Survival After Intra-Arrest Transport vs On-Scene Cardiopulmonary Resuscitation in Children

Importance

For pediatric out-of-hospital cardiac arrest (OHCA), emergency medical services (EMS) may elect to transport to the hospital during active cardiopulmonary resuscitation (CPR) (ie, intra-arrest transport) or to continue on-scene CPR for the entirety of the resuscitative effort. The comparative effectiveness of these strategies is unclear.

Objective

To evaluate the association between intra-arrest transport compared with continued on-scene CPR and survival after pediatric OHCA, and to determine whether this association differs based on the timing of intra-arrest transport.

Design, Setting, and Participants

This cohort study included pediatric patients aged younger than 18 years with EMS-treated OHCA between December 1, 2005 and June 30, 2015. Data were collected from the Resuscitation Outcomes Consortium Epidemiologic Registry, a prospective 10-site OHCA registry in the US and Canada. Data analysis was performed from May 2022 to February 2024.

Exposures

Intra-arrest transport, defined as an initiation of transport prior to the return of spontaneous circulation, and the interval between EMS arrival and intra-arrest transport.

Main Outcomes and Measures

The primary outcome was survival to hospital discharge. Patients who underwent intra-arrest transport at any given minute after EMS arrival were compared with patients who were at risk of undergoing intra-arrest transport within the same minute using time-dependent propensity scores calculated from patient demographics, arrest characteristics, and EMS interventions. We examined subgroups based on age (<1 year vs ≥1 year).

Results

Of 2854 eligible pediatric patients (median [IQR] age, 1 [0-9] years); 1691 males [59.3%]) who experienced OHCA between December 2005 and June 2015, 1892 children (66.3%) were treated with intra-arrest transport and 962 children (33.7%) received continued on-scene CPR. The median (IQR) time between EMS arrival and intra-arrest transport was 15 (9-22) minutes. In the propensity score-matched cohort (3680 matched cases), there was no significant difference in survival to hospital discharge between the intra-arrest transport group and the continued on-scene CPR group (87 of 1840 patients [4.7%] vs 95 of 1840 patients [5.2%]; risk ratio [RR], 0.81 [95% CI, 0.59-1.10]). Survival to hospital discharge was not modified by the timing of intra-arrest transport (P value for the interaction between intra-arrest transport and time to matching = .10). Among patients aged younger than 1 year, intra-arrest transport was associated with lower survival to hospital discharge (RR, 0.52; 95% CI, 0.33-0.83) but there was no association for children aged 1 year or older (RR, 1.22; 95% CI, 0.77-1.93).

Conclusions and Relevance

In this cohort study of a North American OHCA registry, intra-arrest transport compared with continued on-scene CPR was not associated with survival to hospital discharge among children with OHCA. However, intra-arrest transport was associated with a lower likelihood of survival to hospital discharge among children aged younger than 1 year.

Sequence of Epinephrine and Advanced Airway Placement After Out-of-Hospital Cardiac Arrest

Importance

While epinephrine and advanced airway management (AAM) (supraglottic airway insertion and endotracheal intubation) are commonly used for out-of-hospital cardiac arrest (OHCA), the optimal sequence of these interventions remains unclear.

Objective

To evaluate the association of the sequence of epinephrine administration and AAM with patient outcomes after OHCA.

Design, Setting, and Participants

This cohort study analyzed the nationwide, population-based OHCA registry in Japan and included adults (aged ≥18 years) with OHCA for whom emergency medical services personnel administered epinephrine and/or placed an advanced airway between January 1, 2014, and December 31, 2019. The data analysis was performed between October 1, 2022, and May 12, 2023.

Exposure

The sequence of intravenous epinephrine administration and AAM.

Main Outcomes and Measures

The primary outcome was 1-month survival. Secondary outcomes were 1-month survival with favorable functional status and prehospital return of spontaneous circulation. To control imbalances in measured patient demographics, cardiac arrest characteristics, and bystander and prehospital interventions, propensity scores and inverse probability of treatment weighting (IPTW) were performed for shockable and nonshockable initial rhythm subcohorts.

Results

Of 259 237 eligible patients (median [IQR] age, 79 [69-86] years), 152 289 (58.7%) were male. A total of 21 592 patients (8.3%) had an initial shockable rhythm, and 237 645 (91.7%) had an initial nonshockable rhythm. Using IPTW, all covariates between the epinephrine-first and AAM-first groups were well balanced, with all standardized mean differences less than 0.100. After IPTW, the epinephrine-first group had a higher likelihood of 1-month survival for both shockable (odds ratio [OR], 1.19; 95% CI, 1.09-1.30) and nonshockable (OR, 1.28; 95% CI, 1.19-1.37) rhythms compared with the AAM-first group. For the secondary outcomes, the epinephrine-first group experienced an increased likelihood of favorable functional status and prehospital return of spontaneous circulation for both shockable and nonshockable rhythms compared with the AAM-first group.

Conclusions and Relevance

These findings suggest that for patients with OHCA, administration of epinephrine before placement of an advanced airway may be the optimal treatment sequence for improved patient outcomes.

Association between intrarenal venous flow from Doppler ultrasonography and acute kidney injury in patients with sepsis in critical care: a prospective, exploratory observational study

BACKGROUND

Intrarenal venous flow (IRVF) patterns assessed using Doppler renal ultrasonography are real-time bedside visualizations of renal vein hemodynamics. Although this technique has the potential to detect renal congestion during sepsis resuscitation, there have been few studies on this method. We aimed to examine the relationship between IRVF patterns, clinical parameters, and outcomes in critically ill adult patients with sepsis. We hypothesized that discontinuous IRVF was associated with elevated central venous pressure (CVP) and subsequent acute kidney injury (AKI) or death.

METHODS

We conducted a prospective observational study in two tertiary-care hospitals, enrolling adult patients with sepsis who stayed in the intensive care unit for at least 24 h, had central venous catheters placed, and received invasive mechanical ventilation. Renal ultrasonography was performed at a single time point at the bedside after sepsis resuscitation, and IRVF patterns (discontinuous vs. continuous) were confirmed by a blinded assessor. The primary outcome was CVP obtained at the time of renal ultrasonography. We also repeatedly assessed a composite of Kidney Disease Improving Global Outcomes of Stage 3 AKI or death over the course of a week as a secondary outcome. The association of IRVF patterns with CVP was examined using Student's t-test (primary analysis) and that with composite outcomes was assessed using a generalized estimating equation analysis, to account for intra-individual correlations. A sample size of 32 was set in order to detect a 5-mmHg difference in CVP between IRVF patterns.

RESULTS

Of the 38 patients who met the eligibility criteria, 22 (57.9%) showed discontinuous IRVF patterns that suggested blunted renal venous flow. IRVF patterns were not associated with CVP (discontinuous flow group: mean 9.24 cm H2O [standard deviation: 3.19], continuous flow group: 10.65 cm H2O [standard deviation: 2.53], p = 0.154). By contrast, the composite outcome incidence was significantly higher in the discontinuous IRVF pattern group (odds ratio: 9.67; 95% confidence interval: 2.13-44.03, p = 0.003).

CONCLUSIONS

IRVF patterns were not associated with CVP but were associated with subsequent AKI in critically ill adult patients with sepsis. IRVF may be useful for capturing renal congestion at the bedside that is related to clinical patient outcomes.

Contamination of Blood Cultures From Arterial Catheters and Peripheral Venipuncture in Critically Ill Patients: A Prospective Multicenter Diagnostic Study

BACKGROUND

Collecting blood cultures from indwelling arterial catheters is an attractive option in critically ill adult patients when peripheral venipuncture is difficult. However, whether the contamination proportion of blood cultures from arterial catheters is acceptable compared with that from venipuncture is inconclusive.

RESEARCH QUESTION

Is contamination of blood cultures from arterial catheters noninferior to that from venipuncture in critically ill adult patients with suspected bloodstream infection?

STUDY DESIGN AND METHODS

In this multicenter prospective diagnostic study conducted at five hospitals, we enrolled episodes of paired blood culture collection, each set consisting of blood drawn from an arterial catheter and another by venipuncture, were obtained from critically ill adult patients with cilinical indication. The primary measure was the proportion of contamination, defined as the number of false-positive results relative to the total number of procedures done. The reference standard for true bloodstream infection was blinded assessment by infectious disease specialists. We examined the noninferiority hypothesis that the contamination proportion of blood cultures from arterial catheters did not exceed that from venipuncture by 2.0%.

RESULTS

Of 1,655 episodes of blood culture from December 2018 to July 2021, 590 paired blood culture episodes were enrolled, and 41 of the 590 episodes (6.9%) produced a true bloodstream infection. In blood cultures from arterial catheters, 33 of 590 (6.0%) were positive, and two of 590 (0.3%) were contaminated; in venipuncture, 36 of 590 (6.1%) were positive, and four of 590 (0.7%) were contaminated. The estimated difference in contamination proportion (arterial catheter - venipuncture) was -0.3% (upper limit of one-sided 95% CI, +0.3%). The upper limit of the 95% CI did not exceed the predefined margin of +2.0%, establishing noninferiority (P for noninferiority < .001).

INTERPRETATION

Obtaining blood cultures from arterial catheters is an acceptable alternative to venipuncture in critically ill patients.

CLINICAL TRIAL REGISTRATION

University Hospital Medical Information Network Center (UMIN-CTR); No.: UMIN000035392; URL: https://center6.umin.ac.jp/.

