Improving outcome after out-of-hospital cardiac arrest by strengthening weak links of the local Chain of Survival; quality of advanced life support and post-resuscitation care

Good outcome in every fourth resuscitation attempt is achievable--an Utstein template report from the Stavanger region

AIM OF THE STUDY

Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the western world. We wanted to study changes in survival over time and factors linked to this in a region which have already reported high survival rates.

METHODS

We used a prospectively collected Utstein template database to identify all resuscitation attempts in adult patients with OHCA of presumed cardiac origin. We included 846 resuscitation attempts and compared survival to discharge with good outcome in two time periods (2001-2005 vs. 2006-2008).

RESULTS

We found no significant differences between the two time periods for mean age (71 and 70 years (p=0.309)), sex distribution (males 70% and 71% (p=0.708)), location of the OHCA (home 64% and 63% (p=0.732)), proportion of shockable rhythms (44% and 47% (p=0.261)) and rate of return of spontaneous circulation (38% and 43% (p=0.136)), respectively. Bystander cardiopulmonary resuscitation (CPR), however, increased significantly from 60% to 73% (p<0.0001), as did the overall rate of survival to discharge from 18% to 25% (p=0.018). In patients with a shockable first rhythm, rate of survival to discharge increased significantly from 37% to 48% (p=0.036). In witnessed arrest with shockable rhythm survival to discharge increased from 37% to 52% (p=0.0105).

CONCLUSION

Overall, good outcome is now achievable in every fourth resuscitation attempt and in every second resuscitation attempt when patients have a shockable rhythm. The reason for the better outcomes is most likely multi-factorial and linked to improvements in the local chain of survival.

Post-resuscitation care at the emergency department with critical care facilities--a length-of-stay analysis

AIM OF THE STUDY

An emergency department providing critical care will have an effect on outcome and intensive-care-units' resources by avoiding unnecessary or futile intensive-care admissions and thereby save hospital expenses. The study focussed on this result.

METHODS

The study employed a retrospective analysis of prospectively collected data of out-of-hospital cardiac arrest patients with return of spontaneous circulation, comatose on arrival. Outcomes and length of stay of patients who either stayed at the 'emergency department only' or were 'transferred in addition to an intensive care unit' were compared. Linear regression with log length of stay as outcome and 'emergency department only' as predictor with covariates was used for modelling.

RESULTS

From 1991 to 2008, out of 1236 patients (age 57 ± 15 years, female 31%), the 'emergency department only' group (n=349 (28%)) survived to discharge in 81(23%) cases, with a median length-of-stay in critical care of 1.7 (interquartile range 0.8; 3.1) days. The patients 'transferred in addition to an intensive care unit' (n=887 (72%)), with a survival rate of 55% (n=486, p<0.001) stayed 10 (5; 18) days (p<0.001). The length-of-stay in hospital was significantly shorter if patients were treated in the 'emergency department only' independent of other cardiac-arrest-related factors (regression coefficient -1.42, confidence interval -1.60 to -1.24).

CONCLUSIONS

An emergency department with critical care prevents admissions to intensive care units in 28% of patients with out-of-hospital cardiac arrest. It saves intensive-care-unit resources and shortens length of stay for comatose out-of-hospital cardiac-arrest survivors, regardless of their outcome.

Usefulness of cooling and coronary catheterization to improve survival in out-of-hospital cardiac arrest

