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1.
Medicine (Baltimore) ; 98(45): e17502, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31702610

RESUMO

AIM: Our objective is to assess the effects of epinephrine for out of hospital cardiac arrest. BACKGROUND: Cardiac arrest was the most serious medical incidents with an estimated incidence in the United States of 95.7 per 100,000 person years. Though epinephrine improved coronary and cerebral perfusion, improving a return of spontaneous circulation, potentially harmful effects on the heart lead to greater myocardial oxygen demand. Concerns about the effect of epinephrine for out-of-hospital cardiac arrest were controversial and called for a higher argument to determine whether the effects of epinephrine is safe and effective for shor and long terms outcomes. METHOD: Searching databases consist of all kinds of searching tools, such as Medline, the Cochrane Library, Embase, PubMed, etc. All the included studies should meet our demand of this meta-analysis. In the all interest outcomes blow we take the full advantage of STATA to assess, the main measure is Risk Ratio (RR) with 95% confidence, the publication bias are assessed by Egger Test. RESULT: In current systematic review and meta-analysis of randomized trials investigating epinephrine for out of hospital cardiac arrest, we found that epinephrine was associated with a significantly higher likelihood of ROSC (RR = 3.05, I = 23.1%, P = .0001) and survival to hospital discharge (RR = 1.40, I = 36.3%, P = .008) compared with non-adrenaline administration. Conversely, epinephrine did not increase CPC 1 or 2 (RR = 1.15, I = 40.5%, P = .340) and hospital admission (RR = 2.07, I = 88.2%, P = .0001). CONCLUSION: In conclusion, in this systematic review and meta-analysis involving studies, the use of epinephrine resulted in a significantly higher likelihood of survival to hospital discharge and ROSC than the non-epinephrine administration, but, there was no significant between group difference in the rate of a favorable neurologic outcome.


Assuntos
Epinefrina/uso terapêutico , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Idoso , Epinefrina/efeitos adversos , Hospitalização , Humanos , Pessoa de Meia-Idade , Razão de Chances , Alta do Paciente , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
2.
Emerg Med J ; 36(9): 535-540, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31427472

RESUMO

OBJECTIVES: We set out to investigate paramedics' views of ethics and research, drawing on experiences from Paramedic-2, a randomised controlled trial comparing epinephrine and placebo in out-of-hospital cardiac arrest (OHCA). METHODS: An interpretative phenomenological approach was adopted. A purposive sample of paramedics (n=6) from North East Ambulance Service NHS Foundation Trust were invited to a semi-structured, in-depth interview. RESULTS: Three superordinate themes emerged: (1) morality, (2) emotion and (3) equipoise. Some viewed Paramedic-2 as an opportunity to improve OHCA outcomes for the many, viewing participation as a moral obligation; others viewed the study as unethical, equating participation with immoral behaviour. Morality was a motivator to drive individual action. Positive and negative emotions were exhibited by the paramedics involved reflecting the wider view each paramedic held about trial participation. Those morally driven to participate in Paramedic-2 discussed their pride in being associated with the trial, while those who found participation unethical, discussed feelings of guilt and regret. Individual experience and perceptions of epinephrine guided each paramedic's willingness to accept or reject equipoise. Some questioned the role of epinephrine in OHCA; others believed withholding epinephrine was synonymous to denying patient care. CONCLUSION: A paucity of evidence exists to support any beneficial role of epinephrine in OHCA. Despite this, some paramedics were reluctant to participate in Paramedic-2 and relied on their personal perceptions and experiences of epinephrine to guide their decision regarding participation. Failure to acknowledge the importance of individual perspectives may jeopardise the success of future out-of-hospital trials.


Assuntos
Atitude do Pessoal de Saúde , Ensaios Clínicos como Assunto/ética , Auxiliares de Emergência/psicologia , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Adulto , Ambulâncias/ética , Emoções , Epinefrina/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Princípios Morais , Seleção de Pacientes/ética , Placebos/administração & dosagem , Pesquisa Qualitativa , Recusa de Participação/ética , Recusa de Participação/psicologia , Ressuscitação/ética , Ressuscitação/métodos , Reino Unido
3.
Crit Care ; 23(1): 101, 2019 Mar 27.
Artigo em Inglês | MEDLINE | ID: mdl-30917838