Comparison of mainstream end tidal carbon dioxide on Y-piece side versus patient side of heat and moisture exchanger filters in critically ill adult patients: a prospective observational study

The purpose of the study was to investigate the accuracy of mainstream EtCO2 measurements on the Y-piece (filtered) side of the heat and moisture exchanger filter (HMEF) in adult critically ill patients, compared to that on the patient (unfiltered) side of HMEF. We conducted a prospective observational method comparison study between July 2019 and December 2019. Critically ill adult patients receiving mechanical ventilation with HMEF were included. We performed a noninferiority comparison of the accuracy of EtCO2 measurements on the two sides of HMEF. The accuracy was measured by the absolute difference between PaCO2 and EtCO2. We set the non-inferiority margin at + 1 mmHg in accuracy difference between the two sides of HMEF. We also assessed the agreement between PaCO2 and EtCO2 using Bland-Altman analysis. Among thirty-seven patients, the accuracy difference was - 0.14 mmHg (two-sided 90% CI - 0.58 to 0.29), and the upper limit of the CI did not exceed the predefined margin of + 1 mmHg, establishing non-inferiority of EtCO2 on the Y-piece side of HMEF (P for non-inferiority < 0.001). In the Bland-Altman analyses, 95% limits of agreement between PaCO2 and EtCO2 were similar on both sides of HMEF (Y-piece side, - 8.67 to  + 10.65 mmHg; patient side, - 8.93 to  + 10.67 mmHg). The accuracy of mainstream EtCO2 measurements on the Y-piece side of HMEF was noninferior to that on the patient side in critically ill adults. Mechanically ventilated adult patients could be accurately monitored with mainstream EtCO2 on the Y-piece side of the HMEF unless their tidal volume was extremely low.

Association between blood urea nitrogen to creatinine ratio and neurologically favourable outcomes in out-of-hospital cardiac arrest in adults: A multicentre cohort study

BACKGROUND

We aimed to investigate the association between blood urea nitrogen to creatinine ratio (BCR) and survival with favourable neurological outcomes in patients with out-of-hospital cardiac arrest (OHCA).

METHODS

This prospective, multicentre, observational study conducted in Osaka, Japan enrolled consecutive OHCA patients transported to 16 participating institutions from 2012 through 2019. We included adult patients with non-traumatic OHCA who achieved a return of spontaneous circulation and whose blood urea nitrogen and creatinine levels on hospital arrival were available. Based on BCR values, they were divided into: 'low BCR' (BCR <10), 'normal BCR' (10 ≤ BCR < 20), 'high BCR' (20 ≤ BCR < 30), and 'very high BCR' (BCR ≥ 30). We evaluated the association between BCR values and neurologically favourable outcomes, defined as cerebral performance category score of 1 or 2 at one month after OHCA.

RESULTS

Among 4415 eligible patients, the 'normal BCR' group had the highest favourable neurological outcome [19.4 % (461/2372)], followed by 'high BCR' [12.5 % (141/1127)], 'low BCR' [11.2 % (50/445)], and 'very high BCR' groups [6.6 % (31/471)]. In the multivariable analysis, adjusted odds ratios for 'low BCR', 'high BCR', and 'very high BCR' compared with 'normal BCR' for favourable neurological outcomes were 0.58 [95 % confidence interval (CI 0.37-0.91)], 0.70 (95 % CI 0.49-0.99), and 0.40 (95 % CI 0.21-0.76), respectively. Cubic spline analysis indicated that the association between BCR and favourable neurological outcomes was non-linear (p for non-linearity = 0.003). In subgroup analysis, there was an interaction between the aetiology of arrest and BCR in neurological outcome (p for interaction <0.001); favourable neurological outcome of cardiogenic OHCA patients was lower when the BCR was higher or lower, but not in non-cardiogenic OHCA patients.

CONCLUSIONS

Both higher and lower BCR were associated with poor neurological outcomes compared to normal BCR, especially in cardiogenic OHCA patients.

Evaluation of Use of Epinephrine and Time to First Dose and Outcomes in Pediatric Patients With Out-of-Hospital Cardiac Arrest

Importance

While epinephrine has been widely used in prehospital resuscitation for pediatric patients with out-of-hospital cardiac arrest (OHCA), the benefit and optimal timing of epinephrine administration have not been fully investigated.

Objectives

To evaluate the association between epinephrine administration and patient outcomes and to ascertain whether the timing of epinephrine administration was associated with patient outcomes after pediatric OHCA.

Design, Setting, and Participants

This cohort study included pediatric patients (<18 years) with OHCA treated by emergency medical services (EMS) from April 2011 to June 2015. Eligible patients were identified from the Resuscitation Outcomes Consortium Epidemiologic Registry, a prospective OHCA registry at 10 sites in the US and Canada. Data analysis was performed from May 2021 to January 2023.

Exposures

The main exposures were prehospital intravenous or intraosseous epinephrine administration and the interval between arrival of an advanced life support (ALS)-capable EMS clinician (ALS arrival) and the first administration of epinephrine.

Main Outcomes and Measures

The primary outcome was survival to hospital discharge. Patients who received epinephrine at any given minute after ALS arrival were matched with patients who were at risk of receiving epinephrine within the same minute using time-dependent propensity scores calculated from patient demographics, arrest characteristics, and EMS interventions.

Results

Of 1032 eligible individuals (median [IQR] age, 1 [0-10] years), 625 (60.6%) were male. 765 patients (74.1%) received epinephrine and 267 (25.9%) did not. The median (IQR) time interval between ALS arrival and epinephrine administration was 9 (6.2-12.1) minutes. In the propensity score-matched cohort (1432 patients), survival to hospital discharge was higher in the epinephrine group compared with the at-risk group (epinephrine: 45 of 716 [6.3%] vs at-risk: 29 of 716 [4.1%]; risk ratio, 2.09; 95% CI, 1.29-3.40). The timing of epinephrine administration was also not associated with survival to hospital discharge after ALS arrival (P for the interaction between epinephrine administration and time to matching = .34).

Conclusions and Relevance

In this study of pediatric patients with OHCA in the US and Canada, epinephrine administration was associated with survival to hospital discharge, while timing of the administration was not associated with survival.

Outcomes associated with intra-arrest hyperoxaemia in out-of-hospital cardiac arrest: A registry-based cohort study

BACKGROUND

An association between post-arrest hyperoxaemia and worse outcomes has been reported for out-of-hospital cardiac arrest (OHCA) patients, but little is known about the relationship between intra-arrest hyperoxaemia and clinically relevant outcomes. This study aimed to investigate the association between intra-arrest hyperoxaemia and outcomes for OHCA patients.

METHODS

This was an observational study using a registry database of OHCA cases that occurred between 2014 and 2017 in Japan. We included adult, non-traumatic OHCA patients who were in cardiac arrest at the time of hospital arrival and for whom partial pressure of arterial oxygen (PaO₂) levels was measured during resuscitation. Main exposure was intra-arrest PaO₂ level, which was divided into three categories: hypoxaemia, PaO₂ < 60 mmHg; normoxaemia, 60-300; or hyperoxaemia, ≥300. Primary outcome was favourable functional survival at one month or at hospital discharge. Multivariable logistic regression was performed to adjust for clinically relevant variables.

RESULTS

Among 16,013 patients who met the eligibility criteria, the proportion of favourable functional survival increased as the PaO₂ categories became higher: 0.5 % (57/11,484) in hypoxaemia, 1.1 % (48/4243) in normoxaemia, and 5.2 % (15/286) in hyperoxaemia (p-value for trend < 0.001). Higher PaO₂ categories were associated with favourable functional survival and the adjusted odds ratios increased as the PaO₂ categories became higher: 2.09 (95 % CI: 1.39-3.14) in normoxaemia and 5.04 (95 % CI: 2.62-9.70) in hyperoxaemia when compared to hypoxaemia as a reference.

CONCLUSION

In this observational study of adult OHCA patients, intra-arrest normoxaemia and hyperoxaemia were associated with better functional survival, compared to hypoxaemia.

High versus low blood pressure targets for cardiac surgery while on cardiopulmonary bypass

BACKGROUND

Cardiac surgery is performed worldwide. Most types of cardiac surgery are performed using cardiopulmonary bypass (CPB). Cardiac surgery performed with CPB is associated with morbidities. CPB needs an extracorporeal circulation that replaces the heart and lungs, and performs circulation, ventilation, and oxygenation of the blood. The lower limit of mean blood pressure to maintain blood flow to vital organs increases in people with chronic hypertension. Because people undergoing cardiac surgery commonly have chronic hypertension, we hypothesised that maintaining a relatively high blood pressure improves desirable outcomes among the people undergoing cardiac surgery with CPB.

OBJECTIVES

To evaluate the benefits and harms of higher versus lower blood pressure targets during cardiac surgery with CPB.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search of databases was November 2021 and trials registries in January 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing a higher blood pressure target (mean arterial pressure 65 mmHg or greater) with a lower blood pressure target (mean arterial pressure less than 65 mmHg) in adults undergoing cardiac surgery with CPB.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Primary outcomes were 1. acute kidney injury, 2. cognitive deterioration, and 3. all-cause mortality. Secondary outcomes were 4. quality of life, 5. acute ischaemic stroke, 6. haemorrhagic stroke, 7. length of hospital stay, 8. renal replacement therapy, 9. delirium, 10. perioperative transfusion of blood products, and 11. perioperative myocardial infarction. We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included three RCTs with 737 people compared a higher blood pressure target with a lower blood pressure target during cardiac surgery with CPB. A high blood pressure target may result in little to no difference in acute kidney injury (risk ratio (RR) 1.30, 95% confidence interval (CI) 0.81 to 2.08; I² = 72%; 2 studies, 487 participants; low-certainty evidence), cognitive deterioration (RR 0.82, 95% CI 0.45 to 1.50; I² = 0%; 2 studies, 389 participants; low-certainty evidence), and all-cause mortality (RR 1.33, 95% CI 0.30 to 5.90; I² = 49%; 3 studies, 737 participants; low-certainty evidence). No study reported haemorrhagic stroke. Although a high blood pressure target may increase the length of hospital stay slightly, we found no differences between a higher and a lower blood pressure target for the other secondary outcomes. We also identified one ongoing RCT which is comparing a higher versus a lower blood pressure target among the people who undergo cardiac surgery with CPB.

AUTHORS' CONCLUSIONS

A high blood pressure target may result in little to no difference in patient outcomes including acute kidney injury and mortality. Given the wide CIs, further studies are needed to confirm the efficacy of a higher blood pressure target among those who undergo cardiac surgery with CPB.

