European Resuscitation Council Guidelines for Resuscitation ... - CPR

prone to failure because of kinking of the cannula, and is unsuitablefor patient transfer.4f Assisting the circulationDrugs and fluids for cardiac arrestThis topic is divided into: drugs used during the managementof a cardiac arrest; anti-arrhythmic drugs used in the peri-arrestperiod; other drugs used in the peri-arrest period; fluids; and routesfor drug delivery. Every effort has been made to provide accurateinformation on the drugs in these guidelines, but literature fromthe relevant pharmaceutical companies will provide the most upto-datedata.Drugs used during the treatment of cardiac arrestOnly a few drugs are indicated during the immediate managementof a cardiac arrest, and there is limited scientific evidencesupporting their use. Drugs should be considered only after initialshocks have been delivered (if indicated) and chest compressionsand ventilation have been started. The evidence for the optimaltiming and order of drug delivery, and the optimal dose, is limited.There are three groups of drugs relevant to the management ofcardiac arrest that were reviewed during the 2010 Consensus Conference:vasopressors, anti-arrhythmics and other drugs. Routes ofdrug delivery other than the optimal intravenous route were alsoreviewed and are discussed.VasopressorsDespite the continued widespread use of adrenaline andincreased use of vasopressin during resuscitation in some countries,there is no placebo-controlled study that shows that theroutine use of any vasopressor during human cardiac arrestincreases survival to hospital discharge, although improved shorttermsurvival has been documented. 245,246 The primary goal ofcardiopulmonary resuscitation is to re-establish blood flow to vitalorgans until the restoration of spontaneous circulation. Despite thelack of data from cardiac arrest in humans, vasopressors continueto be recommended as a means of increasing cerebral and coronaryperfusion during CPR.Adrenaline (epinephrine) versus vasopressinAdrenaline has been the primary sympathomimetic agentfor the management of cardiac arrest for 40 years. 438 Itsalpha-adrenergic, vasoconstrictive effects cause systemic vasoconstriction,which increases coronary and cerebral perfusionpressures. The beta-adrenergic actions of adrenaline (inotropic,chronotropic) may increase coronary and cerebral blood flow, butconcomitant increases in myocardial oxygen consumption, ectopicventricular arrhythmias (particularly when the myocardium isacidotic), transient hypoxaemia due to pulmonary arteriovenousshunting, impaired microcirculation, 281 and worse post-cardiacarrest myocardial dysfunction 283,284 may offset these benefits.The potentially deleterious beta-effects of adrenaline have ledto exploration of alternative vasopressors. Vasopressin is a naturallyoccurring antidiuretic hormone. In very high doses it is apowerful vasoconstrictor that acts by stimulation of smooth muscleV1 receptors. Three randomised controlled trials 439–441 and ameta-analysis 442 demonstrated no difference in outcomes (ROSC,survival to discharge, or neurological outcome) with vasopressinversus adrenaline as a first line vasopressor in cardiac arrest. Twomore recent studies comparing adrenaline alone or in combinationwith vasopressin also demonstrated no difference in ROSC, survival18 de 0ctubre de 2010 www.elsuapdetodos.comC.D. Deakin et al. / Resuscitation 81 (2010) 1305–1352 1323to discharge or neurological outcome. 443,444 There are no alternativevasopressors that provide survival benefit during cardiac arrestresuscitation when compared with adrenaline.Participants at the 2010 Consensus Conference debated in depththe treatment recommendations that should follow from this evidence.Despite the absence of data demonstrating an increase inlong-term survival, adrenaline has been the standard vasopressorin cardiac arrest. It was agreed that there is currently insufficientevidence to support or refute the use of any other vasopressor asan alternative to, or in combination with, adrenaline in any cardiacarrest rhythm to improve survival or neurological outcome. Currentpractice still supports adrenaline as the primary vasopressor for thetreatment of cardiac arrest of all rhythms. Although the evidenceof benefit from the use of adrenaline is limited, it was felt that theimproved short-term survival documented in some studies 245,246warranted its continued use, although in the absence of clinicalevidence, the dose and timing have not been changed in the 2010guidelines.AdrenalineIndications.• Adrenaline is the first drug used in cardiac arrest of any cause:it is included in the ALS algorithm for use every 3–5 min of CPR(alternate cycles).• Adrenaline is preferred in the treatment of anaphylaxis (Section8g). 294• Adrenaline is a second-line treatment for cardiogenic shock.Dose. During cardiac arrest, the initial IV/IO dose of adrenalineis 1 mg. There are no studies showing survival benefit for higherdoses of adrenaline for patients in refractory cardiac arrest. In somecases, an adrenaline infusion is required in the post-resuscitationperiod.Following return of spontaneous circulation, even small dosesof adrenaline (50–100 g) may induce tachycardia, myocardialischaemia, VT and VF. Once a perfusing rhythm is established, iffurther adrenaline is deemed necessary, titrate the dose carefully toachieve an appropriate blood pressure. Intravenous doses of 50 gare usually sufficient for most hypotensive patients. Use adrenalinecautiously in patients with cardiac arrest associated with cocaineor other sympathomimetic drugs.Use.www.elsuapdetodos.comAdrenaline is available most commonly in two dilutions:• 1 in 10,000 (10 ml of this solution contains 1 mg of adrenaline).• 1 in 1000 (1 ml of this solution contains 1 mg of adrenaline).Both these dilutions are used routinely in Europe.Anti-arrhythmicsAs with vasopressors, the evidence that anti-arrhythmic drugsare of benefit in cardiac arrest is limited. No anti-arrhythmic druggiven during human cardiac arrest has been shown to increase survivalto hospital discharge, although amiodarone has been shownto increase survival to hospital admission. 285,286 Despite the lackof human long-term outcome data, the balance of evidence is infavour of the use anti-arrhythmic drugs for the management ofarrhythmias in cardiac arrest.AmiodaroneAmiodarone is a membrane-stabilising anti-arrhythmic drugthat increases the duration of the action potential and refractoryperiod in atrial and ventricular myocardium. Atrioventricular