Corticosteroid use with extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A nationwide observational study

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR) (n=6142). Intervention: Intravenous corticosteroids on the day of admission (hydrocortisone, methylprednisolone, prednisolone, betamethasone, and/or dexamethasone) vs. No corticosteroid administration on the day of admission. Primary outcome: In-hospital mortality (1:4 propensity score-matched cohort) (Risk difference 5.5%, 95% CI 1.5% to 9.5%, p=0.012).

Q: What does this research mean for the field?

Corticosteroid administration on the day of admission is associated with significantly increased in-hospital mortality in out-of-hospital cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation. Novelty: ClaimNovelty.CONTRADICTORY. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

Takaki Hirano; Mikio Nakajima; Hiroyuki Ohbe; Richard H. Kaszynski; Yudai Iwasaki; Yuki Arakawa; Yusuke Sasabuchi; Kiyohide Fushimi; Hiroki Matsui; Hideo Yasunaga

doi:10.1016/j.resplu.2022.100308

September 23, 2022Resuscitation PlusOpen Access

Corticosteroid use with extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A nationwide observational study

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Key result

Early corticosteroid use linked to ~6-point higher in-hospital mortality during ECPR for OHCA.

Risk difference +5.5%
95% CI 1.5% to 9.5%
P=0.012
n=6,142

Figures

Why the study?

Although several studies have reported that corticosteroid administration may improve outcomes after cardiac arrest, previous studies had not examined the effect of corticosteroid use specifically in OHCA patients treated with ECPR.

Does intravenous corticosteroid administration on the day of admission reduce in-hospital mortality in out-of-hospital cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation?

Key Points

To examine the effectiveness of corticosteroid administration on outcomes in out-of-hospital cardiac arrest patients receiving extracorporeal cardiopulmonary resuscitation.
Identified 6,142 out-of-hospital cardiac arrest patients who received extracorporeal cardiopulmonary resuscitation on the day of admission between July 2010 and March 2019 using the Japanese Diagnosis Procedure Combination database.
Categorized patients into a corticosteroid group (n = 459) and a control group (n = 5,683) based on intravenous steroid receipt on the day of admission.
Compared outcomes using one-to-four propensity score matching (457 corticosteroid patients vs 1,827 control patients).
In-hospital mortality was significantly higher in the corticosteroid group compared with the control group (82.1% vs 76.6%; risk difference, 5.5%; 95% CI, 1.5 to 9.5%).
Neurologically favorable survival did not differ significantly between the groups (13.6% vs 16.9%; risk difference, -3.3%; 95% CI, -6.9 to 0.3%).
Major bleeding complications (0.9% vs 1.5%; risk difference, -0.7%; 95% CI, -1.7 to 0.4%) and infection-related complications (14.7% vs 15.7%; risk difference, -1.0%; 95% CI, -4.6 to 2.7%) did not differ significantly between the two groups.

Study Design

Type

Cohort (n=6,142)

Multicenter

Yes

Structured PICO

Does intravenous corticosteroid administration on the day of admission reduce in-hospital mortality in out-of-hospital cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation?

P

Population

6,142 adults (median age 61 years, 19.9% female) with out-of-hospital cardiac arrest treated with ECPR on the day of admission across 445 acute-care hospitals in Japan, followed until hospital discharge.

E

Exposure

Intravenous corticosteroid administration (hydrocortisone, methylprednisolone, prednisolone, betamethasone, and/or dexamethasone) on the day of admission, median dosage 100 mg (IQR 40–915 mg) in methylprednisolone equivalency, alongside ECPR and standard emergency care

C

Comparator

Control group not receiving corticosteroids on the day of admission, treated with ECPR and standard emergency care (matched 1:4 via propensity score)

O

Outcome

In-hospital mortalityhard clinical

Main Result

Absolute Risk Reduction: -5.5 (95% CI -9.5–-1.5)

Absolute Event Rate: 82.1% vs 76.6%

Absolute Risk Reduction: -5.5%

p-value: p=0.012

In this nationwide Japanese observational study, early corticosteroid administration in out-of-hospital cardiac arrest patients receiving ECPR was associated with a 5.5% higher absolute risk of in-hospital mortality, arguing against routine corticosteroid use in this population.

