Primary outcomes for resuscitation science studies: a consensus statement from the American Heart Association

Patient Outcomes After Palliative Care Consultation Among Patients Undergoing Therapeutic Hypothermia

OBJECTIVES

To compare the clinical outcomes of patients who did and did not receive palliative care consultation among those who experienced out-of-hospital cardiac arrest and underwent therapeutic hypothermia.

METHODS

We identified patients at a single academic medical center who had undergone therapeutic hypothermia after out-of-hospital cardiac arrest between 2009 and 2013. We performed a retrospective chart review for demographic data, hospital and critical care length of stay, and clinical outcomes of care.

RESULTS

We reviewed the charts of 62 patients, of which 35 (56%) received a palliative care consultation and 27 (44%) did not. Palliative care consultation occurred an average of 8.3 days after admission. Patients receiving palliative care consultation were more likely to have a do-not-resuscitate (DNR) order placed (odds ratio: 2.3, P < .001). The mean length of stay in the hospital was similar for patients seen by palliative care or not (16.7 vs 17.1 days, P = .90). Intensive care length of stay was also similar (11.3 vs 12.6 days, P = .55).

CONCLUSIONS

Palliative care consultation was underutilized and utilized late in this cohort. Palliative consultation was associated with DNR orders but did not affect measures of utilization such as hospital and intensive care length of stay.

Initial Blood Ammonia Level Is a Useful Prognostication Tool in Out-of-Hospital Cardiac Arrest - Multicenter Prospective Study (SOS-KANTO 2012 Study)

BACKGROUND

Initial blood ammonia level is associated with neurologic outcomes in out-of-hospital cardiac arrest (OHCA). We tested the usefulness of blood ammonia for prediction of long-term neurological outcome of OHCA.Methods and Results:A total of 3,011 hospitalized adult OHCA patients were enrolled. Blood samples were obtained at the ED. Cut-offs (ammonia <100 μmol/L and lactate <12 mmol/L) were determined in a previous study. Neurological outcomes in survivors were assessed at 3 months. A logistic regression model with adjustment for within-hospital clustering and other risk factors was used to evaluate the association between biomarkers and outcomes. Of 3,011 patients, 380 (13.8%) had favorable neurological outcomes. Ammonia and lactate predicted neurological outcome with an AUC of 0.80 (95% CI: 0.76-0.84) and 0.77 (95% CI: 0.72-0.82), respectively. Adjusted OR for ammonia <100 μmol/L (4.55; 95% CI: 2.67-7.81) was higher than that for lactate <12 mmol/L (2.63; 95% CI: 1.61-4.28) and most other risk factors, such as cardiac etiology (3.47; 95% CI: 2.55-4.72), age<80 years (3.16; 95% CI: 2.17-4.61), bystander CPR (2.39; 95% CI: 1.70-3.38), and initial rhythm shockable (1.66; 95% CI: 1.16-2.37). The combination of ammonia and lactate had an increased predictive value (AUC, 0.86; 95% CI: 0.85-0.87) compared with that without biomarkers (AUC, 0.81; 95% CI: 0.80-0.82).

CONCLUSIONS

Initial blood ammonia level is as useful as other traditional prognostic indicators such as lactate. Measurement of both initial blood ammonia and lactate helped accurately predict neurological outcomes after OHCA.

Functional Neurologic Outcomes Change Over the First 6 Months After Cardiac Arrest

OBJECTIVES

To determine the longitudinal changes in functional outcome and compare ordinal outcome scale assessments in comatose cardiac arrest survivors.

DESIGN

Prospective observational study of comatose cardiac arrest survivors. Subjects who survived to 1 month were included.

SETTING

Academic medical center ICU.

PATIENTS

Ninety-eight consecutive patients who remained comatose after resuscitation from cardiac arrest; 45 patients survived to 1 month.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients' functional neurologic outcomes were assessed by phone call or in-person clinic visit at 1, 3, 6, and 12 months postcardiac arrest using the modified Rankin Scale, Glasgow Outcome Scale, and Barthel Index. A "good" outcome was defined as modified Rankin Scale 0-3, Barthel Index 70-100, and Glasgow Outcome Scale 4-5. Changes in dichotomized outcomes and shifts on each outcome scale were analyzed. The mean age of survivors was 51 ± 19 years and 18 (40%) were women. Five (19%) out of 26 patients with data available at all timepoints improved to good modified Rankin Scale outcome and none worsened to poor outcome between postarrest months 1 and 6 (p = 0.06). Thirteen patients (50%) improved on the modified Rankin Scale by 1-3 points and four (15%) worsened by 1-2 points between months 1 and 6 (overall improvement by 0.5 points; 95% CI, 0-1; p = 0.04). From postarrest months 6 to 12, there was no change in the number of patients with good versus poor outcomes. The modified Rankin Scale and Barthel Index were more sensitive to detecting changes in outcome than the Glasgow Outcome Scale.

CONCLUSIONS

In initially comatose cardiac arrest survivors, improvements in functional status occur over the first 6 months after the event. There was no significant change in outcome between postarrest months 6 and 12. The modified Rankin Scale is a sensitive outcome scale in this population.

Functional Outcome Trajectories After Out-of-Hospital Pediatric Cardiac Arrest

OBJECTIVES

To analyze functional performance measures collected prospectively during the conduct of a clinical trial that enrolled children (up to age 18 yr old), resuscitated after out-of-hospital cardiac arrest, who were at high risk of poor outcomes.

DESIGN

Children with Glasgow Motor Scale score less than 5, within 6 hours of resuscitation, were enrolled in a clinical trial that compared two targeted temperature management interventions (THAPCA-OH, NCT00878644). The primary outcome, 12-month survival with Vineland Adaptive Behavior Scale, second edition, score greater or equal to 70, did not differ between groups.

SETTING

Thirty-eight North American PICUs.

PARTICIPANTS

Two hundred ninety-five children were enrolled; 270 of 295 had baseline Vineland Adaptive Behavior Scale, second edition, scores greater or equal to 70; 87 of 270 survived 1 year.

INTERVENTIONS

Targeted temperatures were 33.0°C and 36.8°C for hypothermia and normothermia groups.

MEASUREMENTS AND MAIN RESULTS

Baseline measures included Vineland Adaptive Behavior Scale, second edition, Pediatric Cerebral Performance Category, and Pediatric Overall Performance Category. Pediatric Cerebral Performance Category and Pediatric Overall Performance Category were rescored at hospital discharges; all three were scored at 3 and 12 months. In survivors with baseline Vineland Adaptive Behavior Scale, second edition scores greater or equal to 70, we evaluated relationships of hospital discharge Pediatric Cerebral Performance Category with 3- and 12-month scores and between 3- and 12-month Vineland Adaptive Behavior Scale, second edition, scores. Hospital discharge Pediatric Cerebral Performance Category scores strongly predicted 3- and 12-month Pediatric Cerebral Performance Category (r = 0.82 and 0.79; p < 0.0001) and Vineland Adaptive Behavior Scale, second edition, scores (r = -0.81 and -0.77; p < 0.0001). Three-month Vineland Adaptive Behavior Scale, second edition, scores strongly predicted 12-month performance (r = 0.95; p < 0.0001). Hypothermia treatment did not alter these relationships.

