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Kreutz J, Patsalis N, Müller C, Chatzis G, Syntila S, Sassani K, Betz S, Schieffer B, Markus B. EPOS-OHCA: Early Predictors of Outcome and Survival after non-traumatic Out-of-Hospital Cardiac Arrest. Resusc Plus 2024; 19:100728. [PMID: 39157414 PMCID: PMC11327594 DOI: 10.1016/j.resplu.2024.100728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 07/10/2024] [Accepted: 07/11/2024] [Indexed: 08/20/2024] Open
Abstract
Background Post-cardiac arrest syndrome (PCAS) after out-of-hospital cardiac arrest (OHCA) poses significant challenges due to its complex pathomechanisms involving inflammation, ischemia, and reperfusion injury. The identification of early available prognostic indicators is essential for optimizing therapeutic decisions and improving patient outcomes. Methods In this retrospective single-center study, we analyzed real-world data from 463 OHCA patients with either prehospital or in-hospital return of spontaneous circulation (ROSC), treated at the Cardiac Arrest Center of the University Hospital of Marburg (MCAC) from January 2018 to December 2022. We evaluated demographic, prehospital, and clinical variables, including initial rhythms, resuscitation details, and early laboratory results. Statistical analyses included logistic regression to identify predictors of survival and neurological outcomes. Results Overall, 46.9% (n = 217) of patients survived to discharge, with 70.1% (n = 152) achieving favorable neurological status (CPC 1 or 2). Age, initial shockable rhythm, resuscitation time to return of spontaneous circulation (ROSC), and early laboratory parameters like lactate, C-reactive protein, and glomerular filtration rate were identified as independent and combined Early Predictors of Outcome and Survival (EPOS), with high significant predictive value for survival (AUC 0.86 [95% CI 0.82-0.89]) and favorable neurological outcome (AUC 0.84 [95% CI 0.80-0.88]). Conclusion Integration of EPOS into clinical procedures may significantly improve clinical decision making and thus patient prognosis in the early time-crucial period after OHCA. However, further validation in other patient cohorts is needed.
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Affiliation(s)
- Julian Kreutz
- Philipps University of Marburg, Germany
- University Hospital of Marburg, Department of Cardiology, Angiology, and Intensive Care Medicine, Germany
- University Hospital of Marburg, Center for Emergency Medicine, Germany
| | - Nikolaos Patsalis
- Philipps University of Marburg, Germany
- University Hospital of Marburg, Department of Cardiology, Angiology, and Intensive Care Medicine, Germany
| | - Charlotte Müller
- Philipps University of Marburg, Germany
- University Hospital of Marburg, Department of Cardiology, Angiology, and Intensive Care Medicine, Germany
| | - Georgios Chatzis
- Philipps University of Marburg, Germany
- University Hospital of Marburg, Department of Cardiology, Angiology, and Intensive Care Medicine, Germany
| | - Styliani Syntila
- Philipps University of Marburg, Germany
- University Hospital of Marburg, Department of Cardiology, Angiology, and Intensive Care Medicine, Germany
| | - Kiarash Sassani
- Philipps University of Marburg, Germany
- University Hospital of Marburg, Department of Cardiology, Angiology, and Intensive Care Medicine, Germany
| | - Susanne Betz
- University Hospital of Marburg, Department of Cardiology, Angiology, and Intensive Care Medicine, Germany
- University Hospital of Marburg, Center for Emergency Medicine, Germany
| | - Bernhard Schieffer
- Philipps University of Marburg, Germany
- University Hospital of Marburg, Department of Cardiology, Angiology, and Intensive Care Medicine, Germany
- University Hospital of Marburg, Center for Emergency Medicine, Germany
| | - Birgit Markus
- Philipps University of Marburg, Germany
- University Hospital of Marburg, Department of Cardiology, Angiology, and Intensive Care Medicine, Germany
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Wimmer H, Benth JŠ, Lundqvist C, Andersen GØ, Henriksen J, Drægni T, Solberg P, Stær-Jensen H, Sunde K, Nakstad ER. Changes in health status and health related quality of life from six months to five years in out-of-hospital cardiac arrest survivors - A NORCAST sub study. Resuscitation 2022; 181:182-189. [PMID: 36084805 DOI: 10.1016/j.resuscitation.2022.08.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Brain injury in out-of-hospital cardiac arrest (OHCA) survivors affects health status and health-related quality of life (HRQoL). It is unknown how HRQoL evolves over time, and assessments at different time points may lead to different results. METHODS In a NORCAST sub study, OHCA survivors eligible for health status (EQ-5D-3L) and HRQoL (SF-36) assessments were examinated six months and five years after OHCA. At five-year follow-up, survivors also retrospectively assessed their health status for each consecutive year following OHCA. The next of kin independently assessed health status and HRQoL of their respective OHCA survivors. RESULTS Among 138 survivors alive after six months and 117 after five years, 80 (88% male) completed both follow-ups. Health status and HRQoL remained stable over time, except for increasing SF-36 mental summary score and decreasing physical functioning and physical component score. Anxiety and depression levels were generally low, although younger survivors stated more anxiety than older survivors. Retrospective assessment showed reduced health status for the first two years, which increased only from the third year. Explorative analyses revealed that younger age, longer time to return of spontaneous circulation (tROSC) and late awakening affected health status, particularly in the first two years post-arrest. CONCLUSIONS OHCA survivors showed stable health status and HRQoL with only minor differences between six months and five years. Younger survivors with long tROSC, late awakening, and more anxiety and depression symptoms at six months, had reduced health status the first two years with significant improvements towards the fourth year.
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Affiliation(s)
- Henning Wimmer
- Department of Acute Medicine, Oslo University Hospital, Ullevål, Norway; Institute of Clinical Medicine, University of Oslo, Norway.
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, University of Oslo, Norway; Health Services Research Unit, Akershus University Hospital, Norway
| | - Christofer Lundqvist
- Institute of Clinical Medicine, University of Oslo, Norway; Department of Neurology, Akershus University Hospital, Norway; Health Services Research Unit, Akershus University Hospital, Norway
| | | | - Julia Henriksen
- Department of Neurology, Oslo University Hospital, Ullevål, Norway
| | - Tomas Drægni
- Institute of Clinical Medicine, University of Oslo, Norway; Department of Research and Development, Oslo University Hospital, Norway
| | - Pål Solberg
- Department of Cardiology, Oslo University Hospital, Ullevål, Norway
| | - Henrik Stær-Jensen
- Department of Anaesthesia and Intensive Care Medicine, Oslo University Hospital, Ullevål, Norway
| | - Kjetil Sunde
- Institute of Clinical Medicine, University of Oslo, Norway; Department of Anaesthesia and Intensive Care Medicine, Oslo University Hospital, Ullevål, Norway
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Havranek S, Fingrova Z, Rob D, Smalcova J, Kavalkova P, Franek O, Smid O, Huptych M, Dusik M, Linhart A, Belohlavek J. Initial rhythm and survival in refractory out-of-hospital cardiac arrest. Post-hoc analysis of the Prague OHCA randomized trial. Resuscitation 2022; 181:289-296. [PMID: 36243225 DOI: 10.1016/j.resuscitation.2022.10.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/26/2022] [Accepted: 10/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The prognosis of refractory out-of-hospital cardiac arrest (OHCA) is generally poor. A recent Prague OHCA study has demonstrated that an invasive approach (including extracorporeal cardiopulmonary resuscitation, ECPR) is a feasible and effective treatment strategy in refractory OHCA. Here we present a post-hoc analysis of the role of initial rhythm on patient outcomes. METHODS The study enrolled patients who had a witnessed OHCA of presumed cardiac cause without early recovery of spontaneous circulation. The initial rhythm was classified as either a shockable or a non-shockable rhythm. The primary outcome was a composite of 180 day-survival with Cerebral Performance in Category 1 or 2. RESULTS 256 (median age 58y, 17% females) patients were enrolled. The median (IQR) duration of resuscitation was 52 (33-68) minutes. 156 (61%) and 100 (39%) of patients manifested a shockable and non-shockable rhythm, respectively. The primary outcome was achieved in 63 (40%) patients with a shockable rhythm and in 5 (5%) patients with a non-shockable rhythm (p < 0.001). When patients were analyzed separately based on whether the treatment was invasive (n = 124) or standard (n = 132), the difference in the primary endpoint between shockable and non-shockable initial rhythms remained significant (35/72 (49%) vs 4/52 (8%) in the invasive arm and 28/84 (33%) vs 1/48 (2%) in the standard arm; p < 0.001). CONCLUSION An initial shockable rhythm and treatment with an invasive approach is associated with a reasonable neurologically favorable survival for 180 days despite refractory OHCA. Non-shockable initial rhythms bear a poor prognosis in refractory OHCA even when ECPR is readily available.
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Affiliation(s)
- Stepan Havranek
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic.
| | - Zdenka Fingrova
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
| | - Daniel Rob
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
| | - Jana Smalcova
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
| | - Petra Kavalkova
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
| | | | - Ondrej Smid
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
| | - Michal Huptych
- Czech Institute of Informatics, Robotics and Cybernetics (CIIRC), Czech Technical University in Prague, Czech Republic
| | - Milan Dusik
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
| | - Ales Linhart
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
| | - Jan Belohlavek
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
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Gottula AL, Shaw CR, Gorder KL, Lane BH, Latessa J, Qi M, Koshoffer A, Al-Araji R, Young W, Bonomo J, Langabeer JR, Yannopoulos D, Henry TD, Hsu CH, Benoit JL. Eligibility of out-of-hospital cardiac arrest patients for extracorporeal cardiopulmonary resuscitation in the United States: A geographic information system model. Resuscitation 2022; 180:111-120. [PMID: 36183812 DOI: 10.1016/j.resuscitation.2022.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/10/2022] [Accepted: 09/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recent evidence suggest that extracorporeal cardiopulmonary resuscitation (ECPR) may improve survival rates for nontraumatic out-of-hospital cardiac arrest (OHCA). Eligibility criteria for ECPR are often based on patient age, clinical variables, and facility capabilities. Expanding access to ECPR across the U.S. requires a better understanding of how these factors interact with transport time to ECPR centers. METHODS We constructed a Geographic Information System (GIS) model to estimate the number of ECPR candidates in the U.S. We utilized a Resuscitation Outcome Consortium (ROC) database to model time-dependent rates of ECPR eligibility and the Cardiac Arrest Registry to Enhance Survival (CARES) registry to determine the total number of OHCA patients who meet pre-specified ECPR criteria within designated transportation times. The combined model was used to estimate the total number of ECPR candidates. RESULTS There were 588,203 OHCA patients in the CARES registry from 2013 to 2020. After applying clinical eligibility criteria, 22,104 (3.76%) OHCA patients were deemed eligible for ECPR. The rate of ROSC increased with longer resuscitation time, which resulted in fewer ECPR candidates. The proportion of OHCA patients eligible for ECPR increased with older age cutoffs. Only 1.68% (9,889/588,203) of OHCA patients in the U.S. were eligible for ECPR based on a 45-minute transportation time to an ECMO-ready center model. CONCLUSIONS Less than 2% of OHCA patients are eligible for ECPR in the U.S. GIS models can identify the impact of clinical criteria, transportation time, and hospital capabilities on ECPR eligibility to inform future implementation strategies.
