Cardiopulmonary resuscitation duration and favorable neurological outcome after out-of-hospital cardiac arrest: a nationwide multicenter observational study in Japan (the JAAM-OHCA registry)

Cost-effectiveness analysis of a 'Termination of Resuscitation' protocol for the management of out-of-hospital cardiac arrest

BACKGROUND

Historically in Singapore, all out-of-hospital cardiac arrests (OHCA) were transported to hospital for pronouncement of death. A 'Termination of Resuscitation' (TOR) protocol, implemented from 2019 onwards, enables emergency responders to pronounce death at-scene in Singapore. This study aims to evaluate the cost-effectiveness of the TOR protocol for OHCA management.

METHODS

Adopting a healthcare provider's perspective, a Markov model was developed to evaluate three competing options: No TOR, Observed TOR reflecting existing practice, and Full TOR if TOR is exercised fully. The model had a cycle duration of 30 days after the initial state of having a cardiac arrest, and was evaluated over a 10-year time horizon. Probabilistic sensitivity analysis was performed to account for uncertainties. The costs per quality adjusted life years (QALY) was calculated.

RESULTS

A total of 3,695 OHCA cases eligible for the TOR protocol were analysed; mean age of 73.0 ± 15.5 years. For every 10,000 hypothetical patients, Observed TOR and Full TOR had more deaths by approximately 19 and 31 patients, respectively, compared to No TOR. Full TOR had the least costs and QALYs at $19,633,369 (95 % Uncertainty Interval (UI) 19,469,973 to 19,796,764) and 0 QALYs. If TOR is exercised for every eligible case, it could expect to save approximately $400,440 per QALY loss compared to No TOR, and $821,151 per QALY loss compared to Observed TOR.

CONCLUSION

The application of the TOR protocol for the management of OHCA was found to be cost-effective within acceptable willingness-to-pay thresholds, providing some justification for sustainable adoption.

Impact of time to revascularization on outcomes in patients after out-of-hospital cardiac arrest with STEMI

BACKGROUND

International guidelines recommend emergency coronary angiography in patients after out-of-hospital cardiac arrest (OHCA) with ST-segment elevation on 12‑lead electrocardiography. However, the association between time to revascularization and outcomes remains unknown. This study aimed to evaluate the association between time to revascularization and outcomes in patients with OHCA due to ST-segment-elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI).

METHODS

This multicenter, retrospective, nationwide observational study included patients aged ≥18 years with OHCA due to STEMI who underwent PCI between 2014 and 2020. The time of the first return of spontaneous circulation (ROSC) was defined as the time of first ROSC during resuscitation, regardless of the pre-hospital or in-hospital setting. The primary outcome was a 1-month favorable neurological outcome, defined as cerebral performance category 1 or 2. Multivariable logistic regression analysis was used to assess the association between the time to revascularization and favorable neurological outcomes.

RESULTS

A total of 547 patients were included in this analysis. The multivariable logistic regression analysis showed that a shorter time from the first ROSC to revascularization was associated with 1-month favorable neurological outcomes (63/86 [73.3%] in the time from the first ROSC to revascularization ≤60 min group versus 98/193 [50.8%] in the >120 min group; adjusted OR, 0.26; 95% CI, 0.11-0.56; P for trend, 0.015).

CONCLUSIONS

Shorter time to revascularization was significantly associated with 1-month favorable neurological outcomes in patients with OHCA due to STEMI who underwent PCI.

The relationship between the initial pH and neurological outcome in patients with out-of-hospital cardiac arrest is affected by the status of recovery of spontaneous circulation on hospital arrival

The early prediction of neurological outcomes is useful for out-of-hospital cardiac arrest (OHCA). The initial pH was associated with neurological outcomes, but the values varied among the studies. Patients admitted to our division with OHCA of cardiac origin between January 2015 and December 2022 were retrospectively examined (N = 199). A good neurological outcome was defined as a Glasgow-Pittsburgh cerebral performance category (CPC) of 1-2 at discharge. Patients were divided according to the achievement of recovery of spontaneous circulation (ROSC) on hospital arrival, and the efficacy of pH in predicting good neurological outcomes was compared. In patients with ROSC on hospital arrival (N = 100), the initial pH values for good and poor neurological outcomes were 7.26 ± 0.14 and 7.09 ± 0.18, respectively (p < 0.001). In patients without ROSC on hospital arrival (N = 99), the initial pH values for good and poor neurological outcomes were 7.06 ± 0.23 and 6.92 ± 0.15, respectively (p = 0.007). The pH associated with good neurological outcome was much lower in patients without ROSC than in those with ROSC on hospital arrival (P = 0.003). A higher initial pH is associated with good neurological outcomes in patients with OHCA. However, the pH for a good or poor neurological outcome depends on the ROSC status on hospital arrival.

