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Bernard SA, Smith K, Finn J, Hein C, Grantham H, Bray JE, Deasy C, Stephenson M, Williams TA, Straney LD, Brink D, Larsen R, Cotton C, Cameron P. Induction of Therapeutic Hypothermia During Out-of-Hospital Cardiac Arrest Using a Rapid Infusion of Cold Saline: The RINSE Trial (Rapid Infusion of Cold Normal Saline). Circulation 2016; 134:797-805. [PMID: 27562972 DOI: 10.1161/circulationaha.116.021989] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 07/27/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients successfully resuscitated by paramedics from out-of-hospital cardiac arrest often have severe neurologic injury. Laboratory and observational clinical reports have suggested that induction of therapeutic hypothermia during cardiopulmonary resuscitation (CPR) may improve neurologic outcomes. One technique for induction of mild therapeutic hypothermia during CPR is a rapid infusion of large-volume cold crystalloid fluid. METHODS In this multicenter, randomized, controlled trial we assigned adults with out-of-hospital cardiac arrest undergoing CPR to either a rapid intravenous infusion of up to 2 L of cold saline or standard care. The primary outcome measure was survival at hospital discharge; secondary end points included return of a spontaneous circulation. The trial was closed early (at 48% recruitment target) due to changes in temperature management at major receiving hospitals. RESULTS A total of 1198 patients were assigned to either therapeutic hypothermia during CPR (618 patients) or standard prehospital care (580 patients). Patients allocated to therapeutic hypothermia received a mean (SD) of 1193 (647) mL cold saline. For patients with an initial shockable cardiac rhythm, there was a decrease in the rate of return of a spontaneous circulation in patients who received cold saline compared with standard care (41.2% compared with 50.6%, P=0.03). Overall 10.2% of patients allocated to therapeutic hypothermia during CPR were alive at hospital discharge compared with 11.4% who received standard care (P=0.71). CONCLUSIONS In adults with out-of-hospital cardiac arrest, induction of mild therapeutic hypothermia using a rapid infusion of large-volume, intravenous cold saline during CPR may decrease the rate of return of a spontaneous circulation in patients with an initial shockable rhythm and produced no trend toward improved outcomes at hospital discharge. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01173393.
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Affiliation(s)
- Stephen A Bernard
- From Ambulance Victoria, Doncaster, Victoria, Australia (S.A.B., K.S., M.S.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (S.A.B., K.S., J.F., J.E.B., C.D., M.S., L.D.S., P.C.); Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia (J.F., J.E.B., T.A.W., D.B.); St. John Ambulance Western Australia, Perth, Western Australia, Australia (J.F., D.B.); SA Ambulance Service, Adelaide, South Australia, Australia (C.H., H.G., R.L., C.C.); Paramedic Unit, Flinders University, Adelaide, South Australia, Australia (C.H., H.G.); and Cork University Hospital, Wilton, Cork, Ireland (C.D.).
| | - Karen Smith
- From Ambulance Victoria, Doncaster, Victoria, Australia (S.A.B., K.S., M.S.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (S.A.B., K.S., J.F., J.E.B., C.D., M.S., L.D.S., P.C.); Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia (J.F., J.E.B., T.A.W., D.B.); St. John Ambulance Western Australia, Perth, Western Australia, Australia (J.F., D.B.); SA Ambulance Service, Adelaide, South Australia, Australia (C.H., H.G., R.L., C.C.); Paramedic Unit, Flinders University, Adelaide, South Australia, Australia (C.H., H.G.); and Cork University Hospital, Wilton, Cork, Ireland (C.D.)
