Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital 'Utstein style'. American Heart Association

Survival Differences in Asian and Hispanic Patients With In-Hospital Cardiac Arrest

BACKGROUND

Although they are fast-growing populations in the United States, little is known about survival outcomes of Hispanic and Asian patients after in-hospital cardiac arrest.

METHODS AND RESULTS

In Get With The Guidelines-Resuscitation, we identified Asian, Hispanic, and White adults with in-hospital cardiac arrest during 2005 to 2023. Using multivariable models, we compared rates of survival to discharge separately for Asian and Hispanic patients versus White patients, as well as rates of sustained return of spontaneous circulation for ≥20 minutes and favorable neurologic survival as secondary outcomes. Of 189 557 in-hospital cardiac arrests, 167 640 (88.4%), 16 800 (8.9%), and 5117 (2.7%) patients were White, Hispanic, and Asian, respectively. Compared with the survival rate to discharge for White patients (22.0%), rates were lower for Hispanic (19.4%; adjusted odds ratio [OR], 0.93 [95% CI, 0.89-0.97]; P<0.001) and Asian patients (17.8%; adjusted OR, 0.90 [95% CI, 0.83-0.97]; P=0.008), and these differences were attenuated after accounting for the hospital at which patients received care (adjusted OR: Hispanic patients, 0.95 [95% CI, 0.91-1.00]; Asian patients, 0.91 [95% CI, 0.84-0.99]). Although there were no differences in rates of return of spontaneous circulation between White (68.7%), Hispanic (69.0%), and Asian patients (69.7%), both Asian and Hispanic patients were less likely to have favorable neurologic survival (White: 18.3%; Hispanic: 15.4%; adjusted OR, 0.88 [95% CI, 0.84-0.93]; Asian: 13.2%; adjusted OR, 0.80 [95% CI, 0.73-0.87]). These differences were also attenuated after accounting for hospital site.

CONCLUSIONS

Compared with White patients, Hispanic and Asian patients with in-hospital cardiac arrest had lower rates of overall survival and favorable neurologic survival. Some of these differences were associated with the hospital at which patients received care.

Re-arrest immediately after return of spontaneous circulation: A retrospective observational study of in-hospital cardiac arrest

BACKGROUND

Patients who achieve return of spontaneous circulation (ROSC) after in-hospital cardiac arrest (IHCA) may re-arrest. This phenomenon has not been sufficiently investigated. The aim of this study was to examine the immediate (1-min) and short-term (20-min) risks of re-arrest in IHCA.

METHODS

We retrospectively analyzed four datasets of IHCA episodes, comprising defibrillator recordings collected between 2002 and 2022. Re-arrest was defined as the resumption of chest compressions following a period of ROSC after cardiac arrest of any duration. Parametric models were applied to calculate the immediate risk of re-arrest. In addition, we estimated the short-term risk of re-arrest within 20 min.

RESULTS

In 763 episodes of IHCA, we observed 316 re-arrests: 68% to pulseless electrical activity (PEA), 25% to ventricular fibrillation/ventricular tachycardia (VF/VT), and 7% to asystole. Most re-arrests occurred with the same rhythm as in the initial arrest. When ROSC was achieved from a non-shockable rhythm, the risk of re-arrest to a non-shockable rhythm was initially 2% per minute and decreased to 1% per minute after 9 min. The corresponding risk of re-arrest to VF/VT was constant at 2% per minute. If ROSC was obtained from a shockable rhythm, the risk of re-arrest to a shockable rhythm was initially 5% per minute, decreasing to 4% per minute after 9 min. The corresponding risk to a non-shockable rhythm was constant at 1% per minute. The risk of re-arrest within 20 min was 27%, and the overall risk of at least one re-arrest per episode was 33%.

CONCLUSIONS

The immediate risk of re-arrest was approximately 2% per minute, with the highest risk occurring as a reversion to VF/VT if ROSC was obtained from VF/VT. The risk of re-arrest within 20 min of the initial arrest was 27%, and the overall risk of at least one re-arrest per episode was 33%.

The elephant in the room: In-hospital resuscitation research is impeded by flawed time data

Not applicable.

In-hospital cardiac arrest survival before and after the COVID-19 pandemic: Have higher performing hospitals stayed high-performing?

BACKGROUND

Survival for in-hospital cardiac arrest (IHCA) has declined since the COVID-19 pandemic. Because the burden of COVID-19 was uneven throughout the U.S., it remains unknown if top-performer hospitals in IHCA survival have remained top-performers since the pandemic.

METHODS

Within Get With The Guidelines®-Resuscitation, we identified hospitals with at least 2 years of registry participation pre-pandemic (2017-2019) and post-pandemic (July 2020-2022) and with at least 20 IHCA cases in both periods. Using multivariable hierarchical models with hospital as a random effect and adjusting for patient and arrest characteristics, we calculated risk-standardized survival rates to discharge (RSSR) for IHCA at each hospital during the pre- and post-pandemic periods. We then assessed the correlation between a hospital's pre-pandemic and post-pandemic RSSR for IHCA, and whether the correlation differed by the proportion of Black or Hispanic IHCA patients at each hospital.

RESULTS

A total of 243 hospitals were included, comprising 122,561 IHCAs (pre-pandemic: 57,601; post-pandemic: 64,960). Pre-pandemic, the mean RSSR was 26.8% (SD, 5.2%) whereas the mean RSSR post-pandemic was 21.7% (SD, 5.5%). There was good correlation between a hospital's pre- and post-pandemic RSSR: correlation of 0.55. When hospitals were categorized into tertiles based on the proportion of their IHCA patients who were Black or Hispanic, this correlation remained similar: 0.48, 0.68, and 0.45 (interaction P-value: 0.69) for hospitals in the upper, middle and lower tertiles, respectively.

CONCLUSION

Although the COVID-19 pandemic affected the U.S. unevenly, there was good correlation in a hospital's performance for IHCA survival before and after the pandemic, even at hospitals caring for a larger proportion of Black and Hispanic patients. Future studies are needed to understand what characteristics of high-performing hospitals pre-pandemic allowed many to continue to excel in the post-pandemic period.

Correlation between hospital rates of survival to discharge and long-term survival for in-hospital cardiac arrest: Insights from Get With The Guidelines®-Resuscitation registry

AIM

Given challenges in collecting long-term outcomes for survivors of in-hospital cardiac arrest (IHCA), most studies have focused on in-hospital survival. We evaluated the correlation between a hospital's risk-standardized survival rate (RSSR) at hospital discharge for IHCA with its RSSR for long-term survival.

METHODS

We identified patients ≥65 years of age with IHCA at 472 hospitals in Get With The Guidelines®-Resuscitation registry during 2000-2012, who could be linked to Medicare files to obtain post-discharge survival data. We constructed hierarchical logistic regression models to compute RSSR at discharge, and 30-day, 1-year, and 3-year RSSRs for each hospital. The association between in-hospital and long-term RSSR was evaluated with weighted Kappa coefficients.

RESULTS

Among 56,231 Medicare beneficiaries (age 77.2 ± 7.5 years and 25,206 [44.8%] women), 10,536 (18.7%) survived to discharge and 8,485 (15.1%) survived to 30 days after discharge. Median in-hospital, 30-day, 1-year, and 3-year RSSRs were 18.6% (IQR, 16.7-20.4%), 14.9% (13.2-16.7%), 10.3% (9.1-12.1%), and 7.6% (6.8-8.8%), respectively. The weighted Kappa coefficient for the association between a hospital's RSSR at discharge with its 30-day, 1-year, and 3-year RSSRs were 0.72 (95% CI, 0.68-0.76), 0.56 (0.50-0.61), and 0.47 (0.41-0.53), respectively.

CONCLUSIONS

There was a strong correlation between a hospital's RSSR at discharge and its 30-day RSSR for IHCA, although this correlation weakens over time. Our findings suggest that a hospital's RSSR at discharge for IHCA may be a reasonable surrogate of its 30-day post-discharge survival and could be used by Medicare to benchmark hospital performance for this condition without collecting 30-day survival data.

Post cardiac arrest left ventricular ejection fraction associated with survival to discharge

Background

Post cardiac arrest left ventricular ejection fraction (LVEF) is routinely assessed, but the implications of this are unknown. This study aimed to assess the association between post cardiac arrest LVEF and survival to hospital discharge.

Methods

In this retrospective cohort study, all in-hospital and out of hospital cardiac arrests at our tertiary care center between January 2012 and September 2015 were included. Baseline demographics, clinical data, characteristics of the arrest, and interventions performed were collected. Earliest post cardiac arrest echocardiograms were reviewed with LVEF documented. The primary outcome was survival to discharge.

Results

A total of 736 patients were included in the analysis (mean age 58 years, 44% female). 15% were out of hospital cardiac arrest (24% shockable rhythm). After adjusting for covariates, patients with LVEF < 30% had 36% lower odds of surviving to hospital discharge than those with LVEF ≥ 52% (p = 0.014). Shockable initial rhythm and targeted temperature management were associated with improved survival.

Conclusion

After a cardiac arrest, an initial LVEF < 30% is associated with significantly lower odds of survival to hospital discharge.

The association of intravenous vs. humeral-intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests

AIM

While intravenous (IV) vascular access for out-of-hospital cardiac arrest (OHCA) resuscitation is standard, humeral-intraosseous (IO) access is commonly used, despite few supporting data. We investigated the association between IV vs. humeral-IO and outcomes.

METHODS

We utilized BC Cardiac Arrest Registry data, including adult OHCA where the first-attempted intra-arrest vascular access route performed by advanced life support (ALS)-trained paramedics was IV or humeral-IO. We fit a propensity-score adjusted model with inverse probability treatment weighting to estimate the association between IV vs. humeral-IO routes and favorable neurological outcomes (CPC 1-2) and survival at hospital discharge. We repeated models within subgroups defined by initial cardiac rhythm.

RESULTS

We included 2,112 cases; the first-attempted route was IV (n = 1,575) or humeral-IO (n = 537). Time intervals from ALS-paramedic on-scene arrival to vascular access (6.6 vs. 6.9 min) and epinephrine administration (9.0 vs. 9.3 min) were similar between IV and IO groups, respectively. Among IV and humeral-IO groups, 98 (6.2%) and 20 (3.7%) had favorable neurological outcomes. Compared to humeral-IO, an IV-first approach was associated with improved hospital-discharge favorable neurological outcomes (AOR 1.7; 95% CI 1.1-2.7) and survival (AOR 1.5; 95% CI 1.0-2.3). Among shockable rhythm cases, an IV-first approach was associated with improved favorable neurological outcomes (AOR 4.2; 95% CI 2.1-8.2), but not among non-shockable rhythm cases (AOR 0.73; 95% CI 0.39-1.4).

