Out-of-hospital cardiac arrests in the older age groups in Melbourne, Australia

Increasing neurologically intact survival after out-of-hospital cardiac arrest among elderly: Singapore Experience

Objectives

With more elderly presenting with Out-of-Hospital Cardiac Arrests (OHCAs) globally, neurologically intact survival (NIS) should be the aim of resuscitation. We aimed to study the trend of OHCA amongst elderly in a large Asian registry to identify if age is independently associated with NIS and factors associated with NIS.

Methods

All adult OHCAs aged ≥18 years attended by emergency medical services (EMS) from April 2010 to December 2019 in Singapore was extracted from the Pan-Asian Resuscitation Outcomes Study (PAROS) registry. Cases pronounced dead at scene, non-EMS transported, traumatic OHCAs and OHCAs in ambulances were excluded. Patient characteristics and outcomes were compared across four age categories (18-64, 65-79, 80-89, ≥90). Multivariable logistic regression analysis determined the factors associated with NIS.

Results

19,519 eligible cases were analyzed. OHCA incidence increased with age almost doubling in octogenarians (from 312/100,000 in 2011 to 652/100,000 in 2019) and tripling in those ≥90 years (from 458/100,000 in 2011 to 1271/100,000 in 2019). The proportion of patients with NIS improved over time for the 18-64, 65-79- and 80-89-years age groups, with the greatest improvement in the youngest group. NIS decreased with each increasing year of age and minute of response time. NIS increased in the arrests of presumed cardiac etiology, witnessed and bystander CPR.

Conclusions

Survival with good outcomes has increased even amongst the elderly. Regardless of age, NIS is possible with good-quality CPR, highlighting its importance. End-of-life planning is a complex yet necessary decision that requires qualitative exploration with elderly, their families and care providers.

A two-point strategy to clarify prognosis in >80 year olds experiencing out of hospital cardiac arrest

BACKGROUND

The global population is aging, with the number of ≥80-year-olds projected to triple over the next 30 years. Rates of out-of-hospital cardiac arrest (OHCA) are also increasing within this age group.

METHODS

The Victorian Ambulance Cardiac Arrest Registry was utilised to identify OHCAs in patients aged ≥80 years between 2002-2021. Predictors of survival to discharge were defined and a prognostic score derived from this cohort.

RESULTS

77,628 patients experienced OHCA of whom 25,269 (32.6%) were ≥80 years (80-90 years = 18,956; 90-100 years = 6,148; >100 years = 209). The number of patients ≥80 years increased over time both absolutely (p = 0.002) and proportionally (p = 0.028). 619 (2.4%) patients survived to discharge without change over time. Older ages had no difference in witnessed OHCA status but were less likely to have shockable rhythm (OR 0.50 (95% CI 0.44-0.57) for 90-100-year-olds, OR 0.28 (95% CI 0.12-0.63) for 90-100-year-olds). If OHCA was witnessed and there was a shockable rhythm then survival was 14%; if one factor was present survival was 5-6% and if neither factor was present, survival was 0.09%. These survival rates enabled derivation of a simplified prognostic assessment score - the '15/5/0' score - highly comparable to a previously-published American cohort.

CONCLUSIONS

Elderly OHCA rates have increased to one-third of caseload. The most important factors predicting survival were whether the OHCA was witnessed and there was a shockable rhythm. We present a simple two-point '15/5/0' prognostic score defining which patients will gain most from advanced resuscitative measures.

Risk prediction models for out-of-hospital cardiac arrest outcomes in England

AIMS

The out-of-hospital cardiac arrest (OHCA) outcomes project is a national research registry. One of its aims is to explore sources of variation in OHCA survival outcomes. This study reports the development and validation of risk prediction models for return of spontaneous circulation (ROSC) at hospital handover and survival to hospital discharge.

METHODS AND RESULTS

The study included OHCA patients who were treated during 2014 and 2015 by emergency medical services (EMS) from seven English National Health Service ambulance services. The 2014 data were used to identify important variables and to develop the risk prediction models, which were validated using the 2015 data. Model prediction was measured by area under the curve (AUC), Hosmer-Lemeshow test, Cox calibration regression, and Brier score. All analyses were conducted using mixed-effects logistic regression models. Important factors included age, gender, witness/bystander cardiopulmonary resuscitation (CPR) combined, aetiology, and initial rhythm. Interaction effects between witness/bystander CPR with gender, aetiology and initial rhythm and between aetiology and initial rhythm were significant in both models. The survival model achieved better discrimination and overall accuracy compared with the ROSC model (AUC = 0.86 vs. 0.67, Brier score = 0.072 vs. 0.194, respectively). Calibration tests showed over- and under-estimation for the ROSC and survival models, respectively. A sensitivity analysis individually assessing Index of Multiple Deprivation scores and location in the final models substantially improved overall accuracy with inconsistent impact on discrimination.

CONCLUSION

Our risk prediction models identified and quantified important pre-EMS intervention factors determining survival outcomes in England. The survival model had excellent discrimination.

Age, pre-arrest neurological condition, and functional status as outcome predictors in out-of-hospital cardiac arrest: Secondary analysis of the Jerusalem Cohort Study data

PURPOSE

Investigate the relation between age, baseline neurological and functional status, and survival after out-of-hospital cardiac arrest (OHCA).

METHODS

Data analysis from the Jerusalem District Resuscitation Study. Patients >80 years and those 18-80 years with OHCA from 4/2005-12/2010 were compared.

PRIMARY OUTCOME

survival at four time points; secondary outcomes: neurological and functional status at hospital discharge, and relationship between survival, age and pre-arrest activities of daily living (ADL) and Cerebral Performance Category (CPC) scores (higher scores indicate worse function in both).

RESULTS

3,211 patients (1,259 >80 years, 1952 aged 18-80) with median follow-up 5.9 years (range 0.1-11.1 years) were included. Survival was better for younger patients at all four time points, including 7.8% versus 2.5% at hospital discharge, 4.6% versus 0.2% at late follow-up. Functional status at discharge was also better, 4.8 ± 5.4 versus 9.0 ± 4.7, p<0.001, and more young patients had CPC1/2, 60.7% versus 32.2%, p = 0.004. Older patients who survived to emergency department admission had increased mortality per year of age (2.6%, hazard ratio [HR] 1.026, 95% confidence interval [CI] 1.006-1.048 versus 1.7%, HR 1.017, 95% CI 1.010-1.025), per point in pre-arrest ADL (3.0%, HR 1.030, 95% CI 1.007-1.054 versus 5.8%, HR 1.058, 95% CI 1.036-1.080), and per point in pre-arrest CPC (24%, HR 1.242, 95% CI 1.097-1.406 versus 37%, HR 1.370 95% CI 1.232-1.524).

