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Chander S, Parkash O, Luhana S, Lohana AC, Sadarat F, Sapna F, Raja F, Rahaman Z, Mohammed YN, Shiwlani S, Kiran N, Wang HY, Tan S, Kumari R. Mortality, morbidity & clinical outcome with different types of vasopressors in out of hospital cardiac arrest patients- a systematic review and meta-analysis. BMC Cardiovasc Disord 2024; 24:283. [PMID: 38816786 PMCID: PMC11137957 DOI: 10.1186/s12872-024-03962-4] [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: 12/14/2023] [Accepted: 05/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND & OBJECTIVE Despite their continued use, the effectiveness and safety of vasopressors in post-cardiac arrest patients remain controversial. This study examined the efficacy of various vasopressors in cardiac arrest patients in terms of clinical, morbidity, and mortality outcomes. METHODS A comprehensive literature search was performed using online databases (MeSH terms: MEDLINE (Ovid), CENTRAL (Cochrane Library), Embase (Ovid), CINAHL, Scopus, and Google Scholar) from 1997 to 2023 for relevant English language studies. The primary outcomes of interest for this study included short-term survival leading to death, return of spontaneous circulation (ROSC), survival to hospital discharge, neurological outcomes, survival to hospital admission, myocardial infarction, and incidence of arrhythmias. RESULTS In this meta-analysis, 26 studies, including 16 RCTs and ten non-RCTs, were evaluated. The focus was on the efficacy of epinephrine, vasopressin, methylprednisolone, dopamine, and their combinations in medical emergencies. Epinephrine treatment was associated with better odds of survival to hospital discharge (OR = 1.52, 95%CI [1.20, 1.94]; p < 0.001) and achieving ROSC (OR = 3.60, 95% CI [3.45, 3.76], P < 0.00001)) over placebo but not in other outcomes of interest such as short-term survival/ death at 28-30 days, survival to hospital admission, or neurological function. In addition, our analysis indicates non-superiority of vasopressin or epinephrine vasopressin-plus-epinephrine therapy over epinephrine monotherapy except for survival to hospital admission where the combinatorial therapy was associated with better outcome (0.76, 95%CI [0.64, 0.92]; p = 0.004). Similarly, we noted the non-superiority of vasopressin-plus-methylprednisolone versus placebo. Finally, while higher odds of survival to hospital discharge (OR = 3.35, 95%CI [1.81, 6.2]; p < 0.001) and ROSC (OR = 2.87, 95%CI [1.97, 4.19]; p < 0.001) favoring placebo over VSE therapy were observed, the risk of lethal arrhythmia was not statistically significant. There was insufficient literature to assess the effects of dopamine versus other treatment modalities meta-analytically. CONCLUSION This meta-analysis indicated that only epinephrine yielded superior outcomes among vasopressors than placebo, albeit limited to survival to hospital discharge and ROSC. Additionally, we demonstrate the non-superiority of vasopressin over epinephrine, although vasopressin could not be compared to placebo due to the paucity of data. The addition of vasopressin to epinephrine treatment only improved survival to hospital admission.
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Affiliation(s)
- Subhash Chander
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Om Parkash
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Sindhu Luhana
- Department of Medicine, AGA khan University Hospital, Karachi, Pakistan
| | - Abhi Chand Lohana
- Department of Medicine, Western Michigan University, Kalamazoo, WV, USA
| | - Fnu Sadarat
- Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Fnu Sapna
- Department of Pathology, Montefiore Medical Center, Bronx, NY, USA
| | - Fnu Raja
- Department of Pathology, MetroHealth Hospital, Cleveland, OH, USA
| | - Zubair Rahaman
- Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | | | - Sheena Shiwlani
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nfn Kiran
- Department of Pathology, Northwell Health Hospital, New York, NY, USA
| | - Hong Yu Wang
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sam Tan
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roopa Kumari
- Department of Pathology, Icahn School of Medicine, Mount Sinai, New York, NY, USA
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Ho JKM, Tam HL, Leung LYL. Effectiveness of Vasopressin Against Cardiac Arrest: A Systematic Review of Systematic Reviews. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07571-3. [PMID: 38470507 DOI: 10.1007/s10557-024-07571-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE This systematic review (SR) of SRs evaluates the effectiveness of vasopressin alone or in combination with other drugs in improving the outcomes of cardiac arrest (CA). METHODS Using a three-step approach, we searched five databases to identify all relevant SRs. Two reviewers independently selected suitable studies, assessed study quality, and extracted relevant data. If an outcome was reported by multiple SRs, a re-meta-analysis was conducted as needed; otherwise, a narrative analysis was performed. RESULTS Twelve SRs covering 16 original studies were included in this review. The meta-analysis results revealed a significant increase in survival to hospital admission for patients with in-hospital CA (IHCA) or out-of-hospital CA (OHCA) receiving vasopressin alone compared with that for those receiving epinephrine alone. Furthermore, the return of spontaneous circulation (ROSC) was significantly increased in patients with OHCA receiving vasopressin with epinephrine compared with that in those receiving epinephrine alone. Compared with patients with IHCA receiving epinephrine with placebo, those receiving vasopressin, steroids, and epinephrine (VSE) exhibited significant increases in ROSC, survival to hospital discharge, favorable neurological outcomes, mean arterial pressure, renal failure-free days, coagulation failure-free days, and insulin requirement. CONCLUSION VSE is the most effective drug combination for improving the short- and long-term outcomes of IHCA. It is recommended to use VSE in patients with IHCA. Future studies should investigate the effectiveness of VSE against OHCA and CA of various etiologies, the types and standard dosages of steroids for cardiac resuscitation, and the effectiveness of vasopressin-steroid in improving CA outcomes.
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Affiliation(s)
- Jonathan Ka-Ming Ho
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Homantin, Kowloon, Hong Kong.
| | - Hon-Lon Tam
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Leona Yuen-Ling Leung
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Homantin, Kowloon, Hong Kong
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Hou M, Dong S, Kan Q, Ouyang M, Zhang Y. Is epinephrine still the drug of choice during cardiac arrest in the emergency department of the hospital? A meta-analysis. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2023; 73:325-339. [PMID: 37708961 DOI: 10.2478/acph-2023-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/04/2023] [Indexed: 09/16/2023]
Abstract
Epinephrine is the first-line emergency drug for cardiac arrest and anaphylactic reactions but is reported to be associated with many challenges resulting in its under- or improper utilization. Therefore, in this meta-analysis, the efficacy and safety of epinephrine as a first-line cardiac emergency drug for both out-of-hospital and in-hospital patients was assessed. Pertinent articles were searched in central databases like PubMed, Scopus, and Web of Science, using appropriate keywords as per the PRISMA guidelines. Retrospective and prospective studies were included according to the predefined PICOS criteria. RevMan and MedCalc software were used and statistical parameters such as odds ratio and risk ratio were calculated. Twelve clinical trials with a total of 208,690 cardiac arrest patients from 2000 to 2022 were included, in accordance with the chosen inclusion criteria. In the present meta-analysis, a high odds ratio (OR) value of 3.67 (95 % CI 2.32-5.81) with a tau2 value of 0.64, a chi2 value of 12,446.86, df value of 11, I2 value of 100 %, Z-value 5.53, and a p-value < 0.00001 were reported. Similarly, the risk ratio of 1.89 (95 % CI 1.47-2.43) with a tau2 value of 0.19, chi2 value of 11,530.67, df value of 11, I2 value of 100 %, Z-value of 4.95, and p-value < 0.000001. The present meta-analysis strongly prefers epinephrine injection as the first cardiac emergency drug for both out-of-hospital and in-hospital patients during cardiac arrest.
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Affiliation(s)
- Min Hou
- Department of Cardiovascular Internal Medicine, People's Hospital of Dongxihu District, Wuhan, Wuhan City, Hubei Province, 430040, China
| | - Su Dong
- Department of Pharmacy, People's Hospital of Dongxihu District, Wuhan Wuhan City, Hubei Province, 430040 China
| | - Qing Kan
- Department of Pharmacy, Hankou Hospital of Wuhan, Wuhan City, Hubei Province, 430040, China
| | - Meng Ouyang
- Department of Pharmacy, The First People's Hospital of Jiang Xia District Wuhan City, Hubei Province, 430000 China
| | - Yun Zhang
- Department of Pharmacy, The First People's Hospital of Jiang Xia District Wuhan City, Hubei Province, 430000 China
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Yan W, Dong W, Song X, Zhou W, Chen Z. Therapeutic effects of vasopressin on cardiac arrest: a systematic review and meta-analysis. BMJ Open 2023; 13:e065061. [PMID: 37068900 PMCID: PMC10111914 DOI: 10.1136/bmjopen-2022-065061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
OBJECTIVE To demonstrate the therapeutic effect of vasopressin as an alternative treatment for cardiac arrest. DESIGN Systematic review and meta-analysis. METHODS PubMed, EMBASE, the Cochrane Library and Web of Science were searched for randomised controlled trials. The intervention included administration of vasopressin alone or vasopressin combined with epinephrine or vasopressin, steroids and epinephrine (VSE) versus epinephrine combined with placebo as control group. The primary outcome was the return of spontaneous circulation (ROSC). The secondary outcomes included mid-term survival and mid-term good neurological outcome. We conducted subgroup analyses of the primary outcome based on different settings, different study drug strategies and different types of initial rhythm. RESULTS Twelve studies (n=6718) were included, of which eight trials (n=5638) reported the data on patients with out-of-hospital cardiac arrest and four trials (n=1080) on patients with in-hospital cardiac arrest (IHCA). There were no significant differences between intravenous vasopressin and placebo in the outcomes of ROSC (relative risk (RR): 1.11; 95% CI: 0.99 to 1.26), mid-term survival (RR: 1.23; 95% CI: 0.90 to 1.66) and mid-term good neurological outcome (RR: 1.20; 95% CI: 0.77 to 1.87). However, in the subgroup analysis, intravenous vasopressin as part of VSE can significantly improve the rate of ROSC (RR: 1.32; 95% CI: 1.18 to 1.47) but not the rate of mid-term survival (RR: 2.15; 95% CI: 0.75 to 6.16) and mid-term good neurological outcome (RR: 1.80; 95% CI: 0.81 to 4.01) for patients with IHCA. CONCLUSIONS Our study failed to demonstrate increased benefit from vasopressin with or without epinephrine compared with the standard of care. However, vasopressin as a part of VSE is associated with the improvement of ROSC in patients with IHCA, and the benefit on mid-term survival or mid-term good neurological outcome is uncertain. Larger trials should be conducted in the future to address the effect of vasopressin only, vasopressin plus epinephrine or VSE on cardiac arrest. PROSPERO REGISTRATION NUMBER CRD42021293347.
