A multiple logistic regression analysis of in-hospital factors related to survival at six months in patients resuscitated from out-of-hospital ventricular fibrillation

2024 RECOVER Guidelines: Monitoring. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR

OBJECTIVE

To systematically review evidence on and devise treatment recommendations for patient monitoring before, during, and following CPR in dogs and cats, and to identify critical knowledge gaps.

DESIGN

Standardized, systematic evaluation of literature pertinent to peri-CPR monitoring following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by Evidence Evaluators, and findings were reconciled by Monitoring Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk:benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization.

SETTING

Transdisciplinary, international collaboration in university, specialty, and emergency practice.

RESULTS

Thirteen questions pertaining to hemodynamic, respiratory, and metabolic monitoring practices for identification of cardiopulmonary arrest, quality of CPR, and postcardiac arrest care were examined, and 24 treatment recommendations were formulated. Of these, 5 recommendations pertained to aspects of end-tidal CO2 (ETco2) measurement. The recommendations were founded predominantly on very low quality of evidence, with some based on expert opinion.

CONCLUSIONS

The Monitoring Domain authors continue to support initiation of chest compressions without pulse palpation. We recommend multimodal monitoring of patients at risk of cardiopulmonary arrest, at risk of re-arrest, or under general anesthesia. This report highlights the utility of ETco2 monitoring to verify correct intubation, identify return of spontaneous circulation, evaluate quality of CPR, and guide basic life support measures. Treatment recommendations further suggest intra-arrest evaluation of electrolytes (ie, potassium and calcium), as these may inform outcome-relevant interventions.

Association between the red cell distribution width and mortality in elderly patients with non-traumatic coma: An observational cohort study

Elevated red blood cell distribution width (RDW) can be associated with disease severity. However, studies on RDW for the prognosis of elderly patients with non-traumatic coma (NTC) are lacking. This study aims to examine the relationship between RDW and outcomes in elderly patients with NTC. This observational cohort study included elderly patients (aged ≥ 65 years) with NTC between January 2022 and December 2022. We measured RDW upon patient arrival at the emergency department (ED). We conducted a multivariable analysis using logistic regression of relevant covariates to predict in-hospital mortality. Survival curves based on 30-day mortality were designed using the Kaplan-Meier method. The primary outcome was in-hospital mortality, and the secondary outcome was 30-day mortality. A total of 689 patients were included in the study, and in-hospital mortality was 29.6% (n = 204). Our results found that the RDWs of non-survivors were significantly greater than those of survivors (14.6% vs 13.6%). Multivariable analysis showed that RDWs at ED arrival were independently associated with in-hospital mortality (odds ratio, 1.126; 95% confidence interval, 1.047-1.212; P < .001). The Kaplan-Meier curve indicated that the survival probability of patients with a low RDW was greater than those with a high RDW. Having a high RDW at ED arrival was associated with in-hospital mortality in elderly patients with NTC.

Post-Cardiac Arrest Care

A structured approach to postcardiac arrest care is needed. Although immediate goals include obtaining a blood pressure reading and ECG immediately after return of spontaneous circulation, other more advanced goals include minimizing CNS injury, managing cardiovascular dysfunction, reducing systemic ischemic/reperfusion injury, and identifying and treating the underlying cause to the arrest. This article summarizes the current understanding of the hemodynamic, neurologic, and metabolic abnormalities encountered in postarrest patients.

General Critical Care, Temperature Control, and End-of-Life Decision Making in Patients Resuscitated from Cardiac Arrest

Cardiac arrest affects millions of people per year worldwide. Although advances in cardiopulmonary resuscitation and intensive care have improved outcomes over time, neurologic impairment and multiple organ dysfunction continue to be associated with a high mortality rate. The pathophysiologic mechanisms underlying the post-resuscitation disease are complex, and a coordinated, evidence-based approach to post-resuscitation care has significant potential to improve survival. Critical care management of patients resuscitated from cardiac arrest focuses on the identification and treatment of the underlying cause(s), hemodynamic and respiratory support, organ protection, and active temperature control. This review provides a state-of-the-art appraisal of critical care management of the post-cardiac arrest patient.

Developments in Post-Resuscitation Care for Out-of-Hospital Cardiac Arrests in Adults-A Narrative Review

This review focuses on current developments in post-resuscitation care for adults with an out-of-hospital cardiac arrest (OHCA). As the incidence of OHCA is high and with a low percentage of survival, it remains a challenge to treat those who survive the initial phase and regain spontaneous circulation. Early titration of oxygen in the out-of-hospital phase is not associated with increased survival and should be avoided. Once the patient is admitted, the oxygen fraction can be reduced. To maintain an adequate blood pressure and urine output, noradrenaline is the preferred agent over adrenaline. A higher blood pressure target is not associated with higher rates of good neurological survival. Early neuro-prognostication remains a challenge, and prognostication bundles should be used. Established bundles could be extended by novel biomarkers and methods in the upcoming years. Whole blood transcriptome analysis has shown to reliably predict neurological survival in two feasibility studies. This needs further investigation in larger cohorts.

