How long is long enough? Good neurologic outcome in out-of-hospital cardiac arrest survivors despite prolonged resuscitation: a retrospective cohort study

Dynamic Course of Clinical State Transitions in Patients Undergoing Advanced Life Support after Out-of-Hospital Cardiac Arrest

OBJECTIVES

Studies of out-of-hospital cardiac arrest generally document the presenting (pulseless electrical activity [PEA], ventricular fibrillation/tachycardia (VF/VT), asystole), and the final states (resuming stable spontaneous circulation [s-ROSC], being declared dead). Only a few studies described the transitions between clinical states during advanced life support (ALS). The aim of this study was to describe and analyze the dynamics of state transitions during ALS.

METHODS

A retrospective analysis of 464 OHCA events was conducted. Any observed state and its corresponding changing time were documented through continuous electrocardiographic and trans-thoracic impedance recording.

RESULTS

When achieved, most s-ROSCs were obtained by 30 min, regardless of the presenting state. After this time point, the persistence of any transient state was associated with a great probability of being declared dead. The most probable change for VF/VT or PEA at any time was the transition to asystole (36.4% and 34.4%, respectively); patients in asystole at any time had a 70% probability of death. Patients achieving s-ROSC mostly came from a VF/VT state.In most cases, the presenting rhythm tended to persist over time during ALS. Asystole was the most stable state; a higher degree of instability was observed when the presenting rhythms were VF/VT or PEA. Transient ROSC episodes occurred mainly as the first transition after the presenting state, especially for initial PEA.

CONCLUSIONS

An understanding of the dynamic course of clinical state transitions during ALS may allow treatment strategies to be tailored in patients affected by OHCA.

Coronary angiography after cardiac arrest without ST-elevation myocardial infarction: a network meta-analysis

AIMS

This network meta-analysis aimed to assess the effect of early coronary angiography (CAG) compared with selective CAG (late and no CAG) for patients after out-of-hospital cardiac arrest without ST-elevation myocardial infarction (NSTE-OHCA).

METHODS AND RESULTS

A systematic literature search was performed using the EMBASE, MEDLINE and Web of Science databases without restrictions on publication date. The last search was performed on 15 July 2022. Randomized controlled trials (RCTs) and non-randomized studies (NRS) comparing the effect of early CAG to selective CAG after NSTE-OHCA on survival and/or neurological outcomes were included. Meta-analyses were performed based on a DerSimonian-Laird random effects model. A total of 18 studies were identified by the literature search. After the exclusion of two studies due to high risk of bias, 16 studies (six RCTs, ten NRS) were included in the final analyses. Meta-analyses showed a statistically significant increase in survival after early CAG compared with selective CAG in the overall analysis [OR: 1.40, 95% confidence interval (CI): (1.12-1.76), P < 0.01, I2 = 68%]. This effect was lost in the subgroup analysis of RCTs [OR: 0.89, 95% CI: (0.73-1.10), P = 0.29, I2 = 0%]. Random effects model network meta-analysis of NRS based on a Bayesian method showed statistically significant increased survival after late compared with early CAG [OR: 4.20, 95% CI: (1.22, 20.91)].

CONCLUSION

The previously reported superiority of early CAG after NSTE-OHCA is based on NRS at high risk of selection and survivorship bias. The meta-analysis of RCTs does not support routinely performing early CAG after NSTE-OHCA.

Extracorporeal cardiopulmonary resuscitation for cardiac arrest: An updated systematic review

OBJECTIVES

To provide an updated systematic review on the use of extracorporeal cardiopulmonary resuscitation (ECPR) compared with manual or mechanical cardiopulmonary resuscitation during cardiac arrest.

METHODS

This was an update of a systematic review published in 2018. OVID Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched for randomized trials and observational studies between January 1, 2018, and June 21, 2022. The population included adults and children with out-of-hospital or in-hospital cardiac arrest. Two investigators reviewed studies for relevance, extracted data, and assessed bias. The certainty of evidence was evaluated using GRADE.

RESULTS

The search identified 3 trials, 27 observational studies, and 6 cost-effectiveness studies. All trials included adults with out-of-hospital cardiac arrest and were terminated before enrolling the intended number of subjects. One trial found a benefit of ECPR in survival and favorable neurological status, whereas two trials found no statistically significant differences in outcomes. There were 23 observational studies in adults with out-of-hospital cardiac arrest or in combination with in-hospital cardiac arrest, and 4 observational studies in children with in-hospital cardiac arrest. Results of individual studies were inconsistent, although many studies favored ECPR. The risk of bias was intermediate for trials and critical for observational studies. The certainty of evidence was very low to low. Study heterogeneity precluded meta-analyses. The cost-effectiveness varied depending on the setting and the analysis assumptions.

CONCLUSIONS

Recent randomized trials suggest potential benefit of ECPR, but the certainty of evidence remains low. It is unclear which patients might benefit from ECPR.

Neurologisches Ergebnis und allgemeiner Gesundheitszustand bei Langzeitüberleben nach außerklinischer kardiopulmonaler Reanimation

Fragestellung

Für Deutschland liegen nur wenige Daten zum Gesundheitszustand und Langzeitüberleben nach außerklinischer Reanimation vor. Die vorliegende Studie untersucht den allgemeinen Gesundheitszustand und das neurologische Langzeitergebnis 2,5 bis 5 Jahre nach dem Reanimationsereignis sowie den Zusammenhang zwischen Behandlungsergebnis und präklinischen Patienten- und Behandlungsfaktoren.

