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Kishihara Y, Kashiura M, Yasuda H, Kitamura N, Nomura T, Tagami T, Yasunaga H, Aso S, Takeda M, Moriya T. Association between institutional volume of out-of-hospital cardiac arrest cases and short term outcomes. Am J Emerg Med 2024; 75:65-71. [PMID: 37922832 DOI: 10.1016/j.ajem.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/04/2023] [Accepted: 10/08/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a serious condition. The volume-outcome relationship and various post-cardiac arrest care elements are believed to be associated with improved neurological outcomes. Although previous studies have investigated the volume-outcome relationship, adjusting for post-cardiac arrest care, intra-class correlation for each institution, and other covariates may have been insufficient. OBJECTIVE To investigate the volume-outcome relationships and favorable neurological outcomes among OHCA cases in each institution. METHODS We conducted a prospective observational study of adult patients with non-traumatic OHCA using the OHCA registry in Japan. The primary outcome was 30-day favorable neurological outcomes, and the secondary outcome was 30-day survival. We set the cutoff values to trisect the number of patients as equally as possible and classified institutions into high-, middle-, and low-volume. Generalized estimating equations (GEE) were performed to adjust for covariates and within-hospital clustering. RESULTS Among the 9909 registry patients, 7857 were included. These patients were transported to either low- (2679), middle- (2657), or high- (2521) volume institutions. The median number of eligible patients per institution in 19 months of study periods was 82 (range, 1-207), 252 (range, 210-353), and 463 (range, 390-701), respectively. After multivariable GEE using the low-volume institution as a reference, no significant difference in odds ratios and 95% confidence intervals were noted for 30-day favorable neurological outcomes for middle volume [1.22 (0.69-2.17)] and high volume [0.80 (0.47-1.37)] institutions. Moreover, there was no significant difference for 30-day survival for middle volume [1.02 (0.51-2.02)] and high volume [1.09 (0.53-2.23)] institutions. CONCLUSION The patient volume of each institution was not associated with 30-day favorable neurological outcomes. Although this result needs to be evaluated more comprehensively, there may be no need to set strict requirements for the type of institution when selecting a destination for OHCA cases.
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Affiliation(s)
- Yuki Kishihara
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama 330-8503, Japan
| | - Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama 330-8503, Japan.
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama 330-8503, Japan; Department of Clinical Research Education and Training Unit, Keio University Hospital Clinical and Translational Research Center, 35 Shinanomachi, Sinzyuku-ku, Tokyo 160-0016, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu-shi, Chiba 292-0822, Japan.
| | - Tomohisa Nomura
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima-ku, Tokyo 177-8521, Japan.
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugi-cho, Nakahara-ku, Kawasaki-shi, Kanagawa 211-8533, Japan.
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
| | - Shotaro Aso
- Department of Real World Evidence, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
| | - Munekazu Takeda
- Department of Critical Care and Emergency Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinzyuku-ku, Tokyo 162-8666, Japan.
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama 330-8503, Japan.
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Bayır H, Dixon SJ, Tyurina YY, Kellum JA, Kagan VE. Ferroptotic mechanisms and therapeutic targeting of iron metabolism and lipid peroxidation in the kidney. Nat Rev Nephrol 2023; 19:315-336. [PMID: 36922653 DOI: 10.1038/s41581-023-00689-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 03/17/2023]
Abstract
Ferroptosis is a mechanism of regulated necrotic cell death characterized by iron-dependent, lipid peroxidation-driven membrane destruction that can be inhibited by glutathione peroxidase 4. Morphologically, it is characterized by cellular, organelle and cytoplasmic swelling and the loss of plasma membrane integrity, with the release of intracellular components. Ferroptosis is triggered in cells with dysregulated iron and thiol redox metabolism, whereby the initial robust but selective accumulation of hydroperoxy polyunsaturated fatty acid-containing phospholipids is further propagated through enzymatic and non-enzymatic secondary mechanisms, leading to formation of oxidatively truncated electrophilic species and their adducts with proteins. Thus, ferroptosis is dependent on the convergence of iron, thiol and lipid metabolic pathways. The kidney is particularly susceptible to redox imbalance. A growing body of evidence has linked ferroptosis to acute kidney injury in the context of diverse stimuli, such as ischaemia-reperfusion, sepsis or toxins, and to chronic kidney disease, suggesting that ferroptosis may represent a novel therapeutic target for kidney disease. However, further work is needed to address gaps in our understanding of the triggers, execution and spreading mechanisms of ferroptosis.
