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Chen DL, Chung CM, Wang GJ, Chang KC. Lactate-to-albumin ratio and cholesterol levels predict neurological outcome in cardiac arrest survivors. Am J Emerg Med 2024; 83:9-15. [PMID: 38943710 DOI: 10.1016/j.ajem.2024.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/10/2024] [Accepted: 06/20/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) increases lactate levels and reduces albumin levels on admission and tends to lead to a poor neurological prognosis. In our experience, reduced cholesterol levels predict poor neurological prognosis. However, the relationship between cholesterol levels and neurological prognosis in OHCA survivors remains unclear. METHODS This retrospective observational study included data from January 2015 to June 2023 on 219 OHCA survivors at our intensive care unit. Patients were categorized into two groups based on cerebral functional classification (CPC) scores: Group A (CPC score of 1 or 2), including patients with a favorable neurological outcome, and Group B (CPC scores of 3 to 5), comprising those with a poor neurological outcome. We analyzed their lactate, albumin levels, and lipid profiles measured at 6 h after resuscitation. A model to predict the neurological prognosis of admission of OHCA survivors was developed. RESULTS Approximately 40% of the patients had favorable neurological outcomes at the 30-day follow-up. The lactate-to-albumin ratio (LAR) was significantly lower in Group A than in Group B (3.1 vs. 5.0 mmol/dag, p < 0.001). However, the albumin, total cholesterol, and high-density lipoprotein (HDL) cholesterol levels were significantly higher in Group A than in Group B (3.6 vs. 2.9 g/dL, 166.1 vs. 131.4 mg/dL, and 38.8 vs. 29.7 mg/dL, respectively, p < 0.001). Favorable neurological outcome was indicated at the following thresholds: LAR < 3.7 mmol/dag, albumin level > 3.1 g/dL, total cholesterol level > 146.4 mg/dL, and HDL-cholesterol level > 31.9 mg/dL. These findings underscore the high sensitivity and negative predictive value of the biomarkers. Furthermore, the area under the curve values for LAR, albumin, total cholesterol, and HDL-cholesterol levels were 0.70, 0.75, 0.71, and 0.71, respectively. The corresponding odds ratios were 3.37, 7.08, 3.67, and 3.94, respectively. CONCLUSIONS The LAR, albumin, total cholesterol, and HDL-cholesterol levels measured on admission may predict neurological prognosis in OHCA survivors. Thus, routine practice should include the measurement of these biomarkers at 6 h after resuscitation, especially in patients with a lactate level of > 5 mmol/L. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT02633358.
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Affiliation(s)
- Da-Long Chen
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan; Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung, Taiwan.
| | - Chia-Min Chung
- Environment-Omics-Diseases Research Centre, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Guei-Jane Wang
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan; Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan; Pharmacy Department, Wizcare Medical Corporation Aggregate, Taichung, Taiwan; School of Medicine, Weifang University of Science and Technology, Weifang, Shandong, China.
| | - Kuan-Cheng Chang
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan; Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.
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Zhou D, Lv Y, Wang C, Li D. The early change in pH values after out-of-hospital cardiac arrest is not associated with neurological outcome at hospital discharge. Resusc Plus 2024; 18:100650. [PMID: 38711912 PMCID: PMC11070929 DOI: 10.1016/j.resplu.2024.100650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/10/2024] [Accepted: 04/19/2024] [Indexed: 05/08/2024] Open
Abstract
Background The association between pH values and outcome for patients after out-of-hospital cardiac arrest (OHCA) was not fully elucidated; besides, the relationship of change in pH values and neurological outcome was unknown. The aim was to explore the association of pH values as well as change in pH values and neurological outcome for OHCA cardiac patients. Methods The adult patients with non-traumatic out-of-hospital cardiac arrest, shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, and at least two arterial blood gases analysis recorded after admission were included. The change in pH values is calculated as the difference between the second and first pH value, and divided by time interval got the rate of change in pH values. The primary outcome was modified Rankin Score (mRS), dichotomized to good (mRS 0-3) and poor (mRS 4-6) outcomes at hospital discharge. The independent relationship of the first pH value, second pH value, and changes in pH values with neurological outcome was investigated with multivariable logistic regression models, respectively. Results A total of 1388 adult patients were included for analysis, of which 514 (37%) had good neurological outcome. The median first pH value and second pH value after admission were 7.21 (interquartile range [IQR] 7.09-7.29) and 7.28 (IQR 7.20-7.36), respectively. The median absolute, relative change, and rate of changes in pH values were 0.08 (IQR 0.01-0.16), 1.10% (IQR 0.11-2.22%), and 0.02 (IQR 0-0.06) per hour, respectively. After adjusting for confounders, the higher first pH value (odds ratio [OR] 3.81, confidence interval [CI] 1.60-9.24, P = 0.003) and higher second pH value (OR 9.54, CI 3.45-26.87, P < 0.001) after admission were associated with good neurological outcome, respectively. The absolute (OR 1.58, CI 0.58-4.30, P = 0.368) and relative (OR 1.03, CI 0.96-1.11, P = 0.399) change as well as the rate of change (OR 0.98, CI 0.33-2.71, P = 974) in pH values were not associated with neurological outcome. Conclusions For OHCA patients, abnormality in pH values was very common, with a more acidic pH value indicating poor neurological outcome. However, the change in pH values was not associated with outcomes.
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Affiliation(s)
- Dawei Zhou
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yi Lv
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chao Wang
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Dan Li
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Yoshida R, Komukai K, Kubota T, Kinoshita K, Fukushima K, Yamamoto H, Niijima A, Matsumoto T, Nakayama R, Watanabe M, Yoshimura M. 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. Heart Vessels 2024; 39:446-453. [PMID: 38300278 DOI: 10.1007/s00380-023-02352-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 12/27/2023] [Indexed: 02/02/2024]
Abstract
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.
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Affiliation(s)
- Ritsu Yoshida
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Kimiaki Komukai
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan.
| | - Takeyuki Kubota
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Koji Kinoshita
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Keisuke Fukushima
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Hiromasa Yamamoto
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Akira Niijima
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Takuya Matsumoto
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Ryo Nakayama
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Masato Watanabe
- Division of Cardiology, The Jikei University Kashiwa Hospital, 163-1 Kashiwa-Shita, Kashiwa, Chiba, 277-8567, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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Laurikkala J, Ameloot K, Reinikainen M, Palmers PJ, De Deyne C, Bert F, Dupont M, Janssens S, Dens J, Hästbacka J, Jakkula P, Loisa P, Birkelund T, Wilkman E, Vaara ST, Skrifvars MB. The effect of higher or lower mean arterial pressure on kidney function after cardiac arrest: a post hoc analysis of the COMACARE and NEUROPROTECT trials. Ann Intensive Care 2023; 13:113. [PMID: 37987871 PMCID: PMC10663425 DOI: 10.1186/s13613-023-01210-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/06/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND We aimed to study the incidence of acute kidney injury (AKI) in out-of-hospital cardiac arrest (OHCA) patients treated according to low-normal or high-normal mean arterial pressure (MAP) targets. METHODS A post hoc analysis of the COMACARE (NCT02698917) and Neuroprotect (NCT02541591) trials that randomized patients to lower or higher targets for the first 36 h of intensive care. Kidney function was defined using the Kidney Disease Improving Global Outcome (KDIGO) classification. We used Cox regression analysis to identify factors associated with AKI after OHCA. RESULTS A total of 227 patients were included: 115 in the high-normal MAP group and 112 in the low-normal MAP group. Eighty-six (38%) patients developed AKI during the first five days; 40 in the high-normal MAP group and 46 in the low-normal MAP group (p = 0.51). The median creatinine and daily urine output were 85 μmol/l and 1730 mL/day in the high-normal MAP group and 87 μmol/l and 1560 mL/day in the low-normal MAP group. In a Cox regression model, independent AKI predictors were no bystander cardiopulmonary resuscitation (p < 0.01), non-shockable rhythm (p < 0.01), chronic hypertension (p = 0.03), and time to the return of spontaneous circulation (p < 0.01), whereas MAP target was not an independent predictor (p = 0.29). CONCLUSION Any AKI occurred in four out of ten OHCA patients. We found no difference in the incidence of AKI between the patients treated with lower and those treated with higher MAP after CA. Higher age, non-shockable initial rhythm, and longer time to ROSC were associated with shorter time to AKI. CLINICAL TRIAL REGISTRATION COMACARE (NCT02698917), NEUROPROTECT (NCT02541591).
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Affiliation(s)
- Johanna Laurikkala
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland.
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Pieter-Jan Palmers
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Cathy De Deyne
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
- Department of Anesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ferdinande Bert
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Joseph Dens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Johanna Hästbacka
- Department of Anesthesia and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Pekka Jakkula
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Pekka Loisa
- Department of Intensive Care, Päijät-Häme Central Hospital, Lahti, Finland
| | | | - Erika Wilkman
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Suvi T Vaara
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Sharpe AR, Richardson K, Stanton M, Dang C, Feih J, Brazauskas R, Teng BQ, Feldman R. Lack of Association of Initial Vasopressor Dosing with Survival and Cardiac Re-Arrest Likelihood After Return of Spontaneous Circulation. J Emerg Med 2023; 65:e209-e220. [PMID: 37635036 DOI: 10.1016/j.jemermed.2023.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 04/26/2023] [Accepted: 05/26/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Cardiac arrest occurs in approximately 350,000 patients outside the hospital and approximately 30,000 patients in the emergency department (ED) annually in the United States. When return of spontaneous circulation (ROSC) is achieved, hypotension is a common complication. However, optimal dosing of vasopressors is not clear. OBJECTIVE The objective of this study was to determine if initial vasopressor dosing was associated with cardiac re-arrest in patients after ROSC. METHODS This was a retrospective, single-center analysis of adult patients experiencing cardiac arrest prior to arrival or within the ED. Patients were assigned to one of four groups based on starting dose of vasopressor: low dose (LD; < 0.25 µg/kg/min), medium dose (MD; 0.25-0.49 µg/kg/min), high dose (HD; 0.5-0.99 µg/kg/min), and very high dose (VHD; ≥ 1 µg/kg/min). Data collection was performed primarily via manual chart review of medical records. The primary outcome was incidence of cardiac re-arrest within 1 h of vasopressor initiation. Multivariate logistic regression analysis was conducted to identify any covariates strongly associated with the primary outcome. RESULTS No difference in cardiac re-arrest incidence was noted between groups. The VHD group was significantly more likely to require a second vasopressor (p = 0.003). The HD group had lower survival rates to hospital discharge compared with the LD and MD groups (p = 0.0033 and p = 0.0147). In the multivariate regression, longer duration of pre-vasopressor re-arrests and hyperkalemic cardiac arrest etiology were significant predictors of cardiac re-arrest after vasopressor initiation. CONCLUSIONS Initial vasopressor dosing was not found to be associated with risk of cardiac re-arrest or, conversely, risk of adverse events.
