IV attempts), Group 2 (failed IV access), Group 3 (successful IV access without epinephrine), and Group 4 (successful IV access with epinephrine), with comparisons using logistic regression analysis. RESULTS Among 2,656 patients, Group 4 had significantly lower survival to hospital discharge (adjusted OR 0.520, 95% CI 0.346-0.782, p = 0.002) and favorable neurological outcomes (adjusted OR 0.292, 95% CI 0.140-0.611, p = 0.001) than Group 1. Groups 2 and 3 showed insignificant survival to hospital discharge (adjusted OR 0.814, 95% CI 0.566-1.171, p = 0.268) and (adjusted OR 1.069, 95% CI 0.810-1.412, p = 0.636) and favorable neurological outcomes (adjusted OR 0.585, 95% CI 0.299-1.144, p = 0.117) and (adjusted OR 1.075, 95% CI 0.689-1.677, p = 0.751). In the shockable rhythm group, Group 3 had better survival to hospital discharge (adjusted OR 1.700, 95% CI 1.044-2.770, p = 0.033). CONCLUSIONS Successful IV access with epinephrine showed worse outcomes in both rhythm groups than no IV attempts. Outcomes for failed IV and successful IV access without epinephrine were inconclusive. Importantly, successful IV access without epinephrine showed favorable survival to hospital discharge in the shockable rhythm group, warranting further research into IV access for fluid resuscitation in shockable rhythm OHCA patients.
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Affiliation(s)
- Song Yi Park
- Department of Emergency Medicine, Dong-A University College of Medicine, Dong-A University Hospital, Busan, Republic of Korea
| | - Byungho Choi
- Department of Emergency Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 25, Daehakbyeongwon-ro, Ulsan, Dong-gu, 44033, Republic of Korea
| | - Sun Hyu Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 25, Daehakbyeongwon-ro, Ulsan, Dong-gu, 44033, Republic of Korea.
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5
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Couper K, Ji C, Lall R, Deakin CD, Fothergill R, Long J, Mason J, Michelet F, Nolan JP, Nwankwo H, Quinn T, Slowther AM, Smyth MA, Walker A, Chowdhury L, Norman C, Sprauve L, Starr K, Wood S, Bell S, Bradley G, Brown M, Brown S, Charlton K, Coppola A, Evans C, Evans C, Foster T, Jackson M, Kearney J, Lang N, Mellett-Smith A, Osborne R, Pocock H, Rees N, Spaight R, Tibbetts B, Whitley GA, Wiles J, Williams J, Wright A, Perkins GD. Route of drug administration in out-of-hospital cardiac arrest: A protocol for a randomised controlled trial (PARAMEDIC-3). Resusc Plus 2024; 17:100544. [PMID: 38260121 PMCID: PMC10801302 DOI: 10.1016/j.resplu.2023.100544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
Aims The PARAMEDIC-3 trial evaluates the clinical and cost-effectiveness of an intraosseous first strategy, compared with an intravenous first strategy, for drug administration in adults who have sustained an out-of-hospital cardiac arrest. Methods PARAMEDIC-3 is a pragmatic, allocation concealed, open-label, multi-centre, superiority randomised controlled trial. It will recruit 15,000 patients across English and Welsh ambulance services. Adults who have sustained an out-of-hospital cardiac arrest are individually randomised to an intraosseous access first strategy or intravenous access first strategy in a 1:1 ratio through an opaque, sealed envelope system. The randomised allocation determines the route used for the first two attempts at vascular access. Participants are initially enrolled under a deferred consent model.The primary clinical-effectiveness outcome is survival at 30-days. Secondary outcomes include return of spontaneous circulation, neurological functional outcome, and health-related quality of life. Participants are followed-up to six-months following cardiac arrest. The primary health economic outcome is incremental cost per quality-adjusted life year gained. Conclusion The PARAMEDIC-3 trial will provide key information on the clinical and cost-effectiveness of drug route in out-of-hospital cardiac arrest.Trial registration: ISRCTN14223494, registered 16/08/2021, prospectively registered.
