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Trends Over Time in Drug Administration During Adult In-Hospital Cardiac Arrest.

ABSTRACT: OBJECTIVES:Clinical providers have access to a number of pharmacologic agents during in-hospital cardiac arrest. Few studies have explored medication administration patterns during in-hospital cardiac arrest. Herein, we examine trends in use of pharmacologic interventions during in-hospital cardiac arrest both over time and with respect to the American Heart Association Advanced Cardiac Life Support guideline updates. DESIGN:Observational cohort study. SETTING:Hospitals contributing data to the American Heart Association Get With The Guidelines-Resuscitation database between 2001 and 2016. PATIENTS:Adult in-hospital cardiac arrest patients. INTERVENTIONS:The percentage of patients receiving epinephrine, vasopressin, amiodarone, lidocaine, atropine, bicarbonate, calcium, magnesium, and dextrose each year were calculated in patients with shockable and nonshockable initial rhythms. Hierarchical multivariable logistic regression was used to determine the annual adjusted odds of medication administration. An interrupted time series analysis was performed to assess change in atropine use after the 2010 American Heart Association guideline update. MEASUREMENTS AND MAIN RESULTS:A total of 268,031 index in-hospital cardiac arrests were included. As compared to 2001, the adjusted odds ratio of receiving each medication in 2016 were epinephrine (adjusted odds ratio, 1.5; 95% CI, 1.3-1.8), vasopressin (adjusted odds ratio, 1.5; 95% CI, 1.1-2.1), amiodarone (adjusted odds ratio, 3.4; 95% CI, 2.9-4.0), lidocaine (adjusted odds ratio, 0.2; 95% CI, 0.2-0.2), atropine (adjusted odds ratio, 0.07; 95% CI, 0.06-0.08), bicarbonate (adjusted odds ratio, 2.0; 95% CI, 1.8-2.3), calcium (adjusted odds ratio, 2.0; 95% CI, 1.7-2.3), magnesium (adjusted odds ratio, 2.2; 95% CI, 1.9-2.7; p < 0.0001), and dextrose (adjusted odds ratio, 2.8; 95% CI, 2.3-3.4). Following the 2010 American Heart Association guideline update, there was a downward step change in the intercept and slope change in atropine use (p < 0.0001). CONCLUSIONS:Prescribing patterns during in-hospital cardiac arrest have changed significantly over time. Changes to American Heart Association Advanced Cardiac Life Support guidelines have had a rapid and substantial effect on the use of a number of commonly used in-hospital cardiac arrest medications.

SUBMITTER: Moskowitz A

PROVIDER: S-EPMC6336500 | biostudies-literature | 2019 Feb

REPOSITORIES: biostudies-literature

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Trends Over Time in Drug Administration During Adult In-Hospital Cardiac Arrest.

Moskowitz Ari A Ross Catherine E CE Andersen Lars W LW Grossestreuer Anne V AV Berg Katherine M KM Donnino Michael W MW

Critical care medicine 20190201 2

<h4>Objectives</h4>Clinical providers have access to a number of pharmacologic agents during in-hospital cardiac arrest. Few studies have explored medication administration patterns during in-hospital cardiac arrest. Herein, we examine trends in use of pharmacologic interventions during in-hospital cardiac arrest both over time and with respect to the American Heart Association Advanced Cardiac Life Support guideline updates.<h4>Design</h4>Observational cohort study.<h4>Setting</h4>Hospitals con ...[more]

PMID: 30407950

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Project description:Importance:Tracheal intubation is common during adult in-hospital cardiac arrest, but little is known about the association between tracheal intubation and survival in this setting. Objective:To determine whether tracheal intubation during adult in-hospital cardiac arrest is associated with survival to hospital discharge. Design, Setting, and Participants:Observational cohort study of adult patients who had an in-hospital cardiac arrest from January 2000 through December 2014 included in the Get With The Guidelines-Resuscitation registry, a US-based multicenter registry of in-hospital cardiac arrest. Patients who had an invasive airway in place at the time of cardiac arrest were excluded. Patients intubated at any given minute (from 0-15 minutes) were matched with patients at risk of being intubated within the same minute (ie, still receiving resuscitation) based on a time-dependent propensity score calculated from multiple patient, event, and hospital characteristics. Exposure:Tracheal intubation during cardiac arrest. Main Outcomes and Measures:The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and a good functional outcome. A cerebral performance category score of 1 (mild or no neurological deficit) or 2 (moderate cerebral disability) was considered a good functional outcome. Results:The propensity-matched cohort was selected from 108?079 adult patients at 668 hospitals. The median age was 69 years (interquartile range, 58-79 years), 45?073 patients (42%) were female, and 24?256 patients (22.4%) survived to hospital discharge. Of 71?615 patients (66.3%) who were intubated within the first 15 minutes, 43?314 (60.5%) were matched to a patient not intubated in the same minute. Survival was lower among patients who were intubated compared with those not intubated: 7052 of 43?314 (16.3%) vs 8407 of 43?314 (19.4%), respectively (risk ratio [RR]?=?0.84; 95% CI, 0.81-0.87; P?<?.001). The proportion of patients with ROSC was lower among intubated patients than those not intubated: 25?022 of 43?311 (57.8%) vs 25?685 of 43?310 (59.3%), respectively (RR?=?0.97; 95% CI, 0.96-0.99; P?<?.001). Good functional outcome was also lower among intubated patients than those not intubated: 4439 of 41?868 (10.6%) vs 5672 of 41?733 (13.6%), respectively (RR?=?0.78; 95% CI, 0.75-0.81; P?<?.001). Although differences existed in prespecified subgroup analyses, intubation was not associated with improved outcomes in any subgroup. Conclusions and Relevance:Among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding by indication, these findings do not support early tracheal intubation for adult in-hospital cardiac arrest.

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.

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Trends Over Time in Drug Administration During Adult In-Hospital Cardiac Arrest.

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Trends Over Time in Drug Administration During Adult In-Hospital Cardiac Arrest.

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