Association between insulin administration method and six-month neurological outcome in survivors of out-of-hospital cardiac arrest who underwent targeted temperature management

We investigated the association of insulin administration method with the achievement of mean glucose ≤ 180 mg/dL and neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors who had hyperglycemia after the return of spontaneous circulation. From a multicenter prospective registry, we extracted the data of adult OHCA survivors who underwent targeted temperature management (TTM) between 2015 and 2018. Blood glucose levels every 4 h after initiating TTM were obtained for 72 h. We divided insulin administration methods into three categories: subcutaneous (SQI), intravenous bolus (IBI), and continuous intravenous (CII). We calculated the mean glucose and standard deviation (SD) of glucose. The primary outcome was the achievement of mean glucose ≤ 180 mg/dL. The secondary outcomes were the 6-month neurological outcome based on the Cerebral Performance Category (CPC) scale (good, CPC 1-2; poor, CPC 3-5), mean glucose, and SD of glucose. Of the 549 patients, 296 (53.9%) achieved mean glucose ≤ 180 mg/dL, and 438 (79.8%) had poor neurological outcomes, 134 (24.4%), 132 (24.0), and 283 (51.5%) were in the SQI, IBI, and CII groups, respectively. The SQI (adjusted odds ratio [aOR], 0.848; 95% confidence intervals [CIs], 0.493-1.461) and IBI (aOR, 0.673; 95% CIs, 0.415-1.091) groups were not associated with mean glucose ≤ 180 mg/dL and the SQI (aOR, 0.660; 95% CIs, 0.335-1.301) and IBI (aOR, 1.757; 95% CIs, 0.867-3.560) groups were not associated with poor neurological outcomes compared to the CII group. The CII (168 mg/dL [147-202]) group had the lowest mean glucose than the SQI (181 mg/dL [156-218]) and IBI (184 mg/dL [162-216]) groups. The CII (45.0[33.9-63.5]) group had a lower SD of glucose than the IBI (50.8 [39.1-72.0]) group. The insulin administration method was not associated with achieving mean glucose ≤ 180 mg/dL and 6-month neurological outcomes.

Ion Shift Index at the Immediate Post-Cardiac Arrest Period as an Early Prognostic Marker in Out-of-Hospital Cardiac Arrest Survivors

The ion shift index (ISI) is a suggested marker to reflect the magnitude of ischemic damage. This study aimed to investigate the prognostic value of the ISI for predicting poor neurological outcomes at 6 months in comatose out-of-hospital cardiac arrest (OHCA) survivors by comparing it with the OHCA and Cardiac Arrest Hospital Prognosis (CAHP) scores. This observational registry-based cohort study included adult comatose OHCA survivors admitted to a tertiary care hospital in Korea between 2015 and 2021. The ISI was calculated using the serum electrolyte levels obtained within one hour of resuscitation. The primary outcome was poor neurological function (Cerebral Performance Category score of 3−5) at 6 months. Of the 250 OHCA survivors, 164 (65.6%) had poor neurological outcomes. These patients had a higher median ISI than those with good neurological outcomes (4.95 vs. 3.26, p < 0.001). ISI (adjusted odds ratio, 2.107; 95% confidence interval, 1.350−3.288, p = 0.001) was associated with poor neurological outcomes. The prognostic performance of ISI (area under the curve [AUC], 0.859) was similar to that of the OHCA score (AUC, 0.858; p = 0.968) and the CAHP score (AUC, 0.894; p = 0.183). ISI would be a prognostic biomarker for comatose OHCA survivors that is available during the immediate post-cardiac arrest period.

Beta-Adrenergic Blockade in Critical Illness

Catecholamine upregulation is a core pathophysiological feature in critical illness. Sustained catecholamine β-adrenergic induction produces adverse effects relevant to critical illness management. β-blockers (βB) have proposed roles in various critically ill disease states, including sepsis, trauma, burns, and cardiac arrest. Mounting evidence suggests βB improve hemodynamic and metabolic parameters culminating in decreased burn healing time, reduced mortality in traumatic brain injury, and improved neurologic outcomes following cardiac arrest. In sepsis, βB appear hemodynamically benign after acute resuscitation and may augment cardiac function. The emergence of ultra-rapid βB provides new territory for βB, and early data suggest significant improvements in mitigating atrial fibrillation in persistently tachycardic septic patients. This review summarizes the evidence regarding the pharmacotherapeutic role of βB on relevant pathophysiology and clinical outcomes in various types of critical illness.

Association between ion shift index and prognosis in severe trauma patients without isolated head injury

INTRODUCTION

This study aimed to investigate the ion shift index (ISI) as a prognostic factor of severe trauma. We hypothesized that the initial ISI measured in the emergency department (ED) is associated with discharge survival in severe non-isolated head injury (IHI) patients.

MATERIALS AND METHODS

This retrospective observational study included severe trauma patients with available medical records from January 2017 to December 2018 but excluded those with IHI. Logistic regression analysis was conducted to identify the risk factors for mortality in non-IHI patients, and adjustments were performed for relevant covariates. An area under the receiver operating characteristics curve (AUROC) analysis was performed to examine the primary outcome of our study, which was mortality at hospital discharge in severe non-IHI trauma patients.