A national multi centre pre-hospital ECPR stepped wedge study; design and rationale of the ON-SCENE study

BACKGROUND

The likelihood of return of spontaneous circulation with conventional advanced life support is known to have an exponential decline and therefore neurological outcome after 20 min in patients with a cardiac arrest is poor. Initiation of venoarterial ExtraCorporeal Membrane Oxygenation (ECMO) during resuscitation might improve outcomes if used in time and in a selected patient category. However, previous studies have failed to significantly reduce the time from cardiac arrest to ECMO flow to less than 60 min. We hypothesize that the initiation of Extracorporeal Cardiopulmonary Resuscitation (ECPR) by a Helicopter Emergency Medical Services System (HEMS) will reduce the low flow time and improve outcomes in refractory Out of Hospital Cardiac Arrest (OHCA) patients.

METHODS

The ON-SCENE study will use a non-randomised stepped wedge design to implement ECPR in patients with witnessed OHCA between the ages of 18-50 years old, with an initial presentation of shockable rhythm or pulseless electrical activity with a high suspicion of pulmonary embolism, lasting more than 20, but less than 45 min. Patients will be treated by the ambulance crew and HEMS with prehospital ECPR capabilities and will be compared with treatment by ambulance crew and HEMS without prehospital ECPR capabilities. The primary outcome measure will be survival at hospital discharge. The secondary outcome measure will be good neurological outcome defined as a cerebral performance categories scale score of 1 or 2 at 6 and 12 months.

DISCUSSION

The ON-SCENE study focuses on initiating ECPR at the scene of OHCA using HEMS. The current in-hospital ECPR for OHCA obstacles encompassing low survival rates in refractory arrests, extended low-flow durations during transportation, and the critical time sensitivity of initiating ECPR, which could potentially be addressed through the implementation of the HEMS system. When successful, implementing on-scene ECPR could significantly enhance survival rates and minimize neurological impairment.

TRIAL REGISTRATION

Clinicaltyrials.gov under NCT04620070, registration date 3 November 2020.

Utility of end-tidal carbon dioxide to guide resuscitation termination in prolonged out-of-hospital cardiac arrest

STUDY OBJECTIVE

To evaluate if the change in end-tidal carbon dioxide (ETCO2) over time has improved discriminatory value for determining resuscitation futility compared to a single ETCO2 value in prolonged, refractory non-shockable out-of-hospital cardiac arrest (OHCA).

METHODS

This is a retrospective analysis of adult refractory non-shockable, non-traumatic OHCA patients in the Portland Cardiac Arrest Epidemiologic Registry (PDX Epistry) from 2018 to 2021. We defined refractory non-shockable OHCA cases as patients with lack of a shockable rhythm at any time or return of spontaneous circulation at any time prior to 30-min of on-scene resuscitation. We abstracted ETCO2 values first recorded after advanced airway placement and nearest to the 30-min mark of on-scene resuscitation (30 min-ETCO2) from EMS charts. The primary outcome was survival to hospital discharge. We compared 30 min-ETCO2 cutoffs of 10 mmHg and 20 mmHg to the trend (increasing or not) from initial to 30 min-ETCO2 (delta-ETCO2) using sensitivity, specificity, and area under the receiver operating curves (AUROC).

RESULTS

Of 3837 adult OHCA, 2850 were initially non-shockable, and there were 617 (16.1%) cases of refractory non-shockable OHCA at 30-min. We excluded 320 cases without at least two ETCO2 recordings in the EMS chart, leaving 297 cases that met inclusion criteria. Of these, 176 (59.3%) were transported and 2 (0.7%) survived to discharge. Using absolute 30 min-ETCO2 cutoffs, both survivors were in the >10 mmHg group (sensitivity 100.0%, specificity 12.5%), whereas only one survivor was identified in the >20 mmHg group (sensitivity 50.0%, specificity 32.5%). Using delta-ETCO2, both survivors were in the increasing ETCO2 group (sensitivity 100.0%, specificity 60.7%). In comparing the two tests that did not misclassify survivors, the AUROC [95% CI] was higher when using delta-ETCO2 (0.803 [0.775-0.831]) compared to an absolute cutoff of 10 mmHg (0.563 [0.544-0.582]).

