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Guideline removal of atropine and survival after adult in-hospital cardiac arrest with a non-shockable rhythm.

ABSTRACT: AIM:To determine whether the removal of atropine from the 2010 ACLS guidelines for non-shockable cardiac arrests was associated with a change in survival. METHODS:Using the Get With The Guidelines®-Resuscitation registry, we included adults with an index in-hospital cardiac arrest between 2006 and 2015. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and favorable functional outcome. An interrupted time-series analysis was used to compare survival before (pre-guidelines) and after (post-guidelines) introduction of the 2010 guidelines. A difference-in-difference approach was used to compare the interrupted time-series results between the non-shockable and shockable cohorts to account for guideline changes unrelated to atropine. RESULTS:We included 20,499 non-shockable and 3968 shockable cardiac arrests. Patient characteristics were similar between the pre-guidelines and post-guidelines period. Atropine was used for 8653 (87%) non-shockable and 680 (35%) shockable cardiac arrests in the pre-guidelines period and 3643 (35%) non-shockable and 320 (16%) shockable cardiac arrests in the post-guidelines period. The change over time in survival from the pre-guidelines to the post-guidelines period was not significantly different for the non-shockable compared to the shockable cohort (risk difference: 2.0% [95%CI: -0.8, 4.8] per year, p?=?0.17). The immediate change in survival after introducing the guidelines was also not different between the cohorts (risk difference: 3.5% [95%CI: -2.6, 9.7], p?=?0.26). Results were similar for the secondary outcomes and in multiple sensitivity analyses. CONCLUSIONS:The removal of atropine from the 2010 guidelines was not associated with a significant change in survival.

SUBMITTER: Holmberg MJ

PROVIDER: S-EPMC6467532 | biostudies-literature | 2019 Apr

REPOSITORIES: biostudies-literature

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Guideline removal of atropine and survival after adult in-hospital cardiac arrest with a non-shockable rhythm.

Holmberg Mathias J MJ Moskowitz Ari A Wiberg Sebastian S Grossestreuer Anne V AV Yankama Tuyen T Witten Lise L Perman Sarah M SM Donnino Michael W MW Andersen Lars W LW

Resuscitation 20190213

<h4>Aim</h4>To determine whether the removal of atropine from the 2010 ACLS guidelines for non-shockable cardiac arrests was associated with a change in survival.<h4>Methods</h4>Using the Get With The Guidelines<sup>®</sup>-Resuscitation registry, we included adults with an index in-hospital cardiac arrest between 2006 and 2015. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and favorable functional outcome. An interrupted ti ...[more]

PMID: 30771452

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Project description:Background and importanceBystander cardiopulmonary resuscitation (CPR) and initial shockable rhythm are crucial predictors of survival after out-of-hospital cardiac arrest (OHCA). However, the relationship between dispatcher-assisted CPR (DA-CPR) and initial shockable rhythm is not completely elucidated.ObjectiveTo examine the association of DA-CPR with initial shockable rhythm and outcomes.Design, setting and participantsThis nationwide population-based observational study conducted in Japan included 59 688 patients with witnessed OHCA of cardiac origin after excluding those without bystander CPR. Patients were divided into DA-CPR (n = 42 709) and CPR without dispatcher assistance (unassisted CPR, n = 16 979) groups.Outcome measures and analysisThe primary outcome measure was initial shockable rhythm, and secondary outcome measures were 1-month survival and neurologically intact survival. A Cox proportional hazards model adjusted for collapse-to-first-rhythm-analysis time and multivariable logistic regression models were used after propensity score (PS) matching to compare the incidence of initial shockable rhythm and outcomes, respectively.Main resultsAmong all patients (mean age 76.7 years), the rates of initial shockable rhythm, 1-month survival and neurologically intact survival were 20.8, 10.7 and 7.0%, respectively. The incidence of initial shockable rhythm in the DA-CPR group (20.4%, 3462/16 979) was significantly higher than that in the unassisted CPR group (18.5%, 3133/16 979) after PS matching (P < 0.0001). However, no significant differences were found between the two groups with respect to the incidence of initial shockable rhythm in the Cox proportional hazards model [adjusted hazard ratio of DA-CPR for initial shockable rhythm compared with unassisted CPR, 0.99; 95% confidence interval (CI), 0.97-1.02, P = 0.56]. No significant differences were observed in the survival rates in the two groups after PS matching [10.8% (1833/16 979) vs. 10.3% (1752/16 979), P = 0.16] and neurologically intact survival rates [7.3% (1233/16 979) vs. 6.8% (1161/16 979), P = 0.13]. The multivariable logistic regression model showed no significant differences between the groups with regard to survival (adjusted odds ratio of DA-CPR compared with unassisted CPR: 1.00; 95% CI, 0.89-1.13, P = 0.97) and neurologically intact survival (adjusted odds ratio: 1.12; 95% CI, 0.98-1.29, P = 0.14).ConclusionDA-CPR after OHCA had the same independent association with the likelihood of initial shockable rhythm and 1-month meaningful outcome as unassisted CPR.

