Consensus on Science with Treatment Recommendations (CoSTR)
Thank-you for your feedback. I will discuss and consider all your comments with my colleagues on the ILCOR ALS Task Force and post a response in the next few weeks. Regards, Jas. Jasmeet Soar ALS Task Force Chair
Thank-you for your feedback. I will discuss and consider all your comments with my colleagues on the ILCOR ALS Task Force and post a response in the next few weeks. Regards, Jas.
Jasmeet Soar ALS Task Force Chair
Good guidelines, except that you recommend supraglottic airway only in low intubation success settings. You suggest that the Wang and also Benger trials have low success rates (51.6% and 69.8%) and the Jabre as high (97.9%). So low success is more-or -less defined here as 50 to 70%? If a service has a success rate in the70’s or 80’s they would not be low by your informal definition. Should these services stick with intubation? I believe not. An intubation success rate in cardiac arrest that is anywhere in the 70’s or 80’s is still poor, and this tells you that these clinicians cannot competently use intubation. Only when success proportions approach mid to high 90’s such as in the Jabre trial can you say competent intubation takes place. I would prefer stronger recommendations here. If clinicians cannot intubate successfully (similar to Benger et al.) then they should be using supraglottic airways.
A good attempt to bring clarity to a long standing problem.
ABC is a well recognised mantra but in CA it’s the C in the form of continuous compressions that has proven benefits.
I think this helps to concentrate attention on compressions and airway techniques employed depend upon the skill set of the operator.
The gold standard remains tracheal intubation, in skilled hands.
The BVM options of one or two hands could do with some good evidence to clarify the best way forward but likely again to be operator dependent particularly for those unfamiliar with the device.
Is there any high-quality evidence comparing no airway intervention with any airway intervention which shows a significant improvement by adding an airway intervention?
We need to stop creating problems that do not benefit the patients.
Stop encouraging airway management where airway management has not been clearly demonstrated to improve outcomes over the passive ventilation provided by chest compressions only.
The CoSTR of airway was nicely written. It will give us a room in the national Resuscitation councils when writing the guidelines particularly for the out-of- hospital management of airway. With consideration of training of EMTs and Paramedics and the time of arrival of EMS services.
Thank you to the committee for tackling this subject. Obviously, it is very difficult to make any recommendation based on what was written. There are no definitions of high vs low tracheal intubation success rates; the same conclusions were drawn for out-of-hospital cardiac arrest as for in-hospital cardiac arrest using the same patient population (I'm confused about how those numbers add up); and it's difficult to compare when the advanced airway management could have occurred at any time during the resuscitation attempt. Based on the 2010 guidelines, and reinforced in the 2015 guidelines, continuous chest compressions are a key to ROSC. Insertion of the advanced airway early in the resuscitation should therefor allow for an earlier onset of continuous compressions and should yield a higher rate of ROSC, and hopefully a higher discharge rate. In order to determine this, I believe we need to look at the sequence of events in a resuscitation and program them. Otherwise, we will continue to have "very low" evidence recommendations which really don't provide clinicians with much guidance.
We thank ILCOR and the ALS Task Force for inviting comment on the draft consensus on science and treatment recommendations on the use of vasopressors for cardiac arrest.
As authors of the PARAMEDIC2 study we wish to share the following insights.
The Core Outcome Set for Cardiac Arrest (COSCA) highlights the difficulty of identifying the optimal time for measuring neurological outcomes after cardiac arrest. Assessment at hospital discharge has the advantage of ease of data collection but does not allow sufficient time for any functional recovery to occur over the months ahead. Follow-up at 3 to 12 months may provide a more stable assessment of long term outcomes, but is limited by loss to follow-up. This increases the risk of attrition bias as those with worse outcomes are more likely to be lost to follow-up.[3, 4]
In PARAMEDIC2, loss to follow-up amongst survivors at hospital discharge was 5 (4%) in the placebo group and 8 (6%) in the adrenaline group. By 3 months this had increased to 20 (23%) in the placebo and 29 (24%) in the adrenaline group. Sensitivity analyses exploring the different possible reasons for loss to follow-up are contained in the electronic supplemental material presented with the main paper.
Our assessment of the PARAMEDIC2 data on longer term outcomes is that adrenaline increases survival with both good and poor neurological outcomes. The overall effect is small (0.8% absolute difference in survival). Resource use is high – extrapolating PARAMEDIC2 data across the UK National Health Service, the use of adrenaline in out of hospital cardiac arrest contributes to 3555 additional hospital admissions each year (1643 ITU admissions, for 5143 ICU days) for 68 additional survivors with a favourable neurological outcome and 135 with an unfavourable neurological outcome at hospital discharge. We suggest the cost to health care systems should be highlighted in the undesirable effects section of the evidence to decision framework.