CONCLUSION

Patient independence before arrest may be a more crucial determinant of resuscitation outcome than older age alone. Discussion of end-of-life preferences is particularly important for older individuals with functional and cognitive decline.

Cardiac arrest in older adult patients

PURPOSE OF REVIEW

To describe the epidemiology, prognostication, and treatment of out- and in-hospital cardiac arrest (OHCA and IHCA) in elderly patients.

RECENT FINDINGS

Elderly patients undergoing cardiac arrest (CA) challenge the appropriateness of attempting cardiopulmonary resuscitation (CPR). Current literature suggests that factors traditionally associated with survival to hospital discharge and neurologically intact survival after CA cardiac arrest in general (e.g. presenting ryhthm, bystander CPR, targeted temperature management) may not be similarly favorable in elderly patients. Alternative factors meaningful for outcome in this special population include prearrest functional status, comorbidity load, the specific age subset within the elderly population, and CA location (i.e., nursing versus private home). Age should therefore not be a standalone criterion for withholding CPR. Attempts to perform CPR in an elderly patient should instead stem from a shared decision-making process.

SUMMARY

An appropriate CPR attempt is an attempt resulting in neurologically intact survival. Appropriate CPR in elderly patients requires better risk classification. Future research should therefore focus on the associations of specific within-elderly age subgroups, comorbidities, and functional status with neurologically intact survival. Reporting must be standardized to enable such evaluation.

Impact of population aging on the presentation of out-of-hospital cardiac arrest in the Pan Asian Resuscitation Outcomes Study

Aim

As a population ages, it can impact on the characteristics and outcomes of cardiogenic out‐of‐hospital cardiac arrest (OHCA) patients. This study aimed to evaluate the relationship between the age incidence of cardiogenic OHCA and population aging.

Methods

This was a post‐hoc analysis of the Pan Asian Resuscitation Outcomes Study (PAROS) database. Data on the population old‐age dependency ratio (i.e. elderly/non‐elderly) were extracted from publicly accessible sources (United Nations and World Health Organization).

Results

We analyzed 40,872 OHCA cases from seven PAROS countries over the period 2009 to 2013. We found significant correlation between the population old‐age dependency ratio and elderly/non‐elderly ratio in OHCA patients (r = 0.92, P = 0.003). There was a significant correlation between the population old‐age dependency ratio and risk differences of 30‐day survival rates for non‐elderly and elderly OHCA patients (r = 0.89, P = 0.007).

Conclusions

Our findings suggest that the proportion of elderly among OHCA patients will increase, and outcomes could increasingly differ between elderly and non‐elderly as a society ages progressively. This has implications for planning and delivery of emergency services as a society ages.

Outcomes of Patients 65 Years or Older After Out-of-Hospital Cardiac Arrest Based on Location of Cardiac Arrest in Japan

IMPORTANCE

Out-of-hospital cardiac arrest (OHCA) is a major public health issue, and in recent years, the number of OHCAs among the elderly population, aged 65 years or older, has significantly increased in developed countries.

OBJECTIVE

To evaluate the demographic and clinical characteristics and outcomes of patients 65 years or older who experienced OHCA based on the location-public, residential, or nursing home-where it occurred in Japan.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, nationwide, population-based cohort study used information collected by the All-Japan Utstein Registry to examine data from 293 615 patients 65 years or older who experienced OHCA during the period from January 2013 to December 2015 in Japan. Data analyses were conducted from June to July 2018.

MAIN OUTCOMES AND MEASURES

The primary outcome was 1-month survival with a favorable outcome that was defined as a cerebral performance category score of 1 or 2 (1, good cerebral performance; 2, moderate cerebral disability; 3, severe cerebral disability; 4, coma or vegetative state; and 5, death or brain death). Multivariable logistic regression analyses were conducted to examine favorable outcome by location.

RESULTS

A total of 233 511 patients with OHCA were included in the final analysis; 29 911 (12.8%) occurred in a public location, 157 087 (67.3%) at a residential location, and 46 513 (19.9%) at a nursing home. The median age of the patients was 83.0 years (interquartile range, 76.0-88.0 years), and the proportion of men was 53.1% (124 108 of 233 511). The proportion of favorable neurologic outcomes was 4.5% (1351 of 29 911) in public locations, 1.0% (1555 of 157 087) in residential locations, and 0.6% (301 of 46 513) in nursing homes. Patients with cardiac arrests in public locations had a significantly higher likelihood of achieving a favorable neurologic outcome than those in residential locations (adjusted odds ratio, 1.36; 95% CI, 1.25-1.48), whereas those in nursing homes were less likely to achieve a favorable neurologic outcome (adjusted odds ratio, 0.62; 95% CI, 0.54-0.72). However, this difference in outcomes among patients based on location decreased with age.

CONCLUSIONS AND RELEVANCE

The outcomes of patients 65 years or older after OHCA differed by the location of the cardiac arrest. These outcomes may be improved by updating existing response measures across all locations.

Long-term outcome of elderly out-of-hospital cardiac arrest survivors as compared with their younger counterparts and the general population

BACKGROUND:

Over the past decade, prehospital and in-hospital treatment for out-of-hospital cardiac arrest (OHCA) has improved considerably. There are sparse data on the long-term outcome, especially in elderly patients. We studied whether elderly patients benefit to the same extent compared with younger patients and at long-term follow up as compared with the general population.

METHODS:

Between 2001 and 2010, data from all patients presented to our hospital after OHCA were recorded. Elderly patients (⩾75 years) were compared with younger patients. Neurological outcome was classified as cerebral performance category (CPC) at hospital discharge and long-term survival was compared with younger patients and predicted survival rates of the general population.

RESULTS:

Of the 810 patients admitted after OHCA, a total of 551 patients (68%) achieved return of spontaneous circulation, including 125 (23%) elderly patients with a mean age of 81 ± 5 years. In-hospital survival was lower in elderly patients compared with younger patients with rates of 33% versus 57% ( p < 0.001). A CPC of 1 was present in 73% of the elderly patients versus 86% of the younger patients ( p = 0.031). In 7.3% of the elderly patients, a CPC >2 was observed versus 2.5% of their younger counterparts ( p = 0.103). Elderly patients had a median survival of 6.5 [95% confidence interval (CI) 2.0-7.9] years compared with 7.7 (95% CI 7.5-7.9) years of the general population ( p = 0.019).

CONCLUSIONS:

The survival rate after OHCA in elderly patients is approximately half that of younger patients. Elderly patients who survive to discharge frequently have favorable neurological outcomes and a long-term survival that approximates that of the general population.