Intravenous Tranexamic Acid in Percutaneous Kidney Biopsy: A Randomized Controlled Trial

<b><i>Background:</i></b> Tranexamic acid is frequently reported to reduce bleeding-related complications in major surgery and trauma. We aimed to investigate whether tranexamic acid reduced hematoma size after percutaneous kidney biopsy. <b><i>Methods:</i></b> We conducted a double-blind, parallel three-group, randomized placebo-controlled trial at a teaching hospital in Japan between January 2016 and July 2018. Adult patients with clinical indication for ultrasound-guided percutaneous biopsy of a native kidney were included. Participants were randomly assigned into three groups: high-dose tranexamic acid (1,000 mg in total), low-dose tranexamic acid (500 mg in total), or placebo (counterpart saline). Intervention drugs were intravenously administered twice, as a bolus just before the biopsy and as a continuous infusion initiated just after the biopsy. Primary outcome was post-biopsy perirenal hematoma size as measured by ultrasound on the morning after the biopsy. <b><i>Results:</i></b> We assessed 90 adult patients for study eligibility, of whom 56 were randomly allocated into the three groups: 20 for high-dose tranexamic acid, 19 for low-dose tranexamic acid, and 17 for placebo. The median size of perirenal hematoma was 200 mm² (interquartile range, 21–650) in the high-dose tranexamic acid group, 52 mm² (0–139) in the low-dose tranexamic acid group, and 0 mm² (0–339) in the placebo group (<i>p</i> = 0.048 for high-dose tranexamic acid vs. placebo). <b><i>Conclusion:</i></b> In this trial, the median size of post-kidney biopsy hematoma was unexpectedly larger in the high-dose tranexamic acid group than in the placebo group. Although our results do not support the routine use of tranexamic acid in percutaneous kidney biopsy at present, further studies are needed to confirm the results.

No Association of Early Postoperative Heart Rate With Outcomes After Coronary Artery Bypass Grafting

BACKGROUND

Elevated perioperative heart rate potentially causes perioperative myocardial injury because of imbalance in oxygen supply and demand. However, large multicenter studies evaluating early postoperative heart rate and major adverse cardiac and cerebrovascular events (MACCEs) are lacking.

OBJECTIVE

To assess the associations of 4 postoperative heart rate assessment methods with in-hospital MACCEs after elective coronary artery bypass grafting (CABG).

METHODS

Using data from the eICU Collaborative Research Database in the United States from 2014 to 2015, the study evaluated postoperative heart rate measured during hospitalization within 24 hours after intensive care unit admission. Four heart rate assessment methods were evaluated: maximum heart rate, duration above heart rate 100/min, area above heart rate 100/min, and time-weighted average heart rate. The outcome was in-hospital MACCEs, defined as a composite of in-hospital death, myocardial infarction, angina, arrhythmia, heart failure, stroke, cardiac arrest, or repeat revascularization.

RESULTS

Among 2585 patients, the crude rate of in-hospital MACCEs was 6.2%. In multivariable logistic regression analysis, the adjusted odds ratios (95% CI) for in-hospital MAC-CEs assessed by maximum heart rate in each heart rate category (beats per minute: >100-110, >110-120, >120-130, and >130) were 1.43 (0.95-2.15), 0.98 (0.56-1.64), 1.47 (0.76-2.69), and 1.71 (0.80-3.35), respectively. Similarly, none of the other 3 methods were associated with MACCEs.

CONCLUSIONS

More research is needed to assess the usefulness of heart rate measurement in patients after CABG.

Association of Advanced Airway Insertion Timing and Outcomes After Out-of-Hospital Cardiac Arrest

STUDY OBJECTIVE

While often prioritized in the resuscitation of patients with out-of-hospital cardiac arrest, the optimal timing of advanced airway insertion is unknown. We evaluated the association between the timing of advanced airway (laryngeal tube and endotracheal intubation) insertion attempt and survival to hospital discharge in adult out-of-hospital cardiac arrest.

METHODS

We performed a secondary analysis of the Pragmatic Airway Resuscitation Trial (PART), a clinical trial comparing the effects of laryngeal tube and endotracheal intubation on outcomes after adult out-of-hospital cardiac arrest. We stratified the cohort by randomized airway strategy (laryngeal tube or endotracheal intubation). Within each subset, we defined a time-dependent propensity score using patients, arrest, and emergency medical services systems characteristics. Using the propensity score, we matched each patient receiving an initial attempt of laryngeal tube or endotracheal intubation with a patient at risk of receiving laryngeal tube or endotracheal intubation attempt within the same minute.

RESULTS

Of 2,146 eligible patients, 1,091 (50.8%) and 1,055 (49.2%) were assigned to initial laryngeal tube and endotracheal intubation strategies, respectively. In the propensity score-matched cohort, timing of laryngeal tube insertion attempt was not associated with survival to hospital discharge: 0 to lesser than 5 minutes (risk ratio [RR]=1.35, 95% confidence interval [CI] 0.53 to 3.44); 5 to lesser than10 minutes (RR=1.07, 95% CI 0.66 to 1.73); 10 to lesser than 15 minutes (RR=1.17, 95% CI 0.60 to 2.31); or 15 to lesser than 20 minutes (RR=2.09, 95% CI 0.35 to 12.47) after advanced life support arrival. Timing of endotracheal intubation attempt was also not associated with survival: 0 to lesser than 5 minutes (RR=0.50, 95% CI 0.05 to 4.87); 5 to lesser than10 minutes (RR=1.20, 95% CI 0.51 to 2.81); 10 to lesser than15 minutes (RR=1.03, 95% CI 0.49 to 2.14); 15 to lesser than 20 minutes (RR=0.85, 95% CI 0.30 to 2.42); or more than/equal to 20 minutes (RR=0.71, 95% CI 0.07 to 7.14).

CONCLUSION

In the PART, timing of advanced airway insertion attempt was not associated with survival to hospital discharge.

Timing of Prehospital Advanced Airway Management for Adult Patients With Out-of-Hospital Cardiac Arrest: A Nationwide Cohort Study in Japan

Background

The timing of advanced airway management (AAM) on patient outcomes after out‐of‐hospital cardiac arrest has not been fully investigated. We evaluated the association between the timing of prehospital AAM and 1‐month survival.

Methods and Results

We conducted a secondary analysis of a prospective, nationwide, population‐based out‐of‐hospital cardiac arrest registry in Japan. We included emergency medical services–treated adult (≥18 years) out‐of‐hospital cardiac arrests from 2014 through 2017, stratified into initial shockable or nonshockable rhythms. Patients who received AAM at any minute after emergency medical services–initiated cardiopulmonary resuscitation underwent risk‐set matching with patients who were at risk of receiving AAM within the same minute using time‐dependent propensity scores. Eleven thousand three hundred six patients with AAM in shockable and 163 796 with AAM in nonshockable cohorts, respectively, underwent risk‐set matching. For shockable rhythms, the risk ratios (95% CIs) of AAM on 1‐month survival were 1.01 (0.89–1.15) between 0 and 5 minutes, 1.06 (0.98–1.15) between 5 and 10 minutes, 0.99 (0.87–1.12) between 10 and 15 minutes, 0.74 (0.59–0.92) between 15 and 20 minutes, 0.61 (0.37–1.00) between 20 and 25 minutes, and 0.73 (0.26–2.07) between 25 and 30 minutes after emergency medical services–initiated cardiopulmonary resuscitation. For nonshockable rhythms, the risk ratios of AAM were 1.12 (1.00–1.27) between 0 and 5 minutes, 1.34 (1.25–1.44) between 5 and 10 minutes, 1.39 (1.26–1.54) between 10 and 15 minutes, 1.20 (0.99–1.45) between 15 and 20 minutes, 1.18 (0.80–1.73) between 20 and 25 minutes, 0.63 (0.29–1.38) between 25 and 30 minutes, and 0.44 (0.11–1.69) after 30 minutes.

Conclusions

In this observational study, the timing of AAM was not statistically associated with improved 1‐month survival for shockable rhythms, but AAM within 15 minutes after emergency medical services–initiated cardiopulmonary resuscitation was associated with improved 1‐month survival for nonshockable rhythms.

Association of Timing of Epinephrine Administration With Outcomes in Adults With Out-of-Hospital Cardiac Arrest

IMPORTANCE

Administration of epinephrine has been found to be associated with an increased chance of survival after out-of-hospital cardiac arrest (OHCA), but the optimal timing of administration has not been fully investigated.

OBJECTIVE

To ascertain whether there is an association between timing of epinephrine administration and patient outcomes after OHCA.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included adults 18 years or older with OHCA treated by emergency medical services (EMS) personnel from April 1, 2011, to June 30, 2015. Initial cardiac rhythm was stratified as either initially shockable (ventricular defibrillation or pulseless ventricular tachycardia) or nonshockable (pulseless electrical activity or asystole). Eligible individuals were identified from among publicly available, deidentified patient-level data from the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registry, a prospective registry of adults with EMS-treated, nontraumatic OHCA with 10 sites in North America. Data analysis was conducted from May 2019 to April 2021.

EXPOSURES

Interval between advanced life support (ALS)-trained EMS personnel arrival at the scene and the first prehospital intravenous or intraosseous administration of epinephrine.

MAIN OUTCOMES AND MEASURES

The primary outcome was survival to hospital discharge. In each cohort of initial cardiac rhythms, patients who received epinephrine at any period (minutes) after EMS arrival at the scene were matched with patients who were at risk of receiving epinephrine within the same period using time-dependent propensity scores calculated from patient demographic characteristics, arrest characteristics, and EMS interventions.

