Elsevier

Resuscitation

Volume 120, November 2017, Pages 77-87
Resuscitation

Review
Bystander automated external defibrillator use and clinical outcomes after out-of-hospital cardiac arrest: A systematic review and meta-analysis

https://doi.org/10.1016/j.resuscitation.2017.09.003Get rights and content

Abstract

Aim

To systematically review studies comparing bystander automated external defibrillator (AED) use to no AED use in regard to clinical outcomes in out-of-hospital cardiac arrest (OHCA), and to provide a descriptive summary of studies on the cost-effectiveness of bystander AED use.

Methods

We searched Medline, Embase, the Web of Science, and the Cochrane Library for randomized trials and observational studies published before June 1, 2017. Meta-analyses were performed for patients with all rhythms, shockable rhythms, and non-shockable rhythms.

Results

Forty-four observational studies, 3 randomized trials, and 13 cost-effectiveness studies were included. Meta-analysis of 6 observational studies without critical risk of bias showed that bystander AED use was associated with survival to hospital discharge (all rhythms OR: 1.73 [95%CI: 1.36, 2.18], shockable rhythms OR: 1.66 [95%CI: 1.54, 1.79]) and favorable neurological outcome (all rhythms OR: 2.12 [95%CI: 1.36, 3.29], shockable rhythms OR: 2.37 [95%CI: 1.58, 3.57]). There was no association between bystander AED use and neurological outcome for non-shockable rhythms (OR: 0.76 [95%CI: 0.10, 5.87]). The Public-Access Defibrillation trial found higher survival rates when volunteers were equipped with AEDs. The other trials found no survival difference, although their study settings differed. The quality of evidence was low for randomized trials and very low for observational studies. AEDs were cost-effective in settings with high cardiac arrest incidence, with most studies reporting ratios < $100,000 per quality-adjusted life years.

Conclusions

The evidence supports the association between bystander AED use and improved clinical outcomes, although the quality of evidence was low to very low.

Introduction

Out-of-hospital cardiac arrest (OHCA) affects over 350,000 individuals in the United States [1], and 275,000 individuals in Europe [2], [3] each year. Mortality remains poor with a survival rate of approximately 10% [1], [2]. In about one quarter of cases, patients with OHCA present with an initial shockable rhythm, i.e. ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) [4], [5].

Important determinants of survival in OHCA are early cardiopulmonary resuscitation (CPR) and rapid defibrillation to restore spontaneous circulation [6], [7]. While chest compressions are essential for maintaining perfusion and oxygen delivery, an effective approach for terminating VF/pVT and reestablishing a normal cardiac rhythm is by defibrillation [8].

Delayed response time of emergency medical services have been associated with poor survival [9], [10]. Automated external defibrillators (AEDs) permit bystanders not trained in rhythm interpretation to provide early defibrillation prior to emergency medical services arrival. However, while AEDs may be effective in patients with VF or pVT, interrupted CPR during AED application and rhythm analysis may theoretically reduce the likelihood of successful resuscitation in those with a non-shockable rhythm [11], [12].

A number of systematic reviews have assessed aspects of AED use [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28]. However, few have focused specifically on bystander AED use and the last meta-analysis was performed in 2008 [13], [14], [15], [16], [22], [25], [29]. In this systematic review and meta-analysis, we assessed observational and randomized studies comparing bystander AED use to no AED use in regard to clinical outcomes in OHCA. We also provide a descriptive summary of studies on the cost-effectiveness of bystander AED use.

Section snippets

Protocol and registration

This systematic review was performed in accordance with the Preferred Reporting Items for Systematic-Reviews and Meta-Analyses (PRISMA) guidelines [30]. The PRISMA checklist is provided in the Supplemental Material (eAppendix A). The review was prospectively registered with PROSPERO at www.crd.york.ac.uk/PROSPERO/ (CRD42016053819). There were minor changes to the protocol after registration, which are outlined in the Supplemental Material (eTable 1). The full original protocol is provided in

Study selection

The search strategy yielded 3611 unique titles and abstracts of which 223 full-text articles were potentially eligible. Sixty studies met all inclusion and none of the exclusion criteria. We included 44 observational studies [4], [5], [36], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69], [70], [71], [72], [73], [74], [75], [76], [77], [78], 3 randomized

Discussion

In this systematic review and meta-analysis, we found that bystander AED use was associated with increased survival to hospital discharge and favorable neurological outcome when applied to OHCA patients in all rhythms and in the subgroup of those with an initial shockable rhythm. There was insufficient evidence to establish whether AED use is beneficial or harmful for patients with non-shockable rhythms. The overall quality of evidence was low for randomized trials and very low for

Conclusions

The current evidence supports the association between bystander AED use and improved clinical outcomes. However, the overall quality of evidence was low to very low. High-quality studies are warranted to confirm these findings, particularly to understand the role of AEDs in patients with non-shockable rhythms which constitutes the majority of OHCA.

Conflicts of interest

None of the authors have any conflicts of interest.

Acknowledgments

Dr. Holmberg and Dr. Andersen conceived the idea, performed the statistical analyses, and drafted the manuscript. Dr. Holmberg, Dr. Vognsen, and Mr. Andersen reviewed the initial titles and abstracts. Dr. Holmberg and Dr. Andersen reviewed full articles, extracted data, and performed the bias assessment. All authors contributed substantially to the design of the review, interpreted the results, critically revised the manuscript, and approved the manuscript prior to submission.

There was no

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