Factors determining level of hospital care and its association with outcome after resuscitation from pre-hospital pulseless electrical activity

Background

Patients resuscitated from out-of-hospital cardiac arrest (OHCA) with pulseless electrical activity (PEA) as initial cardiac rhythm are not always treated in intensive care units (ICUs): some are admitted to high dependency units with various level of care, others to ordinary wards. Aim of this study was to describe the factors determining level of hospital care after OHCA with PEA, post-resuscitation care and survival.

Methods

Adult OHCA patients with PEA (n = 221), who were resuscitated in southern Finland between 2010 and 2013 were included, provided patient survived to hospital admission. The patients were divided into four groups according to the level of hospital care provided: ordinary ward and Level 1–3 ICUs. Differences in patient characteristics, post-resuscitation care and survival were compared between the groups.

Results

Most patients (62.4%) were treated at Level 2 ICUs. Longer time to ROSC and advanced age decreased admission rate to Level 2 or 3 post-resuscitation care, whereas good pre-arrest CPC (1–2) increased the admission rate to Level 2/3 ICUs independently. Treatment with targeted temperature management (TTM) (4.1%) or early coronary angiography (3.2%) were very rare. Prognostic decisions were made earlier in the lower treatment intensity groups (p < 0.01). One-year survival rate was 24.0, 17.1% survived with good neurological outcome. Neurological outcome was better with more intensive care. After adjustment, level of care was not independent predictor for outcome: only return of spontaneous circulation (ROSC) time, cardiac arrest cause and pre-arrest performance affected independently to 1-year survival, age and ROSC for neurologic outcome.

Conclusions

PEA are usually admitted to Level 2 ICUs for post-resuscitation care in the capital area of Finland. Age, ROSC and pre-arrest CPC were independent predictors for level of post-resuscitation care. TTM and early CAG were rare and provided only for Level 3 ICU patients. Prognostication was earlier in lower level of care units. Good neurologic survival was more common with more intensive level of post-resuscitation care. After adjustment, level of care was not independent predictor for survival or neurologic outcome: only ROSC, cardiac arrest cause and pre-arrest performance predicted 1-year survival; age and ROSC neurologic outcome.

Impact of Targeted Temperature Management on ED Patients with Drug Overdose-Related Cardiac Arrest

INTRODUCTION

Drug overdose is the leading cause of non-traumatic out-of-hospital cardiac arrest (OHCA) among young adults. This study investigates whether targeted temperature management (TTM) improves hospital survival from presumed overdose-related cardiac arrest.

METHODS

Retrospective chart review of consecutive cardiac arrests presenting to an urban tertiary care hospital ED from 2011 to 2015. ED patients with cardiac arrest were included if < 50 years old, and excluded if there was a non-overdose etiology (e.g., trauma, ST-elevation myocardial infarction, subarachnoid hemorrhage). The main intervention was TTM, carried out with a combination of the Arctic Sun device and refrigerated crystalloid/antipyretics (goal temperature 33-36 °C). The primary outcome was survival to hospital discharge; neurologically intact survival was the secondary outcome.

RESULTS

Of 923 patients with cardiac arrest, 802 (86.9%) met exclusion criteria, leaving 121 patients for final analysis. There were 29 patients in the TTM group (24.0%) vs 92 patients in the non-TTM group (76.0%). Eleven patients (9.1%) survived to hospital discharge. TTM was associated with increased odds of survival to hospital discharge (OR 11.3, 95% CI 2.8-46.3, p < 0.001), which increased substantially when palliative outcomes were excluded from the cohort (OR 117.3, 95% CI 17.0-808.4, p < 0.001). Despite achieving statistical significance (OR 1.1, 95% CI 1.0-1.3), TTM had no clinically significant effect on neurologically intact survival.

CONCLUSIONS

TTM was associated with improved survival in ED patients with presumed drug overdose-related cardiac arrest. The impact of TTM on neurologically intact survival among these patients requires further study.

Out-of-hospital cardiac arrests in nursing homes and primary care facilities in Pirkanmaa, Finland

BACKGROUND

Dispatching Emergency Medical Services to treat patients with deteriorating health in nursing homes and primary care facilities is common in Finland. We examined the cardiac arrest patients to describe this phenomenon. We had a special interest in patients for whom cardiopulmonary resuscitation was considered futile.

METHODS

We conducted an observational study between 1 June 2013 and 31 May 2014 in the Pirkanmaa area. We included cases in which Emergency Medical Services participated in the treatment of cardiac arrest patients in nursing homes and primary care facilities.

RESULTS

Emergency Medical Services attended to a total of 355 cardiac arrest patients, and 65 patients (18%) met the inclusion criteria. The included patients were generally older than 65 years, but otherwise heterogeneous. Nineteen patients (29%) had a valid do-not-attempt-resuscitation order, but paramedics were not informed about it in 10 (53%) of those cases. Eight (12%) of the 65 patients survived to hospital admission and 3 (5%) survived to hospital discharge with a neurologically favourable outcome. Two patients were alive 90 days after the cardiac arrest; both were younger than 70 years of age and had ventricular fibrillation as primary rhythm. There were no survivors in nursing homes.

CONCLUSIONS

The do-not-attempt-resuscitation orders were often unavailable during a cardiopulmonary resuscitation attempt. Although resuscitation attempts were futile for patients in nursing homes, some patients in primary care facilities demonstrated a favourable outcome after cardiac arrest. Emergency Medical Services seem to be able to recognise potential survivors and focus resources on their treatment.

Assessment of the 11-year nationwide trend of out-of-hospital cardiac arrest cases among elderly patients in Japan (2005-2015)

OBJECTIVE

Japan has one of the most rapidly aging societies worldwide. This study aimed to assess the long-term nationwide trend of out-of-hospital cardiac arrest (OHCA) cases among elderly patients in Japan.

METHODS

This prospective, nationwide observational study in Japan included elderly patients aged ≥65 years who experienced OHCA from January 1, 2005 to December 31, 2015. The patients were classified into three groups: young-old, aged 65-74 years; old-old, aged 75-84 years; and oldest-old, aged ≥85 years. The primary outcome of this study was one-month survival with a favorable neurological outcome, which was defined as a cerebral performance category scale score of 1 or 2.

RESULTS

A total of 877,009 patients were included in our analysis. The number of elderly patients with OHCA increased from 65,968 in 2005 to 87,339 in 2015, and each age category showed a significantly increasing trend (p value <0.001 for each trend). The proportions of favorable neurological outcomes also increased from 1.2% in 2005 to 2.8% in 2015 in the young-old group; from 0.6% in 2005 to 1.1% in 2015 in the old-old group; and from 0.2% in 2005 to 0.5% in 2014 in the oldest-old group. Furthermore, this improving trend was notable for those with a shockable first documented rhythm.