RESULTS

Of 41 079 eligible individuals (median [interquartile range] age, 67 [55-79] years), 26 579 (64.7%) were men. A total of 10 088 individuals (24.6%) initially had shockable cardiac rhythms, and 30 991 (75.4%) had nonshockable rhythms. Those who received epinephrine included 8223 patients (81.5%) with shockable cardiac rhythms and 27 901 (90.0%) with nonshockable rhythms. In the shockable cardiac rhythm cohort, the risk ratio (RR) for receipt of epinephrine with survival to hospital discharge was highest between 0 and 5 minutes after EMS arrival (1.12; 95% CI, 0.99-1.26) across the categorized timing of the administration of epinephrine by 5-minute intervals after EMS arrival; however, that finding was not statistically significant. Treating the timing of epinephrine administration as a continuous variable, the RR for survival to hospital discharge decreased 5.5% (95% CI, 3.4%-7.5%; P < .001 for the interaction between epinephrine administration and time to matching) per minute after EMS arrival. In the nonshockable cardiac rhythm cohort, the RR for the association of receipt of epinephrine with survival to hospital discharge was the highest between 0 and 5 minutes (1.28; 95% CI, 0.95-1.72), although not statistically significant, and decreased 4.4% (95% CI, 0.8%-7.9%; P for interaction = .02) per minute after EMS arrival.

CONCLUSIONS AND RELEVANCE

Among adults with OHCA, survival to hospital discharge differed across the timing of epinephrine administration and decreased with delayed administration for both shockable and nonshockable rhythms.

Association Between Resuscitative Time on the Scene and Survival After Pediatric Out-of-Hospital Cardiac Arrest

Background: The optimal timing for transporting pediatric patients with out-of-hospital cardiac arrest (OHCA) who do not achieve return of spontaneous circulation (ROSC) is unclear. Therefore, we assessed the association between resuscitation time on the scene and 1-month survival.

Methods and Results: Data from the All-Japan Utstein Registry from 2013 through 2015 for 3,756 pediatric OHCA patients (age <18 years) who did not achieve ROSC prior to departing the scene were analyzed. Overall, the proportion of 1-month survival for on-scene resuscitation time <5, 5–9, 10–14, and ≥15 min was 13.6% (104/767), 10.2% (170/1,666), 8.6% (75/870), and 4.0% (18/453), respectively. Among specific age groups, the proportion of 1-month survival for on-scene resuscitation time of <5, 5–9, 10–14, and ≥15 min was 12.6% (54/429), 8.7% (59/680), 8.6% (23/267), and 6.8% (8/118), respectively, for patients aged 0 years; 16.4% (38/232), 11.0% (52/473), 11.9% (23/194), and 7.1% (6/85), respectively, for those aged 1–7 years; and 11.3% (12/106), 11.5% (59/513), 7.1% (29/409), and 1.6% (4/250), respectively, for those aged 8–17 years.

Conclusions: Longer on-scene resuscitation was associated with decreased chance of 1-month survival among pediatric OHCA patients without ROSC. For patients aged <8 years, earlier departure from the scene, within 5 min, may increase the chances of 1-month survival. Conversely, for patients aged ≥8 years, continuing on-scene resuscitation for up to 10 min would be reasonable.

Epinephrine administration for adult out-of-hospital cardiac arrest patients with refractory shockable rhythm: time-dependent propensity score-sequential matching analysis from a nationwide population-based registry

BACKGROUND

Little is known about the effect of prehospital epinephrine administration in out-of-hospital cardiac arrest (OHCA) patients with refractory shockable rhythm, for whom initial defibrillation was unsuccessful.

METHODS

This study using Japanese nationwide population-based registry included all adult OHCA patients aged ≥18 years with refractory shockable rhythm between January 2014 and December 2017. Patients with or without epinephrine during cardiac arrest were sequentially matched using a risk set matching based on the time-dependent propensity scores within the same minute. The primary outcome was 1-month survival. The secondary outcomes included 1-month survival with favourable neurological outcome (cerebral performance category scale: 1 or 2) and prehospital return of spontaneous circulation (ROSC).

RESULTS

Of the 499,944 patients registered in the database during the study period, 22,877 were included. Among them, 8,467 (37.0%) received epinephrine. After time-dependent propensity score-sequential matching, 16,798 patients were included in the matched cohort. In the matched cohort, positive associations were observed between epinephrine and 1-month survival (epinephrine: 17.3% [1,454/8,399] vs. no epinephrine: 14.6% [1,224/8,399]; RR 1.22 [95% confidence interval {CI}, 1.13-1.32]) and prehospital ROSC (epinephrine: 22.2% [1,868/8,399] vs. no epinephrine: 10.7% [900/8399]; RR, 2.07 [95% CI, 1.91-2.25]). No significant positive association was observed between epinephrine and favourable neurological outcome (epinephrine: 7.8% [654/8,399] vs. no epinephrine: 7.1% [611/8,399]; RR, 1.13 [95% CI, 0.998-1.27]).

CONCLUSIONS

Using the nationwide population-based registry with time-dependent propensity score-sequential matching analysis, prehospital epinephrine administration in adult OHCA patients with refractory shockable rhythm was positively associated with 1-month survival and prehospital ROSC.

Pre-Hospital Administration of Epinephrine in Pediatric Patients With Out-of-Hospital Cardiac Arrest

BACKGROUND

There is little evidence about pre-hospital advanced life support including epinephrine administration for pediatric out-of-hospital cardiac arrests (OHCAs).

OBJECTIVES

This study aimed to assess the effect of pre-hospital epinephrine administration by emergency-medical-service (EMS) personnel for pediatric OHCA.

METHODS

This nationwide population-based observational study in Japan enrolled pediatric patients age 8 to 17 years with OHCA between January 2007 and December 2016. Patients were sequentially matched with or without epinephrine during cardiac arrest using a risk-set matching based on time-dependent propensity score (probability of receiving epinephrine) calculated at each minute after initiation of cardiopulmonary resuscitation by EMS personnel. The primary endpoint was 1-month survival. Secondary endpoints were 1-month survival with favorable neurological outcome, defined as the cerebral performance category scale of 1 or 2, and pre-hospital return of spontaneous circulation (ROSC).

RESULTS

During the study period, a total of 1,214,658 OHCA patients were registered, and 3,961 pediatric OHCAs were eligible for analyses. Of these, 306 (7.7%) patients received epinephrine and 3,655 (92.3%) did not receive epinephrine. After time-dependent propensity score-sequential matching, 608 patients were included in the matched cohort. In the matched cohort, there were no significant differences between the epinephrine and no epinephrine groups in 1-month survival (epinephrine: 10.2% [31 of 304] vs. no epinephrine: 7.9% [24 of 304]; risk ratio [RR]: 1.13 [95% confidence interval (CI): 0.67 to 1.93]) and favorable neurological outcome (epinephrine: 3.6% [11 of 304] vs. no epinephrine: 2.6% [8 of 304]; RR: 1.56 [95% CI: 0.61 to 3.96]), whereas the epinephrine group had a higher likelihood of achieving pre-hospital ROSC (epinephrine: 11.2% [34 of 304] vs. no epinephrine: 3.3% [10 of 304]; RR: 3.17 [95% CI: 1.54 to 6.54]).

CONCLUSIONS

In this study, pre-hospital epinephrine administration was associated with ROSC, whereas there were no significant differences in 1-month survival and favorable neurological outcome between those with and without epinephrine.

Mortality associated with new risk classification of developing refeeding syndrome in critically ill patients: A cohort study

BACKGROUND & AIMS

Although refeeding syndrome (RFS) has been recognized as a potentially fatal metabolic complication, the definition of RFS has remained unclear. Recently, European researchers suggested an evidence-based and consensus-supported algorithm that consisted of a new RFS risk classification and treatment strategies for medical inpatients. The classification was based on the National Institute for Health and Clinical Excellence (NICE) criteria for patients at risk of developing RFS. In this study, we aimed to investigate the frequency of each applied new risk group and the association between the new classification and mortality in critically ill patients.

METHODS

This cohort study was conducted at a Japanese metropolitan tertiary-care university hospital from December 2016 to December 2018. We included critically ill adult patients who were admitted to the intensive care unit (ICU) via the emergency department and who stayed in the ICU for 24 h or longer. We applied the new risk classification based on the NICE RFS risk factors on ICU admission. The main exposure was risk classification of RFS: no risk, low risk, high risk, or very high risk. The primary outcome was in-hospital mortality censored at day 30 after ICU admission. We performed a multivariable analysis using Cox proportional hazard regression.

RESULTS

We analyzed 542 patients who met the eligibility criteria. The prevalence of the four RFS risk classification groups was 25.8% for no risk, 25.7% for low risk, 46.5% for high risk, and 2.0% for very high risk. The 30-day mortality was 5.0%, 7.2%, 16.3%, and 27.3%, respectively (log-rank trend test: p < 0.001). In the multivariable Cox regression, adjusted hazard ratios with no risk group as a reference were 1.28 (95% CI 0.48-3.38) for low risk, 2.81 (95% CI 1.24-6.35) for high risk, and 3.17 (95% CI 0.78-12.91) for very high risk.

CONCLUSIONS

Approximately half the critically ill patients were categorized as high or very high risk based on the new risk classification. Furthermore, as the risk categories progressed, the 30-day in-hospital mortality increased. Early recognition of patients at risk of developing RFS may improve patient outcomes through timely and optimal nutritional treatment.

Sex Differences in Receiving Layperson Cardiopulmonary Resuscitation in Pediatric Out-of-Hospital Cardiac Arrest: A Nationwide Cohort Study in Japan

Background

Layperson cardiopulmonary resuscitation (CPR) is a crucial intervention for patients with out‐of‐hospital cardiac arrest (OHCA). Although a sex disparity in receiving layperson CPR (ie, female patients were less likely to receive layperson CPR) has been reported in adults, there are few data in the pediatric population, and we therefore investigated sex differences in receiving layperson CPR in pediatric patients with OHCA.

Methods and Results

From the All‐Japan Utstein Registry, a prospective, nationwide, population‐based OHCA database, we included pediatric patients (≤17 years) with layperson‐witnessed OHCA from 2005 through 2015. The primary outcome was receiving layperson CPR. Patient sex was the main exposure. We fitted multivariable logistic regression models to examine associations between patient sex and receiving layperson CPR. We included a total of 4525 pediatric patients with layperson‐witnessed OHCA in this study, 1669 (36.9%) of whom were female. Female patients received layperson CPR more often than male patients (831/1669 [49.8%] versus 1336/2856 [46.8%], P=0.05). After adjustment for age, time of day of arrest, year, witnesses persons, and dispatcher CPR instruction, the sex difference in receiving layperson CPR was not significant (adjusted odds ratio for female subjects 1.14, 95% CI, 0.996‐1.31).