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Affiliation(s)
- Wenqing Yan
- Department of Emergency, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi, People's Republic of China
- Medical Department, Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Weihua Dong
- Department of Emergency, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi, People's Republic of China
| | - Xin Song
- Department of Emergency, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi, People's Republic of China
- Medical Department, Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Wenqiang Zhou
- Department of Emergency, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi, People's Republic of China
- Medical Department, Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Zhi Chen
- Department of Emergency, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi, People's Republic of China
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The Heart as a Target of Vasopressin and Other Cardiovascular Peptides in Health and Cardiovascular Diseases. Int J Mol Sci 2022; 23:ijms232214414. [PMID: 36430892 PMCID: PMC9699305 DOI: 10.3390/ijms232214414] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/09/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
The automatism of cardiac pacemaker cells, which is tuned, is regulated by the autonomic nervous system (ANS) and multiple endocrine and paracrine factors, including cardiovascular peptides. The cardiovascular peptides (CPs) form a group of essential paracrine factors affecting the function of the heart and vessels. They may also be produced in other organs and penetrate to the heart via systemic circulation. The present review draws attention to the role of vasopressin (AVP) and some other cardiovascular peptides (angiotensins, oxytocin, cytokines) in the regulation of the cardiovascular system in health and cardiovascular diseases, especially in post-infarct heart failure, hypertension and cerebrovascular strokes. Vasopressin is synthesized mostly by the neuroendocrine cells of the hypothalamus. There is also evidence that it may be produced in the heart and lungs. The secretion of AVP and other CPs is markedly influenced by changes in blood volume and pressure, as well as by other disturbances, frequently occurring in cardiovascular diseases (hypoxia, pain, stress, inflammation). Myocardial infarction, hypertension and cardiovascular shock are associated with an increased secretion of AVP and altered responsiveness of the cardiovascular system to its action. The majority of experimental studies show that the administration of vasopressin during ventricular fibrillation and cardiac arrest improves resuscitation, however, the clinical studies do not present consisting results. Vasopressin cooperates with the autonomic nervous system (ANS), angiotensins, oxytocin and cytokines in the regulation of the cardiovascular system and its interaction with these regulators is altered during heart failure and hypertension. It is likely that the differences in interactions of AVP with ANS and other CPs have a significant impact on the responsiveness of the cardiovascular system to vasopressin in specific cardiovascular disorders.
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Elbadawi A, Tan BEX, Assaf Y, Elzeneini M, Baig B, Hamed M, Elgendy IY, Mamas M. Meta-Analysis of Efficacy of Vasopressin During Cardiopulmonary Resuscitation. Am J Cardiol 2022; 181:122-129. [DOI: 10.1016/j.amjcard.2022.06.042] [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: 04/09/2022] [Revised: 05/23/2022] [Accepted: 06/14/2022] [Indexed: 11/01/2022]
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Abdelazeem B, Awad AK, Manasrah N, Elbadawy MA, Ahmad S, Savarapu P, Abbas KS, Kunadi A. The Effect of Vasopressin and Methylprednisolone on Return of Spontaneous Circulation in Patients with In-Hospital Cardiac Arrest: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Cardiovasc Drugs 2022; 22:523-533. [PMID: 35314927 DOI: 10.1007/s40256-022-00522-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Cardiac arrest is often fatal if not treated immediately by cardiopulmonary resuscitation to restore a normal heart rhythm and spontaneous circulation. We aim to evaluate the clinical benefits of vasopressin and methylprednisolone versus placebo for patients with in-hospital cardiac arrest. DATA SOURCES We searched PubMed, EMBASE, Scopus, Web of Science, Cochrane Central, and Google Scholar from inception to October 17, 2021, by using search terms included "Vasopressin" AND "Methylprednisolone" AND "Cardiac arrest". STUDY SELECTION AND DATA EXTRACTION We included randomized controlled trials (RCTs) that compared vasopressin and methylprednisolone to placebo. The main outcomes were the return of spontaneous circulation (ROSC) and survival to hospital discharge. DATA SYNTHESIS A total of three RCTs, with a total of 869 patients, were included. The pooled risk ratios (RRs) were calculated along with their 95% confidence intervals (CIs). Our result showed an increase in ROSC in patients who received vasopressin and methylprednisolone (RR = 1.32; 95% CI = [1.18, 1.47], p < 0.00001) when compared with the placebo group. However, there was no difference between both groups regarding survival to hospital discharge (RR = 1.76; 95% CI = [0.68, 4.56], p= 0.25). RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The current guidelines recommend epinephrine for patients with in-hospital cardiac arrest. Our meta-analysis updates clinicians about using vasopressin and methylprednisolone besides epinephrine, providing them with the best available evidence in managing patients with in-hospital cardiac arrest. CONCLUSION Among patients with in-hospital cardiac arrest, administration of vasopressin and methylprednisolone besides epinephrine is associated with increased ROSC compared with placebo and epinephrine. However, high-quality RCTs are necessary before drawing a firm conclusion regarding the efficacy of vasopressin and methylprednisolone for patients with in-hospital cardiac arrest.
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Sahebnasagh A, Nejad PS, Salehi-Abargouei A, Dehghani MH, Saghafi F. A characterization of cortisol level and adrenal reservation in human cardiopulmonary arrest: systematic review and meta-analysis. Syst Rev 2021; 10:266. [PMID: 34625103 PMCID: PMC8499554 DOI: 10.1186/s13643-021-01820-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/25/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cardiopulmonary arrest (CPA) is an urgency, which is associated with high mortality. This systematic review evaluated the relationship between baseline cortisol level and the outcome of resuscitated CPA patients. METHODS We searched the following databases: PubMed, Scopus, ISI Web of Science, and Google Scholar. Relevant observational and controlled trials were explored from inception by April 2020. The quality of the articles was assessed using the Newcastle-Ottawa Scale (NOS). RESULTS Finally, five cohort studies (n = 201 participants in total) were eligible for including in the meta-analysis. The results of this meta-analysis showed that although the baseline serum cortisol levels were higher in survivors of cardiac arrest compared with non-survivors, the differences between groups do not reach a significance level (Hedges' g = 0.371, 95% CI, -0.727, 1.469, P value = 0.508). Between-study heterogeneity was statistically significant (Cochrane Q test: P value < 0.001, I2 = 89.323). CONCLUSIONS The result of the present meta-analysis was suggestive of a higher baseline serum cortisol levels in survivors of CPA. Future randomized controlled studies with a large sample size will determine the exact relationship between adrenal reservation and the eventual outcome of patients with CPA. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018085468.
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Affiliation(s)
- Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Paria Soltani Nejad
- Pharmaceutical Sciences Research Center, School of Pharmacy, Student Research Committee, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Amin Salehi-Abargouei
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Hossein Dehghani
- Department of Anesthesiology and Critical Care, Shahid Rahnemoun Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Fatemeh Saghafi
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Shahid Sadoughi University of Medical Sciences, Professor Hesabi Blvd, Yazd, Iran.
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Oh J, Cha KC, Lee JH, Park S, Kim DH, Lee BK, Park JS, Jung WJ, Lee DK, Roh YI, Kim TY, Chung SP, Kim YM, Park JD, Kim HS, Lee MJ, Na SH, Cho GC, Kim ARE, Hwang SO. 2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 4. Adult advanced life support. Clin Exp Emerg Med 2021; 8:S26-S40. [PMID: 34034448 PMCID: PMC8171171 DOI: 10.15441/ceem.21.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/19/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Jaehoon Oh
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Seungmin Park
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Hyeok Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Woo Jin Jung
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Dong Keon Lee
- Department of Anesthesiology and Pain Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Young Il Roh
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Tae Youn Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Min Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - June Dong Park
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Jin Lee
- Department of Emergency Medicine, Kyungpook National University College of Medicine, Daegu, Korea
| | - Sang-Hoon Na
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Gyu Chong Cho
- Department of Emergency Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Ai-Rhan Ellen Kim
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Andersen LW, Sindberg B, Holmberg M, Isbye D, Kjærgaard J, Zwisler ST, Darling S, Larsen JM, Rasmussen BS, Løfgren B, Lauridsen KG, Pælestik KB, Sølling C, Kjærgaard AG, Due-Rasmussen D, Folke F, Charlot MG, Iversen K, Schultz M, Wiberg S, Jepsen RMH, Kurth T, Donnino M, Kirkegaard H, Granfeldt A. Vasopressin and methylprednisolone for in-hospital cardiac arrest - Protocol for a randomized, double-blind, placebo-controlled trial. Resusc Plus 2021; 5:100081. [PMID: 34223347 PMCID: PMC8244400 DOI: 10.1016/j.resplu.2021.100081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To describe the clinical trial "Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest" (VAM-IHCA). METHODS The VAM-IHCA trial is an investigator-initiated, multicenter, randomized, placebo-controlled, parallel group, double-blind, superiority trial of vasopressin and methylprednisolone during adult in-hospital cardiac arrest. The study drugs consist of 40 mg methylprednisolone and 20 IU of vasopressin given as soon as possible after the first dose of adrenaline. Additional doses of vasopressin (20 IU) will be administered after each adrenaline dose for a maximum of four doses (80 IU).The primary outcome is return of spontaneous circulation and key secondary outcomes include survival and survival with a favorable neurological outcome at 30 days. 492 patients will be enrolled. The trial was registered at the EU Clinical Trials Register (EudraCT Number: 2017-004773-13) on Jan. 25, 2018 and ClinicalTrials.gov (Identifier: NCT03640949) on Aug. 21, 2018. RESULTS The trial started in October 2018 and the last patient is anticipated to be included in January 2021. The primary results will be reported after 3-months follow-up and are, therefore, anticipated in mid-2021. CONCLUSION The current article describes the design of the VAM-IHCA trial. The results from this trial will help clarify whether the combination of vasopressin and methylprednisolone when administered during in-hospital cardiac arrest improves outcomes.
