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Maurer H, Masterson S, Tjelmeland IBM, Strömsöe A, Ortiz FR, Gräsner JT, Wnent J. EuReCa - The European Registry of Cardiac Arrest and the related studies. Resusc Plus 2024; 19:100666. [PMID: 38827274 PMCID: PMC11143888 DOI: 10.1016/j.resplu.2024.100666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) is a major health issue throughout Europe. Due to limited knowledge about the epidemiology of OHCA in Europe, in 2011, the European Registry of Cardiac Arrest (EuReCa) project was established. Initially based on existing resuscitation registries in a few countries, the network expanded and in October 2014 the EuReCa ONE study was launched, bringing together 27 countries and showing that appropriate data acquisition (10,682 cases submitted) is feasible within Europe. EuReCa TWO was conducted from October to December 2017 and included 37,054 cases. EuReCa THREE data collection was carried out from September to November 2022 and data analysis is currently being conducted. EuReCa TWO and THREE studies generated more robust data, with both studies covering 3-month periods in 28 countries, respectively. While EuReCa TWO focused on the bystander, EuReCa THREE investigated the impact of time-related aspects (time from call to scene, time at scene, transport times and other) on resuscitation outcomes. EuReCa is a network supporting countries in their ambition to establishing continuously running registries as quality management tools and for scientific work.
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Affiliation(s)
- Holger Maurer
- University Hospital Schleswig-Holstein, Department of Anaesthesiology and Intensive Care Medicine, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Siobhán Masterson
- National Ambulance Service and National University of Ireland Galway (on behalf of the Out-of-Hospital Cardiac Arrest Register (OHCAR)), Ireland
| | - Ingvild Beathe Myrhaugen Tjelmeland
- Division of Prehospital Services, Oslo University Hospital, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Norway
| | - Anneli Strömsöe
- School of Education, Health and Social Studies, Dalarna University, S-79188 Falun, Sweden
- Centre for Clinical Research Dalarna, Uppsala University, S-79182 Falun, Sweden
- Department of Prehospital Care, Region of Dalarna, S-79129 Falun, Sweden
| | - Fernando Rosell Ortiz
- Servicio de Emergencias 061, Centro de Investigación Biomédica de La Rioja (CIBIR), C/ Piqueras 96, Hospital San Pedro, 26005 Logroño, Spain
| | - Jan-Thorsten Gräsner
- University Hospital Schleswig-Holstein, Institute for Emergency Medicine, Holzkoppelweg 8-12, 24118 Kiel, Germany
- University Hospital Schleswig-Holstein, Department of Anaesthesiology and Intensive Care Medicine, Arnold-Heller-Str. 3, Haus R3, 24105 Kiel, Germany
| | - Jan Wnent
- University Hospital Schleswig-Holstein, Institute for Emergency Medicine, Holzkoppelweg 8-12, 24118 Kiel, Germany
- University Hospital Schleswig-Holstein, Department of Anaesthesiology and Intensive Care Medicine, Arnold-Heller-Str. 3, Haus R3, 24105 Kiel, Germany
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Katzenschlager S, Elshaer A, Metelmann B, Metelmann C, Thilakasiri K, Karageorgos V, Barry T, Alm-Kruse K, Karim H, Maurer H, Kramer-Johansen J, Orlob S. Top 5 barriers in cardiac arrest research as perceived by international early career researchers - A consensus study. Resusc Plus 2024; 18:100608. [PMID: 38524147 PMCID: PMC10957401 DOI: 10.1016/j.resplu.2024.100608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
Aim of the study Cardiac arrest research has not received as much scientific attention as research on other topics. Here, we aimed to identify cardiac arrest research barriers from the perspective of an international group of early career researchers. Methods Attendees of the 2022 international masterclass on cardiac arrest registry research accompanied the Global Out-of-Hospital Cardiac Arrest Registry collaborative meeting in Utstein, Norway, and used an adapted hybrid nominal group technique to obtain a diverse and comprehensive perspective. Barriers were identified using a web-based questionnaire and discussed and ranked during an in-person follow-up meeting. After each response was discussed and clarified, barriers were categorized and ranked over two rounds. Each participant scored these from 1 (least significant) to 5 (most significant). Results Nine participants generated 36 responses, forming seven overall categories of cardiac arrest research barriers. "Allocated research time" was ranked first in both rounds. "Scientific environment", including appropriate mentorship and support systems, ranked second in the final ranking. "Resources", including funding and infrastructure, ranked third. "Access to and availability of cardiac arrest research data" was the fourth-ranked barrier. This included data from the cardiac arrest registries, medical devices, and clinical studies. Finally, "uniqueness" was the fifth-ranked barrier. This included ethical issues, patient recruitment challenges, and unique characteristics of cardiac arrest. Conclusion By identifying cardiac arrest research barriers and suggesting solutions, this study may act as a tool for stakeholders to focus on helping early career researchers overcome these barriers, thus paving the road for future research.