CONCLUSIONS

In comatose children, with Glasgow Motor Scale score less than 5 in the initial hours after out-of-hospital cardiac arrest resuscitation, function scores at hospital discharge and at 3 months predicted 12-month performance well in the majority of survivors.

A novel scoring system for predicting the neurologic prognosis prior to the initiation of induced hypothermia in cases of post-cardiac arrest syndrome: the CAST score

BACKGROUND

The aim of this study was to develop a scoring system for identifying the post-cardiac arrest syndrome (PCAS) patients with a good potential for recovery prior to the initiation of induced therapeutic hypothermia.

METHODS

A multi-center, retrospective, observational study was performed. Data of a total of 151 consecutive adults who underwent induced hypothermia after cardiac arrest (77 learning cases from two hospitals and 74 validation cases from two other hospitals) were analyzed.

RESULTS

In the learning set, 8 factors (initial rhythm, witnessed status and time until return of spontaneous circulation, pH, serum lactate, motor score according to the Glasgow Coma Scale (GCS), gray matter attenuation to white matter attenuation ratio (GWR), serum albumin, and hemoglobin) were found to be strongly correlated with the neurological outcomes. A tentative scoring system was created from the learning data using these factors, and the predictive accuracy (sensitivity and specificity) was evaluated in terms of both internal validation (0.85 and 0.84) and external validation (cutoff 50%: 0.95 and 0.90, 30%: 0.87 and 0.98, 15%: 0.67 and 1.00). Finally, using all the data, we established a post-Cardiac Arrest Syndrome for induced Therapeutic hypothermia (CAST) score to predict the neurologic prognosis prior to initiation of induced hypothermia.

CONCLUSIONS

The CAST score was developed to predict the neurological outcomes of PCAS patients treated by induced hypothermia. The likelihood of good recovery at 30 days was extremely low in PCAS patients with a CAST score of ≤15%. Prospective validation of the score is needed in the future.

Bystander Efforts and 1-Year Outcomes in Out-of-Hospital Cardiac Arrest

BACKGROUND

The effect of bystander interventions on long-term functional outcomes among survivors of out-of-hospital cardiac arrest has not been extensively studied.

METHODS

We linked nationwide data on out-of-hospital cardiac arrests in Denmark to functional outcome data and reported the 1-year risks of anoxic brain damage or nursing home admission and of death from any cause among patients who survived to day 30 after an out-of-hospital cardiac arrest. We analyzed risks according to whether bystander cardiopulmonary resuscitation (CPR) or defibrillation was performed and evaluated temporal changes in bystander interventions and outcomes.

RESULTS

Among the 2855 patients who were 30-day survivors of an out-of-hospital cardiac arrest during the period from 2001 through 2012, a total of 10.5% had brain damage or were admitted to a nursing home and 9.7% died during the 1-year follow-up period. During the study period, among the 2084 patients who had cardiac arrests that were not witnessed by emergency medical services (EMS) personnel, the rate of bystander CPR increased from 66.7% to 80.6% (P<0.001), the rate of bystander defibrillation increased from 2.1% to 16.8% (P<0.001), the rate of brain damage or nursing home admission decreased from 10.0% to 7.6% (P<0.001), and all-cause mortality decreased from 18.0% to 7.9% (P=0.002). In adjusted analyses, bystander CPR was associated with a risk of brain damage or nursing home admission that was significantly lower than that associated with no bystander resuscitation (hazard ratio, 0.62; 95% confidence interval [CI], 0.47 to 0.82), as well as a lower risk of death from any cause (hazard ratio, 0.70; 95% CI, 0.50 to 0.99) and a lower risk of the composite end point of brain damage, nursing home admission, or death (hazard ratio, 0.67; 95% CI, 0.53 to 0.84). The risks of these outcomes were even lower among patients who received bystander defibrillation as compared with no bystander resuscitation.

CONCLUSIONS

In our study, we found that bystander CPR and defibrillation were associated with risks of brain damage or nursing home admission and of death from any cause that were significantly lower than those associated with no bystander resuscitation. (Funded by TrygFonden and the Danish Heart Foundation.).

The association between physician turnover (the "July Effect") and survival after in-hospital cardiac arrest

IMPORTANCE

The July Effect refers to adverse outcomes that occur as a result of turnover of the physician workforce in teaching hospitals during the month of June.

OBJECTIVE

As a surrogate for physician turnover, we used a multivariable difference-in-difference approach to determine if there was a difference in outcomes between May and July in teaching versus non-teaching hospitals.

DESIGN

We used prospectively collected observational data from United States hospitals participating in the Get With The Guidelines^®-Resuscitation registry. Participants were adults with index in-hospital cardiac arrest between 2005-2014. They were a priori divided by location of arrest (general medical/surgical ward, intensive care unit, emergency department). The primary outcome was survival to hospital discharge. Secondary outcomes included neurological outcome at discharge, return of spontaneous circulation, and several process measures.

RESULTS

We analyzed 16,328 patients in intensive care units, 11,275 in general medical/surgical wards and 3790 in emergency departments. Patient characteristics were similar between May and July in both teaching and non-teaching hospitals. The models for intensive care unit patients indicated the presence of a July Effect with the difference-in-difference ranging between 1.9-3.1%, which reached statistical significance (p<0.05) in all but one model (p=0.07). Visual inspection of monthly survival curves did not show a discernible trend, and no July Effect was observed for return of spontaneous circulation, neurological outcome or process measures except for airway confirmation in the intensive care unit. We found no July Effect for survival in emergency departments or general medical/surgical wards (p>0.20 for all models).

CONCLUSIONS

There may be a July Effect in the intensive care unit but the results were mixed. Most survival models showed a statistically significant difference but this was not supported by the secondary analyses of return of spontaneous circulation and neurological outcome. We found no July Effect in the emergency department or the medical/surgical ward for patients with in-hospital cardiac arrest.

Characterization of mitochondrial injury after cardiac arrest (COMICA)

INTRODUCTION

Mitochondrial injury post-cardiac arrest has been described in pre-clinical settings but the extent to which this injury occurs in humans remains largely unknown. We hypothesized that increased levels of mitochondrial biomarkers would be associated with mortality and neurological morbidity in post-cardiac arrest subjects.

METHODS

We performed a prospective multicenter study of post-cardiac arrest subjects. Inclusion criteria were comatose adults who suffered an out-of-hospital cardiac arrest. Mitochondrial biomarkers were measured at 0, 12, 24, 36 and 48h after return of spontaneous circulation as well as in healthy controls.

RESULTS

Out of 111 subjects enrolled, 102 had evaluable samples at 0h. Cardiac arrest subjects had higher baseline cytochrome c levels compared to controls (2.18ng/mL [0.74, 7.74] vs. 0.16ng/mL [0.03, 0.91], p<0.001), and subjects who died had higher 0h cytochrome c levels compared to survivors (3.66ng/mL [1.40, 14.9] vs. 1.27ng/mL [0.16, 2.37], p<0.001). There were significantly higher Ribonuclease P (RNaseP) (3.3 [1.2, 5.7] vs. 1.2 [0.8, 1.2], p<0.001) and Beta-2microglobulin (B2M) (12.0 [1.0, 22.9], vs. 0.6 [0.6, 1.3], p<0.001) levels in cardiac arrest subjects at baseline compared to the control subjects. There were no differences between survivors and non-survivors for mitochondrial DNA, nuclear DNA, or cell free DNA.