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Affiliation(s)
- Lars W. Andersen
- Research Centre for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
- Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Birthe Sindberg
- Research Centre for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark
| | - Mathias Holmberg
- Research Centre for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark
- Department of Cardiology, Viborg Regional Hospital, Viborg, Denmark
| | - Dan Isbye
- Department of Anaesthesia 6011, Rigshospitalet - University of Copenhagen, Denmark
| | - Jesper Kjærgaard
- Department of Cardiology, The Heart Centre, Rigshospitalet - University of Copenhagen, Denmark
| | - Stine T. Zwisler
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Søren Darling
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Jacob Moesgaard Larsen
- Department of Cardiology, Aalborg University Hospital, Denmark
- Department of Clinical Medicine, Aalborg University, Denmark
| | - Bodil S. Rasmussen
- Department of Clinical Medicine, Aalborg University, Denmark
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Denmark
| | - Bo Løfgren
- Research Centre for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark
- Department of Medicine, Randers Regional Hospital, Randers, Denmark
| | - Kasper Glerup Lauridsen
- Research Centre for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark
- Department of Medicine, Randers Regional Hospital, Randers, Denmark
| | - Kim B. Pælestik
- Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Christoffer Sølling
- Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Anders G. Kjærgaard
- Department of Anesthesiology and Intensive Care, Horsens Regional Hospital, Horsens, Denmark
| | - Dorte Due-Rasmussen
- Department of Anesthesiology and Intensive Care, Horsens Regional Hospital, Horsens, Denmark
| | - Fredrik Folke
- Copenhagen Emergency Medical Services, University of Copenhagen, Denmark
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Mette Gitz Charlot
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Emergency Medicine, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Martin Schultz
- Department of Internal Medicine, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Sebastian Wiberg
- Department of Anesthesiology and Intensive Care, University Hospital Zealand, Køge, Denmark
| | | | - Tobias Kurth
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark
- Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Asger Granfeldt
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
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Morgan RW, Kirschen MP, Kilbaugh TJ, Sutton RM, Topjian AA. Pediatric In-Hospital Cardiac Arrest and Cardiopulmonary Resuscitation in the United States: A Review. JAMA Pediatr 2021; 175:293-302. [PMID: 33226408 PMCID: PMC8787313 DOI: 10.1001/jamapediatrics.2020.5039] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Pediatric in-hospital cardiac arrest (IHCA) occurs frequently and is associated with high morbidity and mortality. The objective of this narrative review is to summarize the current knowledge and recommendations regarding pediatric IHCA and cardiopulmonary resuscitation (CPR). OBSERVATIONS Each year, more than 15 000 children receive CPR for cardiac arrest during hospitalization in the United States. As many as 80% to 90% survive the event, but most patients do not survive to hospital discharge. Most IHCAs occur in intensive care units and other monitored settings and are associated with respiratory failure or shock. Bradycardia with poor perfusion is the initial rhythm in half of CPR events, and only about 10% of events have an initial shockable rhythm. Pre-cardiac arrest systems focus on identifying at-risk patients and ensuring that they are in monitored settings. Important components of CPR include high-quality chest compressions, timely defibrillation when indicated, appropriate ventilation and airway management, administration of epinephrine to increase coronary perfusion pressure, and treatment of the underlying cause of cardiac arrest. Extracorporeal CPR and measurement of physiological parameters are evolving areas in improving outcomes. Structured post-cardiac arrest care focused on targeted temperature management, optimization of hemodynamics, and careful intensive care unit management is associated with improved survival and neurological outcomes. CONCLUSIONS AND RELEVANCE Pediatric IHCA occurs frequently and has a high mortality rate. Early identification of risk, prevention, delivery of high-quality CPR, and post-cardiac arrest care can maximize the chances of achieving favorable outcomes. More research in this field is warranted.
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Affiliation(s)
- Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Matthew P. Kirschen
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Alexis A. Topjian
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Lind PC, Johannsen CM, Vammen L, Magnussen A, Andersen LW, Granfeldt A. Translation from animal studies of novel pharmacological therapies to clinical trials in cardiac arrest: A systematic review. Resuscitation 2020; 158:258-269. [PMID: 33147523 DOI: 10.1016/j.resuscitation.2020.10.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/09/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is a lack of new promising therapies to improve the dismal outcomes from cardiac arrest. The objectives of this study were: (1) To identify novel pharmacological therapies investigated in experimental animal studies and (2) to identify pharmacological therapies translated from experimental animal studies to clinical trials. METHODS PubMed was searched to first identify relevant experimental cardiac arrest animal models published within the last 20 years. Based on this, a list of interventions was created and a second search was performed to identify clinical trials testing one of these interventions. Data extraction was performed using standardised data extraction forms. RESULTS We identified 415 animal studies testing 190 different pharmacological interventions. The most commonly tested interventions were classified as vasopressors, anaesthetics/gases, or interventions aimed at molecular targets. We found 43 clinical trials testing 26 different interventions identified in the animal studies. Of these, 13 trials reported positive findings and 30 trials reported neutral findings with regards to the primary endpoint. No study showed harm of the intervention. Some interventions tested in human clinical trials, had previously been tested in animal studies without a positive effect on outcomes. A large number of animal studies was performed after publication of a clinical trial. CONCLUSION Numerous different pharmacological interventions have been tested in experimental animal models. Despite this only a limited number of these interventions have advanced to clinical trials, however several of the clinical trials tested interventions that were first tested in experimental animal models.
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Affiliation(s)
- Peter Carøe Lind
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Lauge Vammen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Intensive Care and Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Lars W Andersen
- Department of Intensive Care and Anesthesiology, Aarhus University Hospital, Aarhus, Denmark; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Asger Granfeldt
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Intensive Care and Anesthesiology, Aarhus University Hospital, Aarhus, Denmark; Department of Anesthesiology and Intensive Care Medicine, Randers Regional Hospital, Randers, Denmark.
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13
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Herrera-Perez D, Fox-Lee R, Bien J, Prasad V. Frequency of Medical Reversal Among Published Randomized Controlled Trials Assessing Cardiopulmonary Resuscitation (CPR). Mayo Clin Proc 2020; 95:889-910. [PMID: 32370852 DOI: 10.1016/j.mayocp.2020.01.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/31/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To characterize what proportion of all randomized controlled trials (RCTs) among patients experiencing cardiac arrest find that an established practice is ineffective or harmful, that is, a medical reversal. METHODS We reviewed a database of all published RCTs of cardiac arrest patient populations between 1995 and 2014. Articles were classified on the basis of whether they tested a new or existing therapy and whether results were positive or negative. A reversal was defined as a negative RCT of an established practice. Further review and categorization were performed to confirm that reversals were supported by subsequent systematic review, as well as to identify the type of medical practice studied in each reversal. This study was conducted from October 2017 to June 17, 2019. RESULTS We reviewed 92 original articles, 76 of which could be conclusively categorized. Of these, 18 (24%) articles examined a new medical practice, whereas 58 (76%) tested an established practice. A total of 18 (24%) studies had positive findings, whereas 58 (76%) reached a negative conclusion. Of the 58 articles testing existing standard of care, 44 (76%) reversed that practice, whereas 14 (24%) reaffirmed it. CONCLUSION Reversal of cardiopulmonary resuscitation practices is widespread. This investigation sheds new light on low-value practices and patterns of medical research and suggests that novel resuscitation practices have low pretest probability and should be empirically tested with rigorous trials before implementation.
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Affiliation(s)
- Diana Herrera-Perez
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland
| | - Ryan Fox-Lee
- School of Medicine, Oregon Health and Science University, Portland
| | - Jeffrey Bien
- School of Medicine, Oregon Health and Science University, Portland
| | - Vinay Prasad
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland; Center for Health Care Ethics, Oregon Health and Science University, Portland.
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Ge W, Zheng G, Ji X, He F, Hu J, Bradley JL, Moore CE, Peberdy MA, Ornato JP, Mangino MJ, Tang W. Effects of Polyethylene Glycol-20k on Coronary Perfusion Pressure and Postresuscitation Myocardial and Cerebral Function in a Rat Model of Cardiac Arrest. J Am Heart Assoc 2020; 9:e014232. [PMID: 32013701 PMCID: PMC7033902 DOI: 10.1161/jaha.119.014232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/06/2019] [Indexed: 01/12/2023]
Abstract
Background Epinephrine increases the rate of return of spontaneous circulation. However, it increases severity of postresuscitation myocardial and cerebral dysfunction and reduces duration of survival. We investigated the effects of aortic infused polyethylene glycol, 20 000 molecular weight (PEG-20k) during cardiopulmonary resuscitation on coronary perfusion pressure, postresuscitation myocardial and cerebral function, and duration of survival in a rat model of cardiac arrest. Methods and Results Twenty-four male rats were randomized into 4 groups: (1) PEG-20k, (2) epinephrine, (3) saline control-intravenous, and (4) saline control-intra-aortic. Cardiopulmonary resuscitation was initiated after 6 minutes of untreated ventricular fibrillation. In PEG-20k and Saline-A, either PEG-20k (10% weight/volume in 10% estimated blood volume infused over 3 minutes) or saline was administered intra-aortically after 4 minutes of precordial compression. In epinephrine and placebo groups, either epinephrine (20 μg/kg) or saline placebo was administered intravenously after 4 minutes of precordial compression. Resuscitation was attempted after 8 minutes of cardiopulmonary resuscitation. Sublingual microcirculation was measured at baseline and 1, 3, and 5 hours after return of spontaneous circulation. Myocardial function was measured at baseline and 2, 4, and 6 hours after return of spontaneous circulation. Neurologic deficit scores were recorded at 24, 48, and 72 hours after return of spontaneous circulation. Aortic infusion of PEG-20k increased coronary perfusion pressure to the same extent as epinephrine. Postresuscitation sublingual microcirculation, myocardial and cerebral function, and duration of survival were improved in PEG-20k (P<0.05) compared with epinephrine (P<0.05). Conclusions Aortic infusion of PEG-20k during cardiopulmonary resuscitation increases coronary perfusion pressure to the same extent as epinephrine, improves postresuscitation myocardial and cerebral function, and increases duration of survival in a rat model of cardiac arrest.
