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Association Between Prompt Defibrillation and Epinephrine Treatment With Long-Term Survival After In-Hospital Cardiac Arrest.

ABSTRACT: BACKGROUND:Prior studies have reported higher in-hospital survival with prompt defibrillation and epinephrine treatment in patients with in-hospital cardiac arrest (IHCA). Whether this survival benefit persists after discharge is unknown. METHODS:We linked data from a national IHCA registry with Medicare files and identified 36?961 patients ?65 years of age with an IHCA at 517 hospitals between 2000 and 2011. Patients with IHCA caused by pulseless ventricular tachycardia or ventricular fibrillation were stratified by prompt (?2 minutes) versus delayed (>2 minutes) defibrillation, whereas patients with IHCA caused by asystole or pulseless electric activity were stratified by prompt (?5 minutes) versus delayed (>5 minutes) epinephrine treatment. The association between prompt treatment and long-term survival for each rhythm type was assessed with multivariable hierarchical modified Poisson regression models. RESULTS:Of 8119 patients with an IHCA caused by ventricular tachycardia or ventricular fibrillation, the rate of 1-year survival was higher in those treated with prompt defibrillation than with delayed defibrillation (25.7% [1466 of 5714] versus 15.5% [373 of 2405]; adjusted relative risk [RR], 1.49; 95% confidence interval [CI] 1.32-1.69; P<0.0001). This survival advantage persisted at 3 years (19.1% versus 11.0%; adjusted RR, 1.45; 95% CI, 1.23-1.69; P<0.0001) and at 5 years (14.7% versus 7.9%; adjusted RR, 1.50; 95% CI, 1.22-1.83; P<0.0001). Of 28?842 patients with an IHCA caused by asystole/pulseless electric activity, the rate of 1-year survival with prompt epinephrine treatment was higher than with delayed treatment (5.4% [1341 of 24?885] versus 4.3% [168 of 3957]; adjusted RR, 1.20; 95% CI, 1.02-1.41; P=0.02), but this survival benefit was no longer present at 3 years (3.5% versus 2.9%; adjusted RR, 1.17; 95% CI, 0.95-1.45; P=0.15) and at 5 years (2.3% versus 1.9%; adjusted RR, 1.18; 95% CI, 0.88-1.58; P=0.27). CONCLUSIONS:Prompt defibrillation for IHCA caused by ventricular tachycardia or ventricular fibrillation was associated with higher rates of long-term survival throughout 5 years of follow-up, whereas prompt epinephrine treatment for asystole/pulseless electric activity was associated with greater survival at 1 year but not at 3 or 5 years. By quantifying the greater survival associated with timely defibrillation and epinephrine administration, these findings provide important insights into the durability of survival benefits for 2 process-of-care measures in current resuscitation guidelines.

SUBMITTER: Patel KK

PROVIDER: S-EPMC5940568 | biostudies-literature | 2018 May

REPOSITORIES: biostudies-literature

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Association Between Prompt Defibrillation and Epinephrine Treatment With Long-Term Survival After In-Hospital Cardiac Arrest.

Patel Krishna K KK Spertus John A JA Khariton Yevgeniy Y Tang Yuanyuan Y Curtis Lesley H LH Chan Paul S PS

Circulation 20171226 19

<h4>Background</h4>Prior studies have reported higher in-hospital survival with prompt defibrillation and epinephrine treatment in patients with in-hospital cardiac arrest (IHCA). Whether this survival benefit persists after discharge is unknown.<h4>Methods</h4>We linked data from a national IHCA registry with Medicare files and identified 36 961 patients ≥65 years of age with an IHCA at 517 hospitals between 2000 and 2011. Patients with IHCA caused by pulseless ventricular tachycardia or ventri ...[more]

