Frailty and Neurologic Outcomes of Patients Resuscitated From Nontraumatic Out-of-Hospital Cardiac Arrest: A Prospective Observational Study

Sarcopenia and frailty in critical illness

PURPOSE OF REVIEW

Sarcopenia and frailty are common conditions, associated with worse clinical outcomes during critical illness. Recent studies on sarcopenia and frailty in ICU patients are presented in this review, aiming to identify accurate diagnostic tools, investigate the effects on clinical and functional outcomes, and propose possible effective interventions.

RECENT FINDINGS

The recent change of the sarcopenia definition underlines the importance of muscle strength over mass, this is however challenging to assess in ICU patients. There is currently no unified sarcopenia definition, nor standard frailty assessment tool; Clinical Frailty Scale is most frequently used in the ICU. Meta-analyses show worse clinical and functional outcomes for frail as well as sarcopenic patients admitted to the ICU, regardless of admission diagnosis. Frailty is a dynamic condition, worsening in severity by the time of hospital discharge, but showing improvement by 6 months post-ICU. Therapeutic interventions for frailty and sarcopenia remain limited. Although mobilization strategies show promise in improving functional and cognitive outcomes, inconsistent outcomes are reported. Heterogeneity in definitions, patient populations, and care practices challenge interpretation and comparison of study results and recognition of beneficial interventions. This highlights the need for more research.

SUMMARY

The importance of preexisting sarcopenia and frailty is recognized in ICU patients and associated with worse clinical outcomes. Multidimensional interventions are most promising, including patient-tailored mobilization and nutrition.

The impact of dispatcher-assisted CPR and prior bystander CPR training on neurologic outcomes in out-of-hospital cardiac arrest: a multicenter study

BACKGROUND

The objective of this study was to evaluate the effectiveness of dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) among laypersons, focusing on its impact on those with and without prior CPR training in out-of-hospital cardiac arrest (OHCA) cases.

METHODS

This prospective multicenter observational study included 42 emergency hospitals participating in the SOS-KANTO 2017 study (September 2019-March 2021). Patients with non-traumatic OHCA witnessed by laypersons were categorized into five groups: no bystander CPR, bystander non-DA-CPR without CPR training, bystander non-DA-CPR with CPR training, bystander DA-CPR without CPR training, and bystander DA-CPR with CPR training. The primary outcome was favorable neurological outcomes at one month.

RESULTS

Among 2,772 patients analyzed, the proportions of favorable neurological outcomes were 3.0%, 7.4%, 7.4%, 15.7%, and 25.6% in the respective groups. In multivariable analyses, the highest odds of favorable neurological outcomes were observed in the non-DA-CPR with CPR training group (OR 9.0, 95% CI 2.8-29.6), followed by the DA-CPR with CPR training group (OR 3.1, 95% CI 1.1-8.5), DA-CPR without CPR training group (OR 2.5, 95% CI 1.3-4.9), and bystander non-DA-CPR without CPR training group (OR 1.6, 95% CI 0.8-3.2), with no bystander CPR as the reference.

CONCLUSION

DA-CPR and prior CPR training play crucial roles in improving favorable neurological outcomes in bystander-witnessed OHCA cases. Additionally, DA-CPR may be particularly effective for untrained bystanders. These findings highlight the importance of integrating widespread CPR training programs and robust DA-CPR protocols into community-based emergency response systems.

Temporalis muscle thickness correlates with premorbid frailty in patients resuscitated from cardiac arrest

INTRODUCTION

Frailty is associated with mortality and functional outcome after cardiac arrest. Temporalis muscle thickness (TMT) is a measure of sarcopenia, which represents one dimension of frailty. We assessed the correlation between TMT, measured on head computed tomography (CT), and Clinical Frailty Scale (CFS) in patients resuscitated from cardiac arrest.

METHODS

We enrolled adults resuscitated from cardiac arrest who had a head CT obtained within 48 h of collapse. Study investigators prospectively obtained data to determine pre-arrest CFS and blinded investigators measured TMT. We calculated Spearman rank-order correlation to assess the relationship between TMT and CFS. We also performed multivariable regression adjusting for confounders of frailty and sarcopenia.

RESULTS

We enrolled 50 subjects with median CFS 4 [IQR 2-6] and median TMT 6.6 [IQR 5.0-8.9] mm. There was a moderate, negative correlation between TMT and CFS (ρ = -0.52 (p < 0.001)). In linear regression, TMT (R2 = 25%) explained more of the variance in CFS than age (R2 = 17%).

