G Model
ARTICLE IN PRESS
RESUS 6657 1–2
1
Resuscitation xxx (2015) xxx.e1–xxx.e2
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor
2 3
Changes in atropine use for out-of-hospital cardiac arrest patients with non-shockable rhythm between 2002 and 2012 Sir,
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Q2
Atropine sulfate was recommended in the resuscitation guidelines for patients with out-of-hospital cardiac arrest (OHCA) due to non-shockable rhythms [i.e. asystole or pulseless electric activity (PEA)] until the early 2000s. However, no prospective controlled clinical trials have examined atropine use in nonshockable rhythms; several observational clinical studies have failed to demonstrate any benefit of routine atropine use in cardiac arrest.1,2 In the 2010 international guidelines, atropine use was no longer recommended for routine management of cardiac arrest patients with non-shockable rhythms.3 However, the actual changes in atropine use in clinical situations after 2010 remain unknown. We therefore evaluated the changes in atropine use for cardiac arrest patients with non-shockable rhythms before and after the 2010 guidelines. We here report a post-hoc analysis of the survey of survivors after out-of-hospital cardiac arrest in the Kanto region (SOSKANTO) in 20022 and 2012,4 a study that was done between September 2002 and December 2003, and between January 2012 and December 2012, respectively. The two studies were prospective multicentre observational studies performed to accumulate pre- and in-hospital records of cardiac arrest patients who were transported to participating hospitals in the Kanto area of Japan.2,4 The current study included patients aged >18 years who had
cardiac arrest with a non-shockable rhythm (i.e. asystole or PEA) on arrival at the emergency room.2 Patients who did not undergo resuscitative treatment were excluded. The primary endpoint was the proportion of atropine provision for asystole or PEA patients between 2002 and 2012. A total of 9592 and 16,452 patients experienced cardiac arrest during the SOS-KANTO 2002 and 2012, respectively. Of these, 8421 patients met the inclusion criteria in SOS-KANTO 2002 and 11520 patients in SOS-KANTO 2012. The proportion of atropine use in clinical situations decreased significantly from 2002 to 2012 [2002 vs. 2012, 22.2%, 1871/8421 vs. 3.9%, 448/11,520; differences, 18.3%, 95% confidence interval (CI) 17.4 to 19.2; Fig. 1A]. Logistic regression analysis showed a significant decline in the atropine use in 2012, even after adjustment for confounding factors (odds ratio, 0.14; 95% CI, 0.13–0.16; Fig. 1B). The current results suggest that using atropine in cardiac arrest patients with non-shockable rhythms during the resuscitation process has decreased significantly in 10 years. This significant reduction may be due to the impact of the revised guidelines in 2010. The first few minutes of initial medical decision-making, particularly in critical situations, may relate directly to the outcome of the cardiac arrest patients. A previous report demonstrated that adherence to Advanced Cardiac Life Support protocols are associated with an increased return of spontaneous circulation in the setting of in-hospital cardiac arrest.5 Our study suggests that revision of the resuscitation guidelines significantly changed doctors’ prescription behaviour in Japan. Therefore, the guidelines had a large effect on clinical treatment.
Fig. 1. (A) Proportion of atropine provision for non-shockable cardiac arrest patients between 2002 and 2012 (22.2% vs. 3.9%; p < 0.001). (B) Logistic regression analysis for atropine use. http://dx.doi.org/10.1016/j.resuscitation.2015.11.032 0300-9572/© 2016 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Tanaka C, et al. Changes in atropine use for out-of-hospital cardiac arrest patients with non-shockable rhythm between 2002 and 2012. Resuscitation (2015), http://dx.doi.org/10.1016/j.resuscitation.2015.11.032
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G Model RESUS 6657 1–2 xxx.e2 56
ARTICLE IN PRESS Letter to the Editor / Resuscitation xxx (2015) xxx.e1–xxx.e2
Funding
This study was supported by the Japanese Association for Acute 58 Q4 Medicine of Kanto. The funder had no role in the execution of this 59 study or interpretation of the results. 57 Q3
60
Conflict of interest statement
63
All members that participated in the current study are members of the Japanese Association for Acute Medicine of Kanto. We declare that we have no financial conflicts of interest.
