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Treatment & Research

Questions and Answers about Treatment and Research

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A recently published study in the New England Journal of Medicine, and an accompanying editorial have thrown down the gauntlet to those organisations that produce guidelines for cardiac arrest management. In this large European study, the investigators evaluated the potential role of vasopressin as the initial vasopressor in the management of out-of-hospital cardiac arrests. Two doses of either vasopressin (40 Units) or adrenaline (1 mg) were administered to patients who required vasopressor support (in accord with European Resuscitation Council guidelines). Across the board, there were no differences in rates of hospital admission or hospital discharge but two post-hoc observations did however raise some interesting points. Firstly, there was a small but significant increase in the hospital discharge rates with vasopressin when the initial cardiac rhythm was asystole. Secondly, the benefits associated with vasopressin seemed to be associated with patients who did not respond to vasopressin alone, but required additional management with adrenaline.

This study was performed in a pre-hospital setting with physician–staffed emergency medical service units. The time intervals to administration of drugs were long (mean of 8 minutes of untreated [no BLS] cardiac arrest, then 10 minutes more until administration of first dose of study drug). There were some disturbing trends towards increased likelihood of adverse neurological outcomes (eg. coma, and severe cerebral disability) in the survivors from the vasopressor group, and this study contradicts the earlier out-of-hospital study of ventricular fibrillation that found dramatically improved short-term survival advantage with a single dose (40 Units) vasopressin.

The ARC is in the process of completing an evidence-based review, but at this stage no change in management or algorithms are required.

Further reading:

  1. Lindner KH, Dirks B, Strohmenger HU, Prengel AW, Lindner IM, Lurie KG. Randomised comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation. Lancet 1997;349(9051):535-7.
  2. Stiell IG, Hebert PC, Wells GA, Vandemheen KL, Tang AS, Higginson LA, et al. Vasopressin versus epinephrine for inhospital cardiac arrest: a randomised controlled trial. Lancet 2001;358(9276):105-9.
  3. Wenzel V, Krismer AC, Arntz HR, Sitter H, Stadlbauer KH, Lindner KH. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med 2004;350(2):105-13.
  4. McIntyre KM. Vasopressin in asystolic cardiac arrest. N Engl J Med 2004;350(2):179-81.

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In a recent email from the USA, it was quoted: “In what may prove to be the biggest shift in emergency care of cardiac arrest in 40 years, cities across the country are leading a move away from the familiar practice of using mouth-to-mouth resuscitation. (Related Story: Many 911 dispatchers eliminating mouth-to-mouth) In its place, the cities are recommending simple chest compressions pushing down repeatedly on the victim’s chest – to mimic a steady heartbeat. The emergency medical directors who are behind the shift say research in Seattle and Richmond, Va, suggests it will save many lives. (Related story: People die in just a few seconds lost). The movement became a full-fledged national trend last week at a meeting of emergency medical services (EMS) medical directors from 21 of the nation’s largest cities. Doctors from a dozen cities, including New York, Los Angeles and Chicago, decided to make the switch. They join at least seven other cities that are already advising 911callers to do chest compressions without mouth-to-mouth “rescue breathing””.

This issue has received media attention in the USA following a recent meeting of EMS medical directors. There has also been a recent article in the Weekend Australian newspaper. It mainly results from a study by Dr Hallstrom and published in the Critical Care Medicine in 2000. In this study, callers to EMS reporting a cardiac arrest and did not know CPR, were asked if they wanted to be instructed on how to do CPR. Those agreeing were randomised to receive instructions over the phone to either do full CPR or just chest compressions. This is often referred to ‘dispatcher assisted CPR’. The results of the study showed that the number of survivors in each group to be similar (14.6% for compression only vs 10.4% for full CPR)

It is important to note that the findings of this study refer only to situations where no trained bystanders were performing CPR. It shows that giving minimal telephone instructions (ie compressions only) seems to be as effective in terms of survival as giving full CPR instructions over the phone. However, this study does not compare the outcomes of untrained rescuers who receive dispatcher assisted CPR with that of CPR being performed by trained rescuers.

As such, inferring that mouth to mouth is not required when doing CPR is not supported by any clinical evidence. Furthermore, it ignores other causes of cardiac arrest such as drowning, and cardiac arrest in children, where ventilation (ie mouth to mouth) is vital.

Readers should be aware that the recommendations of the EMS directors were that “compression only” CPR advice should be given to callers receiving assistance from EMS dispatchers. It did not recommend removing mouth to mouth ventilation from CPR training or practice, as has been generally presented in the media.

Futher Reading:

  1. Hallstrom AP. Dispatcher-assisted “phone” cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. Crit Care Med 2000;28(11 Suppl):N190-N192.

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The age-old debate about which fluids are best for the resuscitation of patients was thrown into chaos by the meta-analysis published in the BMJ in 1998 by the Cochrane group [1]. This review suggested a 6% increase in mortality for those patients treated with albumin (one additional death for every 17 patients treated).

Much discussion ensued, and further meta-analyses were published, but the major factor lacking was a well-conducted trial to actually answer the question “is albumin safe?”

The Australian and New Zealand Intensive Care Society Clinical Trials Group recently published a definitive study, which comes closer to help us answer this question. This study [2], published with an editorial3 in the prestigious New England Journal of Medicine in May this year, was a multicenter, randomised, double-blind trial to compare the effect of fluid resuscitation with albumin or saline on mortality in a heterogeneous population of patients in the ICU. They randomly assigned 6997 patients who had been admitted to the ICU to receive intravascular-fluid resuscitation with either 4 percent albumin or normal saline for the next 28 days.

There were no significant differences between the groups with regard to mortality, numbers of days spent in the ICU, days spent in the hospital, days of mechanical ventilation or days of renal-replacement therapy. Two pre-specified subsets raised some additional interest when albumin administration was associated with better outcomes in one (“severe sepsis”), but was associated with a trend toward worse outcomes in the other (“trauma”). Again, as with many studies, this publication has probably raised more questions than it answered, but it seems that we can at least answer the question “is albumin safe?” Yes!

  1. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. Cochrane Injuries Group Albumin Reviewers. BMJ 1998;317(7153):235-40.
  2. Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350(22):2247-56.
  3. Cook D. Is albumin safe? N Engl J Med 2004;350(22):2294-6.

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