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Affiliation(s)
- Stephan Katzenschlager
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg, Germany
| | - Ahmed Elshaer
- The Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Bibiana Metelmann
- Department of Anaesthesiology, Greifswald University Medicine, Greifswald, Germany
| | - Camilla Metelmann
- Department of Anaesthesiology, Greifswald University Medicine, Greifswald, Germany
| | - Kaushila Thilakasiri
- Oxford University Hospitals NHS Trust Oxford UK, Postgraduate Institute of Medicine, UK
- University of Colombo, Ministry of Health, Sri Lanka
| | - Vlasios Karageorgos
- Cardiopulmonary Resuscitation Lab, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | | | - Kristin Alm-Kruse
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hritul Karim
- Department of Medicine Solna, Karolinska Institute, Stockholm, Sweden
| | - Holger Maurer
- Department of Anesthesiology and Intensive Care Medicine, University of Luebeck, Luebeck, Germany
| | - Jo Kramer-Johansen
- Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS) , Norway
- Norwegian Cardiac Arrest Registry, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Simon Orlob
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
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Kelpanides IK, Katzenschlager S, Skogvoll E, Tjelmeland IBM, Grindheim G, Alm-Kruse K, Liberg JP, Kristiansen T, Wnent J, Gräsner JT, Kramer-Johansen J. Out-of-hospital cardiac arrest in children in Norway: A national cohort study, 2016-2021. Resusc Plus 2024; 18:100662. [PMID: 38799717 PMCID: PMC11126965 DOI: 10.1016/j.resplu.2024.100662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
Aim Children constitute an important and distinct subgroup of out-of-hospital cardiac arrest (OHCA) patients. This population-based cohort study aims to establish current age-specific population incidence, precipitating causes, circumstances, and outcome of paediatric OHCA, to guide a focused approach to prevention and intervention to improve outcomes. Methods Data from the national Norwegian Cardiac Arrest Registry was extracted for the six-year period 2016-21 for persons aged <18 years. We present descriptive statistics for the population, resuscitation events, presumed causes, treatment, and outcomes, alongside age-specific incidence and total paediatric mortality rates. Results Three hundred and eight children were included. The incidence of OHCA was 4.6 per 100 000 child-years and markedly higher in children <1 year at 20.9 child-years. Leading causes were choking, cardiac and respiratory disease, and sudden infant death syndrome. Overall, 21% survived to 30 days and 18% to one year. Conclusion A registry-based approach enabled this study to delineate the characteristics and trajectories of OHCA events in a national cohort of children. Precipitating causes of paediatric OHCA are diverse compared to adults. Infants aged <1 year are at particularly high risk. Mortality is high, albeit lower than for adults in Norway. A rational community approach to prevention and treatment may focus on general infant care, immediate first aid by caretakers, and identification of vulnerable children by primary health providers. Cardiac arrest registries are a key source of knowledge essential for quality improvement and research into cardiac arrest in childhood.
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Affiliation(s)
- Inga Katherina Kelpanides
- Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Stephan Katzenschlager
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg, Germany
| | - Eirik Skogvoll
- Clinic of Anaesthesia and Intensive Care, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ingvild Beathe Myrhaugen Tjelmeland
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Institute for Emergency Medicine, University-Hospital Schleswig-Holstein, Kiel, Germany
- Norwegian National Advisory Unit for Prehospital Emergency Care, Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
| | - Guro Grindheim
- Department of Anaesthesiology and Intensive Care, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Kristin Alm-Kruse
- Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - John-Petter Liberg
- Clinic of Anaesthesia and Intensive Care, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Thomas Kristiansen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Anaesthesiology and Intensive Care, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Jan Wnent
- Institute for Emergency Medicine, University-Hospital Schleswig-Holstein, Kiel, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
- School of Medicine, University of Namibia, Windhoek, Namibia
| | - Jan-Thorsten Gräsner
- Institute for Emergency Medicine, University-Hospital Schleswig-Holstein, Kiel, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jo Kramer-Johansen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Norwegian National Advisory Unit for Prehospital Emergency Care, Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
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Tarnovski L, Šantek P, Rožić I, Čučević Đ, Mahečić LM, Marić J, Lovaković J, Martinić D, Rašić F, Rašić Ž. Out-of-Hospital Cardiac Arrest in the Eye of the Beholder and Emergency Medical Service. Open Access Emerg Med 2024; 16:91-99. [PMID: 38699221 PMCID: PMC11063469 DOI: 10.2147/oaem.s449157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 04/17/2024] [Indexed: 05/05/2024] Open
Abstract
Purpose Out-of-hospital cardiac arrest (OHCA) remains a global healthcare problem, with low survival and bystander cardiopulmonary resuscitation (CPR) rates. This study aimed to identify event-related factors in OHCA and their impact on return of spontaneous circulation (ROSC) achievement and maintenance until hospital admission. Patients and Methods All data were collected from Utstein Resuscitation Registry Template for OHCA from The Institute of Emergency Medicine of Zagreb from January 2012 to August 2022. This cross-sectional research analyzed 2839 Utstein reports, including 2001 male, 836 female, and 8 subjects of unknown gender. The average age was 65.4 ± 16.2 years. Results The most frequent place of collapse was private residence, and 27% of collapses were unwitnessed. Dispatcher-provided CPR instructions were provided in 39.7% of cases until the arrival of the emergency service team, which showed a very strong effect on bystander-provided CPR, and were followed in 68.4% of cases, while non-instructed bystander CPR was provided in only 7.9% of cases. Bystander CPR is more likely to be provided in public places than in private residences, often with both compression and ventilation. Bystander CPR was also more likely to be provided to men. Cases with bystander CPR, and compressions with ventilation compared to compression only CPR, showed a significantly greater success in maintaining ROSC later in CPR, both with moderate effects. Conclusion Bystander CPR has been shown to have a significant role in achieving and maintaining ROSC until hospital admission. However, our results showed a location-dependent nature of bystanders' willingness to perform CPR as well as sex disparities in patients receiving CPR. With deficient education in basic life support in Croatia, dispatchers need to insist on and instruct bystander CPR performance.
