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HOT HOT HOT! Die Paramedic2 Studie

Gestern ist die PARAMEDIC2 Studie im New England Journal of Medicine erschienen. In diesem großen RCT mit 8014  Patienten wurde im prähospitalen Setting die Anwendung von Adrenalin gegen Placebo bei erwachsenen Patienten mit Herz-Kreislauf-Stillstand untersucht.

Das primäre Endpunkt war das 30-Tage Überleben, der sekundäre Endpunkt eine gutes neurologisches Outcome nach 30 Tagen.

Hinsichtlich des primären Outcomes hatte die Adrenalin-Gruppe einen leicht signifikanten Vorteil (2.4% vs. 3.2%, P=0.02), es gab jedoch keinen signifikanten Unterschied hinsichtlich des neurologischen Outcomes (2.2% vs. 1.9%), es zeigte sich sogar, dass in der Adrenalin Gruppe mehr Patienten mit einem sehr schlechten neurologischen Outcome entlassen wurden (31.0% vs. 17.8%).

In Kürze: Adrenalin erhöht das primäre Überleben, es gibt jedoch keine Vorteile beim neurologischen Outcome. 

Link zur Studie (NEJM – Open Access)


BACKGROUND

Concern about the use of epinephrine as a treatment for out-of-hospital cardiac arrest led the International Liaison Committee on Resuscitation to call for a placebo-controlled trial to determine whether the use of epinephrine is safe and effective in such patients.

METHODS

In a randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest in the United Kingdom, paramedics at five National Health Service ambulance services administered either parenteral epinephrine (4015 patients) or saline placebo (3999 patients), along with standard care. The primary outcome was the rate of survival at 30 days. Secondary outcomes included the rate of survival until hospital discharge with a favorable neurologic outcome, as indicated by a score of 3 or less on the modified Rankin scale (which ranges from 0 [no symptoms] to 6 [death]).

RESULTS

At 30 days, 130 patients (3.2%) in the epinephrine group and 94 (2.4%) in the placebo group were alive (unadjusted odds ratio for survival, 1.39; 95% confidence interval [CI], 1.06 to 1.82; P=0.02). There was no evidence of a significant difference in the proportion of patients who survived until hospital discharge with a favorable neurologic outcome (87 of 4007 patients [2.2%] vs. 74 of 3994 patients [1.9%]; unadjusted odds ratio, 1.18; 95% CI, 0.86 to 1.61). At the time of hospital discharge, severe neurologic impairment (a score of 4 or 5 on the modified Rankin scale) had occurred in more of the survivors in the epinephrine group than in the placebo group (39 of 126 patients [31.0%] vs. 16 of 90 patients [17.8%]).

CONCLUSIONS

In adults with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group.

[Journal Club] Intubation durch Paramedics in Australien

PubMed LINK

In diesem interessanten Paper wurden über einen Zeitraum von 7 Jahren alle Paramedic-Intubationen ausgewertet (retrospektive Registerauswertung). Dabei intubierten Paramedics im Durchschnitt nur 3 mal pro Jahr,  jene mit mehr Intubations-Erfahrung erzielten eine höhere Erfolgsrate beim ersten Versuch, in der Gesamtschau war die Erfolgsrate jedoch auch so sehr hoch (95% Gesamt-Erfolgsrate und 80% First-Pass- Erfolgsrate).

Eine Einschränkung der Studie ist, dass die Erfolgsrate von den Paramedics selbst berichtet wurde (Reporting Bias), außerdem fehlten in 17% der Fälle die Daten zur Anzahl der Intubationsversuche. In diesen Fällen wurde von den Autoren angenommen, dass die Intubation beim 1. Versuch erfolgreich war.

Bei Patienten mit Herz-Kreislauf Stillstand hatte die Erfahrung des Paramedics keinen signifikaten Einfluss auf die Rate von ROSC oder Patienten-Überleben. Die endotracheale Intubation im allgemeinen hatte jedoch eine höhere Rate an ROSC zu Folge, ein Überlebensvorteil für Patienten konnte allerdings nicht nachgewiesen werden.


Abstract

Paramedic Intubation Experience Is Associated With Successful Tube Placement but Not Cardiac Arrest Survival.
Dyson K, Bray JE, Smith K, Bernard S, Straney L, Nair R, Finn J.
Ann Emerg Med. 2017 Sep;70(3):382-390.e1. doi: 10.1016/j.annemergmed.2017.02.002.

STUDY OBJECTIVE:
Paramedic experience with intubation may be an important factor in skill performance and patient outcomes. Our objective is to examine the association between previous intubation experience and successful intubation. In a subcohort of out-of-hospital cardiac arrest cases, we also measure the association between patient survival and previous paramedic intubation experience.

METHODS:
We analyzed data from Ambulance Victoria electronic patient care records and the Victorian Ambulance Cardiac Arrest Registry for January 1, 2008, to September 26, 2014. For each patient case, we defined intubation experience as the number of intubations attempted by each paramedic in the previous 3 years. Using logistic regression, we estimated the association between intubation experience and (1) successful intubation and (2) first-pass success. In the out-of-hospital cardiac arrest cohort, we determined the association between previous intubation experience and patient survival.

RESULTS:
During the 6.7-year study period, 769 paramedics attempted intubation in 14,857 patients. Paramedics typically performed 3 intubations per year (interquartile range 1 to 6). Most intubations were successful (95%), including 80% on the first attempt. Previous intubation experience was associated with intubation success (odds ratio 1.04; 95% confidence interval 1.03 to 1.05) and intubation first-pass success (odds ratio 1.02; 95% confidence interval 1.01 to 1.03). In the out-of-hospital cardiac arrest subcohort (n=9,751), paramedic intubation experience was not associated with patient survival.

CONCLUSION:
Paramedics in this Australian cohort performed few intubations. Previous experience was associated with successful intubation. Among out-of-hospital cardiac arrest patients for whom intubation was attempted, previous paramedic intubation experience was not associated with patient survival.