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Affiliation(s)
- Hülya Bayır
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA.
- Center for Free Radical and Antioxidant Health, Departments of Environmental Health, Pharmacology and Chemical Biology, Chemistry, Radiation Oncology, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Pediatrics, Division of Critical Care and Hospital Medicine, Redox Health Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA.
| | - Scott J Dixon
- Department of Biology, Stanford University, Stanford, CA, USA
| | - Yulia Y Tyurina
- Center for Free Radical and Antioxidant Health, Departments of Environmental Health, Pharmacology and Chemical Biology, Chemistry, Radiation Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Kellum
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA
| | - Valerian E Kagan
- Center for Free Radical and Antioxidant Health, Departments of Environmental Health, Pharmacology and Chemical Biology, Chemistry, Radiation Oncology, University of Pittsburgh, Pittsburgh, PA, USA
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Goh AXC, Seow JC, Lai MYH, Liu N, Man Goh Y, Ong MEH, Lim SL, Ho JSY, Yeo JW, Ho AFW. Association of High-Volume Centers With Survival Outcomes Among Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. JAMA Netw Open 2022; 5:e2214639. [PMID: 35639377 PMCID: PMC9157264 DOI: 10.1001/jamanetworkopen.2022.14639] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/13/2022] [Indexed: 11/29/2022] Open
Abstract
Importance Although high volume of cases of out-of-hospital cardiac arrest (OHCA) is a key feature of cardiac arrest centers, which have proven survival benefit, the role of center volume as an independent variable associated with improved outcomes is unclear. Objective To assess the association of high-volume centers with survival and neurological outcomes in nontraumatic OHCA. Data Sources Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to October 11, 2021, for studies including adult patients with nontraumatic OHCA who were treated at high-volume vs non-high-volume centers. Study Selection Randomized clinical trials, nonrandomized studies of interventions, prospective cohort studies, and retrospective cohort studies were selected that met the following criteria: (1) adult patients with OHCA of nontraumatic etiology, (2) comparison of high-volume with low-volume centers, (3) report of a volume-outcome association, and (4) report of outcomes of interest. At least 2 authors independently reviewed each article, blinded to each other's decision. Data Extraction and Synthesis Data abstraction and quality assessment were independently conducted by 2 authors. Meta-analyses were performed for adjusted odds ratios (aORs) and crude ORs using a random-effects model. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Main Outcomes and Measures Survival and good neurological outcomes according to the Cerebral Performance Categories Scale at hospital discharge or 30 days. Results A total of 16 studies involving 82 769 patients were included. Five studies defined high volume as 40 or more cases of OHCA per year; 3 studies defined high volume as greater than 100 cases of OHCA per year. All other studies differed in definitions. Survival to discharge or 30 days improved with treatment at high-volume centers, regardless of whether aORs (1.28 [95% CI, 1.00-1.64]) or crude ORs (1.43 [95% CI, 1.09-1.87]) were pooled. There was no association between center volume and good neurological outcomes at 30 days or hospital discharge in patients with OHCA (aOR, 0.96 [95% CI, 0.77-1.20]). Conclusions and Relevance In this meta-analysis and systematic review, care at high-volume centers was associated with improved survival outcomes, even after adjustment for potential confounders, but was not associated with improved neurological outcomes for patients with nontraumatic OHCA. More studies evaluating the relative importance of center volume compared with other variables (eg, the availability of treatment modalities) associated with survival outcomes in patients with OHCA are required.