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Affiliation(s)
- Weiwei Ge
- Department of Emergency SurgeryThe Second Hospital of Anhui Medical UniversityHefeiChina
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth UniversityRichmondVA
| | - Guanghui Zheng
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth UniversityRichmondVA
| | - Xianfei Ji
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth UniversityRichmondVA
| | - Fenglian He
- Department of Emergency SurgeryThe Second Hospital of Anhui Medical UniversityHefeiChina
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth UniversityRichmondVA
| | - Juntao Hu
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth UniversityRichmondVA
| | - Jennifer L. Bradley
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth UniversityRichmondVA
| | - Christine E. Moore
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth UniversityRichmondVA
| | - Mary A. Peberdy
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth UniversityRichmondVA
- Department of Internal Medicine and Emergency MedicineVirginia Commonwealth University Health SystemRichmondVA
| | - Joseph P. Ornato
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth UniversityRichmondVA
- Department of Emergency MedicineVirginia Commonwealth University Health SystemRichmondVA
| | - Martin J. Mangino
- Department of Emergency MedicineVirginia Commonwealth University Health SystemRichmondVA
- Department of SurgeryVirginia Commonwealth University Health SystemRichmondVA
- Department of Physiology and BiophysicsVirginia Commonwealth UniversityRichmondVA
| | - Wanchun Tang
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth UniversityRichmondVA
- Department of Emergency MedicineVirginia Commonwealth University Health SystemRichmondVA
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Soar J, Maconochie I, Wyckoff MH, Olasveengen TM, Singletary EM, Greif R, Aickin R, Bhanji F, Donnino MW, Mancini ME, Wyllie JP, Zideman D, Andersen LW, Atkins DL, Aziz K, Bendall J, Berg KM, Berry DC, Bigham BL, Bingham R, Couto TB, Böttiger BW, Borra V, Bray JE, Breckwoldt J, Brooks SC, Buick J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Cheng A, Chung SP, Considine J, Couper K, Dainty KN, Dawson JA, de Almeida MF, de Caen AR, Deakin CD, Drennan IR, Duff JP, Epstein JL, Escalante R, Gazmuri RJ, Gilfoyle E, Granfeldt A, Guerguerian AM, Guinsburg R, Hatanaka T, Holmberg MJ, Hood N, Hosono S, Hsieh MJ, Isayama T, Iwami T, Jensen JL, Kapadia V, Kim HS, Kleinman ME, Kudenchuk PJ, Lang E, Lavonas E, Liley H, Lim SH, Lockey A, Lofgren B, Ma MHM, Markenson D, Meaney PA, Meyran D, Mildenhall L, Monsieurs KG, Montgomery W, Morley PT, Morrison LJ, Nadkarni VM, Nation K, Neumar RW, Ng KC, Nicholson T, Nikolaou N, Nishiyama C, Nuthall G, Ohshimo S, Okamoto D, O’Neil B, Yong-Kwang Ong G, Paiva EF, Parr M, Pellegrino JL, Perkins GD, Perlman J, Rabi Y, Reis A, Reynolds JC, Ristagno G, Roehr CC, Sakamoto T, Sandroni C, Schexnayder SM, Scholefield BR, Shimizu N, Skrifvars MB, Smyth MA, Stanton D, Swain J, Szyld E, Tijssen J, Travers A, Trevisanuto D, Vaillancourt C, Van de Voorde P, Velaphi S, Wang TL, Weiner G, Welsford M, Woodin JA, Yeung J, Nolan JP, Fran Hazinski M. 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation 2019; 140:e826-e880. [DOI: 10.1161/cir.0000000000000734] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.
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2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2019; 145:95-150. [DOI: 10.1016/j.resuscitation.2019.10.016] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Vasopressors During Cardiopulmonary Resuscitation. A Network Meta-Analysis of Randomized Trials. Crit Care Med 2019; 46:e443-e451. [PMID: 29652719 DOI: 10.1097/ccm.0000000000003049] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Several randomized controlled trials have compared adrenaline (epinephrine) with alternative therapies in patients with cardiac arrest with conflicting results. Recent observational studies suggest that adrenaline might increase return of spontaneous circulation but worsen neurologic outcome. We systematically compared all the vasopressors tested in randomized controlled trials in adult cardiac arrest patients in order to identify the treatment associated with the highest rate of return of spontaneous circulation, survival, and good neurologic outcome. DESIGN Network meta-analysis. PATIENTS Adult patients undergoing cardiopulmonary resuscitation. INTERVENTIONS PubMed, Embase, BioMed Central, and the Cochrane Central register were searched (up to April 1, 2017). We included all the randomized controlled trials comparing a vasopressor with any other therapy. A network meta-analysis with a frequentist approach was performed to identify the treatment associated with the highest likelihood of survival. MEASUREMENTS AND MAIN RESULTS Twenty-eight studies randomizing 14,848 patients in 12 treatment groups were included. Only a combined treatment with adrenaline, vasopressin, and methylprednisolone was associated with increased likelihood of return of spontaneous circulation and survival with a good neurologic outcome compared with several other comparators, including adrenaline. Adrenaline alone was not associated with any significant difference in mortality and good neurologic outcome compared with any other comparator. CONCLUSIONS In randomized controlled trials assessing vasopressors in adults with cardiac arrest, only a combination of adrenaline, vasopressin, and methylprednisolone was associated with improved survival with a good neurologic outcome compared with any other drug or placebo, particularly in in-hospital cardiac arrest. There was no significant randomized evidence to support neither discourage the use of adrenaline during cardiac arrest.
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Vasopressors during adult cardiac arrest: A systematic review and meta-analysis. Resuscitation 2019; 139:106-121. [DOI: 10.1016/j.resuscitation.2019.04.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 02/04/2023]
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Abstract
IMPORTANCE In-hospital cardiac arrest is common and associated with a high mortality rate. Despite this, in-hospital cardiac arrest has received little attention compared with other high-risk cardiovascular conditions, such as stroke, myocardial infarction, and out-of-hospital cardiac arrest. OBSERVATIONS In-hospital cardiac arrest occurs in over 290 000 adults each year in the United States. Cohort data from the United States indicate that the mean age of patients with in-hospital cardiac arrest is 66 years, 58% are men, and the presenting rhythm is most often (81%) nonshockable (ie, asystole or pulseless electrical activity). The cause of the cardiac arrest is most often cardiac (50%-60%), followed by respiratory insufficiency (15%-40%). Efforts to prevent in-hospital cardiac arrest require both a system for identifying deteriorating patients and an appropriate interventional response (eg, rapid response teams). The key elements of treatment during cardiac arrest include chest compressions, ventilation, early defibrillation, when applicable, and immediate attention to potentially reversible causes, such as hyperkalemia or hypoxia. There is limited evidence to support more advanced treatments. Post-cardiac arrest care is focused on identification and treatment of the underlying cause, hemodynamic and respiratory support, and potentially employing neuroprotective strategies (eg, targeted temperature management). Although multiple individual factors are associated with outcomes (eg, age, initial rhythm, duration of the cardiac arrest), a multifaceted approach considering both potential for neurological recovery and ongoing multiorgan failure is warranted for prognostication and clinical decision-making in the post-cardiac arrest period. Withdrawal of care in the absence of definite prognostic signs both during and after cardiac arrest should be avoided. Hospitals are encouraged to participate in national quality-improvement initiatives. CONCLUSIONS AND RELEVANCE An estimated 290 000 in-hospital cardiac arrests occur each year in the United States. However, there is limited evidence to support clinical decision making. An increased awareness with regard to optimizing clinical care and new research might improve outcomes.