| | - Judith Finn
- From Ambulance Victoria, Doncaster, Victoria, Australia (S.A.B., K.S., M.S.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (S.A.B., K.S., J.F., J.E.B., C.D., M.S., L.D.S., P.C.); Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia (J.F., J.E.B., T.A.W., D.B.); St. John Ambulance Western Australia, Perth, Western Australia, Australia (J.F., D.B.); SA Ambulance Service, Adelaide, South Australia, Australia (C.H., H.G., R.L., C.C.); Paramedic Unit, Flinders University, Adelaide, South Australia, Australia (C.H., H.G.); and Cork University Hospital, Wilton, Cork, Ireland (C.D.)
| | - Cindy Hein
- From Ambulance Victoria, Doncaster, Victoria, Australia (S.A.B., K.S., M.S.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (S.A.B., K.S., J.F., J.E.B., C.D., M.S., L.D.S., P.C.); Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia (J.F., J.E.B., T.A.W., D.B.); St. John Ambulance Western Australia, Perth, Western Australia, Australia (J.F., D.B.); SA Ambulance Service, Adelaide, South Australia, Australia (C.H., H.G., R.L., C.C.); Paramedic Unit, Flinders University, Adelaide, South Australia, Australia (C.H., H.G.); and Cork University Hospital, Wilton, Cork, Ireland (C.D.)
| | - Hugh Grantham
- From Ambulance Victoria, Doncaster, Victoria, Australia (S.A.B., K.S., M.S.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (S.A.B., K.S., J.F., J.E.B., C.D., M.S., L.D.S., P.C.); Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia (J.F., J.E.B., T.A.W., D.B.); St. John Ambulance Western Australia, Perth, Western Australia, Australia (J.F., D.B.); SA Ambulance Service, Adelaide, South Australia, Australia (C.H., H.G., R.L., C.C.); Paramedic Unit, Flinders University, Adelaide, South Australia, Australia (C.H., H.G.); and Cork University Hospital, Wilton, Cork, Ireland (C.D.)
| | - Janet E Bray
- From Ambulance Victoria, Doncaster, Victoria, Australia (S.A.B., K.S., M.S.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (S.A.B., K.S., J.F., J.E.B., C.D., M.S., L.D.S., P.C.); Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia (J.F., J.E.B., T.A.W., D.B.); St. John Ambulance Western Australia, Perth, Western Australia, Australia (J.F., D.B.); SA Ambulance Service, Adelaide, South Australia, Australia (C.H., H.G., R.L., C.C.); Paramedic Unit, Flinders University, Adelaide, South Australia, Australia (C.H., H.G.); and Cork University Hospital, Wilton, Cork, Ireland (C.D.)
| | - Conor Deasy
- From Ambulance Victoria, Doncaster, Victoria, Australia (S.A.B., K.S., M.S.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (S.A.B., K.S., J.F., J.E.B., C.D., M.S., L.D.S., P.C.); Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia (J.F., J.E.B., T.A.W., D.B.); St. John Ambulance Western Australia, Perth, Western Australia, Australia (J.F., D.B.); SA Ambulance Service, Adelaide, South Australia, Australia (C.H., H.G., R.L., C.C.); Paramedic Unit, Flinders University, Adelaide, South Australia, Australia (C.H., H.G.); and Cork University Hospital, Wilton, Cork, Ireland (C.D.)
| | - Michael Stephenson
- From Ambulance Victoria, Doncaster, Victoria, Australia (S.A.B., K.S., M.S.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (S.A.B., K.S., J.F., J.E.B., C.D., M.S., L.D.S., P.C.); Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia (J.F., J.E.B., T.A.W., D.B.); St. John Ambulance Western Australia, Perth, Western Australia, Australia (J.F., D.B.); SA Ambulance Service, Adelaide, South Australia, Australia (C.H., H.G., R.L., C.C.); Paramedic Unit, Flinders University, Adelaide, South Australia, Australia (C.H., H.G.); and Cork University Hospital, Wilton, Cork, Ireland (C.D.)