CONCLUSIONS

Cytochrome c was increased in post- cardiac arrest subjects compared to controls, and in post-cardiac arrest non-survivors compared to survivors. Nuclear DNA and cell free DNA was increased in plasma of post-cardiac arrest subjects. There were no differences in mitochondrial DNA, nuclear DNA, or cell free DNA between survivors and non-survivors. Mitochondrial injury markers showed mixed results in the post-cardiac arrest period. Future research needs to investigate these differences.

Outcomes of Adult In-Hospital Cardiac Arrest Treated with Targeted Temperature Management: A Retrospective Cohort Study

Aim

Targeted temperature management (TTM) for in-hospital cardiac arrest (IHCA) is given different recommendation levels within international resuscitation guidelines. We aimed to identify whether TTM would be associated with favourable outcomes following IHCA and to determine which factors would influence the decision to implement TTM.

Methods

We conducted a retrospective observational study in a single medical centre. We included adult patients suffering IHCA between 2006 and 2014. We used multivariable logistic regression analysis to evaluate associations between independent variables and outcomes.

Results

We included a total of 678 patients in our analysis; only 22 (3.2%) patients received TTM. Most (81.1%) patients met at least one exclusion criteria for TTM. In all, 144 (21.2%) patients survived to hospital discharge; among them, 60 (8.8%) patients displayed favourable neurological status at discharge. TTM use was significantly associated with favourable neurological outcome (OR: 3.74, 95% confidence interval [CI]: 1.19–11.00; p-value = 0.02), but it was not associated with survival (OR: 1.41, 95% CI: 0.54–3.66; p-value = 0.48). Arrest in the emergency department was positively associated with TTM use (OR: 22.48, 95% CI: 8.40–67.64; p value < 0.001) and having vasopressors in place at the time of arrest was inversely associated with TTM use (OR: 0.08, 95% CI: 0.004–0.42; p-value = 0.02).

Conclusion

TTM might be associated with favourable neurological outcome of IHCA patients, irrespective of arrest rhythms. The prevalence of proposed exclusion criteria for TTM was high among IHCA patients, but these factors did not influence the use of TTM in clinical practice or neurological outcomes after IHCA.

Identifying Important Gaps in Randomized Controlled Trials of Adult Cardiac Arrest Treatments: A Systematic Review of the Published Literature

BACKGROUND

Cardiac arrest is a major public health concern worldwide. The extent and types of randomized controlled trials (RCT)-our most reliable source of clinical evidence-conducted in these high-risk patients over recent years are largely unknown.

METHODS AND RESULTS

We performed a systematic review, identifying all RCTs published in PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Library from 1995 to 2014 that focused on the acute treatment of nontraumatic cardiac arrest in adults. We then extracted data on the setting of study populations, types and timing of interventions studied, risk of bias, outcomes reported, and how these factors have changed over time. Over this 20-year period, 92 RCTs were published containing 64 309 patients (median, 225.5 per trial). Of these, 81 RCTs (88.0%) involved out-of-hospital cardiac arrest, whereas 4 (4.3%) involved in-hospital cardiac arrest and 7 (7.6%) included both. Eighteen RCTs (19.6%) were performed in the United States, 68 (73.9%) were performed outside the United States, and 6 (6.5%) were performed in both settings. Thirty-eight RCTs (41.3%) evaluated drug therapy, 39 (42.4%) evaluated device therapy, and 15 (16.3%) evaluated protocol improvements. Seventy-four RCTs (80.4%) examined interventions during the cardiac arrest, 15 (16.3%) examined post cardiac arrest treatment, and 3 (3.3%) studied both. Overall, reporting of the risk of bias was limited. The most common outcome reported was return of spontaneous circulation: 86 (93.5%) with only 22 (23.9%) reporting survival beyond 6 months. Fifty-three RCTs (57.6%) reported global ordinal outcomes, whereas 15 (16.3%) reported quality-of-life. RCTs in the past 5 years were more likely to be focused on protocol improvements and postcardiac arrest care.

CONCLUSIONS

Important gaps in RCTs of cardiac arrest treatments exist, especially those examining in-hospital cardiac arrest, protocol improvement, postcardiac arrest care, and long-term or quality-of-life outcomes.

Design and implementation of the AIRWAYS-2 trial: A multi-centre cluster randomised controlled trial of the clinical and cost effectiveness of the i-gel supraglottic airway device versus tracheal intubation in the initial airway management of out of hospital cardiac arrest

Health outcomes after out of hospital cardiac arrest (OHCA) are extremely poor, with only 7-9% of patients in the United Kingdom (UK) surviving to hospital discharge. Currently emergency medical services (EMS) use either tracheal intubation or newer supraglottic airway devices (SGAs) to provide advanced airway management during OHCA. Equipoise between the two techniques has led to calls for a well-designed randomised controlled trial. The primary objective of the AIRWAYS-2 trial is to assess whether the clinical effectiveness of the i-gel, a second-generation SGA, is superior to tracheal intubation in the initial airway management of OHCA patients in the UK. Paramedics recruited to the AIRWAYS-2 trial are randomised to use either tracheal intubation or i-gel as their first advanced airway intervention. Adults who have had a non-traumatic OHCA and are attended by an AIRWAYS-2 paramedic are retrospectively assessed against eligibility criteria for inclusion. The primary outcome is the modified Rankin Scale score at hospital discharge. Secondary objectives are to: (i) estimate differences between groups in outcome measures relating to airway management, hospital stay and recovery at 3 and 6 months; (ii) estimate the cost effectiveness of the i-gel compared to tracheal intubation. Because OHCA patient needs immediate treatment there are several unusual features and challenges to the design and implementation of this trial; these include level of randomisation, the automatic enrolment model, enrolment of patients that lack capacity and minimisation of bias. Patient enrolment began in June 2015. The trial will enrol 9070 patients over two years. The results are expected to influence future resuscitation guidelines. Trial Registration ISRCTN: 08256118.

Association between chest compression rates and clinical outcomes following in-hospital cardiac arrest at an academic tertiary hospital

AIMS

Recent guidelines for management of cardiac arrest recommend chest compression rates of 100-120 compressions/min. However, animal studies have found cardiac output to increase with rates up to 150 compressions/min. The objective of this study was to test the association between chest compression rates during cardiopulmonary resuscitation for in-hospital cardiac arrest (IHCA) and outcome.

METHODS

We conducted a prospective observational study at a single academic medical center.

INCLUSION CRITERIA

age≥18, IHCA, cardiopulmonary resuscitation performed. We analyzed chest compression rates measured by defibrillation electrodes, which recorded changes in thoracic impedance. The primary outcome was return of spontaneous circulation (ROSC). We used multivariable logistic regression to determine odds ratios for ROSC by chest compression rate categories (100-120, 121-140, >140 compressions/min), adjusted for chest compression fraction (proportion of time chest compressions provided) and other known predictors of outcome. We set 100-120 compressions/min as the reference category for the multivariable model.

RESULTS

We enrolled 222 consecutive patients and found a mean chest compression rate of 139±15. Overall 53% achieved ROSC; among 100-120, 121-140, and >140 compressions/min, ROSC was 29%, 64%, and 49% respectively. A chest compression rate of 121-140 compressions/min had the greatest likelihood of ROSC, odds ratio 4.48 (95% CI 1.42-14.14).