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Affiliation(s)
- Abigail R Sharpe
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kelly Richardson
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Matthew Stanton
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cathyyen Dang
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jessica Feih
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ruta Brazauskas
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Bi Qing Teng
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ryan Feldman
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
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Huabbangyang T, Sangketchon C, Noimo G, Pinthong K, Saungun K, Bunta K, Saumok C. Using Sodium Bicarbonate During Prolonged Cardiopulmonary Resuscitation in Prehospital Setting; a Retrospective Cross-sectional Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 11:e41. [PMID: 37609541 PMCID: PMC10440747 DOI: 10.22037/aaem.v11i1.2002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Introduction Although the 2020 American Heart Association (AHA) guidelines recommend that sodium bicarbonate (SB) be avoided during routine cardiopulmonary resuscitation (CPR) a limited number of studies have examined the effects of SB injection during prolonged CPR (>15 min) in prehospital setting. The present study aimed to examine the effects of prehospital SB use during prolonged CPR on patients' outcome. Methods In this retrospective cross-sectional study adult patients aged >18 years who experienced a non-traumatic, out-of-hospital cardiac arrest (OHCA) were compared regarding three outcomes, namely return of spontaneous circulation (ROSC), ROSC > 20 minute, and survival to discharge, based on receiving or not-receiving SB during CPR. Results 330 patients were divided into two equal groups of 165. The two groups had similar conditions regarding gender distribution (p = 0.729); mean age (p = 0.741); underlying diseases (p = 0.027); etiology of arrest (p = 0.135); the initial rhythm (p = 0.324); receiving normal saline solution (p = 1.000), epinephrine (p = 0.848), and atropine during CPR (p = 0.054); and using defibrillation (p = 0.324). Those who received SB had 0.80 times greater likelihood for sustained ROSC (adjusted odds ratio (OR) = 0.80, 95% CI: 0.47-1.37, p = 0.415), 0.93 times greater likelihood for ROSC at the scene (adjusted OR = 0.93, 95% CI: 0.55-1.59, p = 0.798), and 0.34 times greater likelihood for survival to discharge (adjusted OR = 0.34, 95% CI: 0.10-1.17, p = 0.087). Conclusions The present study demonstrated that prehospital SB use by EMS during prolonged CPR did not improve ROSC rate at the scene, sustained ROSC, and survival to discharge.
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Affiliation(s)
- Thongpitak Huabbangyang
- Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, Thailand
| | - Chunlanee Sangketchon
- Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, Thailand
| | - Gotchagorn Noimo
- Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Korawee Pinthong
- Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Ketvipa Saungun
- Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Kaiwit Bunta
- Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Chomkamol Saumok
- Division of Emergency Medical Service and Disaster, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Paul M, Legriel S, Benghanem S, Abbad S, Ferré A, Lacave G, Richard O, Dumas F, Cariou A. Association between the Cardiac Arrest Hospital Prognosis (CAHP) score and reason for death after successfully resuscitated cardiac arrest. Sci Rep 2023; 13:6033. [PMID: 37055444 PMCID: PMC10102274 DOI: 10.1038/s41598-023-33129-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 04/07/2023] [Indexed: 04/15/2023] Open
Abstract
Individualize treatment after cardiac arrest could potentiate future clinical trials selecting patients most likely to benefit from interventions. We assessed the Cardiac Arrest Hospital Prognosis (CAHP) score for predicting reason for death to improve patient selection. Consecutive patients in two cardiac arrest databases were studied between 2007 and 2017. Reasons for death were categorised as refractory post-resuscitation shock (RPRS), hypoxic-ischaemic brain injury (HIBI) and other. We computed the CAHP score, which relies on age, location at OHCA, initial cardiac rhythm, no-flow and low-flow times, arterial pH, and epinephrine dose. We performed survival analyses using the Kaplan-Meier failure function and competing-risks regression. Of 1543 included patients, 987 (64%) died in the ICU, 447 (45%) from HIBI, 291 (30%) from RPRS, and 247 (25%) from other reasons. The proportion of deaths from RPRS increased with CAHP score deciles; the sub-hazard ratio for the tenth decile was 30.8 (9.8-96.5; p < 0.0001). The sub-hazard ratio of the CAHP score for predicting death from HIBI was below 5. Higher CAHP score values were associated with a higher proportion of deaths due to RPRS. This score may help to constitute uniform patient populations likely to benefit from interventions assessed in future randomised controlled trials.
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Affiliation(s)
- Marine Paul
- Intensive Care Unit, Centre Hospitalier de Versailles-Site André Mignot, 177 Rue de Versailles, 78150, Le Chesnay, France.
- AfterROSC Study Group, Paris, France.
| | - Stéphane Legriel
- Intensive Care Unit, Centre Hospitalier de Versailles-Site André Mignot, 177 Rue de Versailles, 78150, Le Chesnay, France
- AfterROSC Study Group, Paris, France
- University Paris-Saclay, UVSQ, INSERM, CESP, Team "PsyDev", Villejuif, France
| | - Sarah Benghanem
- AfterROSC Study Group, Paris, France
- Intensive Care Unit, Cochin Hospital (APHP), Paris, France
| | - Sofia Abbad
- Intensive Care Unit, Centre Hospitalier de Versailles-Site André Mignot, 177 Rue de Versailles, 78150, Le Chesnay, France
| | - Alexis Ferré
- Intensive Care Unit, Centre Hospitalier de Versailles-Site André Mignot, 177 Rue de Versailles, 78150, Le Chesnay, France
| | - Guillaume Lacave
- Intensive Care Unit, Centre Hospitalier de Versailles-Site André Mignot, 177 Rue de Versailles, 78150, Le Chesnay, France
| | - Olivier Richard
- SAMU 78, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay Cedex, France
| | - Florence Dumas
- AfterROSC Study Group, Paris, France
- Sorbonne Paris Cité-Medical School, Paris Descartes University, Paris, France
- Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France
- Paris Sudden Death Expertise Centre, Paris, France
- Emergency Department, Cochin Hospital, Paris, France
| | - Alain Cariou
- AfterROSC Study Group, Paris, France
- Intensive Care Unit, Cochin Hospital (APHP), Paris, France
- Sorbonne Paris Cité-Medical School, Paris Descartes University, Paris, France
- Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France
- Paris Sudden Death Expertise Centre, Paris, France
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Timilsina G, Sahu AK, Jamshed N, Singh SK, Aggarwal P. Emergency Department Point-of-Care Tests during Cardiopulmonary Resuscitation to Predict Cardiac Arrest Outcomes. J Emerg Trauma Shock 2023; 16:48-53. [PMID: 37583382 PMCID: PMC10424736 DOI: 10.4103/jets.jets_138_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/25/2023] [Accepted: 02/20/2023] [Indexed: 08/17/2023] Open
Abstract
Introduction This study evaluated the role of point-of-care tests (POCT) such as blood lactate, anion gap (AG), base deficit, pH, N-terminal pro B-type natriuretic peptide (NT-proBNP), and troponin as the predictors of cardiac arrest outcomes in the emergency department (ED). Methods We conducted a prospective, observational study in the ED of a tertiary care hospital in India. All the adult patients who received cardiopulmonary resuscitation (CPR) in the ED were included in the study. Blood samples were collected within 10 min of initiation of CPR for assay of POCTs. Outcomes assessed were the return of spontaneous circulation (ROSC), 24-h survival, survival to hospital discharge (STHD), survival at 7 days, and favorable neurological outcome (FNO) at day 7 of admission. Results One hundred and fifty-one patients were included in the study (median age: 50 years, 65% males). Out of 151 cases, ROSC, survival at 7 days, STHD, and FNO was observed in 86 patients, six patients, five patients, and two patients, respectively. "No-ROSC" could be significantly predicted by raised lactate (odds ratio [OR]: 1.14, 95% confidence interval: 1.07-1.22) and NT-proBNP (OR: 1.05, 1.01-1.09) values at the time of cardiac arrest. "24-h mortality" could be significantly predicted by the raised lactate (OR: 1.14, 1.01-1.28), low arterial pH (OR: 0.05, 0.01-0.52), raised AG (OR: 1.08, 1.01-1.15), and lower base deficit (<-15) (OR: 1.07, 1.01-1.14). None of the other POCTs was found to be a predictor of other cardiac arrest outcomes. Conclusion Among various POCTs, raised lactate assayed within 10 min of cardiac arrest can predict poor outcomes like "no-ROSC" and 24-h mortality.
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Affiliation(s)
- Ghanashyam Timilsina
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ankit Kumar Sahu
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nayer Jamshed
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Satish Kumar Singh
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
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Lazzarin T, Tonon CR, Martins D, Fávero EL, Baumgratz TD, Pereira FWL, Pinheiro VR, Ballarin RS, Queiroz DAR, Azevedo PS, Polegato BF, Okoshi MP, Zornoff L, Rupp de Paiva SA, Minicucci MF. Post-Cardiac Arrest: Mechanisms, Management, and Future Perspectives. J Clin Med 2022; 12:jcm12010259. [PMID: 36615059 PMCID: PMC9820907 DOI: 10.3390/jcm12010259] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Cardiac arrest is an important public health issue, with a survival rate of approximately 15 to 22%. A great proportion of these deaths occur after resuscitation due to post-cardiac arrest syndrome, which is characterized by the ischemia-reperfusion injury that affects the role body. Understanding physiopathology is mandatory to discover new treatment strategies and obtain better results. Besides improvements in cardiopulmonary resuscitation maneuvers, the great increase in survival rates observed in recent decades is due to new approaches to post-cardiac arrest care. In this review, we will discuss physiopathology, etiologies, and post-resuscitation care, emphasizing targeted temperature management, early coronary angiography, and rehabilitation.
