Resuscitation 85 (2014) e179–e180
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor
Reply to Letter: Adrenaline in out-of hospital cardiac arrest Sir, We appreciate and read with interest the letter by Pierre-Nicolas et al. in regards to our paper, “Adrenaline for out-of-hospital cardiac arrest resuscitation: A systematic review and meta-analysis of randomized controlled trials”.1 We agree that the timing of drug delivery, particularly adrenaline administration, is an important aspect of cardiac arrest resuscitation, which has not been previously well-studied.2,3 Recent observational studies found that the early administration of adrenaline is associated with improved patient outcomes.4,5 Since international guidelines focus on early chest compressions and early defibrillation as priorities in cardiac arrest resuscitation, we agree that the use of adrenaline can be a surrogate marker for prolonged resuscitations. This confounding by indication is very important in observational studies, but should be balanced in randomized controlled trials. Despite the importance of noting time of drug administration, we and others have observed that older clinical studies and trials infrequently report the timing of drug administration.1,6 Therefore, we agree that future studies of adrenaline take in account the timing of administration as a key variable. Moreover, in our systematic review and meta-analysis, many older trials were conducted prior to major advances in cardiac arrest resuscitation that emphasize chest compressions over ventilations, routine targeted temperature management, and percutaneous coronary intervention.1 We believe that the role of adrenaline in the setting of more current practices is not clear. We look forward to the results of upcoming trials, such as the PARAMEDIC 2 trial, led by Professor Gavin Perkins, which plans to evaluate adrenaline vs. placebo in out-of-hospital cardiac arrest (ISRCTN73485024). There is currently a need for well-designed clinical trials to evaluate the efficacy of adrenaline as well as its optimal dosing and timing of administration.7–9
Conflict of interest statement All authors have no financial support from any organization for the submitted work and no financial relationships with any organizations that might have an interest in the submitted work. S.L. was a worksheet author on the C2010 ILCOR acute coronary syndrome taskforce and is an evidence reviewer on the C2015 ILCOR advanced life support (ALS) Taskforce; C.W.C. was a past chair and current http://dx.doi.org/10.1016/j.resuscitation.2014.08.002 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
member of the American Heart Association (AHA) Emergency Cardiovascular Care committee, a member of the editorial board of the 2010 AHA resuscitation guidelines, and currently the co-chair of the C2015 ILCOR ALS taskforce; L.J.M. was a past chair and current member of the AHA Emergency Cardiovascular Care committee, a member of the Editorial Board of the 2010 AHA resuscitation guidelines, and was the co-chair of the C2010 and is the current co-chair of the C2015 ILCOR ALS taskforce; no other relationships or activities that could appear to have influenced the submitted work.
References 1. Lin S, Callaway CW, Shah PS, et al. Adrenaline for out-of-hospital cardiac arrest resuscitation: a systematic review and meta-analysis of randomized controlled trials. Resuscitation 2014;85:732–40. 2. 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. 3. Deakin CD, Morrison LJ, Morley PT, et al. Part 8: advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81(Suppl. 1):e93–174. 4. Donnino MW, Salciccioli JD, Howell MD, et al. Time to administration of epinephrine and outcome after in-hospital cardiac arrest with nonshockable rhythms: retrospective analysis of large in-hospital data registry. BMJ 2014;348:g3028. 5. Hayashi Y, Iwami T, Kitamura T, et al. Impact of early intravenous epinephrine administration on outcomes following out-of-hospital cardiac arrest. Circ J 2012;76:1639–45. 6. Rittenberger JC, Bost JE, Menegazzi JJ. Time to give the first medication during resuscitation in out-of-hospital cardiac arrest. Resuscitation 2006;70: 201–6. 7. Callaway CW. Questioning the use of epinephrine to treat cardiac arrest. JAMA 2012;307:1198–200. 8. Nolan JP, Soar J, Wenzel V, Paal P. Cardiopulmonary resuscitation and management of cardiac arrest. Nat Rev Cardiol 2012;9:499–511. 9. Larabee TM, Liu KY, Campbell JA, Little CM. Vasopressors in cardiac arrest: a systematic review. Resuscitation 2012;83:932–9.