Survival rates after out-of-hospital cardiac arrest (OHCA) continue to be poor. Recent evidence suggests that a more aggressive approach to postresuscitation care, in particular combining therapeutic hypothermia with early coronary intervention, can improve prognosis. We performed a single-center review of 125 patients who were resuscitated from OHCA in 2 distinct treatment periods, from 2002 to 2003 (control group) and from 2007 to 2009 (contemporary group). Patients in the contemporary group had a higher prevalence of cardiovascular risk factors but similar cardiac arrest duration and prehospital treatment (adrenaline administration and direct cardioversion). Rates of cardiogenic shock (48% vs 41%, p = 0.2) and decreased conscious state on arrival (77% vs 86%, p = 0.2) were similar in the 2 cohorts, as was the incidence of ST-elevation myocardial infarction (33% vs 43%, p = 0.1). The contemporary cohort was more likely to receive therapeutic hypothermia (75% vs 0%, p <0.01), coronary angiography (77% vs 45%, p <0.01), and percutaneous coronary intervention (38% vs 23%, p = 0.03). This contemporary therapeutic strategy was associated with better survival to discharge (64% vs 39%, p <0.01) and improved neurologic recovery (57% vs 29%, p <0.01) and was the only independent predictor of survival (odds ratio 5.5, 95% confidence interval 1.2 to 26.2, p = 0.03). Longer resuscitation time, presence of cardiogenic shock, and decreased conscious state were independent predictors of poor outcomes. In conclusion, modern management of OHCA, including therapeutic hypothermia and early coronary angiography is associated with significant improvement in survival to hospital discharge and neurologic recovery.

Postresuscitation care with mild therapeutic hypothermia and coronary intervention after out-of-hospital cardiopulmonary resuscitation: a prospective registry analysis

Introduction

Mild therapeutic hypothermia (MTH) has been shown to result in better neurological outcome after cardiopulmonary resuscitation. Percutaneous coronary intervention (PCI) may also be beneficial in patients after out-of-hospital cardiac arrest (OHCA).

Methods

A selected cohort study of 2,973 prospectively documented adult OHCA patients within the German Resuscitation Registry between 2004 and 2010. Data were analyzed by backwards stepwise binary logistic regression to identify the impact of MTH and PCI on both 24-hour survival and neurological outcome that was based on cerebral performance category (CPC) at hospital discharge. Odds ratios (95% confidence intervals) were calculated adjusted for the following confounding factors: age, location of cardiac arrest, presumed etiology, bystander cardiopulmonary resuscitation, witnessing, first electrocardiogram rhythm, and thrombolysis.

Results

The Preclinical care dataset included 2,973 OHCA patients with 44% initial return of spontaneous circulation (n = 1,302) and 35% hospital admissions (n = 1,040). Seven hundred and eleven out of these 1,040 OHCA patients (68%) were also registered within the Postresuscitation care dataset. Checking for completeness of datasets required the exclusion of 127 Postresuscitation care cases, leaving 584 patients with complete data for final analysis. In patients without PCI (n = 430), MTH was associated with increased 24-hour survival (8.24 (4.24 to 16.0), P < 0.001) and the proportion of patients with CPC 1 or CPC 2 at hospital discharge (2.13 (1.17 to 3.90), P < 0.05) as an independent factor. In normothermic patients (n = 405), PCI was independently associated with increased 24-hour survival (4.46 (2.26 to 8.81), P < 0.001) and CPC 1 or CPC 2 (10.81 (5.86 to 19.93), P < 0.001). Additional analysis of all patients (n = 584) revealed that 24-hour survival was increased by MTH (7.50 (4.12 to 13.65), P < 0.001) and PCI (3.88 (2.11 to 7.13), P < 0.001), while the proportion of patients with CPC 1 or CPC 2 was significantly increased by PCI (5.66 (3.54 to 9.03), P < 0.001) but not by MTH (1.27 (0.79 to 2.03), P = 0.33), although an unadjusted Fisher exact test suggested a significant effect of MTH (unadjusted odds ratio 1.83 (1.23 to 2.74), P < 0.05).

Conclusions

PCI may be an independent predictor for good neurological outcome (CPC 1 or CPC 2) at hospital discharge. MTH was associated with better neurological outcome, although subsequent logistic regression analysis did not show statistical significance for MTH as an independent predictor for good neurological outcome. Thus, postresuscitation care on the basis of standardized protocols including coronary intervention and hypothermia may be beneficial after successful resuscitation. One of the main limitations may be a selection bias for patients subjected to PCI and MTH.