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Affiliation(s)
- Adam L Gottula
- Department of Emergency Medicine, University of Michigan, United States; Department of Anesthesiology, University of Michigan, United States; Max Harry Weil Institute for Critical Care Research and Innovation, United States.
| | - Christopher R Shaw
- Department of Medicine Division of Pulmonary and Critical Care, Oregon Health and Science University, United States
| | - Kari L Gorder
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, United States.
| | - Bennett H Lane
- Department of Emergency Medicine, University of Cincinnati, United States.
| | - Jennifer Latessa
- Department of Planning, The University of Cincinnati, United States.
| | - Man Qi
- Department of Geography and Geographic Information System, The University of Cincinnati, United States.
| | - Amy Koshoffer
- University of Cincinnati Libraries, The University of Cincinnati, United States.
| | - Rabab Al-Araji
- Department of Emergency Medicine, Emory University, United States; The Cardiac Arrest Registry to Enhance Survival, United States.
| | - Wesley Young
- College of Medicine, The University of Cincinnati, United States
| | - Jordan Bonomo
- Department of Emergency Medicine, University of Cincinnati, United States; Department of Neurosurgery, University of Cincinnati, United States.
| | - James R Langabeer
- Department of Emergency, Medicine McGovern School of Medicine, The University of Texas Health Center, United States; UT School of Public Health, The University of Texas Health Center, United States; School of Biomedical Informatics, The University of Texas Health Center, United States.
| | | | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, United States.
| | - Cindy H Hsu
- Department of Emergency Medicine, University of Michigan, United States; Max Harry Weil Institute for Critical Care Research and Innovation, United States; Department of Surgery, University of Michigan, United States.
| | - Justin L Benoit
- Department of Emergency Medicine, University of Cincinnati, United States.
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Kim GW, Moon HJ, Lim H, Kim YJ, Lee CA, Park YJ, Lee KM, Woo JH, Cho JS, Jeong WJ, Choi HJ, Kim CS, Choi HJ, Choi IK, Heo NH, Park JS, Lee YH, Park SM, Jeong DK. Effects of Smart Advanced Life Support protocol implementation including CPR coaching during out-of-hospital cardiac arrest. Am J Emerg Med 2022; 56:211-217. [DOI: 10.1016/j.ajem.2022.03.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 03/21/2022] [Accepted: 03/27/2022] [Indexed: 01/23/2023] Open
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Lascarrou JB, Guichard E, Reignier J, Le Gouge A, Pouplet C, Martin S, Lacherade JC, Colin G. Impact of rewarming rate on interleukin-6 levels in patients with shockable cardiac arrest receiving targeted temperature management at 33 °C: the ISOCRATE pilot randomized controlled trial. Crit Care 2021; 25:434. [PMID: 34920723 PMCID: PMC8680374 DOI: 10.1186/s13054-021-03842-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/24/2021] [Indexed: 02/06/2023] Open
Abstract
Purpose While targeted temperature management (TTM) has been recommended in patients with shockable cardiac arrest (CA) and suggested in patients with non-shockable rhythms, few data exist regarding the impact of the rewarming rate on systemic inflammation. We compared serum levels of the proinflammatory cytokine interleukin-6 (IL6) measured with two rewarming rates after TTM at 33 °C in patients with shockable out-of-hospital cardiac arrest (OHCA). Methods ISOCRATE was a single-center randomized controlled trial comparing rewarming at 0.50 °C/h versus 0.25 °C/h in patients coma after shockable OHCA in 2016–2020. The primary outcome was serum IL6 level 24–48 h after reaching 33 °C. Secondary outcomes included the day-90 Cerebral Performance Category (CPC) and the 48-h serum neurofilament light-chain (NF-L) level. Results We randomized 50 patients. The median IL6 area-under-the-curve was similar between the two groups (12,389 [7256–37,200] vs. 8859 [6825–18,088] pg/mL h; P = 0.55). No significant difference was noted in proportions of patients with favorable day-90 CPC scores (13/25 patients at 0.25 °C/h (52.0%; 95% CI 31.3–72.2%) and 13/25 patients at 0.50 °C/h (52.0%; 95% CI 31.3–72.2%; P = 0.99)). Median NF-L levels were not significantly different between the 0.25 °C/h and 0.50 °C/h groups (76.0 pg mL, [25.5–3074.0] vs. 192 pg mL, [33.6–4199.0]; P = 0.43; respectively). Conclusion In our RCT, rewarming from 33 °C at 0.25 °C/h, compared to 0.50 °C/h, did not decrease the serum IL6 level after shockable CA. Further RCTs are needed to better define the optimal TTM strategy for patients with CA. Trial registration ClinicalTrials.gov, NCT02555254. Registered September 14, 2015. Take-Home Message: Rewarming at a rate of 0.25 °C/h, compared to 0.50 °C, did not result in lower serum IL6 levels after achievement of hypothermia at 33 °C in patients who remained comatose after shockable cardiac arrest. No associations were found between the slower rewarming rate and day-90 functional outcomes or mortality. 140-character Tweet: Rewarming at 0.25 °C versus 0.50 °C did not decrease serum IL6 levels after hypothermia at 33 °C in patients comatose after shockable cardiac arrest. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03842-9.
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Affiliation(s)
- Jean-Baptiste Lascarrou
- Médecine Intensive Reanimation, University Hospital Center, 30 Boulevard Jean Monnet, 44093, Nantes Cedex 1, France. .,Paris Cardiovascular Research Center, INSERM U970, Paris, France. .,AfterROSC Network, Paris, France.
| | | | - Jean Reignier
- Médecine Intensive Reanimation, University Hospital Center, 30 Boulevard Jean Monnet, 44093, Nantes Cedex 1, France
| | | | - Caroline Pouplet
- Médecine Intensive Reanimation, District Hospital Center, La Roche-sur-Yon, France
| | - Stéphanie Martin
- Médecine Intensive Reanimation, District Hospital Center, La Roche-sur-Yon, France
| | | | - Gwenhael Colin
- AfterROSC Network, Paris, France.,Médecine Intensive Reanimation, District Hospital Center, La Roche-sur-Yon, France
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Differential Effectiveness of Hypothermic Targeted Temperature Management According to the Severity of Post-Cardiac Arrest Syndrome. J Clin Med 2021; 10:jcm10235643. [PMID: 34884345 PMCID: PMC8658523 DOI: 10.3390/jcm10235643] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 11/25/2021] [Accepted: 11/25/2021] [Indexed: 11/16/2022] Open
Abstract
International guidelines recommend targeted temperature management (TTM) to improve the neurological outcomes in adult patients with post-cardiac arrest syndrome (PCAS). However, it still remains unclear if the lower temperature setting (hypothermic TTM) or higher temperature setting (normothermic TTM) is superior for TTM. According to the most recent large randomized controlled trial (RCT), hypothermic TTM was not found to be associated with superior neurological outcomes than normothermic TTM in PCAS patients. Even though this represents high-quality evidence obtained from a well-designed large RCT, we believe that we still need to continue investigating the potential benefits of hypothermic TTM. In fact, several studies have indicated that the beneficial effect of hypothermic TTM differs according to the severity of PCAS, suggesting that there may be a subgroup of PCAS patients that is especially likely to benefit from hypothermic TTM. Herein, we summarize the results of major RCTs conducted to evaluate the beneficial effects of hypothermic TTM, review the recent literature suggesting the possibility that the therapeutic effect of hypothermic TTM differs according to the severity of PCAS, and discuss the potential of individualized TTM.
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Srinivasan V, Martin EG, Klemisch RJ. A Chilling Conclusion to the Hypothermia Debate?: November 2021 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2021; 78:690-692. [PMID: 34688442 DOI: 10.1016/j.annemergmed.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
| | - Emily G Martin
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
| | - Robert J Klemisch
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
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Duan J, Ma Q, Zhu C, Shi Y, Duan B. eCPR Combined With Therapeutic Hypothermia Could Improve Survival and Neurologic Outcomes for Patients With Cardiac Arrest: A Meta-Analysis. Front Cardiovasc Med 2021; 8:703567. [PMID: 34485403 PMCID: PMC8414549 DOI: 10.3389/fcvm.2021.703567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/28/2021] [Indexed: 01/01/2023] Open
Abstract
Background: Extracorporeal membrane oxygenation with CPR (eCPR) or therapeutic hypothermia (TH) seems to be a very effective CPR strategy to save patients with cardiac arrest (CA). Furthermore, the subsequent post-CA neurologic outcomes have become the focus. Therefore, there is an urgent need to find a way to improve survival and neurologic outcomes for CA. Objective: We conducted this meta-analysis to find a more suitable CPR strategy for patients with CA. Method: We searched four online databases (PubMed, Embase, CENTRAL, and Web of Science). From an initial 1,436 articles, 23 studies were eligible into this meta-analysis, including a total of 2,035 patients. Results: eCPR combined with TH significantly improved the short-term (at discharge or 28 days) survival [OR = 2.27, 95% CIs (1.60-3.23), p < 0.00001] and neurologic outcomes [OR = 2.60, 95% CIs (1.92-3.52), p < 0.00001). At 3 months of follow-up, the results of survival [OR = 3.36, 95% CIs (1.65-6.85), p < 0.0008] and favorable neurologic outcomes [OR = 3.02, 95% CIs (1.38-6.63), p < 0.006] were the same as above. Furthermore, there was no difference in any bleeding needed intervention [OR = 1.33, 95% CIs (0.09-1.96), p = 0.16] between two groups. Conclusions: From this meta-analysis, we found that eCPR combined with TH might be a more suitable CPR strategy for patients with CA in improving survival and neurologic outcomes, and eCPR with TH did not increase the risk of bleeding. Furthermore, single-arm meta-analyses showed a plausible way of temperature and occasion of TH.
