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Trends Over Time in Drug Administration During Adult In-Hospital Cardiac Arrest

Moskowitz, Ari, MD1; Ross, Catherine E., MD2; Andersen, Lars W., MD, MPH, PhD, DMSc3; Grossestreuer, Anne V., PhD4; Berg, Katherine M., MD1; Donnino, Michael W., MD1,4 for the American Heart Association’s Get With The Guidelines – Resuscitation Investigators

doi: 10.1097/CCM.0000000000003506
Clinical Investigation: PDF Only

Objectives: Clinical providers have access to a number of pharmacologic agents during in-hospital cardiac arrest. Few studies have explored medication administration patterns during in-hospital cardiac arrest. Herein, we examine trends in use of pharmacologic interventions during in-hospital cardiac arrest both over time and with respect to the American Heart Association Advanced Cardiac Life Support guideline updates.

Design: Observational cohort study.

Setting: Hospitals contributing data to the American Heart Association Get With The Guidelines–Resuscitation database between 2001 and 2016.

Patients: Adult in-hospital cardiac arrest patients.

Interventions: The percentage of patients receiving epinephrine, vasopressin, amiodarone, lidocaine, atropine, bicarbonate, calcium, magnesium, and dextrose each year were calculated in patients with shockable and nonshockable initial rhythms. Hierarchical multivariable logistic regression was used to determine the annual adjusted odds of medication administration. An interrupted time series analysis was performed to assess change in atropine use after the 2010 American Heart Association guideline update.

Measurements and Main Results: A total of 268,031 index in-hospital cardiac arrests were included. As compared to 2001, the adjusted odds ratio of receiving each medication in 2016 were epinephrine (adjusted odds ratio, 1.5; 95% CI, 1.3–1.8), vasopressin (adjusted odds ratio, 1.5; 95% CI, 1.1–2.1), amiodarone (adjusted odds ratio, 3.4; 95% CI, 2.9–4.0), lidocaine (adjusted odds ratio, 0.2; 95% CI, 0.2–0.2), atropine (adjusted odds ratio, 0.07; 95% CI, 0.06–0.08), bicarbonate (adjusted odds ratio, 2.0; 95% CI, 1.8–2.3), calcium (adjusted odds ratio, 2.0; 95% CI, 1.7–2.3), magnesium (adjusted odds ratio, 2.2; 95% CI, 1.9–2.7; p < 0.0001), and dextrose (adjusted odds ratio, 2.8; 95% CI, 2.3–3.4). Following the 2010 American Heart Association guideline update, there was a downward step change in the intercept and slope change in atropine use (p < 0.0001).

Conclusions: Prescribing patterns during in-hospital cardiac arrest have changed significantly over time. Changes to American Heart Association Advanced Cardiac Life Support guidelines have had a rapid and substantial effect on the use of a number of commonly used in-hospital cardiac arrest medications.

1Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.

2Division of Medicine Critical Care, Department of Medicine, Boston Children’s Hospital, Boston, MA.

3Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.

4Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.

The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, or the National Institutes of Health.

Members of the American Heart Association’s Get With The Guidelines – Resuscitation Investigators are listed in Appendix 1.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by Harvard Catalyst | The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award UL1 TR001102) and financial contributions from Harvard University and its affiliated academic healthcare centers.

Drs. Moskowitz, Berg, and Donnino are supported by the National Institutes of Health (NIH). Dr. Moskowitz was supported by NIH 2T32HL007374-37 and is presently supported by K23GM128005-01. Dr. Ross received funding from American Heart Association (AHA) Get With the Guidelines Young Investigator Award. Dr. Grossestreuer is supported by a KL2/Catalyst Medical Research Investigator Training award (an appointed KL2 award) from Harvard Catalyst | The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award KL2 TR001100). Dr. Berg is supported by K23 HL128814. Dr. Donnino is supported by R01HL136705 and K24HL127101. Drs. Moskowitz, Berg, Grossestreuer, and Donnino hold volunteer roles at the American Heart Association, and they hold volunteer positions at the International Liaison Committee on Resuscitation. Dr. Donnino received funding from a research grant from the AHA (14GRNT20010002). Dr. Andersen has disclosed that he does not have any potential conflicts of interest.

For information regarding this article, E-mail: amoskowi@bidmc.harvard.edu

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