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Affiliation(s)
| | - Porin Šantek
- Institute of Emergency Medicine of Zagreb, Zagreb, Croatia
| | - Ivana Rožić
- Institute of Emergency Medicine of Zagreb, Zagreb, Croatia
| | - Đivo Čučević
- Department of Anesthesiology and Intensive Care, University Hospital Centre Zagreb, Zagreb, Croatia
| | | | - Jana Marić
- Institute of Emergency Medicine of Zagreb, Zagreb, Croatia
| | - Josip Lovaković
- Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | | | - Fran Rašić
- Department of Obstetrics and Gynecology, University Hospital “Sveti Duh”, Zagreb, Croatia
| | - Žarko Rašić
- Institute of Emergency Medicine of Zagreb, Zagreb, Croatia
- Department of Surgery, University Hospital “Sveti Duh”, Zagreb, Croatia
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Alm-Kruse K, Gjerset GM, Tjelmeland IB, Isern CB, Kramer-Johansen J, Garratt AM. How do survivors after out-of-hospital cardiac arrest perceive their health compared to the norm population? A nationwide registry study from Norway. Resusc Plus 2024; 17:100549. [PMID: 38292469 PMCID: PMC10825523 DOI: 10.1016/j.resplu.2023.100549] [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: 10/16/2023] [Revised: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction Self-perceived health status data is usually collected using patient-reported outcome measures. Information from the patients' perspective is one of the important components in planning person-centred care. The study aimed to compare EQ-5D-5L in survivors after out-of-hospital cardiac arrest (OHCA) with data for Norwegian population controls. Secondary aim included comparing characteristics of respondents and non-respondents from the OHCA population. Methods In this cross-sectional survey, 714 OHCA survivors received an electronic EQ-5D-5L questionnaire 3-6 months following OHCA. EQ-5D-5L assesses for five dimensions of health (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) with five-point descriptive scales and overall health on a visual analogue scale from 0 (worst) to 100 (best) (EQ VAS). Results are used to calculate the EQ index ranging from -0.59 (worst) to 1 (best). Patient responses were matched for age and sex with existing data from controls, collected through a postal survey (response rate 26%), and compared with Chi-square tests or t-tests as appropriate. Results Of 784 OHCA survivors, 714 received the EQ-5D-5L, and 445 (62%) responded. Respondents had higher rates of shockable first rhythm and better cerebral performance category scores than the non-respondents. OHCA survivors reported poorer health compared to controls as assessed by EQ-5D-5L dimensions, the EQ index (0.76 ± 0.24 vs 0.82 ± 0.18), and EQ VAS (69 ± 21 vs 79 ± 17), except for the pain/discomfort dimension. Conclusions Norwegian OHCA survivors reported poorer health than the general population as assessed by the EQ-5D-5L. PROMs use in this population can be used to inform follow-up and health care delivery.
