Adrenaline or salt water. Changes to the way heart attack patients are treated.

[Darkesteyes]

Just seen a report on Newsnight. Instead of injecting with adrenaline some patients (but we wont know which ones until afterwards) will be injected with saltwater as a placebo. It is to see if adrenaline causes more harm than good.
DH has heart disease. He called this an experiment. And i certainly see his point. He says its obviously to "kill some people off" He got quite upset. What do MNers think of this?

What if the adrenaline is killing people off? The only way to know is a double blind trial.

Without peoples knowledge about what is being administered to them?

If what you say is accurate, there must be a good reason to think the adrenaline does more harm than good.

Anyway plenty of best practice trials are done by introducing something and seeing if it works better or worse.

Surely this is unethical? Surely patients have to sign up to be part of a clinical trial, it cannot be done to them in secret? This would never go ahead as described.

This is not about treating people who have heart attacks, you do not give adrenaline to someone having a heart attack. It's to do with the treatment of patients in cardiac arrest, there is quite a lot of evidence to suggest that adrenaline causes severe brain damage even in people who come back from a cardiac arrest and they then die again in a few days.

Unfortunately you cannot get a patients consent for this because at the point at which the adrenaline is administered the patient is in cardiac arrest or dead so unable to give/withhold consent.

Have you read the BBC article, it says you can opt out. How do we find the most effective way of treating people if we don't try new things? I'm sure people felt wary when adrenaline was introduced. Change is scary

It's on the bbc website. No consent (no time) but residents will be made aware there is a trial in their area and can opt out.

It does seem like they're using human guinea pigs, but as long as everyone is consenting I see not problem.

It just didnt seem right. And DH was worried. Thats why i posted.

I saw this, and was deeply perturbed by it; but NCIS has explained why very well; it's a last resort, and they are concerned that the last resort is actually making things worse?

Cardiac arrests and a heart attack are two different things so your DH should not worry.

Thankyou everyone for your replies.

Also..'salt water' is presumably normal saline... Harmless fluid similar ti that in an IV drip but small amounts, same stuff used to flush drips through etc so in everyday use and has been for years .

These news articles are entirely misleading. Adrenaline is not administered to any patient suffering a heart attack or similar episode. Adrenaline is only administered when a patient is in cardiac arrest and the patient is being actively resuscitated. These patients are not alive at this point because their hearts are not beating and they are not breathing.

It has been argued for years that adrenaline does not improve the outcome of surviving a cardiac arrest. The numbers that survive these events are remarkably small and it is thought that the use of adrenaline increases the risk of brain damage if you do survive. Quality of life is just as vital for these patients and their families as well as merely surviving. This is the difference to returning to their normal day to day lives or being kept alive on a ventilator.

Research is the only way that this can be proven. It is already evidenced that the key to surviving a cardiac arrest is good, early CPR. This isn't a new idea, it has been floating around for a while. A double blind trial is the next step. It happens in medicine, otherwise we'd never improve the chances of saving lives.

Quality of life is just as vital for these patients and their families as well as merely surviving.

Agree!

I suspect that to be a good quality clinical trial the people administering the injection will not know whether it is saline or adrenaline so making it a double blinded trial.
Without it being a double blinded trial any results would not pass any form of peer review.

Just to add.

A cardiac arrest is managed 'run' by someone. What I mean by that is that if you have a cardiac arrest in hospital it isn't people running round like headless chickens, there is a procedure to be 'run' and one person runs or manages what other people do.

If you watch 24 hours in A and E you might see this, someone standing at the end of the bed calmly telling others what to do.

This person is trained to go through specific treatments/actions in a specific order. They do not deviate from this so the only way to introduce a new option in a RL scenario is to change some of the drugs in the drugs box so the person running the arrest does not change the arrest procedure itself.

If it is found that adrenaline/epinephrine is not helpful then this change will be incorporated in to the new rules for treating cardiac arrest.

The qualification staff have for managing CA goes 'out of date' and you have to re do it, when I was working in this area it was every 3 years and after that you had to take the entire course again.

The way cardiac arrests are managed has changed and will continue to change. I'm sure almost everyone reading this will have seen a defibrillator used on TV/in film/in RL but how many of you know that these machines have changed over the years in the way the 'shock' is delivered?

Modern machines deliver a biphasic-bipolar shock, yep that won't mean much to many of you, even people working in nursing/medicine. But over the years the way a shock is delivered by the machine has changed.

OP
Please try not to worry and please get your dh to read the replies here. Medicine does tests all the time, it is the way we improve.

