Sir,
The recent publication of the 2017 update on the European Resuscitation Council’s (ERC) Guidelines for Resuscitation stresses the scale and pace of new findings in resuscitation science [
[1]
]. This progress is regularly being summarized by the International Liaison Committee on Resuscitation (ILCOR) that emphasizes the importance of a continuous data review in order not to delay the implementation of new guideline suggestions. With this year’s update the ILCOR-statement did not give the ERC grounds to build new suggestions concerning advanced life support (ALS) on. The updated ERC guidelines concentrate on BLS, pediatric care and ventilation, however not addressing the controversially discussed topic of pharmacotherapy during ALS [[1]
].Level of evidence in literature
The routine administration of epinephrine and amiodarone still seem to be set in stone although once again challenged by new scientific data. While results of the PARAMEDIC-2-trial comparing epinephrine to placebo are still not available, continuous reports suggest only limited benefit of the routine use of epinephrine during resuscitation. While epinephrine may enhance the likelihood of return of spontaneous circulation (ROSC) in patients with cardiac arrest, both large cohort studies and randomized controlled trials (RCTs) proved to have no effect on survival to hospital discharge or favorable neurological outcome [
[2]
]. Of alarming importance, recent data were even able to demonstrate that the cumulative dose of epinephrine during resuscitative attempts is associated with an increased likelihood of poor neurological outcomes [[3]
]. A recent study on the effects of epinephrine on cerebral oxygenation (rSO2) during resuscitation gives a possible explanation, stating that epinephrine did not beneficially influence rSO2 levels [[4]
]. Moreover, data on the effect of epinephrine on long-term survival remain scare and inconclusive.Similar results apply for the use of Amiodarone in patients with cardiac arrest and shock-refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT). In a large, double-blind RCT of the Resuscitation Outcomes Consortium Investigators, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival to hospital discharge or favorable neurologic outcome than the rate with placebo among patients with shock-refractory VF or pVT [
[5]
].Primum non nocere
The current treatment recommendations of the ERC guidelines on adult advanced life support are mainly based on underpowered observational trials. However, since the publication of those guidelines in 2015, several highly powered trials with a strong level of evidence are now available in literature. Of note, those trials were not mentioned in the 2017 update. Moreover, there is no evidence of the effect of both Epinephrine and Amiodarone on the patient outcome from a long-term perspective that proves their safety and justify an application. Since recent data highlighted no therapeutic benefit of Amiodarone on survival to discharge and even proved an inverse effect on favorable neurological outcome of Epinephrine, the recommended pharmacological treatment approach during resuscitative attempts needs to be questioned in a critical fashion within future guidelines on adult advanced life support.
Conflict of interest
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Funding information
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References
- European resuscitation council guidelines for resuscitation:2017 update.Resuscitation. 2018; 123: 43-50
- Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.JAMA. 2009; 302: 2222-2229
- Is epinephrine during cardiac arrest associated with worse outcomes in resuscitated patients?.J Am Coll Cardiol. 2014; 64: 2360-2367
- Effects of epinephrine on cerebral oxygenation during cardiopulmonary resuscitation: a prospective cohort study.Resuscitation. 2016; 109: 138-144
- Amiodarone: lidocaine, or placebo in out-of-hospital cardiac arrest.N Engl J Med. 2016; 374: 1711-1722
Article info
Publication history
Published online: May 04, 2018
Accepted:
February 14,
2018
Received:
February 11,
2018
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Copyright
© 2018 Published by Elsevier B.V.
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- Guidelines 2017 update: response to “In mountain and rural areas all CPR providers should perform chest compressions and rescue breaths for patients in cardiac arrest” and “Pharmacotherapy during cardiac arrest — When evidence-based data failed to be implemented in clinical practice guidelines”ResuscitationVol. 130
- PreviewWe thank Wallner [1], Schnaubelt et al. [2] for their interest in the European Resuscitation Council 2017 Guideline Update [3]. The 2017 update focused on the relationship between chest compressions and ventilations during CPR. It followed the publication of the International Liaison Committee on Resuscitation (ILCOR) Consensus on Science with Treatment Recommendations (CoSTR) on this topic [4]. The ILCOR review provided an update on evidence in relation to dispatcher-assisted CPR, bystander CPR in adults and children, Emergency Medical Services delivered CPR, compression to ventilation ratio and in-hospital CPR.
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