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Affiliation(s)
- Jingwei Duan
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Qingbian Ma
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Changju Zhu
- Emergency Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuanchao Shi
- The First Clinical Medicine School, Lanzhou University, Lanzhou, China
| | - Baomin Duan
- Emergency Department, Kaifeng Centre Hospital, Kaifeng, China
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Outcome Related to Level of Targeted Temperature Management in Postcardiac Arrest Syndrome of Low, Moderate, and High Severities: A Nationwide Multicenter Prospective Registry. Crit Care Med 2021; 49:e741-e750. [PMID: 33826582 DOI: 10.1097/ccm.0000000000005025] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The optimal target temperature during targeted temperature management for patients after cardiac arrest remains under debate. The aim of this study was to evaluate the association between targeted temperature management at lower target temperatures and the neurologic outcomes among patients classified by the severity of postcardiac arrest syndrome. DESIGN A multicenter observational study from the out-of-hospital cardiac arrest registry of the Japanese Association for Acute Medicine, which is a nationwide prospective registry of out-of-hospital cardiac arrest patients. SETTING A total of 125 critical care medical centers or hospitals with an emergency care department across Japan. PATIENTS A total of 1,111 out-of-hospital cardiac arrest patients who had received targeted temperature management. MEASUREMENTS AND MAIN RESULTS We divided all 1,111 postcardiac arrest syndrome patients treated with targeted temperature management into two groups: those who received targeted temperature management at a lower target temperature (33-34°C) and those who received targeted temperature management at a higher target temperature (35-36°C). In regard to classification of the patients, we divided the patients into three categories of severity (low, moderate, and high severities) using the risk classification tool, post-Cardiac Arrest Syndrome for Therapeutic hypothermia, which was previously validated. The primary outcome was the percentage of patients with a good neurologic outcome at 30 days, and the secondary outcome was the survival rate at 30 days. Multivariate analysis showed that targeted temperature management at 33-34°C was significantly associated with a good neurologic outcome and survival at 30 days in the moderate severity (odds ratio, 1.70 [95% CI, 1.03-2.83] and 1.90 [95% CI, 1.15-3.16], respectively), but not in the patients of low or high severity (pinteraction = 0.033). Propensity score analysis also showed that targeted temperature management at 33-34°C was associated with a good neurologic outcome in the moderate-severity group (p = 0.022). CONCLUSIONS Targeted temperature management at 33-34°C was associated with a significantly higher rate of a good neurologic outcome in the moderate-severity postcardiac arrest syndrome group, but not in the low- or high-severity group.
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11
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Lim D, Lee SH, Kim DH, Kang C, Jeong JH, Lee SB. The effect of high-dose intramuscular epinephrine on the recovery of spontaneous circulation in an asphyxia-induced cardiac arrest rat model. BMC Cardiovasc Disord 2021; 21:113. [PMID: 33632131 PMCID: PMC7908791 DOI: 10.1186/s12872-021-01917-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 02/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Obtaining vascular access can be challenging during resuscitation following cardiac arrest, and it is particularly difficult and time-consuming in paediatric patients. We aimed to compare the efficacy of high-dose intramuscular (IM) versus intravascular (IV) epinephrine administration with regard to the return of spontaneous circulation (ROSC) in an asphyxia-induced cardiac arrest rat model. METHODS Forty-five male Sprague-Dawley rats were used for these experiments. Cardiac arrest was induced by asphyxia, and defined as a decline in mean arterial pressure (MAP) to 20 mmHg. After asphyxia-induced cardiac arrest, the rats were randomly allocated into one of 3 groups (control saline group, IV epinephrine group, and IM epinephrine group). After 540 s of cardiac arrest, cardiopulmonary resuscitation was performed, and IV saline (0.01 cc/kg), IV (0.01 mg/kg, 1:100,000) epinephrine or IM (0.05 mg/kg, 1:100,000) epinephrine was administered. ROSC was defined as the achievement of an MAP above 40 mmHg for more than 1 minute. Rates of ROSC, haemodynamics, and arterial blood gas analysis were serially observed. RESULTS The ROSC rate (61.5%) of the IM epinephrine group was less than that in the IV epinephrine group (100%) but was higher than that of the control saline group (15.4%) (log-rank test). There were no differences in MAP between the two groups, but HR in the IM epinephrine group (beta coefficient = 1.02) decreased to a lesser extent than that in the IV epinephrine group with time. CONCLUSIONS IM epinephrine induced better ROSC rates compared to the control saline group in asphyxia-induced cardiac arrest, but not compared to IV epinephrine. The IM route of epinephrine administration may be a promising option in an asphyxia-induced cardiac arrest.
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Affiliation(s)
- Daesung Lim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Samjeongja-ro 11, Seongsan-gu, Changwon, Gyeongsangnam-Do, 51472, Republic of Korea
| | - Soo Hoon Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Gangnam-ro 79, Jinju, Gyeongsangnam-Do, 52727, Republic of Korea.
| | - Dong Hoon Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Gangnam-ro 79, Jinju, Gyeongsangnam-Do, 52727, Republic of Korea
| | - Changwoo Kang
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Gangnam-ro 79, Jinju, Gyeongsangnam-Do, 52727, Republic of Korea
| | - Jin Hee Jeong
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Gangnam-ro 79, Jinju, Gyeongsangnam-Do, 52727, Republic of Korea
| | - Sang Bong Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Gangnam-ro 79, Jinju, Gyeongsangnam-Do, 52727, Republic of Korea
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12
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Affiliation(s)
- J.S. Lemkes
- Department of Cardiology, Amsterdam University Medical Center, Location VUmc, The Netherlands
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13
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Yoo YJ, Kim GW, Lee CA, Park YJ, Lee KM, Cho JS, Jeong WJ, Choi HJ, Choi HJ, Heo NH, Moon HJ. Characteristics and outcomes of public bath-related out-of-hospital cardiac arrests in South Korea. Clin Exp Emerg Med 2020; 7:225-233. [PMID: 33028067 PMCID: PMC7550806 DOI: 10.15441/ceem.19.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/01/2019] [Indexed: 12/03/2022] Open
Abstract
Objective To analyze the differences in characteristics and outcomes between public bath (PB)-related and non-PB-related out-of-hospital cardiac arrest (OHCA) patients in South Korea. Methods We performed a retrospective observational analysis of collected data from the Smart Advanced Cardiac Life Support (SALS) registry between September 2015 and December 2018. We included adult OHCA patients (aged >18 years) with presumed OHCA of non-traumatic etiology who were attended by dispatched emergency medical services. SALS is a field advanced life support with smartphone-based direct medical direction. The primary outcome was the survival to discharge rate measured at the time of discharge. Results Of 38,995 cardiac arrest patients enrolled in the SALS registry, 11,889 were included in the final analysis. In total, 263 OHCAs occurred in PBs. Male sex and bystander cardiopulmonary resuscitation proportions appeared to be higher among PB patients than among non-PB patients. Percentages for shockable rhythm, witnessed rate, and number of underlying disease were lower in the PB group than in the non-PB group. Prehospital return of spontaneous circulation (11.4% vs. 19.5%, P=0.001), survival to discharge (2.3% vs. 9.9%, P<0.001), and favorable neurologic outcome (1.9% vs. 5.8%, P=0.007) in PB patients were significantly poorer than those in non-PB patients. Conclusion Patient characteristics and emergency medical services factors differed between PB and non-PB patients. All outcomes of PB-related OHCA were poorer than those of non-PB-related OHCA. Further treatment strategies should be developed to improve the outcomes of PB-related cardiac arrest.
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Affiliation(s)
- Yung Jae Yoo
- Department of Emergency Medicine, Soonchunhyang University College of Medicine, Asan, Korea
| | - Gi Woon Kim
- Department of Emergency Medicine, Soonchunhyang University College of Medicine, Asan, Korea
| | - Choung Ah Lee
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Dongtan, Korea
| | - Yong Jin Park
- Department of Emergency Medicine, Chosun University Hospital, Gwangju, Korea
| | - Kyoung Mi Lee
- Department of Emergency Medicine, Myongji Hospital, Goyang, Korea
| | - Jin Seong Cho
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Won Jung Jeong
- Department of Emergency Medicine, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Hyuk Joong Choi
- Department of Emergency Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Han Joo Choi
- Department of Emergency Medicine, Dankook University Hospital, Cheonan, Korea
| | - Nam Hun Heo
- Clinical Trial Center, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hyung Jun Moon
- Department of Emergency Medicine, Soonchunhyang University College of Medicine, Asan, Korea
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14
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Chen CT, Chen CH, Chen TY, Yen DHT, How CK, Hou PC. Comparison of in-hospital and out-of-hospital cardiac arrest patients receiving targeted temperature management: A matched case-control study. J Chin Med Assoc 2020; 83:858-864. [PMID: 32371666 PMCID: PMC7478210 DOI: 10.1097/jcma.0000000000000343] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Evidences that support the use of targeted temperature management (TTM) for in-hospital cardiac arrest (IHCA) are lacking. We aimed to investigate the hypothesis that TTM benefits for patients with IHCA are similar to those with out-of-hospital cardiac arrest (OHCA) and to determine the independent predictors of resuscitation outcomes in patients with cardiac arrest receiving subsequent TTM. METHODS This is a retrospective, matched, case-control study (ratio 1:1) including 93 patients with IHCA treated with TTM after the return of spontaneous circulation, who were admitted to Partners HealthCare system in Boston from January 2011 to December 2018. Controls were defined as the same number of patients with OHCA, matched for age, Charlson score, and sex. Survival and neurological outcomes upon discharge were the primary outcome measures. RESULTS Patients with IHCA were more likely to have experienced a witnessed arrest and receive bystander cardiopulmonary resuscitation, a larger total dosage of epinephrine, and extracorporeal membrane oxygenation. The time duration for ROSC was shorter in patients with IHCA than in those with OHCA. The IHCA group was more likely associated with mild thrombocytopenia during TTM than the OHCA group. Survival after discharge and favorable neurological outcomes did not differ between the two groups. Among all patients who had cardiac arrest treated with TTM, the initial shockable rhythm, time to ROSC, and medical history of heart failure were independent outcome predictors for survival to hospital discharge. The only factor to predict favorable neurological outcomes at discharge was initial shockable rhythm. CONCLUSION The beneficial effects of TTM in eligible patients with IHCA were similar with those with OHCA. Initial shockable rhythm was the only independent predictor of both survival and favorable neurological outcomes at discharge in all cardiac arrest survivors receiving TTM.