CONCLUSIONS

Nearly one-sixth of EMS-treated adult OHCA patients had refractory non-shockable arrests after at least 30 min of ongoing resuscitation. In this group, the ETCO2 trend following advanced airway placement may be more accurate in guiding termination of resuscitation than an absolute ETCO2 cutoff of 10 or 20 mmHg.

Association between cardiopulmonary resuscitation duration and survival after out-of-hospital cardiac arrest according: a first nationwide study in France

OBJECTIVE

Determining whether to pursue or terminate resuscitation efforts remains one of the biggest challenges of cardiopulmonary resuscitation (CPR). No ideal cut-off duration has been recommended and the association between CPR duration and survival is still unclear for out-of-hospital cardiac arrest (OHCA). The aim of this study was to assess the association between CPR duration and 30-day survival after OHCA with favorable neurological outcomes according to initial rhythm.

METHODS

This was an observational, retrospective analysis of the French national multicentric registry on cardiac arrest, RéAC. The primary endpoint was neurologically intact 30-day survival according to initial rhythm.

RESULTS

20,628 patients were included. For non-shockable rhythms, the dynamic probability of 30-day survival with a Cerebral Performance Category (CPC) of 1 or 2 was less than 1% after 25 min of CPR. CPR duration over 10 min was not associated with 30-day survival with CPC of 1 or 2 (adjusted OR: 1.67; CI 95% 0.95-2.94). For shockable rhythms, the dynamic probability of 30-day survival with a CPC score of 1 or 2, was less than 1% after 54 min of CPR. CPR duration of 21-25 min was still associated with 30-day survival and 30-day survival with a CPC of 1 or 2 (adjusted OR: 2.77; CI 95% 2.16-3.57 and adjusted OR: 1.82; CI 95% 1.06-3.13, respectively).

CONCLUSIONS

Survival decreased rapidly with increasing CPR duration, especially for non-shockable rhythms. Pursuing CPR after 25 min may be futile for patients presenting a non-shockable rhythm. On the other hand, shockable rhythms might benefit from prolonged CPR.

Associated Factors of Cardiopulmonary Resuscitation Outcomes; a Cohort Study on an Adult In-hospital Cardiac Arrest Registry

Introduction

In-hospital cardiac arrest (IHCA) remains a substantial cause of morbidity and mortality for hospitalized patients worldwide. This study aimed to identify associated factors of return of spontaneous circulation (ROSC) and survival with favorable neurological outcomes of IHCA patients.

Method

A two-year retrospective cohort study was conducted at a university-based tertiary care hospital in Bangkok, Thailand, studying adult patients aged ≥ 18 years with IHCA from January 2021 to December 2022. The primary endpoint was sustained ROSC, and the secondary endpoint was survival with favorable neurological outcomes defined as Cerebral Performance Categories (CPC) Scale of 1 or 2 at discharge. Pre-arrest and intra-arrest variables were collected and analyzed using multivariable logistic regression to identify independent factors associated with the outcomes.

Results

During the study period, 156 patients were included in the study. 105 (67.3%) patients achieved sustained ROSC after the CPR, 28 patients (18.0%) were discharged alive, and 15 patients (9.6%) survived with a favorable neurological outcome at hospital discharge. Overall, sustained ROSC was higher in patients who had IHCA during the day shift (odds ratio (OR): 4.11; 95% confidence interval (CI): 1.05-16.06) and electrocardiogram (ECG) monitoring prior to arrest (OR: 6.38; 95% CI: 1.18-34.54). In contrast, higher adrenaline doses administrated, and increased CPR duration reduced the odds of sustained ROSC (OR: 0.72; 95% CI: 0.54-0.94 and OR: 0.92; 95% CI: 0.85-0.98, respectively). Arrest due to cardiac etiology was associated with increased discharged survival with favorable neurological outcomes (OR: 13.43; 95% CI: 2.00-89.80), while a higher Good Outcome Following Attempted Resuscitation (GO-FAR) score reduced the odds of the secondary outcome (OR: 0.89; 95% CI: 0.81-0.98).

Conclusion

The sustained ROSC was higher in IHCA during the daytime shift and under prior ECG monitoring. The administration of higher doses of adrenaline and prolonged CPR durations decreased the likelihood of achieving sustained ROSC. Furthermore, patients with cardiac-related causes of cardiac arrest exhibited a higher rate of survival to hospital discharge with favorable neurological outcomes.

Investigation of mortality rates and the factors affecting survival in out-of-hospital cardiac arrest patients

BACKGROUND

It is known that even if spontaneous circulation returns after cardiopulmonary resuscitation(CPR) in geriatric out-of-hospital cardiac arrests(OHCA), the overall one-year survival rate of these patients is very low. In our study, we aimed to investigate the factors affecting survival in OHCA cases.