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10
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Sood N, Sangari A, Goyal A, Conway JAS. Predictors of survival for pediatric extracorporeal cardiopulmonary resuscitation: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e30860. [PMID: 36181012 PMCID: PMC9524896 DOI: 10.1097/md.0000000000030860] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The use of extracorporeal cardiopulmonary resuscitation (ECPR) has improved survival in patients with cardiac arrest; however, factors predicting survival remain poorly characterized. A systematic review and meta-analysis was conducted to examine the predictors of survival of ECPR in pediatric patients. METHODS We searched EMBASE, PubMed, SCOPUS, and the Cochrane Library from 2010 to 2021 for pediatric ECPR studies comparing survivors and non-survivors. Thirty outcomes were analyzed and classified into 5 categories: demographics, pre-ECPR laboratory measurements, pre-ECPR co-morbidities, intra-ECPR characteristics, and post-ECPR complications. RESULTS Thirty studies (n = 3794) were included. Pooled survival to hospital discharge (SHD) was 44% (95% CI: 40%-47%, I2 = 67%). Significant predictors of survival for pediatric ECPR include the pre-ECPR lab measurements of PaO2, pH, lactate, PaCO2, and creatinine, pre-ECPR comorbidities of single ventricle (SV) physiology, renal failure, sepsis, ECPR characteristics of extracorporeal membrane oxygenation (ECMO) duration, ECMO flow rate at 24 hours, cardiopulmonary resuscitation (CPR) duration, shockable rhythm, intra-ECPR neurological complications, and post-ECPR complications of pulmonary hemorrhage, renal failure, and sepsis. CONCLUSION Prior to ECPR initiation, increased CPR duration and lactate levels had among the highest associations with mortality, followed by pH. After ECPR initiation, pulmonary hemorrhage and neurological complications were most predictive for survival. Clinicians should focus on these factors to better inform potential prognosis of patients, advise appropriate patient selection, and improve ECPR program effectiveness.
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Affiliation(s)
- Nitish Sood
- Medical College of Georgia at Augusta University, Augusta, GA, USA
- * Correspondence: Nitish Sood, Medical College of Georgia at Augusta University, Augusta, GA 30909, USA (e-mail: )
| | - Anish Sangari
- Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Arnav Goyal
- Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - J. Arden S. Conway
- Department of Pediatrics, Division of Critical Care Medicine, Medical College of GA at Augusta University, Augusta, GA, USA
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11
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Paul M, Benghanem S, Merceron S, Bellut H, Dumas F, Henry A, Bruneel F, Bedos JP, Cariou A, Legriel S. Cerebrospinal fluid features in comatose survivors of cardiac arrest: A pilot study. PLoS One 2022; 17:e0270954. [PMID: 35881643 PMCID: PMC9321437 DOI: 10.1371/journal.pone.0270954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/21/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Lumbar puncture is among the investigations used to identify various neurological conditions, including some that can cause cardiac arrest (CA). However, CA per se may alter cerebrospinal fluid (CSF) characteristics. Few studies have investigated CSF findings after CA. In this descriptive work, we assessed the frequency and risk factors of abnormal CSF findings after CA and the contribution of CSF analysis to the etiological diagnosis. MATERIALS AND METHODS We retrospectively studied data from prospectively established databases of consecutive patients who were admitted to two French ICUs in 2007-2016 with sustained return of spontaneous circulation (ROSC) after CA and who underwent lumbar puncture as an etiological investigation. RESULTS Of 1984 patients with sustained ROSC, 55 (2.7%) underwent lumbar puncture and were included. Lumbar puncture identified a neurological cause of CA in 2/55 (3.6%) patients. Nonspecific CSF abnormalities were noted in 37/53 (69.8%) patients. By multivariate analysis, postresuscitation shock was positively associated with CSF abnormalities (OR, 6.92; 95% confidence interval [95%CI], 1.62-37.26; P = 0.013). A no-flow time above 6 minutes (OR, 0.19; 95%CI, 0.03-1.11; P = 0.076) and a respiratory cause of CA (OR, 2.91; 95%CI, 0.53-23.15; P = 0.24) were not statistically associated with CSF abnormalities. Nonspecific CSF abnormalities were not significantly associated with poor outcomes (Cerebral Performance Category ≥3; P = 0.06). CONCLUSIONS Lumbar puncture, although infrequently performed, may contribute to the etiological diagnosis of CA, albeit rarely. Nonspecific CSF abnormalities seem common after CA, notably with postresuscitation shock, and may be related to blood-brain barrier disruption. These findings may help to interpret CSF findings after CA. Further studies are warranted to assess our results.
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Affiliation(s)
- Marine Paul
- Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
- AfterROSC Study Group, Paris, France
| | - Sarah Benghanem
- Intensive Care Unit, Cochin Hospital, Paris, France
- Sorbonne Paris Cité-Medical School, Paris Descartes University, Paris, France
| | - Sybille Merceron
- Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
| | - Hugo Bellut
- Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
| | - Florence Dumas
- Sorbonne Paris Cité-Medical School, Paris Descartes University, Paris, France
- Emergency Department, Cochin Hospital, Paris, France
- Université de Paris, PARCC, INSERM, Paris, France
- Paris Sudden-Death-Expertise-Centre, Paris, France
| | - Amandine Henry
- Microbiology Department, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
| | - Fabrice Bruneel
- Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
| | - Jean-Pierre Bedos
- Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
| | - Alain Cariou
- AfterROSC Study Group, Paris, France
- Intensive Care Unit, Cochin Hospital, Paris, France
- Sorbonne Paris Cité-Medical School, Paris Descartes University, Paris, France
- Université de Paris, PARCC, INSERM, Paris, France
- Paris Sudden-Death-Expertise-Centre, Paris, France
| | - Stéphane Legriel
- Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
- AfterROSC Study Group, Paris, France
- University Paris-Saclay, UVSQ, INSERM, CESP, PsyDev Team, Villejuif, France
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12
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Mir T, Shafi OM, Uddin M, Nadiger M, Sibghat Tul Llah F, Qureshi WT. Pediatric Cardiac Arrest Outcomes in the United States: A Nationwide Database Cohort Study. Cureus 2022; 14:e26505. [PMID: 35923483 PMCID: PMC9339595 DOI: 10.7759/cureus.26505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/06/2022] Open
Abstract
Background Knowledge about the causes and outcomes of pediatric cardiac arrest in the emergency department is limited. The aim of our study was to evaluate the characteristics and outcomes of pediatric cardiac arrest in the emergency department (EDCA) and inpatient (IPCA) settings in the United States using a large database designed to provide nationwide estimates. Methods We performed a retrospective cohort study using the Nationwide Emergency Department Sample (NEDS), a database that includes both ED and inpatient encounters. The NEDS was analyzed for episodes of cardiac arrest between 2016-2018 in patients aged ≤18 years. Patients with cardiac arrest were identified using the International Classification of Diseases, 10th revision codes. Results A total of 15,348 pediatric cardiac arrest events with cardiopulmonary resuscitation were recorded, of which 13,239 had EDCA and 2,109 had IPCA. A lower survival rate of 19% was observed for EDCA compared to 40.4% for IPCA. While more than half of the EDCA events had no associated diagnoses, trauma (15.6%), respiratory failure (5%), asphyxiation (2.7%), acidosis (2.4%), and ventricular arrhythmia (1.4%) were associated with the remaining events. In comparison, the most frequently associated diagnoses for IPCA were respiratory failure (75.8%), acidosis (43.9%), acute kidney injury (27.2%), trauma (27.1%), and sepsis (22.5%). Conclusions Survival rates for EDCA were less than half of that for IPCA. The low survival rates along with the distinctive characteristics of EDCA events suggest the need for further research in this area to identify remediable factors and improve survival.
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13
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Okada N, Matsuyama T, Okada Y, Okada A, Kandori K, Nakajima S, Kitamura T, Ohta B. Post-Resuscitation Partial Pressure of Arterial Carbon Dioxide and Outcome in Patients with Out-of-Hospital Cardiac Arrest: A Multicenter Retrospective Cohort Study. J Clin Med 2022; 11:jcm11061523. [PMID: 35329849 PMCID: PMC8954853 DOI: 10.3390/jcm11061523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/16/2022] Open
Abstract
We aimed to estimate the association between PaCO2 level in the patient after out-of-hospital cardiac arrest (OHCA) resuscitation with patient outcome based on a multicenter prospective cohort registry in Japan between June 2014 and December 2015. Based on the PaCO2 within 24 h after return of spontaneous circulation (ROSC), patients were divided into six groups as follows: severe hypocapnia (<25 mmHg), mild hypocapnia (25−35 mmHg,), normocapnia (35−45 mmHg), mild hypercapnia (45−55 mmHg), severe hypercapnia (>55 mmHg), or exposure to both hypocapnia and hypercapnia. Multivariate logistic regression analysis was conducted to calculate the adjusted odds ratios (aORs) and 95% confidence interval (CI) for the 1-month poor neurological outcome (Cerebral Performance Category ≥ 3). Among the 13,491 OHCA patients, 607 were included. Severe hypocapnia, mild hypocapnia, severe hypercapnia, and exposure to both hypocapnia and hypercapnia were associated with a higher rate of 1-month poor neurological outcome compared with mild hypercapnia (aORs 6.68 [95% CI 2.16−20.67], 2.56 [1.30−5.04], 2.62 [1.06−6.47], and 5.63 [2.21−14.34], respectively). There was no significant difference between the outcome of patients with normocapnia and mild hypercapnia. In conclusion, maintaining normocapnia and mild hypercapnia during the 24 h after ROSC was associated with better neurological outcomes than other PaCO2 abnormalities in this study.
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Affiliation(s)
- Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan; (T.M.); (S.N.); (B.O.)
- Correspondence: ; Tel.: +81-75-251-5393
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan; (T.M.); (S.N.); (B.O.)
| | - Yohei Okada
- Department of Preventive Services, School of Public Health, Kyoto University, Kyoto 606-8501, Japan;
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
| | - Asami Okada
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto 602-8026, Japan; (A.O.); (K.K.)
| | - Kenji Kandori
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto 602-8026, Japan; (A.O.); (K.K.)
| | - Satoshi Nakajima
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan; (T.M.); (S.N.); (B.O.)