RESUMO

BACKGROUND: The benefits of early epinephrine administration in pediatric with nontraumatic out-of-hospital cardiac arrest (OHCA) have been reported; however, the effects in pediatric cases of traumatic OHCA are unclear. Since the volume-related pharmacokinetics of early epinephrine may differ obviously with and without hemorrhagic shock (HS), beneficial or harmful effects of nonselective epinephrine stimulation (alpha and beta agonists) may also be enhanced with early administration. In this study, we aimed to analyze the therapeutic effect of early epinephrine administration in pediatric cases of HS and non-HS traumatic OHCA. METHODS: This was a multicenter retrospective study (2003-2014). Children (aged ≤ 19 years) who experienced traumatic OHCA and were administered epinephrine for resuscitation were included. Children were classified into the HS (blood loss > 30% of total body fluid) and non-HS groups. The demographics, outcomes, postresuscitation hemodynamics (the first hour) after the sustained return of spontaneous circulation (ROSC), and survival durations were analyzed and correlated with the time to epinephrine administration (early < 15, middle 15-30, late > 30 min) in the HS and non-HS groups. Cox regression analysis was used to adjust for risk factors of mortality. RESULTS: A total of 509 children were included. Most of them (n = 348, 68.4%) had HS OHCA. Early epinephrine administration was implemented in 131 (25.7%) children. In both the HS and non-HS groups, early epinephrine administration was associated with achieving sustained ROSC (both p < 0.05) but was not related to survival or good neurological outcomes (without adjusting for confounding factors). However, early epinephrine administration in the HS group increased cardiac output but induced metabolic acidosis and decreased urine output during the initial postresuscitation period (all p < 0.05). After adjusting for confounding factors, early epinephrine administration was a risk factor of mortality in the HS group (HR 4.52, 95% CI 2.73-15.91). CONCLUSION: Early epinephrine was significantly associated with achieving sustained ROSC in pediatric cases of HS and non-HS traumatic OHCA. For children with HS, early epinephrine administration was associated with both beneficial (increased cardiac output) and harmful effects (decreased urine output and metabolic acidosis) during the postresuscitation period. More importantly, early epinephrine was a risk factor associated with mortality in the HS group.


Assuntos
Epinefrina/farmacologia , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Fatores de Tempo , Adolescente , Criança , Pré-Escolar , Epinefrina/administração & dosagem , Epinefrina/uso terapêutico , Feminino , Humanos , Lactente , Masculino , Parada Cardíaca Extra-Hospitalar/etiologia , Fatores de Proteção , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Taiwan , Ferimentos e Lesões/complicações , Ferimentos e Lesões/tratamento farmacológico
4.
Intern Med ; 58(12): 1713-1721, 2019 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-30799340

RESUMO

Objective The updated guidelines of 2015 for cardiopulmonary resuscitation (CPR) do not recommend the routine use of atropine for cardiopulmonary arrest. Methods The study population included out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythm who were encountered at a Japanese community hospital between October 1, 2012 and April 30, 2017. Results At the outcome, the epinephrine with atropine and epinephrine-only groups had a similar survival rate to that at hospital admission (28.7% vs. 26.7%: p=0.723). The odds ratio (OR) for the survival to hospital admission after the administration of atropine with epinephrine was 1.33 (95% CI 1.09-1.62; p<0.01), while that after the administration of epinephrine was 0.64 (95% CI: 0.55-0.74, p<0.01). The ORs for the survival to hospital admission for patients with pulseless electrical activity in the epinephrine-alone group and the atropine with epinephrine group were 0.62 (95% CI 0.49-0.78; p<0.01) and 1.35 (95% CI 0.99-1.83; p=0.06), respectively, and those for such patients with asystole in the epinephrine-alone group and the atropine with epinephrine group were 0.64 (95% CI 0.53-0.76; p<0.01) and 1.39 (95% CI 1.10-1.77; p<0.01), respectively. The OR for the survival to hospital admission after the administration of atropine sulfate (1 mg) was 2.91 (95% CI 1.49-5.67; p<0.01), while that for the survival to hospital admission after the administration of 0, 2 and ≥3 mg atropine sulfate was 0.38 (95% CI 0.29-0.50; p<0.01), 1.54 (95% CI 0.58-4.08; p=0.38) and 0.23 (95% CI 0.09-0.60; p<0.01), respectively. Conclusion The addition of atropine (within 2 mg) following epinephrine was a comprehensive independent predictor of the survival to hospital admission for non-shockable (especially asystole) OHCA adults.


Assuntos
Atropina/uso terapêutico , Reanimação Cardiopulmonar/métodos , Serviços Médicos de Emergência/métodos , Epinefrina/uso terapêutico , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/terapia , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/etiologia , Atropina/administração & dosagem , Epinefrina/administração & dosagem , Feminino , Hospitais Comunitários , Humanos , Masculino , Razão de Chances , Parada Cardíaca Extra-Hospitalar/complicações , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Taxa de Sobrevida
5.
Cochrane Database Syst Rev ; 1: CD003179, 2019 01 17.
Artigo em Inglês | MEDLINE | ID: mdl-30653257

RESUMO

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.