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Affiliation(s)
- Keith Couper
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chen Ji
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Ranjit Lall
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Charles D Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- South Central Ambulance NHS Foundation Trust, Otterbourne, UK
| | - Rachael Fothergill
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Clinical Audit and Research Unit, London Ambulance Service, London, UK
| | - John Long
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - James Mason
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Felix Michelet
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Jerry P Nolan
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Department of Anaesthesia, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Henry Nwankwo
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | | | - Anne-Marie Slowther
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Michael A Smyth
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Alison Walker
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, UK
- Emergency Department, Harrogate and District NHS Foundation Trust, Harrogate, UK
| | | | - Chloe Norman
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | | | - Kath Starr
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Sara Wood
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Steve Bell
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Gemma Bradley
- Research and Development Department, South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
| | - Martina Brown
- South Central Ambulance NHS Foundation Trust, Otterbourne, UK
| | - Shona Brown
- East of England Ambulance Service NHS Trust, Melbourn, UK
| | - Karl Charlton
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Alison Coppola
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | | | - Christine Evans
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, UK
| | - Theresa Foster
- East of England Ambulance Service NHS Trust, Melbourn, UK
| | - Michelle Jackson
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Justin Kearney
- Clinical Audit and Research Unit, London Ambulance Service, London, UK
| | | | - Adam Mellett-Smith
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Clinical Audit and Research Unit, London Ambulance Service, London, UK
| | - Ria Osborne
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Helen Pocock
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- South Central Ambulance NHS Foundation Trust, Otterbourne, UK
| | - Nigel Rees
- Welsh Ambulance Services NHS Trust, Cwmbran, UK
| | - Robert Spaight
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | | | | | - Jason Wiles
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, UK
| | - Julia Williams
- Research and Development Department, South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
- Department of Paramedic Science, University of Hertfordshire, Hatfield, UK
| | - Adam Wright
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Gavin D Perkins
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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6
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Benner C, Jui J, Neth MR, Sahni R, Thompson K, Smith J, Newgard C, Daya MR, Lupton JR. Outcomes with Tibial and Humeral Intraosseous Access Compared to Peripheral Intravenous Access in Out-of-Hospital Cardiac Arrest. PREHOSP EMERG CARE 2023; 28:761-770. [PMID: 38015053 DOI: 10.1080/10903127.2023.2286621] [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: 07/10/2023] [Revised: 10/10/2023] [Accepted: 10/24/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND The optimal initial vascular access strategy for out-of-hospital cardiac arrest (OHCA) remains unknown. Our objective was to evaluate the association between peripheral intravenous (PIV), tibial intraosseous (TIO), or humeral intraosseous (HIO) as first vascular attempt strategies and outcomes for patients suffering OHCA. METHOD This was a secondary analysis of the Portland Cardiac Arrest Epidemiologic Registry, which included adult patients (≥18 years-old) with EMS-treated, non-traumatic OHCA from 2018-2021. The primary independent variable in our analysis was the initial vascular access strategy, defined as PIV, TIO, or HIO based on the first access attempt. The primary outcome for this study was the return of spontaneous circulation (ROSC) at emergency department (ED) arrival (a palpable pulse on arrival to the hospital). Secondary outcomes included survival to: admission, discharge, and discharge with a favorable outcome (Cerebral Perfusion Category score of ≤2). We conducted multivariable logistic regressions, adjusting for confounding variables and for clustering using a mixed-effects approach, with prespecified subgroup analyses by initial rhythm. RESULTS We included 2,993 patients with initial vascular access strategies of PIV (822 [27.5%]), TIO (1,171 [39.1%]), and HIO (1,000 [33.4%]). Multivariable analysis showed lower odds of ROSC at ED arrival (adjusted odds ratio [95% CI]) with TIO (0.79 [0.64-0.98]) or HIO (0.75 [0.60-0.93]) compared to a PIV-first strategy. These associations remained in stratified analyses for those with shockable initial rhythms (0.60 [0.41-0.88] and 0.53 [0.36-0.79]) but not in patients with asystole or pulseless electrical activity for TIO and HIO compared to PIV, respectively. There were no statistically significant differences in adjusted odds for survival to admission, discharge, or discharge with a favorable outcome for TIO or HIO compared to the PIV-first group in the overall analysis. Patients with shockable initial rhythms had lower adjusted odds of survival to discharge (0.63 [0.41-0.96] and 0.64 [0.41-0.99]) and to discharge with a favorable outcome (0.60 [0.39-0.93] and 0.64 [0.40-1.00]) for TIO and HIO compared to PIV, respectively. CONCLUSIONS TIO or HIO as first access strategies in OHCA were associated with lower odds of ROSC at ED arrival compared to PIV.