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Affiliation(s)
- Kristin Alm-Kruse
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Gunhild M. Gjerset
- National Advisory Unit on Late Effects after Cancer Treatment, Department of Oncology and Department of Clinical Service, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
| | - Ingvild B.M. Tjelmeland
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
- Institute for Emergency Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Cecilie B. Isern
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
- Oslo Sports Trauma Research Centre, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Jo Kramer-Johansen
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
- Institute for Emergency Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Andrew M. Garratt
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
- Health Services Research Centre, Akershus University Hospital, Lørenskog, Norway
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Isern CB, Nilsson BB, Garratt A, Kramer-Johansen J, Tjelmeland IB, Berge HM. Health-related quality of life in young Norwegian survivors of out-of-hospital cardiac arrest related to pre-arrest exercise habits. Resusc Plus 2023; 16:100478. [PMID: 37818171 PMCID: PMC10560841 DOI: 10.1016/j.resplu.2023.100478] [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: 05/23/2023] [Revised: 09/11/2023] [Accepted: 09/15/2023] [Indexed: 10/12/2023] Open
Abstract
Aim To compare health-related quality of life (HRQoL) in young survivors of out-of-hospital cardiac arrest (OHCA) in Norway with an age and sex-matched reference population and to assess the associations between exercise volume prior to OHCA and HRQoL after. Methods We present data from survivors aged 18-50 years registered with OHCA in the Norwegian Cardiac Arrest Registry between January 1st 2015 and December 31st 2017. Survivors were invited to answer two questionnaires; (1) the Short Form 36 (SF-36) Health Survey Version 1, and (2) about exercise habits prior to OHCA. Respondents were randomly matched 1:1 for age and sex with a reference population (data were available from the Norwegian Centre for Research Data). Results Of the 175 survivors invited, 95 (54%) responded, median age was 44 (range 35-48) years, 26 (27%) females. Valid results for SF-36 were available for 91 survivors, of whom 87 reported pre-OHCA exercise-volume. Prior to OHCA, 21 did no regular exercise, 44 exercised 1-4 hours/week and 22 exercised ≥5 hours/week. Compared to the reference population survivors had significantly (p < 0.01) poorer SF-36 scores for scales relating to physical- and mental health. SF-36 scale scores were similar in survivors who did and did not exercise regularly. Within the regular exercisers, survivors reporting ≥5 hours of exercise/week had better SF-36 scores than those exercising less. Conclusion Poorer HRQoL in survivors compared to the reference population should prompt us to explore how treatment and rehabilitation could be improved and adapted. More exercise before OHCA favoured better HRQoL after, which aligns well with the recognised positive association between HRQoL and physical activity in general.
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Affiliation(s)
- Cecilie Benedicte Isern
- Division of Prehospital Services, Oslo University Hospital, Ullevål Hospital, P.O. Box 4956 Nydalen, NO-0424 Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, P.O. Box 1078 Blindern, NO-0316 Oslo, Norway
- Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, P.O. Box 4014 Ullevål Stadion, NO-0806 Oslo, Norway
| | - Birgitta Blakstad Nilsson
- Section for Physiotherapy, Department of Clinical Services, Division of Medicine, Oslo University Hospital, Oslo, Norway
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, OsloMet – Oslo Metropolitan University, Oslo, Norway
| | - Andrew Garratt
- Norwegian Institute of Public Health, Oslo, Norway, Health Services Research Centre, Akershus University Hospital, Lorenskog, Norway
| | - Jo Kramer-Johansen
- Division of Prehospital Services, Oslo University Hospital, Ullevål Hospital, P.O. Box 4956 Nydalen, NO-0424 Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, P.O. Box 1078 Blindern, NO-0316 Oslo, Norway
| | - Ingvild B.M. Tjelmeland
- Division of Prehospital Services, Oslo University Hospital, Ullevål Hospital, P.O. Box 4956 Nydalen, NO-0424 Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, P.O. Box 1078 Blindern, NO-0316 Oslo, Norway
- University Hospital Schleswig-Holstein, Institute for Emergency Medicine, Holzkoppelweg 8-12, Kiel, Germany
| | - Hilde Moseby Berge
- Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, P.O. Box 4014 Ullevål Stadion, NO-0806 Oslo, Norway
- Department of General Practice, Institute of Health and Society, University of Oslo, P.O. Box 1130 Blindern, NO-0318 Oslo, Norway
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Harring AKV, Kramer-Johansen J, Tjelmeland IBM. Resuscitation of older adults in Norway; a comparison of survival and outcome after out-of-hospital cardiac arrest in healthcare institutions and at home. Resuscitation 2023; 189:109871. [PMID: 37327851 DOI: 10.1016/j.resuscitation.2023.109871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Perceptions about expected outcome after out-of-hospital cardiac arrest (OHCA) influence treatment decisions, and there is a need for updated evidence about outcomes for the elderly. METHOD We conducted a cross-sectional study of cases reported to the Norwegian Cardiac Arrest Registry from 2015 through 2021 of patients 60 years and older, suffering cardiac arrest in healthcare institutions or at home. We examined reasons for emergency medical service (EMS) withholding or withdrawing resuscitation. We compared survival and neurological outcome for EMS-treated patients and explored factors associated with survival using multivariate logistic regression. RESULT We included 12,191 cases and the EMS started resuscitation in 10,340 (85%). The incidence per capita of OHCA the EMS were alerted to was 267/100,000 in healthcare institutions and 134/100,000 at home. Resuscitation was most frequently withdrawn due to medical history (n = 1251). In healthcare institutions, 72 of 1503 (4.8%) patients survived to 30 days compared to 752 of 8837 (8.5%) at home (P <.001). We found survivors in all age cohorts both in healthcare institutions and at home, and most of the 824 survivors had a good neurological outcome with a Cerebral Performance Category ≤2 (88%). CONCLUSION Medical history was the most frequent reason for EMS not to start or continue resuscitation, indicating a need for a discussion about, and documentation of, advance directives in this age group. When EMS attempted resuscitation, most survivors had a good neurological outcome, both in healthcare institutions and at home.