RESULTS

Of the 483 severe non-IHI trauma patients included in the study, 86 patients (17.8 %) died. The multiple logistic regression analysis demonstrated ISI (odds ratio [OR], 2.300; 95% CI, 1.183-4.470) was significantly associated with mortality in the non-IHI group. Additionally, trauma and injury severity score (TRISS; OR, 0.538; 95% CI, 0.447-0.649), lactate (OR, 1.410; 95% CI, 1.252-1.588), creatinine (OR, 1.554; 95% CI, 1.221-1.979), and activated partial thromboplastin time (aPTT; OR, 1.050; 95% CI, 1.021-1.080) were independently associated with mortality at hospital discharge. The AUROC values for TRISS, lactate, aPTT, creatinine, and ISI were as follows: 0.892 (95% CI, 0.861-0.918), 0.838 (95% CI, 0.803-0.870), 0.754 (95% CI, 0.712-0.792), 0.650 (95% CI, 0.606-0.693), and 0.848 (95% CI, 0.813-0.879), respectively. The AUROC for the multiple logistic regression model with ISI was 0.942 (95% CI, 0.917-0.962). In a model in which TRISS was omitted, the addition of ISI to other predictors significantly improved the AUROC to 0.900 (95% CI, 0.869-0.925) (p=0.039).

CONCLUSION

The initial ISI in the ED after trauma was associated with mortality in severe non-IHI trauma patients. In conjunction with other prognostic indicators, it could be used as an early prognostic marker, particularly if TRISS is unavailable.

European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.

European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.

Major publications in the critical care pharmacotherapy literature: 2019

PURPOSE

To summarize selected meta-analyses and trials related to critical care pharmacotherapy published in 2019.

MATERIALS AND METHODS

The Critical Care Pharmacotherapy Literature Update (CCPLU) Group screened 36 journals monthly for impactful articles and reviewed 113 articles during 2019 according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria.

RESULTS

Articles with a 1A grade, including three clinical practice guidelines, six meta-analyses, and five original research trials are reviewed here from those included in the monthly CCPLU. Clinical practice guidelines on the use of polymyxins and antiarrhythmic drugs in cardiac arrest as well as meta-analyses on antipsychotic use in delirium, stress ulcer prophylaxis (SUP), and vasoactive medications in septic shock and cardiac arrest were summarized. Original research trials evaluated delirium, sedation, neuromuscular blockade, SUP, anticoagulation reversal, and hemostasis.

CONCLUSION

This clinical review and expert opinion provides summary and perspectives of clinical practice impact on influential critical care pharmacotherapy publications in 2019.

Proportion of time spent in blood glucose range 70 to 140 mg/dL is associated with increased survival in patients admitted to ICU after cardiac arrest: A multicenter observational study

The benefit of any specific target range of blood glucose (BG) for post-cardiac arrest (PCA) care remains unknown.We conducted a multicenter retrospective study of prospectively collected data of all cardiac arrest patients admitted to the ICUs between 2014 and 2015. The main exposure was BG metrics during the first 24 hours, including time-weighted mean (TWM) BG, mean BG, admission BG and proportion of time spent in 4 BG ranges (<= 70 mg/dL, 70-140 mg/dL, 140-180 mg/dL and > 180 mg/dL). The primary outcome was hospital mortality. Multivariable logistic regression, Cox proportion hazard models and generalized estimating equation (GEE) models were built to evaluate the association between the different kinds of BG and hospital mortality.2,028 PCA patients from 144 ICUs were included. 14,118 BG measurements during the first 24 hours were extracted. According to TWM-BG, 9 (0%) were classified into the <= 70 mg/dL range, 693 (34%) into the 70 to 140 mg/dL range, 603 (30%) into the 140 to 180 mg/dL range, and 723 (36%) into the > 180 mg/dL range. Compared with BG 70 to 140 mg/dL range, BG 140 to 180 mg/dL range and > 180 mg/dL range were associated with higher hospital mortality probability. Proportion of time spent in the 70 to 140 mg/dL range was associated with good outcome (odds ratio 0.984, CI [0.970, 0.998], P = .022, for per 5% increase in time), and > 180 mg/dL range with poor outcome (odds ratio 1.019, CI [1.009, 1.028], P< .001, for per 5% increase in time). Results of the 3 kinds of statistical models were consistent.The proportion of time spent in BG range 70 to 140 mg/dL is strongly associated with increased hospital survival in PCA patients. Hyperglycemia (> 180 mg/dL) is common in PCA patients and is associated with increased hospital mortality.