METHODS

OHCA patients over 18 years of age were examined in two different groups as 18-64 years old and over 65 years old. Demographic data, comorbidities, cardiac arrest rhythms and minutes, and the number of days they were hospitalized in the intensive care unit were recorded.

RESULTS

The mean age was 65.9 ± 15.8 years and 39.9% (n = 110) of the patients were female. The number of intensive care unit stays was significantly higher in the over-65 age group (p = 0.011). The mortality rate and one-year survival rate were significantly lower in the over-65 age group (p < 0.001). Median CPR time was 21 min (IQR:14-32) in the entire patient population. The duration of CPR was 22 min (IQR:14-35) in patients with in-hospital mortality, and 15 min (IQR:13-25) in patients discharged from the hospital. In this comparison, the difference is statistically significant (p = 0.008).

CONCLUSION

In our study, it was determined that especially over 65 years of age, coronary artery disease, and post-arrest CPR duration were determinant and predictive factors in in-hospital and long-term survival.

Perinatal Azithromycin Provides Limited Neuroprotection in an Ovine Model of Neonatal Hypoxic-Ischemic Encephalopathy

BACKGROUND

Hypoxic-ischemic brain injury/encephalopathy affects about 1.15 million neonates per year, 96% of whom are born in low- and middle-income countries. Therapeutic hypothermia is not effective in this setting, possibly because injury occurs significantly before birth. Here, we studied the pharmacokinetics, safety, and efficacy of perinatal azithromycin administration in near-term lambs following global ischemic injury to support earlier treatment approaches.

METHODS

Ewes and their lambs of both sexes (n=34, 141-143 days) were randomly assigned to receive azithromycin or placebo before delivery as well as postnatally. Lambs were subjected to severe global hypoxia-ischemia utilizing an acute umbilical cord occlusion model. Outcomes were assessed over a 6-day period.

RESULTS

While maternal azithromycin exhibited relatively low placental transfer, azithromycin-treated lambs recovered spontaneous circulation faster following the initiation of cardiopulmonary resuscitation and were extubated sooner. Additionally, peri- and postnatal azithromycin administration was well tolerated, demonstrating a 77-hour plasma elimination half-life, as well as significant accumulation in the brain and other tissues. Azithromycin administration resulted in a systemic immunomodulatory effect, demonstrated by reductions in proinflammatory IL-6 (interleukin-6) levels. Treated lambs exhibited a trend toward improved neurodevelopmental outcomes while histological analysis revealed that azithromycin supported white matter preservation and attenuated inflammation in the cingulate and parasagittal cortex.

CONCLUSIONS

Perinatal azithromycin administration enhances neonatal resuscitation, attenuates neuroinflammation, and supports limited improvement of select histological outcomes in an ovine model of hypoxic-ischemic brain injury/encephalopathy.

Neuroprotection after cardiac arrest with 2-iminobiotin: a single center phase IIa study on safety, tolerability, and pharmacokinetics

Background

Brain injury is a serious problem in patients who survive out-of-hospital cardiac arrest (OHCA). Neuroprotective drugs could reduce hypoxic-ischemic reperfusion injury. The aim of this study was to investigate the safety, tolerability, and pharmacokinetics (PK) of 2-iminobiotin (2-IB), a selective inhibitor of neuronal nitric oxide synthase.

Methods

Single-center, open-label dose-escalation study in adult OHCA patients, investigating three 2-IB dosing schedules (targeting an AUC_0-24h of 600-1,200 ng*h/m in cohort A, of 2,100-3,300 ng*h/mL in cohort B, and 7,200-8,400 of ng*h/mL in cohort C). Safety was investigated by monitoring vital signs until 15 min after study drug administration and adverse events up to 30 days after admission. Blood sampling for PK analysis was performed. Brain biomarkers and patient outcomes were collected 30 days after OHCA.

Results

A total of 21 patients was included, eight in cohort A and B and five in cohort C. No changes in vital signs were observed, and no adverse events related to 2-IB were reported. A two-compartment PK model described data the best. Exposure in group A (dosed on bodyweight) was three times higher than targeted (median AUC_0-24h 2,398 ng*h/mL). Renal function was an important covariate; therefore, in cohort B, dosing was performed on eGFR on admission. In cohort B and C, the targeted exposure was met (median AUC_0-24h 2,917 and 7,323 ng*h/mL, respectively).

Conclusion

The administration of 2-IB to adults after OHCA is feasible and safe. PK can be well predicted with correction for renal function on admission. Efficacy studies with 2-IB after OHCA are needed.