Conclusions

In a pediatric population, female patients with layperson‐witnessed OHCA received layperson CPR more often than male patients. After adjustment for covariates, there was no significant association between patient sex and receiving layperson CPR.

A 47-Year-Old Man With Progressive Mental Deterioration During Ventilator Management of Asthma in the ICU

CASE PRESENTATION

A 47-year-old man was admitted to the ICU with acute hypercapnic respiratory failure caused by a severe asthma attack. He had a history of asthma, atrial septal defect, chronic heart failure, and atrial fibrillation. He underwent surgical closure of the atrial septal defect at 7 years of age and was asymptomatic until 38 years of age when he developed congestive heart failure because of structural cardiac abnormalities, including left ventricular systolic dysfunction, biatrial enlargement, and mild mitral and tricuspid regurgitation. After ICU admission, he received ventilator management for asthma, IV prednisone, beta-2 agonist via inhalation, and ceftriaxone. Enteral feeding was provided since the day of admission. Hypercapnia gradually improved over 3 days. He remained alert and could communicate through writing during ventilator management until the third day in the ICU. Enteral feeding was titrated up to 32 kcal/kg/d with 1.6 g/kg/d of protein. Despite the recovery from the initial respiratory failure, he became inactive and lethargic on the fourth day in the ICU. ICU-acquired delirium was suspected, and administration of sedatives and analgesics was discontinued. On the following day, he was unresponsive to stimuli.

Prehospital characteristics, incidence trends, and outcome of emergency self-inflicted injury patients with gas substances: a population-based descriptive study in Osaka, Japan

Aim

Little is known about the detailed characteristics of patients using gas substances for self‐inflicted injury in prehospital settings. The aim of this study was to investigate the characteristics, incidence trends, and outcomes of patients who used gas substances for self‐inflicted injury in Osaka City, Japan, using ambulance records.

Methods

This was a retrospective observational study that used data from 2009 to 2015. We extracted details from ambulance records of self‐inflicted injury patients who used gas substances. The annual incidence of self‐inflicted injury by gas substance and age group and Poisson regression models were applied for calculating the annual incidence trend by type of gas substance. The main outcome was confirmed death at the scene, and we also calculated the crude odds ratios and 95% confidence intervals for each gas substance.

Results

During the study period, there were 324 self‐inflicted injury patients who used gas substances. The most commonly used gases were carbon monoxide (CO) (54.9%), followed by hydrogen sulfide (12.7%), helium (6.5%). The incidence of CO and hydrogen sulfide have subsequently decreased (P for trend = 0.023 and <0.001, respectively); however, the incidence of helium did not change during the study period (P for trend = 0.586). The mortality rate was highest in patients who used helium (66.7% [14/21]) and the crude odds ratio of helium was 3.857 (95% confidence interval, 1.267–11.745; P = 0.017) compared with hydrogen sulfide.

Conclusion

This study revealed that the incidence of self‐inflicted injury with helium did not change and its proportion of death at the scene was high in Osaka City.

Pelvic angiography is effective for emergency pediatric patients with pelvic fractures: a propensity-score-matching study with a nationwide trauma registry in Japan

Purpose

The aim of this study was to evaluate the association between the implementation of pelvic angiography (PA) and outcome in emergency pediatric patients with pelvic fracture.

Methods

We extracted data on pelvic fracture patients aged ≤ 19 years between 2004 and 2015 from a nationwide trauma registry in Japan. The main outcome was hospital mortality. We assessed the relationship between implementation of PA and hospital mortality using one-to-one propensity-score-matching analysis to reduce potential confounding effects in comparing the PA group with the non-PA group.

Results

In total, 1351 patients were eligible for our analysis, with 221 patients (16.4%) included in the PA group and 1130 patients (83.6%) included in the non-PA group. For all patients, the proportion of hospital mortality was higher in the PA group than in the non-PA group [13.6% (30/221) vs 7.1% (80/1130), crude odds ratio (OR) 2.062 (95% confidence interval (CI), 1.318–3.224); p = 0.002]. In the propensity-score-matched patients, the proportion of hospital mortality was lower in the PA group than in the non-PA group [10.5% (22/200) vs 18.2% (38/200), p = 0.027]. This finding was confirmed in both the multivariable logistic regression model [adjusted OR 0.392 (95% CI, 0.171–0.896); p = 0.026] and the conditional logistic regression model [conditional OR 0.484 (95% CI, 0.261–0.896); p = 0.021].

Conclusion

The implementation of PA was significantly associated with lower hospital mortality among emergency pediatric patients with pelvic fractures compared with the non-implementation of PA.

Full Moon and Out-of-Hospital Cardiac Arrest in Japan - Population-Based, Double-Controlled Case Series Analysis

Background: It is commonly believed that a full moon affects human behavior or the occurrence and outcome of various diseases; thus, the occurrence of out-of-hospital cardiac arrest (OHCA) might increase during full moon nights.

Methods and Results: This nationwide, population-based observational study consecutively enrolled OHCA patients in Japan with attempted resuscitation between 2005 and 2016. The primary outcome measure was the occurrence of OHCA. Based on the double-control method, assuming Poisson sampling, we evaluated the average number of OHCA events that occurred on full moon nights compared with that which occurred on control nights, which included events that occurred on the same calendar days 1 week before and after the full moon nights. A total of 29,552 OHCA that occurred on 148 full moon nights and 58,707 OHCA that occurred on 296 control nights were eligible for analysis. The occurrence of OHCA did not differ between full moon and control nights (199.7 vs. 198.3 per night; relative risk [RR], 1.007; 95% CI: 0.993–1.021). On subgroup analysis, compared with control nights, the RR of OHCA occurrence were 1.013 (95% CI: 0.994–1.032, P=0.166) and 0.998 (95% CI: 0.977–1.020, P=0.866) for cardiac and non-cardiac origins, respectively.

Conclusions: In this population, there was no significant difference in OHCA occurrence between full moon and control nights.

Sex-Based Disparities in Receiving Bystander Cardiopulmonary Resuscitation by Location of Cardiac Arrest in Japan

OBJECTIVE

To assess whether sex-based disparities occur by location of arrest in out-of-hospital cardiac arrest (OHCA) victims receiving bystander cardiopulmonary resuscitation (BCPR).

PATIENTS AND METHODS

This secondary analysis of the All-Japan Utstein Registry included patients 18 years and older with OHCA of medical origin in public or residential locations, witnessed by bystanders, from January 1, 2013, through December 31, 2015. We assessed the likelihood of receiving BCPR based on sex differences and by arrest location. Sex-based disparities in receiving BCPR stratified by age and location were assessed via multivariable logistic regression analyses.

RESULTS

During the study period, 373,359 OHCAs were registered, and 84,734 were eligible for analysis. Overall, 54.2% of women (3123 of 5766) and 57.0% of men (8672 of 15,213) received BCPR in public locations (P<.001), and 46.5% of women (11,263 of 24,216) and 44.0% of men (17,390 of 39,539) received BCPR in residential locations (P<.001). In the multivariable logistic regression analyses, there was no significant difference between the sexes in terms of who received BCPR in public locations (adjusted odds ratio [AOR], 0.99; 95% CI, 0.92-1.06), and women had a higher likelihood of receiving BCPR in residential locations (AOR, 1.08; 95% CI, 1.04-1.13). In public locations, women aged 18 to 64 years were less likely to receive BCPR (AOR, 0.86; 95% CI, 0.74-0.99), and when witnessed by a non-family member, women were less likely to receive BCPR regardless of age group.

CONCLUSION

The reasons for this sex-based disparity should be better understood to facilitate public health interventions.

Pre-hospital advanced airway management for adults with out-of-hospital cardiac arrest: nationwide cohort study

OBJECTIVE

To determine survival associated with advanced airway management (AAM) compared with no AAM for adults with out-of-hospital cardiac arrest.

DESIGN

Cohort study between January 2014 and December 2016.

SETTING

Nationwide, population based registry in Japan (All-Japan Utstein Registry).

PARTICIPANTS

Consecutive adult patients with out-of-hospital cardiac arrest, separated into two sub-cohorts by their first documented electrocardiographic rhythm: shockable (ventricular fibrillation or pulseless ventricular tachycardia) and non-shockable (pulseless electrical activity or asystole). Patients who received AAM during cardiopulmonary resuscitation were sequentially matched with patients at risk of AAM within the same minute on the basis of time dependent propensity scores.

MAIN OUTCOME MEASURES

Survival at one month or at hospital discharge within one month.

RESULTS

Of the 310 620 patients eligible, 8459 (41.2%) of 20 516 in the shockable cohort and 121 890 (42.0%) of 290 104 in the non-shockable cohort received AAM during cardiopulmonary resuscitation. After time dependent propensity score sequential matching, 16 114 patients in the shockable cohort and 236 042 in the non-shockable cohort were matched at the same minute. In the shockable cohort, survival did not differ between patients with AAM and those with no AAM: 1546/8057 (19.2%) versus 1500/8057 (18.6%) (adjusted risk ratio 1.00, 95% confidence interval 0.93 to 1.07). In the non-shockable cohort, patients with AAM had better survival than those with no AAM: 2696/118 021 (2.3%) versus 2127/118 021 (1.8%) (adjusted risk ratio 1.27, 1.20 to 1.35).

CONCLUSIONS

In the time dependent propensity score sequential matching for out-of-hospital cardiac arrest in adults, AAM was not associated with survival among patients with shockable rhythm, whereas AAM was associated with better survival among patients with non-shockable rhythm.

Prehospital factors associated with death on hospital arrival after traffic crash in Japan: a national observational study

OBJECTIVE

Although it is important to assess prehospital factors associated with traffic crash fatalities to decrease them as a matter of public health, such factors have not been fully revealed.