Postresuscitation Care after Out-of-hospital Cardiac Arrest: Clinical Update and Focus on Targeted Temperature Management

Out-of-hospital cardiac arrest is a major cause of mortality and morbidity worldwide. With the introduction of targeted temperature management more than a decade ago, postresuscitation care has attracted increased attention. In the present review, we discuss best practice hospital management of unconscious out-of-hospital cardiac arrest patients with a special focus on targeted temperature management. What is termed post-cardiac arrest syndrome strikes all organs and mandates access to specialized intensive care. All patients need a secured airway, and most patients need hemodynamic support with fluids and/or vasopressors. Furthermore, immediate coronary angiography and percutaneous coronary intervention, when indicated, has become an essential part of the postresuscitation treatment. Targeted temperature management with controlled sedation and mechanical ventilation is the most important neuroprotective strategy to take. Targeted temperature management should be initiated as quickly as possible, and according to international guidelines, it should be maintained at 32° to 36°C for at least 24 h, whereas rewarming should not increase more than 0.5°C per hour. However, uncertainty remains regarding targeted temperature management components, warranting further research into the optimal cooling rate, target temperature, duration of cooling, and the rewarming rate. Moreover, targeted temperature management is linked to some adverse effects. The risk of infection and bleeding is moderately increased, as is the risk of hypokalemia and magnesemia. Circulation needs to be monitored invasively and any deviances corrected in a timely fashion. Outcome prediction in the individual patient is challenging, and a self-fulfilling prophecy poses a real threat to early prognostication based on clinical assessment alone. Therefore, delayed and multimodal prognostication is now considered a key element of postresuscitation care. Finally, modern postresuscitation care can produce good outcomes in the majority of patients but requires major diagnostic and therapeutic resources and specific training. Hence, recent international guidelines strongly recommend the implementation of regional prehospital resuscitation systems with integrated and specialized cardiac arrest centers.

2018 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the second annual summary of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations that includes the most recent cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation. This summary addresses the role of antiarrhythmic drugs in adults and children and includes the Advanced Life Support Task Force and Pediatric Task Force consensus statements, which summarize the most recent published evidence and an assessment of the quality of the evidence based on Grading of Recommendations, Assessment, Development, and Evaluation criteria. The statements include consensus treatment recommendations approved by members of the relevant task forces. Insights into the deliberations of each task force are provided in the Values and Preferences and Task Force Insights sections. Finally, the task force members have listed the top knowledge gaps for further research.

2018 American Heart Association Focused Update on Advanced Cardiovascular Life Support Use of Antiarrhythmic Drugs During and Immediately After Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Antiarrhythmic medications are commonly administered during and immediately after a ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. However, it is unclear whether these medications improve patient outcomes. This 2018 American Heart Association focused update on advanced cardiovascular life support guidelines summarizes the most recent published evidence for and recommendations on the use of antiarrhythmic drugs during and immediately after shock-refractory ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. This article includes the revised recommendation that providers may consider either amiodarone or lidocaine to treat shock-refractory ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest.

Association between Achievement of Estimated Average Glucose Level and 6-Month Neurologic Outcome in Comatose Cardiac Arrest Survivors: A Propensity Score-Matched Analysis

We investigated whether achieving estimated average glucose (EAG) levels versus achieving standard glucose levels (180 mg/dL) was associated with neurologic outcome in cardiac arrest survivors. This single-center retrospective observational study included adult comatose cardiac arrest survivors undergoing therapeutic hypothermia (TH) from September 2011 to December 2017. EAG level was calculated using HbA1c obtained after the return of spontaneous circulation (ROSC), and the mean glucose level during TH was calculated. We designated patients to the EAG or standard glucose group according to whether the mean blood glucose level was closer to the EAG level or 180 mg/dL. Patients in the EAG and standard groups were propensity score- matched. The primary outcome was the 6-month neurologic outcome. The secondary outcomes were hypoglycemia (≤70 mg/dL) and serum neuron-specific enolase (NSE) at 48 h after ROSC. Of 384 included patients, 137 (35.7%) had a favorable neurologic outcome. The EAG group had a higher favorable neurologic outcome (104/248 versus 33/136), higher incidence of hypoglycemia (46/248 versus 11/136), and lower NSE level. After propensity score matching, both groups had similar favorable neurologic outcomes (24/93 versus 27/93) and NSE levels; the EAG group had a higher incidence of hypoglycemia (21/93 versus 6/93). Achieving EAG levels was associated with hypoglycemia but not neurologic outcome or serum NSE level.

Serum potassium level on hospital arrival and survival after out-of-hospital cardiac arrest: The CRITICAL study in Osaka, Japan

BACKGROUND

Little is known about the association between serum potassium level on hospital arrival and neurological outcome after out-of-hospital cardiac arrest (OHCA). We investigated whether the serum potassium level on hospital arrival had prognostic indications for patients with OHCA.

METHODS

This prospective, multicenter observational study conducted in Osaka, Japan (CRITICAL study) enrolled consecutive patients with OHCA transported to 14 participating institutions from 2012 to 2016. We included adult patients aged ⩾18 years with OHCA of cardiac origin who achieved return of spontaneous circulation and whose serum potassium level on hospital arrival was available. Based on the serum potassium level, patients were divided into four quartiles: Q1 (K ⩽3.8 mEq/L), Q2 (3.8< K⩽4.5 mEq/L), Q3 (4.5< K⩽5.6 mEq/L) and Q4 (K >5.6 mEq/L). The primary outcome was one-month survival with favorable neurological outcome, defined as cerebral performance category scale 1 or 2.