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto 602-8026, Japan; (A.O.); (K.K.)
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan;
| | - Bon Ohta
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan; (T.M.); (S.N.); (B.O.)
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14
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Hibberd O, Hazlerigg A, Cocker PJ, Wilson AW, Berry N, Harris T. The PaCO 2-ETCO 2 gradient in pre-hospital intubations of all aetiologies from a single UK helicopter emergency medicine service 2015-2018. J Intensive Care Soc 2022; 23:11-19. [PMID: 37593537 PMCID: PMC10427849 DOI: 10.1177/1751143720970356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Abstract
Background Control of the arterial partial pressure of carbon dioxide (PaCO2) is important in the ventilated patient. End-tidal carbon dioxide (ETCO2) levels are often used as a proxy, but are clinically limited. The difference between the PaCO2 and ETCO2 has been suggested to be 0.5-1.0 kPa. However, this has not been consistently reflected in the physiologically unstable pre-hospital patient. This study aims to elucidate the PaCO2-ETCO2 gradient for pre-hospital intubated patients. Methods This was a retrospective, cohort study using data identified from the HEMSbase 2 database (Feb 2015-Nov 2018). Patients were included if they had documented ETCO2 and arterial PaCO2 measurements. Arterial PaCO2 data that could not be linked to within 5 minutes of ETCO2 were excluded. Bland-Altman plots were calculated to describe agreement. Results A total of 73 patients were identified. Aetiology was arranged into three categories: 13 (17.8%) medical, 22 (30.1%) traumatic and 38 (52.1%) out-of-hospital cardiac arrest (OHCA). The median PaCO2-ETCO2 gradient was 2.0 [1.3-3.1] kPa. A PaCO2-ETCO2 gradient of 0-1 kPa was seen for only 11 (15.1%) of total patients. The Bland-Altman agreement for all aetiologies was more than the accepted gradient of 0-1 kPa with the largest bias and widest limits of agreement seen for OHCA (-3.2 [0.3 - -6.8]). Conclusion The magnitude of the differences between the ETCO2 and PaCO2, levels of variation and inability to predict this suggest that ETCO2 is not a suitable surrogate upon which to base ventilatory settings in conditions where pH or PaCO2 require precise control.
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Affiliation(s)
| | | | | | | | - Neil Berry
- East Anglian Air Ambulance, Cambridge, UK
| | - Tim Harris
- Blizard Institute, Queen Mary University of London, London, UK
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15
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Pramono A, Widyastuti Y, Soenarto Y, Rochmawati E, Sudadi. Predictive Factors for Cardiopulmonary Resuscitation Failure. Indian J Palliat Care 2021; 27:426-430. [PMID: 34898936 PMCID: PMC8655672 DOI: 10.25259/ijpc_447_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/04/2021] [Indexed: 11/04/2022] Open
Abstract
Objectives Patients with chronic diseases are often admitted to the hospital through the emergency room of the hospital because of complaints of dyspnoea, urinary retention, decreased consciousness and cardiac arrest requiring resuscitation. The purpose of this study is to find predictive factors for failure of cardiopulmonary resuscitation (CPR) in patients of chronic diseases. Materials and Methods This cross-sectional study took medical records of patients who were carried out from primary healthcare center in Yogyakarta from 2017 to 2019. Bivariate statistical analysis used Fisher's exact test to determine the relative risk; if P < 0.25, then multivariate analysis with logistic regression continued with the backward method to obtain the odds ratio (OR). Results The results indicate that cardiac arrest patients with sepsis are most likely to fail at CPR, whereas male patients are 9.1 times (OR 9.1); patients with acidosis, 8.1 times (OR 8.1); and patients with asystole heart rhythm, 7.8 times (OR 7.8, P < 0.05). We can conclude that male patients with sepsis, acidosis or asystole heart rhythm will almost certainly fail to receive resuscitation. Conclusion Sepsis or septic shock, the male gender, acidosis, and asystole rhythm can be determinants of mortality in patients with chronic diseases who undergo CPR. It is necessary for one to test the application of the checklist or data from other hospitals and score the predictive factors to make the determination of the success of CPR easier.
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Affiliation(s)
- Ardi Pramono
- Department of Anesthesiology, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Indonesia
| | - Yunita Widyastuti
- Department of Anesthesiology and Intensive Therapy, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Yati Soenarto
- Department of Pediatrics, Dr Sardjito Hospital Center For Bioethics And Medical Humanities, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Erna Rochmawati
- Department of Palliative Care and Nursing Education, School of Nursing, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Indonesia
| | - Sudadi
- Department of Anesthesiology and Intensive Therapy, Universitas Gadjah Mada, Yogyakarta, Indonesia
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16
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Okada Y, Komukai S, Kitamura T, Kiguchi T, Irisawa T, Yamada T, Yoshiya K, Park C, Nishimura T, Ishibe T, Yagi Y, Kishimoto M, Inoue T, Hayashi Y, Sogabe T, Morooka T, Sakamoto H, Suzuki K, Nakamura F, Matsuyama T, Nishioka N, Kobayashi D, Matsui S, Hirayama A, Yoshimura S, Kimata S, Shimazu T, Ohtsuru S, Iwami T. Clinical Phenotyping of Out-of-Hospital Cardiac Arrest Patients With Shockable Rhythm - Machine Learning-Based Unsupervised Cluster Analysis. Circ J 2021; 86:668-676. [PMID: 34732587 DOI: 10.1253/circj.cj-21-0675] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The hypothesis of this study is that latent class analysis could identify the subphenotypes of out-of-hospital cardiac arrest (OHCA) patients associated with the outcomes and allow us to explore heterogeneity in the effects of extracorporeal cardiopulmonary resuscitation (ECPR).Methods and Results:This study was a retrospective analysis of a multicenter prospective observational study (CRITICAL study) of OHCA patients. It included adult OHCA patients with initial shockable rhythm. Patients from 2012 to 2016 (development dataset) were included in the latent class analysis, and those from 2017 (validation dataset) were included for evaluation. The association between subphenotypes and outcomes was investigated. Further, the heterogeneity of the association between ECPR implementation and outcomes was explored. In the study results, a total of 920 patients were included for latent class analysis. Three subphenotypes (Groups 1, 2, and 3) were identified, mainly characterized by the distribution of partial pressure of O2(PO2), partial pressure of CO2(PCO2) value of blood gas assessment, cardiac rhythm on hospital arrival, and estimated glomerular filtration rate. The 30-day survival outcomes were varied across the groups: 15.7% in Group 1; 30.7% in Group 2; and 85.9% in Group 3. Further, the association between ECPR and 30-day survival outcomes by subphenotype groups in the development dataset was as varied. These results were validated using the validation dataset. CONCLUSIONS The latent class analysis identified 3 subphenotypes with different survival outcomes and potential heterogeneity in the effects of ECPR.
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Affiliation(s)
- Yohei Okada
- Department of Preventive Services, School of Public Health, Kyoto University.,Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Graduate School of Medicine, Osaka University
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University
| | | | - Taro Irisawa
- Department of Traumatology and Acute Critical Medicine, Graduate School of Medicine, Osaka University
| | - Tomoki Yamada
- Emergency and Critical Care Medical Center, Osaka Police Hospital
| | - Kazuhisa Yoshiya
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Takii Hospital
| | - Changhwi Park
- Department of Emergency Medicine, Tane General Hospital
| | | | - Takuya Ishibe
- Department of Emergency and Critical Care Medicine, Kindai University Faculty of Medicine
| | | | | | | | | | - Taku Sogabe
- Traumatology and Critical Care Medical Center, National Hospital Organization Osaka National Hospital
| | - Takaya Morooka
- Emergency and Critical Care Medical Center, Osaka City General Hospital
| | | | - Keitaro Suzuki
- Emergency and Critical Care Medical Center, Kishiwada Tokushukai Hospital
| | - Fumiko Nakamura
- Department of Emergency and Critical Care Medicine, Kansai Medical University
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine
| | - Norihiro Nishioka
- Department of Preventive Services, School of Public Health, Kyoto University
| | - Daisuke Kobayashi
- Department of Preventive Services, School of Public Health, Kyoto University
| | - Satoshi Matsui
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University
| | - Atsushi Hirayama
- Public Health, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University
| | - Satoshi Yoshimura
- Department of Preventive Services, School of Public Health, Kyoto University
| | - Shunsuke Kimata
- Department of Preventive Services, School of Public Health, Kyoto University
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Graduate School of Medicine, Osaka University
| | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University
| | - Taku Iwami
- Department of Preventive Services, School of Public Health, Kyoto University
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17
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Nishioka N, Kobayashi D, Kiguchi T, Irisawa T, Yamada T, Yoshiya K, Park C, Nishimura T, Ishibe T, Yagi Y, Kishimoto M, Kim SH, Hayashi Y, Sogabe T, Morooka T, Sakamoto H, Suzuki K, Nakamura F, Matsuyama T, Okada Y, Matsui S, Yoshimura S, Kimata S, Kawai S, Makino Y, Kitamura T, Iwami T. Development and validation of early prediction for neurological outcome at 90 days after return of spontaneous circulation in out-of-hospital cardiac arrest. Resuscitation 2021; 168:142-150. [PMID: 34619295 DOI: 10.1016/j.resuscitation.2021.09.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/08/2021] [Accepted: 09/26/2021] [Indexed: 11/24/2022]
Abstract
AIM To develop and validate a model for the early prediction of long-term neurological outcome in patients with non-traumatic out-of-hospital cardiac arrest (OHCA). METHODS We analysed multicentre OHCA registry data of adult patients with non-traumatic OHCA who experienced return of spontaneous circulation (ROSC) and had been admitted to the intensive care unit between 2013 and 2017. We allocated 1329 (2013-2015) and 1025 patients (2016-2017) to the derivation and validation sets, respectively. The primary outcome was the dichotomized cerebral performance category (CPC) at 90 days, defined as good (CPC 1-2) or poor (CPC 3-5). We developed 2 models: model 1 included variables without laboratory data, and model 2 included variables with laboratory data available immediately after ROSC. Logistic regression with least absolute shrinkage and selection operator regularization was employed for model development. Measures of discrimination, accuracy, and calibration (C-statistics, Brier score, calibration plot, and net benefit) were assessed in the validation set. RESULTS The C-statistic (95% confidence intervals) of models 1 and 2 in the validation set was 0.947 (0.930-0.964) and 0.950 (0.934-0.966), respectively. The Brier score of models 1 and 2 in the validation set was 0.0622 and 0.0606, respectively. The calibration plot showed that both models were well-calibrated to the observed outcome. Decision curve analysis indicated that model 2 was similar to model 1. CONCLUSION The prediction tool containing detailed in-hospital information showed good performance for predicting neurological outcome at 90 days immediately after ROSC in patients with OHCA.