Duration of cardiopulmonary resuscitation and phenotype of post-cardiac arrest brain injury

BACKGROUND

Patients resuscitated from cardiac arrest have variable severity of primary hypoxic ischemic brain injury (HIBI). Signatures of primary HIBI on brain imaging and electroencephalography (EEG) include diffuse cerebral edema and burst suppression with identical bursts (BSIB). We hypothesize distinct phenotypes of primary HIBI are associated with increasing cardiopulmonary resuscitation (CPR) duration.

METHODS

We identified from our prospective registry of both in-and out-of-hospital CA patients treated between January 2010 to January 2020 for this cohort study. We abstracted CPR duration, neurological examination, initial brain computed tomography gray to white ratio (GWR), and initial EEG pattern. We considered four phenotypes on presentation: awake; comatose with neither BSIB nor cerebral edema (non-malignant coma); BSIB; and cerebral edema (GWR ≤ 1.20). BSIB and cerebral edema were considered as non-mutually exclusive outcomes. We generated predicted probabilities of brain injury phenotype using localized regression.

RESULTS

We included 2,440 patients, of whom 545 (23%) were awake, 1,065 (44%) had non-malignant coma, 548 (23%) had BSIB and 438 (18%) had cerebral edema. Only 92 (4%) had both BSIB and edema. Median CPR duration was 16 [IQR 8-28] minutes. Median CPR duration increased in a stepwise manner across groups: awake 6 [3-13] minutes; non-malignant coma 15 [8-25] minutes; BSIB 21 [13-31] minutes; cerebral edema 32 [22-46] minutes. Predicted probability of phenotype changes over time.

CONCLUSIONS

Brain injury phenotype is related to CPR duration, which is a surrogate for severity of HIBI. The sequence of most likely primary HIBI phenotype with progressively longer CPR duration is awake, coma without BSIB or edema, BSIB, and finally cerebral edema.

Sustained Return of Spontaneous Circulation Following Out-of-Hospital Cardiac Arrest; Developing a Predictive Model Based on Multivariate Analysis

Introduction

Identifying the predictive factors of sustained return of spontaneous circulation (ROSC) following out-of-hospital cardiac arrest (OHCA) will be helpful in management of these patients. This study aimed to develop a predictive model in this regard.

Methods

In a retrospective observational study, data of adult patients with OHCA, were collected from Vajira emergency medical services patient care report. Multiple logistic regression analysis with a regression coefficient was used to develop a predictive score for a sustained ROSC at the scene. Area under the receiver operating characteristic (ROC) curve (AUC) was used to validate the accuracy of the predictive score for a sustained ROSC.

Results

Independent factors associated with a sustained ROSC included cardiopulmonary resuscitation (CPR) duration < 30 min (adjusted odds ratio (AOR)= 5.05, 95% confidence interval (CI): 3.34-7.65; p < 0.001); advanced airway management with an endotracheal tube (AOR= 3.06, 95% CI: 1.77-5.31; p < 0.001); advanced airway management with laryngeal mask airway (AOR= 3.42, 95% CI: 1.02-11.46; p = 0.046); defibrillation (AOR = 2.05, 95% CI: 1.31-3.2; p = 0.002); Capillary blood glucose (CBG) level < 150 mg% (AOR= 1.95, 95% CI: 1.05-3.65; p = 0.035); CBG at least 150 mg% (AOR= 2.87, 95% CI: 1.56-5.29; p = 0.001); pupil reflex (AOR = 2.96, 95% CI: 1.1-7.96; p = 0.032); and response time at most 8 min (AOR= 1.66, 95% CI: 1.07-2.57; p = 0.023). These were developed into the pupil reflex, response time, advanced airway management, defibrillation, CBG, and CPR duration (PRAD-CCPR) score. The most accurate cutoff point of score using Youden's index was ≥ 6 with AUC of 0.759 (95% CI: 0.715-0.802; p < 0.001), sensitivity of 62.0% (95% CI: 51.2-71.9%), specificity of 75.7% (95% CI: 69.4-81.2%), positive predictive value of 51.8% (95% CI: 40.9-62.3%), and negative predictive value of 79.5% (95% CI: 73.5-84.6%).

Conclusion

An optimal PRAD-CCPR score of ≥ 6 provides an acceptable accuracy of 0.759 with sensitivity of 62.0% and specificity of 75.7% in prediction of sustained ROSC following OHCA. This predictive score might help CPR commanders to prognosticate the outcome of patients with OHCA at the scene.