Assuntos
Circulação Sanguínea/efeitos dos fármacos , Epinefrina/administração & dosagem , Parada Cardíaca/tratamento farmacológico , Admissão do Paciente/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Vasoconstritores/administração & dosagem , Vasopressinas/administração & dosagem , Adulto , Idoso , Circulação Sanguínea/fisiologia , Criança , Pré-Escolar , Coração/efeitos dos fármacos , Parada Cardíaca/mortalidade , Parada Cardíaca/fisiopatologia , Humanos , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Parada Cardíaca Extra-Hospitalar/mortalidade , Placebos/administração & dosagem , Ensaios Clínicos Controlados Aleatórios como Assunto , Análise de Sobrevida
6.
Am J Emerg Med ; 37(3): 387-390, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-29857945

RESUMO

BACKGROUND: Epinephrine is recommended for the treatment of non-shockable out of hospital cardiac arrest (OHCA) to obtain return of spontaneous circulation (ROSC). Epinephrine efficiency and safety remain under debate. OBJECTIVE: We propose to describe the association between the cumulative dose of epinephrine and the failure of ROSC during the first 30 min of advanced life support (ALS). METHODOLOGY: A retrospective observational cohort study using the Paris SAMU 75 registry including all non-traumatic OHCA. All OHCA receiving epinephrine during the first 30 min of ALS were enrolled. Cumulative epinephrine dose given during ALS to ROSC was retrieved from medical reports. RESULTS: Among 1532 patients with OHCA, 776 (51%) had initial non-shockable rhythm. Fifty-four patients were excluded for missing data. The mean value of cumulative dose of epinephrine was 10 ±â€¯4 mg in patients who failed to achieve ROSC (ROSC-) and 4 ±â€¯3 mg (p = 0.04) for those who achieved ROSC. ROC curve analysis indicated a cut-off point of 7 mg total cumulative epinephrine associated with ROSC- (AUC = 0.89 [0.86-0.92]). Using propensity score analysis including age, sex and no-flow duration, association with ROSC- only remained significant for epinephrine > 7 mg (p ≤10-3, OR [CI95] = 1.53 [1.42-1.65]). CONCLUSION: An association between total cumulative epinephrine dose administered during OHCA resuscitation and ROSC- was reported with a threshold of 7 mg, best identifying patients with refractory OHCA. We suggest using this threshold in this context to guide the termination of ALS and early decide on the implementation of extracorporeal life support or organ harvesting in the first 30 min of ALS.


Assuntos
Epinefrina/administração & dosagem , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Vasoconstritores/administração & dosagem , Idoso , Reanimação Cardiopulmonar , Relação Dose-Resposta a Droga , Cardioversão Elétrica , Serviços Médicos de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/classificação , Paris , Pontuação de Propensão , Sistema de Registros , Estudos Retrospectivos , Tempo para o Tratamento
7.
Ned Tijdschr Geneeskd ; 1622018 12 17.
Artigo em Holandês | MEDLINE | ID: mdl-30570933

RESUMO

Although epinephrine has been a cornerstone in resuscitation medicine for over 60 years, its use had never been thoroughly studied until recently, probably because the benefits of epinephrine seemed so obvious. The vasoconstriction of arterioles mediated by α-adrenergic receptors, leading to a higher coronary blood flow during chest compression, which in turn leads to a recovery of the spontaneous circulation, was reason enough for epinephrine to have been given its prominent role. A number of studies in the past 10 years, both randomized trials and large observational studies, have failed to show improved outcomes in patients with out-of-hospital cardiac arrest who had received epinephrine. The PARAMEDIC2 trial was published recently, with 4,015 patients receiving parenteral epinephrine and 3,999 receiving placebo. This study showed a survival benefit for epinephrine; however, there was no significant survival with good neurological outcome. The reasons for this may be related to a disturbed cerebral microcirculation and decreased blood flow in the carotid artery, and to epinephrine-mediated platelet activation, with an increased risk of thrombosis.


Assuntos
Reanimação Cardiopulmonar/métodos , Fármacos Cardiovasculares/uso terapêutico , Epinefrina/uso terapêutico , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Feminino , Humanos , Masculino , Estudos Observacionais como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto
8.
Circulation ; 138(23): e714-e730, 2018 12 04.
Artigo em Inglês | MEDLINE | ID: mdl-30571263

RESUMO

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the second annual summary of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations that includes the most recent cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation. This summary addresses the role of antiarrhythmic drugs in adults and children and includes the Advanced Life Support Task Force and Pediatric Task Force consensus statements, which summarize the most recent published evidence and an assessment of the quality of the evidence based on Grading of Recommendations, Assessment, Development, and Evaluation criteria. The statements include consensus treatment recommendations approved by members of the relevant task forces. Insights into the deliberations of each task force are provided in the Values and Preferences and Task Force Insights sections. Finally, the task force members have listed the top knowledge gaps for further research.