CONCLUSION

An IV-first approach, compared to humeral-IO, for intra-arrest resuscitation was associated with an improved odds of favorable neurological outcomes and survival to hospital discharge. This association was seen among an initial shockable rhythm, but not non-shockable rhythm, subgroups.

Characteristics, Outcome and Prognostic Factors of Patients with Emergency Department Cardiac Arrest: A 14-Year Retrospective Study

Introduction: Cardiac arrests are traditionally classified according to the setting in which they occur, including out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). However, cardiac arrests that occur in the emergency department (EDCA) could constitute a third category, due to the peculiar characteristics of the emergency department (ED). In recent years, the need to study EDCAs separately from other intra-hospital events has emerged. The aim of this study was to describe the characteristics and outcomes of a cohort of patients experiencing EDCA in an Italian hospital over a 14-year period. Methods: This was a single-centre retrospective observational study conducted in the ED of the Santa Croce e Carle Hospital in Cuneo, Italy. All adult patients who experienced EDCA between 1 January 2010 and 30 June 2023 were included. OHCA patients, those arriving in the ED with on-going resuscitation measures, patients with EDCA not undergoing resuscitation, and patients with post-traumatic cardiac arrest were excluded from the study. The main outcome of the study was survival at hospital discharge with a favourable neurological outcome. Results: 350 cases of EDCA were included. The median age was 78 (63-85) years, and the median Charlson Comorbidity Index score was 5 (3-6). A total of 35 patients (10%) survived to hospital discharge with a cerebral performance category (CPC) Score of 1-2; survival in the ED was 28.3%. The causes of cardiac arrests were identified in 212 cases (60.6%) and included coronary thrombosis (35%), hypoxia (22%), hypovolemia (17%), pulmonary embolism (11%), metabolic (8%), cardiac tamponade (4%), toxins (2%) and hypothermia (1%). Variables associated with survival with a favourable neurological outcome were young age, a lower Charlson Comorbidity Index, coronary thrombosis as the primary EDCA cause, and shockable presenting rhythm; however, only the latter was associated with the outcome in a multivariate age-weighted model. Conclusions: In a cohort of patients with EDCA over a period of more than a decade, the most frequent cause identified was coronary thrombosis; 10% of patients survived with a good neurological status, and the only factor associated with the best prognosis was presenting a shockable rhythm. EDCA should be considered an independent category in order to fully understand its characteristics and outcomes.

Use of Initial Endotracheal Versus Intravenous Epinephrine During Neonatal Cardiopulmonary Resuscitation in the Delivery Room: Review of a National Database

OBJECTIVE

To assess whether initial epinephrine administration by endotracheal tube (ET) in newly born infants receiving chest compressions and epinephrine in the delivery room (DR) is associated with lower rates of return of spontaneous circulation (ROSC) than newborns receiving initial intravenous (IV) epinephrine.

STUDY DESIGN

We conducted a retrospective review of neonates receiving chest compressions and epinephrine in the DR from the AHA Get With The Guidelines-Resuscitation registry from October 2013 through July 2020. Neonates were classified according to initial route of epinephrine (ET vs IV). The primary outcome of interest was ROSC in the DR.

RESULTS

In total, 408 infants met inclusion criteria; of these, 281 (68.9%) received initial ET epinephrine and 127 (31.1%) received initial IV epinephrine. The initial ET epinephrine group included those infants who also received subsequent IV epinephrine when ET epinephrine failed to achieve ROSC. Comparing initial ET with initial IV epinephrine, ROSC was achieved in 70.1% vs 58.3% (adjusted risk difference 10.02; 95% CI 0.05-19.99). ROSC was achieved in 58.3% with IV epinephrine alone, and 47.0% with ET epinephrine alone, with 40.0% receiving subsequent IV epinephrine.

CONCLUSIONS

This study suggests that initial use of ET epinephrine is reasonable during DR resuscitation, as there were greater rates of ROSC compared with initial IV epinephrine administration. However, administration of IV epinephrine should not be delayed in those infants not responding to initial ET epinephrine, as almost one-half of infants who received initial ET epinephrine subsequently received IV epinephrine before achieving ROSC.

Hospital Variation in Epinephrine Administration Before Defibrillation for Cardiac Arrest Due to Shockable Rhythm

OBJECTIVES

Contrary to advanced cardiac life support guidelines that recommend immediate defibrillation for shockable in-hospital cardiac arrest (IHCA), epinephrine administration before first defibrillation is common and associated with lower survival at a "patient-level." Whether this practice varies across hospitals and its association with "hospital-level" IHCA survival remains unknown. The purpose of this study was to determine hospital variation in rates of epinephrine administration before defibrillation for shockable IHCA and its association with IHCA survival.

DESIGN

Observational cohort study.

SETTING

Five hundred thirteen hospitals participating in the Get With The Guidelines Resuscitation Registry.

PATIENTS

A total of 37,668 adult patients with IHCA due to an initial shockable rhythm from 2000 to 2019.

INTERVENTIONS

Epinephrine before first defibrillation.

MEASUREMENTS AND MAIN RESULTS

Using multivariable hierarchical regression, we examined hospital variation in epinephrine administration before first defibrillation and its association with hospital-level rates of risk-adjusted survival. The median hospital rate of epinephrine administration before defibrillation was 18.8%, with large variation across sites (range, 0-68.8%; median odds ratio: 1.54; 95% CI, 1.47-1.61). Major teaching status and annual IHCA volume were associated with hospital rate of epinephrine administration before defibrillation. Compared with hospitals with the lowest rate of epinephrine administration before defibrillation (Q1), there was a stepwise decline in risk-adjusted survival at hospitals with higher rates of epinephrine administration before defibrillation (Q1: 44.3%, Q2: 43.4%; Q3: 41.9%; Q4: 40.3%; p for trend < 0.001).

CONCLUSIONS

Administration of epinephrine before defibrillation in shockable IHCA is common and varies markedly across U.S. hospitals. Hospital rates of epinephrine administration before defibrillation were associated with a significant stepwise decrease in hospital rates of risk-adjusted survival. Efforts to prioritize immediate defibrillation for patients with shockable IHCA and avoid early epinephrine administration are urgently needed.

Duration of cardiopulmonary resuscitation and outcomes for adults with in-hospital cardiac arrest: retrospective cohort study

OBJECTIVE

To quantify time dependent probabilities of outcomes in patients after in-hospital cardiac arrest as a function of duration of cardiopulmonary resuscitation, defined as the interval between start of chest compression and the first return of spontaneous circulation or termination of resuscitation.

DESIGN

Retrospective cohort study.

SETTING

Multicenter prospective in-hospital cardiac arrest registry in the United States.

PARTICIPANTS

348 996 adult patients (≥18 years) with an index in-hospital cardiac arrest who received cardiopulmonary resuscitation from 2000 through 2021.

MAIN OUTCOME MEASURES

Survival to hospital discharge and favorable functional outcome at hospital discharge, defined as a cerebral performance category score of 1 (good cerebral performance) or 2 (moderate cerebral disability). Time dependent probabilities of subsequently surviving to hospital discharge or having favorable functional outcome if patients pending the first return of spontaneous circulation at each minute received further cardiopulmonary resuscitation beyond the time point were estimated, assuming that all decisions on termination of resuscitation were accurate (that is, all patients with termination of resuscitation would have invariably failed to survive if cardiopulmonary resuscitation had continued for a longer period of time).

RESULTS

Among 348 996 included patients, 233 551 (66.9%) achieved return of spontaneous circulation with a median interval of 7 (interquartile range 3-13) minutes between start of chest compressions and first return of spontaneous circulation, whereas 115 445 (33.1%) patients did not achieve return of spontaneous circulation with a median interval of 20 (14-30) minutes between start of chest compressions and termination of resuscitation. 78 799 (22.6%) patients survived to hospital discharge. The time dependent probabilities of survival and favorable functional outcome among patients pending return of spontaneous circulation at one minute's duration of cardiopulmonary resuscitation were 22.0% (75 645/343 866) and 15.1% (49 769/328 771), respectively. The probabilities decreased over time and were <1% for survival at 39 minutes and <1% for favorable functional outcome at 32 minutes' duration of cardiopulmonary resuscitation.

CONCLUSIONS

This analysis of a large multicenter registry of in-hospital cardiac arrest quantified the time dependent probabilities of patients' outcomes in each minute of duration of cardiopulmonary resuscitation. The findings provide resuscitation teams, patients, and their surrogates with insights into the likelihood of favorable outcomes if patients pending the first return of spontaneous circulation continue to receive further cardiopulmonary resuscitation.

The association of tibial vs. humeral intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests

AIM

Humeral and tibial intraosseous (IO) vascular access can deliver resuscitative medications for out-of-hospital cardiac arrest (OHCA), however the optimal site is unclear. We examined the association between IO tibia vs. humerus as the first-attempted vascular access site with OHCA outcomes.

METHODS

We used prospectively-collected data from the British Columbia Cardiac Arrest registry, including adult OHCAs treated with IO humerus or IO tibia as the first-attempted intra-arrest vascular access. We fit logistic regression models on the full study cohort and a propensity-matched cohort, to estimate the association between IO site and both favorable neurological outcomes (Cerebral Performance Category 1-2) and survival at hospital discharge.

RESULTS

We included 1041 (43%) and 1404 (57%) OHCAs for whom IO humerus and tibia, respectively, were the first-attempted intra-arrest vascular access. Among humerus and tibia cases, 1010 (97%) and 1369 (98%) had first-attempt success, and the median paramedic arrival-to-successful access interval was 6.7 minutes (IQR 4.4-9.4) and 6.1 minutes (IQR 4.1-8.9), respectively. In the propensity-matched cohort (n = 2052), 31 (3.0%) and 44 (4.3%) cases had favourable neurological outcomes in the IO humerus and IO tibia groups, respectively; compared to IO humerus, we did not detect an association between IO tibia with favorable neurological outcomes (OR 1.44; 95% CI 0.90-2.29) or survival to hospital discharge (OR 1.29; 95% CI 0.83-2.01). Results using the full cohort were similar.

CONCLUSIONS

We did not detect an association between the first-attempted intra-arrest IO site (tibia vs. humerus) and clinical outcomes. Clinical trials are warranted to test differences between vascular access strategies.