CONCLUSIONS

In this sample of adult IHCA patients, a chest compression rate of 121-140 compressions/min had the highest odds ratio of ROSC. Rates above the currently recommended 100-120 compressions/min may improve the chances of ROSC among IHCA patients.

The clinical nurse specialist as resuscitation process manager

PURPOSE/OBJECTIVES

The purpose of this article was to describe the history and leadership dimensions of the role of resuscitation process manager and provide specific examples of how this role is implemented at a Midwest medical center.

BACKGROUND

In 1992, a medical center in the Midwest needed a nurse to manage resuscitation care.

RATIONALE

This role designation meant that this nurse became central to all quality improvement efforts in resuscitation care. The role expanded as clinical resuscitation guidelines were updated and as the medical center grew. The role became known as the critical care clinical nurse specialist as resuscitation process manager. This clinical care nurse specialist was called a manager, but she had no direct line authority, so she accomplished her objectives by forming a multitude of collaborative networks.

DESCRIPTION

Based on a framework by Finkelman, the manager role incorporated specific leadership abilities in quality improvement: (1) coordination of medical center-wide resuscitation, (2) use of interprofessional teams, (3) integration of evidence into practice, and (4) staff coaching to develop leadership.

OUTCOME

The manager coordinates resuscitation care with the goals of prevention of arrests if possible, efficient and effective implementation of resuscitation protocols, high quality of patient and family support during and after the resuscitation event, and creation or revision of resuscitation policies for in-hospital and for ambulatory care areas. The manager designs a comprehensive set of meaningful and measurable process and outcome indicators with input from interprofessional teams. The manager engages staff in learning, reflecting on care given, and using the evidence base for resuscitation care. Finally, the manager role is a balance between leading quality improvement efforts and coaching staff to implement and sustain these quality improvement initiatives.

CONCLUSION

Revisions to clinical guidelines for resuscitation care since the 1990s have resulted in medical centers developing improved resuscitation processes that require management. The manager enhances collaborative quality improvement efforts that are in line with Institute of Medicine recommendations.

IMPLICATIONS

The role of resuscitation process manager may be of interest to medical centers striving for excellence in evidence-based resuscitation care.

Initial end-tidal CO2 partial pressure predicts outcomes of in-hospital cardiac arrest

INTRODUCTION

Monitoring the partial pressure of end-tidal carbon dioxide (PEtco₂) has been advocated since 2010 as an index of resuscitation efforts. However, related research has largely focused on out-of-hospital cardiac arrest victims. In-hospital cardiac arrest (IHCA) differs in terms of etiologies and demographics, the merit of initial PEtco₂ values was explored.

METHODS

This was a retrospective study in a single medical center between February 2011 and August 2014. Eligible subjects had suffered nontraumatic IHCA in the emergency department, where resuscitation was performed in accord with 2010 American Heart Association guidelines. Patients with initial PEtco₂ recordings via capnography were recruited.

RESULTS

A total of 353 IHCA events with initial PEtco₂ were recorded in 202 patients (male, 61.4%; mean age, 67.0 ± 16.2 years). Shockable rhythm (ventricular tachycardia/ventricular fibrillation) accounted for 11.8%. A cut point of 25.5 mm Hg was established for initial PEtco₂, creating 2 tiers of sustained return of spontaneous circulation (ROSC) that differed significantly in cumulative survival probability (log rank test, P = .002). For patients with initial PEtco₂ <25.5 mm Hg, survival benefit ceased at an earlier point in resuscitation, whereas above this threshold, the probability of survival cumulatively increased for a longer period. In multivariate analysis, initial PEtco₂ >25.5 mm Hg was found independently predictive of sustained ROSC (odds ratio, 2.64; 95% confidence interval, 1.43-4.88; P = .002), and survival to discharge (odds ratio, 3.10; 95% confidence interval, 1.26-7.60; P = .014), but failed to correlate with neurologic outcome.

CONCLUSION

In IHCA, the therapeutic threshold for initial PEtco₂ should set fairly higher to encourage more pulmonary flow and increase the likelihood of sustained ROSC.

Associations between blood glucose level and outcomes of adult in-hospital cardiac arrest: a retrospective cohort study

BACKGROUND

We intended to analyse the associations between blood glucose (BG) level and clinical outcomes of in-hospital cardiac arrest (IHCA).

METHODS

We conducted a retrospective observational study in a single medical centre and evaluated patients who experienced IHCA between 2006 and 2014. We used multivariable logistic regression analysis to study associations between independent variables and outcomes. We calculated the mean BG level for each patient by averaging the maximum and minimum BG levels in the first 24 h after arrest, and we used mean BG level for our final analysis.

RESULTS

We included a total of 402 patients. Of these, 157 patients (39.1 %) had diabetes mellitus (DM). The average mean BG level was 209.9 mg/dL (11.7 mmol/L). For DM patients, a mean BG level between 183 and 307 mg/dL (10.2-17.1 mmol/L) was significantly associated with favourable neurological outcome (odds ratio [OR] 2.71, 95 % confidence interval [CI] 1.18-6.20; p value = 0.02); a mean BG level between 147 and 317 mg/dL (8.2-17.6 mmol/L) was significantly associated with survival to hospital discharge (OR 2.38, 95 % CI 1.26-4.53; p value = 0.008). For non-DM patients, a mean BG level between 143 and 268 mg/dL (7.9-14.9 mmol/L) was significantly associated with survival to hospital discharge (OR 2.93, 95 % CI 1.62-5.40; p value < 0.001).

CONCLUSIONS

Mean BG level in the first 24 h after cardiac arrest was associated with neurological outcome for IHCA patients with DM. For neurological and survival outcomes, the optimal BG range may be higher for patients with DM than for patients without DM.

What change in outcomes after cardiac arrest is necessary to change practice? Results of an international survey

BACKGROUND

Efficient trials of interventions for patients with out-of-hospital cardiac arrest (OHCA) should have adequate but not excess power to detect a difference in outcomes. The minimum clinically important difference (MCID) is the threshold value in outcomes observed in a trial at which providers should choose to adopt a treatment. There has been limited assessment of MCID for outcomes after OHCA. Therefore, we conducted an international survey of individuals interested in cardiac resuscitation to define the MCID for a range of outcomes after OHCA.

METHODS

A brief survey instrument was developed and modified by consensus. Included were open-ended responses. The survey included an illustrative example of a hypothetical randomized study with distributions of outcomes based on those in a public use datafile from a previous trial. Elicited information included the minimum significant difference required in an outcome to change clinical practice. The population of interest was emergency physicians or other practitioners of acute cardiovascular research.

RESULTS

Usable responses were obtained from 160 respondents (50% of surveyed) in 46 countries (79% of surveyed). MCIDs tended to increase as baseline outcomes increased. For a population of patients with 25% survival to discharge and 20% favorable neurologic status at discharge, the MCID were median 5 (interquartile range [IQR] 3, 10) percent for survival to discharge; median 5 (IQR 2, 10) percent for favorable neurologic status at discharge, median 4 (IQR 2, 9) days of ICU-free survival and median 4 (IQR 2, 8) days of hospital-free survival.