CONCLUSIONS

Based on this long-term nationwide observational study in Japan, the number of elderly patients with OHCA increased annually, and a significant improvement in the patients' neurological outcomes was noted regardless of age category, particularly among those with an initially shockable rhythm.

Impact of a public awareness campaign on out-of-hospital cardiac arrest incidence and mortality rates

Aims

Increased public awareness of the warning signs of a heart attack and the importance of early medical intervention may help to prevent premature deaths from out-of-hospital cardiac arrest (OHCA). We sought to investigate the impact of the Heart Foundation's public awareness campaigns on the monthly incidence of, and deaths from, OHCA in Melbourne, Australia.

Methods and results

Between July 2005 and June 2015, we included registry data for 25 060 OHCA of presumed cardiac aetiology. Time series models with distributed lags were used to explore the effect of campaign activity on OHCA outcomes. A sensitivity analysis involving segmented regression of the pre-intervention, intervention, and post-intervention time segments was also performed. The mean monthly incidence of, and deaths from, OHCA was 207 and 189 events respectively. After adjustment for temporal trends, campaign activity was associated with a 6.0% [95% confidence interval (CI): 2.8-9.0%; P < 0.001] reduction in the monthly incidence of OHCA, or 11.7% (95% CI: 7.7-15.5%, P < 0.001) with the addition of residual effects in two additional lag months. Similarly, the rate of deaths from OHCA reduced by 6.4% (95% CI: 2.8-10.0%; P = 0.001) during months with campaign activity. Campaign activity had a greater effect in males and patients aged ≥65 years, and reduced the incidence of OHCA in unwitnessed and initial non-shockable arrests. In the segmented regression analysis, the intervention period was associated with a 15.2% (95% CI: 9.2-20.9%; P < 0.001) reduction in the mean monthly incidence and a 16.6% (95% CI: 9.9-22.7%; P < 0.001) reduction in deaths from OHCA.

Conclusion

A comprehensive mass media campaign targeting the community's awareness of heart attack symptoms was associated with a substantial reduction in the incidence of OHCA and associated deaths.

Long-term functional recovery and health-related quality of life of elderly out-of-hospital cardiac arrest survivors

INTRODUCTION

Understanding the prognosis of elderly out-of-hospital cardiac arrest (OHCA) patients is vital to informing resuscitation and advanced care planning decisions. However, short-term outcomes such as survival to hospital discharge do not account for post-arrest quality of life. We describe the 12-month functional recovery and health-related quality of life (HR-QOL) of elderly OHCA survivors, including those arresting in aged care facilities.

METHODS

We conducted a retrospective analysis of Victorian Ambulance Cardiac Arrest Registry data for all OHCA survivors to hospital discharge aged ≥65 years between 1 January 2010 and 30 June 2016. The influence of age on functional recovery and independent living was assessed using multivariable logistic regression.

RESULTS

During the study period, 20,103 elderly OHCAs were attended, 9016 (44.9%) of whom received a resuscitation attempt. In total, 876 (9.7%) patients survived to hospital discharge and 777 were alive 12 months post-arrest. Of these, 651 participated in 12-month follow-up (response rate 83.8%). Most (60.6%) resided at home without additional care and 66.6% reported a good functional recovery, however both measures decreased with increasing age (p < 0.001). Mental HR-QOL increased with increasing age and was significantly better than the age- and sex-matched Australian population. Each 10-year increase in age was associated with a 40.8% (95%CI 25.6-53.0%) reduction in the odds of good functional recovery, and a 65.8% (95%CI 55.8-73.5%) reduction in the odds of living independently. Of the 2575 OHCAs in an aged care facility, 2.2% survived to hospital discharge, however no patient reported a good 12-month functional recovery.

CONCLUSIONS

Most elderly OHCA survivors resided independently with good functionality 12 months post-arrest. However, increasing age was associated with less favourable outcomes. New strategies are needed with regard to resuscitation in aged care facilities.

Why do older people refuse resuscitation? A qualitative study examining retirement village residents' resuscitation decisions

BACKGROUND

There is a dearth of qualitative research on resuscitation preferences of older New Zealanders. The aim of this study was to investigate the resuscitation preferences of older New Zealanders in a retirement village or residential care setting, as well as the reasons for these preferences.

METHODS

This study had 37 participants from two retirement villages in Auckland, New Zealand. Participants were interviewed about a hypothetical case vignette about cardiopulmonary resuscitation, and then they completed a semi-structured interview. Interviews were subsequently transcribed and analyzed by two independent researchers using thematic qualitative methodology.

RESULTS

The majority of the participants (n = 25, 67.6%) decided against resuscitation, 10 (27.0%) wanted resuscitation, and 2 (5.4%) were ambivalent about their resuscitation preferences. Three main themes emerged during the data analysis regarding participants' reasons for deciding against resuscitation: (i) the wish for a natural death; (ii) advanced age; and (iii) a realistic awareness about the consequences of resuscitation. Responses related to the third these had three subthemes: (i) reduced quality of life; (ii) loss of personal integrity and sense of existence; and (iii) concern that resuscitation could result in unnecessary costs or a burden on others. Among participants who preferred resuscitation, two main themes emerged regarding their reasons for wanting resuscitation: (i) the wish to prolong a good quality of life; and (ii) unrealistic expectations of resuscitation.

CONCLUSIONS

Older people in this study were able to make reasoned decisions about resuscitation based on balancing their subjective estimations of quality of life and the presumed consequences of resuscitation. It is important therefore to educate older adults about the potential outcomes of resuscitation and explore (and document) their reasoning when discussing resuscitation preferences so their wishes can be respected.

Evolution of Survival in Cardiac Arrest with Age in Elderly Patients: Is Resuscitation a Dead End?

BACKGROUND

Even if age is not considered the key prognostic factor for survival in cardiac arrest (CA), some studies question whether cardiopulmonary resuscitation (CPR) in the elderly could be futile.

OBJECTIVE

The aim of this study was to describe differences in out-of-hospital CA survival rates according to age stratification based on the French National CA registry (RéAC). The second objective was to analyze the differences in resuscitation interventions according to age.

METHODS

We performed a retrospective cohort study based on data extracted from the RéAC. All 18,249 elderly patients (>65 years old) with non-traumatic CA recorded between July 2011 and March 2015 were included. Patients' ages were stratified into 5-year increments.