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Affiliation(s)
| | - Jo Kramer-Johansen
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ingvild B M Tjelmeland
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Alm-Kruse K, Tjelmeland I, Reiner A, Kvåle R, Kramer-Johansen J. Use of healthcare services before and after out-of-hospital cardiac arrest. Resuscitation 2023; 187:109805. [PMID: 37088268 DOI: 10.1016/j.resuscitation.2023.109805] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/27/2023] [Accepted: 04/13/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Knowledge about the use of healthcare services in patients experiencing out-of-hospital cardiac arrest (OHCA) is limited. We aimed to describe and compare the use of healthcare by OHCA survivors two years before and one year after cardiac arrest. METHODS Adult patients with OHCA of medical cause, who survived >30 days, were identified in the Norwegian Cardiac Arrest Registry. The Norwegian Patient Registry, The Cause of Death Registry, and The Norwegian Registry for Primary Healthcare provided data on survival and the use of healthcare services. We investigated the use of primary, specialist and mental healthcare, as well as rehabilitation services. RESULTS In 2015-2018, 13,112 OHCA cases were identified; 1435 (14%) patients survived >30 days (6.8/100,000 patients/year). The proportion of patients in the cohort that used primary healthcare each month increased form 43% before to 69% after OHCAto (p<0.001). We found a doubling of monthly healthcare contacts in both specialist healthcare (from 26% to 57%, p<0.001) and mental healthcare (from 3% to 8%, p>0.001). The observed increases in primary, specialist and mental healthcare use started two weeks, six months, and eight months before OHCA, respectively. Half of the patients had contact with primary healthcare services on the same day as the cardiac arrest. Two out of five patients were registered for rehabilitation after OHCA. CONCLUSION The use of primary, specialist and mental healthcare services increased before OHCA and remained significantly higher the year after OHCA. Less than half of the patients surviving cardiac arrest were registered for rehabilitation.
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Affiliation(s)
- Kristin Alm-Kruse
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ingvild Tjelmeland
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Institute for Emergency Medicine, University-Hospital Schleswig-Holstein, Kiel, Germany
| | - Andrew Reiner
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Rune Kvåle
- Department of Oncology, Haukeland University Hospital, Bergen, Norway; Department of Health Registry Research and Development, National Institute of Public Health, Bergen, Norway
| | - Jo Kramer-Johansen
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
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Randjelovic SS, Nikolovski SS, Tijanic JZ, Obradovic IA, Fiser ZZ, Lazic AD, Raffay VI. Out-of-Hospital Cardiac Arrest Prospective Epidemiology Monitoring during the First Five Years of EuReCa Program Implementation in Serbia. Prehosp Disaster Med 2023; 38:1-8. [PMID: 36600667 PMCID: PMC9885433 DOI: 10.1017/s1049023x22002424] [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: 10/01/2022] [Accepted: 11/10/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Poor outcome is still a challenging concern in patients with out-of-hospital cardiac arrest (OHCA) world-wide and there are large differences between European countries regarding not only incidence rates, but survival rates as well. In 2014, Serbian Resuscitation Council initiated regular data collection on epidemiology of OHCA, according to the European Registry of Cardiac Arrest (EuReCa) study protocol. STUDY OBJECTIVE The aim of this study is to analyze the results of the first five-year period after initiation of EuReCa study protocol elements implementation in OHCA epidemiological data collection in Serbia. METHODS The observed period in this study is about the data on OHCA, collected within the observed area of 16 municipalities covering 1,604,015 citizens, during the period from October 1, 2014 - December 31, 2019. The study included data on all-cause OHCA in both adult and pediatric patients, according to the EuReCa One study protocol, of which all segments were observed. RESULTS Within the study period, 5,196 OHCA patients were observed with annual incidence of 83.60/100,000. Of all registered events, 43.9% were witnessed. The most common collapse location was patient's residence (88.7%). Within the group of initiated cardiopulmonary resuscitation (CPR), cardiac etiology was observed in 80.5% of cases and shockable rhythm in 21.7%. Return of spontaneous circulation (ROSC) prior to hospital admission was significantly more frequently achieved and maintained on admission in witnessed cases, cases occurring out of patient's residence, and in cases with shockable initial rhythm (P <.01). CONCLUSION The OHCA incidence in Serbia is comparable with the incidence in the majority of European countries, and survival rates are now significantly higher in Utstein events compared to previous results from Serbia. Enrolment of witnessing bystanders in initiating CPR measures remains a concern requiring effort towards understanding of CPR initiation importance and education of general population in administering CPR measures.
