Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Template for In-Hospital Cardiac Arrest: A Consensus Report From a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia)

Epinephrine Dosing Intervals Are Associated With Pediatric In-Hospital Cardiac Arrest Outcomes: A Multicenter Study

OBJECTIVES

Data to support epinephrine dosing intervals during cardiopulmonary resuscitation (CPR) are conflicting. The objective of this study was to evaluate the association between epinephrine dosing intervals and outcomes. We hypothesized that dosing intervals less than 3 minutes would be associated with improved neurologic survival compared with greater than or equal to 3 minutes.

DESIGN

This study is a secondary analysis of The ICU-RESUScitation Project (NCT028374497), a multicenter trial of a quality improvement bundle of physiology-directed CPR training and post-cardiac arrest debriefing.

SETTING

Eighteen PICUs and pediatric cardiac ICUs in the United States.

PATIENTS

Subjects were 18 years young or younger and 37 weeks old or older corrected gestational age who had an index cardiac arrest. Patients who received less than two doses of epinephrine, received extracorporeal CPR, or had dosing intervals greater than 8 minutes were excluded.

INTERVENTIONS

The primary exposure was an epinephrine dosing interval of less than 3 vs. greater than or equal to 3 minutes.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was survival to discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1-2 or no change from baseline. Regression models evaluated the association between dosing intervals and: 1) survival outcomes and 2) CPR duration. Among 382 patients meeting inclusion and exclusion criteria, median age was 0.9 years (interquartile range 0.3-7.6 yr) and 45% were female. After adjustment for confounders, dosing intervals less than 3 minutes were not associated with survival with favorable neurologic outcome (adjusted relative risk [aRR], 1.10; 95% CI, 0.84-1.46; p = 0.48) but were associated with improved sustained return of spontaneous circulation (ROSC) (aRR, 1.21; 95% CI, 1.07-1.37; p < 0.01) and shorter CPR duration (adjusted effect estimate, -9.5 min; 95% CI, -14.4 to -4.84 min; p < 0.01).

CONCLUSIONS

In patients receiving at least two doses of epinephrine, dosing intervals less than 3 minutes were not associated with neurologic outcome but were associated with sustained ROSC and shorter CPR duration.

Epidemiology and outcome of out-of-hospital cardiac arrest in Salt Lake City: Sex-based investigations

Objectives

Prior research indicates sex disparities in the incidence and outcomes of out-of-hospital cardiac arrest (OHCA). This study investigates the presence of such differences in Salt Lake City, Utah.

Methods

We analyzed data from the Salt Lake City Fire Department (2008‒2023). We included adults with non-traumatic OHCA. We calculated the annual incidence of OHCA and examined sex-specific survival outcomes using multivariable logistic regression, adjusting for OHCA characteristics known to be associated with survival.

Results

The annual incidence of OHCA was 76 per 100,000 person-years. Among the 894 OHCA cases included in the analysis, 67.5% were males, 37.3% achieved return of spontaneous circulation (ROSC), and 13.6% survived hospital discharge. Unadjusted analysis revealed that males had significantly higher OHCA in public locations (43.9% vs. 28.6%), witnessed arrests (54.5% vs. 47.8%), and shockable rhythms (33.3% vs. 22.9%). Males also showed higher rates of ROSC (37.5% vs. 36.9%), hospital discharge survival (14.5% vs. 11.7%), and neurologically intact survival. After adjusting for the OHCA characteristics, there was no significant differences between males and females in ROSC, survival to hospital discharge, and favorable neurological function with adjusted odds ratios (male vs. female) of 0.92 (95% confidence interval [CI] 0.73‒1.16), 0.85 (95% CI 0.59‒1.22), and 0.92 (95% CI 0.62‒1.40), respectively.

Conclusion

Approximately, 128 adults suffer OHCA in Salt Lake City annually. Males initially showed higher crude survival rates, but after adjusting for OHCA characteristics, no significant sex differences in survival outcomes were found. Enhancing OHCA characteristics could benefit both sexes. Investigations into the relationship between sex- and region-specific factors influencing OHCA outcomes are needed.