CONCLUSIONS

We found that TMT exhibits a moderate negative correlation with the CFS, supporting TMT as a tool to measure frailty. Measuring TMT in patients with early head CTs after resuscitation from cardiac arrest may allow for characterization of sarcopenia as a dimension of pre-arrest frailty.

Association between the Clinical Frailty Scale and Neurological Outcomes in Out-of-Hospital Cardiac Arrest: A Retrospective Study

Background

Frailty is a physical condition characterized by increased vulnerability to external stressors. This study investigated the impact of premorbid frailty, as measured by the Clinical Frailty Scale (CFS), on neurological prognosis in patients with out-of-hospital cardiac arrest (OHCA).

Methods

This is a single-center retrospective study. Data from 2006 to 2020 were analyzed for 595 adult OHCA patients admitted to the intensive care unit of National Taiwan University Hospital following resuscitation. Variables included demographics, medical history, resuscitation details, post-resuscitation data, and frailty assessments based on CFS. The primary outcome was favorable neurological performance, defined as a cerebral performance category (CPC) score of 2 or less at discharge.

Results

In total, 523 of the 595 patients were included in the analysis. Among these, 224 survived, and 173 exhibited favorable neurological outcomes. Patients with favorable outcomes had significantly lower CFS scores than those with poor outcomes (3.2 ± 1.5 vs. 4.5 ± 1.8, p < 0.0001). The proportion of favorable neurological outcomes declined as CFS scores increased. Multivariate logistic regression analysis identified several factors independently associated with worse neurological outcomes: CFS >4 (odds ratio (OR): 0.301, 95% confidence interval (CI): 0.163-0.540), age >70 years (OR: 0.969, 95% CI: 0.953-0.986), history of malignancy (OR: 0.421, 95% CI: 0.209-0.813), epinephrine >2 mg during resuscitation (OR: 0.776, 95% CI: 0.712-0.840), and arterial blood gas pH <7.1 (OR: 28.396, 95% CI: 6.487-129.350). The model demonstrated good performance, with an area under the curve (AUC) value of 0.853. No significant relationships were observed between CFS and other variables.

Conclusions

CFS values ≤4 were independently associated with favorable neurological outcomes following OHCA.

The Relationship Between Beta-Blocker Use and Prognosis of Patients With Out-of-Hospital Cardiac Arrest

BACKGROUND

 Out-of-hospital cardiac arrest (OHCA) has a poor prognosis. Patients with shockable rhythms often have better outcomes than those with nonshockable rhythms. A previous study reported a decline in shockable rhythms and poorer outcomes with the use of beta-blockers before OHCA. This study aimed to investigate the association between beta-blocker use and outcomes in OHCA patients using data from a multicenter prospective observational study in Japan.

PATIENTS AND METHODS

 This study is a post hoc analysis based on data from the Survey of Survivors after Out-of-Hospital Cardiac Arrest in Kanto Area 2017 study, which included 9,909 OHCA patients in Japan. Patients aged 18 years or older with cardiogenic OHCA were included in the analysis, which involved multiple imputation and overlap weighting with propensity scores. As a subgroup analysis, data were extracted for patients with a history of cardiovascular disease and who were also subjected to multiple imputations and overlapping weighting. The outcomes were survival and favorable neurological outcomes at 30 days.

RESULTS

 Out of the 5,392 analyzed patients, 96 were taking beta-blockers before OHCA, and 5,296 were not. After adjusting for confounding factors using overlap weighting, beta-blocker use was not found to be associated with increased survival (odds ratio, OR, 1.07; 95% confidence interval, CI, 0.64-1.81) and favorable neurological outcomes (OR, 1.09; 95% CI, 0.61-1.95). The analysis of patients with a history of cardiovascular disease also showed no significant difference in survival based on beta-blocker use.

CONCLUSION

 In this study, beta-blocker use was not associated with survival and favorable neurological outcomes in OHCA patients.

Overview and future prospects of out-of-hospital cardiac arrest registries in Japan

AIM

Out-of-hospital cardiac arrest (OHCA) is a life-threatening emergency with high mortality. The "chain of survival" is critical to improving patient outcomes. To develop and enhance this chain of survival, measuring and monitoring the resuscitation processes and outcomes are essential for quality assurance. In Japan, several OHCA registries have successfully been implemented at both local and national levels. We aimed to review and summarise the conception, strengths, and challenges of OHCA registries in Japan.

