Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA.
Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA.
Resuscitation. 2023 Oct;191:109933. doi: 10.1016/j.resuscitation.2023.109933. Epub 2023 Aug 9.
The efficacy of empiric calcium for patients with undifferentiated cardiac arrest has come under increased scrutiny, including a randomized controlled trial that was stopped early due to a trend towards harm with calcium administration. However, small sample sizes and non-significant findings have hindered precise effect estimates. In this analysis we evaluate the association of calcium administration with survival in a large retrospective cohort of patients with cardiac arrest treated in the emergency department (ED).
We conducted a retrospective review of medical records from two academic hospitals (one quaternary care center, one county trauma center) in San Francisco between 2011 and 2019. Inclusion criteria were patients aged greater than or equal to 18 years old who received treatment for cardiac arrest during their ED course. Our primary exposure was the administration of calcium while in the ED and the main outcome was survival to hospital admission. The association between calcium and survival to admission was estimated using a multivariable log-binomial regression, and also with two propensity score models.
We examined 781 patients with cardiac arrest treated in San Francisco EDs between 2011 and 2019 and found that calcium administration was associated with decreased survival to hospital admission (RR 0.74; 95% CI 0.66-0.82). These findings remained significant after adjustment for patient age, sex, whether the cardiac arrest was witnessed, and including an interaction term for shockable cardiac rhythms (RR 0.60; 95% CI 0.50-0.72) and non-shockable cardiac rhythms (RR 0.87; 95% CI 0.76-0.99). Risk ratios for the association between calcium and survival to hospital admission were also similar between two propensity score-based models: nearest neighbor propensity matching model (RR 0.79; 95% CI 0.68-0.89) and inverse propensity weighted regression adjustment model (RR 0.75; 95% CI 0.67-0.84).
Calcium administration as part of ED-directed treatment for cardiac arrest was associated with lower survival to hospital admission. Given the lack of statistically significant outcomes from smaller, more methodologically robust evaluations on this topic, we believe these findings have an important role to serve in confirming previous results and allowing for more precise effect estimates. Our data adds to the growing body evidence against the empiric use of calcium in cardiac arrest.
对于未分化心搏骤停患者，经验性钙治疗的疗效受到了越来越多的关注，包括一项因钙给药有危害趋势而提前终止的随机对照试验。然而，小样本量和无显著性发现阻碍了精确的效果估计。在这项分析中，我们评估了钙给药与在旧金山急诊科（ED）接受治疗的大量心搏骤停患者生存的相关性。
我们对 2011 年至 2019 年间旧金山两家学术医院（一家四级保健中心，一家县创伤中心）的病历进行了回顾性审查。纳入标准为年龄大于或等于 18 岁的患者，其在 ED 治疗期间接受了心搏骤停治疗。我们的主要暴露因素是 ED 期间给予钙，主要结局是入院时存活。使用多变量对数二项式回归以及两种倾向评分模型来估计钙与入院存活率之间的关系。
我们检查了 2011 年至 2019 年期间在旧金山 ED 接受治疗的 781 例心搏骤停患者，发现钙给药与入院存活率降低相关（RR 0.74；95%CI 0.66-0.82）。在调整患者年龄、性别、心搏骤停是否有目击者以及包括可电击性心律失常（RR 0.60；95%CI 0.50-0.72）和不可电击性心律失常（RR 0.87；95%CI 0.76-0.99）的交互项后，这些发现仍然具有统计学意义。钙与入院存活率之间关联的风险比在两种基于倾向评分的模型中也相似：最近邻倾向匹配模型（RR 0.79；95%CI 0.68-0.89）和逆概率加权回归调整模型（RR 0.75；95%CI 0.67-0.84）。
作为 ED 指导的心脏骤停治疗的一部分，钙给药与入院存活率降低相关。鉴于在这个主题上较小、更具方法学稳健性的评估结果没有统计学意义，我们认为这些发现对于证实以前的结果和允许更精确的效果估计具有重要作用。我们的数据增加了越来越多的证据，证明经验性钙在心脏骤停中的使用是不合理的。