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Affiliation(s)
| | - Srdjan S. Nikolovski
- University of Belgrade Faculty of Medicine, Belgrade, Serbia; Serbian Resuscitation Council, Novi Sad, Serbia
| | | | - Ivana A. Obradovic
- Department of Anesthesia, Hospital “Sveti Vracevi,”Bijeljina, Bosnia and Herzegovina
| | - Zoran Z. Fiser
- Municipal Institute of Emergency Medicine, Novi Sad, Serbia
| | - Aleksandra D. Lazic
- Serbian Resuscitation Council, Novi Sad, Serbia; Emergency Center, Clinical Center of Vojvodina, Novi Sad, Serbia
| | - Violetta I. Raffay
- European University Cyprus, School of Medicine, Department of Medicine, Nicosia, Cyprus
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Darginavicius L, Kajokaite I, Mikelionis N, Vencloviene J, Dobozinskas P, Vaitkaitiene E, Vaitkaitis D, Krikscionaitiene A. Short- and long-term survival after out-of-hospital cardiac arrest in Kaunas (Lithuania) from 2016 to 2018. BMC Cardiovasc Disord 2022; 22:519. [PMID: 36460967 PMCID: PMC9719236 DOI: 10.1186/s12872-022-02964-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 11/19/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND No studies analysing out-of-hospital cardiac arrest (OHCA) epidemiology and outcomes in Lithuania were published in the last decade. METHODS We conducted a retrospective analysis of prospectively collected data. The incidence of OHCA and the demographics and outcomes of patients who were treated for OHCA between 1 and 2016 and 31 December 2018 at Kaunas Emergency Medical Service (EMS) were collected and are reported in accordance with the Utstein recommendations. Multivariable logistic regression analysis was used to identify predictors of survival to hospital discharge. RESULTS In total, 838 OHCA cases of EMS-treated cardiac arrest (CA) were reported (95.8 per 100.000 inhabitants). The median age was 71 (IQR 58-81) years of age, and 66.7% of patients were males. A total of 73.8% of OHCA cases occurred at home, 59.3% were witnessed by a bystander, and 54.5% received bystander cardiopulmonary resuscitation. The median EMS response time was 10 min. Cardiac aetiology was the leading cause of CA (78.8%). The initial rhythm was shockable in 27.6% of all cases. Return of spontaneous circulation at hospital transfer was evident in 24.9% of all cases. The survival to hospital discharge rate was 10.9%, and the 1-year survival rate was 6.9%. The survival to hospital discharge rate in the Utstein comparator group was 36.1%, and the 1-year survival rate was 27.2%. Five factors were associated with improved survival to hospital discharge: shockable rhythm, time from call to arrival at the patient less than 10 min, witnessed OHCA, age < 80 years, and male sex. CONCLUSION This is the first OHCA study from Lithuania examining OHCA epidemiology and outcomes over a three year period. Routine OHCA data collection and analysis will allow us to track the efficacy of service improvements and should become a standard practice in all Lithuanian regions. TRIAL REGISTRATION This research was registered in the clinicaltrials.gov database: Identifiers: NCT04784117, Unique Protocol ID: LITOHCA. Brief Title: Out-of-hospital Cardiac Arrest Epidemiology and Outcomes in Kaunas 2016-2021.
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Affiliation(s)
- Linas Darginavicius
- grid.45083.3a0000 0004 0432 6841Department of Disaster Medicine, Lithuanian University of Health Sciences, Eiveniu 4-512, 50161 Kaunas, Lithuania
| | | | | | - Jone Vencloviene
- grid.19190.300000 0001 2325 0545Department of Environmental Sciences, Faculty of Natural Sciences, Vytautas Magnus University, Kaunas, Lithuania
| | - Paulius Dobozinskas
- grid.45083.3a0000 0004 0432 6841Department of Disaster Medicine, Lithuanian University of Health Sciences, Eiveniu 4-512, 50161 Kaunas, Lithuania
| | - Egle Vaitkaitiene
- grid.45083.3a0000 0004 0432 6841Department of Disaster Medicine, Lithuanian University of Health Sciences, Eiveniu 4-512, 50161 Kaunas, Lithuania ,grid.45083.3a0000 0004 0432 6841Department of Public Health, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Dinas Vaitkaitis
- grid.45083.3a0000 0004 0432 6841Department of Disaster Medicine, Lithuanian University of Health Sciences, Eiveniu 4-512, 50161 Kaunas, Lithuania
| | - Asta Krikscionaitiene
- grid.45083.3a0000 0004 0432 6841Department of Disaster Medicine, Lithuanian University of Health Sciences, Eiveniu 4-512, 50161 Kaunas, Lithuania
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Harring AKV, Tjelmeland IB, Andenæs R, Kramer-Johansen J. Blir beslutninger om behandlingsbegrensninger respektert utenfor sykehus når man har ringt 113? TIDSSKRIFT FOR OMSORGSFORSKNING 2022. [DOI: 10.18261/tfo.8.3.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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European Registry of Cardiac Arrest - Study-THREE (EuReCa THREE) - An international, prospective, multi-centre, three-month survey of epidemiology, treatment and outcome of patients with out-of-hospital cardiac arrest in Europe - The study protocol. Resusc Plus 2022; 12:100314. [PMID: 36238583 PMCID: PMC9551137 DOI: 10.1016/j.resplu.2022.100314] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/24/2022] Open
