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Impact of Early Vasopressor Administration on Neurological Outcomes after Prolonged Out-of-Hospital Cardiac Arrest

Published online by Cambridge University Press:  22 February 2017

Michael W. Hubble  and
Clark Tyson
Michael W. Hubble*
Affiliation:
Emergency Medical Care Program, School of Health Sciences, Western Carolina University, Cullowhee, North CarolinaUSA
Clark Tyson
Affiliation:
Center for Educational Excellence, Duke Clinical Research Institute, Durham, North CarolinaUSA
*
Correspondence: Michael W. Hubble, PhD, MBA, NREMT-P Emergency Medical Care Program School of Health Sciences Room 404 Health and Human Sciences Building 3971 Little Savannah Road 1 University Drive Western Carolina University Cullowhee, North Carolina 28723 USA E-mail: mhubble@email.wcu.edu
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Abstract

Introduction

Vasopressors are associated with return of spontaneous circulation (ROSC), but no long-term benefit has been demonstrated in randomized trials. However, these trials did not control for the timing of vasopressor administration which may influence outcomes. Consequently, the objective of this study was to develop a model describing the likelihood of favorable neurological outcome (cerebral performance category [CPC] 1 or 2) as a function of the public safety answering point call receipt (PSAP)-to-pressor-interval (PPI) in prolonged out-of-hospital cardiac arrest.

Hypothesis

The likelihood of favorable neurological outcome declines with increasing PPI.

Methods

This investigation was a retrospective study of cardiac arrest using linked data from the Cardiac Arrest Registry to Enhance Survival (CARES) database (Centers for Disease Control and Prevention [Atlanta, Georgia USA]; American Heart Association [Dallas, Texas USA]; and Emory University Department of Emergency Medicine [Atlanta, Georgia USA]) and the North Carolina (USA) Prehospital Medical Information System. Adult patients suffering a bystander-witnessed, non-traumatic cardiac arrest between January 2012 and June 2014 were included. Logistic regression was used to calculate the adjusted odds ratio (OR) of neurological outcome as a function of PPI, while controlling for patient age, gender, and race; endotracheal intubation (ETI); shockable rhythm; layperson cardiopulmonary resuscitation (CPR); and field hypothermia.

Results

Of the 2,100 patients meeting inclusion criteria, 913 (43.5%) experienced ROSC, 618 (29.4%) survived to hospital admission, 187 (8.9%) survived to hospital discharge, and 155 (7.4%) were discharged with favorable neurological outcomes (CPC 1 or 2). Favorable neurological outcome was less likely with increasing PPI (OR=0.90; P<.01) and increasing age (OR=0.97; P<.01). Compared to patients with non-shockable rhythms, patients with shockable rhythms were more likely to have favorable neurological outcomes (OR=7.61; P<.01) as were patients receiving field hypothermia (OR=2.13; P<.01). Patient gender, non-Caucasian race, layperson CPR, and ETI were not independent predictors of favorable neurological outcome.

Conclusion

In this evaluation, time to vasopressor administration was significantly associated with favorable neurological outcome. Among adult, witnessed, non-traumatic arrests, the odds of hospital discharge with CPC 1 or 2 declined by 10% for every one-minute delay between PSAP call-receipt and vasopressor administration. These retrospective observations support the notion of a time-dependent function of vasopressor effectiveness on favorable neurological outcome. Large, prospective studies are needed to verify this relationship.

HubbleMW, TysonC. Impact of Early Vasopressor Administration on Neurological Outcomes after Prolonged Out-of-Hospital Cardiac Arrest. Prehosp Disaster Med. 2017; 32(3):297–304.

Keywords

cardiac arrestEmergency Medical Servicesepinephrineparamedicresuscitation
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 32 , Issue 3 , June 2017 , pp. 297 - 304
Copyright
© World Association for Disaster and Emergency Medicine 2017 

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Footnotes

Conflicts of interest: The authors report no conflicts of interest. The North Carolina (USA) Office of Emergency Medical Services (EMS) and the North Carolina EMS Data System supports state, regional, and local EMS and health care-related service delivery from a patient care, resource allocation, and regulatory perspective. This manuscript was not prepared in collaboration with investigators of the North Carolina EMS Data System and does not necessarily reflect the opinions or views of the North Carolina Office of EMS, EMS Performance Improvement Center, or the study sites participating in the North Carolina EMS Data System. The authors alone are responsible for the content and writing of the paper.

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