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Affiliation(s)
- Lars W Andersen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Intensive Care Medicine, Randers Regional Hospital, Randers, Denmark
| | - Mathias J Holmberg
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Katherine M Berg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael W Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Asger Granfeldt
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
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Abstract
BACKGROUND Adrenaline and vasopressin are widely used to treat people with cardiac arrest, but there is uncertainty about the safety, effectiveness and the optimal dose. OBJECTIVES To determine whether adrenaline or vasopressin, or both, administered during cardiac arrest, afford any survival benefit. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and DARE from their inception to 8 May 2018, and the International Liaison Committee on Resuscitation 2015 Advanced Life Support Consensus on Science and Treatment Recommendations. We also searched four trial registers on 5 September 2018 and checked the reference lists of the included studies and review papers to identify potential papers for review. SELECTION CRITERIA Any randomised controlled trial comparing: standard-dose adrenaline versus placebo; standard-dose adrenaline versus high-dose adrenaline; and adrenaline versus vasopressin, in any setting, due to any cause of cardiac arrest, in adults and children. There were no language restrictions. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials for review, assessed risks of bias and extracted data, resolving disagreements through re-examination of the trial reports and by discussion. We used risk ratios (RRs) with 95% confidence intervals (CIs) to compare dichotomous outcomes for clinical events. There were no continuous outcomes reported. We examined groups of trials for heterogeneity. We report the quality of evidence for each outcome, using the GRADE approach. MAIN RESULTS We included 26 studies (21,704 participants).Moderate-quality evidence found that adrenaline increased survival to hospital discharge compared to placebo (RR 1.44, 95% CI 1.11 to 1.86; 2 studies, 8538 participants; an increase from 23 to 32 per 1000, 95% CI 25 to 42). We are uncertain about survival to hospital discharge for high-dose compared to standard-dose adrenaline (RR 1.10, 95% CI 0.75 to 1.62; participants = 6274; studies = 10); an increase from 33 to 36 per 1000, 95% CI 24 to 53); standard-dose adrenaline versus vasopressin (RR 1.25, 95% CI 0.84 to 1.85; 6 studies; 2511 participants; an increase from 72 to 90 per 1000, 95% CI 60 to 133); and standard-dose adrenaline versus vasopressin plus adrenaline (RR 0.76, 95% CI 0.47 to 1.22; 3 studies; 3242 participants; a possible decrease from 24 to 18 per 1000, 95% CI 11 to 29), due to very low-quality evidence.Moderate-quality evidence found that adrenaline compared with placebo increased survival to hospital admission (RR 2.51, 95% CI 1.67 to 3.76; 2 studies, 8489 participants; an increase from 83 to 209 per 1000, 95% CI 139 to 313). We are uncertain about survival to hospital admission when comparing standard-dose with high-dose adrenaline, due to very low-quality evidence. Vasopressin may improve survival to hospital admission when compared with standard-dose adrenaline (RR 1.27, 95% CI 1.04 to 1.54; 3 studies, 1953 participants; low-quality evidence; an increase from 260 to 330 per 1000, 95% CI 270 to 400), and may make little or no difference when compared to standard-dose adrenaline plus vasopressin (RR 0.95, 95% CI 0.83 to 1.08; 3 studies; 3249 participants; low-quality evidence; a decrease from 218 to 207 per 1000 (95% CI 181 to 236).There was no evidence that adrenaline (any dose) or vasopressin improved neurological outcomes.The rate of return of spontaneous circulation (ROSC) was higher for standard-dose adrenaline versus placebo (RR 2.86, 95% CI 2.21 to 3.71; participants = 8663; studies = 3); moderate-quality evidence; an increase from 115 to 329 per 1000, 95% CI 254 to 427). We are uncertain about the effect on ROSC for the comparison of standard-dose versus high-dose adrenaline and standard-does adrenaline compared to vasopressin, due to very low-quality evidence. Standard-dose adrenaline may make little or no difference to ROSC when compared to standard-dose adrenaline plus vasopressin (RR 0.97, 95% CI 0.87 to 1.08; 3 studies, 3249 participants; low-quality evidence; a possible decrease from 299 to 290 per 1000, 95% CI 260 to 323).The source of funding was not stated in 11 of the 26 studies. The study drugs were provided by the manufacturer in four of the 26 studies, but neither drug represents a profitable commercial option. The other 11 studies were funded by organisations such as research foundations and government funding bodies. AUTHORS' CONCLUSIONS This review provides moderate-quality evidence that standard-dose adrenaline compared to placebo improves return of spontaneous circulation, survival to hospital admission and survival to hospital discharge, but low-quality evidence that it did not affect survival with a favourable neurological outcome. Very low -quality evidence found that high-dose adrenaline compared to standard-dose adrenaline improved return of spontaneous circulation and survival to admission. Vasopressin compared to standard dose adrenaline improved survival to admission but not return of spontaneous circulation, whilst the combination of adrenaline and vasopressin compared with adrenaline alone had no effect on these outcomes. Neither standard dose adrenaline, high-dose adrenaline,vasopressin nor a combination of adrenaline and vasopressin improved survival with a favourable neurological outcome. Many of these studies were conducted more than 20 years ago. Treatment has changed in recent years, so the findings from older studies may not reflect current practice.
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Affiliation(s)
- Judith Finn
- Curtin UniversityPrehospital, Resuscitation and Emergency Care Research Unit (PRECRU)Kent StreetBentleyWestern AustraliaAustralia6102
- St John Ambulance Western AustraliaBelmontAustralia
| | - Ian Jacobs
- Curtin UniversityPrehospital, Resuscitation and Emergency Care Research Unit (PRECRU)Kent StreetBentleyWestern AustraliaAustralia6102
- St John Ambulance Western AustraliaBelmontAustralia
| | | | - Simon Gates
- University of BirminghamCancer Research UK Clinical Trials Unit, School of Cancer Sciences, Institute of Cancer and Genomic SciencesBirminghamUKB15 2TT
| | - Gavin D Perkins
- University of WarwickWarwick Medical School and University Hospitals BirminghamCoventryUK
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Morgan RW, Kilbaugh TJ, Berg RA, Sutton RM. Pediatric In-Hospital Cardiac Arrest and Cardiopulmonary Resuscitation. CURRENT PEDIATRICS REPORTS 2017. [DOI: 10.1007/s40124-017-0142-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sutton RM, Morgan RW, Kilbaugh TJ, Nadkarni VM, Berg RA. Cardiopulmonary Resuscitation in Pediatric and Cardiac Intensive Care Units. Pediatr Clin North Am 2017; 64:961-972. [PMID: 28941543 DOI: 10.1016/j.pcl.2017.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Approximately 5000 to 10,000 children suffer an in-hospital cardiac arrest requiring cardiopulmonary resuscitation (CPR) each year in the United States. Importantly, 2% to 6% of all children admitted to pediatric intensive care units (ICUs) receive CPR, as do 4% to 6% of children admitted to pediatric cardiac ICUs. Survival from pediatric ICU cardiac arrest has improved substantially during the past 20 years presumably due to improved training methods, CPR quality, and post-resuscitation care. Extracorporeal life support CPR remains an important treatment option for both cardiac and noncardiac ICU patients.
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Affiliation(s)
- Robert M Sutton
- Department of Anesthesia and Critical Care Medicine, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Ryan W Morgan
- Department of Anesthesia and Critical Care Medicine, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Todd J Kilbaugh
- Department of Anesthesia and Critical Care Medicine, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Vinay M Nadkarni
- Department of Anesthesia and Critical Care Medicine, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Robert A Berg
- Department of Anesthesia and Critical Care Medicine, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0330-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Fraser GL, Bagwell SP. Important Changes in the ACLS 2000 Guidelines for the Management of Cardiac Arrest. Hosp Pharm 2017. [DOI: 10.1177/001857870203700504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This feature examines the impact of pharmacologic interventions on the treatment of the critically ill patient—an area of health care that has become increasingly complex. It will review recent advances (including evolving and controversial data) in drug therapy for adult ICU patients and assess these new modalities in terms of clinical, humanistic, and economic outcomes.
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25
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An Update on Cardiopulmonary Resuscitation in Children. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0216-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Park KS, Yoo KY. Role of vasopressin in current anesthetic practice. Korean J Anesthesiol 2017; 70:245-257. [PMID: 28580075 PMCID: PMC5453886 DOI: 10.4097/kjae.2017.70.3.245] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 05/01/2017] [Accepted: 05/02/2017] [Indexed: 11/10/2022] Open
Abstract
Arginine vasopressin (AVP), also known as antidiuretic hormone, is a peptide endogenously secreted by the posterior pituitary in response to hyperosmolar plasma or systemic hypoperfusion states. When administered intravenously, it causes an intense peripheral vasoconstriction through stimulation of V1 receptors on the vascular smooth muscle. Patients in refractory shock associated with severe sepsis, cardiogenic or vasodilatory shock, or cardiopulmonary bypass have inappropriately low plasma levels of AVP (‘relative vasopressin deficiency’) and supersensitivity to exogenously-administered AVP. Low doses of AVP and its synthetic analog terlipressin can restore vasomotor tone in conditions that are resistant to catecholamines, with preservation of renal blood flow and urine output. They are also useful in the treatment of refractory arterial hypotension in patients chronically treated with renin-angiotensin system inhibitors, cardiac arrest, or bleeding esophageal varices. In the perioperative setting, they represent attractive adjunct vasopressors in advanced shock states that are unresponsive to conventional therapeutic strategies.
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Affiliation(s)
- Keun Suk Park
- Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Kyung Yeon Yoo
- Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Gwangju, Korea
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Choong K. Vasopressin in Pediatric Critical Care. J Pediatr Intensive Care 2016; 5:182-188. [PMID: 31110903 PMCID: PMC6512420 DOI: 10.1055/s-0036-1583282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 10/15/2015] [Indexed: 10/21/2022] Open
Abstract
Vasopressin is a unique hormone with complex receptor physiology and numerous physiologic functions beyond its well-known vascular actions and osmoregulation. While vasopressin has in the past been primarily used in the management of diabetes insipidus and acute gastrointestinal bleeding, an increased understanding of the physiology of refractory shock, and the role of vasopressin in maintaining cardiovascular homeostasis prompted a renewed interest in the therapeutic roles for this hormone in the critical care setting. Identifying vasopressin-deficient individuals for the purposes of assessing responsiveness to exogenous hormone and prognosticating outcome has expanded research into the evaluation of vasopressin and its precursor, copeptin as useful biomarkers. This review summarizes the current evidence for vasopressin in critically ill children, with a specific focus on its use in the management of shock. We outline important considerations and current guidelines, when considering the use of vasopressin or its analogues in the pediatric critical care setting.