CONCLUSION

Reported MCIDs for outcomes after OHCA vary according to the outcome considered as well as the baseline rate of achieving it. MCIDs of ICU-free survival or hospital-free survival may be useful to accelerate the rate of evidence-based change in resuscitation care.

Decreased a disintegrin-like and metalloprotease with thrombospondin type 1 motif 13 activity and neurologic outcome in patients with successful resuscitation of out-of-hospital cardiac arrest: A prospective observational study

PURPOSE

The purpose of this study is to investigate the association between a disintegrin-like and metalloprotease with thrombospondin type 1 motif 13 (ADAMTS13) and neurologic outcome in patients with resuscitation of out-of-hospital cardiac arrest (R-OHCA).

MATERIALS AND METHODS

A prospective observational study of adult patients with R-OHCA was conducted. Plasma activity of ADAMTS13 and inflammatory markers, an immunologic marker, and a marker of endothelial damage were measured on admission and day 2. Neurologic outcome was evaluated using the Cerebral Performance Categories on day 90.

RESULTS

Plasma activity of ADAMTS13 on day 2 was lower in patients with poor neurologic outcome (n = 18) than that in those with good neurologic outcome (n = 16; P = .008). It was also lower in 28-day nonsurvivors (n = 12) than in survivors (n = 21; P = .019). Soluble thrombomodulin showed a strong correlation with ADAMTS13 (P = .021). Furthermore, ADAMTS13 activity was negatively correlated with the Sequential Organ Failure Assessment score (P < .001), levels of high-mobility group box 1 (P = .028), and levels of interleukin 6 (P = .047) but positively correlated with the monocyte expression of human leukocyte antigen DR (P = .023).

CONCLUSION

Decreased ADAMTS13 activity was associated with poor neurologic outcome, high mortality, and worsened immune-inflammatory status in patients with R-OHCA. These results suggest that ADAMTS13 may have pathophysiologic relevance in postcardiac arrest syndrome.

Comparison of health-related quality of life and functional recovery measurement tools in out-of-hospital cardiac arrest survivors

INTRODUCTION

Although a number of validated health-related quality of life (HR-QOL) instruments exist for critical care populations, a standardised approach to assessing the HR-QOL of out-of-hospital cardiac arrest (OHCA) survivors has not been developed. We sought to compare the responses of 12-month OHCA survivors to three HR-QOL and functional recovery instruments, and assess instrument validity.

METHODS

The Victorian Ambulance Cardiac Arrest Registry invited 12-month OHCA survivors to participate in telephone follow-up between January 2011 and December 2015. Responders provided answers to the 12 Item Short Form Health Survey (SF-12), Three-Level EuroQol-5D (EQ-5D-3L) and the Glasgow Outcome Scale-Extended (GOSE). The SF-12 was also used to derive the SF-6D. Responses were used to assess the interpretability and construct validity of the instruments.

RESULTS

A total of 1188 patients and proxies responded. Large ceiling effects were observed for the EQ-5D-3L (patients=46%, proxies=23%). Substantial variability was also observed in SF-6D responses for patients who reported full health according to the EQ-5D-3L. For patient responders, the strongest correlations were observed between the EQ-5D-3L index score and SF-6D (ρ=0.65, p<0.001), and between the SF-6D and SF-12 physical component (ρ=0.69, p<0.001). The distribution of the SF-6D and EQ-5D-3L differed significantly for patients reporting a lower or upper moderate GOSE outcome and lower or upper good recovery (p<0.001 for all comparisons).

CONCLUSIONS

The EQ-5D-3L demonstrated limited interpretability due to the presence of ceiling effects. However, the measurement properties of the SF-12, SF-6D and GOSE suggest that these may be useful measures of HR-QOL and functional recovery in OHCA survivors.

Incidence and Outcomes of Cardiopulmonary Resuscitation in PICUs

OBJECTIVES

To determine the incidence of cardiopulmonary resuscitation in PICUs and subsequent outcomes.

DESIGN, SETTING, AND PATIENTS

Multicenter prospective observational study of children younger than 18 years old randomly selected and intensively followed from PICU admission to hospital discharge in the Collaborative Pediatric Critical Care Research Network December 2011 to April 2013.

RESULTS

Among 10,078 children enrolled, 139 (1.4%) received cardiopulmonary resuscitation for more than or equal to 1 minute and/or defibrillation. Of these children, 78% attained return of circulation, 45% survived to hospital discharge, and 89% of survivors had favorable neurologic outcomes. The relative incidence of cardiopulmonary resuscitation events was higher for cardiac patients compared with non-cardiac patients (3.4% vs 0.8%, p <0.001), but survival rate to hospital discharge with favorable neurologic outcome was not statistically different (41% vs 39%, respectively). Shorter duration of cardiopulmonary resuscitation was associated with higher survival rates: 66% (29/44) survived to hospital discharge after 1-3 minutes of cardiopulmonary resuscitation versus 28% (9/32) after more than 30 minutes (p < 0.001). Among survivors, 90% (26/29) had a favorable neurologic outcome after 1-3 minutes versus 89% (8/9) after more than 30 minutes of cardiopulmonary resuscitation.

CONCLUSIONS

These data establish that contemporary PICU cardiopulmonary resuscitation, including long durations of cardiopulmonary resuscitation, results in high rates of survival-to-hospital discharge (45%) and favorable neurologic outcomes among survivors (89%). Rates of survival with favorable neurologic outcomes were similar among cardiac and noncardiac patients. The rigorous prospective, observational study design avoided the limitations of missing data and potential selection biases inherent in registry and administrative data.

Associations among gender, marital status, and outcomes of adult in-hospital cardiac arrest: A retrospective cohort study

AIM

To analyse the association between gender and outcomes of in-hospital cardiac arrest (IHCA) and the influences of age and marital status on the gender-based difference in clinical outcome.

METHODS

This retrospective observational study conducted in a single medical centre evaluated patients who had experienced IHCA from 2006 to 2014. Multivariate logistic regression analysis was used to study associations between independent variables and outcomes. Patients 18-49 years old were considered of reproductive age. The presence or absence of a legitimate spouse was retrieved from the family pedigree presented in the medical records. Reproductive age and marital status were each analysed as an interaction term with gender.

RESULTS

A total of 1524 patients, of which 598 were women (39.2%), were included in this study. There were 269 patients (17.7%) of reproductive age and 490 patients (32.2%) without a living spouse. Only 215 patients (14.1%) survived to hospital discharge. Among these, 110 patients (7.2%) demonstrated a favourable neurological status. Our analysis indicated that being female was inversely associated with a favourable neurological outcome (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.29-0.87; p=0.02). Being female without a living spouse was inversely associated with a favourable neurological outcome (OR, 0.43; 95% CI, 0.17-0.96; p=0.05). Neither female nor female-associated interaction terms were significantly associated with survival to hospital discharge.

CONCLUSION

Female patients with IHCA had worse neurological outcomes than their male counterparts, especially for women without a living spouse. However, survival outcome did not differ between genders.

Early Electroencephalographic Findings Correlate With Neurologic Outcome in Children Following Cardiac Arrest

OBJECTIVES

To determine the clinical and electroencephalographic findings associated with prognosis in nonneonate children following cardiac arrest.

DESIGN

Retrospective observational study.

SETTING

PICU and cardiac ICU.