Many years ago I was at a hospital where a trial was taking place of angioplasty vs bypass surgery, the trial was actually halted because the results of the angioplasty were so good. No one now is sent directly for bypass surgery, everyone has angioplasty first. That means for many thousands of people a long operation with a GA and a long recovery time has been avoided

According to the information we have been given it is to be double blind and only carried out at present in pre hospital cardiac arrests.

A heart attack (myocardial infarction or MI) and a cardiac arrest are completely different things. Although an MI can lead to cardiac arrest as can lots of other things.

To be honest a lot of CPR attempts aren't successful. A lot of adrenaline is used (10mls every 5 mins of resuscitation). I've seen someone worked on for an hour and a half. They would have had 70 mls of adrenaline. You would not give that to someone who was alive. Btw they give the saline anyway as they flush the adrenaline through th every time they give it with 10mls of saline. Often there is a saline drip going my too (this is in hospital though).

I am all up for it. And would Def be a guinea pig if needed. Not that I would be in a position to consent though. If they can find out they have been doing it wrong giving adrenaline then they may be able to save more lives.

Btw I'm a nurse and understand what biphasic-bipolar shock means

So, if they manage to find out you've opted out, do they have kits that they know for certain contain 'real' adrenaline, alongside kits that may or may not? Also, with regards to consent, surely the patient (if they survive), or their relatives (if they do not), should be advised that they have taken part in a trial, and should be asked for consent to allow data gathered to be entered into that trial. Anything else is unethical, and who are these ethical experts who allow these things to happen answerable to? And they are also hiding behind 'commercial confidentiality', so we cannot know what discussions have taken place. This sort of practice should be outlawed, and the NHS should be fully transparent, where patients and their treatment are involved.

A similar study transformed how head injury patients are treated. It was initially thought (not unreasonably) that steroids would reduce inflammation so steroids were given to head injury patients when they arrived in hospital.

A similar study to this adrenaline in cardiac arrest one happened randomising them to steroids or no steroids - and it was discovered that steroids led to MORE deaths, so routine administration was stopped, saving lives.

www.ncbi.nlm.nih.gov/pubmed/15936423

These studies are done under the very, very careful supervision of ethics committees, in an attempt to SAVE lives. It is unethical for us to continue using drugs that might be causing harm, so I'd be interested in Pseudonym99's more expert opinion about how we might improve patient care in the pre-hospital or critical care setting without studies like this.

There's a nice discussion of the reasons behind the study here in the Telegraph article:

www.telegraph.co.uk/health/healthnews/11028692/Heart-patients-to-be-given-placebo-by-paramedics-in-controversial-trial.html

This practice cannot be "outlawed" or there will never be any further improvements in truly emergency care. It does need to be, and is, subject to very stringent rules, to approval by an ethics committee with no link to any vested interest, and to a lot of oversight.

To pick one example. Everyone knew that albumin was a really good resuscitation fluid, and only cheapskates used ordinary old saline in adult resuscitation. Until someone did a study rather like the one in this thread, and found out that ordinary old saline actually worked better, and more people survived.

Pseudonym I have worked in clinical trials. Before any trial can go ahead it has to be approved by an ethics committee that looks at the evidence that has been gathered to create the trial. Every detail of these trials are carefully considered before they can go ahead.
Patients who are recruited to the trial will have had the benefits and disadvantages of the trial discussed with them and by consenting to being in the trial they consent to their data being used. However, the data is anonymoised by assigning case numbers. It is likely to be double blinded trail so the clinicians performing the resc will not known whether they have used adrenaline or not so that their responses on the trial recording sheets can not be biased by knowing.
In this case no drug company is likely to be involved because there is no commercial gain in switching adrenaline to normal saline. In all likelihood this trial has been designed by senior emergency medicine clinicians who deal with this kind of case every day. They will have compared instances where adrenaline has been used and instances where it hasn't been used as it may have been unavailable.
Without double blinded clinical trials no advances would be made in these kind of situations.

For this sort of thing to be approved it will have already gone through probably multiple hospital/university ethics committee procedures. It will have been a long process and the committee and researchers will have spent a long time thinking about this and weighing up the potential benefits of the study against the lack of consent.

My impression is that the reason permission was granted is because there is some evidence that adrenaline does harm in these circumstances, and that that evidence is strong enough to be worth investigating even without consent.

Clinical trials can be halted if the results start showing that a new treatment has significantly poorer outcomes than the old one: conversely they can be stopped if the results of the new treatment are so good that it becomes unethical to continue treating people with the old treatment.