Methodik

Alle über einen Zeitraum von 30 Monaten (2011–2013) durch den Rettungsdienst der Stadt Bonn durchgeführten Reanimationen wurden auf Grundlage der Notarzteinsatzprotokolle und des Deutschen Reanimationsregisters retrospektiv analysiert. Der allgemeine Gesundheitszustand wurde in Anlehnung an den SF-12 erfasst und das neurologische Langzeitergebnis kategorisiert (Cerebral Performance Category [CPC]). Die vorliegenden Daten wurden einer uni- und multivariaten logistischen Regressionsanalyse unterzogen.

Ergebnis

Von insgesamt 458 Patienten überlebten 17,9 % bis zur Krankenhausentlassung, 13,8 % mehr als 2,5 Jahre und 7,7 % bis zum Stichtag der Befragung. Von den noch lebenden Patienten hatten 85,3 % ein gutes neurologisches Ergebnis (CPC ≤ 2), welches durch ein geringeres Alter, einen beobachteten Kollaps, die Durchführung einer Defibrillation und das Ausbleiben einer Vasopressorgabe begünstigt wurde (multivariate Analyse). 74,2 % der Überlebenden beschrieben ihren Gesundheitszustand als gut.

Interpretation

Insgesamt überleben langfristig nur wenige Patienten einen außerklinischen Herz-Kreislauf-Stillstand. Die überlebenden Patienten beurteilen ihren Gesundheitszustand als gut und zeigen ein gutes neurologisches Ergebnis. Dabei hängt dieses Behandlungsergebnis von denselben Parametern wie der primäre Reanimationserfolg (Überleben bis Krankenhausaufnahme) ab. Die Etablierung klinischer Instrumente zur frühen Prognoseerstellung ist wünschenswert. Hierzu sind weitere Langzeituntersuchungen größerer Patientenkollektive mit Zugriff auf Routinedaten notwendig.

Goal-Directed Care Using Invasive Neuromonitoring Versus Standard of Care After Cardiac Arrest: A Matched Cohort Study

PURPOSE

Following return of spontaneous circulation after cardiac arrest, hypoxic ischemic brain injury is the primary cause of mortality and disability. Goal-directed care using invasive multimodal neuromonitoring has emerged as a possible resuscitation strategy. We evaluated whether goal-directed care was associated with improved neurologic outcome in hypoxic ischemic brain injury patients after cardiac arrest.

DESIGN

Retrospective, single-center, matched observational cohort study.

SETTING

Quaternary academic medical center.

PATIENTS

Adult patients admitted to the ICU following return of spontaneous circulation postcardiac arrest with clinical evidence of hypoxic ischemic brain injury defined as greater than or equal to 10 minutes of cardiac arrest with an unconfounded postresuscitation Glasgow Coma Scale of less than or equal to 8.

INTERVENTIONS

We compared patients who underwent goal-directed care using invasive neuromonitoring with those treated with standard of care (using both total and matched groups).

MEASUREMENTS AND MAIN RESULTS

Goal-directed care patients were matched 1:1 to standard of care patients using propensity scores and exact matching. The primary outcome was a 6-month favorable neurologic outcome (Cerebral Performance Category of 1 or 2). We included 65 patients, of whom 21 received goal-directed care and 44 patients received standard of care. The median age was 50 (interquartile range, 35-61), 48 (74%) were male, and seven (11%) had shockable rhythms. Favorable neurologic outcome at 6 months was significantly greater in the goal-directed care group (n = 9/21 [43%]) compared with the matched (n = 2/21 [10%], p = 0.016) and total (n = 8/44 [18%], p = 0.034) standard of care groups. Goal-directed care group patients had higher mean arterial pressure (p < 0.001 vs total; p = 0.0060 vs matched) and lower temperature (p = 0.007 vs total; p = 0.041 vs matched).

CONCLUSIONS

In this preliminary study of patients with hypoxic ischemic brain injury postcardiac arrest, goal-directed care guided by invasive neuromonitoring was associated with a 6-month favorable neurologic outcome (Cerebral Performance Category 1 or 2) versus standard of care. Significant work is required to confirm this finding in a prospectively designed study.

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: first results and outcomes of a newly established ECPR program in a large population area

OBJECTIVES

Out-of-hospital cardiac arrest (OHCA) is associated with excessively high mortality rates. Recent studies suggest benefits from extracorporeal cardiopulmonary resuscitation (ECPR) performed in selected patients. We sought to present the first results from our interdisciplinary ECPR program with a particular focus on early outcomes and potential risk factors associated with in-hospital mortality.

METHODS

Between January 2016 and December 2019, 44 patients who underwent ECPR selected according to our institutional ECPR protocol were retrospectively analyzed regarding pre-hospital, in-hospital, and early outcome parameters. Patients were divided into survivors (S) and non-survivors (NS). Statistical analysis of risk factors regarding in-hospital mortality of the patient cohort analyzed was performed.

RESULTS

The mean age of the population was 53 ± 12 years, with most patients being male (n = 40). The leading cause of cardiac arrest (CA) was myocardial infarction (n = 24, 55%). The median hospital stay was 1 (1;13) day. Twenty-three percent of patients (n = 10) were discharged from hospital including eight patients (18%) with CPC 1-2. Survivors showed a trend toward shorter pre-hospital CPR duration (60 (59;60) min (S) vs 60 (55;90) min (NS), p = 0.07).

CONCLUSION

Establishing ECPR programs in large population areas offers the option to improve survival rates for OHCA patients. Stringent compliance of institutional criteria (mainly age, witnessed arrest, and time of pre-hospital resuscitation) and providing ECPR to strictly selected patients seems to be a vital factor for such programs' success. Pre-clinical settings and therapeutic measures must be adjusted in this regard to improve outcomes for this highly demanding patient cohort.