RESULTS

A total of 9822 patients were registered, and 1516 of these were eligible for analyses. The highest proportion of favorable neurological outcome was 44.8% (189/422) in Q1 group, followed by 30.3% (103/340), 11.7% (44/375) and 4.5% (17/379) in the Q2, Q3 and Q4 groups, respectively (p<0.001). In the multivariable analysis, the proportion of favorable neurological outcome decreased as the serum potassium level increased (p<0.001).

CONCLUSIONS

High serum potassium level was significantly and dose-dependently associated with poor neurological outcome. Serum potassium on hospital arrival would be one of the effective prognostic indications for OHCA achieving return of spontaneous circulation.

Prophylactic antibiotic use following cardiac arrest: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of prophylactic/ early antibiotics (intervention group) compared with clinically driven/ delayed antibiotics (control group) on patient and infectious outcomes in adult cardiac arrest patients admitted to hospital.

DATA SOURCES

We searched MEDLINE (1946-current), EMBASE (1947-current) and the Cochrane library (inception-current) on 8th May 2018. Additional citations were identified through forward and backward citation tracking.

STUDY SELECTION

Two reviewers independently screened titles, abstracts, and full-texts. We included observational and interventional primary research studies with a concurrent or retrospective control group that were relevant to our study objective.

DATA EXTRACTION

We extracted data using a piloted data extraction form. Risk of bias was assessed using the Cochrane tool for randomised controlled trials or the GRADE tool for risk of bias in observational studies. Overall evidence quality for each outcome was assessed using the GRADE system.

DATA SYNTHESIS

Databases searches and citation tracking identified 6825 citations, of which ten citations containing 11 studies (3 randomised controlled trials, 8 observational studies) were eligible for inclusion. Data were summarised in meta-analyses using random-effect models. The intervention was not associated with increased survival (odds ratio 1.16, 95% CI 0.97-1.40), survival with good neurological outcome (odds ratio 2.25, 95% CI 0.93-5.45), critical care length of stay (mean difference -0.6, 95% CI -3.6 to 2.4) or incidence of pneumonia (odds ratio 0.58, 95% CI 0.23-1.46). Findings were generally consistent between observational studies and randomised controlled trials.

CONCLUSIONS

Antibiotic prophylaxis following cardiac arrest is not associated with a change in key clinical outcomes. Further high-quality trials may be needed to address this important clinical question. Review registration: PROSPERO CRD42016039358.

Mechanical Cardiopulmonary Resuscitation and Hospital Survival Among Adult Patients With Nontraumatic Out-of-Hospital Cardiac Arrest Attending the Emergency Department: A Prospective, Multicenter, Observational Study in Japan (SOS-KANTO [Survey of Survivors after Out-of-Hospital Cardiac Arrest in Kanto Area] 2012 Study)

Background

Mechanical cardiopulmonary resuscitation (mCPR) for patients with out‐of‐hospital cardiac arrest attending the emergency department has become more widespread in Japan. The objective of this study is to determine the association between the mCPR in the emergency department and clinical outcomes.

Methods and Results

In a prospective, multicenter, observational study, adult patients with out‐of‐hospital cardiac arrest with sustained circulatory arrest on hospital arrival were identified. The primary outcome was survival to hospital discharge. The secondary outcomes included a return of spontaneous circulation and successful hospital admission. Multivariate analyses adjusted for potential confounders and within‐institution clustering effects using a generalized estimation equation were used to analyze the association of the mCPR with outcomes. Between January 1, 2012 and March 31, 2013, 6537 patients with out‐of‐hospital cardiac arrest were eligible; this included 5619 patients (86.0%) in the manual CPR group and 918 patients (14.0%) in the mCPR group. Of those patients, 28.1% (1801/6419) showed return of spontaneous circulation in the emergency department, 20.4% (1175/5754) had hospital admission, 2.6% (168/6504) survived to hospital discharge, and 1.2% (75/6419) showed a favorable neurological outcome at 1 month after admission. Multivariate analyses revealed that mCPR was associated with a decreased likelihood of survival to hospital discharge (adjusted odds ratio, 0.40; 95% confidence interval, 0.20–0.78; P=0.005), return of spontaneous circulation (adjusted odds ratio, 0.71; 95% confidence interval, 0.53–0.94; P=0.018), and hospital admission (adjusted odds ratio, 0.57; 95% confidence interval, 0.40–0.80; P=0.001).

Conclusions

After accounting for potential confounders, the mCPR in the emergency department was associated with decreased likelihoods of good clinical outcomes after adult nontraumatic out‐of‐hospital cardiac arrest. Further studies are needed to clarify circumstances in which mCPR may benefit these patients.

Does Antiarrhythmic Drug During Cardiopulmonary Resuscitation Improve the One-month Survival: The SOS-KANTO 2012 Study

BACKGROUND

Antiarrhythmic drugs (AAD) are often used for fatal ventricular arrhythmias during cardiopulmonary resuscitation (CPR). However, the efficacy of initial AAD administration during CPR in improving long-term prognosis remains unknown. This study retrospectively evaluated the effect of AAD administration during CPR on 1-month prognosis in the SOS-KANTO 2012 study population.

