Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest: A Randomized Trial

Abstract

CONTEXT: Intravenous access and drug administration are included in advanced cardiac life support (ACLS) guidelines despite a lack of evidence for improved outcomes. Epinephrine was an independent predictor of poor outcome in a large epidemiological study, possibly due to toxicity of the drug or cardiopulmonary resuscitation (CPR) interruptions secondary to establishing an intravenous line and drug administration. OBJECTIVE: To determine whether removing intravenous drug administration from an ACLS protocol would improve survival to hospital discharge after out-of-hospital cardiac arrest. DESIGN, SETTING, AND PATIENTS: Prospective, randomized controlled trial of consecutive adult patients with out-of-hospital nontraumatic cardiac arrest treated within the emergency medical service system in Oslo, Norway, between May 1, 2003, and April 28, 2008. INTERVENTIONS: Advanced cardiac life support with intravenous drug administration or ACLS without access to intravenous drug administration. MAIN OUTCOME MEASURES: The primary outcome was survival to hospital discharge. The secondary outcomes were 1-year survival, survival with favorable neurological outcome, hospital admission with return of spontaneous circulation, and quality of CPR (chest compression rate, pauses, and ventilation rate). RESULTS: Of 1183 patients for whom resuscitation was attempted, 851 were included; 418 patients were in the ACLS with intravenous drug administration group and 433 were in the ACLS with no access to intravenous drug administration group. The rate of survival to hospital discharge was 10.5% for the intravenous drug administration group and 9.2% for the no intravenous drug administration group (P = .61), 32% vs 21%, respectively, (P<.001) for hospital admission with return of spontaneous circulation, 9.8% vs 8.1% (P = .45) for survival with favorable neurological outcome, and 10% vs 8% (P = .53) for survival at 1 year. The quality of CPR was comparable and within guideline recommendations for both groups. After adjustment for ventricular fibrillation, response interval, witnessed arrest, or arrest in a public location, there was no significant difference in survival to hospital discharge for the intravenous group vs the no intravenous group (adjusted odds ratio, 1.15; 95% confidence interval, 0.69-1.91). CONCLUSION: Compared with patients who received ACLS without intravenous drug administration following out-of-hospital cardiac arrest, patients with intravenous access and drug administration had higher rates of short-term survival with no statistically significant improvement in survival to hospital discharge, quality of CPR, or long-term survival. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00121524.