Epinephrine dosing strategies during pediatric extracorporeal cardiopulmonary resuscitation reveal novel impacts on survival: A multicenter study utilizing time-stamped epinephrine dosing records

OBJECTIVES

To describe epinephrine dosing distribution using time-stamped data and assess the impact of dosing strategy on survival after ECPR in children.

METHODS

This was a retrospective study at five pediatric hospitals of children <18 years with an in-hospital ECPR event. Mean number of epinephrine doses was calculated for each 10-minute CPR interval and compared between survivors and non-survivors. Patients were also divided by dosing strategy into a frequent epinephrine group (dosing interval of ≤5 min/dose throughout the first 30 minutes of the event), and a limited epinephrine group (dosing interval of ≤5 min/dose for the first 10 minutes then >5 min/dose for the time between 10 and 30 minutes).

RESULTS

A total of 191 patients were included. Epinephrine was not evenly distributed throughout ECPR, with 66% of doses being given during the first half of the event. Mean number of epinephrine doses was similar between survivors and non-survivors the first 10 minutes (2.7 doses). After 10 minutes, survivors received fewer doses than non-survivors during each subsequent 10-minute interval. Adjusted survival was not different between strategy groups [OR of survival for frequent epinephrine strategy: 0.78 (95% CI 0.36-1.69), p = 0.53].

CONCLUSIONS

Survivors received fewer doses than non-survivors after the first 10 minutes of CPR and although there was no statistical difference in survival based on dosing strategy, the findings of this study question the conventional approach to EPCR analysis that assumes dosing is evenly distributed.

Sex differences in the association between bystander CPR and survival for Out-of-Hospital cardiac arrest

BACKGROUND

Prior studies have identified socio-cultural barriers in laypersons performing high-quality cardiopulmonary resuscitation (CPR) in women. Whether the effect of layperson bystander CPR on survival from out-of-hospital cardiac arrest (OHCA) differs by patients' sex is unknown.

METHODS

Using data during 2013-2020 from an OHCA registry in the U.S., we identified adult patients with non-traumatic OHCA. The primary outcome was favorable neurological survival and the secondary outcome was survival to discharge. Multivariable logistic regression models evaluated the interaction between patients' sex and bystander CPR with survival, adjusted for patient and cardiac arrest characteristics.

RESULTS

Of 420,671 patients with OHCA, 151,145 (35.9 %) occurred in women and 269,526 (64.1 %) in men. Rates of layperson bystander CPR were similar between women (38.3 %) and men (40.0 %). Rates of favorable neurological survival were 11.4 % in those with bystander CPR and 5.6 % in those without, but the association between bystander CPR and favorable neurological survival was weaker for women than men (women: adjusted OR, 1.33 [95 % CI: 1.27-1.39]; men: adjusted OR, 1.55 [95 % CI: 1.51-1.61]; interaction p < 0.001)]. Rates of survival to discharge were 13.1 % and 7.3 % in those with and without layperson bystander CPR, and the association between bystander CPR was weaker for women than men (women: adjusted OR, 1.21 [95 % CI: 1.16-1.26]; men: adjusted OR, 1.43 [95 % CI: 1.39-1.47]; interaction p < 0.001).

CONCLUSIONS

For OHCA, bystander CPR was associated with higher survival in women and men. However, as currently practiced, the association between bystander CPR and higher survival was weaker for women as compared with men.

Calcium Administration During Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest in Children With Heart Disease Is Associated With Worse Survival-A Report From the American Heart Association's Get With The Guidelines-Resuscitation (GWTG-R) Registry

OBJECTIVES

IV calcium administration during cardiopulmonary resuscitation (CPR) for pediatric in-hospital cardiac arrest (IHCA) is associated with worse survival. We evaluated survival to hospital discharge in children with heart disease (HD), where calcium is more frequently administered during CPR.

DESIGN

Retrospective study of a multicenter registry database.

SETTING

Data reported to the American Heart Association's (AHA) Get With The Guidelines-Resuscitation registry.

PATIENTS

Children younger than 18 years with HD experiencing an index IHCA event requiring CPR between January 2000 and January 2019. Using propensity score matching (PSM), we selected matched cohorts of children receiving and not receiving IV calcium during CPR and compared the primary outcome of survival to hospital discharge.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We included 4,556 children with HD experiencing IHCA. Calcium was administered in 1,986 (44%), more frequently in children younger than 1 year old (65% vs 35%; p < 0.001) and surgical cardiac (SC) compared with medical cardiac patients (51% vs 36%; p < 0.001). Calcium administration during CPR was associated with longer duration CPR (median 27 min [interquartile range (IQR): 10-50 min] vs 5 min [IQR, 2-16 min]; p < 0.001) and more frequent extracorporeal-CPR deployment (25% vs 8%; p < 0.001). In the PSM cohort, those receiving calcium had decreased survival to hospital discharge (39% vs 46%; p = 0.02) compared with those not receiving calcium. In a subgroup analysis, decreased discharge survival was only seen in SC cohorts.

CONCLUSIONS

Calcium administration during CPR for children with HD experiencing IHCA is common and is associated with worse survival. Administration of calcium during CPR in children with HD should be restricted to specific indications as recommended by the AHA CPR guidelines.

Patient characteristics and survival outcomes of cardiac arrest in the cardiac catheterization laboratory: Insights from get with the Guidelines®-Resuscitation registry

BACKGROUND

Characteristics and outcomes of patients with in-hospital cardiac arrest (IHCA) in the cardiac catheterization laboratory (CCL) have not been well-described. Thus, we compared the outcomes of patients with an IHCA in the CCL versus those in the intensive care unit (ICU) and operating rooms (OR).

METHODS

Within the American Heart Association's Get With the Guidelines®-Resuscitation registry, we identified patients ≥ 18 years old with IHCA in the CCL, ICU, or OR between 2000-2019. Using hierarchical multivariable logistic regression, we compared rates of survival to discharge for patients with IHCA in the CCL versus ICU and OR.

RESULTS

Across 428 hospitals, 193,950 patients had IHCA, of whom 6865, 181,905 and 5180 were in the CCL, ICU and OR, respectively. Overall, 2614 (38.1%) patients with IHCA in the CCL survived to discharge, whereas 30,830 (16.9%) and 2096 (40.5%) survived to discharge from the ICU and OR, respectively. After adjustment, patients with IHCA in CCL were more likely to survive to discharge as compared to those with IHCA in the ICU (odds ratio, 1.37 [95%CI: 1.29-1.46], p < 0.001). In contrast, those who had IHCA in the CCL were less likely to survive to discharge as compared to patients with IHCA in the OR (odds ratio, 0.81 [95%CI: 0.69-0.94], p = 0.006).

CONCLUSION

IHCA in the CCL is not uncommon and has a lower survival rate when compared with IHCA in the OR. The reasons for this difference deserve further study given that cardiac arrest in both settings is witnessed and response time should be similar.

Association between time to advanced airway management and survival during pediatric out-of-hospital cardiac arrest

Background

Respiratory care, including advanced airway management (AAM), is an important part of pediatric resuscitation. This study aimed to determine whether time to AAM is associated with outcomes after out-of-hospital cardiac arrest (OHCA) in children.

Methods

This was a nationwide population-based observational study using the Japanese government-led registry of OHCA patients. Children (aged 1–17 years) who experienced OHCA and received AAM by emergency medical service (EMS) personnel in the prehospital setting from 2014 to 2019 were included. Multivariable logistic regression models were used to assess the associations between time to AAM (defined as time in minutes from emergency call to the first successful AAM) and outcomes after OHCA. The primary outcome was one-month overall survival. The secondary outcomes were prehospital return of spontaneous circulation (ROSC) and one-month neurologically favorable survival.

Results

A total of 761 patients (mean [SD] age, 12.7 [4.8] years) were included. The mean time to AAM was 18.9 min (SD, 7.9). Overall, 77 (10.1%) patients survived one month after OHCA. After adjusting for potential confounders, longer time to AAM was significantly associated with a decreased chance of one-month survival (multivariable adjusted OR per minute delay, 0.93 [95% CI, 0.89–0.97]; P = 0.001). Similar association was observed for prehospital ROSC (adjusted OR, 0.94 [95% CI, 0.90–0.99]; P = 0.01) and neurologically favorable survival (adjusted OR, 0.83 [95% CI, 0.72–0.95]; P = 0.006). This association between time to AAM and survival was consistent across a variety of sensitivity and subgroup analyses.

Conclusions

Among pediatric OHCA patients, delayed AAM was associated with a decreased chance of survival, although the influence of resuscitation time bias might remain.

Survival From Pediatric Out-of-Hospital Cardiac Arrest During Nights and Weekends: An Updated Japanese Registry-Based Study

Background

Disparities in survival after pediatric out-of-hospital cardiac arrest (OHCA) between on-duty hours and off-duty hours have previously been reported. However, little is known about whether these disparities have remained in recent years.

Objectives

This study aimed to examine the association of outcomes after pediatric OHCA with time of day and day of week.

Methods

This observational study analyzed the Japanese government-led nationwide population-based registry data of OHCA patients. Pediatric (<18 years) patients who experienced OHCA between 2012 and 2017 were included. A multivariable logistic regression model was used to examine the association of both time of day (day/evening vs night) and day of week (weekday vs weekend) with outcomes after OHCA. The primary outcome was 1-month survival.

Results

A total of 7,106 patients (mean age, 5.7 ± 6.5 years; 60.9% male) were included. 1,897 events (26.7%) occurred during night hours, and 2,096 events (29.5%) occurred on weekends. Overall, 1,192 (16.8%) survived 1 month after OHCA. After adjusting for potential confounders, 1-month survival during day/evening (1,047/5,209 [20.1%]) was significantly higher than that at night (145/1,897 [7.6%]) (adjusted odds ratio: 2.31 [95% CI: 1.87-2.86]), whereas there was no significant difference in 1-month survival between weekdays (845/5,010 [16.9%]) and weekends (347/2,096 [16.6%]) (adjusted odds ratio: 1.04 [95% CI: 0.88-1.23]).

Conclusions

One-month survival after pediatric OHCA remained significantly lower during night than during day/evening, although disparities in 1-month survival between weekdays and weekends have been eliminated over time. Further studies are warranted to investigate the mechanisms underlying decreased survival at night.