METHODS AND RESULTS

Of the 16,164 out-of-hospital cardiac arrest cases, 1350 shock-refractory patients were included: 747 patients not administered AAD and 603 patients administered AAD. Statistical adjustment for potential selection bias was performed using propensity score matching, yielding 1162 patients of whom 792 patients were matched (396 pairs). The primary outcome was 1-month survival. The secondary outcome was the proportion of patients with favorable neurological outcome at 1 month. Logistic regression with propensity scoring demonstrated an odds ratio (OR) for 1-month survival in the AAD group of 1.92 (P < 0.01), whereas the OR for favorable neurological outcome at 1 month was 1.44 (P = 0.26).

CONCLUSIONS

Significantly greater 1-month survival was observed in the AAD group compared with the non-AAD group. However, the effect of ADD on the likelihood of a favorable neurological outcome remains unclear. The findings of the present study may indicate a requirement for future randomized controlled trials evaluating the effect of ADD administration during CPR on long-term prognosis.

Critical Care Management Focused on Optimizing Brain Function After Cardiac Arrest

The discussion of neurocritical care management in post-cardiac arrest syndrome (PCAS) has generally focused on target values used for targeted temperature management (TTM). There has been less attention paid to target values for systemic and cerebral parameters to minimize secondary brain damage in PCAS. And the neurologic indications for TTM to produce a favorable neurologic outcome remain to be determined. Critical care management of PCAS patients is fundamental and essential for both cardiologists and general intensivists to improve neurologic outcome, because definitive therapy of PCAS includes both special management of the cause of cardiac arrest, such as coronary intervention to ischemic heart disease, and intensive management of the results of cardiac arrest, such as ventilation strategies to avoid brain ischemia. We reviewed the literature and the latest research about the following issues and propose practical care recommendations. Issues are (1) prediction of TTM candidate on admission, (2) cerebral blood flow and metabolism and target value of them, (3) seizure management using continuous electroencephalography, (4) target value of hemodynamic stabilization and its method, (5) management and analysis of respiration, (6) sedation and its monitoring, (7) shivering control and its monitoring, and (8) glucose management. We hope to establish standards of neurocritical care to optimize brain function and produce a favorable neurologic outcome.

Hyperglycaemia in comatose survivors of out-of-hospital cardiac arrest

BACKGROUND

The optimal blood glucose target during the early hospitalisation of comatose survivors of out-of-hospital cardiac arrest (OHCA) has not been established.

METHODS

In a retrospective cohort study, we examined clinical outcomes in relation to mean blood glucose during the first 96 hours of hospital admission in comatose survivors of OHCA with an initial shockable rhythm. Mean blood glucose was assessed as a continuous (primary analysis) and categorical variable: <6 mmol/L, 6 to <8 mmol/L and ⩾8 mmol/L. Co-primary outcomes were the rates of death during the index hospitalisation and severe neurological dysfunction at discharge. We used multivariable logistic regression analyses to adjust for baseline differences in patient and index event characteristics.

RESULTS

Among 122 eligible patients, death and severe neurological dysfunction occurred in 29 (24%) and 40 (33%) patients, respectively. Higher mean blood glucose levels during the first 96 hours of admission were associated with increased odds of death (odds ratio (OR): 1.50; 95% confidence interval (CI): 1.17-1.92; p = 0.001) and severe neurological dysfunction (OR: 1.42; 95% CI: 1.11-1.80; p = 0.004). The associations between mean blood glucose and the odds of death (OR: 1.35; 95% CI: 1.04-1.76; p = 0.02) and severe neurological dysfunction (OR: 1.28; 95% CI: 1.00-1.64; p = 0.05) persisted after adjusting for age, time from cardiac arrest to return of spontaneous circulation (ROSC) and vasoactive agent use. There was no interaction between age, time from cardiac arrest to ROSC or a history of diabetes mellitus and the relationship between mean blood glucose and co-primary outcomes.

CONCLUSIONS

In comatose survivors of OHCA with initial shockable rhythms, higher mean blood glucose levels during the first 96 hours of admission are associated with increased rates of death and severe neurological dysfunction.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Therapeutic hypothermia in the intensive cardiac care unit

Therapeutic hypothermia has demonstrated to improve both survival and neurological outcome in patients who experienced an out-of-hospital cardiac arrest. Nevertheless, many aspects of its clinical application are still controversial. Current guidelines recommend to cool patients who survive a cardiac arrest due to either ventricular fibrillation or ventricular tachycardia, whereas the beneficial effect of lowering body temperature in nonshockable rhythms is still questionable due to the lack of randomized controlled trial involving this subgroup of patients. Although therapeutic hypothermia is often begun before hospital arrival, the optimal time to start cooling is still a matter of debate. Furthermore, different methods are available to low body temperature, but no direct comparisons are available to establish which device performs better than others, and a combination of external and endovascular cooling is usually preferred. The present review is aimed at summarizing the available evidence supporting the use in clinical practice of mild hypothermia in comatose survivors from cardiac arrest and at evaluating its adverse events and their treatment.