Abstract
Background The aim of the European Registry of Cardiac Arrest (EuReCa) network is to provide high quality evidence on epidemiology of out-of-hospital cardiac arrest (OHCA) in Europe by supporting and developing cardiac arrest registries and performing European-wide studies. To date, the EuReCa ONE and EuReCa TWO studies have involved around 28 countries, with population covered increasing from the first to the second study. The aim of the EuReCa THREE study is to build on previous work and to support the promotion of quality data collection on OHCA throughout Europe. Methods/design EuReCa THREE will be the third prospective cohort study on epidemiology of OHCA and will involve around 30 European countries. The study will be conducted between 1st September and 30th November 2022. Data will be collected on cardiac arrest cases attended, resuscitation attempted, patient and cardiac arrest event characteristics and outcomes (including return of spontaneous circulation, status on hospital arrival and discharge). A particular focus for EuReCa THREE will be to describe key time intervals in OHCA management; time from call to EMS arrival on scene, time from cardiac arrest to start CPR, time from EMS arrival to delivery of patient to hospital.EuReCa THREE was registered with the German Registry of Clinical Trials Registration Number: DRKS00028591 searchable via WHO meta-registry (https://apps.who.int/trialsearch/). Discussion The EuReCa THREE study will increase our knowledge on longitudinal OHCA epidemiology and provide new knowledge on crucial time intervals in OHCA management in Europe. However, the primary aim of building a network to support quality data on OHCA, remains the central tenant of the EuReCa project.
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Hagberg G, Ihle-Hansen H, Sandset EC, Jacobsen D, Wimmer H, Ihle-Hansen H. Long Term Cognitive Function After Cardiac Arrest: A Mini-Review. Front Aging Neurosci 2022; 14:885226. [PMID: 35721022 PMCID: PMC9204346 DOI: 10.3389/fnagi.2022.885226] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality worldwide. With better pre- and inhospital treatment, including cardiopulmonary resuscitation (CPR) as an integrated part of public education and more public-access defibrillators available, OHCA survival has increased over the last decade. There are concerns, after successful resuscitation, of cerebral hypoxia and degrees of potential acquired brain injury with resulting poor cognitive functioning. Cognitive function is not routinely assessed in OHCA survivors, and there is a lack of consensus on screening methods for cognitive changes. This narrative mini-review, explores available evidence on hypoxic brain injury and long-term cognitive function in cardiac arrest survivors and highlights remaining knowledge deficits.
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Tjelmeland IBM, Alm-Kruse K, Grasner JT, Isern CB, Jakisch B, Kramer-Johansen J, Renzing N, Wnent J, Seewald S. Importance of reporting survival as incidence: a cross-sectional comparative study on out-of-hospital cardiac arrest registry data from Germany and Norway. BMJ Open 2022; 12:e058381. [PMID: 35177465 PMCID: PMC8860078 DOI: 10.1136/bmjopen-2021-058381] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Health registries are a unique source of information about current practice and can describe disease burden in a population. We aimed to understand similarities and differences in the German Resuscitation Registry (GRR) and the Norwegian Cardiac Arrest Registry (NorCAR) and compare incidence and survival for patients resuscitated after out-of-hospital cardiac arrest. DESIGN A cross-sectional comparative analysis reporting incidence and outcome on a population level. SETTING We included data from the cardiac arrest registries in Germany and Norway. PARTICIPANTS Patients resuscitated between 1 January 2015 and 31 December 2019 were included, resulting in 29 222 cases from GRR and 16 406 cases from NorCAR. From GRR, only emergency medical services (EMS) reporting survival information for patients admitted to the hospital were included. PRIMARY AND SECONDARY OUTCOME MEASURES This study focused on the EMS systems, the registries and the patients included in both registries. The results compare the total incidence, incidence of patients resuscitated by EMS, and the incidence of survival. RESULTS We found an incidence of 68 per 100 000 inhabitants in GRR and 63 in NorCAR. The incidence of patients treated by EMS was 67 in GRR and 53 in NorCAR. The incidence of patients arriving at a hospital was higher in GRR (24.3) than in NorCAR (15.1), but survival was similar (8 in GRR and 7.8 in NorCAR). CONCLUSION GRR is a voluntary registry, and in-hospital information is not reported for all cases. NorCAR has mandatory reporting from all EMS and hospitals. EMS in Germany starts treatment on more patients and bring a higher number to hospital, but we found no difference in the incidence of survival. This study has improved our knowledge of both registries and highlighted the importance of reporting survival as incidence when comparing registries.
