Journal reading. Method. Introduction. Measurement. Supervisor: F1 徐 英 洲 Presentor:R1 劉 邦 民

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1 Journal reading Supervisor: F1 徐 英 洲 Presentor:R1 劉 邦 民 Introduction Epinephrine usage in CPR Pro: Ability to augment BP and increased coronary perfusion through systemic vasoconstriction Cons: detrimental effect (due to adrenoreceptor stimulation) heart during ischemia Reperfusion after ROSC Previous studies Unproven survival benefit High dose(5 10 mg) vs standard dose(1 mg): no improved survival Frequency of epinephrine affected survival:? q3 5 min based on expert opinion investigate the association epinephrine dosing period and survival to discharge in IHCA p t Method Database: GWTG(Get With the Guidelins) Resuscitation registry (multi center registry of patient with IHCA) The exact time of the first IV/IO epinephrine total number of epinephrine doses (not the exact time) 2000/01/ /11/23 Adult inpatient in general hospital ward bed or ICU Patient with multiple cardiac arrest event: include the first event At least two epinephrine doses usage Exclusion: vasopressor other than epinephrine use, outlier epinephrine average dosing period(<1 min, >10min), data cannot determined epinephrine average dosing period patient Measurement Epinephrine average dosing period (total epinephrine dose 1)/ duration (since first dose to CPR end point) 1 to < 3 min/dose, 3 to < 4 min/dos, 4 to < 5 min/dose, 5 to <6 min/dose, 9 to <10 min/dose Time period before first dose of epinephrine was not calculated Total epinphrine average dosing period total epinephrine doses/ total cardiac arrest duration 4 to < 5 min/dose category: reference catergory Hypothermia: out of the regression model Cubic splines statistic model :Cardiac arrest duration and time to first epinephrine ()

2 Investigation Primary: Association between epinephrine average dosing period and survival to discharge Secondary analysis Shockable rhythm: time to defibrillation added to model Repeated sequentially after culling Cardiac arrest of >60 min >50 min.. >20 min Time to first epinephrine dose >30 min >20 min >10min Result Baseline characteristics Mean age: 68±16 years, 61 % male Race: 68% white, 23% black Admission illness: 53% medical noncardiac, 27% medical cardiac cardiac rhythm: asystole(46%), PEA(39%), Shockable rhythm(<13 %) Mean cardiac arrest duration: 19±10 min ROSC: 7558 patient Survival to hospital discharge: 1470 patient P<0.001

3 P<0.001 Survival discharge by category of epinephrine average dosing period for IHCA of duration less than 20 min Results(secondary analysis) Epinephrine average dosing period and survival to hospital discharge Cardiac arrest due to shockable rhythm: similar pattern(p<0.001) Cardiac arrest due to nonshockable rhythma: similar pattern(p<0.001) Repeated sequentially after culling Cardiac arrest of greater duration: similar pattern Higher average dosing period vs consensus guidline: improved survival Consistent for both shock and nonshockable rhythm Epinephrine average dosing period of 1 to <3 min lowest rate of survival Possible reason: potential harmful effect of cumulative epinephrine dose on postresuscitation physiology (eg: cerebral perfusion) Without adjustment for duration of cardiac arrest The pattern of association between epinephrine average dosing period and survival to discharge: similar to that of unadjusted model Duration of cardiac arrest was clearly the most influential covariate in this analysis Limitation The consistency of dosing period throughout the duration of cardiac arrest remain unknown(no moment to moment information) Time data were self reported by hospitals and inaccuracies may exist Unable to account for epinephrine dose amount in addition to dose frequency Unable to adjust for post resuscitation hypothermia treatment Study took place over two separate guideline time frame( and ) The results may not generalizable to other population (children and OHCA) or hospital location other than general ward/icu 14.9% missing value (Cerebral performance score) inability to discussion around the impact of epinephrine dosing on cerebral perfusion

4 Conclusion less frequent average epinephrine dosing than recommended by consensus guidelines was associated with improved survival of in hospital cardiac arrest Method Data source: MEDLINE, EMBASE, Web of Science, and the Cochrane Library, /11 Study selection: Randomized and observational studies total body CT with screening imaging VS selective CT in adult trauma patients Two independent reviewers 1585 title 9 full text review 4 article included Data extraction and synthesis Methodological quality by Newcastle Ottawa Scale Mortality: Odds ratios with 95% confidence intervals (CIs) Newcastle-Ottawa Scale 0 9 分 Result All 4 were retrospective cohort study One large study(multicenter): 84.5% of total patient Absolute mortality No significant difference between group Largest study: decreased in mortality with whole body CT when adjusting for injury severity score Reduction in time to disposition Potential drawback of routine whole body scan Increased radiation exposure and cost Previous studies: significant radiation small but measurable increase in lifetime cancer related mortality

5 Conclusion it is important to develop a triage strategy for whole body CT that ensures that only patients most likely to benefit receive the extra radiation dose Design limitation of the studies preclude making any definitive inference to the effect of immediate whole body CT scan on mortality or time to disposition REACT 2(Randomized study of Early Assessment by CT scanning in Trauma patients) Multicenter RCTs April 2011~, Results are expected in mid 2014 Thanks for your attention!!