PATIENTS

Nonneonate children with a history of cardiac arrest more than 2 minutes.

INTERVENTIONS

Electroencephalographic monitoring within 72 hours of return of spontaneous circulation.

MEASUREMENTS AND MAIN RESULTS

Clinical and features, neurophysiologic data, and Pediatric Cerebral Performance Category scores were collected. Electroencephalographic traces were reviewed in a blinded manner, all seizures and electroencephalographic findings noted, and the electroencephalography was scored at 1 hour, 24 hours, and continuous electroencephalographic end. Discrete data regarding specific characteristics of the electroencephalographic background and seizures were studied. Univariate and multivariate analyses were performed to identify associations between clinical variables, electroencephalographic findings, and Pediatric Cerebral Performance Category score at hospital discharge. Multivariate analysis of 73 children revealed duration of cardiac arrest less than 20 minutes or continuous electroencephalographic background activity within 12 hours postreturn of spontaneous circulation were associated with good short term neurologic outcome. Change in electroencephalographic background score over time and electroencephalographic data collected after the initial hour were not associated with outcome.

CONCLUSIONS

Following pediatric cardiac arrest, an initially normal electroencephalography or generalized slowing of the electroencephalographic background was associated with good neurologic outcome at hospital discharge.

Immediate Percutaneous Coronary Intervention Is Associated With Improved Short- and Long-Term Survival After Out-of-Hospital Cardiac Arrest

BACKGROUND

Whether to perform or not an immediate percutaneous coronary intervention (PCI) after out-of-hospital cardiac arrest is still debated. We aimed to evaluate the impact of PCI on short- and long-term survival in out-of-hospital cardiac arrest patients admitted after successful resuscitation.

METHODS AND RESULTS

Between 2000 and 2013, all nontrauma out-of-hospital cardiac arrest patients admitted in a Parisian cardiac arrest center after return of spontaneous circulation were prospectively included. The association between immediate PCI and short- and long-term mortality was analyzed using logistic regression and Cox multivariate analysis, respectively. Propensity score-matching method was used to assess the influence of PCI on short- and long-term survival. During the study period, 1722 patients (71.5% male, median age 60 [49.6, 72.2] years) were analyzed: 628 (35.6%) without coronary angiography, 615 (35.7%) with coronary angiography without PCI, and 479 (27.8%) with both. Among these groups, day 30 and year-10 survival rates were 21% and 11.9%, 35% and 29%, 43% and 38%, respectively (P<0.01 for each). PCI as compared with no coronary angiography was associated with a lower day-30 and long-term mortality (adjORcoro with PCI versus no coro 0.71, 95% confidence interval [0.54, 0.92]; P=0.02 and adjHRcoro with PCI versus no coro 0.44, 95% confidence interval [0.27, 0.71]; P<0.01, respectively). PCI remained associated with a lower risk of long-term mortality (adjHR 0.29; 95% confidence interval [0.14, 0.61]; P<0.01) in propensity score-matching analysis.

CONCLUSIONS

Immediate PCI after out-of-hospital cardiac arrest was associated with significant reduced risk of short- and long-term mortality. These findings should suggest physicians to consider immediate coronary angiography and PCI if indicated in these patients.

Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis

OBJECTIVES

To evaluate whether patients who experience cardiac arrest in hospital receive epinephrine (adrenaline) within the two minutes after the first defibrillation (contrary to American Heart Association guidelines) and to evaluate the association between early administration of epinephrine and outcomes in this population.

DESIGN

Prospective observational cohort study.

SETTING

Analysis of data from the Get With The Guidelines-Resuscitation registry, which includes data from more than 300 hospitals in the United States.

PARTICIPANTS

Adults in hospital who experienced cardiac arrest with an initial shockable rhythm, including patients who had a first defibrillation within two minutes of the cardiac arrest and who remained in a shockable rhythm after defibrillation.

INTERVENTION

Epinephrine given within two minutes after the first defibrillation.

MAIN OUTCOME MEASURES

Survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and survival to hospital discharge with a good functional outcome. A propensity score was calculated for the receipt of epinephrine within two minutes after the first defibrillation, based on multiple characteristics of patients, events, and hospitals. Patients who received epinephrine at either zero, one, or two minutes after the first defibrillation were then matched on the propensity score with patients who were "at risk" of receiving epinephrine within the same minute but who did not receive it.

RESULTS

2978 patients were matched on the propensity score, and the groups were well balanced. 1510 (51%) patients received epinephrine within two minutes after the first defibrillation, which is contrary to current American Heart Association guidelines. Epinephrine given within the first two minutes after the first defibrillation was associated with decreased odds of survival in the propensity score matched analysis (odds ratio 0.70, 95% confidence interval 0.59 to 0.82; P<0.001). Early epinephrine administration was also associated with a decreased odds of return of spontaneous circulation (0.71, 0.60 to 0.83; P<0.001) and good functional outcome (0.69, 0.58 to 0.83; P<0.001).

CONCLUSION

Half of patients with a persistent shockable rhythm received epinephrine within two minutes after the first defibrillation, contrary to current American Heart Association guidelines. The receipt of epinephrine within two minutes after the first defibrillation was associated with decreased odds of survival to hospital discharge as well as decreased odds of return of spontaneous circulation and survival to hospital discharge with a good functional outcome.

Personalized medicine for ARDS: the 2035 research agenda

In the last 20 years, survival among patients with acute respiratory distress syndrome (ARDS) has increased substantially with advances in lung-protective ventilation and resuscitation. Building on this success, personalizing mechanical ventilation to patient-specific physiology for enhanced lung protection will be a top research priority for the years ahead. However, the ARDS research agenda must be broader in scope. Further understanding of the heterogeneous biology, from molecular to mechanical, underlying early ARDS pathogenesis is essential to inform therapeutic discovery and tailor treatment and prevention strategies to the individual patient. The ARDSne(x)t research agenda for the next 20 years calls for bringing personalized medicine to ARDS, asking simultaneously both whether a treatment affords clinically meaningful benefit and for whom. This expanded scope necessitates standard acquisition of highly granular biological, physiological, and clinical data across studies to identify biologically distinct subgroups that may respond differently to a given intervention. Clinical trials will need to consider enrichment strategies and incorporate long-term functional outcomes. Tremendous investment in research infrastructure and global collaboration will be vital to fulfilling this agenda.

Corticosteroid therapy in refractory shock following cardiac arrest: a randomized, double-blind, placebo-controlled, trial

Background

The purpose of this study was to determine whether the provision of corticosteroids improves time to shock reversal and outcomes in patients with post-cardiac arrest shock.

Methods

We conducted a randomized, double-blind trial of post-cardiac arrest patients in shock, defined as vasopressor support for a minimum of 1 hour. Patients were randomized to intravenous hydrocortisone 100 mg or placebo every 8 hours for 7 days or until shock reversal. The primary endpoint was time to shock reversal.

Results

Fifty patients were included with 25 in each group. There was no difference in time to shock reversal between groups (hazard ratio: 0.83 [95 % CI: 0.40–1.75], p = 0.63). We found no difference in secondary outcomes including shock reversal (52 % vs. 60 %, p = 0.57), good neurological outcome (24 % vs. 32 %, p = 0.53) or survival to discharge (28 % vs. 36 %, p = 0.54) between the hydrocortisone and placebo groups. Of the patients with a baseline cortisol < 15 ug/dL, 100 % (6/6) in the hydrocortisone group achieved shock reversal compared to 33 % (1/3) in the placebo group (p = 0.08). All patients in the placebo group died (100 %; 3/3) whereas 50 % (3/6) died in the hydrocortisone group (p = 0.43).