Physiologic effects of stress dose corticosteroids in in-hospital cardiac arrest (CORTICA): A randomized clinical trial

Aim

Postresuscitation hemodynamics are associated with hospital mortality/functional outcome. We sought to determine whether low-dose steroids started during and continued after cardiopulmonary resuscitation (CPR) affect postresuscitation hemodynamics and other physiological variables in vasopressor-requiring, in-hospital cardiac arrest.

Methods

We conducted a two-center, randomized, double-blind trial of patients with adrenaline (epinephrine)-requiring cardiac arrest. Patients were randomized to receive either methylprednisolone 40 mg (steroids group) or normal saline-placebo (control group) during the first CPR cycle post-enrollment. Postresuscitation shock was treated with hydrocortisone 240 mg daily for 7 days maximum and gradual taper (steroids group), or saline-placebo (control group). Primary outcomes were arterial pressure and central-venous oxygen saturation (ScvO₂) within 72 hours post-ROSC.

Results

Eighty nine of 98 controls and 80 of 86 steroids group patients with ROSC were treated as randomized. Primary outcome data were collected from 100 patients with ROSC (control, n = 54; steroids, n = 46). In intention-to-treat mixed-model analyses, there was no significant effect of group on arterial pressure, marginal mean (95% confidence interval) for mean arterial pressure, steroids vs. control: 74 (68–80) vs. 72 (66–79) mmHg] and ScvO₂ [71 (68–75)% vs. 69 (65–73)%], cardiac index [2.8 (2.5–3.1) vs. 2.9 (2.5–3.2) L/min/m²], and serum cytokine concentrations [e.g. interleukin-6, 89.1 (42.8–133.9) vs. 75.7 (52.1–152.3) pg/mL] determined within 72 hours post-ROSC (P = 0.12–0.86). There was no between-group difference in body temperature, echocardiographic variables, prefrontal blood flow index/cerebral autoregulation, organ failure-free days, and hazard for poor in-hospital/functional outcome, and adverse events (P = 0.08–>0.99).

Conclusions

Our results do not support the use of low-dose corticosteroids in in-hospital cardiac arrest.

Trial Registration:ClinicalTrials.gov number: NCT02790788 (https://www.clinicaltrials.gov).

Outcomes of pediatric patients with COVID-19 and in-hospital cardiopulmonary resuscitation

BACKGROUND

Early studies found low survival rates for adults with COVID-19 infection and in-hospital cardiac arrest (IHCA). We evaluated the association of COVID-19 infection on survival outcomes in pediatric patients undergoing cardiopulmonary resuscitation (CPR).

METHODS

Within Get-With-The-Guidelines®-Resuscitation, we identified pediatric patients who underwent CPR for an IHCA or bradycardia with poor perfusion between March and December, 2020. We compared survival outcomes (survival to discharge and return of spontaneous circulation for ≥20 minutes [ROSC]) between patients with suspected/confirmed COVID-19 infection and non-COVID-19 patients using multivariable hierarchical regression, with hospital site as a random effect and patient and cardiac arrest variables with a significant (p < 0.05) bivariate association as fixed effects.

RESULTS

Overall, 1328 pediatric in-hospital CPR events were identified (590 IHCA, 738 bradycardia with poor perfusion), of which 46 (32 IHCA, 14 bradycardia) had suspected/confirmed COVID-19 infection. Rates of survival to discharge were similar between those with and without COVID-19 infection (39.1% vs. 44.9%; adjusted RR, 1.14 [95% CI: 0.55-2.36]), and these estimates were similar for those with IHCA and bradycardia with poor perfusion (adjusted RRs of 1.03 and 1.05; interaction p = 0.96). Rates of ROSC were also similar between pediatric patients with and without COVID-19 overall (67.4% vs. 76.9%; adjusted RR, 0.87 [0.43, 1.77]), and for the subgroups with IHCA or bradycardia requiring CPR (adjusted RRs of 0.95 and 0.86, interaction p = 0.26).

CONCLUSIONS

In a large multicenter national registry of CPR events, COVID-19 infection was not associated with lower rates of ROSC or survival to hospital discharge in pediatric patients undergoing CPR.

Survival outcomes and resuscitation process measures in maternal in-hospital cardiac arrest

BACKGROUND

Maternal in-hospital cardiac arrest is a rare event with the potential for resuscitation treatment delays because of the difficulty accessing hospital obstetrical units and limited simulation training or resuscitation experience of obstetrical staff. However, it is unclear whether survival rates and processes of care differ between women with a maternal in-hospital cardiac arrest and those with a nonmaternal in-hospital cardiac arrest.

OBJECTIVE

We aimed determine whether to there are delays in process measures and differences in survival outcomes between pregnant and nonpregnant women who have in-hospital cardiac arrest.

STUDY DESIGN

Using data from 2000 to 2019 in the Get With The Guidelines-Resuscitation registry, we compared resuscitation outcomes between women aged 18 to 50 years with a maternal or nonmaternal in-hospital cardiac arrest. Using a nonparsimonious propensity score, we matched patients with a maternal in-hospital cardiac arrest to as many as 10 women with a nonmaternal in-hospital cardiac arrest. We constructed conditional logistic regression models to compare survival outcomes (survival to discharge, favorable neurologic survival [discharge cerebral performance score of 1], and return of spontaneous circulation) and processes of care (delayed defibrillation [>2 minutes] and administration of epinephrine [>5 minutes]) between women with a maternal in-hospital cardiac arrest vs those with a nonmaternal in-hospital cardiac arrest.

RESULTS

Overall, 421 women with a maternal in-hospital cardiac arrest were matched by propensity score to 2316 women with a nonmaternal in-hospital cardiac arrest. The mean age among propensity score-matched women with a maternal in-hospital cardiac arrest was 31.4 (standard deviation, 6.5) years, where 33.7% were of Black race and 86.9% had an initial nonshockable cardiac arrest rhythm. Unadjusted survival rates were higher in women with a maternal in-hospital cardiac arrest than in women with a nonmaternal in-hospital cardiac arrest: survival to discharge of 45.1% vs 26.5%, survival with cerebral performance category 1 status of 36.1% vs 17.7%, and return of spontaneous circulation of 75.8% vs 70.6%. After adjustment, there was no difference in the likelihood of survival to discharge (odds ratio, 1.19; 95% confidence interval, 0.82-1.73) or return of spontaneous circulation (odds ratio, 0.94; 95% confidence interval, 0.65-1.35) between women with a maternal in-hospital cardiac arrest and those with a nonmaternal in-hospital cardiac arrest. However, women with a maternal in-hospital cardiac arrest were more likely to have favorable neurologic survival (odds ratio, 1.57; 95% confidence interval, 1.06-2.33). Compared with women with a nonmaternal in-hospital cardiac arrest, women with a maternal in-hospital cardiac arrest had similar rates of delayed defibrillation (42.5% vs 34.4%; odds ratio, 1.14 [95% confidence interval, 0.41-3.18]; P=.31) and delayed administration of epinephrine (13.8% vs 10.6%; odds ratio, 0.96 [95% confidence interval, 0.50-1.86]; P=.09).

CONCLUSION

Although concerns have been raised about resuscitation outcomes in women with a maternal in-hospital cardiac arrest, the rates of survival and resuscitation processes of care were not worse in women with a maternal in-hospital cardiac arrest.

In-Hospital Cardiac Arrest Survival in the United States During and After the Initial Novel Coronavirus Disease 2019 Pandemic Surge

BACKGROUND

Recent reports on challenges in resuscitation care at hospitals severely affected by the novel coronavirus disease 2019 (COVID-19) pandemic raise questions about how the pandemic affected outcomes for in-hospital cardiac arrest throughout the United States.

METHODS

Within Get With The Guidelines-Resuscitation, we conducted a retrospective cohort study to compare in-hospital cardiac arrest survival during the presurge (January 1-February 29), surge (March 1-May 15) and immediate postsurge (May 16-June 30) periods in 2020 compared to 2015 to 2019. Monthly COVID-19 mortality rates for each hospital's county were categorized, per 1 000 000 residents, as low (0-10), moderate (11-50), high (51-100), or very high (>100). Using hierarchical regression models, we compared rates of survival to discharge in 2020 versus 2015 to 2019 for each period.

RESULTS

Of 61 586 in-hospital cardiac arrests, 21 208 (4309 in 2020), 26 459 (5949 in 2020), and 13 919 (2686 in 2020) occurred in the presurge, surge, and postsurge periods, respectively. During the presurge period, 24.2% survived to discharge in 2020 versus 24.7% in 2015 to 2019 (adjusted odds ratio, 1.12 [95% CI, 1.02-1.22]). In contrast, during the surge period, 19.6% survived to discharge in 2020 versus 26.0% in 2015 to 2019 (adjusted odds ratio, 0.81 [0.75-0.88]). Lower survival was most pronounced in communities with high (28% lower survival) and very high (42% lower survival) monthly COVID-19 mortality rates (interaction P<0.001). Resuscitation times were shorter (median: 22 versus 25 minutes; P<0.001), and delayed epinephrine treatment was more prevalent (11.3% versus 9.9%; P=0.004) during the surge period. Survival was lower even when patients with confirmed/suspected COVID-19 infection were excluded from analyses. During the postsurge period, survival rates were similar in 2020 versus 2015 to 2019 (22.3% versus 25.8%; adjusted odds ratio, 0.93 [0.83-1.04]), including communities with high COVID-19 mortality (interaction P=0.16).

CONCLUSIONS

Early during the pandemic, rates of survival to discharge for IHCA decreased, even among patients without COVID-19 infection, highlighting the early impact of the COVID-19 pandemic on in-hospital resuscitation.

Variation Across Hospitals in In-Hospital Cardiac Arrest Incidence Among Medicare Beneficiaries

IMPORTANCE

Although survival for in-hospital cardiac arrest (IHCA) has improved substantially over the last 2 decades, survival rates have plateaued in recent years. A better understanding of hospital differences in IHCA incidence may provide important insights regarding best practices for prevention of IHCA.

OBJECTIVE

To determine the incidence of IHCA among Medicare beneficiaries, and evaluate hospital variation in incidence of IHCA.

DESIGN, SETTING, AND PARTICIPANTS

This observational cohort study analyzes 2014 to 2017 data from 170 hospitals participating in the Get With The Guidelines-Resuscitation registry, linked to Medicare files. Participants were adults aged 65 years and older. Statistical analysis was performed from January to December 2021.

EXPOSURES

Case-mix index, teaching status, and nurse-staffing.