PMID: 29279412

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Project description:ObjectiveTo determine the use of epinephrine (adrenaline) before defibrillation for treatment of in-hospital cardiac arrest due to a ventricular arrhythmia and examine its association with patient survival.DesignPropensity matched analysis.Setting2000-18 data from 497 hospitals participating in the American Heart Association’s Get With The Guidelines-Resuscitation registry.ParticipantsAdults aged 18 and older with an index in-hospital cardiac arrest due to an initial shockable rhythm treated with defibrillation.InterventionsAdministration of epinephrine before first defibrillation.Main outcome measuresSurvival to discharge; favorable neurological survival, defined as survival to discharge with none, mild, or moderate neurological disability measured using cerebral performance category scores; and survival after acute resuscitation (that is, return of spontaneous circulation for >20 minutes). A time dependent, propensity matched analysis was performed to adjust for confounding due to indication and evaluate the independent association of epinephrine before defibrillation with study outcomes.ResultsAmong 34 820 patients with an initial shockable rhythm, 7054 (20.3%) were treated with epinephrine before defibrillation, contrary to current guidelines. In comparison with participants treated with defibrillation first, participants receiving epinephrine first were less likely to have a history of myocardial infarction or heart failure, but more likely to have renal failure, sepsis, respiratory insufficiency, and receive mechanical ventilation before in-hospital cardiac arrest (standardized differences >10% for all). Treatment with epinephrine before defibrillation was strongly associated with delayed defibrillation (median 4 minutes v 0 minutes). In propensity matched analysis (6569 matched pairs), epinephrine before defibrillation was associated with lower odds of survival to discharge (22.4% v 29.7%; adjusted odds ratio 0.69; 95% confidence interval 0.64 to 0.74; P<0.001), favorable neurological survival (15.8% v 21.6%; 0.68; 0.61 to 0.76; P<0.001) and survival after acute resuscitation (61.7% v 69.5%; 0.73; 0.67 to 0.79; P<0.001). The above findings were consistent in a range of sensitivity analyses, including matching according to defibrillation time.ConclusionsContrary to current guidelines that prioritize immediate defibrillation for in-hospital cardiac arrest due to a shockable rhythm, one in five patients are treated with epinephrine before defibrillation. Use of epinephrine before defibrillation was associated with worse survival outcomes.

Project description:ImportanceDelay in administration of the first epinephrine dose is associated with decreased survival among adults after in-hospital, nonshockable cardiac arrest. Whether this association is true in the pediatric in-hospital cardiac arrest population remains unknown.ObjectiveTo determine whether time to first epinephrine dose is associated with outcomes in pediatric in-hospital cardiac arrest.Design, setting and participantsWe performed an analysis of data from the Get With the Guidelines-Resuscitation registry. We included US pediatric patients (age <18 years) with an in-hospital cardiac arrest and an initial nonshockable rhythm who received at least 1 dose of epinephrine. A total of 1558 patients (median age, 9 months [interquartile range [IQR], 13 days-5 years]) were included in the final cohort.ExposureTime to epinephrine, defined as time in minutes from recognition of loss of pulse to the first dose of epinephrine.Main outcomes and measuresThe primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC), survival at 24 hours, and neurological outcome. A favorable neurological outcome was defined as a score of 1 to 2 on the Pediatric Cerebral Performance Category scale.ResultsAmong the 1558 patients, 487 (31.3%) survived to hospital discharge. The median time to first epinephrine dose was 1 minute (IQR, 0-4; range, 0-20; mean [SD], 2.6 [3.4] minutes). Longer time to epinephrine administration was associated with lower risk of survival to discharge in multivariable analysis (multivariable-adjusted risk ratio [RR] per minute delay, 0.95 [95% CI, 0.93-0.98]). Longer time to epinephrine administration was also associated with decreased risk of ROSC (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.96-0.99]), decreased risk of survival at 24 hours (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.95-0.99]), and decreased risk of survival with favorable neurological outcome (multivariable-adjusted RR per minute delay, 0.95 [95% CI, 0.91-0.99]). Patients with time to epinephrine administration of longer than 5 minutes (233/1558) compared with those with time to epinephrine of 5 minutes or less (1325/1558) had lower risk of in-hospital survival to discharge (21.0% [49/233] vs 33.1% [438/1325]; multivariable-adjusted RR, 0.75 [95% CI, 0.60-0.93]; P = .01).Conclusions and relevanceAmong children with in-hospital cardiac arrest with an initial nonshockable rhythm who received epinephrine, delay in administration of epinephrine was associated with decreased chance of survival to hospital discharge, ROSC, 24-hour survival, and survival to hospital discharge with a favorable neurological outcome.

