IV Drugs During Life Support Don't Improve Survival

Intravenous drugs given as part of advanced cardiac life support failed to improve long-term survival in the first randomized, controlled trial to test outcomes of this nearly universal procedure, according to a report published in JAMA.

Intravenous epinephrine, atropine, and/or amiodarone are given in almost every case of out-of-hospital cardiac arrest in Western nations, but the use of intravenous epinephrine in this setting is based almost entirely on preclinical evidence.

“Because there are no randomized, controlled studies showing improved survival to hospital discharge with any drugs routinely administered during CPR [cardiopulmonary resuscitation], we concluded such a study was warranted,” said Dr. Theresa M. Olasveengen and her associates at Oslo University Hospital.

They assessed 851 patients who required an ambulance for out-of-hospital cardiac arrest between May 2003 and April 2008.

The study subjects were randomly assigned to receive standard advanced cardiac life support, which included intravenous drug administration (418 patients) or advanced cardiac life support without any intravenous drugs (433 patients).

Initially, short-term survival was better with the IV drugs (40%) than without them (25%), and more patients in the intravenous-drug group (30%) than in the no-intravenous-drug group (20%) survived to ICU admission.

However, this early benefit quickly dissipated, and survival to hospital discharge—the primary outcome measure of this trial—was not significantly different between patients who received intravenous drugs (10.5%) and those who did not (9.2%).

The rates of survival with favorable neurologic outcomes also were not significantly different, at 9.8% for the intravenous-drug group and 8.1% for the no-intravenous-drug group, the investigators reported (JAMA 2009;302:2222–9).

In both groups, most patients who died in hospital after initial resuscitation had severe cerebral damage.

It may be that intravenous drug administration represents “unproductive resuscitation of patients whose vital organ injury makes them unlikely candidates for long-term survival,” the researchers wrote.

“If present pharmacological interventions only facilitate cardiac resuscitation in patients who will ultimately experience irreversible cerebral damage, this may cause an additional burden on already overburdened ICUs,” said Dr. Olasveengen and her colleagues.

One encouraging finding was that for the highly trained paramedics in this study, administering intravenous drugs did not interfere with delivery of CPR. Some critics of drug administration have questioned whether the time-consuming and potentially distracting actions of establishing intravenous access and prepping and administering the drugs may detract from delivery of high-quality CPR, they said.

This study was limited in that it was a single-center trial and its results may not be applicable to other emergency medical systems that have different training, infrastructure, treatment protocols, or quality of CPR.

But the findings do justify undertaking larger trials of the issue, and show that it would not be unethical to withhold intravenous drugs for such a trial, they added.

Dr. Olasveengen reported receiving speakers fees from Medtronic Inc. and research support from Laerdal Medical Corp.

Intravenous drugs given as part of advanced cardiac life support failed to improve long-term survival in the first randomized, controlled trial to test outcomes of this nearly universal procedure, according to a report published in JAMA.

Intravenous epinephrine, atropine, and/or amiodarone are given in almost every case of out-of-hospital cardiac arrest in Western nations, but the use of intravenous epinephrine in this setting is based almost entirely on preclinical evidence.

“Because there are no randomized, controlled studies showing improved survival to hospital discharge with any drugs routinely administered during CPR [cardiopulmonary resuscitation], we concluded such a study was warranted,” said Dr. Theresa M. Olasveengen and her associates at Oslo University Hospital.

They assessed 851 patients who required an ambulance for out-of-hospital cardiac arrest between May 2003 and April 2008.

The study subjects were randomly assigned to receive standard advanced cardiac life support, which included intravenous drug administration (418 patients) or advanced cardiac life support without any intravenous drugs (433 patients).

Initially, short-term survival was better with the IV drugs (40%) than without them (25%), and more patients in the intravenous-drug group (30%) than in the no-intravenous-drug group (20%) survived to ICU admission.

However, this early benefit quickly dissipated, and survival to hospital discharge—the primary outcome measure of this trial—was not significantly different between patients who received intravenous drugs (10.5%) and those who did not (9.2%).