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Affiliation(s)
- Amelia Xin Chun Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jie Cong Seow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Melvin Yong Hao Lai
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nan Liu
- Center for Quantitative Medicine, Duke-NUS (National University of Singapore) Medical School, Singapore
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Yi Man Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Center, Singapore
| | - Jamie Sin Ying Ho
- Academic Foundation Programme, Royal Free London NHS (National Health Service) Foundation Trust, London, United Kingdom
| | - Jun Wei Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Prehospital and Emergency Research Center, Duke-NUS Medical School, Singapore
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Yeo JW, Ng ZHC, Goh AXC, Gao JF, Liu N, Lam SWS, Chia YW, Perkins GD, Ong MEH, Ho AFW. Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 11:e023806. [PMID: 34927456 PMCID: PMC9075197 DOI: 10.1161/jaha.121.023806] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background The role of cardiac arrest centers (CACs) in out‐of‐hospital cardiac arrest care systems is continuously evolving. Interpretation of existing literature is limited by heterogeneity in CAC characteristics and types of patients transported to CACs. This study assesses the impact of CACs on survival in out‐of‐hospital cardiac arrest according to varying definitions of CAC and prespecified subgroups. Methods and Results Electronic databases were searched from inception to March 9, 2021 for relevant studies. Centers were considered CACs if self‐declared by study authors and capable of relevant interventions. Main outcomes were survival and neurologically favorable survival at hospital discharge or 30 days. Meta‐analyses were performed for adjusted odds ratio (aOR) and crude odds ratios. Thirty‐six studies were analyzed. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR, 1.85 [95% CI, 1.52–2.26]), even when including high‐volume centers (aOR, 1.50 [95% CI, 1.18–1.91]) or including improved‐care centers (aOR, 2.13 [95% CI, 1.75–2.59]) as CACs. Survival significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59–2.32]), even when including high‐volume centers (aOR, 1.74 [95% CI, 1.38–2.18]) or when including improved‐care centers (aOR, 1.97 [95% CI, 1.71–2.26]) as CACs. The treatment effect was more pronounced among patients with shockable rhythm (P=0.006) and without prehospital return of spontaneous circulation (P=0.005). Conclusions were robust to sensitivity analyses, with no publication bias detected. Conclusions Care at CACs was associated with improved survival and neurological outcomes for patients with nontraumatic out‐of‐hospital cardiac arrest regardless of varying CAC definitions. Patients with shockable rhythms and those without prehospital return of spontaneous circulation benefited more from CACs. Evidence for bypassing hospitals or interhospital transfer remains inconclusive.
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Affiliation(s)
- Jun Wei Yeo
- Yong Loo Lin School of Medicine National University of Singapore Singapore
| | - Zi Hui Celeste Ng
- Yong Loo Lin School of Medicine National University of Singapore Singapore
| | | | | | - Nan Liu
- Centre for Quantitative Medicine Duke-NUS Medical SchoolNational University of Singapore Singapore
| | - Shao Wei Sean Lam
- Health Services Research Centre SingHealth Duke-NUS Academic Medical Centre Singapore
| | - Yew Woon Chia
- Department of Cardiology Tan Tock Seng Hospital Singapore
| | - Gavin D Perkins
- Warwick Medical School University of Warwick Coventry United Kingdom
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine Singapore General Hospital Singapore.,Health Services & Systems Research Duke-NUS Medical School Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine Singapore General Hospital Singapore.,Pre-Hospital and Emergency Research Centre Health Services and Systems Research Duke-NUS Medical School Singapore
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Abstract
Cardiac arrest results from a broad range of etiologies that can be broadly grouped as sudden and asphyxial. Animal studies point to differences in injury pathways invoked in the heart and brain that drive injury and outcome after these different forms of cardiac arrest. Present guidelines largely ignore etiology in their management recommendations. Existing clinical data reveal significant heterogeneity in the utility of presently employed resuscitation and postresuscitation strategies based on etiology. The development of future neuroprotective and cardioprotective therapies should also take etiology into consideration to optimize the chances for successful translation.