The balance of survival, survival with a favourable neurological outcome and survival with an unfavourable neurological outcome will mean different things to different people and will likely vary between communities. We suggest it should be noted in the evidence to decision tables that societal values and preferences may vary and should inform the treatment recommendations in different settings. Furthermore, our lack of knowledge about patient and public preferences for outcomes should be specifically identified as a knowledge gap.
The presence of resuscitation time bias limits the interpretation of observational studies which seek to evaluate the influence of time to treatment. Our preliminary analyses of time to treatment in PARAMEDIC2, support the recommendation, that if adrenaline is going to be given, it is better given as soon as possible. We did not find evidence of an interaction favouring early administration by shockable or non-shockable rhythms, but note the difficulty in interpretation of the shockable rhythm data (as some patients will convert to a non-shockable rhythm after the first attempt at defibrillation). In the PARAMEDIC2 trial, treatment protocols recommended deferring adrenaline until after the third attempt at defibrillation for patients with shockable rhythms.[6, 7]
The findings for the ILCOR review and consensus on science is broadly similar to our Cochrane review of vasopressors for cardiac arrest. Small differences are noted which appear to relate to whether a random effects or fixed effects Mantel-Haenszel meta-analysis was performed. These differences do not materially affect interpretation.
Data on adjusted analyses are presented in both the PARAMEDIC2 and PACA trial publications should the Task Force wish to use these in the meta-analysis as has been performed in other ILCOR consensus on science reviews.
Finally, we believe the PARAMEDIC2 trial highlights the importance of the community response to cardiac arrest (early access (NNT 11), early bystander CPR (NNT 15), early defibrillation(NNT 5). PARAMEDIC2 and this ILCOR review draws attention to the gap in our knowledge around treatments that can enhance neurological recovery after cardiac arrest. It highlights the urgent need for further research to ensure both successful cardio and cerebral recovery.
Clinical Trial Registration: ISRCTN73485024
This project was funded by the NIHR HTA Programme (ref 12/127/126). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
1. Perkins GD, Ji C, Deakin CD, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med 2018;379(8):711-21. doi: 10.1056/NEJMoa1806842 [published Online First: 2018/07/19]
2. Haywood K, Whitehead L, Nadkarni VM, et al. COSCA (Core Outcome Set for Cardiac Arrest) in Adults: An Advisory Statement From the International Liaison Committee on Resuscitation. Resuscitation 2018;127:147-63. doi: 10.1016/j.resuscitation.2018.03.022 [published Online First: 2018/05/01]
3. Nichol G, Guffey D, Stiell IG, et al. Post-discharge outcomes after resuscitation from out-of-hospital cardiac arrest: A ROC PRIMED substudy. Resuscitation 2015;93:74-81. doi: 10.1016/j.resuscitation.2015.05.011
4. Ji C, Lall R, Quinn T, et al. Post-admission outcomes of participants in the PARAMEDIC trial: A cluster randomised trial of mechanical or manual chest compressions. Resuscitation 2017;118:82-88. doi: 10.1016/j.resuscitation.2017.06.026 [published Online First: 2017/07/10]
5. Andersen LW, Grossestreuer AV, Donnino MW. "Resuscitation time bias"-A unique challenge for observational cardiac arrest research. Resuscitation 2018;125:79-82. doi: 10.1016/j.resuscitation.2018.02.006 [published Online First: 2018/02/10]
6. Soar J, Nolan JP, Bottiger BW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation 2015;95:100-47. doi: 10.1016/j.resuscitation.2015.07.016
7. Soar J, Deakin C, Lockey A, et al. Adult advanced life support. 2015. https://www.resus.org.uk/resuscitation-guidelines/adult-advanced-life-support/.
8. Finn J, Jacobs I, Williams TA, et al. Adrenaline and vasopressin for cardiac arrest. Cochrane Database Syst Rev 2019;1:CD003179. doi: 10.1002/14651858.CD003179.pub2 [published Online First: 2019/01/18]
9. Jacobs IG, Finn JC, Jelinek GA, et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation 2011;82(9):1138-43. doi: S0300-9572(11)00405-9 [pii]
10.1016/j.resuscitation.2011.06.029 [published Online First: 2011/07/13]
I am not convinced that epinephrine should be routinely administered. There are cost implications to the use of the drug itself. There are huge costs (fiscal and suffering, for healthcare systems/ relatives/ patients) implications to caring for people with poor neurological outcome even to hospital discharge, and beyond. I doubt that this cost is worthwhile given the few who may survive with good neuro-outcome. I am not sure that the suffering faced by those who do badly can be traded for the good outcome for others.
In remote areas where the first responder with health care training is likely to be a nurse, and sometimes no-one else with adequate training, a supraglottic airway is feasible and makes CPR simpler. Endotracheal tube is usually outside their scope of practice, and juggling a bag valve mask with chest compressions wastes time.