Outcome of Non-Traumatic Out-of-hospital Cardiac Arrest in the Elderly

Influence de l’âge sur les durées de réanimation des arrêts cardiaques préhospitaliers

Introduction : L’objectif de notre étude est de déterminer si l’âge des patients en arrêt cardiaque (AC) a une influence sur les durées de réanimation cardiopulmonaire (RCP) par les équipes préhospitalières.

Patients et méthodes : Nous avons réalisé une étude monocentrique, prospective, à partir des données de notre centre hospitalier universitaire, issues du Registre électronique des arrêts cardiaques. Ont été inclus tous les patients ayant présenté un AC, hormis ceux retrouvés en état de rigidité cadavérique ou qui avaient préalablement exprimé des directives anticipées sur leur fin de vie. Les patients ont été séparés en deux groupes selon leur âge : les moins de 75 ans et ceux de 75 ans et plus. Le critère de jugement principal était la durée de RCP spécialisée décidée par le médecin de l’équipe préhospitalière.

Résultats : Du 1er janvier au 31 décembre 2015, sur 253 patients victimes d’AC, 188 (74 % d’hommes, 78 % d’asystolie) ont bénéficié d’une RCP par une équipe du Service mobile d’urgence et de réanimation. Il y a eu 39 % de récupération d’une activité cardiaque spontanée (RACS). Seuls 31 % des patients étaient admis vivants à l’hôpital, ils étaient 6 % à j30. La durée de RCP était plus importante pour les patients de moins de 75 ans (29 ± 15 vs 23 ± 19 minutes ; p < 0,01). Mais pour les patients ayant une RACS, la durée de RCP était identique entre les deux groupes (16 ± 10 vs 14 ± 9 minutes ; p = 0,34). La survie des patients de 75 ans et plus était de 10 vs 22 % pour les moins de 75 ans (p = 0,35).

Conclusion : Notre étude suggère que l’âge des patients influence négativement les durées de réanimation des équipes préhospitalières.

Severe metabolic acidosis after out-of-hospital cardiac arrest: risk factors and association with outcome

BACKGROUND

Metabolic acidosis is frequently observed as a consequence of global ischemia-reperfusion after out-of-hospital cardiac arrest (OHCA). We aimed to identify risk factors and assess the impact of metabolic acidosis on outcome after OHCA.

METHODS

We included all consecutive OHCA patients admitted between 2007 and 2012. Using admission data, metabolic acidosis was defined by a positive base deficit and was categorized by quartiles. Main outcome was survival at ICU discharge. Factors associated with acidosis severity and with main outcome were evaluated by linear and logistic regressions, respectively.

RESULTS

A total of 826 patients (68.3% male, median age 61 years) were included in the analysis. Median base deficit was 8.8 [5.3, 13.2] mEq/l. Male gender (p = 0.002), resuscitation duration (p < 0.001), initial shockable rhythm (p < 0.001) and post-resuscitation shock (p < 0.001) were associated with an increased level of acidosis. ICU mortality rate increased across base deficit quartiles (39.1, 59.2, 76.3 and 88.3%, p for trend < 0.001), and base deficit was independently associated with ICU mortality (p < 0.001). The proportion of CPC 1 patients among ICU survivors was similar across base deficit quartiles (72.8, 67.1, 70.5 and 62.5%, p = 0.21), and 7.3% of patients with a base deficit higher than 13.2 mEq/l survived to ICU discharge with complete neurological recovery.

CONCLUSION

Severe metabolic acidosis is frequent in OHCA patients and is associated with poorer outcome, in particular due to refractory shock. However, we observed that about 7% of patients with a very severe metabolic acidosis survived to ICU discharge with complete neurological recovery.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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