Project description:Each year, 200,000 patients undergo an in-hospital cardiac arrest (IHCA), with approximately 15-20% surviving to discharge. Little is known, however, about the long-term prognosis of these patients after discharge. Previous efforts to describe out-of-hospital survival of IHCA patients have been limited by small sample sizes and narrow patient populationsA single institution matched cohort study was undertaken to describe mortality following IHCA. Patients surviving to discharge following an IHCA between 2008 and 2010 were matched on age, sex, race and hospital admission criteria with non-IHCA hospital controls and follow-up between 9 and 45 months. Kaplan-Meier curves and Cox PH models assessed differences in survival.Of the 1262 IHCAs, 20% survived to hospital discharge. Of those discharged, survival at 1 year post-discharge was 59% for IHCA patients and 82% for controls (p<0.0001). Hazard ratios (IHCA vs. controls) for mortality were greatest within the 90 days following discharge (HR=2.90, p<0.0001) and decreased linearly thereafter, with those surviving to one year post-discharge having an HR for mortality below 1.0. Survival after discharge varied amongst IHCA survivors. When grouped by discharge destination, out of hospital survival varied; in fact, IHCA patients discharged home without services demonstrated no survival difference compared to their non-IHCA controls (HR 1.10, p=0.72). IHCA patients discharged to long-term hospital care or hospice, however, had a significantly higher mortality compared to matched controls (HR 3.91 and 20.3, respectively; p<0.0001).Among IHCA patients who survive to hospital discharge, the highest risk of death is within the first 90 days after discharge. Additionally, IHCA survivors overall have increased long-term mortality vs.Survival rates were varied widely with different discharge destinations, and those discharged to home, skilled nursing facilities or to rehabilitation services had survival rates no different than controls. Thus, increased mortality was primarily driven by patients discharged to long-term care or hospice.

Project description:ImportanceDelayed defibrillation (>2 minutes) in adult in-hospital cardiac arrest (IHCA) is associated with worse outcomes. Little is known about the timing and outcomes of defibrillation in pediatric IHCA.ObjectiveTo determine whether time to first defibrillation attempt in pediatric IHCA with a first documented shockable rhythm is associated with survival to hospital discharge.Design, setting, and participantsIn this cohort study, data were obtained from the Get With The Guidelines-Resuscitation national registry between January 1, 2000, and December 31, 2015, and analyses were completed by October 1, 2017. Participants were pediatric patients younger than 18 years with an IHCA and a first documented rhythm of pulseless ventricular tachycardia or ventricular fibrillation and at least 1 defibrillation attempt.ExposuresTime between loss of pulse and first defibrillation attempt.Main outcomes and measuresThe primary outcome was survival to hospital discharge. Secondary outcomes were return of circulation, 24-hour survival, and favorable neurologic outcome at hospital discharge.ResultsAmong 477 patients with a pulseless shockable rhythm (median [interquartile range] age, 4 years [3 months to 14 years]; 285 [60%] male), 338 (71%) had a first defibrillation attempt at 2 minutes or less after pulselessness. Children were less likely to be shocked in 2 minutes or less for ward vs intensive care unit IHCAs (48% [11 of 23] vs 72% [268 of 371]; P = .01]). Thirty-eight percent (179 patients) survived to hospital discharge. The median (interquartile range) reported time to first defibrillation attempt was 1 minute (0-3 minutes) in both survivors and nonsurvivors. Time to first defibrillation attempt was not associated with survival in unadjusted analysis (risk ratio [RR] per minute increase, 0.96; 95% CI, 0.92-1.01; P = .15) or adjusted analysis (RR, 0.99; 95% CI, 0.94-1.06; P = .86). There was no difference in survival between those with a first defibrillation attempt in 2 minutes or less vs more than 2 minutes in unadjusted analysis (132 of 338 [39%] vs 47 of 139 [34%]; RR, 0.87; 95% CI, 0.66-1.13; P = .29) or multivariable analysis (RR, 0.99; 95% CI, 0.75-1.30; P = .93). Time to first defibrillation attempt was also not associated with secondary outcome measures.Conclusions and relevanceIn contrast to published adult IHCA and pediatric out-of-hospital cardiac arrest data, no significant association was observed between time to first defibrillation attempt in pediatric IHCA with a first documented shockable rhythm and survival to hospital discharge.