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Affiliation(s)
- Chung-Ting Chen
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- National Yang-Ming University, School of Medicine, Taipei, Taiwan, ROC
| | - Cheng-Han Chen
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- National Yang-Ming University, School of Medicine, Taipei, Taiwan, ROC
| | - Tzu-Yin Chen
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - David Hung-Tsang Yen
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- National Yang-Ming University, School of Medicine, Taipei, Taiwan, ROC
| | - Chorng-Kuang How
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- National Yang-Ming University, School of Medicine, Taipei, Taiwan, ROC
- Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan, ROC
- Address correspondence. Dr. Chorng-Kuang How, Emergency Department, Taipei Veterans General Hospital, 201, Section 2, Shi-Pai Road, Taipei 112, Taiwan, ROC. E-mail: (C.-K.How.)
| | - Peter Chuanyi Hou
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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15
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Johnsson J, Björnsson O, Andersson P, Jakobsson A, Cronberg T, Lilja G, Friberg H, Hassager C, Kjaergard J, Wise M, Nielsen N, Frigyesi A. Artificial neural networks improve early outcome prediction and risk classification in out-of-hospital cardiac arrest patients admitted to intensive care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:474. [PMID: 32731878 PMCID: PMC7394679 DOI: 10.1186/s13054-020-03103-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/17/2020] [Indexed: 01/26/2023]
Abstract
Background Pre-hospital circumstances, cardiac arrest characteristics, comorbidities and clinical status on admission are strongly associated with outcome after out-of-hospital cardiac arrest (OHCA). Early prediction of outcome may inform prognosis, tailor therapy and help in interpreting the intervention effect in heterogenous clinical trials. This study aimed to create a model for early prediction of outcome by artificial neural networks (ANN) and use this model to investigate intervention effects on classes of illness severity in cardiac arrest patients treated with targeted temperature management (TTM). Methods Using the cohort of the TTM trial, we performed a post hoc analysis of 932 unconscious patients from 36 centres with OHCA of a presumed cardiac cause. The patient outcome was the functional outcome, including survival at 180 days follow-up using a dichotomised Cerebral Performance Category (CPC) scale with good functional outcome defined as CPC 1–2 and poor functional outcome defined as CPC 3–5. Outcome prediction and severity class assignment were performed using a supervised machine learning model based on ANN. Results The outcome was predicted with an area under the receiver operating characteristic curve (AUC) of 0.891 using 54 clinical variables available on admission to hospital, categorised as background, pre-hospital and admission data. Corresponding models using background, pre-hospital or admission variables separately had inferior prediction performance. When comparing the ANN model with a logistic regression-based model on the same cohort, the ANN model performed significantly better (p = 0.029). A simplified ANN model showed promising performance with an AUC above 0.852 when using three variables only: age, time to ROSC and first monitored rhythm. The ANN-stratified analyses showed similar intervention effect of TTM to 33 °C or 36 °C in predefined classes with different risk of a poor outcome. Conclusion A supervised machine learning model using ANN predicted neurological recovery, including survival excellently, and outperformed a conventional model based on logistic regression. Among the data available at the time of hospitalisation, factors related to the pre-hospital setting carried most information. ANN may be used to stratify a heterogenous trial population in risk classes and help determine intervention effects across subgroups.
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Affiliation(s)
- Jesper Johnsson
- Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Helsingborg Hospital, Lund University, Helsingborg, Sweden. .,Department of Anaesthesiology and Intensive Care, Helsingborg Hospital, Charlotte Yléns Gata 10, SE-251 87, Helsingborg, Sweden.
| | - Ola Björnsson
- Centre for Mathematical Sciences, Mathematical Statistics, Lund University, Lund, Sweden.,Department of Energy Sciences, Faculty of Engineering, Lund University, Lund, Sweden
| | - Peder Andersson
- Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden
| | - Andreas Jakobsson
- Centre for Mathematical Sciences, Mathematical Statistics, Lund University, Lund, Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Intensive and Perioperative Care, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Christian Hassager
- Department of Cardiology, The Heart Centre, Rigshospitalet University Hospital and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergard
- Department of Cardiology, The Heart Centre, Rigshospitalet University Hospital and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Matt Wise
- Department of Critical Care, University Hospital of Wales, Cardiff, UK
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Helsingborg Hospital, Lund University, Helsingborg, Sweden
| | - Attila Frigyesi
- Centre for Mathematical Sciences, Mathematical Statistics, Lund University, Lund, Sweden.,Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden
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16
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Lotfi A, Klein LW, Hira RS, Mallidi J, Mehran R, Messenger JC, Pinto DS, Mooney MR, Rab T, Yannopoulos D, van Diepen S. SCAI expert consensus statement on out of hospital cardiac arrest. Catheter Cardiovasc Interv 2020; 96:844-861. [PMID: 32406999 DOI: 10.1002/ccd.28990] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Amir Lotfi
- Division of Cardiology, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Lloyd W Klein
- Division of Cardiology, University of California, San Francisco, California, USA
| | - Ravi S Hira
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Jaya Mallidi
- Santa Rosa Memorial Hospital, St. Joseph Cardiology Medical Group, Santa Rosa, California, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York, USA
| | - John C Messenger
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Duane S Pinto
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Michael R Mooney
- Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Tanveer Rab
- Division of Cardiology, Emory University, Atlanta, Georgia, USA
| | - Demetri Yannopoulos
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, University of Alberta, Edmonton, Canada
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17
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Lee ZH, Kim YH, Lee JH, Lee DW, Lee KY, Hwang SY. Association between Cardiac Arrest Time and Favorable Neurological Outcomes in Witnessed Out-of-Hospital Cardiac Arrest Patients Treated with Targeted Temperature Management. J Korean Med Sci 2020; 35:e108. [PMID: 32329257 PMCID: PMC7183844 DOI: 10.3346/jkms.2020.35.e108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/20/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Patients who achieve a return of spontaneous circulation (ROSC) with prolonged cardiac arrest have been recognized to have a poor prognosis. This might lead to reluctance in the provision of post-resuscitation care. Hence, we evaluated the impact of cardiac arrest time on neurologic outcomes in out-of-hospital cardiac arrest (OHCA) patients. METHODS This cross-sectional study used a hospital-based nationwide registry of OHCAs in Korea between 2012 and 2016. All witnessed OHCA patients aged ≥ 15 years and treated with targeted temperature management were included. We collected the time from collapse to sustained ROSC, which was defined as the downtime. The primary outcome was a favorable neurological outcome at hospital discharge. A multiple logistic regression analysis was conducted to determine independent factors for primary outcome in patients with downtime > 30 minutes. RESULTS Overall, neurologically favorable outcome rates were 30.5% in 1,963 patients. When the downtime was stratified into categories of 0-10, 11-20, 21-30, 31-40, 41-50, 51-60, and > 60 minutes according to 10-minute intervals, neurologically favorable outcome rates were 58.2%, 52.3%, 37.3%, 24.6%, 14.1%, 17.4%, and 16.7%, respectively (P < 0.001). In patients with downtime > 30 minutes, age 51-70 years (odds ratio [OR], 5.35; 95% confidence interval [CI], 2.50-11.49), age ≤ 50 years (OR, 13.16; 95% CI, 6.06-28.57), shockable rhythm (OR, 3.92; 95% CI, 2.71-5.68), bystander resuscitation (OR, 1.80; 95% CI, 1.27-2.55), cardiac cause (OR, 3.50; 95% CI, 1.69-7.25), percutaneous coronary intervention (OR, 1.82; 95% CI, 1.18-2.81), and downtime ≤ 40 minutes (OR, 2.02; 95% CI, 1.42-2.88) were associated with favorable neurological outcomes. CONCLUSION In patients with prolonged downtime, predicting favorable neurologic outcome may be multifactorial. The cutoff value for downtime is not the only determining factor to provide post-resuscitation care.
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Affiliation(s)
- Zoon Ho Lee
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Yong Hwan Kim
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea.
| | - Jun Ho Lee
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Dong Woo Lee
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Kyoung Yul Lee
- Department of Physical Education, Kyungnam University, Changwon, Korea
| | - Seong Youn Hwang
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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18
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Skrifvars MB, Soreide E, Sawyer KN, Taccone FS, Toome V, Storm C, Jeppesen A, Grejs A, Duez CHV, Tiainen M, Rasmussen BS, Laitio T, Hassager C, Kirkegaard H. Hypothermic to ischemic ratio and mortality in post-cardiac arrest patients. Acta Anaesthesiol Scand 2020; 64:546-555. [PMID: 31830304 DOI: 10.1111/aas.13528] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND We studied the associations between ischemia and hypothermia duration, that is, the hypothermic to ischemic ratio (H/I ratio), with mortality in patients included in a trial on two durations of targeted temperature management (TTM) at 33°C. METHODS The TTH48 (NCT01689077) trial compared 24 and 48 hours of TTM in patients after cardiac arrest. We calculated the hypothermia time from return of spontaneous circulation (ROSC) until the patient reached 37°C after TTM and the ischemic time from CA to ROSC. We compared continuous variables with the Mann-Whitney U test. Using COX regression, we studied the independent association of the logarithmically transformed H/I ratio and time to death as well as interaction between time to ROSC, hypothermia duration, and intervention group. We visualized the predictive ability of variables with receiver operating characteristic curve analysis. RESULTS Of the 338 patients, 237 (70%) survived for 6 months. The H/I ratio was 155 (IQR 111-238) in survivors and 114 (IQR 80-169) in non-survivors (P < .001). In a Cox regression model including factors associated with outcome in univariate analysis, the logarithmically transformed H/I ratio was a significant predictor of outcome (hazard ratio 0.52 (0.37-0.72, P = .001)). After removing an outlier, we found no interaction between time to ROSC and intervention group (P = .55) or hypothermia duration in quartiles (P = .07) with mortality. There was no significant difference in the area under the curve (AUC) between time to ROSC and H/I ratio (ΔAUC 0.03 95% CI -0.006-0.07, P = .10). CONCLUSIONS We did not find any consistent evidence of a modification of the effect of TTM based on ischemia duration.
