In-Hospital Cardiac Arrest: A New Weapon in the Fight?
In-Hospital Cardiac Arrest: A New Weapon in the Fight?
This is Andy Shorr from George Washington University in Washington, DC, with a pulmonary/critical care literature update. Today I want to highlight an article by Mentzelopoulos and colleagues in the July 17 issue of JAMA. This article focused on our approach to cardiopulmonary resuscitation (CPR) and advanced cardiopulmonary life support (ACLS).
We have all been to that code where we know it is not going to go well. We have gone through multiple rounds of epinephrine. We have tried everything we know, yet the outcome will be poor. More important, we have been to the code where we know the outcome is going to be poor because we know the downtime has been too long, and then miraculously someone finds a pulse -- and now we are faced with having an often complicated conversation with the family about end-of-life goals and goals of care. We know that survival to discharge with intact neurologic function for many of these patients is quite low.
Mentzelopoulos and colleagues looked at how we do ACLS. The study was conducted at 3 tertiary care hospitals in Greece. Investigators randomly assigned patients who suffered cardiac arrest to 2 groups; one group received initial treatment with norepinephrine per the standard ACLS protocol, and the other group received norepinephrine with vasopressin.
Norepinephrine and vasopressin have been studied previously, with little impact of vasopressin on outcomes. But in the group that received norepinephrine plus vasopressin, these authors added methylprednisolone 40 mg vs placebo during the arrest; thus, the first group received epinephrine and placebo vs epinephrine, vasopressin, and steroid in the second group. In the patients who survived, those who went into shock in the vasopressin/steroid/epinephrine group received stress-dose steroids automatically, and patients in the control/epinephrine alone group received open-label hydrocortisone if the investigator felt it was appropriate. The study was double-blinded, and of course it was randomized.
The primary endpoint for this trial was return of spontaneous circulation, but more important, survival to discharge with a good neurologic prognosis, a good performance status -- not just survival, but meaningful survival. The authors enrolled about 300 patients -- 154 in the control group, and about 146 in the intervention group -- and again, remember that multiple interventions were being used.
The population was what you would expect: primarily an older population. Of interest, many of these arrests happened in the intensive care unit (ICU), which would not be what we would see in the United States. Many of these arrests were witnessed, and time to initiation of CPR in both groups was equivalent, and very, very quick -- 2 or 3 minutes. So, this is somewhat different from what we see in the United States in terms of generalizability.
This is Andy Shorr from George Washington University in Washington, DC, with a pulmonary/critical care literature update. Today I want to highlight an article by Mentzelopoulos and colleagues in the July 17 issue of JAMA. This article focused on our approach to cardiopulmonary resuscitation (CPR) and advanced cardiopulmonary life support (ACLS).
We have all been to that code where we know it is not going to go well. We have gone through multiple rounds of epinephrine. We have tried everything we know, yet the outcome will be poor. More important, we have been to the code where we know the outcome is going to be poor because we know the downtime has been too long, and then miraculously someone finds a pulse -- and now we are faced with having an often complicated conversation with the family about end-of-life goals and goals of care. We know that survival to discharge with intact neurologic function for many of these patients is quite low.
Mentzelopoulos and colleagues looked at how we do ACLS. The study was conducted at 3 tertiary care hospitals in Greece. Investigators randomly assigned patients who suffered cardiac arrest to 2 groups; one group received initial treatment with norepinephrine per the standard ACLS protocol, and the other group received norepinephrine with vasopressin.
Norepinephrine and vasopressin have been studied previously, with little impact of vasopressin on outcomes. But in the group that received norepinephrine plus vasopressin, these authors added methylprednisolone 40 mg vs placebo during the arrest; thus, the first group received epinephrine and placebo vs epinephrine, vasopressin, and steroid in the second group. In the patients who survived, those who went into shock in the vasopressin/steroid/epinephrine group received stress-dose steroids automatically, and patients in the control/epinephrine alone group received open-label hydrocortisone if the investigator felt it was appropriate. The study was double-blinded, and of course it was randomized.
The primary endpoint for this trial was return of spontaneous circulation, but more important, survival to discharge with a good neurologic prognosis, a good performance status -- not just survival, but meaningful survival. The authors enrolled about 300 patients -- 154 in the control group, and about 146 in the intervention group -- and again, remember that multiple interventions were being used.
The population was what you would expect: primarily an older population. Of interest, many of these arrests happened in the intensive care unit (ICU), which would not be what we would see in the United States. Many of these arrests were witnessed, and time to initiation of CPR in both groups was equivalent, and very, very quick -- 2 or 3 minutes. So, this is somewhat different from what we see in the United States in terms of generalizability.