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Affiliation(s)
- Norihiro Nishioka
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | | | - Takeyuki Kiguchi
- Critical Care and Trauma Center, Osaka General Medical Center, Osaka, Japan
| | - Taro Irisawa
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomoki Yamada
- Emergency and Critical Care Medical Center, Osaka Police Hospital, Osaka, Japan
| | - Kazuhisa Yoshiya
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Takii Hospital, Moriguchi, Japan
| | - Changhwi Park
- Department of Emergency Medicine, Tane General Hospital, Osaka, Japan
| | - Tetsuro Nishimura
- Department of Critical Care Medicine, Osaka City University, Osaka, Japan
| | - Takuya Ishibe
- Department of Emergency and Critical Care Medicine, Kindai University School of Medicine, Osaka-Sayama, Japan
| | - Yoshiki Yagi
- Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
| | - Masafumi Kishimoto
- Osaka Prefectural Nakakawachi Medical Center of Acute Medicine, Higashi-Osaka, Japan
| | - Sung-Ho Kim
- Senshu Trauma and Critical Care Center, Osaka, Japan
| | - Yasuyuki Hayashi
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Taku Sogabe
- Traumatology and Critical Care Medical Center, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Takaya Morooka
- Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Haruko Sakamoto
- Department of Pediatrics, Osaka Red Cross Hospital, Osaka, Japan
| | - Keitaro Suzuki
- Emergency and Critical Care Medical Center, Kishiwada Tokushukai Hospital, Osaka, Japan
| | - Fumiko Nakamura
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yohei Okada
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Satoshi Matsui
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Satoshi Yoshimura
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Shunsuke Kimata
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Shunsuke Kawai
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Yuto Makino
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Taku Iwami
- Kyoto University Health Services, Kyoto, Japan
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18
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Mueller M, Grafeneder J, Schoergenhofer C, Schwameis M, Schriefl C, Poppe M, Clodi C, Koch M, Sterz F, Holzer M, Ettl F. Initial Blood pH, Lactate and Base Deficit Add No Value to Peri-Arrest Factors in Prognostication of Neurological Outcome After Out-of-Hospital Cardiac Arrest. Front Med (Lausanne) 2021; 8:697906. [PMID: 34604252 PMCID: PMC8483260 DOI: 10.3389/fmed.2021.697906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/19/2021] [Indexed: 12/23/2022] Open
Abstract
Background: In cardiac arrest survivors, metabolic parameters [pH value, lactate concentration, and base deficit (BD)] are routinely added to peri-arrest factors (including age, sex, bystander cardiopulmonary resuscitation, shockable first rhythm, resuscitation duration, adrenaline dose) to enhance early outcome prediction. However, the additional value of this strategy remains unclear. Methods: We used our resuscitation database to screen all patients ≥18 years who had suffered in- or out-of-hospital cardiac arrest (IHCA, OHCA) between January 1st, 2005 and May 1st, 2019. Patients with incomplete data, without return of spontaneous circulation or treatment with sodium bicarbonate were excluded. To analyse the added value of metabolic parameters to prognosticate neurological function, we built three models using logistic regression. These models included: (1) Peri-arrest factors only, (2) peri-arrest factors plus metabolic parameters and (3) metabolic parameters only. Receiver operating characteristics curves regarding 30-day good neurological function (Cerebral Performance Category 1-2) were analysed. Results: A total of 2,317 patients (OHCA: n = 1842) were included. In patients with OHCA, model 1 and 2 had comparable predictive value. Model 3 was inferior compared to model 1. In IHCA patients, model 2 performed best, whereas both metabolic (model 3) and peri-arrest factors (model 1) demonstrated similar power. PH, lactate and BD had interchangeable areas under the curve in both IHCA and OHCA. Conclusion: Although metabolic parameters may play a role in IHCA, no additional value in the prediction of good neurological outcome could be found in patients with OHCA. This highlights the importance of accurate anamnesis especially in patients with OHCA.
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Affiliation(s)
- Matthias Mueller
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Juergen Grafeneder
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.,Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Christoph Schriefl
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Poppe
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Christian Clodi
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Moritz Koch
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Florian Ettl
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
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19
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Lin CH, Yu SH, Chen CY, Huang FW, Chen WK, Shih HM. Early blood pH as an independent predictor of neurological outcome in patients with out-of-hospital cardiac arrest: A retrospective observational study. Medicine (Baltimore) 2021; 100:e25724. [PMID: 33907164 PMCID: PMC8084093 DOI: 10.1097/md.0000000000025724] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/30/2021] [Accepted: 04/12/2021] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Metabolic acidosis is observed in 98% of patients with out-of-hospital cardiac arrest (OHCA). The longer the no-flow or low-flow duration, the more severe is the acidosis in these patients. This study explored whether blood pH in early stages of advanced life support (ALS) was an independent predictor of neurological prognosis in patients with OHCA.We retrospectively enrolled patients with OHCA from January 2012 to June 2018 in a single-medical tertiary hospital in Taiwan. Patients with OHCA whose blood gas analyses within 5 minutes after receiving ALS at the emergency department (ED) were enrolled. Patients younger than 20 years old, with cardiac arrest resulting from traumatic or circumstantial causes, with return of spontaneous circulation (ROSC) before ED arrival, lacking record of initial blood gas analysis, and with do-not-resuscitate orders were excluded. The primary outcome of this study was neurological status at hospital discharge.In total, 2034 patients with OHCA were enrolled. The majority were male (61.89%), and the average age was 67.8 ± 17.0 years. Witnessed OHCA was noted in 571 cases, cardiopulmonary resuscitation was performed before paramedic arrival in 512 (25.2%) cases, and a shockable rhythm was observed in 269 (13.2%). Blood pH from initial blood gas analysis remained an independent predictor of neurological outcome after multivariate regression.Blood pH at early stages of ALS was an independent prognostic factor of post-OHCA neurological outcome. Blood gas analysis on arrival at the ED may provide additional information about the prognosis of patients with OHCA.
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Affiliation(s)
- Chin-Han Lin
- School of Medicine, College of Medicine, China Medical University
- Department of Emergency Medicine, China Medical University Hospital
| | - Shao-Hua Yu
- Department of Emergency Medicine, China Medical University Hospital
- Graduate Institute of Biomedical Sciences
| | - Chih-Yu Chen
- School of Medicine, College of Medicine, China Medical University
| | - Fen-Wei Huang
- Department of Emergency Medicine, China Medical University Hospital
| | - Wei-Kung Chen
- School of Medicine, College of Medicine, China Medical University
- Department of Emergency Medicine, China Medical University Hospital
| | - Hong-Mo Shih
- School of Medicine, College of Medicine, China Medical University
- Department of Emergency Medicine, China Medical University Hospital
- Department of Public Health, China Medical University, Taichung, Taiwan
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20
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Arterial carbon dioxide tension has a non-linear association with survival after out-of-hospital cardiac arrest: A multicentre observational study. Resuscitation 2021; 162:82-90. [PMID: 33571603 DOI: 10.1016/j.resuscitation.2021.01.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/16/2021] [Accepted: 01/22/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE International guidelines recommend targeting normocapnia in mechanically ventilated out-of-hospital cardiac arrest (OHCA) survivors, but the optimal arterial carbon dioxide (PaCO2) target remains controversial. We hypothesised that the relationship between PaCO2 and survival is non-linear, and targeting an intermediate level of PaCO2 compared to a low or high PaCO2 in the first 24-h of ICU admission is associated with an improved survival to hospital discharge (STHD) and at 12-months. METHODS We conducted a retrospective multi-centre cohort study of adults with non-traumatic OHCA requiring admission to one of four tertiary hospital intensive care units for mechanical ventilation. A four-knot restricted cubic spline function was used to allow non-linearity between the mean PaCO2 within the first 24 h of ICU admission after OHCA and survival, and optimal PaCO2 cut-points were identified from the spline curve to generate corresponding odds ratios. RESULTS We analysed 3769 PaCO2 results within the first 24-h of ICU admission, from 493 patients. PaCO2 and survival had an inverted U-shape association; normocapnia was associated with significantly improved STHD compared to either hypocapnia (<35 mmHg) (adjusted odds ratio [aOR] 0.45, 95% confidence interval [CI] 0.24-0.83) or hypercapnia (>45 mmHg) (aOR 0.45, 95% CI 0.24-0.84). Of the twelve predictors assessed, PaCO2 was the third most important predictor, and explained >11% of the variability in survival. The survival benefits of normocapnia extended to 12-months. CONCLUSIONS Normocapnia within the first 24-h of intensive care admission after OHCA was associated with an improved survival compared to patients with hypocapnia or hypercapnia.