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Affiliation(s)
- Markus B. Skrifvars
- Department of Emergency Care and Services University of HelsinkiHelsinki University Hospital Helsinki Finland
- Department of Anesthesiology, Intensive Care and Pain Medicine University of HelsinkiHelsinki University Hospital Helsinki Finland
| | - Eldar Soreide
- Critical Care and Anaesthesiology Research Group Stavanger University Hospital Stavanger Norway
- Department Clinical Medicine University of Bergen Bergen Norway
| | - Kelly N. Sawyer
- Department of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh PA USA
| | - Fabio S. Taccone
- Department of Intensive Care Erasme HospitalUniversité Libre de Bruxelles Brussels Belgium
| | - Valdo Toome
- Department of Intensive Cardiac Care North Estonia Medical Centre Tallinn Estonia
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care Charité‐Universitätsmedizin Berlin Berlin Germany
| | - Anni Jeppesen
- Department of Anaesthesiology Aarhus University Hospital Aarhus Denmark
| | - Anders Grejs
- Department of Intensive Care Medicine Aarhus University Hospital Aarhus Denmark
| | - Christophe H. V. Duez
- Research Center for Emergency Medicine Department of Emergency Medicine and Department of Clinical Medicine Aarhus University Hospital and Aarhus University Aarhus Denmark
| | - Marjaana Tiainen
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Bodil S. Rasmussen
- Department of Anesthesiology and Intensive Care Medicine Aalborg University HospitalClinical InstituteAalborg University Aalborg Denmark
| | - Timo Laitio
- Division of Perioperative Services Intensive Care Medicine and Pain Management Turku University Hospital and University of Turku Finland
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet and Dept of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Hans Kirkegaard
- Research Center for Emergency Medicine Department of Emergency Medicine and Department of Clinical Medicine Aarhus University Hospital and Aarhus University Aarhus Denmark
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19
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Lascarrou JB, Dumas F, Bougouin W, Chocron R, Beganton F, Legriel S, Aissaoui N, Deye N, Lamhaut L, Jost D, Vieillard-Baron A, Marijon E, Jouven X, Cariou A. Temporal trends in the use of targeted temperature management after cardiac arrest and association with outcome: insights from the Paris Sudden Death Expertise Centre. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:391. [PMID: 31796127 PMCID: PMC6892202 DOI: 10.1186/s13054-019-2677-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/15/2019] [Indexed: 01/05/2023]
Abstract
Purpose Recent doubts regarding the efficacy may have resulted in a loss of interest for targeted temperature management (TTM) in comatose cardiac arrest (CA) patients, with uncertain consequences on outcome. We aimed to identify a change in TTM use and to assess the relationship between this change and neurological outcome. Methods We used Utstein data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (capturing CA data from all secondary and tertiary hospitals located in the Great Paris area, France) between May 2011 and December 2017. All cases of non-traumatic OHCA patients with stable return of spontaneous circulation (ROSC) were included. After adjustment for potential confounders, we assessed the relationship between changes over time in the use of TTM and neurological recovery at discharge using the Cerebral Performance Categories (CPC) scale. Results Between May 2011 and December 2017, 3925 patients were retained in the analysis, of whom 1847 (47%) received TTM. The rate of good neurological outcome at discharge (CPC 1 or 2) was higher in TTM patients as compared with no TTM (33% vs 15%, P < 0.001). Gender, age, and location of CA did not change over the years. Bystander CPR increased from 55% in 2011 to 73% in 2017 (P < 0.001) and patients with a no-flow time longer than 3 min decreased from 53 to 38% (P < 0.001). The use of TTM decreased from 55% in 2011 to 37% in 2017 (P < 0.001). Meanwhile, the rate of patients with good neurological recovery remained stable (19 to 23%, P = 0.76). After adjustment, year of CA occurrence was not associated with outcome. Conclusions We report a progressive decrease in the use of TTM in post-cardiac arrest patients over the recent years. During this period, neurological outcome remained stable, despite an increase in bystander-initiated resuscitation and a decrease in “no flow” duration.
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Affiliation(s)
- Jean-Baptiste Lascarrou
- Service de Medecine Intensive Reanimation, Centre Hospitalier Universitaire, 30 Boulevard Jean Monnet, 44093, Nantes Cedex 9, France. .,Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France. .,Paris Sudden Death Expertise Center, Paris, France. .,AfterROSC Network Group, Paris, France.
| | - Florence Dumas
- Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Emergency Department, Cochin University Hospital, APHP, Paris, France
| | - Wulfran Bougouin
- Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,AfterROSC Network Group, Paris, France
| | - Richard Chocron
- Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Emergency Department, Cochin University Hospital, APHP, Paris, France
| | - Frankie Beganton
- Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France.,Paris Sudden Death Expertise Center, Paris, France
| | - Stephane Legriel
- Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,AfterROSC Network Group, Paris, France.,Medical Surgical Intensive Care Unit, Mignot Hospital, Le Chesnay, France
| | - Nadia Aissaoui
- Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,AfterROSC Network Group, Paris, France.,Medical Intensive Care Unit, European University Hospital, Paris, France
| | - Nicolas Deye
- Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,AfterROSC Network Group, Paris, France.,Medical Intensive Care Unit, Lariboisière University Hospital, Paris, France
| | - Lionel Lamhaut
- Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,AfterROSC Network Group, Paris, France.,SAMU de Paris, DAR Necker University Hospital-Assistance, Paris, France
| | - Daniel Jost
- Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France.,Brigade des Sapeurs-Pompiers de Paris, Paris, France
| | - Antoine Vieillard-Baron
- Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France.,Medical Intensive Care Unit, Ambroise Pare University Hospital, APHP, Boulogne-Billancourt, France
| | - Eloi Marijon
- Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France.,Paris Sudden Death Expertise Center, Paris, France
| | - Xavier Jouven
- Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France.,Paris Sudden Death Expertise Center, Paris, France
| | - Alain Cariou
- Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,AfterROSC Network Group, Paris, France.,Medical Intensive Care Unit, Cochin University Hospital, APHP, Paris, France
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20
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Okazaki T, Hifumi T, Kawakita K, Kuroda Y. Targeted temperature management guided by the severity of hyperlactatemia for out-of-hospital cardiac arrest patients: a post hoc analysis of a nationwide, multicenter prospective registry. Ann Intensive Care 2019; 9:127. [PMID: 31745738 PMCID: PMC6864017 DOI: 10.1186/s13613-019-0603-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/09/2019] [Indexed: 12/12/2022] Open
Abstract
Background The International Liaison Committee on Resuscitation guidelines recommend target temperature management (TTM) between 32 and 36 °C for patients after out-of-hospital cardiac arrest, but did not indicate patient-specific temperatures. The association of serum lactate concentration and neurological outcome in out-of-hospital cardiac arrest patient has been reported. The study aim was to investigate the benefit of 32–34 °C in patients with various degrees of hyperlactatemia compared to 35–36 °C. Methods This study was a post hoc analysis of the Japanese Association for Acute Medicine out-of-hospital cardiac arrest registry between June 2014 and December 2015. Patients with complete targeted temperature management and lactate data were eligible. Patients were stratified to mild (< 7 mmol/l), moderate (< 12 mmol/l), or severe (≥ 12 mmol/l) hyperlactatemia group based on lactate concentration after return of spontaneous circulation. They were subdivided into 32–34 °C or 35–36 °C groups. The primary endpoint was an adjusted predicted probability of 30-day favorable neurological outcome, defined as a cerebral performance category score of 1 or 2. Result Of 435 patients, 139 had mild, 182 had moderate, and 114 had severe hyperlactatemia. One hundred and eight (78%) with mild, 128 with moderate (70%), and 83 with severe hyperlactatemia (73%) received TTM at 32–34 °C. The adjusted predicted probability of a 30-day favorable neurological outcome following severe hyperlactatemia was significantly greater with 32–34 °C (27.4%, 95% confidence interval: 22.0–32.8%) than 35–36 °C (12.4%, 95% CI 3.5–21.2%; p = 0.005). The differences in outcomes in those with mild and moderate hyperlactatemia were not significant. Conclusions In OHCA patients with severe hyperlactatemia, the adjusted predicted probability of 30-day favorable neurological outcome was greater with TTM at 32–34 °C than with TTM at 35–36 °C. Further evaluation is needed to determine whether TTM at 32–34 °C can improve neurological outcomes in patients with severe hyperlactatemia after out-of-hospital cardiac arrest.
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Affiliation(s)
- Tomoya Okazaki
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Kita, Miki, Kagawa, 761-0793, Japan.
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Kita, Miki, Kagawa, 761-0793, Japan
| | - Yasuhiro Kuroda
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Kita, Miki, Kagawa, 761-0793, Japan
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Modulating effects of immediate neuroprognosis on early coronary angiography and targeted temperature management following out-of-hospital cardiac arrest: A retrospective cohort study. Resuscitation 2019; 143:42-49. [DOI: 10.1016/j.resuscitation.2019.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/01/2019] [Accepted: 08/06/2019] [Indexed: 12/13/2022]
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Nee J, Jörres A, Krannich A, Leithner C, Schroeder T, Munk AL, Enghard P, Moore C, Steppan S, Storm C. Elimination of glutamate using CRRT for 72 h in patients with post-cardiac arrest syndrome: A randomized clinical pilot trial. Resuscitation 2019; 144:54-59. [PMID: 31557520 DOI: 10.1016/j.resuscitation.2019.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/15/2019] [Accepted: 09/17/2019] [Indexed: 11/29/2022]
Abstract
AIM Glutamine and glutamate are major mediators of secondary brain cell death during post-cardiac arrest syndrome. As there is an equilibrium between brain tissue and plasma concentrations of glutamine and glutamate, their elimination from systemic circulation by extracorporeal blood purification may ultimately lead to reduced secondary cell death in the brain. We hypothesized that systemic glutamine and glutamate can be significantly reduced by continuous venovenous hemodiafiltration (CVVHDF). METHODS This was a prospective, randomized clinical trial in post cardiac-arrest survivors evaluating standard of care or additional CVVHDF over 72 h immediately after admission. Glutamine and glutamate plasma concentrations were analyzed at eight time points in both groups. Primary endpoint was reduction of glutamine and glutamate plasma concentrations. The trial has been registered at clinical trial.gov (NCT02963298). RESULTS In total, 41 patients were randomized over a period of 12 months (control n = 21, CVVHDF n = 20). The primary aim reduction of glutamine and glutamate plasma concentrations by CVVHDF, was not achieved; both groups-maintained concentrations within a normal range over the study period (glutamate: 4.7-11.1 mg/dL; glutamine: 0.2-3.7 mg/dL). However, post-filter concentrations of glutamine and glutamate in CRRT patients were significantly decreased as compared to pre-filter concentrations (glutamate: pre-filter median 8.85 mg/dL IQR 7.1-9.6; post-filter 0.95 mg/dL IQR 0.5-2; p < 0.001; glutamine: pre-filter 0.7 mg/dL IQR 0.6-1; post-filter 0.2 mg/dL IQR 0-0.2; p < 0.001). CONCLUSION In this trial, CVVHDF was not able to statistically significantly lower systemic plasma glutamine and glutamate levels. Post-cardiac arrest patients had plasma glutamine and glutamate levels within the normal range.