The rates of survival with favorable neurologic outcomes also were not significantly different, at 9.8% for the intravenous-drug group and 8.1% for the no-intravenous-drug group, the investigators reported (JAMA 2009;302:2222–9).

In both groups, most patients who died in hospital after initial resuscitation had severe cerebral damage.

It may be that intravenous drug administration represents “unproductive resuscitation of patients whose vital organ injury makes them unlikely candidates for long-term survival,” the researchers wrote.

“If present pharmacological interventions only facilitate cardiac resuscitation in patients who will ultimately experience irreversible cerebral damage, this may cause an additional burden on already overburdened ICUs,” said Dr. Olasveengen and her colleagues.

One encouraging finding was that for the highly trained paramedics in this study, administering intravenous drugs did not interfere with delivery of CPR. Some critics of drug administration have questioned whether the time-consuming and potentially distracting actions of establishing intravenous access and prepping and administering the drugs may detract from delivery of high-quality CPR, they said.

This study was limited in that it was a single-center trial and its results may not be applicable to other emergency medical systems that have different training, infrastructure, treatment protocols, or quality of CPR.

But the findings do justify undertaking larger trials of the issue, and show that it would not be unethical to withhold intravenous drugs for such a trial, they added.

Dr. Olasveengen reported receiving speakers fees from Medtronic Inc. and research support from Laerdal Medical Corp.

Intravenous drugs given as part of advanced cardiac life support failed to improve long-term survival in the first randomized, controlled trial to test outcomes of this nearly universal procedure, according to a report published in JAMA.

Intravenous epinephrine, atropine, and/or amiodarone are given in almost every case of out-of-hospital cardiac arrest in Western nations, but the use of intravenous epinephrine in this setting is based almost entirely on preclinical evidence.

“Because there are no randomized, controlled studies showing improved survival to hospital discharge with any drugs routinely administered during CPR [cardiopulmonary resuscitation], we concluded such a study was warranted,” said Dr. Theresa M. Olasveengen and her associates at Oslo University Hospital.

They assessed 851 patients who required an ambulance for out-of-hospital cardiac arrest between May 2003 and April 2008.

The study subjects were randomly assigned to receive standard advanced cardiac life support, which included intravenous drug administration (418 patients) or advanced cardiac life support without any intravenous drugs (433 patients).

Initially, short-term survival was better with the IV drugs (40%) than without them (25%), and more patients in the intravenous-drug group (30%) than in the no-intravenous-drug group (20%) survived to ICU admission.

However, this early benefit quickly dissipated, and survival to hospital discharge—the primary outcome measure of this trial—was not significantly different between patients who received intravenous drugs (10.5%) and those who did not (9.2%).

The rates of survival with favorable neurologic outcomes also were not significantly different, at 9.8% for the intravenous-drug group and 8.1% for the no-intravenous-drug group, the investigators reported (JAMA 2009;302:2222–9).

In both groups, most patients who died in hospital after initial resuscitation had severe cerebral damage.

It may be that intravenous drug administration represents “unproductive resuscitation of patients whose vital organ injury makes them unlikely candidates for long-term survival,” the researchers wrote.

“If present pharmacological interventions only facilitate cardiac resuscitation in patients who will ultimately experience irreversible cerebral damage, this may cause an additional burden on already overburdened ICUs,” said Dr. Olasveengen and her colleagues.

One encouraging finding was that for the highly trained paramedics in this study, administering intravenous drugs did not interfere with delivery of CPR. Some critics of drug administration have questioned whether the time-consuming and potentially distracting actions of establishing intravenous access and prepping and administering the drugs may detract from delivery of high-quality CPR, they said.

This study was limited in that it was a single-center trial and its results may not be applicable to other emergency medical systems that have different training, infrastructure, treatment protocols, or quality of CPR.

But the findings do justify undertaking larger trials of the issue, and show that it would not be unethical to withhold intravenous drugs for such a trial, they added.

Dr. Olasveengen reported receiving speakers fees from Medtronic Inc. and research support from Laerdal Medical Corp.