Limitations

Confounding by indication due to lack of pre-hospital cardiac arrest data (witness status, bystander CPR, arrest duration) and post-ROSC vital signs.
Detailed information on the exact timing (during CPR vs after ROSC) and purpose of corticosteroid administration was unavailable.
History of corticosteroid medication prior to hospital admission was unavailable in the administrative database.
Potential misclassification of OHCA and ECPR cases due to reliance on administrative procedure codes and admission coma scales.
Confounding by indication due to unavailable pre-hospital cardiac arrest data (witness status, bystander CPR, duration of arrest) and vital signs after ROSC
Lack of detailed information on the timing (during CPR vs after ROSC) and specific purpose of corticosteroid administration
Unavailable history of corticosteroid medication use prior to hospital admission
Potential misclassification of ECPR and OHCA cases due to reliance on administrative procedure codes and admission Japan Coma Scale scores

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Answers are grounded in this paper and cite their sources.

Implication

Corticosteroids on admission were associated with higher mortality in ECPR-treated OHCA; this leaves open whether randomized trials should guide practice.

Abstract

Aim: Several studies have reported that corticosteroid administration for cardiac arrest patients may improve outcomes. However, these previous studies have not examined the effect of corticosteroid use in out-of-hospital cardiac arrest (OHCA) patients administered extracorporeal cardiopulmonary resuscitation (ECPR). Therefore, we aimed to examine the effectiveness of corticosteroids in OHCA patients administered ECPR. Methods: Using the Japanese Diagnosis Procedure Combination inpatient database, we included OHCA patients who were administered ECPR on the day of admission between July 2010 and March 2019. The patients were categorized into the corticosteroid and control groups according to whether they received corticosteroids on the day of admission or not. The primary outcome was in-hospital mortality and the secondary outcomes included percentages of neurologically favorable survival, major bleeding complications, and infection-related complications. We compared the outcomes using a propensity score matching analysis. Results: We identified 6,142 eligible patients (459 vs 5,683, the corticosteroid and control group, respectively). One-to-four propensity score matching analysis (457 vs 1,827) showed in-hospital mortality was significantly higher in the corticosteroid group compared with the control group (82.1% vs 76.6%; risk difference, 5.5%; 95% CI, 1.5 to 9.5%). Neurologically favorable outcomes did not differ between the two groups (13.6% vs 16.9%; risk difference, -3.3%; 95% CI, -6.9 to 0.3%). The percentage of major bleeding complications and infection-related complications did not significantly differ between the two groups. Conclusions: The results of this study demonstrated that administration of corticosteroids on the day of admission to OHCA patients administered ECPR was associated with increased in-hospital mortality.

Discussion

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Cite This Study

Hirano et al. (2022) conducted a cohort in Out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR) (n=6,142). Intravenous corticosteroids on the day of admission (hydrocortisone, methylprednisolone, prednisolone, betamethasone, and/or dexamethasone) vs. No corticosteroid administration on the day of admission was evaluated on In-hospital mortality (1:4 propensity score-matched cohort) (Risk difference 5.5%, 95% CI 1.5% to 9.5%, p=0.012). Corticosteroid administration on the day of admission was associated with significantly higher in-hospital mortality (82.1% vs 76.6%; risk difference 5.5%, p=0.012) in OHCA patients receiving ECPR.

synapsesocial.com/papers/6aefab3364638c6b1581590b https://doi.org/10.1016/j.resplu.2022.100308

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Corticosteroid use with extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A nationwide observational study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Corticosteroid use with extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A nationwide observational study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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