Assuntos
Reanimação Cardiopulmonar , Parada Cardíaca Extra-Hospitalar/terapia , Amiodarona/uso terapêutico , Antiarrítmicos/uso terapêutico , Consenso , Serviços Médicos de Emergência , Humanos , Lidocaína/uso terapêutico , Magnésio/uso terapêutico , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico
9.
Resuscitation ; 132: 63-72, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30179691

RESUMO

PURPOSE: The purpose of this systematic review is to provide up-to-date evidence on effectiveness of antiarrhythmic drugs for shockable cardiac arrest to help inform the 2018 International Liaison Committee on Resuscitation Consensus on Science with Treatment Recommendations. METHODS: A search was conducted in electronic databases Medline, Embase, and Cochrane Library from inception to August 15, 2017. RESULTS: Of the 9371 citations reviewed, a total of 14 RCTs and 17 observational studies met our inclusion criteria for adult population and only 1 observational study for pediatric population. Based on RCT level evidence for adult population, none of the anti-arrhythmic drugs showed any difference in effect compared with placebo, or with other anti-arrhythmic drugs for the critical outcomes of survival to hospital discharge and discharge with good neurological function. For the outcome of return of spontaneous circulation, the results showed a significant increase for lidocaine compared with placebo (RR = 1.16; 95% CI, 1.03-1.29, p = 0.01). CONCLUSION: The high level evidence supporting the use of antiarrhythmic drugs during CPR for shockable cardiac arrest is limited and showed no benefit for critical outcomes of survival at hospital discharge, survival with favorable neurological function and long-term survival. Future high quality research is needed to confirm these findings and also to evaluate the role of administering antiarrhythmic drugs in children with shockable cardiac arrest, and in adults immediately after ROSC.


Assuntos
Amiodarona/administração & dosagem , Antiarrítmicos/administração & dosagem , Reanimação Cardiopulmonar/métodos , Lidocaína/administração & dosagem , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Adulto , Criança , Feminino , Humanos , Masculino , Estudos Observacionais como Assunto , Parada Cardíaca Extra-Hospitalar/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
10.
Aerosp Med Hum Perform ; 89(8): 754-759, 2018 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-30020062

RESUMO

INTRODUCTION: Although cardiac arrest during airline flights is relatively uncommon, the unusual setting, limited resources, and the variability of the skills in medical volunteers present unique challenges. Survival in patients who suffer a witnessed arrest with a shockable rhythm who are treated promptly has improved since the advent of widely available automated external defibrillators (AEDs). In general, the chances of survival from an out-of-hospital cardiac arrest (OHCA) are greater when ventricular fibrillation (VF) is seen as the initial rhythm or if there is return of spontaneous circulation (ROSC). Not all in-flight cardiac arrests are witnessed because cabin crew or fellow passengers might simply assume that the victim is sleeping. Based upon a review of the literature on resuscitation after OHCA, we recommend that automatic external defibrillators be carried on all commercial airline flights, regardless of duration. Patients presenting with shockable rhythm (e.g., VF, unstable ventricular tachycardia) have the best prognosis for survival and usually require diversion of the aircraft for advanced cardiac life support (ACLS). Because diversion may require interruption of cardiopulmonary resuscitation (CPR) and may impact flight safety, the volunteer rescuer, cabin crew, flight crew, and medical consultation services should discuss the possible outcome and operational considerations before recommending a diversion for a patient with a nonshockable rhythm. The recommendations in this article were developed by members of the Air Transport Medicine and Aerospace Human Performance Committees and approved by the Council of the Aerospace Medical Association.Ruskin KJ, Ricaurte EM, Alves PM. Medical guidelines for airline travel: management of in-flight cardiac arrest. Aerosp Med Hum Perform. 2018; 89(8):754-759.


Assuntos
Parada Cardíaca Extra-Hospitalar/terapia , Viagem , Suporte Vital Cardíaco Avançado , Aeronaves , Antiarrítmicos/uso terapêutico , Reanimação Cardiopulmonar , Documentação , Cardioversão Elétrica , Epinefrina/uso terapêutico , Humanos , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Prognóstico , Respiração Artificial , Fibrilação Ventricular
11.
N Engl J Med ; 379(8): 711-721, 2018 Aug 23.
Artigo em Inglês | MEDLINE | ID: mdl-30021076

RESUMO

BACKGROUND: Concern about the use of epinephrine as a treatment for out-of-hospital cardiac arrest led the International Liaison Committee on Resuscitation to call for a placebo-controlled trial to determine whether the use of epinephrine is safe and effective in such patients. METHODS: In a randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest in the United Kingdom, paramedics at five National Health Service ambulance services administered either parenteral epinephrine (4015 patients) or saline placebo (3999 patients), along with standard care. The primary outcome was the rate of survival at 30 days. Secondary outcomes included the rate of survival until hospital discharge with a favorable neurologic outcome, as indicated by a score of 3 or less on the modified Rankin scale (which ranges from 0 [no symptoms] to 6 [death]). RESULTS: At 30 days, 130 patients (3.2%) in the epinephrine group and 94 (2.4%) in the placebo group were alive (unadjusted odds ratio for survival, 1.39; 95% confidence interval [CI], 1.06 to 1.82; P=0.02). There was no evidence of a significant difference in the proportion of patients who survived until hospital discharge with a favorable neurologic outcome (87 of 4007 patients [2.2%] vs. 74 of 3994 patients [1.9%]; unadjusted odds ratio, 1.18; 95% CI, 0.86 to 1.61). At the time of hospital discharge, severe neurologic impairment (a score of 4 or 5 on the modified Rankin scale) had occurred in more of the survivors in the epinephrine group than in the placebo group (39 of 126 patients [31.0%] vs. 16 of 90 patients [17.8%]). CONCLUSIONS: In adults with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group. (Funded by the U.K. National Institute for Health Research and others; Current Controlled Trials number, ISRCTN73485024 .).