METHOD AND RESULTS

The following representing registries in Japan were reviewed: the All-Japan Utstein registry, the Utstein Osaka Project/the Osaka-CRITICAL study, the SOS-KANTO study, the JAAM-OHCA study, and the SAVE-J II study. The All-Japan Utstein registry, operated by the Fire and Disaster Management Agency of Japan and one of the largest nationwide population-based registries in the world, collects data concerning all patients with OHCA in Japan, excluding in-hospital data. Other research- and hospital-based registries collect detailed out-of-hospital and in-hospital data. The Osaka-CRITICAL study and the SOS-KANTO study are organized at regional levels, and hospitals in the Osaka prefecture and in the Kanto area participate in these registries. The JAAM-OHCA study is managed by the Japanese Association of Acute Medicine and includes 107 hospitals throughout Japan. The Save-J II study focuses on patients with OHCA treated with extracorporeal cardiopulmonary resuscitation.

CONCLUSION

Each OHCA registry has its own philosophy, strengths, perspectives, and challenges; however, all have been successful in contributing to the improvement of emergency medical service (EMS) systems through the quality improvement process. These registries are expected to be further utilized to enhance EMS systems and improve outcomes for patients with OHCA, while also contributing to the field of resuscitation science.

Wolf Creek XVII Part 8: Neuroprotection

Introduction

Post-cardiac arrest brain injury (PCABI) is the primary determinant of clinical outcomes for patients who achieve return of spontaneous circulation after cardiac arrest (CA). There are limited neuroprotective therapies available to mitigate the acute pathophysiology of PCABI.

Methods

Neuroprotection was one of six focus topics for the Wolf Creek XVII Conference held on June 14-17, 2023 in Ann Arbor, Michigan, USA. Conference invitees included international thought leaders and scientists in the field of CA resuscitation from academia and industry. Participants submitted via online survey knowledge gaps, barriers to translation, and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category that was debated, revised and ranked by all attendees to identify the top 5 for each category.

Results

Top 5 knowledge gaps included developing therapies for neuroprotection; improving understanding of the pathophysiology, mechanisms, and natural history of PCABI; deploying precision medicine approaches; optimizing resuscitation and CPR quality; and determining optimal timing for and duration of interventions. Top 5 barriers to translation included patient heterogeneity; nihilism & lack of knowledge about cardiac arrest; challenges with the translational pipeline; absence of mechanistic biomarkers; and inaccurate neuro-triage and neuroprognostication. Top 5 research priorities focused on translational research and trial optimization; addressing patient heterogeneity and individualized interventions; improving understanding of pathophysiology and mechanisms; developing mechanistic and outcome biomarkers across post-CA time course; and improving implementation of science and technology.

Conclusion

This overview can serve as a guide to transform the care and outcome of patients with PCABI. Addressing these topics has the potential to improve both research and clinical care in the field of neuroprotection for PCABI.

Prediction of the neurological outcomes post-cardiac arrest: A prospective validation of the CAST and rCAST

INTRODUCTION

The neurologic prognosis of out-of-hospital cardiac arrest (OHCA) patients in whom return of spontaneous circulation (ROSC) is achieved remains poor. The aim of this study was to externally and prospectively validate two scoring systems developed by us: the CAST score, a scoring system to predict the neurological prognosis of OHCA patients undergoing targeted temperature management (TTM), and a simplified version of the same score developed for improved ease of use in clinical settings, the revised CAST (rCAST) score.

METHODS

This study was a prospective, multicenter, observational study conducted using the SOS KANTO 2017 registry, an OHCA registry involving hospitals in the Kanto region (including Tokyo) of Japan. The primary outcome was favorable neurological outcome (defined as Cerebral Performance Category score of 1 or 2) at 30 days and the secondary outcomes were favorable neurological outcome at 90 days and survival at 30 and 90 days. The predictive accuracies of the original CAST (oCAST) and rCAST scores were evaluated by using area under the receiver operating characteristic curve (AUC).

