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Impact of Early Intravenous Amiodarone Administration on Neurological Outcome in Refractory Ventricular Fibrillation: Retrospect

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Impact of Early Intravenous Amiodarone Administration on Neurological Outcome in Refractory Ventricular Fibrillation: Retrospect Lee et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:109 https://doi.org/10.1186/s13049-019-0688-1 ORIGINAL RESEARCH Open Access Impact of early intravenous amiodarone administration on neurological outcome in refractory ventricular fibrillation: retrospective analysis of prospectively collected prehospital data Dong Keon Lee1, Yu Jin Kim1, Giwoon Kim2, Choung Ah. Lee3, Hyung Jun Moon4, Jaehoon Oh5, Hae Chul Yang6, Han Joo Choi7, Young Taeck Oh1*† and Seung Min Park1*† Abstract Background: The 2015 AHA guidelines recommend that amiodarone should be used for patients with refractory ventricular fibrillation (RVF). However, the optimal time interval between the incoming call and amiodarone administration (call-to-amiodarone administration interval) in RVF patients has not been investigated. We hypothesized that the time elapsed until amiodarone administration could affect the neurological outcome at hospital discharge in patients with RVF. Methods and results: This study is a retrospective analysis of prospectively collected data. One hundred thirty-four patients were enrolled. In univariate logistic regression, the probability of a good neurological outcome at hospital discharge decreased as the time elapsed until amiodarone administration increased (OR 0.89 [95% CI = 0.80–0.99]). In multivariate logistic regression, the patients who were administered amiodarone in less than 20 min showed higher rates of prehospital ROSC, survival at hospital arrival, any ROSC, survival at admission, survival to discharge, and good CPC at hospital discharge. The call-to-amiodarone administration interval of ≤20 min (OR 6.92, 95% CI 1.72–27.80) was the independent factor affecting the neurological outcome at hospital discharge. Conclusion: Early amiodarone administration (≤ 20 min) showed better neurological outcome at hospital discharge for OHCA patients who showed initial ventricular fibrillation and subsequent RVF. Keywords: Cardiopulmonary resuscitation, Emergency medical services, Ventricular fibrillation, Amiodarone, Prognosis Introduction ‘refractoriness’ (persistent VF after more than three de- The out-of-hospital cardiac arrest (OHCA) patients who fibrillation attempts) [4, 5]. Sakai et al. reported that the present with initial shockable rhythm (ventricular fibril- age-adjusted incidence rate of shock-resistant VF was lation [VF], pulseless ventricular tachycardia) have a 0.4–0.6 per 100,000 people per year [6]. good prognosis [1, 2], but early defibrillation is crucial The 2015 American Heart Association guidelines for these patients [3]. However, there are patients who recommend amiodarone to be used on patients with re- do not respond to electrical defibrillation and present fractory VF (RVF) [7]. Amiodarone is a class III antiar- rhythmic agent (potassium channel blocker) in the * Correspondence: [email protected]; [email protected] Vaughan-Williams classification. It affects ion channels, †Young Taeck Oh and Seung Min Park contributed equally to this work. 1Department of Emergency Medicine, Seoul National University Bundang receptors, and sympathetic activity. It terminates VF by Hospital, 1362082, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, blocking the potassium currents, sodium and calcium Gyeonggi-do, Republic of Korea channels, and α- and β-receptor actions [8]. However, Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lee et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:109 Page 2 of 8 Kudenchuk reported that amiodarone administration re- and those whose cardiac arrest was caused by non- sulted in a higher survival to admission rate without the medical reasons were excluded. improvement of survival at discharge or neurologically The primary outcome was the neurological outcome intact survival in RVF patients [9]. at hospital discharge according to the time elapsed until Regarding epinephrine, a correlation between the time amiodarone administration, and the secondary outcomes of epinephrine administration and the neurological out- were the prehospital return of spontaneous circulation come was observed, with early intravenous (IV) epineph- (ROSC), total ROSC, survival at admission, and survival rine administration resulting in a better neurological to discharge according to the