Assuntos
Epinefrina/uso terapêutico , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Simpatomiméticos/uso terapêutico , Idoso , Reanimação Cardiopulmonar/métodos , Terapia Combinada , Método Duplo-Cego , Cardioversão Elétrica , Serviços Médicos de Emergência , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/etiologia , Parada Cardíaca Extra-Hospitalar/complicações , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/terapia , Taxa de Sobrevida , Tempo para o Tratamento , Reino Unido
13.
Circulation ; 137(19): 2032-2040, 2018 05 08.
Artigo em Inglês | MEDLINE | ID: mdl-29511001

RESUMO

BACKGROUND: Previous studies have demonstrated that earlier epinephrine administration is associated with improved survival from out-of-hospital cardiac arrest (OHCA) with shockable initial rhythms. However, the effect of epinephrine timing on patients with nonshockable initial rhythms is unclear. The objective of this study was to measure the association between time to epinephrine administration and survival in adults and children with emergency medical services (EMS)-treated OHCA with nonshockable initial rhythms. METHODS: We performed a secondary analysis of OHCAs prospectively identified by the Resuscitation Outcomes Consortium network from June 4, 2011, to June 30, 2015. We included patients of all ages with an EMS-treated OHCA and an initial nonshockable rhythm. We excluded those with return of spontaneous circulation in <10 minutes. We conducted a subgroup analysis involving patients <18 years of age. The primary exposure was time (minutes) from arrival of the first EMS agency to the first dose of epinephrine. Secondary exposure was time to epinephrine dichotomized as early (<10 minutes) or late (≥10 minutes). The primary outcome was survival to hospital discharge. We adjusted for Utstein covariates and Resuscitation Outcomes Consortium study site. RESULTS: From 55 568 EMS-treated OHCAs, 32 101 patients with initial nonshockable rhythms were included. There were 12 238 in the early group, 14 517 in the late group, and 5346 not treated with epinephrine. After adjusting for potential confounders, each minute from EMS arrival to epinephrine administration was associated with a 4% decrease in odds of survival for adults, odds ratio=0.96 (95% confidence interval, 0.95-0.98). A subgroup analysis (n=13 290) examining neurological outcomes showed a similar association (adjusted odds ratio, 0.94 per minute; 95% confidence interval, 0.89-0.98). When epinephrine was given late in comparison with early, odds of survival were 18% lower (odds ratio, 0.82; 95% confidence interval, 0.68-0.98). In a pediatric analysis (n=595), odds of survival were 9% lower (odds ratio, 0.91; 95% confidence interval, 0.81-1.01) for each minute delay in epinephrine. CONCLUSIONS: Among OHCAs with nonshockable initial rhythms, the majority of patients were administered epinephrine >10 minutes after EMS arrival. Each minute delay in epinephrine administration was associated with decreased survival and unfavorable neurological outcomes. EMS agencies should consider strategies to reduce epinephrine administration times in patients with initial nonshockable rhythms.


Assuntos
Agonistas Adrenérgicos/administração & dosagem , Serviços Médicos de Emergência , Epinefrina/administração & dosagem , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Tempo para o Tratamento , Adolescente , Agonistas Adrenérgicos/efeitos adversos , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Canadá , Criança , Pré-Escolar , Epinefrina/efeitos adversos , Feminino , Mortalidade Hospitalar , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/diagnóstico , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Recuperação de Função Fisiológica , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Adulto Jovem
14.
Am J Emerg Med ; 36(11): 1998-2004, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29534919

RESUMO

BACKGROUND: Sodium bicarbonate administration is mostly restricted to in-hospital use in Taiwan. This study was conducted to investigate the effect of sodium bicarbonate on outcomes among patients with out-of-hospital cardiac arrest (OHCA). METHODS: This population-based study used a 16-year database to analyze the association between sodium bicarbonate administration for resuscitation in the emergency department (ED) and outcomes. All adult patients with OHCA were identified through diagnostic and procedure codes. The primary outcome was survival to hospital admission and secondary outcome was the rate of death within the first 30days of incidence of cardiac arrest. Cox proportional-hazards regression, logistic regression, and propensity analyses were conducted. RESULTS: Among 5589 total OHCA patients, 15.1% (844) had survival to hospital admission. For all patients, a positive association was noted between sodium bicarbonate administration during resuscitation in the ED and survival to hospital admission (adjusted odds ratio [OR]: 4.47; 95% confidence interval [CI]: 3.82-5.22, p<0.001). In propensity-matched patients, a positive association was also noted (adjusted OR, 4.61; 95% CI: 3.90-5.46, p<0.001). CONCLUSIONS: Among patients with OHCA in Taiwan, administration of sodium bicarbonate during ED resuscitation was significantly associated with an increased rate of survival to hospital admission.