64
References
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65 66 67 68 69 70 71 72 73 74 75 76 77 78 79
1. van Walraven C, Stiell IG, Wells GA, Hebert PC, Vandemheen K. Do advanced cardiac life support drugs increase resuscitation rates from in-hospital cardiac arrest? The OTAC Study Group. Ann Emerg Med 1998;32:544–53. 2. SOS-KANTO study group. Atropine sulfate for patients with out-of-hospital cardiac arrest due to asystole and pulseless electrical activity. Circ J 2011;75:580–8. 3. Morrison LJ, Deakin CD, Morley PT, et al. Part 8: advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2010;122:S345–421. 4. SOS-KANTO 2012 study group. Changes in treatments and outcomes among elderly patients with out-of-hospital cardiac arrest between 2002 and 2012: a post hoc analysis of the SOS-KANTO 2002 and 2012. Resuscitation 2015;97:76–82. 5. McEvoy MD, Field LC, Moore HE, Smalley JC, Nietert PJ, Scarbrough SH. The effect of adherence to ACLS protocols on survival of event in the setting of in-hospital cardiac arrest. Resuscitation 2014;85:82–7.
Chie Tanaka Q1 Masamune Kuno Hiroyuki Yokota Takashi Tagami ∗,1 Taka-aki Nakada Nobuya Kitamura Yoshio Tahara Atsushi Sakurai Naohiro Yonemoto Ken Nagao Arino Yaguchi Naoto Morimura, SOS-KANTO 2012 Study Group Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo 2068512, Japan ∗ Corresponding author. Fax: +81 423727375. E-mail address: [email protected] (T. Tagami) 1
On behalf of the steering council and study group members of SOS-KANTO 2012.
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95
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98 99
13 November 2015
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15 November 2015
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Please cite this article in press as: Tanaka C, et al. Changes in atropine use for out-of-hospital cardiac arrest patients with non-shockable rhythm between 2002 and 2012. Resuscitation (2015), http://dx.doi.org/10.1016/j.resuscitation.2015.11.032
ARTICLE IN PRESS
RESUS 6657 1–2
1
Resuscitation xxx (2015) xxx.e1–xxx.e2
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor
2 3
Changes in atropine use for out-of-hospital cardiac arrest patients with non-shockable rhythm between 2002 and 2012 Sir,
4
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Q2
Atropine sulfate was recommended in the resuscitation guidelines for patients with out-of-hospital cardiac arrest (OHCA) due to non-shockable rhythms [i.e. asystole or pulseless electric activity (PEA)] until the early 2000s. However, no prospective controlled clinical trials have examined atropine use in nonshockable rhythms; several observational clinical studies have failed to demonstrate any benefit of routine atropine use in cardiac arrest.1,2 In the 2010 international guidelines, atropine use was no longer recommended for routine management of cardiac arrest patients with non-shockable rhythms.3 However, the actual changes in atropine use in clinical situations after 2010 remain unknown. We therefore evaluated the changes in atropine use for cardiac arrest patients with non-shockable rhythms before and after the 2010 guidelines. We here report a post-hoc analysis of the survey of survivors after out-of-hospital cardiac arrest in the Kanto region (SOSKANTO) in 20022 and 2012,4 a study that was done between September 2002 and December 2003, and between January 2012 and December 2012, respectively. The two studies were prospective multicentre observational studies performed to accumulate pre- and in-hospital records of cardiac arrest patients who were transported to participating hospitals in the Kanto area of Japan.2,4 The current study included patients aged >18 years who had
cardiac arrest with a non-shockable rhythm (i.e. asystole or PEA) on arrival at the emergency room.2 Patients who did not undergo resuscitative treatment were excluded. The primary endpoint was the proportion of atropine provision for asystole or PEA patients between 2002 and 2012. A total of 9592 and 16,452 patients experienced cardiac arrest during the SOS-KANTO 2002 and 2012, respectively. Of these, 8421 patients met the inclusion criteria in SOS-KANTO 2002 and 11520 patients in SOS-KANTO 2012. The proportion of atropine use in clinical situations decreased significantly from 2002 to 2012 [2002 vs. 2012, 22.2%, 1871/8421 vs. 3.9%, 448/11,520; differences, 18.3%, 95% confidence interval (CI) 17.4 to 19.2; Fig. 1A]. Logistic regression analysis showed a significant decline in the atropine use in 2012, even after adjustment for confounding factors (odds ratio, 0.14; 95% CI, 0.13–0.16; Fig. 1B). The current results suggest that using atropine in cardiac arrest patients with non-shockable rhythms during the resuscitation process has decreased significantly in 10 years. This significant reduction may be due to the impact of the revised guidelines in 2010. The first few minutes of initial medical decision-making, particularly in critical situations, may relate directly to the outcome of the cardiac arrest patients. A previous report demonstrated that adherence to Advanced Cardiac Life Support protocols are associated with an increased return of spontaneous circulation in the setting of in-hospital cardiac arrest.5 Our study suggests that revision of the resuscitation guidelines significantly changed doctors’ prescription behaviour in Japan. Therefore, the guidelines had a large effect on clinical treatment.