RESULTS

Of 9909 OHCA patients, 565 showed ROSC and received TTM. Of these, we analyzed the data of 259 patients in this study. The areas under the receiver operating characteristic curve (AUCs) of the oCAST and rCAST scores for predicting a favorable neurological outcome at 30 days were 0.86 and 0.87, respectively, and those for predicting a favorable neurological outcome at 90 days were 0.87 and 0.88, respectively. The rCAST showed a higher predictive accuracy for the neurological outcome as compared with the NULL-PLEASE score. The patients with a favorable neurological outcome who had been classified into the high severity group based on the rCAST tended to have hypothermia at hospital arrival and to not show any signs of loss of gray-white matter differentiation on brain CT. Neurological function at 90 days was correlated with the rCAST (r = 0.63, p < 0.001).

CONCLUSIONS

rCAST showed high predictive accuracy for the neurological prognosis of OHCA patients managed by TTM, comparable to that of the oCAST score. The scores on the rCAST were strongly correlated with the neurological functions at 90 days, implying that the rCAST is a useful scale for assessing the severity of brain injury after cardiac arrest.

Frailty is a better predictor than age for shockable rhythm and survival in Out-of-Hospital cardiac arrest in over 16-year-olds

Objective

To determine if the Clinical Frailty Scale (CFS) predicts out-of-hospital cardiac arrest (OHCA) outcomes better than age?Design: The analysed data was collected as part of a larger study run by NCEPOD on hospital admissions for OHCA in 2018. Study selection was OHCA in over 16-year-olds with restoration of spontaneous circulation (ROSC) for >20 mins and who were admitted to hospital, or who died in the emergency department. Patients from hospitals in England, Wales and Northern Ireland were identified using standard coding for cardiac arrest. CFS, age and gender were examined against two binary outcomes (non-shockable rhythm and survival).

Results

304 patients with a known CFS, known original rhythm, and known outcome were included. Younger patients had lower CFSs, as a continuous variable (Pearson correlation coefficient 0.44, p-value < 0.001) and in CFS groupings of 1-3, 4-6, 7-9 (p-value < 0.001). CFSs were higher (p-values < 0.001) for both non-shockable rhythm and death (median CFS was 4 for death and 2 for survivors). Logistic regression analysis of continuous scale CFS showed the association with non-shockable rhythm remained when adjusted for age and sex (odds ratio [95% CI]; age adjustment 1.46 [1.28, 1.68] p-value < 0.001) and remained for survival when adjusted for age alone (odds ratio [95% CI]; 1.60 [1.36, 1.88] p-value < 0.001) and when adjusted for age, sex and initial rhythm combined (1.45 [1.21, 1.73] p-value < 0.001). 3.2% of patients had resuscitation against their advanced-care-directives. 12.9% (23/178) of hospitals had electronic systems which shared advance-care-directives with ambulance services and primary care.

Conclusion

A higher CFS is a prognostic indicator in adult OHCA independent of age. Frail individuals have a lower likelihood of a shockable rhythm and poorer survival. Sensitive sharing of this information with patients when discussing advance-care-directives may enhance shared decision-making.

Assessment of frailty by paramedics using the clinical frailty scale - an inter-rater reliability and accuracy study

BACKGROUND

Frailty assessment by paramedics in the prehospital setting is understudied. The goals of this study were to assess the inter-rater reliability and accuracy of frailty assessment by paramedics using the Clinical Frailty Scale (CFS).

METHODS

This was a cross-sectional study with paramedics exposed to 30 clinical vignettes created from real-life situations. There was no teaching intervention prior to the study and paramedics were only provided with the French version of the CFS (definitions and pictograms). The primary outcome was the inter-rater reliability of the assessment. The secondary outcome was the accuracy, compared with the expert-based assessment. Reliability was determined by calculating an intraclass correlation coefficient (ICC). Accuracy was assessed through a mixed effects logistic regression model. A sensitivity analysis was carried out by considering that an assessment was still accurate if the score differed from no more than 1 level.

RESULTS

A total of 56 paramedics completed the assessment. The overall assessment was found to have good inter-rater reliability (ICC = 0.87 [95%CI 0.81-0.93]). The overall accuracy was moderate at 60.6% (95%CI 54.9-66.1) when considering the full scale. It was however much higher (94.8% [95%CI 92.0-96.7] when close assessments were considered as accurate. The only factor associated with accurate assessment was field experience.

CONCLUSION

The assessment of frailty by paramedics was reliable in this vignette-based study. However, the accuracy deserved to be improved. Future research should focus on the clinical impact of these results and on the association of prehospital frailty assessment with patient outcomes.

REGISTRATION

This study was registered on the Open Science Framework registries ( https://doi.org/10.17605/OSF.IO/VDUZY ).