Assuntos
Reanimação Cardiopulmonar/métodos , Cardiotônicos/administração & dosagem , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Bicarbonato de Sódio/administração & dosagem , Adolescente , Adulto , Idoso , Serviço Hospitalar de Emergência , Tratamento de Emergência/métodos , Feminino , Humanos , Injeções , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/mortalidade , Estudos Retrospectivos , Taiwan , Resultado do Tratamento , Adulto Jovem
15.
Curr Opin Crit Care ; 24(3): 138-142, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29561289

RESUMO

PURPOSE OF REVIEW: The optimal antiarrhythmic drug therapy (amiodarone or lidocaine) in the treatment of ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) cardiac arrest that is refractory to defibrillation is uncertain. This article reviews the evidence for and against these drugs, alternatives treatments for refractory VF/pVT and aims to define the role of antiarrhythmic drugs during cardiopulmonary resuscitation (CPR). RECENT FINDINGS: A large randomized controlled trial that compared amiodarone, lidocaine and saline 0.9% sodium chloride for the treatment of refractory VF/pVT out-of-hospital cardiac arrest reported no difference in survival to hospital discharge or neurological outcome. In patients with witnessed arrest, survival was improved with antiarrhythmic drugs compared to saline. SUMMARY: The benefit of antiarrhythmic drugs appears to be for those patients in whom initial early CPR and defibrillation attempts fail and the antiarrhythmic drug is given early. There does not appear to be any clear survival benefit for any one particular drug and other factors such as availability and cost should be considered when deciding which drug to use. Furthermore, other interventions (e.g. percutaneous coronary intervention and extra-corporeal CPR) may provide additional survival benefit when defibrillation attempts and antiarrhythmic drugs are not effective.


Assuntos
Amiodarona/normas , Antiarrítmicos/normas , Arritmias Cardíacas/tratamento farmacológico , Reanimação Cardiopulmonar/normas , Lidocaína/normas , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Taquicardia Ventricular/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Amiodarona/uso terapêutico , Antiarrítmicos/uso terapêutico , Feminino , Humanos , Lidocaína/uso terapêutico , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Taxa de Sobrevida
16.
Resuscitation ; 125: 99-103, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29425976

RESUMO

BACKGROUND: Little is known about hemodynamics in adult, out-of-hospital (OHCA) patients following return of spontaneous circulation (ROSC). A 1994 study when "high-dose epinephrine" use was common showed consistently elevated systemic vascular resistance (SVR) lasting ≥6 h in 49 adult patients after return of spontaneous circulation (ROSC). STUDY AIM: To characterize hemodynamic abnormalities in adult OHCA patients soon after ROSC. Our hypothesis was that, unlike the consistently high SVR values reported when "high-dose" epinephrine was in common use, there would be a more heterogenous distribution of SVR values using current adrenergic therapy. METHODS: We included adult, OHCA patients transported by paramedics to the Emergency Department (ED) post-ROSC. Children, prisoners, pregnant women, and those with ongoing CPR or arrest due to traumatic injury were excluded. Hemodynamics were recorded non-invasively as soon as feasible after ED arrival but were not used to influence therapy, which was guided by clinical judgment of treating ED physicians. RESULTS: Hemodynamics were recorded on 30 patients 20 [16,25] minutes after ED arrival: 50% had a normal SVR, 30% had a high SVR, and 20% had a low SVR. There was no difference in survival to admission among groups, although there was a difference among groups in survival to discharge. Comparing the low SVR group vs the combined normal and high group revealed a trend for fewer 0/6 (0%) low vs. 10/24 (42%) normal or high SVR patients surviving to hospital discharge (p = .053). CONCLUSION: A heterogeneous range of hemodynamic states exist post-ROSC rather than consistent vasoconstriction. Adequately powered, randomized clinical trials will be needed to determine whether noninvasively-derived, hemodynamic-directed therapy can play a role in improving neurologically-intact survival following OHCA in adults.