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Affiliation(s)
- Ingvild Beathe Myrhaugen Tjelmeland
- Institute for Emergency Medicine, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristin Alm-Kruse
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Jan-Thorsten Grasner
- Institute for Emergency Medicine, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
- Department of Anaesthesiology and Intensive Care Medicine, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Cecilie Benedicte Isern
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Barbara Jakisch
- Organization & Corporate Development, imland gGmbH, Rendsburg, Schleswig-Holstein, Germany
| | - Jo Kramer-Johansen
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Niels Renzing
- Institute for Emergency Medicine, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Jan Wnent
- Institute for Emergency Medicine, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
- University of Namibia School of Medicine, Windhoek, Namibia
| | - Stephan Seewald
- Institute for Emergency Medicine, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
- Department of Anaesthesiology and Intensive Care Medicine, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
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Case completeness in the Norwegian Cardiac Arrest Registry. Resusc Plus 2021; 8:100182. [PMID: 34825238 PMCID: PMC8605216 DOI: 10.1016/j.resplu.2021.100182] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/05/2021] [Accepted: 10/26/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction This study aimed to assess the case completeness of out-of-hospital cardiac arrests (OHCA) in the Norwegian Cardiac Arrest Registry (NorCAR) and describe the differences between the registered and missing patients identified from the case-control assessment. Methods We identified the relevant patients in the Norwegian Patient Registry and the Norwegian Cause of Death Registry and compared them with the patients in NorCAR. Data processors used patient records to confirm if the potential cardiac arrest cases met the inclusion criteria in NorCAR. Results Between 2015 and 2017, 8612 OHCA patients were registered in NorCAR. Through the Patient Registry and the Cause of Death Registry we identified 11,114 potential OHCA patients, 3469 of these were already registered in NorCAR. After evaluating the patient records for the remaining 7645 patients, we found 344 patients (4%), were eligible for inclusion in NorCAR, giving a case completeness of 96%. The registered and missing patients were similar in age and gender distribution. Initial shockable rhythm and presumed cause were also comparable. However, the missing patients more frequently achieved return of spontaneous circulation, were more often transported to hospital, and had higher survival rates. The already registered patients had more key variables registered than the missing patients. Conclusion Our results indicate high case completeness in NorCAR. The missing patients were too few to introduce significant changes in the distribution of patient characteristics, indicating that NorCAR is representative of the Norwegian OHCA population.
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Abstract
In this section of the European Resuscitation Council Guidelines 2021, key information on the epidemiology and outcome of in and out of hospital cardiac arrest are presented. Key contributions from the European Registry of Cardiac Arrest (EuReCa) collaboration are highlighted. Recommendations are presented to enable health systems to develop registries as a platform for quality improvement and to inform health system planning and responses to cardiac arrest.
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Alm-Kruse K, Sørensen G, Osbakk SA, Sunde K, Bendz B, Andersen GØ, Fiane A, Hagen OA, Kramer-Johansen J. Outcome in refractory out-of-hospital cardiac arrest before and after implementation of an ECPR protocol. Resuscitation 2021; 162:35-42. [PMID: 33581226 DOI: 10.1016/j.resuscitation.2021.01.038] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 12/18/2022]
Abstract
AIM To compare the outcomes in patients with refractory out-of-hospital cardiac arrest (OHCA) fulfilling the criteria for extracorporeal cardiopulmonary resuscitation (ECPR) before and after implementation of an ECPR protocol, whether the patient received ECPR or not. METHODS We compared cardiac arrest registry data before (2014-2015) and after (2016-2019) implementation of the ECPR protocol. The ECPR criteria were presumed cardiac origin, witnessed arrest with ventricular fibrillation, bystander CPR, age 18-65, advanced life support (ALS) within 15 min and ALS > 10 min without return of spontaneous circulation (ROSC). The primary outcome was 30-day survival; the secondary outcomes were sustained ROSC, neurological outcome and the proportion of patients transported with ongoing ALS. RESULTS There were 1086 and 3135 patients in the pre- and post-implementation sample; 48 (4%) and 100 (3%) met the ECPR criteria, respectively. Of these, 21 (44%) vs. 37 (37%) were alive after 30 days, p = 0.4, and 30 (63%) vs. 50 (50%) achieved sustained ROSC, p = 0.2. All survivors in the pre-implementation sample had cerebral performance category 1-2 vs. 30 (81%) in the post-implementation sample, p = 0.03. Of the patients fulfilling the ECPR criteria, 7 (15%) and 26 (26%), p = 0.1, were transported with ongoing ALS in the pre- and post-implementation sample, respectively. CONCLUSIONS There were no differences in 30-day survival or prehospital ROSC in patients with refractory OHCA before and after initiation of an ECPR protocol.
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Affiliation(s)
- Kristin Alm-Kruse
- Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Norway.
| | - Gro Sørensen
- Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Svein Are Osbakk
- Division of Prehospital Services, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Kjetil Sunde
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Norway; Division of Emergencies and Critical Care, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Bjørn Bendz
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Norway; Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | - Arnt Fiane
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Norway; Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Ove Andreas Hagen
- Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jo Kramer-Johansen
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Norway; Division of Prehospital Services, Oslo University Hospital and University of Oslo, Oslo, Norway
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