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Affiliation(s)
- Jens Nee
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Achim Jörres
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; Department of Medicine I - Nephrology, Transplantation & Medical Intensive Care, University Witten/Herdecke, Medical Center Cologne-Merheim, Cologne, Germany
| | - Alexander Krannich
- Institute of Medical Immunology, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Christoph Leithner
- Department of Neurology, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Tim Schroeder
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Anna Lena Munk
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Philip Enghard
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Christoph Moore
- EMEA Medical Office, Fresenius Medical Care Deutschland GmbH, Else-Kröner-Str. 1, 61352 Bad Homburg v.d.H., Germany
| | - Sonja Steppan
- EMEA Medical Office, Fresenius Medical Care Deutschland GmbH, Else-Kröner-Str. 1, 61352 Bad Homburg v.d.H., Germany
| | - Christian Storm
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Nehme Z, Andrew E, Bernard S, Haskins B, Smith K. Trends in survival from out-of-hospital cardiac arrests defibrillated by paramedics, first responders and bystanders. Resuscitation 2019; 143:85-91. [PMID: 31430512 DOI: 10.1016/j.resuscitation.2019.08.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/06/2019] [Accepted: 08/11/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although survival from out-of-hospital cardiac arrest (OHCA) is increasing, little is known about the long-term trends in survival for patients defibrillated by first responders and bystanders. METHODS Between 2000 and 2017, we included adult non-traumatic OHCA with an initial shockable rhythm from the Victorian Ambulance Cardiac Arrest Registry. Adjusted logistic regression analyses were used to assess trends in survival to hospital discharge according to whether the patient was initially shocked by paramedics, first responders or bystanders. RESULTS Of the 10,451 initial shockable arrests, 796 (7.6%) and 526 (5.0%) were initially shocked by first responders and bystanders, respectively. Between 2000-02 and 2015-17, the proportion of cases initially shocked by first responders and bystanders increased from 3.8% to 8.2% and from 2.0% to 11.2%, respectively. Over the same period, survival to hospital discharge increased from 11.6% to 28.8% for cases initially shocked by paramedics, from 10.5% to 37.8% for cases initially shocked by first responders, and from 6.7% to 55.5% for cases initially shocked by bystanders (p trend <0.001 for all). In the adjusted analyses, patients initially shocked by first responders (AOR 1.40, 95% CI: 1.18, 1.67; p < 0.001) and bystanders (AOR 2.11, 95% CI: 1.72, 2.59; p < 0.001) were more likely to survive to hospital discharge than those initially shocked by paramedics. The odds of survival increased year-on-year by 8.1% for patients shocked by paramedics (p < 0.001), 6.1% for patients shocked by first responders (p = 0.004), and 11.8% for patients shocked by bystanders (p < 0.001). CONCLUSION OHCA patients initially defibrillated by bystanders yielded the largest improvements in survival over time.
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Affiliation(s)
- Ziad Nehme
- Centre for Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, Victoria, Australia; NHMRC Centre of Research Excellence in Pre-hospital Emergency Care Australia and New Zealand (PEC-ANZ), Monash University, Melbourne, Victoria, Australia.
| | - Emily Andrew
- Centre for Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephen Bernard
- Centre for Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; NHMRC Centre of Research Excellence in Pre-hospital Emergency Care Australia and New Zealand (PEC-ANZ), Monash University, Melbourne, Victoria, Australia; Alfred Hospital, Prahran, Victoria, Australia
| | - Brian Haskins
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, Victoria, Australia; NHMRC Centre of Research Excellence in Pre-hospital Emergency Care Australia and New Zealand (PEC-ANZ), Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- Centre for Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, Victoria, Australia; NHMRC Centre of Research Excellence in Pre-hospital Emergency Care Australia and New Zealand (PEC-ANZ), Monash University, Melbourne, Victoria, Australia; Discipline of Emergency Medicine, University of Western Australia, Crawley, Western Australia, Australia
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Hypothermia in the Neurocritical Care Unit: Physiology and Applications. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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External validation of a risk classification at the emergency department of post-cardiac arrest syndrome patients undergoing targeted temperature management. Resuscitation 2019; 140:135-141. [PMID: 31153943 DOI: 10.1016/j.resuscitation.2019.05.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/09/2019] [Accepted: 05/23/2019] [Indexed: 01/09/2023]
Abstract
INTRODUCTION There are no established risk classification for post-cardiac arrest syndrome (PCAS) patients at the Emergency Department (ED) undergoing targeted temperature management (TTM). The aim of this study was to externally validate a simplified version of our prognostic score, the "post-Cardiac Arrest Syndrome for Therapeutic hypothermia score" (revised CAST [rCAST]) and estimate the predictive accuracy of the risk classification based on it. METHODS For the external validation, we used data from an out-of-hospital cardiac arrest (OHCA) registry of the Japanese Association for Acute Medicine (JAAM), which is a multicenter, prospective registry of OHCA patients across Japan. Eligible patients were PCAS patients treated with TTM at 33-36 °C between June 2014 and December 2015. We validated the accuracy of rCAST for predicting the neurological outcomes at 30 and 90 days. RESULTS Among the 12,024 OHCA patients, the data of 460 PCAS patients treated by TTM were eligible for the validation. The areas under the curve of rCAST for predicting the neurological outcomes at 30 and 90 days were 0.892 and 0.895, respectively. The estimated sensitivity and specificity of the risk categories for the outcomes were as follows: 0.95 (95% CI: 0.92-0.98) and 0.47 (0.40-0.55) for the low (rCAST: ≤5.5), 0.62 (0.56-0.68) and 0.48 (0.40-0.55) for the moderate (rCAST: 6.0-14.0), and 0.57 (0.51-0.63) and 0.95 (0.91-0.98) for the high severity category (rCAST: ≥14.5). CONCLUSIONS The rCAST was useful for predicting the neurological outcomes with high accuracy in PCAS patients, and the three grades was developed for a risk classification based on the rCAST.
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Buchtele N, Schober A, Schoergenhofer C, Spiel AO, Mauracher L, Weiser C, Sterz F, Jilma B, Schwameis M. Added value of the DIC score and of D-dimer to predict outcome after successfully resuscitated out-of-hospital cardiac arrest. Eur J Intern Med 2018; 57:44-48. [PMID: 29958747 DOI: 10.1016/j.ejim.2018.06.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/28/2018] [Accepted: 06/19/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Recent Korean data suggest a high prevalence of overt disseminated intravascular coagulation (DIC) and a good predictive performance of the ISTH DIC score in successfully resuscitated out-of-hospital cardiac arrest. OBJECTIVES We hypothesised that in a European cohort of resuscitated out-of-hospital cardiac arrest patients the prevalence of DIC is substantially lower. Furthermore, the determination of D-dimer levels at admission, but not the DIC score, could improve mortality prediction above traditional predictors. PATIENTS/METHODS Data were extracted from a prospective cardiac arrest registry including patients admitted between 2006 and 2015, who achieved return of spontaneous circulation and had parameters for DIC score calculation available. The primary outcome was the prevalence of overt DIC at admission. Secondary outcomes included the association of overt DIC with 30-day mortality and the contribution of the DIC score and D-dimer levels to 30-day mortality prediction using logistic regression. Three stepwise models were evaluated by receiver-operating-characteristic analysis. RESULTS Out of 1179 patients 388 were included in the study. Overt DIC was present in 8% of patients and associated with substantial 30-day mortality (83% vs. 39%). The AUC for model 1, including traditional mortality predictors, was 0.83. The inclusion of D-dimer levels significantly improved prognostication above traditional predictors (model 3, AUC 0.89), whereas the inclusion of the DIC Score had no effect on mortality prediction (model 2, AUC 0.83). CONCLUSION Overt DIC was rare in a European cohort of out-of-hospital cardiac arrest patients. D-dimer levels improved 30-day mortality prediction and provided added value to assess early mortality risk after successful resuscitation.
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Affiliation(s)
- N Buchtele
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - A Schober
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - C Schoergenhofer
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - A O Spiel
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - L Mauracher
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - C Weiser
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - F Sterz
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - B Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - M Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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Norii T, Crandall C, Braude D. Effect of Time to Vascular Access in Out-of-Hospital Cardiac Arrest. Ann Emerg Med 2018; 72:228-229. [DOI: 10.1016/j.annemergmed.2018.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Indexed: 10/17/2022]
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Ørbo MC, Vangberg TR, Tande PM, Anke A, Aslaksen PM. Memory performance, global cerebral volumes and hippocampal subfield volumes in long-term survivors of Out-of-Hospital Cardiac Arrest. Resuscitation 2018; 126:21-28. [DOI: 10.1016/j.resuscitation.2018.02.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 02/07/2018] [Accepted: 02/13/2018] [Indexed: 10/18/2022]
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Nishikimi M, Ogura T, Nishida K, Takahashi K, Fukaya K, Liu K, Nakamura M, Matsui S, Matsuda N. Differential effect of mild therapeutic hypothermia depending on the findings of hypoxic encephalopathy on early CT images in patients with post-cardiac arrest syndrome. Resuscitation 2018; 128:11-15. [PMID: 29698752 DOI: 10.1016/j.resuscitation.2018.04.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/29/2018] [Accepted: 04/23/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The aim of this study was to evaluate the differential effects of mild therapeutic hypothermia (MTH) in post-cardiac arrest syndrome (PCAS) patients depending on the presence/absence of hypoxic encephalopathy (HE) in the early brain CT images obtained before the initiation of MTH. METHODS We conducted a retrospective review of the data of a total of 129 patients with PCAS who were treated by MTH (34 °C) or normothermia treatment (NT) (35 °C or 36 °C), and had undergone brain CT examination prior to the initiation of these treatments. We divided the subjects into 4 groups, namely, the HE(-)/MTH, HE(-)/NT, HE(+)/MTH, and HE(+)/NT groups, for evaluating the interaction effect between the two variables. Then, we compared the neurological outcomes between the HE(-)/MTH and HE(-)/NT groups by multivariate logistic analysis. Good outcome was defined as a Cerebral Performance Category score of ≤2 at 30 days. RESULTS The percentages of subjects with a good outcome in the HE(-)/MTH and HE(-)/NT group were 68.9% (42/61) and 36.1% (13/36), respectively (p = .003), while those in the HE(+)/MTH and HE(+)/NT groups were lower, at 7.4% (2/27) and 20.0% (1/5), respectively (p = .410), suggesting a statistically significant interaction effect between the two variables (pinteraction = 0.002). In the HE(-) group, MTH was associated with a higher odds ratio of a good outcome as compared to NT (OR 6.80, 95% CI 1.19-38.96, p = .031). CONCLUSIONS The effect of MTH in patients with PCAS differed depending on the presence/absence of evidence of HE on the early CT images.
