Abstract
INTRODUCTION: Adrenaline, an alpha and beta agonist, has been established as a life-saving drug, strongly influencing Return Of Spontaneous Circulation(ROSC) and hence had found its place in ACLS guidelines.([1][2][3]) Though most hospitals have a Cardiac Arrest Resuscitation Team(CART), there was great spectrum of difference that each member takes to appear at the scene of action and thus delay in instituting focused therapy including Adrenaline, occasionally as late as 30 minutes. As nurses are almost always the primary witnesses in bedside, empowering nurses in ACLS training, including administration of drugs like Adrenaline([4][5]) was decided to be studied in a tertiary care center in South India for IHCA. OBJECTIVES: To assess and compare ACLS effectiveness resulting in an improvement in outcomes between doctor-led administration versus early nurse-led administration of first-dose adrenaline for IHCA in a tertiary care center over 3 years. MATERIALS AND METHODS: Our retrospective descriptive observational study was conducted in ward patients, aged 18years or above, who had sustained IHCA and resuscitation initiated as per ACLS protocol. Databases were retrieved from CART resuscitation analysis sheets and Electronic Medical Records, during the period of November 2019 till December 2021 and was segregated into pre-and post-intervention arm, based on hospital protocol of ‘early nurse-led adrenaline administration without doctor's pre-order’ enforced since 27/11/2019]. Primary outcome was number of patients with ROSC and other outcomes assessed included time to adrenaline, time to ROSC, and proportion of survived-to-24 hours and -to-discharge. RESULTS: We analysed data on 467 eligible patients with IHCA arrests, of which, first rhythm analysis at arrest were 425[91%]asystole, 25[5.4%]PEA, 10[2.1%]Vf and 7[1.5%]pulselessVT. Mean age was 52.39+/-15.96years. 36.4% were females and 63.6% were males. ROSC was achieved in 269[57.6%] resuscitated IHCA patients, of which 48.6% had arrest within next 24 hours and survival-to-24 hours was 31.3% and survival-to-discharge was 13.5%. Pre-intervention arm[01/11/2018-26/11/2019] had 170 patients and post-intervention arm [27/11/2019-31/12/2021] had 297 patients. Proportion of ROSC achieved in both arms were similar[57.6%]. In post-intervention arm, compliance to adrenaline administration was significantly better[63%vs75%, p<0.01] and median time-to-adrenaline was significantly faster[3.5min-IQR(0.75, 6.25) vs 2min-IQR(0, 3) p<0.000]. Median time-to-CART activation [4min-IQR(1, 7) vs 2min-IQR(0, 3)] and median time-to-CART arrival [6.5min-IQR(4, 10) vs 4min-IQR(3, 6), p<0.000] was significantly earlier in post-intervention arm. Reversible causes were identified and treated in 79.3% post-intervention compared to 53.1% pre-intervention arm patients, with better CART resuscitation appropriateness in post-intervention arm [47.6%vs60.6%, p<0.000]. Median time-to-ROSC among those survived post CPR was significantly earlier in post-intervention arm[22min-IQR(15, 40) vs 12-IQR(8, 22)p<0.000]. DISCUSSION: Cardiac arrest resuscitation was seen more in middle-aged males in hospital-wards. Most arrests were witnessed but few monitored in wards, attributing to a possibility of lesser identification of shockable rhythms in wards than areas closely monitored. Early adrenaline administration was found to be significantly improved in post-intervention arm and also had enhanced quality of CPR-ACLS outcome, in terms of improved time to ROSC. CART team effectiveness in terms of activation, response, adherence to ACLS guidelines and reversible cause assessment was significantly better in post-intervention arm. Studies on a larger scale are warranted to assess effect of early adrenaline on IHCA resuscitation outcomes including neurological outcome.