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21
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Okada A, Okada Y, Kandori K, Nakajima S, Okada N, Matsuyama T, Kitamura T, Hiromichi N, Iiduka R. Associations between initial serum pH value and outcomes of pediatric out-of-hospital cardiac arrest. Am J Emerg Med 2020; 40:89-95. [PMID: 33360395 DOI: 10.1016/j.ajem.2020.12.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/06/2020] [Accepted: 12/10/2020] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Pediatric out-of-hospital cardiac arrest (OHCA) is one of the most critical conditions seen in the emergency department (ED). Although initial serum pH value is reported to be associated with outcome in adult OHCA patients, the association is unclear in pediatric OHCA patients. Thus, we aimed to identify the association between initial pH value and outcome among pediatric OHCA patients. METHODS This study was a retrospective analysis of a multicenter prospective cohort registry (Japanese Association for Acute Medicine out-of-hospital cardiac arrest registry) from 87 hospitals in Japan. We included pediatric OHCA patients younger than 16 years of age who were registered in this registry between June 2014 and December 2017. Of the 34,754 patients in the database, 458 patients were ultimately included in the analysis. We equally divided the patients into four groups, based on their initial pH value, and conducted a multivariate logistic regression analysis to calculate the adjusted odds ratios of the initial pH value on hospital arrival with their 95% confidence intervals for the primary outcome. RESULTS The median (interquartile range) age was 1 (0-6) year, and 77.9% (357/458) of the first monitored rhythm was asystole. The primary outcome was 1-month survival. The overall 1-month survival was 13.3% (61/458), and a 1-month favorable neurologic outcome was seen in 5.2% (24/458) of cases. The adjusted odds ratios and 95% confidence intervals for the pH 6.81-6.64, pH 6.63-6.47, pH <6.47, and pH unknown groups compared with the pH ≥6.82 group for 1-month survival were 0.39 (0.16-0.97), 0.13 (0.04-0.44), 0.03 (0.00-0.24), and 0.07 (0.02-0.21), respectively. CONCLUSIONS This study demonstrated the association between the initial pH value on hospital arrival and 1-month survival among pediatric OHCA patients.
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Affiliation(s)
- Asami Okada
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, 355-5 Haruobicho Kamigyoku, Kyoto 602-8026, Japan
| | - Yohei Okada
- Preventive Services, School of Public Health, Kyoto University, Yoshida-honmachi, Sakyo-ku, Kyoto 606-8501, Japan; Department of Primary care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan.
| | - Kenji Kandori
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, 355-5 Haruobicho Kamigyoku, Kyoto 602-8026, Japan
| | - Satoshi Nakajima
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, 355-5 Haruobicho Kamigyoku, Kyoto 602-8026, Japan; Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Narumiya Hiromichi
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, 355-5 Haruobicho Kamigyoku, Kyoto 602-8026, Japan
| | - Ryoji Iiduka
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, 355-5 Haruobicho Kamigyoku, Kyoto 602-8026, Japan
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22
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Jozwiak M, Bougouin W, Geri G, Grimaldi D, Cariou A. Post-resuscitation shock: recent advances in pathophysiology and treatment. Ann Intensive Care 2020; 10:170. [PMID: 33315152 PMCID: PMC7734609 DOI: 10.1186/s13613-020-00788-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/02/2020] [Indexed: 12/28/2022] Open
Abstract
A post-resuscitation shock occurs in 50–70% of patients who had a cardiac arrest. It is an early and transient complication of the post-resuscitation phase, which frequently leads to multiple-organ failure and high mortality. The pathophysiology of post-resuscitation shock is complex and results from the whole-body ischemia–reperfusion process provoked by the sequence of circulatory arrest, resuscitation manoeuvers and return of spontaneous circulation, combining a myocardial dysfunction and sepsis features, such as vasoplegia, hypovolemia and endothelial dysfunction. Similarly to septic shock, the hemodynamic management of post-resuscitation shock is based on an early and aggressive hemodynamic management, including fluid administration, vasopressors and/or inotropes. Norepinephrine should be considered as the first-line vasopressor in order to avoid arrhythmogenic effects of other catecholamines and dobutamine is the most established inotrope in this situation. Importantly, the optimal mean arterial pressure target during the post-resuscitation shock still remains unknown and may probably vary according to patients. Mechanical circulatory support by extracorporeal membrane oxygenation can be necessary in the most severe patients, when the neurological prognosis is assumed to be favourable. Other symptomatic treatments include protective lung ventilation with a target of normoxia and normocapnia and targeted temperature management by avoiding the lowest temperature targets. Early coronary angiogram and coronary reperfusion must be considered in ST-elevation myocardial infarction (STEMI) patients with preserved neurological prognosis although the timing of coronary angiogram in non-STEMI patients is still a matter of debate. Further clinical research is needed in order to explore new therapeutic opportunities regarding inflammatory, hormonal and vascular dysfunction.
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Affiliation(s)
- Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Paris-Centre, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27, rue du faubourg Saint Jacques, 75014, Paris, France. .,Université de Paris, Paris, France.
| | - Wulfran Bougouin
- Service de Médecine Intensive Réanimation, Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France.,INSERM U970, Paris-Cardiovascular-Research-Center, Paris, France.,Paris Sudden-Death-Expertise-Centre, Paris, France.,AfterROSC Network Group, Paris, France
| | - Guillaume Geri
- Service de Médecine Intensive Réanimation, Hôpital Universitaire Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France.,Université Paris-Saclay, Paris, France.,INSERM UMR1018, Centre de Recherche en Epidémiologie Et Santé Des Populations, Villejuif, France.,AfterROSC Network Group, Paris, France
| | - David Grimaldi
- Service de Soins Intensifs CUB-Erasme, Université Libre de Bruxelles (ULB), Bruxelles, Belgium.,AfterROSC Network Group, Paris, France
| | - Alain Cariou
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Paris-Centre, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27, rue du faubourg Saint Jacques, 75014, Paris, France.,Université de Paris, Paris, France.,INSERM U970, Paris-Cardiovascular-Research-Center, Paris, France.,Paris Sudden-Death-Expertise-Centre, Paris, France.,AfterROSC Network Group, Paris, France
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23
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Shoaib M, Becker LB. A walk through the progression of resuscitation medicine. Ann N Y Acad Sci 2020; 1507:23-36. [PMID: 33040363 DOI: 10.1111/nyas.14507] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 09/03/2020] [Accepted: 09/14/2020] [Indexed: 01/11/2023]
Abstract
Cardiac arrest (CA) is a sudden and devastating disease process resulting in more deaths in the United States than many cancers, metabolic diseases, and even car accidents. Despite such a heavy mortality burden, effective treatments have remained elusive. The past century has been productive in establishing the guidelines for resuscitation, known as cardiopulmonary resuscitation (CPR), as well as developing a scientific field whose aim is to elucidate the underlying mechanisms of CA and develop therapies to save lives. CPR has been successful in reinitiating the heart after arrest, enabling a survival rate of approximately 10% in out-of-hospital CA. Although current advanced resuscitation methods, including hypothermia and extracorporeal membrane oxygenation, have improved survival in some patients, they are unlikely to significantly improve the national survival rate any further without a paradigm shift. Such a change is possible with sustained efforts in the basic and clinical sciences of resuscitation and their implementation. This review seeks to discuss the current landscape in resuscitation medicine-how we got here and where we are going.
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Affiliation(s)
- Muhammad Shoaib
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,The Feinstein Institutes for Medical Research, Manhasset, New York
| | - Lance B Becker
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,The Feinstein Institutes for Medical Research, Manhasset, New York.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, New York
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24
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Sharma A, Miranda DF, Rodin H, Bart BA, Smith SW, Shroff GR. Do not disregard the initial 12 lead ECG after out-of-hospital cardiac arrest: It predicts angiographic culprit despite metabolic abnormalities. Resusc Plus 2020; 4:100032. [PMID: 34223310 PMCID: PMC8244459 DOI: 10.1016/j.resplu.2020.100032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/19/2020] [Accepted: 09/18/2020] [Indexed: 01/14/2023] Open
Abstract
Objectives The initial 12 lead electrocardiogram (ECG) following return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), is often disregarded by clinicians in ability to predict acute thrombotic coronary occlusion (ATCO) due to markedly abnormal metabolic milieu (AMM). We sought to evaluate the accuracy of initial vs. follow-up ECG prior to invasive coronary angiography (ICA) to predict ATCO following resuscitated OHCA. Methods We included OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA). AMM was defined as one of: pH < 7.1, lactate >2 mmol/L, serum potassium <2.8 or >6.0 mEq/L. Two ECGs A (initial) and B (follow-up) following ROSC but prior to ICA were adjudicated by 2 experienced readers using expanded ECG criteria to predict angiographic ATCO on ICA. Results 152 consecutive patients (mean age 58 years, 75% male) met inclusion criteria, 77% had AMM. Among those with both ECGs (n = 102), overall accuracy, sensitivity, specificity, positive predictive value, negative predictive value for correctly predicting angiographic ATCO for ECG A was 72%, 63%, 81%, 61%, 83% and for ECG B was 71%, 50%, 91%, 73%, 80% respectively. Predictive accuracy for angiographic ATCO was similar between ECG A [odds ratio (OR) 7.31, CI 2.87–18.62, p < 0.0001) and ECG B [OR 10.67; CI 3.6–31.61, p < 0.0001], and consistent in AMM. Conclusions In OHCA, despite AMM, the initial post ROSC ECG retains a statistically significant, and similar accuracy as the follow-up ECG to predict angiographic ATCO using expanded criteria.
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Affiliation(s)
- Amit Sharma
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC, Minneapolis, MN, USA.,Regions Hospital, St. Paul, MN, USA
| | - David F Miranda
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC, Minneapolis, MN, USA.,CentraCare Heart and Vascular Center, St. Cloud, MN, USA
| | - Holly Rodin
- Analytic Center of Excellence, Hennepin Healthcare System, HCMC, Minneapolis, MN, USA
| | - Bradley A Bart
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, USA.,Veterans Affairs Medical Center, Minneapolis, MN, USA
| | - Stephen W Smith
- Emergency Department, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, USA
| | - Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, USA
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25
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Muramatsu KI, Omori K, Kushida Y, Nagasawa H, Takeuchi I, Jitsuiki K, Shitara J, Ohsaka H, Oode Y, Yanagawa Y. Clinical significance of the level of fibrin degradation products in drowning patients without cardiac arrest. J Rural Med 2020; 15:201-203. [PMID: 33033542 PMCID: PMC7530585 DOI: 10.2185/jrm.2020-012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/10/2020] [Indexed: 11/27/2022] Open
Abstract
Objective: This study aimed to retrospectively investigate the clinical
significance of the level of fibrin degradation products in drowning patients without
cardiac arrest. Patients and Methods: All drowning patients who were transported to our
department from January 2011 to December 2019 were retrospectively investigated through a
medical chart review and included as subjects in the present study. The exclusion criteria
were the occurrence of cardiac arrest before patient arrival to our department and lack of
measurement of the fibrin degradation product level on arrival. The subjects were divided
into two groups: early discharge group, which included patients who were discharged within
3 days, and late discharge group, which included patients who were discharged after 3
days. Results: The early discharge group included 10 subjects and the late
discharge group included 39 subjects. No significant differences were observed in age,
sex, proportion of freshwater drowning cases, proportion of alcohol drinkers, vital signs,
blood gas analysis findings, proportion of lung lesions, or survival rate between the two
groups. The levels of glucose and fibrin degradation products on arrival were
significantly greater in the early discharge group than in the late discharge group. A
multivariate analysis showed that the only significant predictor of early discharge was
the fibrin degradation product level among variables identified in a univariate
analysis. Conclusion: This is the first study to show that the level of fibrin
degradation products on arrival can predict early or late discharge in drowning patients
without cardiac arrest before arriving to the hospital.