Conclusions

In a population of cardiac arrest patients with vasopressor-dependent shock, treatment with hydrocortisone did not improve time to shock reversal, rate of shock reversal, or clinical outcomes when compared to placebo.

Clinical trial registration

Clinicaltrials.gov: NCT00676585, registration date: May 9, 2008.

Duration of Prehospital Resuscitation Efforts After Out-of-Hospital Cardiac Arrest

BACKGROUND

During out-of-hospital cardiac arrest, it is unclear how long prehospital resuscitation efforts should be continued to maximize lives saved.

METHODS AND RESULTS

Between 2005 and 2012, we enrolled 282 183 adult patients with bystander-witnessed out-of-hospital cardiac arrest from the All-Japan Utstein Registry. Prehospital resuscitation duration was calculated as the time interval from call receipt to return of spontaneous circulation in cases achieving prehospital return of spontaneous circulation or from call receipt to hospital arrival in cases not achieving prehospital return of spontaneous circulation. In each of 4 groups stratified by initial cardiac arrest rhythm (shockable versus nonshockable) and bystander resuscitation (presence versus absence), we calculated minimum prehospital resuscitation duration, defined as the length of resuscitation efforts in minutes required to achieve ≥99% sensitivity for the primary end point, favorable 30-day neurological outcome after out-of-hospital cardiac arrest. Prehospital resuscitation duration to achieve prehospital return of spontaneous circulation ranged from 1 to 60 minutes. Longer prehospital resuscitation duration reduced the likelihood of favorable neurological outcome (adjusted odds ratio, 0.84; 95% confidence interval, 0.838-0.844). Although the frequency of favorable neurological outcome was significantly different among the 4 groups, ranging from 20.0% (shockable/bystander resuscitation group) to 0.9% (nonshockable/bystander resuscitation group; P<0.001), minimum prehospital resuscitation duration did not differ widely among the 4 groups (40 minutes in the shockable/bystander resuscitation group and the shockable/no bystander resuscitation group, 44 minutes in the nonshockable/bystander resuscitation group, and 45 minutes in the nonshockable/no bystander resuscitation group).

CONCLUSIONS

On the basis of time intervals from the shockable arrest groups, prehospital resuscitation efforts should be continued for at least 40 minutes in all adults with bystander-witnessed out-of-hospital cardiac arrest.

CLINICAL TRIAL REGISTRATION

URL: http://www.umin.ac.jp/ctr/. Unique identifier: 000009918.

Rationale, design, and profile of Comprehensive Registry of In-Hospital Intensive Care for OHCA Survival (CRITICAL) study in Osaka, Japan

Background

We established a multi-center, prospective cohort that could provide appropriate therapeutic strategies such as criteria for the introduction and the effectiveness of in-hospital advanced treatments, including percutaneous coronary intervention (PCI), target temperature management, and extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) patients.

Methods

In Osaka Prefecture, Japan, we registered all consecutive patients who were suffering from an OHCA for whom resuscitation was attempted and who were then transported to institutions participating in this registry since July 1, 2012. A total of 11 critical care medical centers and one hospital with an emergency care department participated in this registry. The primary outcome was neurological status after OHCA, defined as cerebral performance category (CPC) scale.

Results

A total of 688 OHCA patients were documented between July 2012 and December 2012. Of them, 657 were eligible for our analysis. Patients’ average age was 66.2 years old, and male patients accounted for 66.2 %. The proportion of OHCAs having a cardiac origin was 50.4 %. The proportion as first documented rhythm of ventricular fibrillation/pulseless ventricular tachycardia was 11.6 %, pulseless electrical activity 23.4 %, and asystole 54.5 %. After hospital arrival, 10.5 % received defibrillation, 90.8 % tracheal intubation, 3.0 % ECPR, 3.5 % PCI, and 83.1 % adrenaline administration. The proportions of 90-day survival and CPC 1/2 at 90 days after OHCAs were 5.9 and 3.0 %, respectively.

Conclusions

The Comprehensive Registry of In-hospital Intensive Care for OHCA Survival (CRITICAL) study will enroll over 2000 OHCA patients every year. It is still ongoing without a set termination date in order to provide valuable information regarding appropriate therapeutic strategies for OHCA patients (UMIN000007528).

The Utility of Therapeutic Hypothermia for Post-Cardiac Arrest Syndrome Patients With an Initial Nonshockable Rhythm

BACKGROUND

Therapeutic hypothermia (TH) attenuates reperfusion injury in comatose survivors of cardiac arrest. The utility of TH in patients with nonshockable initial rhythms has not been widely accepted. We sought to determine whether TH improved neurological outcome and survival in postarrest patients with nonshockable rhythms.

METHODS AND RESULTS

We identified 519 patients after in- and out-of-hospital cardiac arrest with nonshockable initial rhythms from the Penn Alliance for Therapeutic Hypothermia (PATH) registry between 2000 and 2013. Propensity score matching was used. Patient and arrest characteristics used to estimate the propensity to receive TH were age, sex, location of arrest, witnessed arrest, and duration of arrest. To determine the association between TH and outcomes, we created 2 multivariable logistic models controlling for confounders. Of 201 propensity score-matched pairs, mean age was 63 ± 17 years, 51% were male, and 60% had an initial rhythm of pulseless electric activity. Survival to hospital discharge was greater in patients who received TH (17.6% versus 28.9%; P < 0.01), as was a discharge Cerebral Performance Category of 1 to 2 (13.7% versus 21.4%; P = 0.04). In adjusted analyses, patients who received TH were more likely to survive (odds ratio, 2.8; 95% confidence interval, 1.6-4.7) and to have better neurological outcome (odds ratio, 3.5; 95% confidence interval, 1.8-6.6) than those that did not receive TH.

CONCLUSIONS

Using propensity score matching, we found that patients with nonshockable initial rhythms treated with TH had better survival and neurological outcome at hospital discharge than those who did not receive TH. Our findings further support the use of TH in patients with initial nonshockable arrest rhythms.

Anxiety and depression among out-of-hospital cardiac arrest survivors

AIM

Survivors of out-of-hospital cardiac arrest (OHCA) may experience psychological distress but the actual prevalence is unknown. The aim of this study was to investigate anxiety and depression within a large cohort of OHCA-survivors.

METHODS

OHCA-survivors randomized to targeted temperature of 33 °C or 36 °C within the Target Temperature Management trial (TTM-trial) attended a follow-up after 6 months that included the questionnaire Hospital Anxiety and Depression Scale (HADS). A control group with ST-elevation myocardial infarction (STEMI) completed the same follow-up. Correlations to variables assumed to be associated with anxiety and depression in OHCA-survivors were tested.

