Guideline removal of atropine and survival after adult in-hospital cardiac arrest with a non-shockable rhythm

• Published in: Resuscitation 2019-04, Vol.137, p.69-77
• Main Authors: Holmberg, Mathias J., Moskowitz, Ari, Wiberg, Sebastian, Grossestreuer, Anne V., Yankama, Tuyen, Witten, Lise, Perman, Sarah M., Donnino, Michael W., Andersen, Lars W.
• Format: Article
• Language: English
• Subjects: Advanced cardiac life support; Aged; American heart association; Anti-Arrhythmia Agents - administration & dosage; Atropine; Atropine - administration & dosage; Electric Countershock; Female; Guideline; Heart arrest; Heart Arrest - drug therapy; Heart Arrest - mortality; Humans; Interrupted Time Series Analysis; Male; Middle Aged; Practice Guidelines as Topic; Propensity Score; Prospective Studies; Registries; Survival Rate; United States
• ISSN: 0300-9572; 1873-1570
• DOI: 10.1016/j.resuscitation.2019.02.002

To determine whether the removal of atropine from the 2010 ACLS guidelines for non-shockable cardiac arrests was associated with a change in survival. Using the Get With The Guidelines®-Resuscitation registry, we included adults with an index in-hospital cardiac arrest between 2006 and 2015. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and favorable functional outcome. An interrupted time-series analysis was used to compare survival before (pre-guidelines) and after (post-guidelines) introduction of the 2010 guidelines. A difference-in-difference approach was used to compare the interrupted time-series results between the non-shockable and shockable cohorts to account for guideline changes unrelated to atropine. We included 20,499 non-shockable and 3968 shockable cardiac arrests. Patient characteristics were similar between the pre-guidelines and post-guidelines period. Atropine was used for 8653 (87%) non-shockable and 680 (35%) shockable cardiac arrests in the pre-guidelines period and 3643 (35%) non-shockable and 320 (16%) shockable cardiac arrests in the post-guidelines period. The change over time in survival from the pre-guidelines to the post-guidelines period was not significantly different for the non-shockable compared to the shockable cohort (risk difference: 2.0% [95%CI: −0.8, 4.8] per year, p = 0.17). The immediate change in survival after introducing the guidelines was also not different between the cohorts (risk difference: 3.5% [95%CI: −2.6, 9.7], p = 0.26). Results were similar for the secondary outcomes and in multiple sensitivity analyses. The removal of atropine from the 2010 guidelines was not associated with a significant change in survival.