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Kim KH, Ro YS, Park JH, Kim TH, Jeong J, Hong KJ, Song KJ, Shin SD. Association between case volume of ambulance stations and clinical outcomes of out-of-hospital cardiac arrest: A nationwide multilevel analysis. Resuscitation 2021; 163:71-77. [PMID: 33895233 DOI: 10.1016/j.resuscitation.2021.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/12/2021] [Accepted: 04/06/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The case volume effects of ambulance stations on the survival of out-of-hospital cardiac arrest (OHCA) patients are uncertain. This study was conducted to evaluate the association between the case volume of ambulance stations and clinical outcomes in OHCAs by the number of emergency medical services (EMS) providers at the scene. METHODS Adult cardiac EMS-treated OHCAs between 2015 and 2018 were enrolled. The main exposure was the annual OHCA case volumes of 204 ambulance stations in Korea, which were categorized into three groups; low-volume (<100), moderate-volume (100-159) and high-volume (≥160). The primary and secondary outcomes were good neurological recovery and survival to discharge. Multilevel multivariable logistic regression analysis was conducted to calculate adjusted odds ratios (AORs). Interaction analysis between the number of EMS providers at the scene and the exposure variable was performed. RESULTS A total of 92,534 patients were enrolled. OHCAs in the low-volume group tended to be arrest in a public place or a non-metropolitan area, less prehospital administration of an advanced airway and intravenous management. Significant differences were found the main analysis: AORs (95% CIs) compared to the low-volume group were 1.15 (1.03-1.29) and 1.14 (1.03-1.27) in the high-volume and moderate-volume groups for good neurological recovery and 1.19 (1.07-1.33) and 1.14 (1.04-1.25) in the high-volume and moderate-volume groups for survival to discharge. Significant interaction effects between the number of EMS providers at the scene and case volume on clinical outcomes were found. CONCLUSION OHCA case volumes of ambulance stations are associated with clinical outcomes after cardiac arrest.
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Affiliation(s)
- Ki Hong Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
| | - Young Sun Ro
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
| | - Jeong Ho Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
| | - Tae Han Kim
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
| | - Joo Jeong
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
| | - Ki Jeong Hong
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
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Association between Hospital volume of cardiopulmonary resuscitation for in-hospital cardiac arrest and survival to Hospital discharge. Resuscitation 2020; 148:25-31. [PMID: 31945429 DOI: 10.1016/j.resuscitation.2019.12.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/17/2019] [Accepted: 12/31/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Prior studies have shown that hospital case volume is not associated with survival in patients with out-of-hospital cardiac arrest (OHCA). However, how case volume impact on survival for in-hospital cardiac arrest (IHCA) is unknown. METHODS We queried the National Inpatient Sample (NIS) in the U.S. 2005-2011 to identify cases in which in-hospital CPR was performed for IHCA. Restricted cubic spine was used to evaluate the association between hospital annual CPR volume and survival to hospital discharge. RESULTS Across more than 1000 hospitals in NIS, we identified 125,082 cases (mean age 67, 45% female) of IHCA for which CPR was performed over the study period. Median [Q1, Q3] case volume was 60 [34, 99]. Compared to those in the 1 st quartile of case volume, hospitals in the 4th quartile tends to have younger patients (mean = 66 vs 68 yrs), higher comorbidities (median Elixhauser score = 4 vs 3), and in low income areas (37 vs 30%). Overall, 23% of the patients survived to hospital discharge. There was a non-linear association between CPR volume and survival: a non-significant trend towards better survival was observed with increasing annual CPR volume that reached a plateau at 51-55 cases per year, after which survival began to drop and became significantly lower after 75 cases per year (p for non-linearity<0.001). Compared to those in first quartile of case volume, hospitals in 4th quartile had higher length of stay (median = 8 vs 10 days, respectively) and higher rate of non-routine home discharge (64% vs 67%) among those who survived. CONCLUSION Unlike OHCA, low CPR volume is an indicator of good performing hospitals and increasing CPR case volume does not translate to improve survival for IHCA.