RESULTS

At follow-up 278 OHCA-survivors and 119 STEMI-controls completed the HADS where 24% of OHCA-survivors (28% in 33 °C group/22% in 36 °C group, p=0.83) and 19% of the STEMI-controls reported symptoms of anxiety (OR 1.32; 95% CI (0.78-2.25), p=0.30). Depressive symptoms were reported by 13% of OHCA-survivors (equal in both intervention groups, p=0.96) and 8% of STEMI-controls (OR 1.76; 95% CI (0.82-3.79), p=0.15). Anxiety and depression among OHCA-survivors correlated to Health-Related Quality-of-Life, and subjectively reported cognitive deterioration by patient or observer. In addition, depression was associated with a poor neurological outcome.

CONCLUSION

One fourth of OHCA-survivors reported symptoms of anxiety and/or depression at 6 months which was similar to STEMI-controls and previous normative data. Subjective cognitive problems were associated with an increased risk for psychological distress. Since psychological distress affects long-term prognosis of cardiac patients in general it should be addressed during follow-up of survivors with OHCA due to a cardiac cause. ClinicalTrials.gov NCT01020916/NCT01946932.

Monitoring of serum lactate level during cardiopulmonary resuscitation in adult in-hospital cardiac arrest

Introduction

Serum lactate level may correlate with no-flow and low-flow status during cardiac arrest. Current guidelines have no recommended durations for cardiopulmonary resuscitation (CPR) before transition to the next strategy. We hypothesized that the lactate level measured during CPR could be associated with the survival probability and accordingly be useful in estimating the optimal duration for CPR.

Methods

We conducted a retrospective observational study in a single medical centre and included adult patients who had suffered an in-hospital cardiac arrest between 2006 and 2012. We used multivariable logistic regression analysis to study the association of lactate level measured during CPR and outcomes. We used generalized additive models to examine the nonlinear effects of continuous variables and conditional effect plots to visualize the estimated survival probability against CPR duration.

Results

Of the 340 patients included in our analysis, 50 patients (14.7 %) survived to hospital discharge. The mean lactate level was 9.6 mmol/L and mean CPR duration was 28.8 min. There was an inverse near-linear relationship between lactate level and probability of survival to hospital discharge. A serum lactate level <9 mmol/L was positively associated with patient survival to hospital discharge (odds ratio 2.00, 95 % confidence interval 1.01-4.06). The optimal CPR duration may not be a fixed value but depend on other conditions.

Conclusions

Serum lactate level measured during CPR could correlate with survival outcomes. A lactate level threshold of 9 mmol/L may be used as a reference value to identify patients with different survival probabilities and determine the optimal CPR durations.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1058-7) contains supplementary material, which is available to authorized users.

Functional Outcomes: One Year after a Cardiac Arrest

Objective. The study aim was to characterize the time-course of recovery in impairments, activity limitations, participation restrictions, disability, and quality of life during the first year after cardiac arrest. Secondarily, the study described the associations between the instruments used to measure each of these domains. Methods. Measures of global disability (Cerebral Performance Category, CPC, Modified Rankin Scale, mRS), quality of life, activity limitations, participation restrictions, and affective and cognitive impairments were administered to 29 participants 1, 6, and 12 months after cardiac arrest. Results. Global measures of disability indicated recovery between one month and one year after cardiac arrest (mean CPC: 2.1 versus 1.69,  P < 0.05; mean mRS: 2.55 versus 1.83, P < 0.05). While global measures of disability were moderately associated with participation, they were poorly associated with other measures. The cohort endorsed depressive symptomatology throughout the year but did not have detectable cognitive impairment. Conclusions. Recovery from cardiac arrest is multifaceted and recovery continues for months depending upon the measures being used. Measures of global disability, reintegration into the community, and quality of life yield different information. Future clinical trials should include a combination of measures to yield the most complete representation of recovery after cardiac arrest.

Association between treatment at an ST-segment elevation myocardial infarction center and neurologic recovery after out-of-hospital cardiac arrest

BACKGROUND

For patients resuscitated from out-of-hospital cardiac arrest (OHCA), the American Heart Association recommends regionalized care at cardiac resuscitation centers that are aligned with ST-segment elevation myocardial infarction (STEMI) centers. The effectiveness of treatment at STEMI centers remains unknown.

OBJECTIVE

To evaluate whether good neurologic recovery after OHCA is associated with treatment at an STEMI center and if volume of admitted OHCA patients is associated with good neurologic recovery.

METHODS

We included patients in the 2011 California Office of Statewide Health Planning and Development database with a "present on admission" diagnosis of cardiac arrest. Primary outcome was good neurologic recovery at hospital discharge. Hierarchical multiple logistic regression models were used to determine the association between treating hospital and good neurologic recovery after adjusting for patient factors (age, sex, race, ethnicity, insurance type, and ventricular arrest rhythm) and hospital factors (hospital size, intensive care unit bed days, trauma center designation, and teaching status).

RESULTS

We included 7,725 patients; two-thirds (5,202) were treated at an STEMI center and 1,869 (24%, 95% CI 23%-25%) had good neurologic recovery. After adjustment, treatment at an STEMI center with ≥40 and <40 OHCA cases/year were associated with good neurologic recovery (odds ratio 1.32 [95% CI 1.06-1.64] and 1.63 [95% CI 1.35-1.97], respectively). Higher volume of admitted OHCA patients was associated with decreased odds of good neurologic recovery (adjusted odds ratio per 10 patients 0.96, 95% CI 0.92-1.00), but this association was not statistically significant after excluding the highest-volume outlier.

CONCLUSIONS

Treatment at an STEMI center-regardless of its annual OHCA volume-after resuscitation from OHCA is associated with good neurologic recovery. Regionalized systems of care should prioritize STEMI centers as destinations for resuscitated OHCA patients.

Resuscitation and post resuscitation care of the very old after out-of-hospital cardiac arrest is worthwhile

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis. As comorbidity and frailty increase with age; ethical dilemmas may arise when OHCA occur in the very old.

OBJECTIVES

We aimed to investigate mortality, neurological outcome and post resuscitation care in octogenarians (≥80) to assess whether resuscitation and post resuscitation care should be avoided.

METHODS

During 2007-2011 consecutive OHCA-patients were attended by the physician-based Emergency Medical Services-system in Copenhagen. Pre-hospital data based on Utstein-criteria, and data on post resuscitation care were collected. Primary outcome was successful resuscitation; secondary endpoints were 30-day mortality and neurological outcome (Cerebral Performance Category (CPC)).

RESULTS

2509 OHCA-patients with attempted resuscitation were recorded, 22% (n=558) were octogenarians/nonagenarians. 166 (30% of all octogenarians with resuscitation attempted) octogenarians were successfully resuscitated compared to 830 (43% with resuscitation attempted) patients <80 years. 30-day mortality in octogenarians was significantly higher after adjustment for prognostic factors (HR=1.61 CI: 1.22-2.13, p<0.001). Octogenarians received fewer coronary angiographies (CAG) (14 vs. 37%, p<0.001), and had lower odds of receiving CAG by multivariate logistic regression (OR: 0.19, CI: 0.08-0.44, p<0.001). A favorable neurological outcome (CPC 1/2) in survivors to discharge was found in 70% (n=26) of octogenarians compared to 86% (n=317, p=0.03) in the younger patients.

CONCLUSION

OHCA in octogenarians was associated with a significantly higher mortality rate after adjustment for prognostic factors. However, the majority of octogenarian survivors were discharged with a favorable neurological outcome. Withholding resuscitation and post resuscitation care in octogenarians does not seem justified.