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Affiliation(s)
- Karen Choong
- Department of Pediatrics, Critical Care, Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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28
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Nichol G, Brown SP, Perkins GD, Kim F, Sterz F, Broeckel Elrod JA, Mentzelopoulos S, Lyon R, Arabi Y, Castren M, Larsen P, Valenzuela T, Graesner JT, Youngquist S, Khunkhlai N, Wang HE, Ondrej F, Sastrias JMF, Barasa A, Sayre MR. What change in outcomes after cardiac arrest is necessary to change practice? Results of an international survey. Resuscitation 2016; 107:115-20. [PMID: 27565860 DOI: 10.1016/j.resuscitation.2016.08.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 08/01/2016] [Accepted: 08/04/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Efficient trials of interventions for patients with out-of-hospital cardiac arrest (OHCA) should have adequate but not excess power to detect a difference in outcomes. The minimum clinically important difference (MCID) is the threshold value in outcomes observed in a trial at which providers should choose to adopt a treatment. There has been limited assessment of MCID for outcomes after OHCA. Therefore, we conducted an international survey of individuals interested in cardiac resuscitation to define the MCID for a range of outcomes after OHCA. METHODS A brief survey instrument was developed and modified by consensus. Included were open-ended responses. The survey included an illustrative example of a hypothetical randomized study with distributions of outcomes based on those in a public use datafile from a previous trial. Elicited information included the minimum significant difference required in an outcome to change clinical practice. The population of interest was emergency physicians or other practitioners of acute cardiovascular research. RESULTS Usable responses were obtained from 160 respondents (50% of surveyed) in 46 countries (79% of surveyed). MCIDs tended to increase as baseline outcomes increased. For a population of patients with 25% survival to discharge and 20% favorable neurologic status at discharge, the MCID were median 5 (interquartile range [IQR] 3, 10) percent for survival to discharge; median 5 (IQR 2, 10) percent for favorable neurologic status at discharge, median 4 (IQR 2, 9) days of ICU-free survival and median 4 (IQR 2, 8) days of hospital-free survival. CONCLUSION Reported MCIDs for outcomes after OHCA vary according to the outcome considered as well as the baseline rate of achieving it. MCIDs of ICU-free survival or hospital-free survival may be useful to accelerate the rate of evidence-based change in resuscitation care.
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Affiliation(s)
| | | | - Gavin D Perkins
- University of Warwick, Warwick, UK; Heart of England NHS Foundation Trust, Coventry, UK
| | | | - Fritz Sterz
- Medical University of Vienna, Vienna, Austria
| | | | | | | | - Yaseen Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Maaret Castren
- Department of Emergency Medicine and Services, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | | | | | | | | | - Nalinas Khunkhlai
- Department of Emergency Medicine & Narenthorn EMS Center Rajavithi Hospital, Ministry of Public Health, Thailand
| | - Henry E Wang
- University of Alabama at Birmingham, Birmingham, AL, USA
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Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars MB, Smith GB, Sunde K, Deakin CD. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation 2016; 95:100-47. [PMID: 26477701 DOI: 10.1016/j.resuscitation.2015.07.016] [Citation(s) in RCA: 920] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Pierre Carli
- SAMU de Paris, Department of Anaesthesiology and Intensive Care, Necker University Hospital, Paris, France
| | - Tommaso Pellis
- Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Gary B Smith
- Centre of Postgraduate Medical Research & Education, Bournemouth University, Bournemouth, UK
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
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Abstract
Arginine vasopressin is a peptide produced in the posterior pituitary whose primary physiologic role is fluid homeostasis. Recent investigations have demonstrated a therapeutic role for arginine vasopressin in adult cardiac arrest as well as adult and pediatric vasodilatory shock. We review the physiology of arginine vasopressin and examine the supporting data behind the developing clinical applications of this naturally produced peptide.
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Affiliation(s)
- Peter C Dyke
- Department of Child Health, Division of Pediatric Critical Care/Pediatric Anesthesiology, University of Missouri-Columbia, MO 65212, USA
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31
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Beavers CJ, Pandya KA. Pharmacotherapy Considerations for the Management of Advanced Cardiac Life Support. Nurs Clin North Am 2016; 51:69-82. [PMID: 26897425 DOI: 10.1016/j.cnur.2015.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Health care providers should be aware of the pharmacotherapy considerations in the American Heart Association's guidelines for advanced cardiac life support (ACLS). Current evidence does not suggest a reduction in mortality with ACLS medications; however, these medications can improve return of spontaneous circulation. Proper agent selection and dosing are imperative to maximize benefit and minimize harm. The latest guideline update included major changes to the ventricular fibrillation/pulseless ventricular tachycardia and pulseless electrical activity/asystole algorithms, which providers should adopt. It is critical that providers be prepared for post-code management. Health care professionals should remain abreast of changing evidence and guidelines.
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Affiliation(s)
- Craig J Beavers
- Department of Pharmacy Practice and Science, University of Kentucky UK Healthcare, Room H-110, 800 Rose Street, Lexington, KY 40536, USA.
| | - Komal A Pandya
- Department of Pharmacy Practice and Science, University of Kentucky UK Healthcare, Room H-110, 800 Rose Street, Lexington, KY 40536, USA
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Linsenmaier U, Wirth S, Kanz KG, Geyer LL. Imaging minor head injury (MHI) in emergency radiology: MRI highlights additional intracranial findings after measurement of trauma biomarker S-100B in patients with normal CCT. Br J Radiol 2015; 89:20150827. [PMID: 26607648 DOI: 10.1259/bjr.20150827] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To investigate whether MRI in emergency radiology can detect (a) additional trauma-related findings after minor head injury (MHI) or (b) structural, non-trauma-related intracranial lesions when trauma biomarker S-100B concentration is raised, or clinical symptoms are unexplained, or both. METHODS 41 patients with MHI were included. Concentrations of S-100B in serum were measured and categorized using an established cut-off at 0.1 μg l(-1). Intracerebral trauma-related as well as non-trauma-related chronic structural findings (atrophy, microangiopathy and chronic parenchymal defects) were assessed by cranial CT (CCT) and MRI by two independent radiologists (UL and LLG). All CCT and MRI results were compared with biomarker S-100B. RESULTS Compared with CCT, MRI detected 10 additional lesions. 5 patients had abnormal MRI with a total of 15 trauma-related lesions and showed elevated S-100B concentrations. Although sensitivity of S-100B was 100%, specificity was only 25%. Patients with structural brain lesions showed significantly higher S-100B serum levels (0.50 and 0.14 μg l(-1), p = 0.01). CONCLUSION Biomarker S-100B has proven its high negative-predictive value to rule out intracranial bleeding in patients after MHI even if MRI is used as imaging modality. Regarding the low specificity of S-100B, structural lesions of the brain parenchyma not related to the acute trauma may be associated with increased serum concentrations of protein S-100B. ADVANCES IN KNOWLEDGE Biomarker S-100B has a high negative-predictive value to rule out intracranial bleeding after MHI. Biomarker S-100B's low specificity may be associated with non-traumatic brain parenchyma lesions. MRI is superior to CCT in detecting subtle findings in neuroimaging after MHI. Biomarker S-100B can potentially reduce the large number of normal CCT studies after MHI.
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Affiliation(s)
- Ulrich Linsenmaier
- 1 Institute for Diagnostic and Interventional Radiology, HELIOS Kliniken München WEST & München Perlach & Klinikum Augustinum München, Munich, Germany.,2 ESER, European Society of Emergency Radiology, Vienna, Austria
| | - Stefan Wirth
- 3 Department of Clinical Radiology, LMU University Munich, Munich, Germany
| | - Karl-Georg Kanz
- 4 Department of Trauma Surgery, Technical University Munich (TUM), Munich, Germany
| | - Lucas L Geyer
- 3 Department of Clinical Radiology, LMU University Munich, Munich, Germany
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Song T, Kim M, Kim ML, Jung Y, Yun B, Seong S. Use of vasopressin vs epinephrine to reduce haemorrhage during myomectomy: a randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 2015; 195:177-181. [DOI: 10.1016/j.ejogrb.2015.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 09/01/2015] [Accepted: 10/14/2015] [Indexed: 02/06/2023]
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Monsieurs K, Nolan J, Bossaert L, Greif R, Maconochie I, Nikolaou N, Perkins G, Soar J, Truhlář A, Wyllie J, Zideman D. Kurzdarstellung. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0097-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Johnson D, Giles K, Acuna A, Saenz C, Bentley M, Budinich C. Effects of tibial intraosseous and IV administration of vasopressin on kinetics and survivability in cardiac arrest. Am J Emerg Med 2015; 34:429-32. [PMID: 26778642 DOI: 10.1016/j.ajem.2015.11.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 11/13/2015] [Accepted: 11/14/2015] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Purposes of this study were to compare tibial intraosseous (TIO) and intravenous (IV) administration of vasopressin relative to return of spontaneous circulation (ROSC) and time to ROSC in an adult swine cardiac arrest model. In addition, the purposes were to compare the concentration maximum (Cmax), time to maximum concentration (Tmax), and odds of ROSC. METHODS This was a between-subjects, prospective experimental study. Yorkshire swine (N = 21) were randomly assigned to 1 of 3 groups: TIO, IV, or control groups. The swine were anesthetized and instrumented, and then cardiac arrest was induced and sustained for 2 minutes. Cardiopulmonary resuscitation was initiated and continued for 2 minutes. Vasopressin was then administered via the TIO or IV route. Blood samples were collected for 4 minutes to determine the Cmax and Tmax of vasopressin. Concentration maximum and Tmax were calculated by use of liquid chromatography with mass spectrometry. RESULTS There was no difference in ROSC between the TIO and IV groups (P = .63). The Cmax of vasopressin was significantly higher in the IV group compared to the TIO group (P = .017). However, there was no significant difference in ROSC, time to ROSC, or Tmax between groups (P > .05). All subjects had ROSC in both the IV and TIO groups, and none had ROSC in the control group. There was 225 times greater chance of survival for both the IV and TIO groups compared to the control group. CONCLUSION The data support that the TIO is an effective route for vasopressin in a cardiac arrest model.
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Affiliation(s)
- Don Johnson
- Department of the Army, Academy of Health Sciences, Fort Sam Houston, TX 78234-6130.
| | - Kirk Giles
- Department of the Army, Academy of Health Sciences, Fort Sam Houston, TX 78234-6130.
| | - Alexis Acuna
- Department of the Army, Academy of Health Sciences, Fort Sam Houston, TX 78234-6130.
| | - Crystal Saenz
- Department of the Army, Academy of Health Sciences, Fort Sam Houston, TX 78234-6130.
| | - Michael Bentley
- Department of the Army, Academy of Health Sciences, Fort Sam Houston, TX 78234-6130.
| | - Craig Budinich
- Department of the Army, Academy of Health Sciences, Fort Sam Houston, TX 78234-6130.