METHODS

Using data from the Japanese Trauma Data Bank, a large hospital-based trauma registry in Japan, we retrospectively analysed traffic crash patients transported to participating facilities that treated patients with severe trauma from 2004 to 2015. This study defined registered emergency patients whose systolic blood pressure was 0 mm Hg or heart rate was 0 bpm at hospital arrival as being in prehospital cardiopulmonary arrest (CPA). Prehospital factors associated with prehospital CPA due to traffic crash were assessed with multivariable logistic regression analysis.

RESULTS

In total, 66 243 patients were eligible for analysis. Of them, 3390 (5.1%) patients were in CPA at hospital arrival. A multivariable logistic regression model showed the following factors to be significantly associated with prehospital CPA: ages 60-74 years (adjusted OR (AOR) 1.256, 95% CI 1.142 to 1.382) and ≥75 years (AOR 1.487, 95% CI 1.336 to 1.654), male sex (AOR 1.234, 95% CI 1.139 to 1.338), night-time (AOR 1.575, 95% CI 1.458 to 1.702), weekend including holiday (AOR 1.078, 95% CI 1.001 to 1.161), rural area (AOR 1.181, 95% CI 1.097 to 1.271), back seat passenger (AOR 1.227, 95% CI 0.985 to 1.528) and pedestrian (AOR 1.754, 95% CI 1.580 to 1.947) as types of patients.

CONCLUSION

In this population, factors associated with prehospital CPA due to a traffic crash were elderly people, male sex, night-time, weekend/holiday, back seat passenger, pedestrian and rural area. These fundamental data may be of help in reducing and preventing traffic crash deaths.

A Smartphone Application to Reduce the Time to Automated External Defibrillator Delivery After a Witnessed Out-of-Hospital Cardiac Arrest: A Randomized Simulation-Based Study

INTRODUCTION

We developed a new smartphone application to deliver an automated external defibrillator (AED) to out-of-hospital cardiac arrest scene. The aim of this study was to evaluate whether an AED could be delivered earlier with or without an application in a simulated randomized controlled trial.

METHODS

Participants, who were asked to work as bystanders, were randomly assigned to either an application group or control group and were asked to bring an AED in both groups. The bystanders in the application group sent a signal notification using the application to two responders, who were stationed within 200 meters of the arrest scene, to carry an AED. The primary outcome was the AED delivery time by either the bystander or his/her responder.

RESULTS

In total, 61 bystanders were eligible and randomized to either the application group (32) or the control group (29). The 52 with time data were available and analyzed. The AED delivery time by either the bystander or his/her responder was significantly shorter in the application group than in the control group [133.6 (44.4) seconds vs. 202.2 (122.2) seconds, P = 0.01].

CONCLUSIONS

In this simulation-based trial, AED delivery time was shortened by our newly developed smartphone application for the bystander to ask nearby responders to find and bring an AED to the cardiac arrest scene (UMIN-Clinical Trials Registry 000016506).

Motor vehicle accident mortality by elderly drivers in the super-aging era: A nationwide hospital-based registry in Japan

Motor vehicle accidents (MVAs) are one of the major public health burdens worldwide. In particular, MVAs by elderly drivers have been significantly increasing in recent years in industrialized countries. This study aimed to assess the MVA characteristics and outcomes caused by elderly drivers in Japan.Japan Trauma Data Bank (JTDB) is a prospective, nationwide, hospital-based registry for trauma patients from 256 institutions in Japan. This study enrolled all MVA drivers older than the legal age for driving between 2004 and 2015. The included patients were divided into the following 3 groups: adults (aged ≤64 years), young-old (aged 65-74 years), and old-old (aged ≥75 years). The primary outcome was in-hospital mortality. The trend in the proportion of MVAs caused by the young-old or the old-old group was evaluated using the Cochran-Armitage trend test. To assess the association of the old-old group with in-hospital mortality, compared with the adult group, we used multivariable logistic regression analysis.During the study period, a total of 236,698 trauma patients were registered, and 39,691 patients (16.8%) were eligible for our analysis. The proportion of MVAs caused by elderly drivers aged ≥65 years significantly increased from 11.7% in 2004 to 23.8% in 2015 (P < .001). As for the primary outcome, unadjusted in-hospital mortality increased with age, but decreased year-by-year irrespective of the age group. In multivariable logistic regression analysis, in-hospital mortality was significantly higher in the old-old group than in the adult group [17.3% (584/3372) vs 8.0% (2556/31,985); adjusted odds ratio 4.80; 95% confidence interval 4.06-5.67].In the super-aging society of Japan, the proportion of MVAs by elderly drivers increased year-by-year, and the mortality rate was highest in those aged above 75 years.

Delay of computed tomography is associated with poor outcome in patients with blunt traumatic aortic injury: A nationwide observational study in Japan

According to guidelines from the Eastern Association for the Surgery of Trauma, computed tomography (CT) with intravenous contrast is strongly recommended to diagnose clinically significant blunt traumatic aortic injury (BTAI). However, it remains unclear whether the timing of CT scanning is associated with the prognosis of BTAI patients.We extracted data on emergency patients who suffered a BTAI in the chest and/or the abdomen from 2004 to 2015 from the Japanese Trauma Data Bank, a nationwide trauma registry. The primary outcome was death in the emergency department (ED) and secondary outcome was discharge to death. In addition, we assessed the relationship between death in the ED and the timing of CT scanning by shock status in subgroup analysis. We divided these patients into the tertile groups of early (≤26 minutes), middle (27-40 minutes), and late (≥41 minutes) phases based on the time interval from hospital arrival to start of first CT scanning, and assessed death of BTAI patients in the ED by CT scanning time with the use of a multivariable logistic regression model.In total, 421 patients who suffered BTAI in the chest and/or the abdomen were eligible for our analysis. The proportion of patients dying at hospital admission was 7.7% (11/142) in the early group, 11.1% (15/135) in the middle group, and 17.6% (25/144) in the late group. In a multivariable logistic regression adjusted for confounding factors, the adjusted odds ratio (AOR) of death in the ED was 1.833 (95% confidence interval [CI]: 0.601-5.590, P = .287) in the middle group and 2.832 (95% CI: 1.007-7.960, P = .048) in the late group compared with the early group. Compared with the early group, the late group tended to have a higher rate of discharge to death (AOR: 1.438, 95% CI: 0.735-2.813). In the patients with shock, the AOR was 3.292 (95% CI: 0.495-21.902) in the middle group and 6.039 (95% CI: 0.990-36.837) in the late group compared with the early group.This study revealed that a longer time interval from hospital arrival to CT scanning was associated with higher mortality in the ED in patients with BTAI.

Mortality and detailed characteristics of pre-ICU qSOFA-negative patients with suspected sepsis: an observational study

BACKGROUND

Recent studies have suggested that quick Sequential Organ Failure Assessment (qSOFA) scores have limited utility in early prognostication in high-mortality populations. The purpose of this study was to investigate the association between pre-ICU qSOFA scores and in-hospital mortality among patients admitted to the ICU with suspected sepsis. This study also aimed to describe detailed clinical characteristics of qSOFA-negative (< 2) patients.

METHODS

This single center, observational study, conducted in a Japanese tertiary care teaching hospital between May 2012 and June 2016, enrolled all consecutive adult patients admitted to the ICU with suspected sepsis. We assessed pre-ICU qSOFA scores with the most abnormal vital signs during the 24-h period before ICU admission. The primary outcome was in-hospital mortality censored at 90 days. We analyzed the association between pre-ICU qSOFA scores and in-hospital mortality.

RESULTS

Among 185 ICU patients with suspected sepsis, 14.1% (26/185) of patients remained qSOFA-negative at the time of ICU admission and 29.2% (54/185) of patients died while in hospital. In-hospital mortality was similar between the groups (qSOFA-positive [≥ 2]: 30.2% [48/159] vs qSOFA-negative: 23.1% [6/26], p = 0.642). The Cox proportional hazard regression model revealed that being qSOFA-positive was not significantly associated with in-hospital mortality (adjusted hazard ratio 1.35, 95% confidence interval 0.56-3.22, p = 0.506). Bloodstream infection, immunosuppression, and hematologic malignancy were observed more frequently in qSOFA-negative patients.

CONCLUSIONS

Among ICU patients with suspected sepsis, we could not find a strong association between pre-ICU qSOFA scores and in-hospital mortality. Our study suggested high mortality and bacterial diversity in pre-ICU qSOFA-negative patients.

Prognostic Impact of Serum Albumin Concentration for Neurologically Favorable Outcome in Patients Treated with Targeted Temperature Management After Out-of-Hospital Cardiac Arrest: A Multicenter Prospective Study

To assess whether serum albumin concentration measured upon hospital arrival was useful as an early prognostic biomarker for neurologically favorable outcome in out-of-hospital cardiac arrest (OHCA) patients treated with target temperature management (TTM). This prospective, multicenter observational study (The CRITICAL Study) carried out between July 1, 2012 and December 31, 2014 in Osaka Prefecture, Japan involving 13 critical care medical centers (CCMCs) and one non-CCMC with an emergency department. This study included patients ≥18 years of age who underwent an OHCA, for whom resuscitation was attempted by Emergency Medical Services personnel and were then transported to participating institutions, and who were then treated with TTM. Based on the serum albumin concentration upon hospital arrival, involved patients were divided into four quartiles (Q1-Q4) defined as Q1 (<3.0 g/dL), Q2 (≥3.0, <3.4 g/dL), Q3 (≥3.4, <3.8 g/dL), and Q4 (≥3.8 g/dL). The primary outcome of this study was 1-month survival with neurologically favorable outcome defined by cerebral performance category 1 or 2. During the study period, a total of 327 were eligible for our analysis. The overall proportion of neurologically favorable outcome was 33.0% (108/327). The Q4 group had the highest proportion of neurologically favorable outcome (52.5% [48/91]), followed by Q3 (34.5% [30/87]), Q2 (27.3% [21/77]), and Q1 (12.5% [9/72]). The multivariable logistic regression analysis demonstrated that the proportion of neurologically favorable outcome was significantly higher in the Q4 group than that in the Q1 group (adjusted odds ratio 10.39; 95% confidence interval 3.36-32.17). The adjusted proportion of neurologically favorable outcome increased in a stepwise fashion across increasing quartiles (p < 0.001). In this study, higher serum albumin concentration upon hospital arrival had a positive association with neurologically favorable outcome after OHCA in a dose-dependent manner.