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Affiliation(s)
- Ken-Ichi Muramatsu
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Kazuhiko Omori
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Yoshihiro Kushida
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Hiroki Nagasawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Ikuto Takeuchi
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Kei Jitsuiki
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Jun Shitara
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Hiromichi Ohsaka
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Yasumasa Oode
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Youichi Yanagawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
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26
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Li CJ, Wu KH, Chen CC, Law YY, Chuang PC, Chen YC. Comparison of Dopamine and Norepinephrine Use for the Treatment of Hypotension in Out-Of-Hospital Cardiac Arrest Patients with Return of Spontaneous Circulation. Emerg Med Int 2020; 2020:7951025. [PMID: 38264544 PMCID: PMC10805545 DOI: 10.1155/2020/7951025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/01/2020] [Accepted: 08/05/2020] [Indexed: 01/25/2024] Open
Abstract
In patients experiencing out-of-hospital cardiac arrest (OHCA), hypotension is common after return of spontaneous circulation (ROSC). Both dopamine and norepinephrine are recommended as inotropic therapeutic agents. This study aimed to determine the impact of the use of these two medications on hypotension. This is a multicenter retrospective cohort study. OHCA patients with ROSC were divided into three groups according to the post resuscitation inotropic agent used for treatment in the emergency department, namely, dopamine, norepinephrine, and dopamine and norepinephrine combined therapy. Thirty-day survival and favorable neurologic performance were analyzed among the three study groups. The 30-day survival and favorable neurologic performance rates in the three study groups were 12.5%, 13.0%, and 6.8% as well as 4.9%, 4.3%, and 1.2%, respectively. On controlling the potential confounding factors by logistic regression, there was no difference between dopamine and norepinephrine treatment in survival and neurologic performance (adjusted odds ratio (aOR): 1.0, 95% confidence interval (CI) 0.48-2.06; aOR: 0.8, 95% CI: 0.28-2.53). The dopamine and norepinephrine combined treatment group had worse outcome (aOR: 0.6, 95% CI: 0.35-1.18; aOR: 0.2, 95% CI: 0.05-0.89). In conclusion, there was no significant difference in post-ROSC hypotension treatment between dopamine and norepinephrine in 30-day survival and favorable neurologic performance rates.
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Affiliation(s)
- Chao-Jui Li
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuan-Han Wu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Chih Chen
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yat-Yin Law
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Orthopedics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Po-Chun Chuang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Chuan Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6 W. Sec., Jiapu Rd., Puzih, Chiayi County 613, Taiwan
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi, Taiwan
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27
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Boller M, Fletcher DJ. Update on Cardiopulmonary Resuscitation in Small Animals. Vet Clin North Am Small Anim Pract 2020; 50:1183-1202. [PMID: 32798056 DOI: 10.1016/j.cvsm.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cardiopulmonary arrest (CPA), the acute cessation of ventilation and systemic perfusion, leads to discontinuation of tissue oxygen delivery and death if not quickly reversed. Reported resuscitation rates suggest that the heart can be restarted in 40% to 50% of dogs and cats treated with cardiopulmonary resuscitation (CPR). However, approximately 80% of these animals do not survive to hospital discharge. To minimize mortality due to CPA a broad strategy is required including preparedness and prevention measures, basic and advanced life support as well as post-cardiac arrest care. This article summarizes the current guidelines on the treatment of small animals with CPA..
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Affiliation(s)
- Manuel Boller
- Melbourne Veterinary School, The University of Melbourne, Melbourne, Victoria, Australia.
| | - Daniel J Fletcher
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, DCS Box 31, Ithaca, NY 14853, USA
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28
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Hifumi T, Inoue A, Arimoto H, Yonemoto N, Kuroda Y, Tahara Y, Kawakita K, Yokoyama H, Nagao K, Nonogi H. The association between neuromuscular blockade use during target temperature management and neurological outcomes. Am J Emerg Med 2020; 46:289-294. [PMID: 33051089 DOI: 10.1016/j.ajem.2020.07.078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/21/2020] [Accepted: 07/28/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND To date, no study has comprehensively analyzed the association between neuromuscular blockade (NMB) during target temperature management (TTM) and the neurological outcomes after out-of-hospital cardiac arrest (OHCA) using a multicenter dataset. We aimed to examine the association between NMB during TTM after cardiac arrest and neurological outcomes after OHCA. METHODS This study was a secondary analysis of the Japanese Population-based Utstein-style study with defibrillation and basic/advanced Life Support Education and implementation-Hypothermia (J-PULSE-HYPO) study registry. The exposure of the current study was the use of NMB during TTM. The primary outcome was favorable neurological outcome, i.e., a cerebral performance category of 1-2, at hospital discharge. RESULTS Of the 452 patients with OHCA enrolled in the J-PULSE-HYPO study, 431 were analyzed. NMB was used in 353 patients (81.9%). Multivariable logistic regression analysis revealed that NMB use was not independently associated with favorable outcomes [odds ratio (OR), 0.96; 95% confidence interval (CI), 0.42-2.18; p = .918)] or survival at discharge (OR, 0.83; 95% CI, 0.31-2.02; p = .688). After adjusting the covariates, the predicted probabilities did not reveal significant differences between NMB use and non-NMB use in the respective mean (95% CI) values for favorable neurological outcomes [53.6 (50.2-57.0) % vs. 58.0 (50.4-65.6) %, p = .304], and survival rates [77.1 (74.7-79.5) % vs. 75.8 (70.5-81.0) %, p = .647]. CONCLUSIONS The NMB use during TTM was not associated with favorable neurological outcomes and survival rate in patients with OHCA.
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Affiliation(s)
- Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Japan; Emergency Medical Center, Kagawa University Hospital, Japan.
| | - Akihiko Inoue
- Emergency Medical Center, Kagawa University Hospital, Japan; Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Japan
| | - Hideki Arimoto
- Emergency and Critical Care Medical Center, Osaka City General Hospital, Japan
| | - Naohiro Yonemoto
- Department of Biostatistics, Kyoto University School of Public Health, Japan
| | | | - Yoshio Tahara
- Division of Cardiovascular Care Unit, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Japan
| | | | - Ken Nagao
- Cardiovascular Center, Nihon University Hospital, Japan
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Carr C, Carson KA, Millin MG. Acidemia Detected on Venous Blood Gas After Out-of-Hospital Cardiac Arrest Predicts Likelihood to Survive to Hospital Discharge. J Emerg Med 2020; 59:e105-e111. [PMID: 32684378 DOI: 10.1016/j.jemermed.2020.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 05/04/2020] [Accepted: 06/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Sudden cardiac arrest is the most common cause of death worldwide, and prognostication after survival remains challenging. Decisions regarding prognosis can be fraught with error in the immediate postarrest period, with guidelines recommending the use of various tests, including blood gas pH, to determine which interventions to perform. Despite these recommendations, the prognostic utility of blood gas pH remains unclear. OBJECTIVES In this retrospective cohort study, we aimed to demonstrate the prognostic utility of emergency department blood gas pH after return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest. METHODS A retrospective cohort study was performed, including all adult survivors of out-of-hospital cardiac arrest (n = 79). Primary disease-oriented outcome was venous blood pH after ROSC and survival to hospital discharge. RESULTS In patients with out-of-hospital cardiac arrest, pH < 7.2 was associated with decreased likelihood of survival to hospital discharge (odds ratio 0.06), with every 0.1-unit increase in pH being associated with an increased likelihood of survival (1.98). Based on the area under the receiver curve, the pH that optimizes sensitivity and specificity for predicting survival was 7.04. CONCLUSION Both presence and degree of acidemia on initial blood gas after ROSC was associated with a decreased likelihood of survival to hospital discharge. The optimal cutoff for prediction in this cohort of patients was 7.04. Using a higher pH cutoff would result in fewer patients receiving intervention that would otherwise have survived.
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Affiliation(s)
- Casey Carr
- Departments of Emergency Medicine and Critical Care, University of Florida - Shands Hospital, Gainesville, Florida
| | - Kathryn A Carson
- Department of Emergency Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael G Millin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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30
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Okada Y, Kiguchi T, Irisawa T, Yoshiya K, Yamada T, Hayakawa K, Noguchi K, Nishimura T, Ishibe T, Yagi Y, Kishimoto M, Shintani H, Hayashi Y, Sogabe T, Morooka T, Sakamoto H, Suzuki K, Nakamura F, Nishioka N, Matsuyama T, Sado J, Matsui S, Shimazu T, Koike K, Kawamura T, Kitamura T, Iwami T. Association between low pH and unfavorable neurological outcome among out-of-hospital cardiac arrest patients treated by extracorporeal CPR: a prospective observational cohort study in Japan. J Intensive Care 2020; 8:34. [PMID: 32426140 PMCID: PMC7212572 DOI: 10.1186/s40560-020-00451-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/22/2020] [Indexed: 12/13/2022] Open
Abstract
Background We aimed to identify the association of pH value in blood gas assessment with neurological outcome among out-of-hospital cardiac arrest (OHCA) patients treated by extracorporeal cardiopulmonary resuscitation (ECPR). Methods We retrospectively analyzed the database of a multicenter prospective observational study on OHCA patients in Osaka prefecture, Japan (CRITICAL study), from July 1, 2012 to December 31, 2016. We included adult OHCA patients treated by ECPR. Patients with OHCA from external causes such as trauma were excluded. We conducted logistic regression analysis to identify the odds ratio (OR) and 95% confidence interval (CI) of the pH value for 1 month favorable neurological outcome adjusted for potential confounders including sex, age, witnessed by bystander, CPR by bystander, pre-hospital initial cardiac rhythm, and cardiac rhythm on hospital arrival. Results Among the 9822 patients in the database, 260 patients were finally included in the analysis. The three groups were Tertile 1: pH ≥ 7.030, Tertile 2: pH 6.875–7.029, and Tertile 3: pH < 6.875. The adjusted OR of Tertiles 2 and 3 compared with Tertile 1 for 1 month favorable neurological outcome were 0.26 (95% CI 0.10–0.63) and 0.24 (95% CI 0.09–0.61), respectively. Conclusions This multi-institutional observational study showed that low pH value (< 7.03) before the implementation of ECPR was associated with 1 month unfavorable neurological outcome among OHCA patients treated with ECPR. It may be helpful to consider the candidate for ECPR.