MAIN OUTCOMES AND MEASURES

Hospital incidence of IHCA among Medicare beneficiaries was estimated as the number of IHCA patients divided by the total number of hospital admissions. Multivariable hierarchical regression models were used to calculate hospital incidence rates adjusted for differences in patient case-mix and evaluate the association of hospital variables with IHCA incidence.

RESULTS

Among a total of 4.5 million admissions at 170 hospitals, 38 630 patients experienced an IHCA during 2014 to 2017. Among the 38 630 patients with IHCAs, 7571 (19.6%) were non-Hispanic Black, 26 715 (69.2%) were non-Hispanic White, and 16 732 (43.3%) were female; the mean (SD) age at admission was 76.3 (7.8) years. The median risk-adjusted IHCA incidence was 8.5 per 1000 admissions (95% CI, 8.2-9.0 per 1000 admissions). After adjusting for differences in case-mix index, IHCA incidence varied markedly across hospitals ranging from 2.4 per 1000 admissions to 25.5 per 1000 admissions (IQR, 6.6-11.4; median odds ratio, 1.51 [95% CI, 1.44-1.58]). Among hospital variables, a higher case-mix index, higher nurse staffing, and teaching status were associated with a lower hospital incidence of IHCA.

CONCLUSIONS AND RELEVANCE

This cohort study found that the incidence of IHCA varies markedly across hospitals, and hospitals with higher nurse staffing and teaching status had lower IHCA incidence rates. Future studies are needed to better understand processes of care at hospitals with exceptionally low IHCA incidence to identify best practices for cardiac arrest prevention.

Preparedness for paediatric cardiopulmonary resuscitation amongst medical doctors working in primary health care facilities in Cape Town, South Africa

Background

Cardiopulmonary resuscitation (CPR) is the principal medical intervention used to reduce the high mortality associated with the cardiorespiratory arrest. There is a paucity of literature on the preparedness for paediatric cardiopulmonary resuscitation (pCPR) amongst doctors in Cape Town. This study aimed to assess the preparedness for pCPR of doctors working in Western Cape Provincial Government primary health care facilities (PHCFs) in Cape Town with regard to knowledge, confidence and doctors’ knowledge of equipment availability.

Methods

A cross-sectional study using a questionnaire to collect quantitative data from a sample of 206 doctors working in Cape Town PHCFs.

Results

The questionnaire was completed by 173 doctors (84% response rate). The majority (81.8%) had not undergone pCPR training (Paediatric Advanced Life Support or Advanced Paediatric Life Support). Basic life support was done by 88.3%: 28% greater than two years ago. The average pCPR knowledge score was 61% (standard deviation [s.d.]: 20.3, range: 8.3% – 100%). Doctors in their community service and internship years had significantly higher knowledge scores compared to grade 3 Medical officers (p = 0.001 and p = 0.010, respectively). Eleven per cent had performed pCPR > 10 times in the past year; 20% had never performed pCPR and 35% did not feel confident performing pCPR. More than 35% of doctors were uncertain about the availability of equipment in their facility.

Conclusion

Doctors working in Cape Town PHCFs have poor knowledge, have low confidence levels and are poorly prepared to perform pCPR. Urgent attention needs to be given to ensuring formal pCPR training and acquaintance with equipment availability and location in Cape Town PHCFs.

Association of Nights and Weekends with Survival of Traumatic Out-of-Hospital Cardiac Arrest following Traffic Collisions: Japanese Registry-Based Study

BACKGROUND

The process of care for traumatic out-of-hospital cardiac arrest (OHCA) may be different at night and on the weekend. However, little is known about whether the rate of survival after OHCA is affected by the time of day and day of the week.

METHODS

This observational study analyzed the Japanese government-led nationwide population-based registry data of OHCA patients. Patients who experienced traumatic OHCA following traffic collisions from 2013 to 2017 were included in the study. A multivariable logistic regression model was used to examine the association of both time of day (day/evening vs. night) and day of the week (weekday vs. weekend) with outcomes after traumatic OHCA. Night was defined as 23:00 p.m. to 6:59 a.m., and weekends were defined as Saturday and Sunday. The primary outcome was one-month survival.

RESULTS

A total of 8500 patients (mean [SD] age, 57.7 [22.3] years; 68.6% male) were included. 2267 events (26.7%) occurred at night, and 2482 events (29.2%) occurred on weekends. Overall, 173 patients (2.0%) survived one month after OHCA. After adjusting for potential confounders, one-month survival during the day/evening (148/6233 [2.4%]) was significantly higher than during the night (25/2267 [1.1%]) (adjusted OR, 1.95 [95%CI, 1.24-3.07]), whereas there was no significant difference in one-month survival between weekdays (121/6018 [2.0%]) and weekends (52/2482 [2.1%]) (adjusted OR, 0.97 [95%CI, 0.69-1.38]).

CONCLUSIONS

One-month survival after traumatic OHCA was significantly lower during the night than during the day/evening, although there was no difference in one-month survival between weekdays and weekends. Further studies are warranted to investigate the underlying mechanisms of decreased survival at night.

Impact of the three COVID-19 surges in 2020 on in-hospital cardiac arrest survival in the United States

Background

Studies have reported lower survival for in-hospital cardiac arrest (IHCA) during the initial COVID-19 surge. Whether the pandemic reduced IHCA survival during subsequent surges and in areas with lower COVID-19 rates is unknown.

Methods

Within Get-With-The-Guidelines®-Resuscitation, we identified 22,899 and 79,736 IHCAs during March to December in 2020 and 2015–2019, respectively. Using hierarchical regression, we compared risk-adjusted rates of survival to discharge in 2020 vs. 2015–19 during five COVID-19 periods: Surge 1 (March to mid-May), post-Surge 1 (mid-May to June), Surge 2 (July to mid-August), post-Surge 2 (mid-August to mid-October), and Surge 3 (mid-October to December). Monthly COVID-19 mortality rates for each hospital’s county were categorized, per 1,000,000 residents, as very low (0–10), low (11–50), moderate (51–100), or high (>100).

Results

During each COVID-19 surge period in 2020, rates of survival to discharge for IHCA were lower, as compared with the same period in 2015–2019: Surge 1: adjusted OR: 0.81 (0.75–0.88); Surge 2: adjusted OR: 0.88 (0.79–0.97), Surge 3: adjusted OR: 0.79 (0.73–0.86). Lower survival was most pronounced at hospitals located in counties with moderate to high monthly COVID-19 mortality rates. In contrast, during the two post-surge periods, survival rates were similar in 2020 vs. 2015–2019: post-Surge 1: adjusted OR 0.93 (0.83–1.04) and post-Surge 2: adjusted OR 0.94 (0.86–1.03), even at hospitals with the highest county-level COVID-19 mortality rates.

Conclusions

During the three COVID-19 surges in the U.S. during 2020, rates of survival to discharge for IHCA dropped substantially, especially in communities with moderate to high COVID-19 mortality rates.

Epinephrine before defibrillation in patients with shockable in-hospital cardiac arrest: propensity matched analysis

OBJECTIVE

To determine the use of epinephrine (adrenaline) before defibrillation for treatment of in-hospital cardiac arrest due to a ventricular arrhythmia and examine its association with patient survival.

DESIGN

Propensity matched analysis.

SETTING

2000-18 data from 497 hospitals participating in the American Heart Association’s Get With The Guidelines-Resuscitation registry.

PARTICIPANTS

Adults aged 18 and older with an index in-hospital cardiac arrest due to an initial shockable rhythm treated with defibrillation.

INTERVENTIONS

Administration of epinephrine before first defibrillation.

MAIN OUTCOME MEASURES

Survival to discharge; favorable neurological survival, defined as survival to discharge with none, mild, or moderate neurological disability measured using cerebral performance category scores; and survival after acute resuscitation (that is, return of spontaneous circulation for &gt;20 minutes). A time dependent, propensity matched analysis was performed to adjust for confounding due to indication and evaluate the independent association of epinephrine before defibrillation with study outcomes.

RESULTS

Among 34 820 patients with an initial shockable rhythm, 7054 (20.3%) were treated with epinephrine before defibrillation, contrary to current guidelines. In comparison with participants treated with defibrillation first, participants receiving epinephrine first were less likely to have a history of myocardial infarction or heart failure, but more likely to have renal failure, sepsis, respiratory insufficiency, and receive mechanical ventilation before in-hospital cardiac arrest (standardized differences &gt;10% for all). Treatment with epinephrine before defibrillation was strongly associated with delayed defibrillation (median 4 minutes v 0 minutes). In propensity matched analysis (6569 matched pairs), epinephrine before defibrillation was associated with lower odds of survival to discharge (22.4% v 29.7%; adjusted odds ratio 0.69; 95% confidence interval 0.64 to 0.74; P&lt;0.001), favorable neurological survival (15.8% v 21.6%; 0.68; 0.61 to 0.76; P&lt;0.001) and survival after acute resuscitation (61.7% v 69.5%; 0.73; 0.67 to 0.79; P&lt;0.001). The above findings were consistent in a range of sensitivity analyses, including matching according to defibrillation time.

CONCLUSIONS

Contrary to current guidelines that prioritize immediate defibrillation for in-hospital cardiac arrest due to a shockable rhythm, one in five patients are treated with epinephrine before defibrillation. Use of epinephrine before defibrillation was associated with worse survival outcomes.

Timing of Intravenous Epinephrine Administration During Out-of-Hospital Cardiac Arrest

BACKGROUND

Current guidelines for cardiopulmonary resuscitation recommend that standard dose of epinephrine be administered every 3 to 5 min during cardiac arrest. However, there is controversy about the association between timing of epinephrine administration and outcomes after out-of-hospital cardiac arrest (OHCA). This study aimed to determine whether the timing of intravenous epinephrine administration is associated with outcomes after OHCA.

METHODS

We analyzed Japanese government-led nationwide population-based registry data for OHCA. Adult OHCA patients who received intravenous epinephrine by emergency medical service personnel in the prehospital setting from 2011 to 2017 were included. Multivariable logistic regression models were used to assess the associations between time to first epinephrine administration and outcomes after OHCA. Subsequently, associations between early (≤20 min) versus delayed (>20 min) epinephrine administration and outcomes after OHCA were examined using propensity score-matched analyses. The primary outcome was 1-month neurologically favorable survival.

