Return of spontaneous circulation

Vasopressin, Steroids, and Epinephrine and Neurologically Favorable Survival After In-Hospital Cardiac Arrest.

Posted by

0


A Randomized Clinical Trial

 

Importance  Among patients with cardiac arrest, preliminary data have shown improved return of spontaneous circulation and survival to hospital discharge with the vasopressin-steroids-epinephrine (VSE) combination.

Objective  To determine whether combined vasopressin-epinephrine during cardiopulmonary resuscitation (CPR) and corticosteroid supplementation during and after CPR improve survival to hospital discharge with a Cerebral Performance Category (CPC) score of 1 or 2 in vasopressor-requiring, in-hospital cardiac arrest.

Design, Setting, and Participants  Randomized, double-blind, placebo-controlled, parallel-group trial performed from September 1, 2008, to October 1, 2010, in 3 Greek tertiary care centers (2400 beds) with 268 consecutive patients with cardiac arrest requiring epinephrine according to resuscitation guidelines (from 364 patients assessed for eligibility).

Interventions  Patients received either vasopressin (20 IU/CPR cycle) plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes) (VSE group, n = 130) or saline placebo plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes) (control group, n = 138) for the first 5 CPR cycles after randomization, followed by additional epinephrine if needed. During the first CPR cycle after randomization, patients in the VSE group received methylprednisolone (40 mg) and patients in the control group received saline placebo. Shock after resuscitation was treated with stress-dose hydrocortisone (300 mg daily for 7 days maximum and gradual taper) (VSE group, n = 76) or saline placebo (control group, n = 73).

Main Outcomes and Measures  Return of spontaneous circulation (ROSC) for 20 minutes or longer and survival to hospital discharge with a CPC score of 1 or 2.

Results  Follow-up was completed in all resuscitated patients. Patients in the VSE group vs patients in the control group had higher probability for ROSC of 20 minutes or longer (109/130 [83.9%] vs 91/138 [65.9%]; odds ratio [OR], 2.98; 95% CI, 1.39-6.40; P = .005) and survival to hospital discharge with CPC score of 1 or 2 (18/130 [13.9%] vs 7/138 [5.1%]; OR, 3.28; 95% CI, 1.17-9.20; P = .02). Patients in the VSE group with postresuscitation shock vs corresponding patients in the control group had higher probability for survival to hospital discharge with CPC scores of 1 or 2 (16/76 [21.1%] vs 6/73 [8.2%]; OR, 3.74; 95% CI, 1.20-11.62; P = .02), improved hemodynamics and central venous oxygen saturation, and less organ dysfunction. Adverse event rates were similar in the 2 groups.

Conclusion and Relevance  Among patients with cardiac arrest requiring vasopressors, combined vasopressin-epinephrine and methylprednisolone during CPR and stress-dose hydrocortisone in postresuscitation shock, compared with epinephrine/saline placebo, resulted in improved survival to hospital discharge with favorable neurological status.

Source: JAMA

Paralyzing Comatose Cardiac Arrest Survivors Improves Outcomes.

Posted by

0


Neuromuscular blockade for at least 24 hours improved in-hospital survival rate.
The 2010 American Heart Association guidelines recommend limiting neuromuscular blockade (NMB) in patients with return of spontaneous circulation (ROSC) because it could be harmful. However, NMB is often used to prevent shivering in post–cardiac arrest patients receiving therapeutic hypothermia. Researchers performed a post-hoc analysis of a prospective, observational study of comatose adults with nontraumatic out-of-hospital cardiac arrest who had sustained ROSC (palpable pulses for ≥20 minutes) and were transported to four centers over a 9-month period.

Of 111 patients, 18 received NMB for at least 24 hours after ROSC (sustained NMB), 59 received NMB for less than 24 hours, and 34 received no NMB. In-hospital survival was higher in patients who received NMB at any point than in those who received no NMB (52% vs. 35%). Patients who received sustained NMB were more likely to survive than the other two groups combined (78% vs. 41%). Fifty percent of those who received sustained NMB and 28% of the other two groups had favorable neurologic outcomes (not a significant difference). The sustained-NMB group had similar prognostic scores but shorter time from collapse to ROSC, higher baseline blood pH, and lower incidence of chronic obstructive pulmonary disease than the other two groups combined. Multivariable analysis showed that sustained NMB was independently associated with survival (adjusted odds ratio, 7.23) and improvement in lactic acidosis.