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Affiliation(s)
- Mitsuaki Nishikimi
- Department of Emergency and Critical Care, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Takayuki Ogura
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Kazuki Nishida
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kunihiko Takahashi
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenji Fukaya
- Department of Emergency and Critical Care, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keibun Liu
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Mitsunobu Nakamura
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Shigeyuki Matsui
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoyuki Matsuda
- Department of Emergency and Critical Care, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Secher N, Østergaard L, Tønnesen E, Hansen FB, Granfeldt A. Impact of age on cardiovascular function, inflammation, and oxidative stress in experimental asphyxial cardiac arrest. Acta Anaesthesiol Scand 2018; 62:49-62. [PMID: 29072303 DOI: 10.1111/aas.13014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/23/2017] [Accepted: 09/26/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Advanced age is an independent predictor of poor outcome after cardiac arrest (CA). From experimental studies of regional ischemia-reperfusion injury, advanced age is associated with larger infarct size, reduced organ function, and augmented oxidative stress. The objective of this study was to investigate the effect of age on cardiovascular function, oxidative stress, inflammation, and endothelial activation after CA representing global ischemia-reperfusion. METHODS Aged (26 months) and young (5 months) rats were subjected to 8 min of asphyxia induced CA, resuscitated and observed for 360 min. Left ventricular pressure-derived cardiac function was measured at baseline and 360 min after CA. Blood samples obtained at baseline, 120 min, and 360 min after CA were analyzed for IL-1β, IL-6, IL-10, TNF-α, elastase, sE-selectin, sL-selectin, sI-CAM1, hemeoxygenase-1 (HO-1) and protein carbonyl. Tissue samples of brain, heart, kidney, and lung were analyzed for HO-1. RESULTS Cardiac function, evaluated by dP/dtmax and dP/dtmin , was decreased after CA in both young and aged rats, with no group differences. Mean arterial pressure increased after CA in young, but not old rats. Aged rats showed significantly higher plasma levels of elastase and sE-selectin after CA, and there was a significant different development over time between groups for IL-6 and IL-10. Young rats showed higher levels of HO-1 in plasma and renal tissue after CA. CONCLUSION In a rat model of asphyxial CA, advanced age is associated with an attenuated hyperdynamic blood pressure response and increased endothelial activation.
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Affiliation(s)
- N. Secher
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus C Denmark
- Department of Internal Medicine; Horsens Regional Hospital; Horsens Denmark
| | - L. Østergaard
- Center of Functionally Integrative Neuroscience; Aarhus University; Aarhus C Denmark
| | - E. Tønnesen
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus C Denmark
| | - F. B. Hansen
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus C Denmark
| | - A. Granfeldt
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus C Denmark
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Martinell L, Herlitz J, Karlsson T, Nielsen N, Rylander C. Mild induced hypothermia and survival after out-of-hospital cardiac arrest. Am J Emerg Med 2017; 35:1595-1600. [DOI: 10.1016/j.ajem.2017.04.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 04/24/2017] [Accepted: 04/26/2017] [Indexed: 01/09/2023] Open
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Neurologic Recovery After Cardiac Arrest: a Multifaceted Puzzle Requiring Comprehensive Coordinated Care. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:52. [PMID: 28536893 DOI: 10.1007/s11936-017-0548-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT Surviving cardiac arrest (CA) requires a longitudinal approach with multiple levels of responsibility, including fostering a culture of action by increasing public awareness and training, optimization of resuscitation measures including frequent updates of guidelines and their timely implementation into practice, and optimization of post-CA care. This clearly goes beyond resuscitation and targeted temperature management. Brain-directed physiologic goals should dictate the post-CA management, as accumulating evidence suggests that the degree of hypoxic brain injury is the main determinant of survival, regardless of the etiology of arrest. Early assessment of the need for further hemodynamic and electrophysiologic cardiac interventions, adjusting ventilator settings to avoid hyperoxia/hypoxia while targeting high-normal to mildly elevated PaCO2, maintaining mean arterial blood pressures >65 mmHg, evaluating for and treating seizures, maintaining euglycemia, and aggressively pursuing normothermia are key steps in reducing the bioenergetic failure that underlies secondary brain injury. Accurate neuroprognostication requires a multimodal approach with standardized assessments accounting for confounders while recognizing the importance of a delayed prognostication when there is any uncertainty regarding outcome. The concept of a highly specialized post-CA team with expertise in the management of post-CA syndrome (mindful of the brain-directed physiologic goals during the early post-resuscitation phase), TTM, and neuroprognostication, guiding the comprehensive care to the CA survivor, is likely cost-effective and should be explored by institutions that frequently care for these patients. Finally, providing tailored rehabilitation care with systematic reassessment of the needs and overall goals is key for increasing independence and improving quality-of-life in survivors, thereby also alleviating the burden on families. Emerging evidence from multicenter collaborations advances the field of resuscitation at an incredible pace, challenging previously well-established paradigms. There is no more room for "conventional wisdom" in saving the survivors of cardiac arrest.
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Martinell L, Nielsen N, Herlitz J, Karlsson T, Horn J, Wise MP, Undén J, Rylander C. Early predictors of poor outcome after out-of-hospital cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:96. [PMID: 28410590 PMCID: PMC5391587 DOI: 10.1186/s13054-017-1677-2] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 03/22/2017] [Indexed: 12/24/2022]
Abstract
Background Early identification of predictors for a poor long-term outcome in patients who survive the initial phase of out-of-hospital cardiac arrest (OHCA) may facilitate future clinical research, the process of care and information provided to relatives. The aim of this study was to determine the association between variables available from the patient’s history and status at intensive care admission with outcome in unconscious survivors of OHCA. Methods Using the cohort of the Target Temperature Management trial, we performed a post hoc analysis of 933 unconscious patients with OHCA of presumed cardiac cause who had a complete 6-month follow-up. Outcomes were survival and neurological function as defined by the Cerebral Performance Category (CPC) scale at 6 months after OHCA. After multiple imputations to compensate for missing data, backward stepwise multivariable logistic regression was applied to identify factors independently predictive of a poor outcome (CPC 3–5). On the basis of these factors, a risk score for poor outcome was constructed. Results We identified ten independent predictors of a poor outcome: older age, cardiac arrest occurring at home, initial rhythm other than ventricular fibrillation/tachycardia, longer duration of no flow, longer duration of low flow, administration of adrenaline, bilateral absence of corneal and pupillary reflexes, Glasgow Coma Scale motor response 1, lower pH and a partial pressure of carbon dioxide in arterial blood value lower than 4.5 kPa at hospital admission. A risk score based on the impact of each of these variables in the model yielded a median (range) AUC of 0.842 (0.840–0.845) and good calibration. Internal validation of the score using bootstrapping yielded a median (range) AUC corrected for optimism of 0.818 (0.816–0.821). Conclusions Among variables available at admission to intensive care, we identified ten independent predictors of a poor outcome at 6 months for initial survivors of OHCA. They reflected pre-hospital circumstances (six variables) and patient status on hospital admission (four variables). By using a simple and easy-to-use risk scoring system based on these variables, patients at high risk for a poor outcome after OHCA may be identified early.
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Affiliation(s)
- Louise Martinell
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden.
| | - Niklas Nielsen
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Johan Herlitz
- The Centre for Pre-hospital Research in Western Sweden, University College of Borås and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Thomas Karlsson
- Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Johan Undén
- Department of Intensive Care and Perioperative Medicine, Lund University, Malmö, Sweden
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
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Impact of Early Vasopressor Administration on Neurological Outcomes after Prolonged Out-of-Hospital Cardiac Arrest. Prehosp Disaster Med 2017; 32:297-304. [PMID: 28222830 DOI: 10.1017/s1049023x17000115] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Introduction Vasopressors are associated with return of spontaneous circulation (ROSC), but no long-term benefit has been demonstrated in randomized trials. However, these trials did not control for the timing of vasopressor administration which may influence outcomes. Consequently, the objective of this study was to develop a model describing the likelihood of favorable neurological outcome (cerebral performance category [CPC] 1 or 2) as a function of the public safety answering point call receipt (PSAP)-to-pressor-interval (PPI) in prolonged out-of-hospital cardiac arrest. Hypothesis The likelihood of favorable neurological outcome declines with increasing PPI. METHODS This investigation was a retrospective study of cardiac arrest using linked data from the Cardiac Arrest Registry to Enhance Survival (CARES) database (Centers for Disease Control and Prevention [Atlanta, Georgia USA]; American Heart Association [Dallas, Texas USA]; and Emory University Department of Emergency Medicine [Atlanta, Georgia USA]) and the North Carolina (USA) Prehospital Medical Information System. Adult patients suffering a bystander-witnessed, non-traumatic cardiac arrest between January 2012 and June 2014 were included. Logistic regression was used to calculate the adjusted odds ratio (OR) of neurological outcome as a function of PPI, while controlling for patient age, gender, and race; endotracheal intubation (ETI); shockable rhythm; layperson cardiopulmonary resuscitation (CPR); and field hypothermia. RESULTS Of the 2,100 patients meeting inclusion criteria, 913 (43.5%) experienced ROSC, 618 (29.4%) survived to hospital admission, 187 (8.9%) survived to hospital discharge, and 155 (7.4%) were discharged with favorable neurological outcomes (CPC 1 or 2). Favorable neurological outcome was less likely with increasing PPI (OR=0.90; P<.01) and increasing age (OR=0.97; P<.01). Compared to patients with non-shockable rhythms, patients with shockable rhythms were more likely to have favorable neurological outcomes (OR=7.61; P<.01) as were patients receiving field hypothermia (OR=2.13; P<.01). Patient gender, non-Caucasian race, layperson CPR, and ETI were not independent predictors of favorable neurological outcome. CONCLUSION In this evaluation, time to vasopressor administration was significantly associated with favorable neurological outcome. Among adult, witnessed, non-traumatic arrests, the odds of hospital discharge with CPC 1 or 2 declined by 10% for every one-minute delay between PSAP call-receipt and vasopressor administration. These retrospective observations support the notion of a time-dependent function of vasopressor effectiveness on favorable neurological outcome. Large, prospective studies are needed to verify this relationship. Hubble MW , Tyson C . Impact of early vasopressor administration on neurological outcomes after prolonged out-of-hospital cardiac arrest. Prehosp Disaster Med. 2017; 32(3):297-304.
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Jentzer JC, Clements CM, Murphy JG, Scott Wright R. Recent developments in the management of patients resuscitated from cardiac arrest. J Crit Care 2017; 39:97-107. [PMID: 28242531 DOI: 10.1016/j.jcrc.2017.02.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/18/2017] [Accepted: 02/01/2017] [Indexed: 01/31/2023]
Abstract
Cardiac arrest is the leading cause of death in Europe and the United States. Many patients who are initially resuscitated die in the hospital, and hospital survivors often have substantial neurologic dysfunction. Most cardiac arrests are caused by coronary artery disease; patients with coronary artery disease likely benefit from early coronary angiography and intervention. After resuscitation, cardiac arrest patients remain critically ill and frequently suffer cardiogenic shock and multiorgan failure. Early cardiopulmonary stabilization is important to prevent worsening organ injury. To achieve best patient outcomes, comprehensive critical care management is needed, with primary goals of stabilizing hemodynamics and preventing progressive brain injury. Targeted temperature management is frequently recommended for comatose survivors of cardiac arrest to mitigate the neurologic injury that drives outcomes. Accurate neurologic assessment is central to managing care of cardiac arrest survivors and should combine physical examination with objective neurologic testing, with the caveat that delaying neurologic prognosis is essential to avoid premature withdrawal of supportive care. A combination of clinical findings and diagnostic results should be used to estimate the likelihood of functional recovery. This review focuses on recent advances in care and specific cardiac intensive care strategies that may improve morbidity and mortality for patients after cardiac arrest.