RESULTS

Cardiopulmonary resuscitation (CPR) was started significantly more often in younger patients (p = 0.019). Ventilation and automated external defibrillation by bystanders were started without any difference between age subgroups (p = 0.147 and p = 0.123, respectively). No difference in terms of rate of external chest compressions or ventilation initiation was found between the subgroups (p = 0.357 and p = 0.131, respectively). Advanced cardiac life support was started significantly more often in younger patients (p = 0.023). Total CPR duration, return of spontaneous circulation, and survival at hospital admission and at 30 days or hospital discharge decreased significantly with age (p < 10^-3). The survival decrease was linear, with a loss of 3% survival chances each 5-year interval.

CONCLUSIONS

This study found that survival in older persons decreased linearly by 3% every 5 years. However, this diminished rate of survival could be the consequence of a shorter duration and less advanced life support.

Age discrimination in out-of-hospital cardiac arrest care: a case-control study

BACKGROUND

Although some studies have questioned whether cardiopulmonary resuscitation (CPR) in older people could be futile, age is not considered an essential out-of-hospital cardiac arrest (OHCA) prognostic factor. However, in the daily clinical practice of mobile medical teams (MMTs), age seems to be an important factor affecting OHCA care.

AIMS

The purpose of this study was to compare OHCA care and outcomes between young patients (<65 years old) and older patients.

METHODS

We performed a case-control study based on data extracted from the French National Cardiac Arrest (CA) registry. All adult patients with CA recorded between July 2011 and May 2014 were included. Each older patient was matched on three criteria: sex, initial cardiac rhythm and no-flow duration.

RESULTS

We studied 4347 pairs. We found significantly less basic life support initiation, shorter advanced cardiac life support duration, less MMT automated chest compression, less MMT ventilation and less MMT epinephrine injection in the older patients. Significant differences were also observed for return of spontaneous circulation (odds ratio (OR)=0.84, 95% confidence interval (CI) 0.77-0.92, p<0.001), transport to hospital (OR=0.58, 95% CI 0.51-0.61, p<0.001), vital status at hospital admission (OR=0.55, 95% CI 0.50-0.60, p<0.001) and vital status 30 days after CA (OR=0.42, 95% CI 0.35-0.50, p<0.001).

CONCLUSION

All OHCA guidelines, ethical statements and clinical procedures do not propose age as a discrimination criterion in OHCA care. However, in our case-control study, we notice a shorter duration and less intensive care among older patients. This finding may partly explain the lower survival rate compared with younger people.

A 95 year-old suffering circulatory arrest after accidental hypothermia: a case report

BACKGROUND

The elderly are vulnerable to cold and prone to accidental hypothermia, both because of environmental and endogenous factors. The incidence of severe accidental hypothermia among the elderly is poorly described, but many cases probably go unrecorded. Going through literature one finds few publications on severe hypothermia among the elderly, and, to our knowledge, nothing about extracorporeal re-warming of geriatric hypothermia victims.

CASE PRESENTATION

We present a case were a 95 year-old man with severe accidental hypothermia and circulatory arrest was brought to our hospital under on-going CPR, and was successfully resuscitated with extracorporeal circulation. He was discharged to his home without physical sequelae a few weeks later.

CONCLUSION

The decision whether or not to continue resuscitation of a nonagenarian can be difficult in many respects. Knowing that resuscitation with extracorporeal circulation is resource intensive may complicate the discussion. In light of our experience with this case we discuss medical and ethical aspects of modern treatment of severe accidental hypothermia.

Intravenous Fluid Administration and the Survival of Pre hospital Resuscitated out of Hospital Cardiac Arrest Patients in Thailand

Introduction

Out of Hospital Cardiac Arrest (OHCA) is a leading cause of death worldwide. The Emergency Medical Service (EMS) provides early care to critical OHCA patients. Pre hospital intervention has been improving OHCA survival rate, however it is still unclear for the recommendation of routine infusion of Intravenous (IV) fluids during cardiac arrest resuscitation.

Aim

This study aimed to determine whether IV fluid administration was associated with increasing survival of resuscitated OHCA patients and to assess the survival rate of resuscitated OHCA patients.

Materials and Methods

This cross-sectional analytical study was conducted among 33,006 resuscitated OHCA patients who received emergency medical service in Thailand. Data set from the EMS Registry of the OHCA patients who received Advanced Life Support (ALS) and Cardiopulmonary Resuscitation (CPR) during January 2011 to December 2015 was enrolled as per inclusion criteria. Data were analysed by using both descriptive statistic and multiple logistic regression.

Results

The result indicated that 27,270 OHCA patients (82.62%:95%CI=82.121-83.030%) survived until they reached hospital. In addition, after adjusting for effect modifiers and covariates, it was found that adult (≥18 years) with IV fluid administration were more likely to survive (adjusted OR=4.389; 95% CI: 3.911-4.744) when compared to children (<18 years) with IV fluid administration (adjusted OR =2.952; 95% CI: 2.040-4.273). Other factors associated with OHCA patients' survival were female gender (adjusted OR =1.151; 95% CI: 1.067-1.241), response time per minutes (adjusted OR =0.993; 95% CI: 0.989-0.997), scene time per minutes (adjusted OR=0.948; 95% CI: 0.944-0.952) and transport time per minutes (adjusted OR=0.973, 95%CI: 0.968-0.978).

Conclusion

This study revealed that IV fluid administration was significantly associated with survival of OHCA patients while controlled other covariates including female gender, response time, scene time and transport time. Therefore, it is recommended that the IV fluid administration should be medicated for resuscitated OHCA patients.

Irrational Exuberance: Cardiopulmonary Resuscitation as Fetish

The Institute of Medicine and the American Heart Association have issued a "call to action" to expand the performance of cardiopulmonary resuscitation (CPR) in response to out-of-hospital cardiac arrest. Widespread advertising campaigns have been created to encourage more members of the lay public to undergo training in the technique of closed-chest compression-only CPR, based upon extolling the virtues of rapid initiation of resuscitation, untempered by information about the often distressing outcomes, and hailing the "improved" results when nonprofessional bystanders are involved. We describe this misrepresentation of CPR as a highly effective treatment as the fetishization of this valuable, but often inappropriately used, therapy. We propose that the medical profession has an ethical duty to inform the public through education campaigns about the procedure's limitations in the out-of-hospital setting and the narrow clinical indications for which it has been demonstrated to have a reasonable probability of producing favorable outcomes.

The benefits of youth are lost on the young cardiac arrest patient

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.

Impact of acute kidney injury on patient outcome in out-of-hospital cardiac arrest: a prospective observational study

BACKGROUND

Kidney disease after out-of-hospital cardiac arrest (OHCA) is incompletely described. We examined the occurrence of acute kidney injury (AKI) in OHCA patients and impact of AKI, with or without renal replacement therapy (RRT), on 6-month mortality and neurological outcome.