| | - Teresa A Williams
- From Ambulance Victoria, Doncaster, Victoria, Australia (S.A.B., K.S., M.S.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (S.A.B., K.S., J.F., J.E.B., C.D., M.S., L.D.S., P.C.); Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia (J.F., J.E.B., T.A.W., D.B.); St. John Ambulance Western Australia, Perth, Western Australia, Australia (J.F., D.B.); SA Ambulance Service, Adelaide, South Australia, Australia (C.H., H.G., R.L., C.C.); Paramedic Unit, Flinders University, Adelaide, South Australia, Australia (C.H., H.G.); and Cork University Hospital, Wilton, Cork, Ireland (C.D.)
| | - Lahn D Straney
- From Ambulance Victoria, Doncaster, Victoria, Australia (S.A.B., K.S., M.S.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (S.A.B., K.S., J.F., J.E.B., C.D., M.S., L.D.S., P.C.); Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia (J.F., J.E.B., T.A.W., D.B.); St. John Ambulance Western Australia, Perth, Western Australia, Australia (J.F., D.B.); SA Ambulance Service, Adelaide, South Australia, Australia (C.H., H.G., R.L., C.C.); Paramedic Unit, Flinders University, Adelaide, South Australia, Australia (C.H., H.G.); and Cork University Hospital, Wilton, Cork, Ireland (C.D.)
| | - Deon Brink
- From Ambulance Victoria, Doncaster, Victoria, Australia (S.A.B., K.S., M.S.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (S.A.B., K.S., J.F., J.E.B., C.D., M.S., L.D.S., P.C.); Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia (J.F., J.E.B., T.A.W., D.B.); St. John Ambulance Western Australia, Perth, Western Australia, Australia (J.F., D.B.); SA Ambulance Service, Adelaide, South Australia, Australia (C.H., H.G., R.L., C.C.); Paramedic Unit, Flinders University, Adelaide, South Australia, Australia (C.H., H.G.); and Cork University Hospital, Wilton, Cork, Ireland (C.D.)
| | - Richard Larsen
- From Ambulance Victoria, Doncaster, Victoria, Australia (S.A.B., K.S., M.S.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (S.A.B., K.S., J.F., J.E.B., C.D., M.S., L.D.S., P.C.); Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia (J.F., J.E.B., T.A.W., D.B.); St. John Ambulance Western Australia, Perth, Western Australia, Australia (J.F., D.B.); SA Ambulance Service, Adelaide, South Australia, Australia (C.H., H.G., R.L., C.C.); Paramedic Unit, Flinders University, Adelaide, South Australia, Australia (C.H., H.G.); and Cork University Hospital, Wilton, Cork, Ireland (C.D.)
| | - Chris Cotton
- From Ambulance Victoria, Doncaster, Victoria, Australia (S.A.B., K.S., M.S.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (S.A.B., K.S., J.F., J.E.B., C.D., M.S., L.D.S., P.C.); Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia (J.F., J.E.B., T.A.W., D.B.); St. John Ambulance Western Australia, Perth, Western Australia, Australia (J.F., D.B.); SA Ambulance Service, Adelaide, South Australia, Australia (C.H., H.G., R.L., C.C.); Paramedic Unit, Flinders University, Adelaide, South Australia, Australia (C.H., H.G.); and Cork University Hospital, Wilton, Cork, Ireland (C.D.)
| | - Peter Cameron
- From Ambulance Victoria, Doncaster, Victoria, Australia (S.A.B., K.S., M.S.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (S.A.B., K.S., J.F., J.E.B., C.D., M.S., L.D.S., P.C.); Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia (J.F., J.E.B., T.A.W., D.B.); St. John Ambulance Western Australia, Perth, Western Australia, Australia (J.F., D.B.); SA Ambulance Service, Adelaide, South Australia, Australia (C.H., H.G., R.L., C.C.); Paramedic Unit, Flinders University, Adelaide, South Australia, Australia (C.H., H.G.); and Cork University Hospital, Wilton, Cork, Ireland (C.D.)
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