Regional variation in functional outcome after out-of-hospital cardiac arrest across 47 prefectures in Japan

BACKGROUND

Although prior work reported regional variation in survival after out-of-hospital cardiac arrest (OHCA), mechanisms of the variation have not been fully investigated. We sought to evaluate regional variation in favourable functional outcome after OHCA across 47 prefectures in Japan as our primary aim. We also evaluated the associations between favourable functional outcome and the numbers of basic life support (BLS) providers and public access automated external defibrillators (AEDs) within each prefecture as our secondary aim.

METHODS

Using the All-Japan Utstein Registry, a nationwide prospective, population-based OHCA database, we identified 97,408 patients with OHCA of medical origin across 47 prefectures in 2014. Primary outcome was 1-month survival with favourable functional outcome, defined as Cerebral Performance Category (CPC) scale 1 or 2. We fitted multivariable hierarchical logistic regression models (patients nested within prefectures) to adjust for potential confounding factors at patient- and prefecture-level and clustering of patients within prefectures. We calculated median odds ratios (ORs) from the hierarchical models to quantify the outcome variation at prefecture-level. We also evaluated the associations between OHCA outcome and the numbers of BLS providers and public access AEDs within each prefecture, using the hierarchical models.

RESULTS

A total of 2246 patients (2.3%) had 1-month survival with favourable functional outcome. The unadjusted rates of 1-month survival with favourable functional outcome in each prefecture ranged from 1.1% to 4.1% (median OR = 1.29; 95% credible interval, 1.20-1.40) and the adjusted rates varied from 0.9% to 3.5% (median OR = 1.34; 95% credible interval, 1.24-1.48). We observed no associations between 1-month survival with favourable functional outcome and the numbers of BLS providers (correlation coefficient = -0.25; 95% confidence interval [CI], -0.50 to 0.04; p = 0.09) and public access AEDs (correlation coefficient = -0.27; 95% CI, -0.51 to 0.02; p = 0.07) within prefectures.

CONCLUSIONS

We found substantial regional variation in favourable functional outcome after OHCA of medical origin that was not explained by the numbers of BLS providers and public access AEDs within each prefecture.

Improvements in Patient Acceptance by Hospitals Following the Introduction of a Smartphone App for the Emergency Medical Service System: A Population-Based Before-and-After Observational Study in Osaka City, Japan

Background

Recently, the number of ambulance dispatches has been increasing in Japan, and it is therefore difficult for hospitals to accept emergency patients smoothly and appropriately because of the limited hospital capacity. To facilitate the process of requesting patient transport and hospital acceptance, an emergency information system using information technology (IT) has been built and introduced in various communities. However, its effectiveness has not been thoroughly revealed. We introduced a smartphone app system in 2013 that enables emergency medical service (EMS) personnel to share information among themselves regarding on-scene ambulances and the hospital situation.

Objective

The aim of this study was to assess the effects of introducing this smartphone app on the EMS system in Osaka City, Japan.

Methods

This retrospective study analyzed the population-based ambulance records of Osaka Municipal Fire Department. The study period was 6 years, from January 1, 2010 to December 31, 2015. We enrolled emergency patients for whom on-scene EMS personnel conducted hospital selection. The main endpoint was the difficulty experienced in gaining hospital acceptance at the scene. The definition of difficulty was making ≥5 phone calls by EMS personnel at the scene to hospitals until a decision to transport was determined. The smartphone app was introduced in January 2013, and we compared the patients treated from 2010 to 2012 (control group) with those treated from 2013 to 2015 (smartphone app group) using an interrupted time-series analysis to assess the effects of introducing this smartphone app.

Results

A total of 600,526 emergency patients for whom EMS personnel selected hospitals were eligible for our analysis. There were 300,131 emergency patients in the control group (50.00%, 300,313/600,526) from 2010 to 2012 and 300,395 emergency patients in the smartphone app group (50.00%, 300,395/600,526) from 2013 to 2015. The rate of difficulty in hospital acceptance was 14.19% (42,585/300,131) in the control group and 10.93% (32,819/300,395) in the smartphone app group. No change over time in the number of difficulties in hospital acceptance was found before the introduction of the smartphone app (regression coefficient: −2.43, 95% CI −5.49 to 0.64), but after its introduction, the number of difficulties in hospital acceptance gradually decreased by month (regression coefficient: −11.61, 95% CI −14.57 to −8.65).

Conclusions

Sharing information between an ambulance and a hospital by using the smartphone app at the scene was associated with decreased difficulty in obtaining hospital acceptance. Our app and findings may be worth considering in other areas of the world where emergency medical information systems with IT are needed.

Early-phase cumulative hypotension duration and severe-stage progression in oliguric acute kidney injury with and without sepsis: an observational study

BACKGROUND

Managing blood pressure in patients with acute kidney injury (AKI) could effectively prevent severe-stage progression. However, the effect of hypotension duration in the early phase of AKI remains poorly understood. This study investigated the association between early-phase cumulative duration of hypotension below threshold mean arterial pressure (MAP) and severe-stage progression of oliguric AKI in critically ill patients, and assessed the difference in association with presence of sepsis.

METHODS

This was a single-center, observational study conducted in the ICU of a university hospital in Japan. We examined data from adults with oliguric AKI who were admitted to the ICU during 2010-2014 and stayed in the ICU for ≥24 h after diagnosis of stage-1 oliguric AKI defined in the Kidney Disease Improving Global Outcomes (KDIGO) guidelines. The primary outcome was the progression from stage-1 oliguric AKI to stage-3 oliguric AKI (progression to oligoanuria and use of renal replacement therapy) according to the KDIGO criteria. During the first 6 h after oliguric AKI, we analyzed the association between cumulative time the patient had below threshold MAP (65, 70, and 75 mm Hg) and progression to stage-3.

RESULTS

Among 538 patients with oliguric AKI, progression to stage-3 increased as the time spent below any threshold MAP was elongated. In the multivariable analysis of all patients, longer hypotension time (3-6 h) showed significant association with stage-3 progression for the time spent below MAP of 65 mm Hg (adjusted odds ratio (OR) 3.73, 95% confidence interval (CI) 1.53-9.09, p = 0.004), but the association was attenuated for the threshold MAP of 70 mm Hg (adjusted OR 2.35, 95% CI 0.96-5.78, p = 0.063) and 75 mm Hg (adjusted OR 1.92, 95% CI 0.72-5.15, p = 0.200). Longer hypotension time with the thresholds of 65 and 70 mm Hg was significantly associated with the risk of stage-3 progression in patients without sepsis, whereas the association was weak and not significant in patients with sepsis.

CONCLUSIONS

Even in a short time frame (6 h) after oliguric AKI diagnosis, early-phase cumulative hypotension duration was associated with progression to stage-3 oliguric AKI, especially in patients without sepsis.

Public-Access Defibrillation and Out-of-Hospital Cardiac Arrest in Japan

BACKGROUND

Early defibrillation plays a key role in improving survival in patients with out-of-hospital cardiac arrests due to ventricular fibrillation (ventricular-fibrillation cardiac arrests), and the use of publicly accessible automated external defibrillators (AEDs) can help to reduce the time to defibrillation for such patients. However, the effect of dissemination of public-access AEDs for ventricular-fibrillation cardiac arrest at the population level has not been extensively investigated.

METHODS

From a nationwide, prospective, population-based registry of patients with out-of-hospital cardiac arrest in Japan, we identified patients from 2005 through 2013 with bystander-witnessed ventricular-fibrillation arrests of presumed cardiac origin in whom resuscitation was attempted. The primary outcome measure was survival at 1 month with a favorable neurologic outcome (Cerebral Performance Category of 1 or 2, on a scale from 1 [good cerebral performance] to 5 [death or brain death]). The number of patients in whom survival with a favorable neurologic outcome was attributable to public-access defibrillation was estimated.

RESULTS

Of 43,762 patients with bystander-witnessed ventricular-fibrillation arrests of cardiac origin, 4499 (10.3%) received public-access defibrillation. The percentage of patients receiving public-access defibrillation increased from 1.1% in 2005 to 16.5% in 2013 (P<0.001 for trend). The percentage of patients who were alive at 1 month with a favorable neurologic outcome was significantly higher with public-access defibrillation than without public-access defibrillation (38.5% vs. 18.2%; adjusted odds ratio after propensity-score matching, 1.99; 95% confidence interval, 1.80 to 2.19). The estimated number of survivors in whom survival with a favorable neurologic outcome was attributed to public-access defibrillation increased from 6 in 2005 to 201 in 2013 (P<0.001 for trend).

CONCLUSIONS

In Japan, increased use of public-access defibrillation by bystanders was associated with an increase in the number of survivors with a favorable neurologic outcome after out-of-hospital ventricular-fibrillation cardiac arrest.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

High-rise buildings and neurologically favorable outcome after out-of-hospital cardiac arrest

BACKGROUND

The number of people living in high-rise buildings has recently been increasing in Japan, and delayed transport time by emergency-medical-service (EMS) personnel from higher floors could lead to lower survival after out-of-hospital cardiac arrest (OHCA). However, there are no clinical studies assessing the association between the floor where patients reside and neurologically favorable outcome after OHCA.

METHODS

This was a prospective, population-based study conducted in Osaka City, Japan that enrolled adults aged >=18years suffering an OHCA of cardiac origin before EMS arrival between 2013 and 2014. The primary outcome measure was one-month survival with neurologically favorable outcome. We divided OHCA patients into the following groups: those residing on >=3 floors (the high floor group) and <3 floors (the low floor group). Multiple logistic regression analysis was used to assess factors associated with neurologically favorable outcome.