METHODS

Prospective study at Oslo University Hospital, Oslo, Norway. Adult resuscitated comatose OHCA patients treated with targeted temperature management at 33°C for 24 h were included. AKI and chronic kidney disease (CKD) were classified according to the Kidney Disease Improving Global Outcomes (KDIGO) guidelines. Main outcomes were 6-month mortality and good neurological outcome defined as Cerebral Performance Category 1-2.

RESULTS

Among 245 included patients (84% males, mean age 61 years), 11 (4%) had previously known CKD and 112 (46%) developed AKI. Overall 6-month outcome revealed that 112 (46%) died and 123 (50%) had good neurological outcome. Compared with no kidney disease, the presence of AKI was significantly associated with 6-month mortality (odds ratio (OR) 3.17, 95% confidence interval (CI) 1.95-5.43, P < 0.001) and good neurological outcome (OR 0.28, 95% CI 0.16-0.48, P < 0.001). Six-month mortality (50 vs. 61%, P = 0.401) and frequency of good neurological outcome (44 vs. 35%, P = 0.417) were not statistically different in AKI patients with or without RRT, also after excluding patients where RRT was withheld due to futility.

CONCLUSIONS

Kidney disease occurred in about half of patients successfully resuscitated from OHCA. Presence of AKI, but not RRT, was associated with unfavourable 6-month outcome.

A Descriptive Analysis of Therapeutic Hypothermia Application Across Adult Age Groups

Therapeutic hypothermia (TH) has been recommended for comatose adults recovering from out-of-hospital cardiac arrest (OHCA) for a decade. However, TH has never been evaluated in a randomized control trial in patients aged 75 or older. How the administration of TH varies across age groups experiencing an OHCA is unknown. The objective was to describe the use of TH across predefined age groups with an emphasis on geriatric OHCA survivors using data compiled through Cardiac Arrest Registry to Enhance Survival (CARES). We hypothesized that TH provision would decline in patients aged 75 or older. This was a secondary analysis of prospectively collected and verified registry data. The study was Institutional Review Board exempt. Through December 2013, CARES had 130,852 completed records for consideration. All nontraumatic adult index arrests of presumed cardiac etiology with attempted resuscitation were study eligible. Sustained return of spontaneous circulation with survival to hospital admission was a prerequisite for inclusion. Exclusion criteria were as follows: records before November 2010 when TH became a mandatory reporting field; pre-existing Do Not Resuscitate directive; missing TH status or outcome classification; and OHCA location and timing variables potentially affecting treatment decisions or eligibility. All records in our final sample were categorized (TH or no TH) for descriptive analysis. Our final sample size was 11,533. The percentage of patients <75 who received TH was 58.5% (95% CI: 57.5-59.6) and 46.4% (95% CI: 44.5-48.3) for those 75 or older. There was no difference in the rate of TH across the age groups from <25 to 65-74 (p = 0.205). Treatment rates significantly decreased from age 75-84 to 95+ (p < 0.001). There is a significant decline in the provision of TH at age 75 years within CARES. Further research is needed to determine if age is an independent predictor of TH underutilization in the elderly.

Improved Survival With Favorable Neurological Outcome in Elderly Individuals With Out-of-Hospital Cardiac Arrest in Japan - A Nationwide Observational Cohort Study

BACKGROUND

There is sparse data regarding the survival and neurological outcome of elderly patients with out-of-hospital cardiac arrest (OHCA).

METHODS AND RESULTS

OHCA patients (334,730) aged ≥75 years were analyzed using a nationwide, prospective, population-based Japanese OHCA database from 2008 to 2012. The overall 1-month survival with favorable neurological outcome (Cerebral Performance Category Scale, category 1 or 2; CPC 1-2) rate was 0.88%. During the study period, the annual 1-month CPC 1-2 rate in whole OHCA significantly improved (0.73% to 0.96%, P for trend <0.001). In particular, outcomes of OHCA patients aged 75 to 84 years and those aged 85 to 94 years significantly improved (0.98% to 1.28%, P for trend=0.01; 0.46% to 0.70%, P for trend <0.001, respectively). However, in OHCA patients aged ≥95 years, the outcomes did not improve. Multivariate logistic regression analysis indicated that younger age, shockable first documented rhythm, witnessed arrest, earlier emergency medical service (EMS) response time, and cardiac etiology were significantly associated with the 1-month CPC 1-2. Under these conditions, elderly OHCA patients who had cardiac etiology, shockable rhythm and had a witnessed arrest had acceptable 1-month CPC1-2 rate; 7.98% in cases where OHCA was witnessed by family, 15.2% by non-family, and 25.6% by EMS.

CONCLUSIONS

The annual 1-month CPC 1-2 rate after OHCA among elderly patients significantly improved, and the resuscitation of elderly patients in a selected population is not futile. (Circ J 2016; 80: 1153-1162).

Epidemiology of Out-of-Hospital Cardiac Arrests Among Japanese Centenarians: 2005 to 2013

Although the number of centenarians has been rapidly increasing in industrialized countries, no clinical studies evaluated their characteristics and outcomes from out-of-hospital cardiac arrests (OHCAs). This nationwide, population-based, observation of the whole population of Japan enrolled consecutive OHCA centenarians with resuscitation attempts before emergency medical service arrival from 2005 to 2013. The primary outcome measure was 1-month survival from OHCAs. The multivariate logistic regression model was used to assess factors associated with 1-month survival in this population. Among a total of 4,937 OHCA centenarians before emergency medical service arrival, the numbers of those with OHCAs increased from 70 in 2005 to 136 in 2013 in men and from 227 in 2005 to 587 in 2013 in women. Women accounted for 80.3%. Ventricular fibrillation (VF) as first documented rhythm was 2.5%. The proportions of victims receiving bystander cardiopulmonary resuscitation were 64.2%. The proportion of 1-month survival from OHCAs in centenarians was only 1.1%. In a multivariate analysis, age was not associated with 1-month survival from OHCAs (adjusted odds ratio [OR] for one increment of age 1.01; 95% confidence interval [CI] 0.87 to 1.18). Witness by a bystander (adjusted OR 3.45; 95% CI 1.88 to 6.31) and VF as first documented rhythm (adjusted OR 5.49; 95% CI 2.24 to 13.43) were significant positive predictors for 1-month survival. Cardiac origin was significantly poor in 1-month survival compared with noncardiac origin (adjusted OR 0.37; 95% CI 0.21 to 0.64). In conclusion, survival from OHCAs in centenarians was very poor, but witness by a bystander and VF as first documented rhythm were associated with improved survival.