The administration of dextrose during in-hospital cardiac arrest is associated with increased mortality and neurologic morbidity

INTRODUCTION

Dextrose may be used during cardiac arrest resuscitation to prevent or reverse hypoglycemia. However, the incidence of dextrose administration during cardiac arrest and the association of dextrose administration with survival and other outcomes are unknown.

METHODS

We used the Get With The Guidelines®-Resuscitation national registry to identify adult patients with an in-hospital cardiac arrest between the years 2000 and 2010. To assess the adjusted effects of dextrose administration on survival, we used multivariable regression models with adjustment for multiple patient, event, and hospital characteristics. We performed additional analyses to examine the effects of dextrose on neurological outcome and return of spontaneous circulation.

RESULTS

Among the 100,029 patients included in our study, 4,189 (4.2%) received dextrose during cardiac arrest resuscitation. The rate of dextrose administration increased during the study period (odds ratio 1.11, 95% confidence interval (CI) 1.09-1.12 per year, P <0.001). Patients who received dextrose during resuscitation had lower rates of survival compared with patients who did not receive dextrose (relative risk 0.88, 95% CI 0.80-0.98, P = 0.02). Administration of dextrose was associated with worse neurological outcome (relative risk 0.88, 95% CI 0.79-0.99, P = 0.03) but an increased chance of return of spontaneous circulation (relative risk 1.07, 95% CI 1.04-1.10, P <0.001).

CONCLUSIONS

In this dataset, the administration of dextrose during resuscitation in patients with in-hospital cardiac arrest was found to be associated with a significantly decreased chance of survival and a decreased chance of good neurological outcome.

SOPs and the right hospitals to improve outcome after cardiac arrest

Approximately 400,000 Europeans are yearly resuscitated from out-of-hospital cardiac arrest (OHCA).(1,2) Despite evolving evidence based guidelines for cardiopulmonary resuscitation (CPR), survival rates after OHCA has not improved much in several places around the world. However, a potential for improved survival is absolutely present, based on the huge spread in worldwide survival; some cities with survival over 20-30% and some cities with just a few percent.(1,2) These survival differences can partly be explained by different definitions of OHCA,(2) but mainly due to the overall quality of the local Chain of Survival (COS)(3); early arrest recognition and call for help, early CPR, early defibrillation and early post resuscitation care. By identifying and thereafter improving weak links in the local COS, survival can indeed increase. This review will focus on the quality of the last link in the COS, the hospital treatment after return of spontaneuous circulation (ROSC), and how good quality post resuscitation care can improve not only survival, but survival with neurologically intact outcome.

Blood glucose level and outcome after cardiac arrest: insights from a large registry in the hypothermia era

INTRODUCTION

The influence of blood glucose (BG) level during the post-resuscitation period after out-of-hospital cardiac arrest (OHCA) is still debated. To evaluate the relationship between blood glucose level and outcome, we included the median glycemia and its maximal amplitude over the first 48 h following ICU admission in an analysis of outcome predictors.

METHODS

We conducted a database study in a cardiac arrest center in Paris, France. Between 2006 and 2010, we included 381 patients who were all resuscitated from an OHCA. A moderate glycemic control was applied in all patients. The median glycemia and the largest change over the first 48 h were included in a multivariate analysis that was performed to determine parameters associated with a favorable outcome.

RESULTS

Of the 381 patients, 136 (36 %) had a favorable outcome (CPC 1-2). Median BG level was 7.6 mmol/L (6.3-9.8) in patients with a favorable outcome compared to 9.0 mmol/L (IQR 7.1-10.6) for patients with an unfavorable outcome (p < 0.01). Median BG level variation was 7.1 (4.2-11) and 9.6 (5.9-13.6) mmol/L in patients with and without a favorable outcome, respectively (p < 0.01). In multivariate analysis, an increased median BG level over the first 48 h was found to be an independent predictor of poor issue [OR = 0.43; 95 % CI (0.24-0.78), p = 0.006]. Finally a progressive increase in median BG level was associated with a progressive increase in the proportion of patients with a poor outcome.

CONCLUSION

We observed a relationship between high blood glucose level and outcome after cardiac arrest. These results suggest the need to test a strategy combining both control of glycemia and minimization of glycemic variations for its ability to improve post-resuscitation care.

The association between systolic blood pressure on arrival at hospital and outcome in adults surviving from out-of-hospital cardiac arrests of presumed cardiac aetiology

BACKGROUND

The optimal blood pressure target following successful resuscitation from out-of-hospital cardiac arrest (OHCA) is uncertain. This study aimed to explore the association between level of systolic blood pressure (SBP) on arrival at hospital and survival to hospital discharge.

METHODS

We analysed eligible OHCAs occurring between January 2003 and December 2011 from the Victorian Ambulance Cardiac Arrest Register (VACAR). Inclusion criteria were: adults (≥18 years), presumed cardiac aetiology, not paramedic witnessed, and ROSC at hospital arrival. Multivariate logistic regression models were performed by initial rhythm (shockable/non-shockable) to examine the relationship between SBP at hospital arrival in 10 mmHg increments and survival to hospital discharge. Models were adjusted for known predictors of survival, including duration of arrest.