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Phenotyping Cardiac Arrest: Bench and Bedside Characterization of Brain and Heart Injury Based on Etiology. Crit Care Med 2019. [PMID: 29533310 DOI: 10.1097/ccm.0000000000003070] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Cardiac arrest etiology may be an important source of between-patient heterogeneity, but the impact of etiology on organ injury is unknown. We tested the hypothesis that asphyxial cardiac arrest results in greater neurologic injury than cardiac etiology cardiac arrest (ventricular fibrillation cardiac arrest), whereas ventricular fibrillation cardiac arrest results in greater cardiovascular dysfunction after return of spontaneous circulation. DESIGN Prospective observational human and randomized animal study. SETTING University laboratory and ICUs. PATIENTS Five-hundred forty-three cardiac arrest patients admitted to ICU. SUBJECTS Seventy-five male Sprague-Dawley rats. INTERVENTIONS We examined neurologic and cardiovascular injury in Isoflurane-anesthetized rat cardiac arrest models matched by ischemic time. Hemodynamic and neurologic outcomes were assessed after 5 minutes no flow asphyxial cardiac arrest or ventricular fibrillation cardiac arrest. Comparison was made to injury patterns observed after human asphyxial cardiac arrest or ventricular fibrillation cardiac arrest. MEASUREMENTS AND MAIN RESULTS In rats, cardiac output (20 ± 10 vs 45 ± 9 mL/min) and pH were lower and lactate higher (9.5 ± 1.0 vs 6.4 ± 1.3 mmol/L) after return of spontaneous circulation from ventricular fibrillation cardiac arrest versus asphyxial cardiac arrest (all p < 0.01). Asphyxial cardiac arrest resulted in greater early neurologic deficits, 7-day neuronal loss, and reduced freezing time (memory) after conditioned fear (all p < 0.05). Brain antioxidant reserves were more depleted following asphyxial cardiac arrest. In adjusted analyses, human ventricular fibrillation cardiac arrest was associated with greater cardiovascular injury based on peak troponin (7.8 ng/mL [0.8-57 ng/mL] vs 0.3 ng/mL [0.0-1.5 ng/mL]) and ejection fraction by echocardiography (20% vs 55%; all p < 0.0001), whereas asphyxial cardiac arrest was associated with worse early neurologic injury and poor functional outcome at hospital discharge (n = 46 [18%] vs 102 [44%]; p < 0.0001). Most ventricular fibrillation cardiac arrest deaths (54%) were the result of cardiovascular instability, whereas most asphyxial cardiac arrest deaths (75%) resulted from neurologic injury (p < 0.0001). CONCLUSIONS In transcending rat and human studies, we find a consistent phenotype of heart and brain injury after cardiac arrest based on etiology: ventricular fibrillation cardiac arrest produces worse cardiovascular dysfunction, whereas asphyxial cardiac arrest produces worsened neurologic injury associated with greater oxidative stress.