Trends in Outcomes for Out-of-Hospital Cardiac Arrest by Age in Japan: An Observational Study

Population aging has rapidly advanced throughout the world and the elderly accounting for out-of-hospital cardiac arrest (OHCA) has increased yearly.We identified all adults who experienced an out-of-hospital cardiac arrest in the All-Japan Utstein Registry of the Fire and Disaster Management Agency, a prospective, population-based clinical registry, between 2005 and 2010. Using multivariable regression, we examined temporal trends in outcomes for OHCA patients by age, as well as the influence of advanced age on outcomes. The primary outcome was a favorable neurological outcome at 1 month after OHCA.Among 605,505 patients, 454,755 (75.1%) were the elderly (≥65 years), and 154,785 (25.6%) were the oldest old (≥85 years). Although neurological outcomes were worse as the age group was older (P < 0.0001 for trend), there was a significant trend toward improved neurological outcomes during the study period by any age group (P < 0.005 for trend). After adjustment for temporal trends in various confounding variables, neurological outcomes improved yearly in all age groups (18-64 years: adjusted OR per year 1.15 [95% CI 1.13-1.18]; 65-84 years: adjusted OR per year 1.12 [95% CI 1.10-1.15]; and ≥85 years: adjusted OR per year 1.08 [95% CI 1.04-1.13]). Similar trends were found in the secondary outcomes.Although neurological outcomes from OHCA ware worse as the age group was older, the rates of favorable neurological outcomes have substantially improved since 2005 even in the elderly, including the oldest old. Careful consideration may be necessary in limiting treatment on OHCA solely for the reason of advanced age.

Changes in treatments and outcomes among elderly patients with out-of-hospital cardiac arrest between 2002 and 2012: A post hoc analysis of the SOS-KANTO 2002 and 2012

BACKGROUND

Little is known about recent changes in pre- and in-hospital treatments and outcomes for elderly patients with out-of-hospital cardiac arrest (OHCA).

METHODS

We compared data collected for the SOS-KANTO study in 2002 and 2012. We included patients aged ≥65 years who experienced OHCA of cardiac aetiology. The primary endpoint was favourable neurological outcomes 1 month after cardiac arrest.

RESULTS

A total of 8,964 (2002 vs. 2012: 3,544 vs. 5,420) patients were eligible for the current analysis. The proportion of pre-hospital return of spontaneous circulation (ROSC) increased significantly (3.8 vs. 5.6%, p<0.001). Among patients achieving ROSC, the proportion of advanced in-hospital treatments (i.e., extracorporeal membrane oxygenation, therapeutic hypothermia, and/or percutaneous coronary angiogram/intervention) provided increased significantly in 2012 (1.2 vs. 5.5%, p<0.001; 2.6 vs. 15.1%, p<0.001; 4.9 vs. 16.5%, p<0.001; respectively). The proportion of favourable neurological outcomes at 1 month increased significantly in 2012 (1.6 vs. 2.7%, p=0.001). A logistic regression analysis that did not consider advanced in-hospital treatments showed a significantly higher rate of favourable neurological outcomes in the 2012 group than that in the 2002 group (OR, 2.2; 95% CI, 1.4-3.5). However, this difference was no longer observed in the second regression model that accounted for advanced in-hospital treatments (OR, 1.6; 95% CI, 0.9-2.9).

CONCLUSION

There was an increased proportion of aggressive treatment, both pre- and in-hospital, for elderly patients with cardiogenic OHCA in the Kanto area, Japan. Favourable neurological outcomes improved significantly over 10 years.

The relationship between age and outcome in out-of-hospital cardiac arrest patients

AIM

To determine the association between age and outcome in a large multicenter cohort of out-of-hospital cardiac arrest patients.

METHODS

Retrospective, observational, cohort study of out-of-hospital cardiac arrest from the CARES registry between 2006 and 2013. Age was categorized into 5-year intervals and the association between age group and outcomes (return of spontaneous circulation (ROSC), survival and good neurological outcome) was assessed in univariable and multivariable analysis. We performed a subgroup analysis in patients who had return of spontaneous circulation.

RESULTS

A total of 101,968 people were included. The median age was 66 years (quartiles: 54, 78) and 39% were female. 31,236 (30.6%) of the included patients had sustained ROSC, 9761 (9.6%) survived to hospital discharge and 8058 (7.9%) survived with a good neurological outcome. The proportion of patients with ROSC was highest in those with age <20 years (34.1%) and lowest in those with age 95-99 years (23.5%). Patients with age <20 years had the highest proportion of survival (16.7%) and good neurological outcome (14.8%) whereas those with age 95-99 years had the lowest proportion of survival (1.7%) and good neurological outcome (1.2%). In the full cohort and in the patients with ROSC there appeared to be a progressive decline in survival and good neurological outcome after the age of approximately 45-64 years. Age alone was not a good predictor of outcome.

CONCLUSIONS

Advanced age is associated with outcomes in out-of-hospital cardiac arrest. We did not identify a specific age threshold beyond which the chance of a meaningful recovery was excluded.

Trends in survival among elderly patients with out-of-hospital cardiac arrest: a prospective, population-based observation from 1999 to 2011 in Osaka

BACKGROUND

Little is known about the improvement in out-of-hospital cardiac arrest (OHCA) survival among elderly patients. The aim of this study was to evaluate the trends in the survival after bystander-witnessed OHCA of cardiac origin in this age group.

METHODS

This prospective, population-based, observation of the whole population of Osaka, Japan included consecutive OHCA patients aged ≥65 years with emergency responder resuscitation attempts from January 1999 to December 2011. The primary outcome measure was one-month survival with neurologically favorable outcome, and the trends in the outcome from OHCA were evaluated by location. Multiple logistic regression analysis was used to assess factors that were potentially associated with neurologically favorable outcome.

RESULTS

During the study period, a total of 10,876 bystander-witnessed OHCA of cardiac origin were eligible for our analyses. In whole arrests, the proportion of one-month survival with neurologically favorable outcome improved from 1.4% in 1999 to 4.8% in 2011 (P for trend <0.001). The proportion of neurologically favorable outcome in homes and public places improved from 0.7% in 1999 to 3.2% in 2011 (P for trend <0.001) and from 4.2% in 1999 to 20.9% in 2011 (P for trend <0.001), respectively, whereas, in nursing homes, the proportion of neurologically favorable outcome did not improve. In a multivariate analysis, bystander-initiated cardiopulmonary resuscitation and emergency response time were significant predictors for neurologically favorable outcome.