Steve Lin a,b,∗ Rescu, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada b Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada a
Clifton W. Callaway Department of Emergency Medicine, University of Pittsburgh School of Medicine, 400A Iroquois, Pittsburgh, PA 15260, USA
e180
Letter to the Editor / Resuscitation 85 (2014) e179–e180
Laurie J. Morrison a,b Rescu, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada b Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada a
∗ Corresponding author at: Rescu, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada. E-mail address: [email protected] (S. Lin)
28 July 2014 2 August 2014
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor
Reply to Letter: Adrenaline in out-of hospital cardiac arrest Sir, We appreciate and read with interest the letter by Pierre-Nicolas et al. in regards to our paper, “Adrenaline for out-of-hospital cardiac arrest resuscitation: A systematic review and meta-analysis of randomized controlled trials”.1 We agree that the timing of drug delivery, particularly adrenaline administration, is an important aspect of cardiac arrest resuscitation, which has not been previously well-studied.2,3 Recent observational studies found that the early administration of adrenaline is associated with improved patient outcomes.4,5 Since international guidelines focus on early chest compressions and early defibrillation as priorities in cardiac arrest resuscitation, we agree that the use of adrenaline can be a surrogate marker for prolonged resuscitations. This confounding by indication is very important in observational studies, but should be balanced in randomized controlled trials. Despite the importance of noting time of drug administration, we and others have observed that older clinical studies and trials infrequently report the timing of drug administration.1,6 Therefore, we agree that future studies of adrenaline take in account the timing of administration as a key variable. Moreover, in our systematic review and meta-analysis, many older trials were conducted prior to major advances in cardiac arrest resuscitation that emphasize chest compressions over ventilations, routine targeted temperature management, and percutaneous coronary intervention.1 We believe that the role of adrenaline in the setting of more current practices is not clear. We look forward to the results of upcoming trials, such as the PARAMEDIC 2 trial, led by Professor Gavin Perkins, which plans to evaluate adrenaline vs. placebo in out-of-hospital cardiac arrest (ISRCTN73485024). There is currently a need for well-designed clinical trials to evaluate the efficacy of adrenaline as well as its optimal dosing and timing of administration.7–9
Conflict of interest statement All authors have no financial support from any organization for the submitted work and no financial relationships with any organizations that might have an interest in the submitted work. S.L. was a worksheet author on the C2010 ILCOR acute coronary syndrome taskforce and is an evidence reviewer on the C2015 ILCOR advanced life support (ALS) Taskforce; C.W.C. was a past chair and current http://dx.doi.org/10.1016/j.resuscitation.2014.08.002 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
member of the American Heart Association (AHA) Emergency Cardiovascular Care committee, a member of the editorial board of the 2010 AHA resuscitation guidelines, and currently the co-chair of the C2015 ILCOR ALS taskforce; L.J.M. was a past chair and current member of the AHA Emergency Cardiovascular Care committee, a member of the Editorial Board of the 2010 AHA resuscitation guidelines, and was the co-chair of the C2010 and is the current co-chair of the C2015 ILCOR ALS taskforce; no other relationships or activities that could appear to have influenced the submitted work.
References 1. Lin S, Callaway CW, Shah PS, et al. Adrenaline for out-of-hospital cardiac arrest resuscitation: a systematic review and meta-analysis of randomized controlled trials. Resuscitation 2014;85:732–40. 2. 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. 3. Deakin CD, Morrison LJ, Morley PT, et al. Part 8: advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81(Suppl. 1):e93–174. 4. Donnino MW, Salciccioli JD, Howell MD, et al. Time to administration of epinephrine and outcome after in-hospital cardiac arrest with nonshockable rhythms: retrospective analysis of large in-hospital data registry. BMJ 2014;348:g3028. 5. Hayashi Y, Iwami T, Kitamura T, et al. Impact of early intravenous epinephrine administration on outcomes following out-of-hospital cardiac arrest. Circ J 2012;76:1639–45. 6. Rittenberger JC, Bost JE, Menegazzi JJ. Time to give the first medication during resuscitation in out-of-hospital cardiac arrest. Resuscitation 2006;70: 201–6. 7. Callaway CW. Questioning the use of epinephrine to treat cardiac arrest. JAMA 2012;307:1198–200. 8. Nolan JP, Soar J, Wenzel V, Paal P. Cardiopulmonary resuscitation and management of cardiac arrest. Nat Rev Cardiol 2012;9:499–511. 9. Larabee TM, Liu KY, Campbell JA, Little CM. Vasopressors in cardiac arrest: a systematic review. Resuscitation 2012;83:932–9.
Steve Lin a,b,∗ Rescu, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada b Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada a
Clifton W. Callaway Department of Emergency Medicine, University of Pittsburgh School of Medicine, 400A Iroquois, Pittsburgh, PA 15260, USA
e180
Letter to the Editor / Resuscitation 85 (2014) e179–e180
Laurie J. Morrison a,b Rescu, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada b Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada a
∗ Corresponding author at: Rescu, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada. E-mail address: [email protected] (S. Lin)
28 July 2014 2 August 2014