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Zhang Q, Qi Z, Liu B, Li C. Predictors of survival and favorable neurological outcome in patients treated with targeted temperature management after cardiac arrest: A systematic review and meta-analysis. Heart Lung 2018; 47:602-609. [DOI: 10.1016/j.hrtlng.2018.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 07/03/2018] [Accepted: 07/11/2018] [Indexed: 01/11/2023]
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Kim KH, Shin SD, Song KJ, Ro YS, Kim YJ, Hong KJ, Jeong J, Park JH, Kim TH, Kong SY. Cooling methods of targeted temperature management and neurological recovery after out-of-hospital cardiac arrest: A nationwide multicenter multi-level analysis. Resuscitation 2018; 125:56-65. [DOI: 10.1016/j.resuscitation.2018.01.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 01/28/2018] [Accepted: 01/28/2018] [Indexed: 12/14/2022]
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Abstract
OBJECTIVES To determine whether ICUs caring for higher volumes of acute respiratory distress syndrome patients would be associated with lower ICU mortality. DESIGN A 9-year multicenter retrospective cohort study of prospectively collected data. SETTING French medical ICUs. PATIENTS From 2004 to 2012, acute respiratory distress syndrome cases were identified from a coding system through a regional database (Collège des Utilisateurs de Données en Réanimation). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Volume was calculated as the cumulative annual mean number of acute respiratory distress syndrome cases. Severity (Simplified Acute Physiology Score 2) and ICU mortality between categories (low, medium, and high) of acute respiratory distress syndrome cases volume were analyzed. Multivariable analysis using mixed effects models was performed to adjust for severity of illness and confounding factors. Over the study period, 8,383 acute respiratory distress syndrome patients among 31 ICUs met the study inclusion criteria. Overall, Simplified Acute Physiology Score 2 (median [interquartile]) was 58 (43-74), whereas ICU mortality was 53.7%. Severity as assessed by Simplified Acute Physiology Score 2 (median [interquartile]) was significantly higher in high-volume ICUs (> 65 acute respiratory distress syndrome per year) as compared to low (≤ 29 acute respiratory distress syndrome per year) and medium-volume ICUs (> 29-65 acute respiratory distress syndrome per year): 61 (46-77) versus 55 (41-72) and 55.0 (40-72), respectively (p < 0.01). ICU mortality was similar across the acute respiratory distress syndrome volume categories (53.6%, 54.1%, and 53.3% in low-, medium-, and high-volume categories ICUs, respectively). After adjustment for confounders, acute respiratory distress syndrome case volume was independently associated with ICU mortality (odds ratio for log-transformed volume: 0.77 [95% CI, 0.62-0.96]; p = 0.02). CONCLUSIONS ICUs caring for higher volumes of acute respiratory distress syndrome cases were associated with lower ICU mortality.
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Geri G, Gilgan J, Wu W, Vijendira S, Ziegler C, Drennan IR, Morrison L, Lin S. Does transport time of out-of-hospital cardiac arrest patients matter? A systematic review and meta-analysis. Resuscitation 2017; 115:96-101. [DOI: 10.1016/j.resuscitation.2017.04.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 02/21/2017] [Accepted: 04/02/2017] [Indexed: 11/26/2022]
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Abstract
Children and young adults tend to have reduced mortality and disability after acquired brain injuries such as trauma or stroke and across other disease processes seen in critical care medicine. However, after out-of-hospital cardiac arrest (OHCA), outcomes are remarkably similar across age groups. The consistent lack of witnessed arrests and a high incidence of asphyxial or respiratory etiology arrests among pediatric and young adult patients with OHCA account for a substantial portion of the difference in outcomes. Additionally, in younger children, differences in pre-hospital response and the activation of developmental apoptosis may explain more severe outcomes after OHCA. These require us to consider whether present practices are in line with the science. The present recommendations for compression-only cardiopulmonary resuscitation in young adults, normothermia as opposed to hypothermia (33°C) after asphyxial arrests, and paramedic training are considered within this review in light of existing evidence. Modifications in present standards of care may help restore the benefits of youth after brain injury to the young survivor of OHCA.