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Lundin A, Djärv T, Engdahl J, Hollenberg J, Nordberg P, Ravn-Fischer A, Ringh M, Rysz S, Svensson L, Herlitz J, Lundgren P. Drug therapy in cardiac arrest: a review of the literature. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 2:54-75. [DOI: 10.1093/ehjcvp/pvv047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 10/28/2015] [Indexed: 01/01/2023]
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0085-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, Perkins GD, Soar J, Truhlář A, Wyllie J, Zideman DA, Alfonzo A, Arntz HR, Askitopoulou H, Bellou A, Beygui F, Biarent D, Bingham R, Bierens JJ, Böttiger BW, Bossaert LL, Brattebø G, Brugger H, Bruinenberg J, Cariou A, Carli P, Cassan P, Castrén M, Chalkias AF, Conaghan P, Deakin CD, De Buck ED, Dunning J, De Vries W, Evans TR, Eich C, Gräsner JT, Greif R, Hafner CM, Handley AJ, Haywood KL, Hunyadi-Antičević S, Koster RW, Lippert A, Lockey DJ, Lockey AS, López-Herce J, Lott C, Maconochie IK, Mentzelopoulos SD, Meyran D, Monsieurs KG, Nikolaou NI, Nolan JP, Olasveengen T, Paal P, Pellis T, Perkins GD, Rajka T, Raffay VI, Ristagno G, Rodríguez-Núñez A, Roehr CC, Rüdiger M, Sandroni C, Schunder-Tatzber S, Singletary EM, Skrifvars MB, Smith GB, Smyth MA, Soar J, Thies KC, Trevisanuto D, Truhlář A, Vandekerckhove PG, de Voorde PV, Sunde K, Urlesberger B, Wenzel V, Wyllie J, Xanthos TT, Zideman DA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation 2015; 95:1-80. [PMID: 26477410 DOI: 10.1016/j.resuscitation.2015.07.038] [Citation(s) in RCA: 568] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Koenraad G Monsieurs
- Emergency Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - Robert Greif
- Department of Anaesthesiology and Pain Medicine, University Hospital Bern, Bern, Switzerland; University of Bern, Bern, Switzerland
| | - Ian K Maconochie
- Paediatric Emergency Medicine Department, Imperial College Healthcare NHS Trust and BRC Imperial NIHR, Imperial College, London, UK
| | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jonathan Wyllie
- Department of Neonatology, The James Cook University Hospital, Middlesbrough, UK
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Abstract
Cardiac arrest is a dynamic disease that tests the multitasking and leadership abilities of emergency physicians. Providers must simultaneously manage the logistics of resuscitation while searching for the cause of cardiac arrest. The astute clinician will also realize that he or she is orchestrating only one portion of a larger series of events, each of which directly affects patient outcomes. Resuscitation science is rapidly evolving, and emergency providers must be familiar with the latest evidence and controversies surrounding resuscitative techniques. This article reviews evidence, discusses controversies, and offers strategies to provide quality cardiac arrest resuscitation.
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Affiliation(s)
- Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Suite 10028, Forbes Tower, Pittsburgh, PA 15260, USA
| | - Joshua C Reynolds
- Department of Emergency Medicine, Michigan State University College of Human Medicine, 15 Michigan Street Northeast, Suite 420, Grand Rapids, MI 49503, USA.
| | - Adam Frisch
- Department of Emergency Medicine, Albany Medical Center, 47 New Scotland Avenue, MC 139, Albany, NY 12208, USA
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Halvorsen P, Sharma HS, Basu S, Wiklund L. Neural injury after use of vasopressin and adrenaline during porcine cardiopulmonary resuscitation. Ups J Med Sci 2015; 120:11-9. [PMID: 25645317 PMCID: PMC4389003 DOI: 10.3109/03009734.2015.1010665] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Our aim was to investigate cerebral and cardiac tissue injury subsequent to use of vasopressin and adrenaline in combination compared with vasopressin alone during cardiopulmonary resuscitation (CPR). METHODS In a randomized, prospective, laboratory animal study 28 anesthetized piglets were subject to a 12-min untreated cardiac arrest and subsequent CPR. After 1 min of CPR, 10 of the piglets received 0.4 U/kg of arg(8)-vasopressin (V group), and 10 piglets received 0.4 U/kg of arg(8)-vasopressin, 1 min later followed by 20 µg/kg body weight of adrenaline, and another 1 min later continuous administration (10 µg/kg/min) of adrenaline (VA group). After 8 min of CPR, the piglets were defibrillated and monitored for another 3 h. Then they were killed and the brain immediately removed pending histological analysis. RESULTS During CPR, the VA group had higher mean blood pressure and cerebral cortical blood flow (CCBF) but similar coronary perfusion pressure. After restoration of spontaneous circulation there was no difference in the pressure variables, but CCBF tended to be (36% ± 16%) higher in the V group. Neuronal injury and signs of a disrupted blood-brain barrier (BBB) were greater, 20% ± 4% and 21% ± 4%, respectively, in the VA group. In a background study of repeated single doses of adrenaline every third minute after 5 min arrest but otherwise the same protocol, histological measurements showed even worse neural injury and disruption of the BBB. CONCLUSION Combined use of vasopressin and adrenaline caused greater signs of cerebral and cardiac injury than use of vasopressin alone during experimental cardiopulmonary resuscitation.
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Affiliation(s)
- Peter Halvorsen
- Department of Surgical Sciences/Anesthesiology and Intensive Care Medicine, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Hari Shanker Sharma
- Department of Surgical Sciences/Anesthesiology and Intensive Care Medicine, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Samar Basu
- Department of Public Health and Caring Sciences/Oxidative Stress and Inflammation, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Lars Wiklund
- Department of Surgical Sciences/Anesthesiology and Intensive Care Medicine, Uppsala University, SE-751 85 Uppsala, Sweden
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Abstract
PURPOSE OF REVIEW Whereas there is clear evidence for improved survival with cardiopulmonary resuscitation (CPR) and defibrillation during cardiac arrest management, there is today lacking evidence that any of the recommended and used drugs lead to any long-term benefit for the patients. In this review, we try to discuss our current view on why advanced life support (ALS) today can be performed without the use of drugs, and instead gain all focus on improving the tasks we know improve survival: CPR and defibrillation. RECENT FINDINGS Previous and recent cardiac arrest drug studies have been reviewed. These are mostly consisting of retrospective register data, some experimental data and a few new randomized trials. The alternative drug-free ALS concept is also discussed with relevant studies. SUMMARY There is currently no evidence to support any specific drugs during cardiac arrest. Good-quality CPR, early defibrillation and goal-directed postresuscitation care is more important. Healthcare systems should not prioritize implementation of unproven drugs before good quality of care can be documented. More drug studies are indeed required, and future research needs to incorporate better diagnostic tools to test more specific and tailored therapies that account for underlying causes and individual responsiveness.
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Sutton RM, Friess SH, Naim MY, Lampe JW, Bratinov G, Weiland TR, Garuccio M, Nadkarni VM, Becker LB, Berg RA. Patient-centric blood pressure-targeted cardiopulmonary resuscitation improves survival from cardiac arrest. Am J Respir Crit Care Med 2015; 190:1255-62. [PMID: 25321490 DOI: 10.1164/rccm.201407-1343oc] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Although current resuscitation guidelines are rescuer focused, the opportunity exists to develop patient-centered resuscitation strategies that optimize the hemodynamic response of the individual in the hopes to improve survival. OBJECTIVES To determine if titrating cardiopulmonary resuscitation (CPR) to blood pressure would improve 24-hour survival compared with traditional CPR in a porcine model of asphyxia-associated ventricular fibrillation (VF). METHODS After 7 minutes of asphyxia, followed by VF, 20 female 3-month-old swine randomly received either blood pressure-targeted care consisting of titration of compression depth to a systolic blood pressure of 100 mm Hg and vasopressors to a coronary perfusion pressure greater than 20 mm Hg (BP care); or optimal American Heart Association Guideline care consisting of depth of 51 mm with standard advanced cardiac life support epinephrine dosing (Guideline care). All animals received manual CPR for 10 minutes before first shock. Primary outcome was 24-hour survival. MEASUREMENTS AND MAIN RESULTS The 24-hour survival was higher in the BP care group (8 of 10) compared with Guideline care (0 of 10); P = 0.001. Coronary perfusion pressure was higher in the BP care group (point estimate +8.5 mm Hg; 95% confidence interval, 3.9-13.0 mm Hg; P < 0.01); however, depth was higher in Guideline care (point estimate +9.3 mm; 95% confidence interval, 6.0-12.5 mm; P < 0.01). Number of vasopressor doses before first shock was higher in the BP care group versus Guideline care (median, 3 [range, 0-3] vs. 2 [range, 2-2]; P = 0.003). CONCLUSIONS Blood pressure-targeted CPR improves 24-hour survival compared with optimal American Heart Association care in a porcine model of asphyxia-associated VF cardiac arrest.
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Affiliation(s)
- Robert M Sutton
- 1 Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, and
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Banh E, Wu WD, Rinehart J. Principles of pharmacologic hemodynamic management and closed-loop systems. Best Pract Res Clin Anaesthesiol 2014; 28:453-62. [PMID: 25480774 DOI: 10.1016/j.bpa.2014.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 08/25/2014] [Accepted: 08/29/2014] [Indexed: 01/30/2023]
Abstract
Every day, physicians in critical-care settings are challenged with the hemodynamic management of patients with severe cardiovascular derangements. There is a potential role for closed-loop (automated) systems to assist clinicians in managing these patients and growing interest in the possible applications. In this review, we discuss the basic principles of critical-care hemodynamic management and the closed-loop systems that have been developed to help in this setting.