RESULTS

A total of 119,946 patients (mean [SD] age, 75.2 [14.8] years; 61.4% male) were included. The median time to epinephrine was 23 min (interquartile range, 19-29). Longer time to epinephrine was significantly associated with a decreased chance of 1-month neurologically favorable survival (multivariable adjusted OR per minute delay, 0.91 [95% CI, 0.90-0.92]). In the propensity score-matched cohort, when compared with early (≤20 min) epinephrine, delayed (>20 min) epinephrine was associated with a decreased chance of 1-month neurologically favorable survival (959/42,804 [2.2%] vs. 330/42,804 [0.8%]; RR, 0.34; 95% CI, 0.30-0.39; NNT, 69).

CONCLUSIONS

Delay in epinephrine administration was associated with a decreased chance of 1-month neurologically favorable survival among patients with OHCA.

Effect of Shenfu Injection () on Lactate and Lactate Clearance in Patients with Post-cardiac Arrest Syndrome: A Post Hoc Analysis of a Multicenter Randomized Controlled Trial

OBJECTIVE

To assess the effects of Shenfu Injection (, SFI) on blood lactate, and secondarily its effect on the lactate clearance (LC) in patients with post cardiac arrest syndrome (PCAS).

METHODS

The present study is a post hoc study of a randomized, assessor-blinded, controlled trial. Patients experienced in-hospital cardiac arrest between 2012 and 2015 were included in the predefined post hoc analyses. Of 1,022 patients enrolled, a total of 978 patients were allocated to the control group (486 cases) and SFI (492 cases) group, receiving standardized post-resuscitation care bundle (PRCB) treatment or PRCB combined with SFI (100 mL/d), respectively. Patients' serum lactate was measured simultaneously with artery blood gas, lactate clearance (LC) was calculated on days 1, 3, and 7 after admission and compared between groups. Lactate and LC were also compared between the survivors and non-survivors according to the 28-d mortality, as well as the survivors and non-survivors subgroups both in the SFI and control groups.

RESULTS

In both groups, compared with pre-treatment levels, mean arterial pressure (MAP) and PaO₂ were significantly improved on 1, 3, 7 d after treatment (P<0.05), while heart rate (HR) and blood glucose levels were significantly decreased on 1, 3 and 7 d after treatment (P<0.05). compared with control group, SFI treatment improved the values of MAP and PaO₂ (P<0.05), and significantly decreased the levels of HR and the blood glucose level on 3 and 7 d after treatment (P<0.05). Compared with the control group, lactate levels decreased faster in the SFI group versus the control group on 3 and 7 d (P<0.05). From initiation of treatment and the following 3 and 7 d, SFI treatment greatly increased the LC compared with that in the control group (P<0.05). Compared with survivors, non-survivors had higher admission lactate levels (7.3 ±1.1 mmol/L vs. 5.5 ±2.3 mmol/L; P<0.01), higher lactate levels on days 1, 3 and 7 (P<0.05), and LC were decreased significantly on 3 and 7 d after treatment (P<0.05). Similar results were also found both in the SFI and control groups between survivors and non-survivors subgroups.

CONCLUSION

SFI in combination with PRCB treatment is effective at lowering lactate level and resulted in increasing LC in a targeted population of PCAS patients.

Resuscitation Team Roles and Responsibilities: In-Hospital Cardiopulmonary Arrest Teams

Patients who experience an in-hospital cardiopulmonary arrest event often have poor outcomes. Those outcomes are influenced by institutional factors, including the effectiveness of the responding team. Two main types of response teams may exist for in-hospital settings: basic life support trained staff providing initial interventions, and advanced cardiac life support teams. The interface between these two responses, and differences in discipline, experience, and skill mix, adds complexity to team dynamics. In-hospital cardiopulmonary arrest teams benefit from addressing these and other factors, which may lead to lack of clarity in role and responsibility identification and ultimately team performance.

Epidemiology and outcomes of infants after cardiopulmonary resuscitation in the neonatal or pediatric intensive care unit from a national registry

AIM

Cardiopulmonary resuscitation (CPR) in hospitalized infants is a relatively uncommon but high-risk event associated with mortality. The study objective was to identify factors associated with mortality and survival among infants who receive CPR in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU).

METHODS

Retrospective observational study of infants with an index CPR event in the NICU or PICU between 1/1/06 and 12/31/18 in the American Heart Association's Get With The Guidelines-Resuscitation registry. Associations between patient, event, unit, and hospital factors and the primary outcome, mortality prior to discharge, were examined using multivariable logistic regression.

RESULTS

Among 3521 infants who received CPR, 2080 (59%) died before discharge, with 25% mortality during CPR and 40% within 24 h. Mortality prior to discharge occurred in 65% and 47% of cases in the NICU and PICU, respectively. Factors most strongly independently associated with pre-discharge mortality were vasoactive agent before CPR (adjusted odds ratio (aOR): 2.77, 95% confidence interval (CI) 2.15-3.58), initial pulseless condition (aOR: 2.38, 95% CI 1.46-3.86) or development of pulselessness (aOR: 2.36, 95% CI 1.78-3.12), and NICU location compared with PICU (aOR: 3.85, 95% CI 2.86-5.19). Endotracheal intubation during CPR was associated with decreased odds of pre-discharge mortality (aOR: 0.40, 95% CI 0.33-0.49).

CONCLUSION

Infants who receive CPR in the intensive care unit experience high mortality rates; identifiable patient, event, and unit factors increase the odds of mortality. Further investigation should explore the association between unit type, resuscitation processes, and mortality.

Predicting in-hospital mortality after an in-hospital cardiac arrest: A multivariate analysis

Aim of the study

Most survivors of an in-hospital cardiac arrest do not leave the hospital alive, and there is a need for a more patient-centered, holistic approach to the assessment of prognosis after an arrest. We sought to identify pre-, peri-, and post-arrest variables associated with in-hospital mortality amongst survivors of an in-hospital cardiac arrest.

Methods

This was a retrospective cohort study of patients ≥18 years of age who were resuscitated from an in-hospital arrest at our University Medical Center from January 1, 2013 to September 31, 2016. In-hospital mortality was chosen as a primary outcome and unfavorable discharge disposition (discharge disposition other than home or skilled nursing facility) as a secondary outcome.

Results

925 patients comprised the in-hospital arrest cohort with 305 patients failing to survive the arrest and a further 349 patients surviving the initial arrest but dying prior to hospital discharge, resulting in an overall survival of 29%. 620 patients with a ROSC of greater than 20 min following the in-hospital arrest were included in the final analysis. In a stepwise multivariable regression analysis, recurrent cardiac arrest, increasing age, time to ROSC, higher serum creatinine levels, and a history of cancer were predictors of in-hospital mortality. A history of hypertension was found to exert a protective effect on outcomes. In the regression model including serum lactate, increasing lactate levels were associated with lower odds of survival.

Conclusion

Amongst survivors of in-hospital cardiac arrest, recurrent cardiac arrest was the strongest predictor of poor outcomes with age, time to ROSC, pre-existing malignancy, and serum creatinine levels linked with increased odds of in-hospital mortality.

Association between time to advanced airway management and neurologically favourable survival during out-of-hospital cardiac arrest

BACKGROUND

Advanced airway management (AAM) is commonly performed as part of advanced life support. However, there is controversy about the association between the timing of AAM and outcomes after out-of-hospital cardiac arrest (OHCA). This study aimed to determine whether time to AAM is associated with outcomes after OHCA.

METHODS

This was a nationwide population-based observational study using the Japanese government-led registry of OHCA. Adults who experienced OHCA and received AAM by EMS personnel in the prehospital setting from 2014 to 2017 were included. Multivariable logistic regression models were used to assess the associations between time to AAM (defined as time in minutes from emergency call to the first successful AAM) and outcomes after OHCA. Then, associations between early (≤ 20 min) vs. delayed (> 20 min) AAM and outcomes after OHCA were examined using propensity score-matched analyses. The primary outcome was one-month neurologically favourable survival.

RESULTS

A total of 164,223 patients (median [IQR] age, 80 [69-86] years; 57.7% male) were included. The median time to AAM was 17 min (IQR, 14-22). Longer time to AAM was significantly associated with a decreased chance of one-month neurologically favourable survival (multivariable adjusted OR per minute delay, 0.90 [95% CI, 0.90-0.91]). In the propensity score-matched cohort, compared with early AAM, delayed AAM was associated with a decreased chance of one-month neurologically favourable survival (516 of 50,997 [1.0%] vs. 226 of 50,997 [0.4%]; RR, 0.44; 95% CI, 0.37-0.51; NNT, 176).

CONCLUSIONS

Delay in AAM was associated with a decreased chance of one-month neurologically favourable survival among patients with OHCA.

Epinephrine dosing interval and neurological outcome in out-of-hospital cardiac arrest

OBJECTIVE

Current guidelines for cardiopulmonary resuscitation (CPR) recommend that standard-dose epinephrine be administered every 3-5 minutes during cardiac arrest. However, there is a knowledge gap regarding the optimal epinephrine dosing interval. This study aimed to examine the association between epinephrine dosing intervals and outcomes after out-of-hospital cardiac arrest (OHCA).

METHODS

This was a nationwide population-based observational study using data from a Japanese government-led registry of OHCA, including patients who experienced OHCA in Japan from 2011 to 2017. We defined the epinephrine dosing interval as the time interval between the first epinephrine administration and return of spontaneous circulation in the prehospital setting, divided by the total number of epinephrine doses. The primary outcome was 1-month neurologically favorable survival.

RESULTS

A total of 10,965 patients (mean (SD) age, 75.8 (14.3) years; 59.8% male) were included. The median epinephrine dosing interval was 3.5 minutes (IQR, 2.5-4.5; mean (SD), 3.6 (1.8)). Only approximately half of the patients received epinephrine administration with a standard dosing interval, as recommended in the current CPR guidelines. After multivariable adjustment, compared with the standard dosing interval, neither shorter nor longer epinephrine dosing intervals were associated with neurologically favorable survival after OHCA (Short vs Standard: adjusted OR 0.87 [95%CI 0.66-1.15]; and Long vs Standard: adjusted OR 1.08 [95%CI 0.76-1.55]). Similar associations were observed in propensity score-matched analyses.

CONCLUSIONS

The epinephrine dosing interval was not associated with 1-month neurologically favorable survival after OHCA. Our findings do not deny the recommended epinephrine dosing interval in the current CPR guidelines.

