title: Impact of Early Vasopressor Administration on Neurological Outcomes after Prolonged Out-of-Hospital Cardiac Arrest.
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.
  
  
  CONCLUSIONS
  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. Hubble MW , Tyson C . Impact of early vasopressor administration on neurological outcomes after prolonged out-of-hospital cardiac arrest. Prehosp Disaster Med. 2017; 32(3):297-304.
authors.affiliation: 1Emergency Medical Care Program,School of Health Sciences,Western Carolina University,Cullowhee,North CarolinaUSA.
authors.forename: Michael W
authors.initials: MW
authors.lastname: Hubble
authors.affiliation: 2Center for Educational Excellence,Duke Clinical Research Institute,Durham,North CarolinaUSA.
authors.forename: Clark
authors.initials: C
authors.lastname: Tyson
mesh_terms: D000368:Aged; D016887:Cardiopulmonary Resuscitation; D004334:Drug Administration Schedule; D004554:Electric Countershock; D004632:Emergency Medical Services; D005260:Female; D023261:Glasgow Outcome Scale; D006801:Humans; D007442:Intubation, Intratracheal; D008297:Male; D058687:Out-of-Hospital Cardiac Arrest / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D020127:Recovery of Function; D012042:Registries; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States; D014662:Vasoconstrictor Agents / Q000008:administration & dosage*; D014667:Vasopressins / Q000008:administration & dosage*
chemical_list: D014662:Vasoconstrictor Agents; D014667:Vasopressins
keywords:  BIAD blind insertion airway device;  CARES Cardiac Arrest Registry to Enhance Survival;  CPC cerebral performance category;  CPR cardiopulmonary resuscitation;  ECG electrocardiogram;  EMS Emergency Medical Services;  ETI endotracheal intubation;  IO intraosseous;  IV intravenous;  PPI PSAP-to-pressor interval;  PSAP public safety answering point;  PreMIS Prehospital Medical Information System;  ROSC return of spontaneous circulation; Emergency Medical Services; cardiac arrest; epinephrine; paramedic; resuscitation