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Affiliation(s)
- Cameron Benner
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jonathan Jui
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Matthew R Neth
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Ritu Sahni
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Kathryn Thompson
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jeffrey Smith
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Craig Newgard
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Joshua R Lupton
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
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Brebner C, Asamoah-Boaheng M, Zaidel B, Yap J, Scheuermeyer F, Mok V, Christian M, Kawano T, Singh L, van Diepen S, Christenson J, Grunau B. The association of tibial vs. humeral intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests. Resuscitation 2023; 193:110031. [PMID: 37923113 DOI: 10.1016/j.resuscitation.2023.110031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
AIM Humeral and tibial intraosseous (IO) vascular access can deliver resuscitative medications for out-of-hospital cardiac arrest (OHCA), however the optimal site is unclear. We examined the association between IO tibia vs. humerus as the first-attempted vascular access site with OHCA outcomes. METHODS We used prospectively-collected data from the British Columbia Cardiac Arrest registry, including adult OHCAs treated with IO humerus or IO tibia as the first-attempted intra-arrest vascular access. We fit logistic regression models on the full study cohort and a propensity-matched cohort, to estimate the association between IO site and both favorable neurological outcomes (Cerebral Performance Category 1-2) and survival at hospital discharge. RESULTS We included 1041 (43%) and 1404 (57%) OHCAs for whom IO humerus and tibia, respectively, were the first-attempted intra-arrest vascular access. Among humerus and tibia cases, 1010 (97%) and 1369 (98%) had first-attempt success, and the median paramedic arrival-to-successful access interval was 6.7 minutes (IQR 4.4-9.4) and 6.1 minutes (IQR 4.1-8.9), respectively. In the propensity-matched cohort (n = 2052), 31 (3.0%) and 44 (4.3%) cases had favourable neurological outcomes in the IO humerus and IO tibia groups, respectively; compared to IO humerus, we did not detect an association between IO tibia with favorable neurological outcomes (OR 1.44; 95% CI 0.90-2.29) or survival to hospital discharge (OR 1.29; 95% CI 0.83-2.01). Results using the full cohort were similar. CONCLUSIONS We did not detect an association between the first-attempted intra-arrest IO site (tibia vs. humerus) and clinical outcomes. Clinical trials are warranted to test differences between vascular access strategies.
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Affiliation(s)
- Callahan Brebner
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Michael Asamoah-Boaheng
- Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada
| | - Bianca Zaidel
- Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Justin Yap
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada
| | - Frank Scheuermeyer
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada
| | - Valerie Mok
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Michael Christian
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Division of Critical Care Medicine, University of British Columbia, British Columbia, Canada; British Columbia Emergency Health Services, British Columbia, Canada
| | - Takahisa Kawano
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Department of Emergency Medicine, University of Fukui Hospital, Fukui Prefecture, Japan
| | - Lovepreet Singh
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada
| | - Sean van Diepen
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Department of Critical Care Medicine and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Jim Christenson
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada
| | - Brian Grunau
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada; British Columbia Emergency Health Services, British Columbia, Canada.
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8
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Segond N, Jaeger D, Debaty G. Epinephrine and brain perfusion during cardiac arrest: every minute counts. Resuscitation 2023; 193:110006. [PMID: 37865223 DOI: 10.1016/j.resuscitation.2023.110006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 10/23/2023]
Affiliation(s)
- Nicolas Segond
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alps, Grenoble, France; University of Grenoble Alps, CNRS, UMR 5525, TIMC, Grenoble, France
| | - Deborah Jaeger
- Emergency Department, University Hospital of Nancy, Nancy, France; INSERM U1116, Acute and Chronic Cardiovascular Deficiency, University of Lorraine, Vandoeuvre-les-Nancy, France
| | - Guillaume Debaty
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alps, Grenoble, France; University of Grenoble Alps, CNRS, UMR 5525, TIMC, Grenoble, France.
