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Vasopressors and Cardiac Re-arrest
12
LACK OF ASSOCIATION OF INITIAL VASOPRESSOR DOSING WITH SURVIVAL AND
CARDIAC RE-ARREST LIKELIHOOD AFTER RETURN OF SPONTANEOUS
CIRCULATION
Emergency Medicine
7/28/23
Abigail R. Sharpe, PHARMD, Kelly Richardson, PHARMD,∗ Matthew Stanton, PHARMD, BCPS, DABAT, Cathyyen Dang, PHARMD, BCPS,∗ Jessica Feih, PHARMD, BCPS,∗ Ruta Brazauskas, PHD, Bi Qing Teng, MS, and Ryan Feldman, PHARMD, BCPS, DABAT∗
Background
Background
Objectives
Cardiac Arrest
Cardiac Arrest
Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
2 types of cardiac arrest:
- Shockable Rhythm
- Non-shockable Rhythm
Cardiac Arrest with a Shockable Rhythm
ACLS algorithm for shockable rhythms (pulseless ventricular tachycardia and ventricular fibrilation)
When using amiodarone:
300 mg for 1st dose, 150 mg for 2nd dose
When using Lidocaine:
1 to 1.5 mg/kg for 1st dose, 0.5 to 0.75 mg/kg for 2nd dose
Cardiac Arrest Without a Shockable Rhythm
ACLS algorithm for non-shockable rhythms (pulseless electrical activity and asystole)
Post-cardiac Arrest Care
Temperature Managment:
- Goal temp 89.6 to 96.8F
- Improved neurologic outcomes
- AKA therapeutic hypothermia
Ventilator optimization:
- Maintain arterial O2 of 92 to 98%
Hemodynamic optimization:
- Goal MAP of 65 mmHg or more
Other:
- Glycemic control within normal range
- coronary reperfusion via PCI
Post-cardiac Arrest Care
IV infusions for hypotension:
- IV Fluid Bolus: Give 1-2 L of normal saline or LR
- Epinephrine 2-10 mcg/min
- Dopamine 5-20 mcg/kg/min
- Norepinephrine 0.1-0.5 mcg/kg/min
Objective of the study
Objectives
this study aimed to assess the association between the initial dose of vasopressors in patients who experienced cardiac arrest in ranges from low doses to very high doses of vasopressors
Methods
Study Design and Study Setting
Inclusion Crtieria and Exclusion Criteria
Interventions
Endpoints
Statistical analysis
Design and Setting
Study Design
Single-center, retrospective record analysis of patients in the Froedtert Hospital Emergency Department
Study Location
Froedtert Hospital Milwaukee, Wisconsin
Study period 11/1/2015 to 10/31/2020
Study Criteria
Inclusion Criteria
Exclusion Criteria
Study Criteria
Inclusion
- all patients 18+ who experienced cardiac arrest prior to arrival
- patient achieved ROSC
- Started on a norepinephrine, epinephrine, or vasopressin infusion
Exclusion Criteria
Exclusion
- Known pregnancy
- DNR status
- transfer from OSH
- vasopressor infusion initiated prior to hospital arrival
- vasopressor started >1 hour after ROSC
- patients who recieved dopamine infusion
4 Study arms
Interventions
Low dose (<0.25 mcg/kg/min)
Middle dose (0.25 to 0.49 mcg/kg/min)
High dose (0.5 to 0.99 mcg/kg/min)
Very high dose (1 or more mcg/kg/min)
Endpoints
Primary and Secondary Endpoints
Primary Endpoint
Primary
Incidence of cardiac re-arrest within 1 hour of vasopressor initiation
Secondary Endpoints
Secondary
- Need for second vasopressor in the ED
- % of MAP at goal (65 mmHg +)
- Incidence of malignant hypertension (SBP > 180 mmHg) during ED stay
- Incidence of atrial or ventricular dysrythmia
- Survival to ICU admission
- Survival to hospital discharge
Data Analysis
Statiscial Analysis
- Fischer's Exact Test and Kruskal-Wallis Test for continuous and categorical measurements between groups
- chi-squared or 2-tailed T-test were used for inter-group comparisons
Results
Baseline Study Characteristics
Number lost to follow-up
Study Outcomes
Participant Characteristics
Average age of participants was 63 (+/- 16) years old
predominantly male (58.4% of all participants)
Most commonly observed rhythm was asystole/PEA (68.6%)
Pateints excluded from regression analysis
Number Lost to Follow-up
2
1 - d/t Hypokalemia as cause of arrest rather than hyperkalemia
2 - Time and date of ROSC not recorded
Outcomes
Re-arrests within 1 hour
Secondary Outcomes
Primary Outcome - Re-arrests
There was no significant difference in re-arrests within 1 hour of vassopressor initiation regardless of dose
There was no diference between number of re-arrests regardless of vasopressor dose
Secondary Endpoints
no difference in MAP at goal , incidence of malignant hypertension, or dysrhythmia development in the ED,
Patients initiated at very high doses were more likely to require additional vasopressors to meet hemodynamic support needs
Patients in the high dose group were less likely to survive to hospital discharge than the low dose or medium dose groups
Additional Findings
This study supported existing data regarding metabolic acidosis being associated with poor outcomes in ICU patients
- Higher post-ROSC pH and longer time to initiation of vasopressors were associated with decreased likelihood of re-arrest
Additional Findings
Longer duration of arrest and hyperkalemia as etiology of arrest was associated with increased incidnce of re-arrest
Hyperkalemia is associated with reduced survival at time of discharge
Discussion
Strengths and Weaknesses
Conclusions
Clinical Significance
Strengths of the study
Strengths
- The study was exended over a long time frame allowing for a larger study population
- Matching the study period to the AHA ALS guideline timeline allows for greater internal validity. Providers would be held to the same standard per guideline recommendations for the duration of the study period.
Weaknesses of the study
Weaknesses
- Assessment of pre-existing comorbidities and bystander CPR prior to EMS arrival were not assessed reducing internal validty.
- retrospective study design limits data to what was collected during admission or via outside medical record systems
- Setting of a single hospital limits patient enrollment and overall external validity of this study.
Conclusions
Author's Conclusions
Author's conclusions
- Dose of vasopressors initiated within 1 hour of ROSC do not have a significant impact on incidence of re-arrest.
- Patients started on higher initial doses of vasopressors may have been more acutely unwell than those started on lower doses
- More studies are needed to assess initial vasopressor dose post ROSC in patients presenting to emergency departments to better understand the relationship between dose and re-arrest
My conclusion
My conclusions
I think more research is required before we can conclude that a particular regimen is efficacious at reducing re-arrest in patients who have acheived ROSC following cardiac arrest
What does this study tell us?
Clinical Significance
To date, there is not substantial data on the dose of vasopressor following cardiac arrest to reduce morbidity and mortality.
This study was meant to fill a gap in care; however, the study findings did not provide a clear direction for dosing of vasopressors following cardiac arrest. Provider preferrance should continue guiding vasopressor dose following ROSC after cardiac arrest untill more data comes out supporting a particular dosing regimen.
I look forward to hearing more information about advances in post-cardiac arrest care in the future in order to increase patient survival to hospital discharge in the future.