Effect of Therapeutic Hypothermia on Survival and Neurologic Outcome in the Elderly

Age and benefit of early coronary angiography after out-of-hospital cardiac arrest in patients presenting with shockable rhythm: Insights from the Sudden Death Expertise Center registry

BACKGROUND

Little is known about the association between provision of post-resuscitation care and prognosis of out-of-hospital cardiac arrest (OHCA) in elderly patients. Previous studies have suggested futility after 65 years of age.

OBJECTIVES

We aimed to evaluate the association of early coronary angiogram (CAG) followed if necessary by percutaneous coronary intervention (PCI), with favorable outcome after OHCA among elderly patients, compared to younger patients.

METHODS

Using a large French registry, we included all OHCA patients with an initial shockable rhythm, transported to hospital from 2011 to 2015. Favorable outcome was defined as hospital discharge with Cerebral Performance Category (CPC) 1 or 2. and were evaluated by multivariate logistic regression. Subgroup analyses were performed according to age groups: <65, 65-75 and >75 years.

RESULTS

Among 1502 included patients, 31% were older than 65 and 12% older than 75 years. An early CAG was performed in 79%, 88% and 76% of patients below 65, between 65 and 75 and above 75, respectively (P = 0.002). The rate of patients discharged with CPC1 or 2 was 42% below 65, 38% between 65 and 75 and 24% above 75 (P < 0.001). Among the whole population, early CAG (OR = 6.4, 95% CI = 3.9-10.5, P < 0.001) was associated with favorable outcome. In subgroups analysis, CAG was associated with favorable outcome among patients <65 and 65-75. In patients >75, there was a trend towards a favorable outcome (OR2.9, 95CI = 0.9-9.1).

CONCLUSIONS

In a large registry of OHCA survivors, the early CAG use was associated with a better prognosis. This benefit was persistent up to 75 years of age, suggesting that age alone should not guide the decision for early invasive strategy.

Effect of target temperature management at 32-34 °C in cardiac arrest patients considering assessment by regional cerebral oxygen saturation: A multicenter retrospective cohort study

AIM

Target temperature management (TTM) is used in comatose post-cardiac arrest patients, but the recommended temperature range is wide. This study aimed to assess the effectiveness of TTM at 32-34 °C while considering the degree of cerebral injury and cerebral circulation, as assessed by regional cerebral oxygen saturation (rSO₂).

METHODS

This is a secondary analysis of prospectively collected registry data from comatose patients who were transferred to 15 hospitals in Japan after out-of-hospital cardiac arrest (OHCA) from 2011 to 2013. The primary outcome was all-cause mortality at 90 days after OHCA, and the secondary outcome was favorable neurological outcomes as evaluated according to the Cerebral Performance Category. We monitored rSO₂ noninvasively with near-infrared spectroscopy, which could assess cerebral perfusion and the balance of oxygen delivery and uptake.

RESULTS

We stratified 431 study patients into three groups according to rSO₂ on hospital arrival: rSO₂ ≤40% (n = 296), rSO₂ 41-60% (n = 67), and rSO₂ ≥61% (n = 68). Propensity score analysis revealed that TTM at 32-34 °C decreased all-cause mortality in patients with rSO₂ 41-60% (average treatment effect on treated [ATT] by propensity score matching [PSM] -0.51, 95%CI -0.70 to -0.33; ATT by inverse probability of treatment weighting [IPW] -0.52, 95%CI -0.71 to -0.34), and increased favorable neurological outcomes in patients with rSO₂ 41-60% (ATT by PSM 0.50, 95%CI 0.32-0.68; ATT by IPW 0.52, 95%CI 0.35-0.69).

CONCLUSION

TTM at 32-34 °C effectively decreased all-cause mortality in comatose OHCA patients with rSO₂ 41-60% on hospital arrival in Japan.

Caring for critically ill oldest old patients: a clinical review

Despite technological advances, the mortality rate for critically ill oldest old patients remains high. The intensive caring should be able to combine technology and a deep humanity considering that the patients are living the last part of their lives. In addition to the traditional goals of ICU of reducing morbidity and mortality, of maintaining organ functions and restoring health, caring for seriously oldest old patients should take into account their end-of-life preferences, the advance or proxy directives if available, the prognosis, the communication, their life expectancy and the impact of multimorbidity. The aim of this review was to focus on all these aspects with an emphasis on some intensive procedures such as mechanical ventilation, noninvasive mechanical ventilation, cardiopulmonary resuscitation, renal replacement therapy, hemodynamic support, evaluation of delirium and malnutrition in this heterogeneous frail ICU population.