Efficacy of Adrenaline in Out-of-Hospital Cardiac Arrest
Levels of evidence
Issues with Prior Studies
Efficacy of Adrenaline in Out-of-hospital Cardiac Arrest
Levels of evidence
Randomized control trials
Randomized clinical blinded trial
This objective of this paper was to find out whether adrenaline is efficient in out-of-hospital patient. Therefore, information here within can be of help to investigators on the same, students and any other reader. The study uses simple English, which makes it understandable to a wide variety of readers.
For this study, the electronic databases including Pub Med, EmBase, Medline, Cochrane, and Google Scholar were searched to identify relevant literature. The study used some search terms for the strategy such as, "efficacy of adrenaline, effectiveness of norepinephrine and the effectiveness of vasopressor" and "heart arrest, cardiac arrest and therapy," "cardiopulmonary resuscitation, cerebral resuscitation" to retrieve relevant literature.
In this study, the identified studies were those of empirical studies. Even though it is not possible to conduct studies, which are free of limitations, the study included studies that followed research designs that could lead to empirical data. In addition, studies, which coincided with the following criteria, for example, human studies, controlled trials, meta-analyses and case studies.
Consequently, studies were excluded when the study failed to have an abstract, if the abstract existed, but it had no study, the reference was a non-English abstract, the investigation in the study was an animal trial, the study was a case report, the study was a literature review and the vasopressor was used in the treatment of traumatic cardiac arrest.
There is evidence that has shown adrenaline was a historical drug. Currently, it is still in use for the same purpose as before; in cardiac arrest patients. However, despite this usage since 1896, there is still no enough evidence on its influence on out-of-hospital cardiac arrest patients. Therefore, this study aims to address whether adrenaline is effective, and the information relies greatly on a number of prior studies.
For this study, information was retrieved from relevant paper through a search on Pub Med, EmBase, Medline, Cochrane and the Google Scholar. Terms including "efficacy of adrenaline, effectiveness of norepinephrine and the effectiveness of vasopressor" and "heart arrest, cardiac arrest and therapy," "cardiopulmonary resuscitation, cerebral resuscitation" were central in this study.
The search yielded a mixture of studies, ranging from cohort, randomized clinical trials, observational and they showed similar results in terms of improved short-term outcomes, and circulation, but mixed results on the efficacy of adrenaline in out-of-hospital in cardiac arrest patients.
From the literature, it was evident that cardiac arrest is a significant health problem in the globe. In addition, there are a number of studies reporting on the use of adrenaline in out-of-hospital patients, but the mixed results on the same has raised concerns and scrutiny of the methodologies employed by the investigators. However, results are consistent and there is inadequate evidence to support the efficacy of adrenaline. Nonetheless, there is room for future research to ascertain the same.
Cardiac arrest is a global medical issue with very poor prognosis. For example, in United States, studies report that the incidences of cardiac arrest ranges from 165,000 to 450,000 in a year. In the same context, survival to hospital discharge in events of pre-hospital cardiac arrests is around 5-8% in the United States, and in the globe, the survival rate is less than 1%. Moreover, in-hospital arrest, the incidences of survival are better because they are around 12%. Nonetheless, the overall survival incidents for both in and out of hospital remain poor (1). In addition, survival without adverse neurological impairment is still low, and has not improved over the past few decades.
Conversely, adrenalines has been widely utilized in cardiac arrest for more than ten decades, but have attracted diverse controversies, mainly because of their association with negative effects (2). The controversies are further widening in scope because there is evidence, which supports that adrenaline can be a potential promising alternative vasopressor to use in case of cardiac arrest. In this regard, there are substantial clinical trials, which have demonstrated that the adrenaline has improved survival rates. Until recently, the promising advantages of the drug have attracted attention from investigators. Some human studies have also shown improved survival rates after patients used the drug for cardiac arrest.
What even calls for further research is the emerging evidence, which suggests that the use of adrenaline in cardiac arrest has shown poor neurologic and survival rate. The evidence shows that the drug has associations with adverse alterations in cerebral perfusion, microculation and myocardial function post-arrest. Therefore, although there is a large body of research concerning the topic, it is apparent that there is no conclusive evidence about the effectiveness of adrenaline in patients with out of hospital cardiac arrest (5, 8). On the other hand, it is not clear if pre-hospital use of adrenaline has benefits in long-term prognoses, which remains inconclusive; however, the use of adrenaline is effective in terms of returning spontaneous circulation.
In comparison, randomized control trials have suggested that pre-hospital adrenaline improves survival rates, whereas observational studies have suggested the exact opposite. The contradictory outcomes from studies may be due to methodological flaws (15). In this context, the randomized trials may be underpowered, whereas the observational studies may not have been capable of adjusting in time dependent imbalance (20). A few studies, on the other hand, have focused on timing, and then shown that timing in the administration of adrenaline could influence the outcomes. Prior studies ignored the potential use of adrenaline in the hospital and without such data, assessing of the pharmacological influence of adrenaline becomes unachievable.
Apparently, most of the early studies, which assessed the effect of adrenaline in the adult out-of-hospital cardiac arrest, were primarily observational studies. The studies often examined the variations in ROSC, survival rates and neurological outcomes amid OHCA patients treated through administration of adrenaline, and patients treated without adrenaline, within the same study (3). A particular study showed that there was a link between decreased survival rates when in case of adrenaline administration. There was another category of observational studies that aimed to show modifications in cardiac arrest guidelines to make it possible for administration of adrenaline (4). This was in Japan, where administration of adrenaline was only permissible for the patients who physicians attended to by a physician-manned ambulance.
The adrenaline treated cohort of 15030 patients was then put in comparison with patients not treated with adrenaline. In the results, it is clear that there was a one month reduction of survival rates in the patients who went through treatment by administration of adrenaline (4). However, there were cases of poor effects in the context of neurological results, particularly in cerebral performance, but there was improved ROSC for the group treated with adrenaline. In another study conducted in Singapore to examine the effects of treating patients with adrenaline, the study did not find any significant variations between the treated and untreated group of patients (5).
Another observational study in Japan, which aimed to compare regions where emergency departments involved manning (where there was no administration of adrenaline), and where the physician manned emergency departments, and in this case, they could administer adrenaline. Similarly, there was no significant difference noted in the two studies (6). Evidence shows that there is an association between adrenaline and increased ROSC. In this regard, the clinical significance of this result is inconclusive with several studies reporting either no improvement or a reduction in survival rates to hospital discharge, or a reduction in significant neurological results (4).
In a randomized trials of adrenaline in relation to cardiac arrest, the study illustrated that adrenaline resulted to an increase in ROSC, but not in the outcomes of survival rates to hospital discharge. The findings are in line with the observational and non-randomized trials; however, there is a need for randomized trials in humans to allow for direct comparison and generalization (7). In an intravenous drug administration in comparison to no such intervention during cardiac arrest, prior studies suggest that there were many patients who achieved ROSC and a non-significant increase in the survival rates of hospital discharge (8).
In a particular randomized study, this specifically aimed to investigate the survival outcomes in HDE vs. SDE vs. placebo in all the patients, who presented in either asystole or VF arrest. In the study design, investigators conducted randomized trials, and blinded patients to receive HDE (10 mg) or placebo (saline) in the first 5-10 minutes of cardiac arrest, followed by 1 mg doses of adrenaline in accordance to the ACLS requirements at the time. The findings, however, showed results, which were consistent with prior studies. The authors showed that there was no difference in the survival rates, including hospital discharge between any of the groups.
In another retrospective study, this aimed at examining patients with VF arrest…