RESULTS

Of 3620 eligible cases, 14% were hypotensive (SBP<90 mmHg) on hospital arrival (10% shockable and 19% non-shockable). For patients in shockable rhythms, discharge survival was maximal at 120-129 mmHg (54%), and in the adjusted model (≥120 mmHg as reference) SBP decrements below 90 mmHg were associated with lower survival: 80-89 mmHg AOR=0.49 (95% CI: 0.24-0.95); <80 mmHg AOR=0.24 (95% CI: 0.10-0.61); unrecordable AOR=0.10 (95% CI: 0.04-0.30). In patients found in non-shockable rhythms, SBP was not significant associated with discharge survival (AOR=1.01, 95% CI: 0.89-1.15).

CONCLUSIONS

In an EMS system using intravenous adrenaline and fluids to maintain post-resuscitation SBP at 120 mmHg, hypotension on hospital arrival was relatively uncommon. However, in presumed cardiac OHCA patients with an initial shockable rhythm, SBPs below 90 mmHg was associated with significant lower odds of survival to hospital discharge. This level of hypotension may indicate patients who require more aggressive post-resuscitation blood pressure management.

Decision-tree model for predicting outcomes after out-of-hospital cardiac arrest in the emergency department

Introduction

Estimation of outcomes in patients after out-of-hospital cardiac arrest (OHCA) soon after arrival at the hospital may help clinicians guide in-hospital strategies, particularly in the emergency department. This study aimed to develop a simple and generally applicable bedside model for predicting outcomes after cardiac arrest.

Methods

We analyzed data for 390,226 adult patients who had undergone OHCA, from a prospectively recorded nationwide Utstein-style Japanese database for 2005 through 2009. The primary end point was survival with favorable neurologic outcome (cerebral performance category (CPC) scale, categories 1 to 2 [CPC 1 to 2]) at 1 month. The secondary end point was survival at 1 month. We developed a decision-tree prediction model by using data from a 4-year period (2005 through 2008, n = 307,896), with validation by using external data from 2009 (n = 82,330).

Results

Recursive partitioning analysis of the development cohort for 10 predictors indicated that the best single predictor for survival and CPC 1 to 2 was shockable initial rhythm. The next predictors for patients with shockable initial rhythm were age (<70 years) followed by witnessed arrest and age (>70 years) followed by arrest witnessed by emergency medical services (EMS) personnel. For patients with unshockable initial rhythm, the next best predictor was witnessed arrest. A simple decision-tree prediction mode permitted stratification into four prediction groups: good, moderately good, poor, and absolutely poor. This model identified patient groups with a range from 1.2% to 30.2% for survival and from 0.3% to 23.2% for CPC 1 to 2 probabilities. Similar results were observed when this model was applied to the validation cohort.

Conclusions

On the basis of a decision-tree prediction model using four prehospital variables (shockable initial rhythm, age, witnessed arrest, and witnessed by EMS personnel), OHCA patients can be readily stratified into the four groups (good, moderately good, poor, and absolutely poor) that help predict both survival at 1 month and survival with favorable neurologic outcome at 1 month. This simple prediction model may provide clinicians with a practical bedside tool for the OHCA patient's stratification in the emergency department.

Out-of-hospital cardiac arrest: 10 years of progress in research and treatment

Cardiac disease is the most common cause of mortality in Western countries, with most deaths due to out-of-hospital cardiac arrest (OHCA). In Sweden, 5000-10 000 OHCAs occur annually. During the last decade, the time from cardiac arrest to start of cardiopulmonary resuscitation (CPR) and defibrillation has increased, whereas survival has remained unchanged or even increased. Resuscitation of OHCA patients is based on the 'chain-of-survival' concept, including early (i) access, (ii) CPR, (iii) defibrillation, (iv) advanced cardiac life support and (v) post-resuscitation care. Regarding early access, agonal breathing, telephone-guided CPR and the use of 'track and trigger systems' to detect deterioration in patients' condition prior to an arrest are all important. The use of compression-only CPR by bystanders as an alternative to standard CPR in OHCA has been debated. Based on recent findings, guidelines recommend telephone-guided chest compression-only CPR for untrained rescuers, but trained personnel are still advised to give standard CPR with both compressions and ventilation, and the method of choice for this large group remains unclear and demands for a randomized study. Data have shown the benefit of public access defibrillation for dispatched rescuers (e.g. police and fire fighters) but data are not as strong for the use of automated defibrillators (AEDs) by trained or untrained rescuers. Postresuscitation, use of therapeutic hypothermia, the importance of specific prognostic survival factors in the intensive care unit and the widespread use of percutaneous coronary intervention have all been considered. Despite progress in research and improved treatment regimens, most patients do not survive OHCA. Particular areas of interest for improving survival include (i) identification of high-risk patients prior to their arrest (e.g. early warning symptoms and genes); (ii) increased use of bystander CPR training (e.g. in schools) and simplified CPR techniques; (iii) better identification of high-incidence sites and better recruitment of AEDs (via mobile phone solutions?); (iv) improved understanding of the use of therapeutic hypothermia; (v) determining which patients should undergo immediate coronary angiography on hospital admission; and (vi) clarifying the importance of extracorporeal membrane oxygenation during CPR.