Project description:For patients with in-hospital cardiac arrests attributable to nonshockable rhythms, delays in epinephrine administration beyond 5 minutes is associated with worse survival. However, the extent of hospital variation in delayed epinephrine administration and its effect on hospital-level outcomes is unknown.Within Get With The Guidelines-Resuscitation, we identified 103?932 adult patients (?18 years) at 548 hospitals with an in-hospital cardiac arrest attributable to a nonshockable rhythm who received at least 1 dose of epinephrine between 2000 and 2014. We constructed 2-level hierarchical regression models to quantify hospital variation in rates of delayed epinephrine administration (>5 minutes) and its association with hospital rates of survival to discharge and survival with functional recovery.Overall, 13?213 (12.7%) patients had delays to epinephrine, and this rate varied markedly across hospitals (range, 0%-53.8%). The odds of delay in epinephrine administration were 58% higher at 1 randomly selected hospital in comparison with a similar patient at another randomly selected hospital (median odds ratio, 1.58; 95% confidence interval, 1.51-1.64). The median risk-standardized survival rate was 12.0% (range, 5.4%-31.9%), and the risk-standardized survival with functional recovery was 7.4% (range, 0.9%-30.8%). There was an inverse correlation between a hospital's rate of delayed epinephrine administration and its risk-standardized rate of survival to discharge (?=-0.22, P<0.0001) and survival with functional recovery (?=-0.14, P=0.001). In comparison with a median survival rate of 12.9% (interquartile range, 11.1%-15.4%) at hospitals in the lowest quartile of epinephrine delay, risk-standardized survival was 16% lower at hospitals in the quartile with the highest rate of epinephrine delays (10.8%; interquartile range, 9.7%-12.7%).Delays in epinephrine administration following in-hospital cardiac arrest are common and variy across hospitals. Hospitals with high rates of delayed epinephrine administration had lower rates of overall survival for in-hospital cardiac arrest attributable to nonshockable rhythm. Further studies are needed to determine whether improving hospital performance on time to epinephrine administration, especially at hospitals with poor performance on this metric, will lead to improved outcomes.

Project description:ImportanceData on long-term survival beyond 12 months after out-of-hospital cardiac arrest (OHCA) of a presumed cardiac cause are scarce.ObjectiveTo investigate the long-term survival of adult patients after surviving the initial hospital stay for an OHCA.Data sourcesA systematic search of the EMBASE and MEDLINE databases was performed from database inception to March 25, 2021.Study selectionClinical studies reporting long-term survival after OHCA were selected based on predefined inclusion and exclusion criteria according to a preregistered study protocol.Data extraction and synthesisPatient data were reconstructed from Kaplan-Meier curves using an iterative algorithm and then pooled to generate survival curves. As a separate analysis, an aggregate data meta-analysis was performed.Main outcomes and measuresThe primary outcome was long-term survival (>12 months) after OHCA for patients surviving to hospital discharge or 30 days after OHCA.ResultsThe search identified 15 347 reports, of which 21 studies (11 800 patients) were included in the Kaplan-Meier-based meta-analysis and 33 studies (16 933 patients) in an aggregate data meta-analysis. In the Kaplan-Meier-based analysis, the median survival time for patients surviving to hospital discharge was 5.0 years (IQR, 2.3-7.9 years). The estimated survival rates were 82.8% (95% CI, 81.9%-83.7%) at 3 years, 77.0% (95% CI, 75.9%-78.0%) at 5 years, 63.9% (95% CI, 62.3%-65.4%) at 10 years, and 57.5% (95% CI, 54.8%-60.1%) at 15 years. Compared with patients with a nonshockable initial rhythm, patients with a shockable rhythm had a lower risk of long-term mortality (hazard ratio, 0.30; 95% CI, 0.23-0.39; P < .001). Different analyses, including an aggregate data meta-analysis, confirmed these results.Conclusions and relevanceIn this comprehensive systematic review and meta-analysis, long-term survival after 10 years in patients surviving the initial hospital stay after OHCA was between 62% and 64%. Additional research is needed to understand and improve the long-term survival in this vulnerable patient population.