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Affiliation(s)
- Esther Banh
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - Wei Der Wu
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, CA, USA.
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Does a resuscitation pharmacologic bundle of epinephrine, terlipressin, and corticosteroids improve outcome from asphyxial cardiac arrest? Pediatr Crit Care Med 2014; 15:573-4. [PMID: 25000425 DOI: 10.1097/pcc.0000000000000166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Adrenaline, terlipressin, and corticoids versus adrenaline in the treatment of experimental pediatric asphyxial cardiac arrest. Pediatr Crit Care Med 2014; 15:e280-7. [PMID: 24751789 DOI: 10.1097/pcc.0000000000000127] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze if treatment with adrenaline (epinephrine) plus terlipressin plus corticoids achieves higher return of spontaneous circulation than adrenaline in an experimental infant animal model of asphyxial cardiac arrest. DESIGN Prospective randomized animal study. SETTING Experimental department in a University Hospital. SUBJECTS Forty-nine piglets were studied. INTERVENTIONS Cardiac arrest was induced by at least 10 minutes of removal of mechanical ventilation and was followed by manual external chest compressions and mechanical ventilation. After 3 minutes of resuscitation, piglets that did not achieve return of spontaneous circulation were randomized to two groups: adrenaline 0.02 mg kg every 3 minutes (20 animals) and adrenaline 0.02 mg kg every 3 minutes plus terlipressin 20 μg kg every 6 minutes plus hydrocortisone 30 mg kg one dose (22 animals). Resuscitation was discontinued when return of spontaneous circulation was achieved or after 24 minutes. MEASUREMENT AND MAIN RESULTS Return of spontaneous circulation was achieved in 14 piglets (28.5%), 14.2% with only cardiac massage and ventilation. Return of spontaneous circulation was achieved in 25% of piglets treated with adrenaline and in 9.1% of those treated with adrenaline plus terlipressin plus hydrocortisone (p = 0.167). Return of spontaneous circulation was achieved in 45.4% of animals with pulseless electric activity, 20% with asystole, and 0% with ventricular fibrillation (p = 0.037). Shorter duration of cardiac arrest, higher mean blood pressure and EtCO2 and lower PaCO2 before resuscitation, and higher mean blood pressure during resuscitation were associated with higher return of spontaneous circulation. CONCLUSIONS Treatment with adrenaline plus terlipressin plus corticoids does not achieve higher return of spontaneous circulation than that with adrenaline in an infant animal model of asphyxial cardiac arrest.
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Layek A, Maitra S, Pal S, Bhattacharjee S, Baidya DK. Efficacy of vasopressin during cardio-pulmonary resuscitation in adult patients: a meta-analysis. Resuscitation 2014; 85:855-63. [PMID: 24704138 DOI: 10.1016/j.resuscitation.2014.03.303] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 02/03/2014] [Accepted: 03/07/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Experimental and animal studies suggested that vasopressin may have a favorable survival profile during CPR. This meta-analysis aimed to determine the efficacy of vasopressin in adult cardiac patients. METHODOLOGY Meta-analysis of randomized control trials (RCTs) comparing the efficacy of vasopressin containing regimen during CPR in adult cardiac arrest population with an epinephrine only regimen. RESULTS A total of 6120 patients from 10 RCTs were included in this meta-analysis. Vasopressin use during CPR has no beneficial impact in an unselected population in ROSC [OR 1.19, 95% CI 0.93, 1.52], survival to hospital discharge [OR 1.13, 95% CI 0.89, 1.43], survival to hospital admission [OR 1.12, 95% CI 0.99, 1.27] and favorable neurological outcome [OR 1.02, 95% CI 0.75, 1.38]. ROSC in "in-hospital" cardiac arrest setting [OR 2.20, 95% CI 1.08, 4.47] is higher patients receiving vasopressin. Subgroup analyses revealed equal or higher chance of ROSC [OR 2.15, 95% CI 1.00, 4.61], higher possibility of survival to hospital discharge [OR 2.39, 95% CI 1.34, 4.27] and favorable neurological outcome [OR 2.58, 95% CI 1.39, 4.79] when vasopressin was used as repeated boluses of 4-5 times titrating desired effects during CPR. CONCLUSION ROSC in "in-hospital" cardiac arrest patients is significantly better when vasopressin was used. A subgroup analysis of this meta-analysis found that ROSC, survival to hospital admission and discharge and favorable neurological outcome may be better when vasopressin was used as repeated boluses of 4-5 times titrated to desired effects; however, overall no beneficial effect was noted in unselected cardiac arrest population.
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Affiliation(s)
- Amitava Layek
- Department of Anaesthesiology, CNBC, New Delhi, India
| | - Souvik Maitra
- Department of Anaesthesiology & Intensive Care, All India Institute of Medical Sciences, New Delhi, India
| | - Sugata Pal
- Department of Anaesthesiology & Intensive Care, JPNATC, All India Institute of Medical Sciences, New Delhi, India
| | - Sulagna Bhattacharjee
- Department of Anaesthesiology & Intensive Care, All India Institute of Medical Sciences, New Delhi, India.
| | - Dalim K Baidya
- Department of Anaesthesiology & Intensive Care, CDER, All India Institute of Medical Sciences, New Delhi, India
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Ma C, Zhu Z, Wang X, Zhao G, Liu X, Li R. Vasopressin decreases neuronal apoptosis during cardiopulmonary resuscitation. Neural Regen Res 2014; 9:622-9. [PMID: 25206865 PMCID: PMC4146244 DOI: 10.4103/1673-5374.130107] [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] [Accepted: 01/10/2014] [Indexed: 11/04/2022] Open
Abstract
The American Heart Association and the European Resuscitation Council recently recommended that vasopressin can be used for cardiopulmonary resuscitation, instead of epinephrine. However, the guidelines do not discuss the effects of vasopressin during cerebral resuscitation. In this study, we intraperitoneally injected epinephrine and/or vasopressin during cardiopulmonary resuscitation in a rat model of asphyxial cardiac arrest. The results demonstrated that, compared with epinephrine alone, the pathological damage to nerve cells was lessened, and the levels of c-Jun N-terminal kinase and p38 expression were significantly decreased in the hippocampus after treatment with vasopressin alone or the vasopressin and epinephrine combination. No significant difference in resuscitation effects was detected between vasopressin alone and the vasopressin and epinephrine combination. These results suggest that vasopressin alone or the vasopressin and epinephrine combination suppress the activation of mitogen-activated protein kinase and c-Jun N-terminal kinase signaling pathways and reduce neuronal apoptosis during cardiopulmonary resuscitation.
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Affiliation(s)
- Chi Ma
- Department of Neurosurgery, the First Hospital, Jilin University, Changchun, Jilin Province, China
| | - Zhe Zhu
- Center for Hand and Foot Surgery and Reparative and Reconstructive Surgery, Orthopedics Hospital, the Second Hospital, Jilin University, Changchun, Jilin Province, China
| | - Xu Wang
- Department of Neurology, the First Hospital, Jilin University, Changchun, Jilin Province, China
| | - Gang Zhao
- Department of Neurosurgery, the First Hospital, Jilin University, Changchun, Jilin Province, China
| | - Xiaoliang Liu
- Emergency Medicine, the First Hospital, Jilin University, Changchun, Jilin Province, China
| | - Rui Li
- Center for Hand and Foot Surgery and Reparative and Reconstructive Surgery, Orthopedics Hospital, the Second Hospital, Jilin University, Changchun, Jilin Province, China
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Goal-directed advanced cardiac life support: coronary perfusion pressure as a target during resuscitation. Crit Care Med 2014; 41:2817-8. [PMID: 24275391 DOI: 10.1097/ccm.0b013e31829cb381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hemodynamic directed cardiopulmonary resuscitation improves short-term survival from ventricular fibrillation cardiac arrest. Crit Care Med 2014; 41:2698-704. [PMID: 23887237 DOI: 10.1097/ccm.0b013e318298ad6b] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES During cardiopulmonary resuscitation, adequate coronary perfusion pressure is essential for establishing return of spontaneous circulation. Current American Heart Association guidelines recommend standardized interval administration of epinephrine for patients in cardiac arrest. The objective of this study was to compare short-term survival using a hemodynamic directed resuscitation strategy versus chest compression depth-directed cardiopulmonary resuscitation in a porcine model of cardiac arrest. DESIGN Randomized interventional study. SETTING Preclinical animal laboratory. SUBJECTS Twenty-four 3-month-old female swine. INTERVENTIONS After 7 minutes of ventricular fibrillation, pigs were randomized to receive one of three resuscitation strategies: 1) Hemodynamic directed care (coronary perfusion pressure-20): chest compressions with depth titrated to a target systolic blood pressure of 100 mm Hg and titration of vasopressors to maintain coronary perfusion pressure greater than 20 mm Hg; 2) Depth 33 mm: target chest compression depth of 33 mm with standard American Heart Association epinephrine dosing; or 3) Depth 51 mm: target chest compression depth of 51 mm with standard American Heart Association epinephrine dosing. All animals received manual cardiopulmonary resuscitation guided by audiovisual feedback for 10 minutes before first shock. MEASUREMENTS AND MAIN RESULTS Forty-five-minute survival was higher in the coronary perfusion pressure-20 group (8 of 8) compared to depth 33 mm (1 of 8) or depth 51 mm (3 of 8) groups; p equals to 0.002. Coronary perfusion pressures were higher in the coronary perfusion pressure-20 group compared to depth 33 mm (p = 0.004) and depth 51 mm (p = 0.006) and in survivors compared to nonsurvivors (p < 0.01). Total epinephrine dosing and defibrillation attempts were not different. CONCLUSIONS Hemodynamic directed resuscitation targeting coronary perfusion pressures greater than 20 mm Hg during 10 minutes of cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest improves short-term survival, when compared to resuscitation with depth of compressions guided to 33 mm or 51 mm and standard American Heart Association vasopressor dosing.
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