Immediate intravenous epinephrine versus early intravenous epinephrine for in-hospital cardiopulmonary arrest

Background

Intravenous epinephrine has been a key treatment in cardiopulmonary arrest since the early 1960s. The ideal timing for the first dose of epinephrinee is uncertain. We aimed to investigate the association of immediate epinephrine administration (within 1-min of recognition of cardiac arrest) with return of spontaneous circulation (ROSC) up to 24-h.

Methods

This was a multicenter retrospective analysis of patients who underwent cardiopulmonary resuscitation. We included the following patients: 1) ≥18 years-old, 2) non-shockable rhythms, 3) received intravenous epinephrine during cardiopulmonary resuscitation, 4) witnessed in-hospital arrest and 5) first resuscitation attempt (for patients requiring more than one resuscitation attempt). We excluded patients who suffered from traumatic arrest, were pregnant, had shockable rhythms, arrested in the operating room, with Do-Not-Resuscitate (DNR) order, and patient aged 17 years-old or less.

Results

A total of 360 patients were included in the analysis. Median age was 62 years old and median epinephrine administration time was two minutes. We found that immediate epinephrine administration (within 1-min) is associated with higher rates of ROSC up to 24-h (OR = 1.25, 95% CI; [1.01–1.56]), compared with early epinephrine (≥2-min) administration. After adjusting for confounding covariates, earlier administration of epinephrine predicted higher rates of ROSC sustained for up to 24-h (OR 1.33 95%CI [1.13–1.55]).

Conclusions

Immediate administration of epinephrine in conjunction with high-quality CPR is associated with higher rates of ROSC.

Utstein Style for emergency care - the first 30 years

BACKGROUND

Utstein Abbey near Stavanger in Norway, hosted a meeting in 1990 on guidelines for the uniform reporting of data from out-of-hospital cardiac arrest. In this paper we describe the last 30 years of the Utstein style.

METHODS

A systematic literature search identified publications from Utstein-style meetings or groups using the Utstein format.

RESULTS

30 outputs were found, describing primarily resuscitation structure, process and outcome measures. They originated from all over the world and from multiple medical disciplines. Some were co-published in multiple journals.

CONCLUSIONS

The meeting at Utstein Abbey in 1990 has had a sustained and far-reaching impact, particularly in resuscitation science, implementation and outcomes. The Utstein format will continue to evolve following the key principles from the original meeting and with the ultimate aim of improving patient care and outcomes.

Association Between Hospital Resuscitation Champion and Survival for In-Hospital Cardiac Arrest

Background Although many hospitals have resuscitation champions, it is unknown if hospitals with very active physician or nonphysician champions have higher survival rates for in-hospital cardiac arrest (IHCA). Methods and Results We surveyed adult hospitals in Get With The Guidelines-Resuscitation about resuscitation practices, including about their resuscitation champion. Hospitals were categorized as having a very active physician champion, a very active nonphysician champion, or other (no champion or not very active champion). For each hospital, we calculated risk-standardized survival rates for IHCA during the period of 2016 to 2018 and categorized them into quintiles of risk-standardized survival rates. The association between a hospital's resuscitation champion type and their quintile of survival was evaluated using multivariable hierarchical proportional odds logistic regression. Overall, 192 hospitals (total of 44 477 IHCAs) comprised the study cohort. Risk-standardized survival rates for IHCA varied widely between hospitals (median: 24.7%; range: 9.2%-37.5%). Very active physician champions were present in 29 (15.1%) hospitals, 64 (33.3%) had very active nonphysician champions, and 99 (51.6%) did not have a very active champion. Compared with sites without a very active resuscitation champion, hospitals with a very active physician champion were 4 times more likely to be in a higher survival quintile, even after adjusting for resuscitation practices across hospital groups (adjusted odds ratio [OR], 3.90; 95% CI, 1.39-10.95). In contrast, there was no difference in survival between sites without very active champions and those with very active non-physician champions (adjusted OR, 1.28; 95% CI, 0.62-2.65). Conclusions The background and engagement level of a resuscitation champion is a critical factor in a hospital's survival outcomes for IHCA.

Postoperative Cardiac Arrest in Cardiac Surgery-How to Improve the Outcome?

Background

In the early postoperative period after cardiac surgery the heart may be temporarily dysfunctional and prone to arrhythmias due to the phenomenon of myocardial stunning, vasoplegic syndrome, systemic inflammatory response syndrome (SIRS), electrolyte disturbances, operative trauma and myocardial edema. Most cases of cardiac arrest after cardiac surgery are reversible.

Objective

To analyse the factors that may influence the outcome of cardiac arrest after adult and pediatric cardiac surgery.

Methods

Retrospective analysis that included cardiac surgical procedures (886 adult and 749 pediatric patients) performed during the 18 month period of this study at Queen Alia Heart Institute/ Amman, Jordan. All cardiac arrest events were recorded and analysed. Data was collected on Utstein style templates designed for the purpose of this study. The outcome of cardiac arrest is examined as an early outcome (ROSC or lethal outcome) and late outcome (full recovery, recovery with complications, or in-hospital mortality). Factors that may influence the outcome of cardiac arrest were recorded and statistically analysed. Ethical committee approval obtained.

Results

The overall mortality rate was 3.3%. Cardiac arrest occurred in 114 patients (6.97%). The age of patients ranged from 5 days to 82 years and constituted 66 pediatric and 48 adult patients. Most pediatric cardiac arrests manifested as non-shockable rhythms (77%). Most in-hospital cardiac arrests occurred in the intensive care unit (86.5%). The majority of patients were mechanically ventilated at the time of occurrence of arrest (62.5% and 54.5% in adult and pediatric patients, respectively). Average time of cardiopulmonary resuscitation was 32.24 minutes. Overall, CA survival was 20% higher in the paediatric sub-group (full recovery rate of 51.5%). Neurological injury was slightly lower in pediatric than adult cardiac arrest survivals. (2% vs. 3%).

Conclusion

Shockable rhythms are more common in adult cardiac arrest, while non-shockable rhythms are more frequent in the pediatric sub-population. Hemodynamic monitoring, witnessed-type of cardiac arrest, non-interrupted cardiac massage, and early recognition of cardiac tamponade are the factors associated with higher rates of survival.

Association Between Hospital Debriefing Practices With Adherence to Resuscitation Process Measures and Outcomes for In-Hospital Cardiac Arrest

Background Identifying actionable resuscitation practices that vary across hospitals could improve adherence to process measures or outcomes after in-hospital cardiac arrest (IHCA). We sought to examine whether hospital debriefing frequency after IHCA varies across hospitals and whether hospitals which routinely perform debriefing have higher rates of process-of-care compliance or survival. Methods We conducted a nationwide survey of hospital resuscitation practices in April of 2018, which were then linked to data from the Get With The Guidelines-Resuscitation national registry for IHCA. Hospitals were categorized according to their reported frequency of debriefing immediately after IHCA; rarely (0%-20% of all IHCA cases), occasionally (21%-80%), and frequently (81%-100%). Hospital-level rates of timely defibrillation (≤2 minutes), epinephrine administration (≤5 minutes), survival to discharge, return of spontaneous circulation, and neurologically intact survival were comparted for patients with IHCA from 2015 to 2017. Results Overall, there were 193 hospitals comprising 44 477 IHCA events. Mean patient age was 65±16, 41% were females, and 68% were of White race. Across hospitals, 84 (43.5%) rarely performed debriefings immediately after an IHCA, 82 (42.5%) performed debriefing sessions occasionally, and 27 (14.0%) performed debriefing frequently. There was no association between higher reported debriefing frequency and hospital rates of timely defibrillation and epinephrine administration. Mean hospital rates of risk-standardized survival to discharge were similar across debriefing frequency groups (rarely 25.6%; occasionally 26.0%; frequently 25.2%, P=0.72), as were hospital rates of risk-adjusted return of spontaneous circulation (rarely 72.2%; occasionally 73.0%; frequently 70.0%, P=0.06) and neurologically intact survival (rarely 21.9%, occasionally 22.2%, frequently 21.1%, P=0.75). Conclusions In a large contemporary nationwide quality improvement registry, hospitals varied widely in how often they conducted debriefings immediately after IHCA. However, hospital debriefing frequency was not associated with better adherence to timely delivery of epinephrine or defibrillation or higher rates of IHCA survival.

Clinical Significance of Low-Flow Time in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation: Results from the RESCUE Registry

Limited data are available on the association between low-flow time and survival in patients with in-hospital cardiac arrest (IHCA) who undergo extracorporeal cardiopulmonary resuscitation (ECPR). We evaluated data from 183 IHCA patients who underwent ECPR as a rescue procedure. Patients were divided into two groups: patients undergoing extracorporeal membrane oxygenation as an adjunct to standard cardiopulmonary resuscitation for less than 38 min (n = 110) or for longer than 38 min (n = 73). The ECPR ≤ 38 min group had a significantly greater incidence of survival to discharge compared to the ECPR > 38 min group (40.0% versus 24.7%, p = 0.032). The incidence of good neurologic outcomes at discharge tended to be greater in the ECPR ≤ 38 min group than in the ECPR > 38 min group (35.5% versus 24.7%, p = 0.102). The incidences of limb ischemia (p = 0.354) and stroke (p = 0.805) were similar between the two groups, but major bleeding occurred less frequently in the ECPR ≤ 38 min group compared to the ECPR > 38 min group (p = 0.002). Low-flow time ≤ 38 min may reduce the risk of mortality and fatal neurologic damage and could be a measure of optimal management in patients with IHCA.

Neonatal delivery room CPR: An analysis of the Get with the Guidelines®-Resuscitation Registry

BACKGROUND

Cardiopulmonary resuscitation (CPR) in the delivery room (DR) after birth is rare. We hypothesized that factors related to maternal, delivery, infant and resuscitation event characteristics associated with outcomes could be identified. We also hypothesized there would be substantial variation from the Neonatal Resuscitation Program (NRP) algorithm.

METHODS

Retrospective review of all neonates receiving chest compressions in the DR from the AHA Get With The Guidelines-Resuscitation registry from 2001 to 2014. The primary outcome was return of spontaneous circulation (ROSC) in the DR. Secondary outcome was survival to hospital discharge. Descriptive statistics were used to characterize data. Odds ratios with confidence intervals were calculated as appropriate to compare survivors and non-survivors.

RESULTS

There were 1153 neonates who received chest compressions in the DR. ROSC was achieved in 968 (84%) newborns and 761 (66%) survived to hospital discharge. Fifty-one percent of the cohort received chest compressions without medications. Cardiac compressions were initiated within the first minute of life in 76% of the events, and prior to endotracheal intubation in 79% of the events. In univariate analysis, factors such as prematurity, number of endotracheal intubation attempts, increased time to first adrenaline dose, and CPR duration were associated with decreased odds of ROSC in the DR. Longer CPR duration was associated with decreased odds of ROSC in multivariate analysis.

