Thursday, April 23, 2015

Initial arrest rhythm to drive post resuscitation care decisions

Here are the findings from an interesting study published in Resuscitation:

We investigated the impact of intensified postresuscitation treatment in comatose survivors of out-of-hospital cardiac arrest (OHCA) of presumed cardiac etiology according to the initial rhythm at the emergency medical team arrival.

Interventions and survival with Cerebral Performance Category (CPC) 1–2 within each group were retrospectively compared between the periods of conservative (1995–2003) and intensified (2004–2012) postresuscitation treatment.

In shockable group, therapeutic hypothermia (TH) increased from 1 to 93%, immediate invasive coronary strategy from 28 to 78%, intraaortic balloon pump from 4 to 21%, vasopressors/inotropes from 47 to 81% and antimicrobial agents from 65 to 86% during the intensified period as compared to conservative period (p less than 0.001). This was associated with increased survival with CPC 1–2 from 27 to 47% (p less than 0.001). After adjusting for age, sex and prehospital confounders, TH (OR = 2.12, 95% CI 1.25–3.61), percutaneous coronary intervention (OR 1.77, 95% CI 1.15–2.73) and antimicrobial agents (OR = 12.21, 95% CI 5.13–29.08) remained associated with survival with CPC 1–2. In non-shockable patients, TH also significantly increased from 1 to 74%, immediate invasive coronary strategy from 8 to 51%, intraaortic balloon pump from 2 to 9% and vasopressors/inotropes from 56 to 84% during intensified period without concomitant increase in survival with CPC 1–2 (7% vs. 9%; p = 0.27). After adjustment, only antimicrobial agents (OR = 8.43, 95% CI: 1.05–67.72) remained associated with survival with CPC 1–2.

Of particular interest is the frequency with which antibiotics were given and the degree to which their use was associated with better survival.

Karl B. Kern MD, in a related editorial, made the following points:

In contrast to the referenced study, findings form a large database in Arizona showed benefit from a similar intensified post-arrest care bundle regardless of the presenting rhythm. (In the referenced study only antibiotics were associated with better outcomes across all rhythm groups).

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