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Affiliation(s)
- Brian Griffith
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Patrick Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Cameron Dezfulian
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Clinical and Translational Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Wong GC, van Diepen S, Ainsworth C, Arora RC, Diodati JG, Liszkowski M, Love M, Overgaard C, Schnell G, Tanguay JF, Wells G, Le May M. Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Position Statement on the Optimal Care of the Postarrest Patient. Can J Cardiol 2017; 33:1-16. [DOI: 10.1016/j.cjca.2016.10.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 10/18/2016] [Accepted: 10/19/2016] [Indexed: 02/07/2023] Open
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Fouche PF, Carlson JN, Ghosh A, Zverinova KM, Doi SA, Rittenberger JC. Frequency of adjustment with comorbidity and illness severity scores and indices in cardiac arrest research. Resuscitation 2017; 110:56-73. [DOI: 10.1016/j.resuscitation.2016.10.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/04/2016] [Accepted: 10/26/2016] [Indexed: 12/16/2022]
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Lee BK, Jeung KW, Jung YH, Lee DH, Lee SM, Cho YS, Heo T, Yun JG, Min YI. Relationship between timing of cooling and outcomes in adult comatose cardiac arrest patients treated with targeted temperature management. Resuscitation 2016; 113:135-141. [PMID: 27987398 DOI: 10.1016/j.resuscitation.2016.12.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 11/28/2016] [Accepted: 12/04/2016] [Indexed: 01/31/2023]
Abstract
AIM OF THE STUDY Studies examining associations between time to target temperature and outcomes in cardiac arrest patients who underwent targeted temperature management (TTM) have shown inconsistent results. We examined these associations separately for time from restoration of spontaneous circulation to TTM initiation (pre-induction time) and time from TTM initiation to target temperature (induction time). Furthermore, we examined whether critical time thresholds exist if there is an association. METHODS This was a single-centre retrospective observational study including adult cardiac arrest patients treated with TTM from 2008 to 2015. We tested the associations of pre-induction time and induction time with outcomes at hospital discharge using multivariate logistic regression analysis. We then performed additional multivariate analyses, each with the significant timing variable at different binary cutoffs. RESULTS A total of 515 patients were analysed. At hospital discharge, 357 patients (69.3%) were alive, of whom 161 (31.3%) had a favourable neurologic outcome. In multivariate analysis, a shorter pre-induction time was independently associated with a favourable neurologic outcome (odds ratio [OR], 1.110; 95% confidence interval [CI], 1.025-1.202), whereas the induction time was not (OR, 0.954; 95% CI, 0.852-1.067). We found two pre-induction time thresholds (120 and 360min) that were associated with neurologic outcome. CONCLUSION We found that a shorter pre-induction time was independently associated with a favorable neurologic outcome at hospital discharge, whereas induction time was not. We also found two time thresholds at 120 and 360min, after which initiation of cooling was associated with a worse neurologic outcome.
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Affiliation(s)
- Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, Republic of Korea.
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, Republic of Korea.
| | - Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, Republic of Korea.
| | - Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, Republic of Korea.
| | - Sung Min Lee
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, Republic of Korea.
| | - Yong Soo Cho
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, Republic of Korea.
| | - Tag Heo
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, Republic of Korea.
| | - Jong Geun Yun
- Department of Emergency Medical Services, Honam University, 417 Eodeung-daero, Gwangsangu, Gwangju, Republic of Korea.
| | - Yong Il Min
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, Republic of Korea.
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Greif R, Lockey A, Conaghan P, Lippert A, De Vries W, Monsieurs K. Ausbildung und Implementierung der Reanimation. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0092-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Greif R, Lockey AS, Conaghan P, Lippert A, De Vries W, Monsieurs KG, Ballance JH, Barelli A, Biarent D, Bossaert L, Castrén M, Handley AJ, Lott C, Maconochie I, Nolan JP, Perkins G, Raffay V, Ringsted C, Soar J, Schlieber J, Van de Voorde P, Wyllie J, Zideman D. European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2015; 95:288-301. [DOI: 10.1016/j.resuscitation.2015.07.032] [Citation(s) in RCA: 272] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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