Induction of Therapeutic Hypothermia During Out-of-Hospital Cardiac Arrest Using a Rapid Infusion of Cold Saline: The RINSE Trial (Rapid Infusion of Cold Normal Saline).

BACKGROUND: Patients successfully resuscitated by paramedics from out-of-hospital cardiac arrest often have severe neurologic injury. Laboratory and observational clinical reports have suggested that induction of therapeutic hypothermia during cardiopulmonary resuscitation (CPR) may improve neurologic outcomes. One technique for induction of mild therapeutic hypothermia during CPR is a rapid infusion of large-volume cold crystalloid fluid. METHODS: In this multicenter, randomized, controlled trial we assigned adults with out-of-hospital cardiac arrest undergoing CPR to either a rapid intravenous infusion of up to 2 L of cold saline or standard care. The primary outcome measure was survival at hospital discharge; secondary end points included return of a spontaneous circulation. The trial was closed early (at 48% recruitment target) due to changes in temperature management at major receiving hospitals. RESULTS: A total of 1198 patients were assigned to either therapeutic hypothermia during CPR (618 patients) or standard prehospital care (580 patients). Patients allocated to therapeutic hypothermia received a mean (SD) of 1193 (647) mL cold saline. For patients with an initial shockable cardiac rhythm, there was a decrease in the rate of return of a spontaneous circulation in patients who received cold saline compared with standard care (41.2% compared with 50.6%, P=0.03). Overall 10.2% of patients allocated to therapeutic hypothermia during CPR were alive at hospital discharge compared with 11.4% who received standard care (P=0.71). CONCLUSIONS: In adults with out-of-hospital cardiac arrest, induction of mild therapeutic hypothermia using a rapid infusion of large-volume, intravenous cold saline during CPR may decrease the rate of return of a spontaneous circulation in patients with an initial shockable rhythm and produced no trend toward improved outcomes at hospital discharge. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01173393.

Defibrillation or cardiopulmonary resuscitation first for patients with out-of-hospital cardiac arrests found by paramedics to be in ventricular fibrillation? A randomised control trial.

AIM: To determine whether in patients with an ambulance response time of >5min who were in VF cardiac arrest, 3min of CPR before the first defibrillation was more effective than immediate defibrillation in improving survival to hospital discharge. METHODS: This randomised control trial was run by the South Australian Ambulance Service between 1 July, 2005, and 31 July, 2007. Patients in VF arrest were eligible for randomisation. Exclusion criteria were: (i) <18 years of age, (ii) traumatic arrest, (iii) paramedic witnessed arrest, (iv) advanced life support performed before arrival of paramedics and (v) not for resuscitation order or similar directive. The primary outcome was survival to hospital discharge with secondary outcomes being neurological status at discharge, the rate of return of spontaneous circulation (ROSC) and the time from first defibrillation to ROSC. RESULTS: For all response times, no differences were observed between the immediate defibrillation group and the CPR first group in survival to hospital discharge (17.1% [18/105] vs. 10.3% [10/97]; P=0.16), the rate of ROSC (53.3% [56/105] vs. 50.5% [49/97]; P=0.69) or the time from the first defibrillation to ROSC (12:37 vs. 11:19; P=0.49). There were also no differences between the immediate defibrillation group and the CPR first group, for response times of < or = or > 5min: survival to hospital discharge (50.0% [7/14] vs. 25.0% [4/16]; P=0.16 or 12.1% [11/91] vs.7.4% [6/81]; P=0.31, respectively) and the rate of ROSC (71.4% [10/14] vs. 75.0% [12/16]; P=0.83 or 50.5% [46/91] vs. 45.7% [37/81]; P=0.54, respectively). No differences were observed in the neurological status of those surviving to hospital discharge. CONCLUSION: For patient in out-of-hospital VF cardiac arrest we found no evidence to support the use of 3min of CPR before the first defibrillation over the accepted practice of immediate defibrillation.

Ethics roundtable debate: is a physician-patient confidentiality relationship subservient to a greater good?

Is a health care provider's most proximal obligation to individuals or society as a whole? Our International panel of critical care providers grapple over the issue of whether patient-physician confidentiality exists as an open ended ideal it should be subservient to a greater good.