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:ObjectivesTo evaluate whether patients who experience cardiac arrest in hospital receive epinephrine (adrenaline) within the two minutes after the first defibrillation (contrary to American Heart Association guidelines) and to evaluate the association between early administration of epinephrine and outcomes in this population.DesignProspective observational cohort study.SettingAnalysis of data from the Get With The Guidelines-Resuscitation registry, which includes data from more than 300 hospitals in the United States.ParticipantsAdults in hospital who experienced cardiac arrest with an initial shockable rhythm, including patients who had a first defibrillation within two minutes of the cardiac arrest and who remained in a shockable rhythm after defibrillation.InterventionEpinephrine given within two minutes after the first defibrillation.Main outcome measuresSurvival to hospital discharge. Secondary outcomes included return of spontaneous circulation and survival to hospital discharge with a good functional outcome. A propensity score was calculated for the receipt of epinephrine within two minutes after the first defibrillation, based on multiple characteristics of patients, events, and hospitals. Patients who received epinephrine at either zero, one, or two minutes after the first defibrillation were then matched on the propensity score with patients who were "at risk" of receiving epinephrine within the same minute but who did not receive it.Results2978 patients were matched on the propensity score, and the groups were well balanced. 1510 (51%) patients received epinephrine within two minutes after the first defibrillation, which is contrary to current American Heart Association guidelines. Epinephrine given within the first two minutes after the first defibrillation was associated with decreased odds of survival in the propensity score matched analysis (odds ratio 0.70, 95% confidence interval 0.59 to 0.82; P<0.001). Early epinephrine administration was also associated with a decreased odds of return of spontaneous circulation (0.71, 0.60 to 0.83; P<0.001) and good functional outcome (0.69, 0.58 to 0.83; P<0.001).ConclusionHalf of patients with a persistent shockable rhythm received epinephrine within two minutes after the first defibrillation, contrary to current American Heart Association guidelines. The receipt of epinephrine within two minutes after the first defibrillation was associated with decreased odds of survival to hospital discharge as well as decreased odds of return of spontaneous circulation and survival to hospital discharge with a good functional outcome.

Project description:Background Hospitals participating in the national Get With The Guidelines-Resuscitation registry receive an award for high rates of adherence to quality metrics for in-hospital cardiac arrest. We sought to evaluate whether awards based on these quality metrics can be considered a proxy for performance on cardiac arrest survival. Methods and Results Among 195 hospitals with continuous participation in Get With The Guidelines-Resuscitation between 2012 and 2015, we identified 78 that received an award (Gold or Silver) for ≥85% compliance for all 4 metrics for in-hospital cardiac arrest-time to chest compressions, ≤1 minute; time to defibrillation, ≤2 minutes; device confirmation of endotracheal tube placement; and a monitored/witnessed arrest-for at least 12 consecutive months during 2014 to 2015. Award hospitals had higher cardiac arrest volumes than nonaward hospitals but otherwise had similar site characteristics. During 2014 to 2015, award hospitals had higher rates of return of spontaneous circulation for in-hospital cardiac arrest than nonaward hospitals (median [interquartile range], 71% [64%-77%] versus 66% [59%-74%]; Spearman ρ, 0.19; P=0.009). However, rates of risk-standardized survival to discharge at award hospitals (median, 25% [interquartile range, 22%-30%]) were similar to nonaward hospitals (median, 24% [interquartile range, 12%-27%]; Spearman ρ, 0.13; P=0.06). Among hospitals in the best tertile for survival to discharge in 2014 to 2015, 55.4% (36/65) did not receive an award, with poor discrimination of high-performing hospitals by award status (C statistic, 0.53). Similarly, there was only a weak association between hospitals' award status in 2014 to 2015 and their rates of survival to discharge in the preceding 2-year period (Spearman ρ, 0.16; P=0.03). Conclusions The current recognition mechanism within a national registry for in-hospital cardiac arrest captures hospital performance on return of spontaneous circulation but is not well correlated with survival to discharge. This suggests that current awards for resuscitation quality may not adequately capture hospital performance on overall survival-the outcome of greatest interest to patients.

Dataset Information

Guideline removal of atropine and survival after adult in-hospital cardiac arrest with a non-shockable rhythm.

Publications

Guideline removal of atropine and survival after adult in-hospital cardiac arrest with a non-shockable rhythm.

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