RESULTS

A total of 2979 patients were eligible for analysis. Of them, 1885 (62.3%) occurred below the third floor and 1094 (37.4%) occurred at or above the third floor. The proportion of neurologically favorable outcome after OHCA was significantly lower in the high floor group than in the low floor group (2.7% [30/1094] versus 4.8% [91/1885], P=0.005). In a multivariate analysis, neurologically favorable outcome after OHCA was significantly lower in the high floor group than in the low floor group (adjusted odds ratio, 0.59 [95% confidence interval, 0.37-0.96]).

CONCLUSIONS

In this population, one-month survival with neurologically favorable outcome from OHCA was lower in the high floor group than in the low floor group.

Factors Predicting Successful Discontinuation of Continuous Renal Replacement Therapy

This multicentre, retrospective observational study was conducted from January 2010 to December 2010 to determine the optimal time for discontinuing continuous renal replacement therapy (CRRT) by evaluating factors predictive of successful discontinuation in patients with acute kidney injury. Analysis was performed for patients after CRRT was discontinued because of renal function recovery. Patients were divided into two groups according to the success or failure of CRRT discontinuation. In multivariate logistic regression analysis, urine output at discontinuation, creatinine level and CRRT duration were found to be significant variables (area under the receiver operating characteristic curve for urine output, 0.814). In conclusion, we found that higher urine output, lower creatinine and shorter CRRT duration were significant factors to predict successful discontinuation of CRRT.

Epidemiology of Out-of-Hospital Cardiac Arrests Among Japanese Centenarians: 2005 to 2013

Although the number of centenarians has been rapidly increasing in industrialized countries, no clinical studies evaluated their characteristics and outcomes from out-of-hospital cardiac arrests (OHCAs). This nationwide, population-based, observation of the whole population of Japan enrolled consecutive OHCA centenarians with resuscitation attempts before emergency medical service arrival from 2005 to 2013. The primary outcome measure was 1-month survival from OHCAs. The multivariate logistic regression model was used to assess factors associated with 1-month survival in this population. Among a total of 4,937 OHCA centenarians before emergency medical service arrival, the numbers of those with OHCAs increased from 70 in 2005 to 136 in 2013 in men and from 227 in 2005 to 587 in 2013 in women. Women accounted for 80.3%. Ventricular fibrillation (VF) as first documented rhythm was 2.5%. The proportions of victims receiving bystander cardiopulmonary resuscitation were 64.2%. The proportion of 1-month survival from OHCAs in centenarians was only 1.1%. In a multivariate analysis, age was not associated with 1-month survival from OHCAs (adjusted odds ratio [OR] for one increment of age 1.01; 95% confidence interval [CI] 0.87 to 1.18). Witness by a bystander (adjusted OR 3.45; 95% CI 1.88 to 6.31) and VF as first documented rhythm (adjusted OR 5.49; 95% CI 2.24 to 13.43) were significant positive predictors for 1-month survival. Cardiac origin was significantly poor in 1-month survival compared with noncardiac origin (adjusted OR 0.37; 95% CI 0.21 to 0.64). In conclusion, survival from OHCAs in centenarians was very poor, but witness by a bystander and VF as first documented rhythm were associated with improved survival.

Rationale, design, and profile of Comprehensive Registry of In-Hospital Intensive Care for OHCA Survival (CRITICAL) study in Osaka, Japan

Background

We established a multi-center, prospective cohort that could provide appropriate therapeutic strategies such as criteria for the introduction and the effectiveness of in-hospital advanced treatments, including percutaneous coronary intervention (PCI), target temperature management, and extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) patients.

Methods

In Osaka Prefecture, Japan, we registered all consecutive patients who were suffering from an OHCA for whom resuscitation was attempted and who were then transported to institutions participating in this registry since July 1, 2012. A total of 11 critical care medical centers and one hospital with an emergency care department participated in this registry. The primary outcome was neurological status after OHCA, defined as cerebral performance category (CPC) scale.

Results

A total of 688 OHCA patients were documented between July 2012 and December 2012. Of them, 657 were eligible for our analysis. Patients’ average age was 66.2 years old, and male patients accounted for 66.2 %. The proportion of OHCAs having a cardiac origin was 50.4 %. The proportion as first documented rhythm of ventricular fibrillation/pulseless ventricular tachycardia was 11.6 %, pulseless electrical activity 23.4 %, and asystole 54.5 %. After hospital arrival, 10.5 % received defibrillation, 90.8 % tracheal intubation, 3.0 % ECPR, 3.5 % PCI, and 83.1 % adrenaline administration. The proportions of 90-day survival and CPC 1/2 at 90 days after OHCAs were 5.9 and 3.0 %, respectively.

Conclusions

The Comprehensive Registry of In-hospital Intensive Care for OHCA Survival (CRITICAL) study will enroll over 2000 OHCA patients every year. It is still ongoing without a set termination date in order to provide valuable information regarding appropriate therapeutic strategies for OHCA patients (UMIN000007528).

Is Survival After Out-of-Hospital Cardiac Arrests Worse During Days of National Academic Meetings in Japan? A Population-Based Study

BACKGROUND

Outcomes after out-of-hospital cardiac arrests (OHCAs) might be worse during academic meetings because many medical professionals attend them.

METHODS

This nationwide population-based observation of all consecutively enrolled Japanese adult OHCA patients with resuscitation attempts from 2005 to 2012. The primary outcome was 1-month survival with a neurologically favorable outcome. Calendar days at three national meetings (Japanese Society of Intensive Care Medicine, Japanese Association for Acute Medicine, and Japanese Circulation Society) were obtained for each year during the study period, because medical professionals who belong to these academic societies play an important role in treating OHCA patients after hospital admission, and we identified two groups: the exposure group included OHCAs that occurred on meeting days, and the control group included OHCAs that occurred on the same days of the week 1 week before and after meetings. Multiple logistic regression analysis was used to adjust for confounding variables.

RESULTS

A total of 20 143 OHCAs that occurred during meeting days and 38 860 OHCAs that occurred during non-meeting days were eligible for our analyses. The proportion of patients with favorable neurologic outcomes after whole arrests did not differ during meeting and non-meeting days (1.6% [324/20 143] vs 1.5% [596/38 855]; adjusted odds ratio 1.02; 95% confidence interval, 0.88-1.19). Regarding bystander-witnessed ventricular fibrillation arrests of cardiac origin, the proportion of patients with favorable neurologic outcomes also did not differ between the groups.

CONCLUSIONS

In this population, there were no significant differences in outcomes after OHCAs that occurred during national meetings of professional organizations related to OHCA care and those that occurred during non-meeting days.

The lower limit of intensity to control uremia during continuous renal replacement therapy

Introduction

The recommended lower limit of intensity during continuous renal replacement therapy (CRRT) is 20 or 25 mL/kg/h. However, limited information is available to support this threshold. We aimed to evaluate the impact of different intensities of CRRT on the clearance of creatinine and urea in critically ill patients with severe acute kidney injury (AKI).

Methods

This is a multicenter retrospective study conducted in 14 Japanese ICUs in 12 centers. All patients older than 18 years and treated with CRRT due to AKI were eligible. We evaluated the effect of CRRT intensity by two different definitions: daily intensity (the mean intensity over each 24-h period) and average intensity (the mean of daily intensity during the period while CRRT was performed). To study the effect of different CRRT intensity on clearance of urea and creatinine, all patients/daily observations were arbitrarily allocated to one of 4 groups based on the average intensity and daily intensity: <10, 10–15, 15–20, and >20 mL/kg/h.

Results

Total 316 patients were included and divided into the four groups according to average CRRT intensity. The groups comprised 64 (20.3%), 138 (43.7%), 68 (21.5%), and 46 patients (14.6%), respectively. Decreases in creatinine and urea increased as the average intensity increased over the first 7 days of CRRT. The relative changes of serum creatinine and urea levels remained close to 1 over the 7 days in the “<10” group. Total 1,101 daily observations were included and divided into the four groups according to daily CRRT intensity. The groups comprised 254 (23.1%), 470 (42.7%), 239 (21.7%), and 138 observations (12.5%), respectively. Creatinine and urea increased (negative daily change) only in the “<10” group and decreased with the increasing daily intensity in the other groups.

Conclusions

The lower limit of delivered intensity to control uremia during CRRT was approximately between 10 and 15 mL/kg/h in our cohort. A prescribed intensity of approximately 15 mL/kg/h might be adequate to control uremia for patients with severe AKI in the ICU. However, considering the limitations due to the retrospective nature of this study, prospective studies are required to confirm our findings.

Who may not benefit from continuous renal replacement therapy in acute kidney injury?

This study aimed to identify factors that may predict early kidney recovery (less than 48 hours) or early death (within 48 hours) after initiating continuous renal replacement therapy (CRRT) in acute kidney injury (AKI) patients. This is a multicenter retrospective observational study of 14 Japanese Intensive care units (ICUs) in 12 tertiary hospitals. Consecutive adult patients with severe AKI requiring CRRT admitted to the participating ICUs in 2010 (n=343) were included. Patient characteristics, variables at CRRT initiation, settings, and outcomes were collected. Patients were grouped into early kidney recovery group (CRRT discontinuation within 48 hours after initiation, n=52), early death group (death within 48 hours after CRRT initiation, n=52), and the rest as the control group (n=239). The mean duration of CRRT in the early kidney recovery group and early death group was 1.3 and 0.9 days, respectively. In multivariable regression analysis, in comparison with the control group, urine output (mL/h) (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 1.01-1.03), duration between ICU admission to CRRT initiation (days) (OR: 0.65, 95% CI: 0.43-0.87), and the sepsis-related organ failure assessment score (OR: 0.87, 95% CI; 0.78-0.96) were related to early kidney recovery. Serum lactate (mmol/L) (OR: 1.19, 95% CI: 1.11-1.28), albumin (g/dL) (OR: 0.52, 95% CI: 0.28-0.92), vasopressor use (OR: 3.68, 95% CI: 1.37-12.16), and neurological disease (OR: 9.64, 96% CI: 1.22-92.95) were related to early death. Identifying AKI patients who do not benefit from CRRT and differentiating such patients from the study cohort may allow previous and future studies to effectively evaluate the indication and role of CRRT.