The authors postulate that NMB reduces metabolic demand and global oxygen consumption, improves pulmonary gas exchange, and prevents ventilator dyssynchrony, thereby protecting against episodic rises in intracranial pressure.

COMMENT

Although some studies have suggested that long-term neuromuscular blockade may lead to critical illness, polyneuropathy, or generalized muscle weakness, this study suggests it may have benefit in post–cardiac arrest patients. A note of caution, however: Be sure that any patient with a chance of awareness is adequately sedated before paralysis!

 

 

 

Man vs. Machine for CPR.

Posted by

0


In this meta-analysis, return of spontaneous circulation was more likely when chest compressions were delivered by a mechanical device than manually.

When applied properly, mechanical devices provide consistent and effective chest compressions; no risk for provider fatigue; and the opportunity for concurrent defibrillation, thereby reducing time to shock. Investigators performed a meta-analysis of controlled (randomized, historical, or case-control) trials in humans to compare prehospital cardiopulmonary resuscitation (CPR) using a mechanical chest compression device versus manual compressions.

Of 12 studies meeting entry criteria, 8 involved load-distributing band CPR and 4 used piston-driven CPR, with a total of 6538 patients and 1824 instances of return of spontaneous circulation (ROSC). ROSC was defined as a measurable blood pressure sustained for at least 1 minute. Use of a mechanical device was superior to manual compressions for achieving ROSC (odds ratio, 1.53 overall, 1.62 for load-distributing band CPR, and 1.25 for piston-driven CPR).

Comment: Compression devices have become more lightweight and portable, making them a more attractive option for prehospital resuscitation, where it may be more difficult to achieve consistently adequate manual compressions. Such devices can be expected to similarly outperform humans in the emergency department and hospital settings, too, making a convincing argument for their routine use during resuscitation.

 

Source: Journal Watch Emergency Medicine

No Return of Pulses in the Field Portends Dismal Survival.

Posted by

0


This study’s findings support use of prehospital termination-of-resuscitation protocols.

Prehospital cardiac arrest patients who do not achieve return of spontaneous circulation (ROSC) continue to be transported to the hospital despite the existence of prehospital termination-of-resuscitation protocols (JW Emerg Med Oct 17 2008). To determine survival rates in such patients, researchers analyzed data from two urban emergency medical service systems for patients who experienced cardiac arrest presumed to be of medical etiology from 2008 to 2010.

Among 2483 patients in whom resuscitation was attempted, survival to hospital discharge was 6.6%. ROSC in the field occurred in 36% of patients. Survival rates were 17.2% in patients with ROSC in the field versus 0.7% in those without ROSC. None of the 11 patients who survived without ROSC in the field had an initial rhythm of asystole.

Comment: If termination-of-resuscitation protocols that are based on ROSC had been followed in this study, the transport rate would have been halved. Although the authors’ recommendation for no transport of patients without field ROSC or shockable rhythm would save critical resources and reduce risks to prehospital providers and the public from collisions, nonmedical indications such as family wishes sometimes mandate transport of nonviable patients. When such patients are transported, these data are useful for receiving-hospital emergency physicians to determine whether to continue resuscitative efforts on arrival.

Source: Journal Watch Emergency Medicine .

No Return of Pulses in the Field Portends Dismal Survival.

Posted by

0


This study’s findings support use of prehospital termination-of-resuscitation protocols.

Prehospital cardiac arrest patients who do not achieve return of spontaneous circulation (ROSC) continue to be transported to the hospital despite the existence of prehospital termination-of-resuscitation protocols (JW Emerg Med Oct 17 2008). To determine survival rates in such patients, researchers analyzed data from two urban emergency medical service systems for patients who experienced cardiac arrest presumed to be of medical etiology from 2008 to 2010.

Among 2483 patients in whom resuscitation was attempted, survival to hospital discharge was 6.6%. ROSC in the field occurred in 36% of patients. Survival rates were 17.2% in patients with ROSC in the field versus 0.7% in those without ROSC. None of the 11 patients who survived without ROSC in the field had an initial rhythm of asystole.

Comment: If termination-of-resuscitation protocols that are based on ROSC had been followed in this study, the transport rate would have been halved. Although the authors’ recommendation for no transport of patients without field ROSC or shockable rhythm would save critical resources and reduce risks to prehospital providers and the public from collisions, nonmedical indications such as family wishes sometimes mandate transport of nonviable patients. When such patients are transported, these data are useful for receiving-hospital emergency physicians to determine whether to continue resuscitative efforts on arrival.

Source: Journal Watch Emergency Medicine