CONCLUSIONS

In this population, survival from OHCA among elderly patients significantly improved during the study period, but the trends differed by the OHCA location.

Acute kidney injury after cardiac arrest of ventricular fibrillation and asphyxiation swine model

PURPOSES

The purposes of the study are to investigate the renal function in ventricular fibrillation (VF) and asphyxiation cardiac arrest in a swine model and to estimate the value of novel biomarkers in the acute kidney injury (AKI) after cardiac arrest.

METHOD

Thirty-two healthy inbred Wu-Zhi-Shan miniature piglets were randomized into 2 groups (n = 16 per group). Cardiac arrest was induced by programmed electric stimulation and clamping the endotracheal tube in the VF group and asphyxiation group, respectively. Cardiopulmonary resuscitation was done for return of spontaneous circulation (ROSC).

RESULTS

One hundred percent (16/16) ROSC was observed in the VF group, and 50% (8/16) in the asphyxiation group (P < .01). All AKI biomarkers elevated significantly after ROSC. The novel biomarkers changed much earlier than the creatinine. The concentration of novel biomarkers in the asphyxiation group was higher than the VF group. Live animals had an oliguria and developed AKI. Characteristic morphological injuries in renal tissues were observed under light microscope and transmission electron microscope and were more serious in the asphyxiation group.

CONCLUSIONS

Acute kidney injury at early stage of postresuscitation is common in different causes of cardiac arrest. Asphyxiation has more severe kidney injury and gets worse prognosis.

Pre-arrest predictors of survival after resuscitation from out-of-hospital cardiac arrest in the elderly a systematic review

Background

To enable older people to make decisions about the appropriateness of cardiopulmonary resuscitation (CPR), information is needed about the predictive value of pre-arrest factors such as comorbidity, functional and cognitive status on survival and quality of life of survivors. We systematically reviewed the literature to identify pre-arrest predictors for survival, quality of life and functional outcomes after out-of-hospital (OHC) CPR in the elderly.

Methods

We searched MEDLINE (through May 2011) and included studies that described adults aged 70 years and over needing CPR after OHC cardiac arrest. Prognostic factors associated with survival to discharge and quality of life of survivors were extracted. Two authors independently appraised the quality of each of the included studies. When possible a meta-analysis of odd’s ratios was performed.

Results

Twenty-three studies were included (n = 44,582). There was substantial clinical and statistical heterogeneity and reporting was often inadequate. The pooled survival to discharge in patients >70 years was 4.1% (95% CI 3.0-5.6%). Several studies showed that increasing age was significantly associated with worse survival, but the predictive value of comorbidity was investigated in only one study. In another study, nursing home residency was independently associated with decreased chances of survival. Only a few small studies showed that age is negatively associated with a good quality of life of survivors. We were unable to perform a meta-analysis of possible predictors due to a wide variety in reporting and statistical methods.

Conclusions

Although older patients have a lower chance of survival after CPR in univariate analysis (i.e. 4.1%), older age alone does not seem to be a good criterion for denying patients CPR. Evidence for the predictive value of comorbidities and for the predictive value of age on quality of life of survivors is scarce. Future studies should use uniform methods for reporting data and pre-arrest factors to increase the available evidence about pre arrest factors on the chance of survival. Furthermore, patient-specific outcomes such as quality of life and post-arrest cognitive function should be investigated too.

Elderly out-of-hospital cardiac arrest has worse outcomes with a family bystander than a non-family bystander

BACKGROUND

A growing elderly population along with advances in equipment and approaches for pre-hospital resuscitation necessitates up-to-date information when developing policies to improve elderly out-of-hospital cardiac arrest (OHCA) outcomes. We examined the effects of bystander type (family or non-family) intervention on 1-month outcomes of witnessed elderly OHCA patients.

METHODS

Data from a total of 85,588 witnessed OHCA events in patients aged ≥65 years, which occurred from 2005 to 2008, were obtained from a nationwide population-based database. Patients were stratified into three age categories (65-74, 75-84, ≥85 years), and the effects of bystander type (family or non-family) on initial cardiac rhythm, rate of bystander cardiopulmonary resuscitation (CPR), and 1-month outcomes were assessed.

RESULTS

The overall survival rate was 6.9% (65-74 years: 9.8%, 75-84 years: 6.9%, ≥85 years: 4.6%). Initial VF/VT was recorded in 11.1% of cases with a family bystander and 12.9% of cases with a non-family bystander. The rate of bystander CPR was constant across the age categories in patients with a family bystander and increased with advancing age categories in patients with a non-family bystander. Patients having a non-family bystander were associated with significantly higher 1-month rates of survival (OR: 1.26; 95% CI: 1.19-1.33) and favorable neurological status (OR: 1.47; 95% CI: 1.34-1.60).

CONCLUSIONS

Elderly patient OHCA events witnessed by a family bystander were associated with worse 1-month outcomes than those witnessed by a non-family bystander. Healthcare providers should consider targeting potential family bystanders for CPR education to increase the rate and quality of bystander CPR.

Acute kidney injury after cardiac arrest

AIM

Cardiac arrest (CA) in humans causes warm renal ischemia-reperfusion injury, similar to animal models of ischemic acute kidney injury (AKI). We aimed to investigate the incidence and risk associations of AKI after CA, with or without post-resuscitation cardiogenic shock (PRCS).

METHODS

We examined the renal outcomes of adult patients admitted to the intensive care unit (ICU), who survived for more than 48 h following successful resuscitation after CA.

RESULTS

Of 105 patients (median age 65 years; 69% male), 58 (55.2%) had PRCS and were on vasoactive drugs beyond 24h; and 9 (8.6%) (all of whom had PRCS) received renal replacement therapy. Only 3 (6.4%) of 47 patients without PRCS had RIFLE-'I'/'F' AKI, compared to 30 (51.7%) of 58 patients with PRCS (p<0.001). Median peak serum creatinine in the non-PRCS group was 102 μmol/L (interquartile range 85-115), compared to 155 μmol/L (interquartile range 112-267) (p<0.001) in the PRCS group. On multivariate analysis, cumulative noradrenaline dose during the first 24h in ICU, PRCS, and pre-CA renin-angiotensin-aldosterone-system blockade were independently associated with RIFLE-'I'/'F' AKI; while higher serum lactate 12h after CA, baseline creatinine, and PRCS were independently associated with greater rise in creatinine from pre-CA levels. Estimated time without spontaneous circulation, total adrenaline dose and initial cardiac rhythm during CA, had no independent associations with renal outcomes.

CONCLUSIONS

In the absence of PRCS, CA in isolation is uncommonly associated with significant AKI. The human kidney may be more resistant to warm ischemia-reperfusion injury than previously thought.