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Affiliation(s)
- Yohei Okada
- 1Department of Preventive Services, School of Public Health, Kyoto University, Kyoto, Japan.,2Department of Primary care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeyuki Kiguchi
- 3Kyoto University Health Service, Yoshida Honmachi, Sakyo, Kyoto, 606-8501 Japan.,Critical Care and Trauma Center, Osaka General Medical Center, Osaka, Japan
| | - Taro Irisawa
- 5Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kazuhisa Yoshiya
- 5Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomoki Yamada
- 6Emergency and Critical Care Medical Center, Osaka Police Hospital, Osaka, Japan
| | - Koichi Hayakawa
- 7Department of Emergency and Critical Care Medicine, Takii Hospital, Kansai Medical University, Moriguchi, Japan
| | - Kazuo Noguchi
- 8Department of Emergency Medicine, Tane General Hospital, Osaka, Japan
| | - Tetsuro Nishimura
- 9Department of Critical Care Medicine, Osaka City University, Osaka, Japan
| | - Takuya Ishibe
- 10Department of Emergency and Critical Care Medicine, Kindai University School of Medicine, Osaka, Sayama Japan
| | - Yoshiki Yagi
- 11Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
| | - Masafumi Kishimoto
- Osaka Prefectural Nakakawachi Medical Center of Acute Medicine, Higashi-, Osaka, Japan
| | | | - Yasuyuki Hayashi
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Taku Sogabe
- 15Traumatology and Critical Care Medical Center, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Takaya Morooka
- 16Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Haruko Sakamoto
- 17Department of Pediatrics, Osaka Red Cross Hospital, Osaka, Japan
| | - Keitaro Suzuki
- 18Emergency and Critical Care Medical Center, Kishiwada Tokushukai Hospital, Osaka, Japan
| | - Fumiko Nakamura
- 19Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka Japan
| | - Norihiro Nishioka
- 1Department of Preventive Services, School of Public Health, Kyoto University, Kyoto, Japan
| | - Tasuku Matsuyama
- 20Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Junya Sado
- 21Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Satoshi Matsui
- 21Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Takeshi Shimazu
- 5Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kaoru Koike
- 2Department of Primary care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Kawamura
- 1Department of Preventive Services, School of Public Health, Kyoto University, Kyoto, Japan.,3Kyoto University Health Service, Yoshida Honmachi, Sakyo, Kyoto, 606-8501 Japan
| | - Tetsuhisa Kitamura
- 21Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Taku Iwami
- 1Department of Preventive Services, School of Public Health, Kyoto University, Kyoto, Japan.,3Kyoto University Health Service, Yoshida Honmachi, Sakyo, Kyoto, 606-8501 Japan
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Zhang Z, Yao M, Ho KM, Hong Y. Subphenotypes of Cardiac Arrest Patients Admitted to Intensive Care Unit: a latent profile analysis of a large critical care database. Sci Rep 2019; 9:13644. [PMID: 31541172 PMCID: PMC6754393 DOI: 10.1038/s41598-019-50178-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 09/05/2019] [Indexed: 02/07/2023] Open
Abstract
Cardiac arrest (CA) may occur due to a variety of causes with heterogeneity in their clinical presentation and outcomes. This study aimed to identify clinical patterns or subphenotypes of CA patients admitted to the intensive care unit (ICU). The clinical and laboratory data of CA patients in a large electronic healthcare database were analyzed by latent profile analysis (LPA) to identify whether subphenotypes existed. Multivariable Logistic regression was used to assess whether mortality outcome was different between subphenotypes. A total of 1,352 CA patients fulfilled the eligibility criteria were included. The LPA identified three distinct subphenotypes: Profile 1 (13%) was characterized by evidence of significant neurological injury (low GCS). Profile 2 (15%) was characterized by multiple organ dysfunction with evidence of coagulopathy (prolonged aPTT and INR, decreased platelet count), hepatic injury (high bilirubin), circulatory shock (low mean blood pressure and elevated serum lactate); Profile 3 was the largest proportion (72%) of all CA patients without substantial derangement in major organ function. Profile 2 was associated with a significantly higher risk of death (OR: 2.09; 95% CI: 1.30 to 3.38) whilst the mortality rates of Profiles 3 was not significantly different from Profile 1 in multivariable model. LPA using routinely collected clinical data could identify three distinct subphenotypes of CA; those with multiple organ failure were associated with a significantly higher risk of mortality than other subphenotypes. LPA profiling may help researchers to identify the most appropriate subphenotypes of CA patients for testing effectiveness of a new intervention in a clinical trial.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.
| | - Min Yao
- Department of Surgery, Wound Care Clinical Research Program, boston University School of Medicine and Boston Medical Center, Boston, MA, 02118, USA
| | - Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, School of Population & Global Health, University of Western Australia, Perth, WA, 6000, Australia
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
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Roedl K, Spiel AO, Nürnberger A, Horvatits T, Drolz A, Hubner P, Warenits AM, Sterz F, Herkner H, Fuhrmann V. Hypoxic liver injury after in- and out-of-hospital cardiac arrest: Risk factors and neurological outcome. Resuscitation 2019; 137:175-182. [PMID: 30831218 DOI: 10.1016/j.resuscitation.2019.02.038] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 02/24/2019] [Accepted: 02/24/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hypoxic liver injury (HLI) is a frequent and life-threatening complication in critically ill patients that occurs in up to ten percent of critically ill patients. However, there is a lack of data on HLI following cardiac arrest and its clinical implications on outcome. Aim of this study was to investigate incidence, outcome and functional outcome of patients with HLI after in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA). METHODS We conducted an analysis of a cardiac arrest registry data over a 7-year period. All patients with non-traumatic OHCA and IHCA with return of spontaneous circulation (ROSC) treated at the emergency department of a tertiary care hospital were included in the study. HLI was defined according to established criteria. Predictors of HLI, occurrence, clinical and neurological outcome were assessed using multivariable regression. RESULTS Out of 1068 patients after IHCA and OHCA with ROSC, 219 (21%) patients developed HLI. Rate of HLI did not differ significantly in IHCA and OHCA patients. Multivariate regression analysis identified time-to-ROSC [OR 1.18, 95% CI (1.01-1.38); p < 0.05], presence of cardiac failure [OR 2.57, 95% CI (1.65-4.01); p < 0.001] and Charlson comorbidity index [OR 0.83, 95% CI (0.72-0.95); p < 0.01] as independent predictors for occurrence of HLI. Good functional outcome was significantly lower in patients suffering from HLI after 28-days (35% vs. 48%, p < 0.001) and 1-year (34% vs. 44%, p < 0.001). Occurrence of HLI was associated with unfavourable neurological outcome [OR 1.74, 95% CI (1.16-2.61); p < 0.01] in multivariate regression analysis. CONCLUSION New onset of HLI is a frequent finding after IHCA and OHCA. HLI is associated with increased mortality, unfavourable neurological and overall outcome.
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Affiliation(s)
- Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Internal Medicine 3, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
| | - Alexander O Spiel
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | - Alexander Nürnberger
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | - Thomas Horvatits
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Internal Medicine 3, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
| | - Andreas Drolz
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Internal Medicine 3, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
| | - Pia Hubner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | | | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Internal Medicine 3, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
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33
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Zhang Z, Zhu C, Mo L, Hong Y. Effectiveness of sodium bicarbonate infusion on mortality in septic patients with metabolic acidosis. Intensive Care Med 2018; 44:1888-1895. [PMID: 30255318 DOI: 10.1007/s00134-018-5379-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 09/15/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Although sodium bicarbonate (SB) solution has been widely used in clinical practice, its effect on mortality when administered to a large population of patients with acidosis is not known. The study aimed to investigate the effectiveness of SB infusion in septic patients with metabolic acidosis. METHODS Septic patients with metabolic acidosis were identified from the Medical Information Mart for Intensive Care (MIMIC)-III database. Propensity score (PS) was used to account for the baseline differences in the probability to receive SB or not. The marginal structural Cox model (MSCM) was employed to adjust for both baseline and time-varying confounding factors. MAIN RESULTS A total of 1718 septic patients with metabolic acidosis were enrolled in the study, including 500 in the SB group and 1218 in the non-SB group. Both pH [7.16 (standard deviation (SD): 0.10) vs. 7.22 (SD: 0.07); p < 0.001] and bicarbonate concentration (BC) [11.84 (SD: 3.63) vs. 14.88 (SD: 3.36) mmol/l; p < 0.001] were significantly lower in the SB than that in the non-SB group. While there was no significant mortality effect in the overall population [hazard ratio (HR): 1.04; 95% CI 0.86-1.26; p = 0.67], SB was observed to be beneficial in patients with acute kidney injury (AKI) stage 2 or 3 and pH < 7.2 (HR 0.74; 95% CI 0.51-0.86; p = 0.021). Similar results were replicated with the MSCM. CONCLUSION Our study observed that SB infusion was not associated with improved outcome in septic patients with metabolic acidosis, but it was associated with improved survival in septic patients with AKI stage 2 or 3 and severe acidosis. The results need to be verified in randomized controlled trials.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3, East Qingchun Road, 310016, Hangzhou, Zhejiang, China.
| | - Carlie Zhu
- Department of Clinical Statistics, 3M China Research and Development Center, Shanghai, China
| | - Lei Mo
- Department of Biostatistics, Lejiu Healthcare Technology Co., Ltd, Shanghai, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3, East Qingchun Road, 310016, Hangzhou, Zhejiang, China
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