Fig. 1. (A) Proportion of atropine provision for non-shockable cardiac arrest patients between 2002 and 2012 (22.2% vs. 3.9%; p < 0.001). (B) Logistic regression analysis for atropine use. http://dx.doi.org/10.1016/j.resuscitation.2015.11.032 0300-9572/© 2016 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Tanaka C, et al. Changes in atropine use for out-of-hospital cardiac arrest patients with non-shockable rhythm between 2002 and 2012. Resuscitation (2015), http://dx.doi.org/10.1016/j.resuscitation.2015.11.032
28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55
G Model RESUS 6657 1–2 xxx.e2 56
ARTICLE IN PRESS Letter to the Editor / Resuscitation xxx (2015) xxx.e1–xxx.e2
Funding
This study was supported by the Japanese Association for Acute 58 Q4 Medicine of Kanto. The funder had no role in the execution of this 59 study or interpretation of the results. 57 Q3
60
Conflict of interest statement
63
All members that participated in the current study are members of the Japanese Association for Acute Medicine of Kanto. We declare that we have no financial conflicts of interest.
64
References
61 62
65 66 67 68 69 70 71 72 73 74 75 76 77 78 79
1. van Walraven C, Stiell IG, Wells GA, Hebert PC, Vandemheen K. Do advanced cardiac life support drugs increase resuscitation rates from in-hospital cardiac arrest? The OTAC Study Group. Ann Emerg Med 1998;32:544–53. 2. SOS-KANTO study group. Atropine sulfate for patients with out-of-hospital cardiac arrest due to asystole and pulseless electrical activity. Circ J 2011;75:580–8. 3. Morrison LJ, Deakin CD, Morley PT, et al. Part 8: advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2010;122:S345–421. 4. SOS-KANTO 2012 study group. Changes in treatments and outcomes among elderly patients with out-of-hospital cardiac arrest between 2002 and 2012: a post hoc analysis of the SOS-KANTO 2002 and 2012. Resuscitation 2015;97:76–82. 5. McEvoy MD, Field LC, Moore HE, Smalley JC, Nietert PJ, Scarbrough SH. The effect of adherence to ACLS protocols on survival of event in the setting of in-hospital cardiac arrest. Resuscitation 2014;85:82–7.
Chie Tanaka Q1 Masamune Kuno Hiroyuki Yokota Takashi Tagami ∗,1 Taka-aki Nakada Nobuya Kitamura Yoshio Tahara Atsushi Sakurai Naohiro Yonemoto Ken Nagao Arino Yaguchi Naoto Morimura, SOS-KANTO 2012 Study Group Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo 2068512, Japan ∗ Corresponding author. Fax: +81 423727375. E-mail address: [email protected] (T. Tagami) 1
On behalf of the steering council and study group members of SOS-KANTO 2012.
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95
96 97
98 99
13 November 2015
100
15 November 2015
101
Please cite this article in press as: Tanaka C, et al. Changes in atropine use for out-of-hospital cardiac arrest patients with non-shockable rhythm between 2002 and 2012. Resuscitation (2015), http://dx.doi.org/10.1016/j.resuscitation.2015.11.032
