Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Amiodarone for Cardiac Arrest in the 2010 ACLS – Part II


Continuing from Amiodarone for Cardiac Arrest in the 2010 ACLS – Part I.

It (amiodarone) can be considered for treatment of VF or pulseless VT unresponsive to shock delivery, CPR, and a vasopressor. In blinded randomized controlled clinical trials in adults with refractory VF/pulseless VT in the out-of-hospital setting,134,136 paramedic administration of amiodarone (300 mg134 or 5 mg/kg136) improved hospital admission rates when compared with administration of placebo134 or 1.5 mg/kg of lidocaine.136[1]

One study from 2 ACLS revisions ago and another one from only one ACLS revision ago. In resuscitation terms, ancient history.

Footnote 134 –

The proportion of patients who survived until discharge from the hospital did not differ significantly in the amiodarone and placebo groups, regardless of whether the analysis included all treated patients (13.4 percent [33 of 246] and 13.2 percent [34 of 258], respectively), only patients whose presenting arrhythmia was ventricular fibrillation (16 percent and 15 percent), or only those who had a transient return of pulses before treatment (24 percent and 15 percent). More than half of the 67 patients discharged alive after treatment with amiodarone or placebo, all after lengthy resuscitation, resumed independent living activities or returned to their former employment (55 percent [18 of 33] in the amiodarone group and 50 percent [17 of 34] in the placebo group).[2]

In other words, vs. placebo the outcomes are almost impressive for amiodarone, as long as we do not follow up on what happens to the patient.

Footnote 136 –

Survival after Hospital Admission
Among the 41 patients who survived to hospital admission after receiving amiodarone, 9 (5 percent of the entire group) survived to hospital discharge, as compared with 5 of the 20 initial survivors in the lidocaine group (3 percent of the entire group, P=0.34). The initial rhythm was ventricular fibrillation in all the long-term survivors; among those in whom the initial rhythm was ventricular fibrillation, 9 of 140 treated with amiodarone (6.4 percent) and 5 of 132 treated with lidocaine (3.8 percent) were discharged from the hospital alive (P=0.32).
[3]

Even though the survival to discharge with amiodarone is almost double the survival to discharge with lidocaine, the study is not large enough for this to be statistically significant.

Where are the large enough to be statistically significant studies of survival to discharge with amiodarone that we were promised so long ago?

Even though there is nothing new with amiodarone, this unproven drug has not been downgraded.

Expert recommendations must come with an expiration date.

 

No exceptions.

 

If the expert recommendation is not followed by appropriate research, then the expert recommendation should not be treated better than the patients. An expert recommendation, that is not followed by research designed to determine if there is improved survival to discharge, is just garbage and needs to be thrown out before the expert recommendation stink becomes too oppressive.

If experts want their recommendations to be followed, these experts need to at least perform due diligence and assure that we are not treating patients based only on surrogate endpoint studies – revision after revision after revision . . . .

Our patients deserve better.

To be continued in Amiodarone for Cardiac Arrest in the 2010 ACLS – Part III.

Footnotes:

[1] Amiodarone
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 8.2: Management of Cardiac Arrest
Medications for Arrest Rhythms
Antiarrhythmics
Free Full Text Article with links to Free Full Text PDF download

[2] Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation.
Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, Hallstrom AP, Murray WA, Olsufka M, Walsh T.
N Engl J Med. 1999 Sep 16;341(12):871-8.
PMID: 10486418 [PubMed – indexed for MEDLINE]

Free Full Text Article from N Engl J Med with links to Free Full Text PDF download

[3] Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation.
Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A.
N Engl J Med. 2002 Mar 21;346(12):884-90. Erratum in: N Engl J Med 2002 Sep 19;347(12):955.
PMID: 11907287 [PubMed – indexed for MEDLINE]

Free Full Text Article from N Engl J Med with links to Free Full Text PDF download

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Comments

  1. I wonder if Nexterone, the new formulation for amiodarone, would have any impact on these studies? Less cardiotoxic == better?

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