Assuntos
Reanimação Cardiopulmonar/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Parada Cardíaca Extra-Hospitalar/mortalidade , Resistência Vascular , Reanimação Cardiopulmonar/métodos , Epinefrina/uso terapêutico , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Estudos Prospectivos , Fatores de Tempo , Tempo para o Tratamento , Vasoconstritores/uso terapêutico
17.
Resuscitation ; 124: 43-48, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29305926

RESUMO

BACKGROUND: International guidelines recommend administration of 1 mg of intravenous epinephrine every 3-5 min during cardiac arrest. The optimal dose of epinephrine is not known. We evaluated the association of reduced frequency and dose of epinephrine with survival after out-of-hospital cardiac arrest (OHCA). METHODS: Included were patients with non-traumatic OHCA treated by advanced life support (ALS) providers from January 1, 2008 to June 30, 2016. During the before period, providers were instructed to give epinephrine 1 mg intravenously at 4 min followed by additional 1 mg doses every eight minutes to patients with OHCA with a shockable rhythm and 1 mg doses every two minutes to patients with a non-shockable rhythm (higher dose). On October 1, 2012, providers were instructed to reduce the dose of epinephrine treatment during out-of-hospital cardiac arrest (OHCA): 0.5 mg at 4 and 8 min followed by additional doses of 0.5 mg every 8 min for shockable rhythms and 0.5 mg every 2 min for non-shockable rhythms (lower dose). Patients with shockable initial rhythms were analyzed separately from those with non-shockable initial rhythms. The primary outcome was survival to hospital discharge with a secondary outcome of favorable neurological status (Cerebral Performance Category [CPC] 1 or 2) at hospital discharge. Multiple logistic regression modeling was used to adjust for age, sex, presence of a witness, bystander CPR, and response interval. RESULTS: 2255 patients with OHCA were eligible for analysis. Of these, 24.6% had an initially shockable rhythm. Total epinephrine dose per patient decreased from a mean ±â€¯standard deviation of 3.4 ±â€¯2.3 mg-2.6 ±â€¯1.9 mg (p < 0.001) in the shockable group and 3.5 ±â€¯1.9 mg-2.8 ±â€¯1.7 mg (p < 0.001) in the non-shockable group. Among those with a shockable rhythm, survival to hospital discharge was 35.0% in the higher dose group vs. 34.2% in the lower dose group. Among those with a non-shockable rhythm, survival was 4.2% in the higher dose group vs. 5.1% in the lower dose group. Lower dose vs. higher dose was not significantly associated with survival: adjusted odds ratio, aOR 0.91 (95% CI 0.62-1.32, p = 0.61) if shockable and aOR 1.26 (95% CI 0.79-2.01, p = 0.33) if non-shockable. Lower dose vs. higher dose was not significantly associated with favorable neurological status at discharge: aOR 0.84 (95% CI 0.57-1.24, p = 0.377) if shockable and aOR 1.17 (95% CI 0.68-2.02, p = 0.577) if non-shockable. CONCLUSION: Reducing the dose of epinephrine administered during out-of-hospital cardiac arrest was not associated with a change in survival to hospital discharge or favorable neurological outcomes after OHCA.


Assuntos
Epinefrina/administração & dosagem , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Vasoconstritores/administração & dosagem , Adulto , Reanimação Cardiopulmonar/métodos , Relação Dose-Resposta a Droga , Cardioversão Elétrica/estatística & dados numéricos , Serviços Médicos de Emergência/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/classificação , Tempo para o Tratamento/estatística & dados numéricos
18.
Eur Heart J Cardiovasc Pharmacother ; 4(3): 144-151, 2018 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-29036580

RESUMO

Aims: Delay in administration of epinephrine is associated with decreased survival among children with in-hospital cardiac arrest with an initial non-shockable rhythm. Whether this association is applicable to paediatric out-of-hospital cardiac arrest (OHCA) population remains unknown. We aimed to determine whether time to epinephrine administration is associated with outcomes in paediatric OHCA. Methods and results: This was a nation-wide population-based study of paediatric OHCA in Japan from 2005 to 2012 based on data from the All-Japan Utstein Registry. We included paediatric OHCA patients (aged between 1 and 17 years) who received at least one dose of epinephrine. The primary outcome was 30-day survival. A total of 225 patients were included in the final cohort. Among the 225 patients, 23 (10.2%) survived 30 days after OHCA. The median time from emergency call to first epinephrine administration was 26 min [interquartile range, 20-32; range, 9-128; mean (standard deviation), 28.7 (15.5) min]. Longer time to epinephrine administration was associated with decreased chance of survival: 50.0, 41.2, 13.0, 11.6, 3.9, and 3.1%, respectively, when time to epinephrine was treated as a categorical variable categorized into ≤10, 11-15, 16-20, 21-25, 26-30, or > 30 min (P for trend <0.0001), and adjusted odds ratio 0.90 (95% confidence interval 0.82-0.96, P = 0.0011) when time to epinephrine was treated as a linear and continuous variable in a multivariable logistic regression model. Similar trends were observed for prehospital return of spontaneous circulation (P = 0.0032) and neurologically favourable survival (P = 0.0014). Conclusions: Among paediatric OHCA patients, delayed administration of epinephrine was associated with a decreased chance of favourable outcomes.