time elapsed until amioda- outcome in OHCA with VF [10]. However, there has rone administration. been no study on the time of amiodarone administration The Good-CPC group was defined as those patients and its association with neurological prognosis. whose cerebral performance category (CPC) score was 1 Therefore, we hypothesized that the time elapsed until or 2 at hospital discharge, and the Poor-CPC group in- amiodarone administration could affect the neurological cluded those patients who had a CPC of 3–5 at hospital outcome at hospital discharge in patients with RVF. discharge. The CPC score was assessed by emergency physicians at hospital discharge. Method Study protocol We performed a retrospective analysis of prospect- Data collection ively collected OHCA data. In South Korea, when a We collected Utstein variables, including age, gender, suspected cardiac arrest victim was reported to emer- pathogenesis, arrest location, witnessed arrest, first mon- gency medical services (EMS), at least two emergency itored rhythm, bystander cardiopulmonary resuscitation medical technician (EMT) teams are dispatched to (CPR), response time, defibrillation time, number of perform ALS under the emergency physician’smed- shocks, call-to-amiodarone administration interval, call- ical control with a video call. The two CPR teams to-epinephrine administration interval, prehospital are consistent with a total of 4 to 6 persons, includ- ROSC, survival at hospital arrival, any ROSC, survival at ing at least two level-1 EMT and the others were admission, and survival to discharge. Level-2 EMT or nurses. The level-1 EMTs corres- Pathogenesis was defined as the most likely primary pond to EMT paramedics in the United States of cause of the cardiac arrest and was recorded as med- America; they are allowed to insert an IV catheter ical/traumatic cause/drug overdose/drowning/electro- and an advanced airway tube but only under an cution/asphyxia/not recorded. The arrest location was emergency physician’s medical control. Level-2 EMTs defined as the specific location where the event oc- correspond to EMT basic [11]. ALS was performed curred or where the patient was found. It was re- according to the 2015 guidelines of the American corded as public or non-public. The first monitored heart association (AHA). When VF was seen, rapid rhythm was defined as the first cardiac rhythm defibrillation was performed, and if VF persisted present when the monitor or defibrillator was at- despite three attempts of defibrillation, 300 mg of tached to the patient after a cardiac arrest, and it was amiodarone mixed with 5% dextrose 30 cc were ad- recorded as VF/pulseless VT/PEA/asystole. Bystander ministered to the patient under the emergency physi- CPRwasdefinedasCPRperformedbyapersonwho cian’s medical direction. If VF persisted after 300 mg did not respond as part of an organized emergency of amiodarone was injected, an additional 150 mg of response system to a cardiac arrest. The response amiodarone was administered. time was defined as the time interval between the in- This study was approved by the Institutional coming call and the time when the first emergency Review Board (IRB) of Seoul National University response vehicle stopped at a point closest to the pa- Bundang Hospital (IRB approval number: B-1904- tient’s location. The defibrillation time was defined as 537-103) and reported according to the STROBE the time interval between the incoming call and the (Strengthening the Reporting of Observational Stud- time when the first shock was delivered. The number ies in Epidemiology) guidelines for reporting obser- of shocks was defined as the number of shocks deliv- vational trials [12]. ered [13]. Prehospital ROSC was defined as the achievement Patients enrollment and outcomes of ROSC at any point during the prehospital resusci- Patients who presented with initial ventricular fibrilla- tation attempt, and any ROSC was defined as the tion and subsequent RVF were included. RVF was de- achievement of ROSC at any point during the entire fined as VF that was not terminated after three resuscitation attempt. Survival at hospital arrival was defibrillation attempts. Patients younger than 18 years defined as the patients’ being alive upon arrival at Lee et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:109 Page 3 of 8 the hospital, and survival to discharge was defined as Result the patients’ being alive when they were discharged. There were 11,210 cardiac arrest patients during the The call-to-amiodarone administration interval study period, and a total
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