CONCLUSION

In this cohort of infants receiving chest compressions following delivery, recognizable pre-birth risk factors as well as resuscitation interventions associated with increased and decreased odds of achieving ROSC were identified. Chest compressions were frequently initiated in the first minute of the event and often prior to endotracheal intubation. Further investigations should focus on methods to decrease time to critical resuscitation interventions, such as successful endotracheal intubation and administration of the first dose of adrenaline, in order to improve DR-CPR outcomes.

Trajectory of Risk-Standardized Survival Rates for In-Hospital Cardiac Arrest

BACKGROUND

A hospital's risk-standardized survival rate (RSSR) for in-hospital cardiac arrest has emerged as an important metric to benchmark and incentivize hospital resuscitation quality. We examined whether hospital performance on the RSSR metric was stable or dynamic year-over-year and whether low-performing hospitals were able to improve survival outcomes over time.

METHODS AND RESULTS

We used data from 84 089 adult patients with an in-hospital cardiac arrest from 166 hospitals with continuous participation in Get With The Guidelines-Resuscitation from 2012 to 2017. A 2-level hierarchical regression model was used to compute RSSRs during a baseline (2012-2013) and two follow-up periods (2014-2015 and 2016-2017). At baseline, hospitals were classified as top-, middle-, and bottom-performing if they ranked in the top 25%, middle 50%, and bottom 25%, respectively, on their RSSR metric during 2012 to 2013. We compared hospital performance on RSSR during follow-up between top, middle, and bottom-performing hospitals' at baseline. During 2012 to 2013, 42 hospitals were identified as top-performing (median RSSR, 31.7%), 82 as middle-performing (median RSSR, 24.6%), and 42 as bottom-performing (median RSSR, 18.7%). During both follow-up periods, >70% of top-performing hospitals ranked in the top 50%, a substantial proportion remained in the top 25% of RSSR during 2014 to 2015 (54.6%) and 2016 to 2017 (40.4%) follow-up periods. Likewise, nearly 75% of bottom-performing hospitals remained in the bottom 50% during both follow-up periods, with 50.0% in the bottom 25% of RSSR during 2014 to 2015 and 40.5% in the bottom 25% during 2016 to 2017. While percentile rankings were generally consistent over time at ≈45% of study hospitals, ≈1 in 5 (21.4%) bottom-performing hospitals showed large improvement in percentile rankings over time and a similar proportion (23.7%) of top-performing hospitals showed large decline in percentile rankings compared with baseline.

CONCLUSIONS

Hospital performance on RSSR during baseline period was generally consistent over 4 years of follow-up. However, 1 in 5 bottom-performing hospitals had large improvement in survival over time. Identifying care and quality improvement innovations at these sites may provide opportunities to improve in-hospital cardiac arrest care at other hospitals.

Association of Hospital-Level Acute Resuscitation and Postresuscitation Survival With Overall Risk-Standardized Survival to Discharge for In-Hospital Cardiac Arrest

IMPORTANCE

Survival after in-hospital cardiac arrest depends on 2 distinct phases: responsiveness and quality of the hospital code team (ie, acute resuscitation phase) and intensive and specialty care expertise (ie, postresuscitation phase). Understanding the association of these 2 phases with overall survival has implications for design of in-hospital cardiac arrest quality measures.

OBJECTIVE

To determine whether hospital-level rates of acute resuscitation survival and postresuscitation survival are associated with overall risk-standardized survival to discharge for in-hospital cardiac arrest.

DESIGN, SETTINGS, AND PARTICIPANTS

This observational cohort study included 86 426 patients with in-hospital cardiac arrest from January 1, 2015, through December 31, 2018, recruited from 290 hospitals participating in the Get With The Guidelines-Resuscitation registry.

EXPOSURES

Risk-adjusted rates of acute resuscitation survival, defined as return of spontaneous circulation for at least 20 minutes, and postresuscitation survival, defined as survival to discharge among patients achieving return of spontaneous circulation.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall risk-standardized survival rate (RSSR) for in-hospital cardiac arrest calculated using a previously validated model. The correlation between a hospital's overall RSSR and risk-adjusted rates of acute resuscitation and postresuscitation survival were examined.

RESULTS

Of 86 426 patients with in-hospital cardiac arrest, the median age was 67.0 years (interquartile range [IQR], 56.0-76.0 years); 50 665 (58.6%) were men, and 71 811 (83.1%) had an initial nonshockable cardiac arrest rhythm. The median RSSR was 25.1% (IQR, 21.9%-27.7%). The median risk-adjusted acute resuscitation survival was 72.4% (IQR, 67.9%-76.9%), and risk-adjusted postresuscitation survival was 34.0% (IQR, 31.5%-37.7%). Although a hospital's RSSR was correlated with survival during both phases, the correlation with postresuscitation survival (ρ, 0.90; P < .001) was stronger compared with the correlation with acute resuscitation survival (ρ, 0.50; P < .001). Of note, there was no correlation between risk-adjusted acute resuscitation survival and postresuscitation survival (ρ, 0.09; P = .11). Compared with hospitals in the lowest RSSR quartile, hospitals in the highest RSSR quartile had higher rates of acute resuscitation survival (75.4% in quartile 4 vs 66.8% in quartile 1; P < .001) and postresuscitation survival (40.3% in quartile 4 vs 28.7% in quartile 1; P < .001), but the magnitude of difference was larger with postresuscitation survival.

CONCLUSIONS AND RELEVANCE

The findings suggest that hospitals that excel in overall in-hospital cardiac arrest survival, in general, excel in either acute resuscitation or postresuscitation care but not both; efforts to strengthen postresuscitation care may offer additional opportunities to improve in-hospital cardiac arrest survival.

Intra-day change in occurrence of out-of-hospital ventricular fibrillation in Japan: The JCS-ReSS study

BACKGROUND

Real-world evidence of out-of-hospital ventricular fibrillation (VF), especially regarding intra-day change, remains unclear. We aimed to investigate that age- and gender-dependent difference of intra-day change of VF occurrence.

METHOD

We enrolled 71,692 patients (males: 56,419 [78.7%], females: 15,273 [21.3%]) in whom cardiac VF had been documented from the 2005-2015 All-Japan Utstein Registry data. Subjects were divided into four groups: group-I (<18 years old), group-II (18-39), group-III (40-69), and group-IV (≥70). Among four groups in each of male and female, we compared the intra-day change of VF occurrence, and evaluated the risk factors of the unfavorable neurologic outcomes at 1 month after VF.

RESULTS

Regardless of age, the incidence of VF was significantly greater in male than in female subjects. In male subjects, VF in group-I, III and IV occurred higher at daytime, however, group-II had no intra-day difference because group-II had a higher VF events at midnight~ early morning compared with other aged groups (Poisson regression analysis, p = .03). While in female, each group showed similar intra-day pattern of VF occurrence. Logistic regression analysis revealed that some of the clinical parameters such as time periods from call receipt to first shock and the presence of bystander cardiopulmonary resuscitation were important for risk of 30-day neurologically unfavorable outcomes.

CONCLUSIONS

The intra-day change of VF occurrence was age-dependently different in males but not in females, suggesting age- and gender-dependent differences in underlying cardiac diseases. These might affect the significant difference in unfavorable neurologic outcome.

Improved survival to hospital discharge in pediatric in-hospital cardiac arrest using 2 Joules/kilogram as first defibrillation dose for initial pulseless ventricular arrhythmia

The American Heart Association (AHA) recommends first defibrillation energy dose of 2 Joules/kilogram (J/kg) for pediatric cardiac arrest with ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT). However, optimal first energy dose remains unclear.

METHODS

Using AHA Get With the Guidelines-Resuscitation® (GWTG-R) database, we identified children ≤12 years with IHCA due to VF/pVT. Primary exposure was energy dose in J/kg. We categorized energy doses: 1.7-2.5 J/kg as reference (reflecting 2 J/kg intended dose), <1.7 J/kg and >2.5 J/kg. We compared survival for reference doses to all other doses. We constructed models to test association of energy dose with survival; adjusting for age, location, illness category, initial rhythm and vasoactive medications.

RESULTS

We identified 301 patients ≤12 years with index IHCA and initial VF/pVT. Survival to discharge was significantly lower with energy doses other than 1.7-2.5 J/kg. Individual dose categories of <1.7 J/kg or >2.5 J/kg were not associated with differences in survival. For patients with initial VF, doses >2.5 J/kg had worse survival compared to reference. For all patients ≤18 years (n = 422), there were no differences in survival between dosing categories. However, all ≤18 with initial VF receiving >2.5 J/kg had worse survival.

CONCLUSIONS

First energy doses other than 1.7-2.5 J/kg are associated with lower rate of survival to hospital discharge in patients ≤12 years old with initial VF/pVT, and first doses >2.5 J/kg had lower survival rates in all patients ≤18 years old with initial VF. These results support current AHA guidelines for first pediatric defibrillation energy dose of 2 J/kg.

Prognostic Value of Early Intermittent Electroencephalography in Patients after Extracorporeal Cardiopulmonary Resuscitation

The aim of this study was to investigate whether early intermittent electroencephalography (EEG) could be used to predict neurological prognosis of patients who underwent extracorporeal cardiopulmonary resuscitation (ECPR). This was a retrospective and observational study of adult patients who were evaluated by EEG scan within 96 h after ECPR. The primary endpoint was neurological status upon discharge from the hospital assessed with a Cerebral Performance Categories (CPC) scale. Among 69 adult cardiac arrest patients who underwent ECPR, 17 (24.6%) patients had favorable neurological outcomes (CPC score of 1 or 2). Malignant EEG patterns were more common in patients with poor neurological outcomes (CPC score of 3, 4 or 5) than in patients with favorable neurological outcomes (73.1% vs. 5.9%, p < 0.001). All patients with highly malignant EEG patterns (43.5%) had poor neurological outcomes. In multivariable analysis, malignant EEG patterns and duration of cardiopulmonary resuscitation were significantly associated with poor neurological outcomes. In this study, malignant EEG patterns within 96 h after cardiac arrest were significantly associated with poor neurological outcomes. Therefore, an early intermittent EEG scan could be helpful for predicting neurological prognosis of post-cardiac arrest patients after ECPR.