Assuntos
Agonistas Adrenérgicos/administração & dosagem , Reanimação Cardiopulmonar/métodos , Epinefrina/administração & dosagem , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Tempo para o Tratamento , Adolescente , Agonistas Adrenérgicos/efeitos adversos , Idade de Início , Reanimação Cardiopulmonar/efeitos adversos , Reanimação Cardiopulmonar/mortalidade , Criança , Pré-Escolar , Esquema de Medicação , Epinefrina/efeitos adversos , Feminino , Humanos , Lactente , Japão/epidemiologia , Masculino , Parada Cardíaca Extra-Hospitalar/diagnóstico , Parada Cardíaca Extra-Hospitalar/mortalidade , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
19.
Resuscitation ; 122: 106-112, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29175357

RESUMO

BACKGROUND: Patients resuscitated from cardiac arrest have brain and cardiac injury. Recent animal studies suggest that the administration of sodium nitrite after resuscitation from 12min of asystole limits acute cardiac dysfunction and improves survival and neurologic outcomes. It has been hypothesized that low doses of IV sodium nitrite given during resuscitation of out of hospital cardiac arrest (OHCA) will improve survival. Low doses of sodium nitrite (e.g., 9.6mg of sodium nitrite) are safe in healthy individuals, however the effect of nitrite on blood pressure in resuscitated cardiac arrest patients is unknown. METHODS: We performed a single-center, pilot trial of low dose sodium nitrite (1 or 9.6mg dose) vs. placebo in hospitalized out-of-hospital cardiac arrest patient to determine whether nitrite administration reduced blood pressure and whether whole blood nitrite levels increased in response to nitrite administration. RESULTS: This is the first reported study of sodium nitrite in cardiac arrest patients. Infusion of low doses of sodium nitrite in comatose survivors of OHCA (n=7) compared to placebo (n=4) had no significant effects on heart rate within 30min after infusion (70±20 vs. 78±3 beats per minute, p=0.18), systolic blood pressure (103±20 vs 108±15mmHg, p=0.3), or methemoglobin levels (0.92±0.33 vs. 0.70±0.26, p=0.45). Serum nitrite levels of 2-4µM were achieved within 15min of a 9.6mg nitrite infusion. CONCLUSIONS: Low dose sodium nitrite does not cause significant hemodynamic effect in patients with OHCA, which suggests that nitrite can be delivered safely in this critically ill patient population. Higher doses of sodium nitrite are necessary in order to achieve target serum level of 10µM.


Assuntos
Pressão Sanguínea/efeitos dos fármacos , Coma/tratamento farmacológico , Fármacos Neuroprotetores/administração & dosagem , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Nitrito de Sódio/administração & dosagem , Administração Intravenosa , Adulto , Idoso , Coma/etiologia , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Frequência Cardíaca/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Fármacos Neuroprotetores/farmacologia , Parada Cardíaca Extra-Hospitalar/complicações , Projetos Piloto , Nitrito de Sódio/sangue , Nitrito de Sódio/farmacologia
20.
Crit Care Med ; 46(2): e118-e125, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29189347

RESUMO

OBJECTIVES: To investigate the effects of the glucagon-like peptide-1 analog exenatide on blood glucose, lactate clearance, and hemodynamic variables in comatose, resuscitated out-of-hospital cardiac arrest patients. DESIGN: Predefined post hoc analyzes from a double-blind, randomized clinical trial. SETTING: The ICU of a tertiary heart center. PATIENTS: Consecutive sample of adult, comatose patients undergoing targeted temperature management after out-of-hospital cardiac arrest from a presumed cardiac cause, irrespective of the initial cardiac rhythm. INTERVENTIONS: Patients were randomized 1:1 to receive 6 hours and 15 minutes of infusion of either 17.4 µg of the glucagon-like peptide-1 analog exenatide (Byetta; Lilly) or placebo within 4 hours from sustained return of spontaneous circulation. The effects of exenatide were examined on the following prespecified covariates within the first 6 hours from study drug initiation: lactate level, blood glucose level, heart rate, mean arterial pressure, and combined dosage of norepinephrine and dopamine. MEASUREMENTS AND MAIN RESULTS: The population consisted of 106 patients receiving either exenatide or placebo. During the first 6 hours from study drug initiation, the levels of blood glucose and lactate decreased 17% (95% CI, 8.9-25%; p = 0.0004) and 21% (95% CI, 6.0-33%; p = 0.02) faster in patients receiving exenatide versus placebo, respectively. Exenatide increased heart rate by approximately 10 beats per minute compared to placebo (p < 0.0001). There was no effect of exenatide on other hemodynamic variables. CONCLUSIONS: In comatose out-of-hospital cardiac arrest patients, infusion with exenatide lowered blood glucose and resulted in increased clearance of lactate as well as increased heart rate. The clinical importance of these physiologic effects remains to be investigated.


Assuntos
Glicemia/efeitos dos fármacos , Coma/metabolismo , Coma/fisiopatologia , Exenatida/farmacologia , Peptídeo 1 Semelhante ao Glucagon/análogos & derivados , Frequência Cardíaca/efeitos dos fármacos , Ácido Láctico/metabolismo , Coma/sangue , Coma/etiologia , Método Duplo-Cego , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/complicações , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico
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