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Report by Elizabeth Hayward, FY2 House Officer, Laurie Showler, Senior House Officer
Checked by Jasmeet Soar, Consultant
Southmead Hospital, Bristol and the Royal Oldham Hospital, Oldham, UK
A short cut review was carried out to establish whether aminophylline improved return of spontaneous circulation rates and eventual outcome in bradyasystolic cardiac arrest. A total of 1154 papers were found using the reported searches, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these four papers are summarised in table 44.. It is concluded that aminophylline offers no benefit in this situation.
In [adults with bradyasystolic cardiac arrest] does [the use of aminophylline as second line agent] [increase restoration of spontaneous circulation (ROSC) and improve long terms survival]?
A 59‐year‐old man has a witnessed out‐of‐hospital cardiac arrest and immediate bystander cardiopulmonary resuscitation (CPR). When the paramedic ambulance crew arrive after 8 min the first recorded rhythm is asystole. Resuscitation continues according to current advanced life support (ALS) guidelines. The patient is intubated, ventilated with high flow oxygen and receives 1 mg of epinephrine (adrenaline) and 3 mg of atropine intravenously. He remains in asystole after a further cycle (2 min) of CPR. You have heard that other agents may be useful at this stage and wonder if there is any evidence that intravenous aminophylline is effective.
Medline 1950 to May week 5 2007, Embase 1980 to 2007 week 22, Cinahl 1982 to June week 1 2007: [exp xanthines/methylxanthines.mp OR exp aminophylline/aminophylline.mp OR exp theophylline/theophylline.mp] AND [exp bradycardia/bradycardia.mp OR exp heart arrest/asystole.mp OR bradyasystole.mp OR cardiac adj arrest].
The Cochrane Library Issue 2 2007: (aminophylline):ti,ab,kw AND (cardiac arrest):ti,ab,kw 4 articles (duplicated in table).
A total of 1154 papers were found from Medline, Embase and Cinahl databases, of which four were relevant and of a sufficient standard of evidence to appraise critically. Cochrane identified the same four articles and no additional articles. All relevant papers are summarised in table 44.
Aminophylline acts as adenosine antagonists on A1/A2 receptors. Adenosine is an endogenous purine nucleoside that depresses the sinoatrial node, blocks atrioventricular conduction, inhibits the pacemaker activity of the His‐Purkinje system and attenuates the effects of catecholamines. Adenosine is produced and released by myocardial cells during ischaemia and hypoxia. Aminophylline blocking the actions of adenosine may therefore be useful in the treatment of bradyasystolic cardiac arrest.
Out of the four relevant randomised controlled trials available, none show a significant difference between the treatment and control groups with respect to ROSC.
Since these trials were completed we now know that the quality of CPR is an important determinant of outcome from CPR. Unfortunately in these studies and all previous drug studies in cardiac arrest patients there is no measure to ensure the patients received good quality CPR.
Aminophylline does not improve survival from bradyasystolic cardiac arrest.