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Vadeyar S, Buckle A, Hooper A, Booth S, Deakin CD, Fothergill R, Ji C, Nolan JP, Brown M, Cowley A, Harris E, Ince M, Marriott R, Pike J, Spaight R, Perkins GD, Couper K. Trends in use of intraosseous and intravenous access in out-of-hospital cardiac arrest across English ambulance services: A registry-based, cohort study. Resuscitation 2023; 191:109951. [PMID: 37648146 DOI: 10.1016/j.resuscitation.2023.109951] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION The optimum route for drug administration in cardiac arrest is unclear. Recent data suggest that use of the intraosseous route may be increasing. This study aimed to explore changes over time in use of the intraosseous and intravenous drug routes in out-of-hospital cardiac arrest in England. METHODS We extracted data from the UK Out-of-Hospital Cardiac Arrest Outcomes registry. We included adult out-of-hospital cardiac arrest patients between 2015-2020 who were treated by an English Emergency Medical Service that submitted vascular access route data to the registry. The primary outcome was any use of the intraosseous route during cardiac arrest. We used logistic regression models to describe the association between time (calendar month) and intraosseous use. RESULTS We identified 75,343 adults in cardiac arrest treated by seven Emergency Medical Service systems between January 2015 and December 2020. The median age was 72 years, 64% were male and 23% presented in a shockable rhythm. Over the study period, the percentage of patients receiving intraosseous access increased from 22.8% in 2015 to 42.5% in 2020. For each study-month, the odds of receiving any intraosseous access increased by 1.019 (95% confidence interval 1.019 to 1.020, p < 0.001). This observed effect was consistent across sensitivity analyses. We observed a corresponding decrease in use of intravenous access. CONCLUSION In England, the use of intraosseous access in out-of-hospital cardiac arrest has progressively increased over time. There is an urgent need for randomised controlled trials to evaluate the clinical effectiveness of the different vascular access routes in cardiac arrest.
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Affiliation(s)
- Sharvari Vadeyar
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alexandra Buckle
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Amy Hooper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Scott Booth
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Charles D Deakin
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, UK; University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Rachael Fothergill
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK; Clinical Audit & Research Unit, London Ambulance Service NHS Trust, London, UK
| | - Chen Ji
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Jerry P Nolan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK; Intensive Care Unit, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Martina Brown
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, UK
| | - Alan Cowley
- South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
| | - Emma Harris
- West Midlands Ambulance Service University NHS Foundation Trust, Brierley Hill, UK
| | - Maureen Ince
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Robert Marriott
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John Pike
- Isle of Wight NHS Trust, Newport, Isle of Wight, UK
| | - Robert Spaight
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Gavin D Perkins
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.
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Perkins GD, Couper K. Improving vasopressor use in cardiac arrest. Crit Care 2023; 27:81. [PMID: 36864469 PMCID: PMC9979497 DOI: 10.1186/s13054-023-04301-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/04/2023] [Indexed: 03/04/2023] Open
Abstract
The Chain of Survival highlights the effectiveness of early recognition of cardiac arrest and call for help, early cardiopulmonary resuscitation and early defibrillation. Most patients, however, remain in cardiac arrest despite these interventions. Drug treatments, particularly the use of vasopressors, have been included in resuscitation algorithms since their inception. This narrative review describes the current evidence base for vasopressors and reports that adrenaline (1 mg) is highly effective at achieving return of spontaneous circulation (number needed to treat 4) but is less effective on long-term outcomes (survival to 30 days, number needed to treat 111) with uncertain effects on survival with a favourable neurological outcome. Randomised trials evaluating vasopressin, either as an alternative to or in addition to adrenaline, and high-dose adrenaline have failed to find evidence of improved long-term outcomes. There is a need for future trials to evaluate the interaction between steroids and vasopressin. Evidence for other vasopressors (e.g. noradrenaline, phenylephedrine) is insufficient to support or refute their use. The use of intravenous calcium chloride as a routine intervention in out of hospital cardiac arrest is not associated with benefit and may cause harm. The optimal route for vascular access between peripheral intravenous versus intraosseous routes is currently the subject of two large randomised trials. Intracardiac, endobronchial, and intramuscular routes are not recommended. Central venous administration should be limited to patients where an existing central venous catheter is in situ and patent.
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Affiliation(s)
- Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
| | - Keith Couper
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
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Kanthimathinathan HK, Cromie KJ, Feltbower RG. The case for causal inference methods in resuscitation research. Resuscitation 2023; 182:109666. [PMID: 36563955 DOI: 10.1016/j.resuscitation.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Affiliation(s)
| | - Kirsten J Cromie
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, UK
| | - Richard G Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, UK
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