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Affiliation(s)
- Jacob C Jentzer
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
| | | | - Joseph G Murphy
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - R Scott Wright
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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Grand J, Thomsen JH, Kjaergaard J, Nielsen N, Erlinge D, Wiberg S, Wanscher M, Bro-Jeppesen J, Hassager C. Prevalence and Prognostic Implications of Bundle Branch Block in Comatose Survivors of Out-of-Hospital Cardiac Arrest. Am J Cardiol 2016; 118:1194-1200. [PMID: 27553102 DOI: 10.1016/j.amjcard.2016.07.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/21/2016] [Accepted: 07/21/2016] [Indexed: 11/29/2022]
Abstract
This study reports the prevalence and prognostic impact of right bundle branch block (RBBB) and left bundle branch block (LBBB) in the admission electrocardiogram (ECG) of comatose survivors of out-of-hospital cardiac arrest (OHCA). The present study is part of the predefined electrocardiographic substudy of the prospective randomized target temperature management trial, which found no benefit of targeting 33°C over 36°C in terms of outcome. Six-hundred eighty-two patients were included in the substudy. An admission ECG, which defined the present study population, was available in 602 patients (88%). These ECGs were stratified by the presence of LBBB, RBBB, or no-BBB (reference) on admission. End points were mortality and neurologic outcome 6 months after OHCA. RBBB was present in 79 patients (13%) and LBBB in 65 patients (11%), and the majority of BBBs (92%) had resolved 4 hours after admission. RBBB was associated with significantly higher 6 months mortality (RBBB: hazard ratio [HR]unadjusted 1.78, 95% confidence interval [CI] 1.30 to 2.43; LBBB: HRunadjusted 1.26, 95% CI 0.87 to 1.81), but this did not reach a level of significance in the adjusted model (HRadjusted 1.33, 95% CI 0.94 to 1.87). Similar findings were seen for neurologic outcome in the unadjusted and adjusted analyses. RBBB was further independently associated with higher odds of unfavorable neurologic outcome (RBBB: adjusted odds ratio 1.97, 95% CI 1.05 to 3.71). In conclusion, BBBs after OHCA were transient in most patients, and RBBB was directly associated with higher mortality and independently associated with higher odds of unfavorable neurologic outcome. RBBB is seemingly an early indicator of an unfavorable prognosis after OHCA.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Niklas Nielsen
- Department of Anesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - David Erlinge
- Department of Cardiology, Lund University Hospital, Lund, Sweden
| | - Sebastian Wiberg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Michael Wanscher
- Department of Cardiothoracic Anesthesia, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - John Bro-Jeppesen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
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López J, Fernández SN, González R, Solana MJ, Urbano J, López-Herce J. Different Respiratory Rates during Resuscitation in a Pediatric Animal Model of Asphyxial Cardiac Arrest. PLoS One 2016; 11:e0162185. [PMID: 27618183 PMCID: PMC5019379 DOI: 10.1371/journal.pone.0162185] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 08/18/2016] [Indexed: 11/29/2022] Open
Abstract
Aims Actual resuscitation guidelines recommend 10 respirations per minute (rpm) for advanced pediatric life support. This respiratory rate (RR) is much lower than what is physiological for children. The aim of this study is to compare changes in ventilation, oxygenation, haemodynamics and return of spontaneous circulation (ROSC) rates with three RR. Methods An experimental model of asphyxial cardiac arrest (CA) in 46 piglets (around 9.5 kg) was performed. Resuscitation with three different RR (10, 20 and 30 rpm) was carried out. Haemodynamics and gasometrical data were obtained at 3, 9, 18 and 24 minutes after beginning of resuscitation. Measurements were compared between the three groups. Results No statistical differences were found in ROSC rate between the three RR (37.5%, 46.6% and 60% in the 10, 20 and 30 rpm group respectively P = 0.51). 20 and 30 rpm groups had lower PaCO2 values than 10 rpm group at 3 minutes (58 and 55 mmHg vs 75 mmHg P = 0.08). 30 rpm group had higher PaO2 (61 mmHg) at 3 minutes than 20 and 10 rpm groups (53 and 45 mmHg P = 0.05). No significant differences were found in haemodynamics or tissue perfusion between hyperventilated (PaCO2 <30 mmHg), normoventilated (30–50 mmHg) and hypoventilated (>50 mmHg) animals. PaO2 was significantly higher in hyperventilated (PaO2 153 mmHg) than in normoventilated (79 mmHg) and hypoventilated (47 mmHg) piglets (P<0.001). Conclusions Our study confirms the hypothesis that higher RR achieves better oxygenation and ventilation without affecting haemodynamics. A higher RR is associated but not significantly with better ROSC rates.
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Affiliation(s)
- Jorge López
- Pediatric Intensive Care Unit, Gregorio Marañón General University Hospital, Madrid, Spain
- School of Medicine Complutense University of Madrid, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Mother-Child Health and Development Network (RedSAMID) of Carlos III Health Institute, Bilbao, Spain
- * E-mail: (JL); (JL-H)
| | - Sarah N. Fernández
- Pediatric Intensive Care Unit, Gregorio Marañón General University Hospital, Madrid, Spain
- School of Medicine Complutense University of Madrid, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Mother-Child Health and Development Network (RedSAMID) of Carlos III Health Institute, Bilbao, Spain
| | - Rafael González
- Pediatric Intensive Care Unit, Gregorio Marañón General University Hospital, Madrid, Spain
- School of Medicine Complutense University of Madrid, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Mother-Child Health and Development Network (RedSAMID) of Carlos III Health Institute, Bilbao, Spain
| | - María J. Solana
- Pediatric Intensive Care Unit, Gregorio Marañón General University Hospital, Madrid, Spain
- School of Medicine Complutense University of Madrid, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Mother-Child Health and Development Network (RedSAMID) of Carlos III Health Institute, Bilbao, Spain
| | - Javier Urbano
- Pediatric Intensive Care Unit, Gregorio Marañón General University Hospital, Madrid, Spain
- School of Medicine Complutense University of Madrid, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Mother-Child Health and Development Network (RedSAMID) of Carlos III Health Institute, Bilbao, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Unit, Gregorio Marañón General University Hospital, Madrid, Spain
- School of Medicine Complutense University of Madrid, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Mother-Child Health and Development Network (RedSAMID) of Carlos III Health Institute, Bilbao, Spain
- * E-mail: (JL); (JL-H)
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Stratil P, Holzer M. Is hypothermia indicated during cardiopulmonary resuscitation and after restoration of spontaneous circulation? Curr Opin Crit Care 2016; 22:212-7. [DOI: 10.1097/mcc.0000000000000299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kirkegaard H, Rasmussen BS, de Haas I, Nielsen JF, Ilkjær S, Kaltoft A, Jeppesen AN, Grejs A, Duez CHV, Larsen AI, Pettilä V, Toome V, Arus U, Taccone FS, Storm C, Skrifvars MB, Søreide E. Time-differentiated target temperature management after out-of-hospital cardiac arrest: a multicentre, randomised, parallel-group, assessor-blinded clinical trial (the TTH48 trial): study protocol for a randomised controlled trial. Trials 2016; 17:228. [PMID: 27142588 PMCID: PMC4855491 DOI: 10.1186/s13063-016-1338-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 04/06/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The application of therapeutic hypothermia (TH) for 12 to 24 hours following out-of-hospital cardiac arrest (OHCA) has been associated with decreased mortality and improved neurological function. However, the optimal duration of cooling is not known. We aimed to investigate whether targeted temperature management (TTM) at 33 ± 1 °C for 48 hours compared to 24 hours results in a better long-term neurological outcome. METHODS The TTH48 trial is an investigator-initiated pragmatic international trial in which patients resuscitated from OHCA are randomised to TTM at 33 ± 1 °C for either 24 or 48 hours. Inclusion criteria are: age older than 17 and below 80 years; presumed cardiac origin of arrest; and Glasgow Coma Score (GCS) <8, on admission. The primary outcome is neurological outcome at 6 months using the Cerebral Performance Category score (CPC) by an assessor blinded to treatment allocation and dichotomised to good (CPC 1-2) or poor (CPC 3-5) outcome. Secondary outcomes are: 6-month mortality, incidence of infection, bleeding and organ failure and CPC at hospital discharge, at day 28 and at day 90 following OHCA. Assuming that 50 % of the patients treated for 24 hours will have a poor outcome at 6 months, a study including 350 patients (175/arm) will have 80 % power (with a significance level of 5 %) to detect an absolute 15 % difference in primary outcome between treatment groups. A safety interim analysis was performed after the inclusion of 175 patients. DISCUSSION This is the first randomised trial to investigate the effect of the duration of TTM at 33 ± 1 °C in adult OHCA patients. We anticipate that the results of this trial will add significant knowledge regarding the management of cooling procedures in OHCA patients. TRIAL REGISTRATION NCT01689077.
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Affiliation(s)
- Hans Kirkegaard
- />Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Bodil S Rasmussen
- />Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Inge de Haas
- />Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Jørgen Feldbæk Nielsen
- />Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Hammel, Denmark
| | - Susanne Ilkjær
- />Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Kaltoft
- />Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anni Nørregaard Jeppesen
- />Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anders Grejs
- />Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Christophe Henri Valdemar Duez
- />Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Alf Inge Larsen
- />Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
- />Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Ville Pettilä
- />Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
- />Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Valdo Toome
- />Department of Anesthesiology, Intensive Care and Emergency Medicine, North Estonia Medical Centre, Tallinn, Estonia
| | - Urmet Arus
- />Department of Intensive Cardiac Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Fabio Silvio Taccone
- />Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Christian Storm
- />Department of Internal Medicine, Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus B. Skrifvars
- />Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Eldar Søreide
- />Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
- />Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Comparing the prognosis of those with initial shockable and non-shockable rhythms with increasing durations of CPR: Informing minimum durations of resuscitation. Resuscitation 2016; 101:50-6. [DOI: 10.1016/j.resuscitation.2016.01.021] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 12/21/2015] [Accepted: 01/21/2016] [Indexed: 12/23/2022]
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Wallmüller C, Testori C, Sterz F, Stratil P, Schober A, Herkner H, Hubner P, Weiser C, Stöckl M, Zeiner A, Losert H. Limited effect of mild therapeutic hypothermia on outcome after prolonged resuscitation. Resuscitation 2016; 98:15-9. [DOI: 10.1016/j.resuscitation.2015.09.400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 09/08/2015] [Accepted: 09/30/2015] [Indexed: 11/26/2022]
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Reynolds JC, Callaway CW. All [post-cardiac arrest patients] are [not] created equal. Resuscitation 2015; 96:A1-2. [PMID: 26277066 DOI: 10.1016/j.resuscitation.2015.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 07/22/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Joshua C Reynolds
- Department of Emergency Medicine, Michigan State University College of Human Medicine, United States
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, United States
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