Project description:ImportanceAdministration of epinephrine has been found to be associated with an increased chance of survival after out-of-hospital cardiac arrest (OHCA), but the optimal timing of administration has not been fully investigated.ObjectiveTo ascertain whether there is an association between timing of epinephrine administration and patient outcomes after OHCA.Design, setting, and participantsThis cohort study included adults 18 years or older with OHCA treated by emergency medical services (EMS) personnel from April 1, 2011, to June 30, 2015. Initial cardiac rhythm was stratified as either initially shockable (ventricular defibrillation or pulseless ventricular tachycardia) or nonshockable (pulseless electrical activity or asystole). Eligible individuals were identified from among publicly available, deidentified patient-level data from the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registry, a prospective registry of adults with EMS-treated, nontraumatic OHCA with 10 sites in North America. Data analysis was conducted from May 2019 to April 2021.ExposuresInterval between advanced life support (ALS)-trained EMS personnel arrival at the scene and the first prehospital intravenous or intraosseous administration of epinephrine.Main outcomes and measuresThe primary outcome was survival to hospital discharge. In each cohort of initial cardiac rhythms, patients who received epinephrine at any period (minutes) after EMS arrival at the scene were matched with patients who were at risk of receiving epinephrine within the same period using time-dependent propensity scores calculated from patient demographic characteristics, arrest characteristics, and EMS interventions.ResultsOf 41 079 eligible individuals (median [interquartile range] age, 67 [55-79] years), 26 579 (64.7%) were men. A total of 10 088 individuals (24.6%) initially had shockable cardiac rhythms, and 30 991 (75.4%) had nonshockable rhythms. Those who received epinephrine included 8223 patients (81.5%) with shockable cardiac rhythms and 27 901 (90.0%) with nonshockable rhythms. In the shockable cardiac rhythm cohort, the risk ratio (RR) for receipt of epinephrine with survival to hospital discharge was highest between 0 and 5 minutes after EMS arrival (1.12; 95% CI, 0.99-1.26) across the categorized timing of the administration of epinephrine by 5-minute intervals after EMS arrival; however, that finding was not statistically significant. Treating the timing of epinephrine administration as a continuous variable, the RR for survival to hospital discharge decreased 5.5% (95% CI, 3.4%-7.5%; P < .001 for the interaction between epinephrine administration and time to matching) per minute after EMS arrival. In the nonshockable cardiac rhythm cohort, the RR for the association of receipt of epinephrine with survival to hospital discharge was the highest between 0 and 5 minutes (1.28; 95% CI, 0.95-1.72), although not statistically significant, and decreased 4.4% (95% CI, 0.8%-7.9%; P for interaction = .02) per minute after EMS arrival.Conclusions and relevanceAmong adults with OHCA, survival to hospital discharge differed across the timing of epinephrine administration and decreased with delayed administration for both shockable and nonshockable rhythms.

Dataset Information

Association Between Prompt Defibrillation and Epinephrine Treatment With Long-Term Survival After In-Hospital Cardiac Arrest.

Publications

Association Between Prompt Defibrillation and Epinephrine Treatment With Long-Term Survival After In-Hospital Cardiac Arrest.

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