Extracting physiologic and clinical data from defibrillators for research purposes to improve treatment for patients in cardiac arrest

Background

A defibrillator should be connected to all patients receiving cardiopulmonary resuscitation (CPR) to allow early defibrillation. The defibrillator will collect signal data such as the electrocardiogram (ECG), thoracic impedance and end-tidal CO2, which allows for research on how patients demonstrate different responses to CPR. The aim of this review is to give an overview of methodological challenges and opportunities in using defibrillator data for research.

Methods

The successful collection of defibrillator files has several challenges. There is no scientific standard on how to store such data, which have resulted in several proprietary industrial solutions. The data needs to be exported to a software environment where signal filtering and classifications of ECG rhythms can be performed. This may be automated using different algorithms and artificial intelligence (AI). The patient can be classified being in ventricular fibrillation or -tachycardia, asystole, pulseless electrical activity or having obtained return of spontaneous circulation. How this dynamic response is time-dependent and related to covariates can be handled in several ways. These include Aalen's linear model, Weibull regression and joint models.

Conclusions

The vast amount of signal data from defibrillator represents promising opportunities for the use of AI and statistical analysis to assess patient response to CPR. This may provide an epidemiologic basis to improve resuscitation guidelines and give more individualized care. We suggest that an international working party is initiated to facilitate a discussion on how open formats for defibrillator data can be accomplished, that obligates industrial partners to further develop their current technological solutions.

Age and sex-related differences in outcomes of OHCA patients after adjustment for sex-based in-hospital management disparities

OBJECTIVES

Out-of-hospital cardiac arrest (OHCA) survival differences due to sex remain controversial. Previous studies adjusted for prehospital variables, but not sex-based in-hospital management disparities. We aimed to investigate age and sex-related differences in survival outcomes in OHCA patients after adjustment for sex-based in-hospital management disparities.

METHODS

This retrospective observational study used a prospective multicenter OHCA registry to review data of patients from October 2015 to December 2020. The primary outcome was good neurological outcome defined as cerebral performance category score 1 or 2. We performed multivariable logistic regression and restricted cubic spline analysis according to age.

RESULTS

Totally, 8988 patients were analyzed. Women showed poorer prehospital characteristics and received fewer coronary angiography, percutaneous coronary interventions, targeted temperature management, and extracorporeal membrane oxygenation than men. Good neurological outcomes were lower in women than in men (5.8% vs. 12.2%, p < 0.001). After adjustment for age, prehospital variables, and in-hospital management, women were more likely to have good neurological outcomes than men (adjusted odds ratio [aOR] 1.37, 95% confidence interval [CI] 1.07-1.74, p = 0.012). The restricted cubic spline curve showed a reverse sigmoid pattern of adjusted predicted probability of outcomes and dynamic associations of sex and age-based outcomes.

CONCLUSIONS

Women with OHCA were more likely to have good neurological outcome after adjusting for age, prehospital variables, and sex-based in-hospital management disparities. There were non-linear associations between sex and survival outcomes according to age and age-related sex-based differences.

Association of Pediatric Postcardiac Arrest Ventilation and Oxygenation with Survival Outcomes

Rationale: Adult and pediatric studies provide conflicting data regarding whether post-cardiac arrest hypoxemia, hyperoxemia, hypercapnia, and/or hypocapnia are associated with worse outcomes. Objectives: We sought to determine whether postarrest hypoxemia or postarrest hyperoxemia is associated with lower rates of survival to hospital discharge, compared with postarrest normoxemia, and whether postarrest hypocapnia or hypercapnia is associated with lower rates of survival, compared with postarrest normocapnia. Methods: An embedded prospective observational study during a multicenter interventional cardiopulmonary resuscitation trial was conducted from 2016 to 2021. Patients ⩽18 years old and with a corrected gestational age of ≥37 weeks who received chest compressions for cardiac arrest in one of the 18 intensive care units were included. Exposures during the first 24 hours postarrest were hypoxemia, hyperoxemia, or normoxemia-defined as lowest arterial oxygen tension/pressure (PaO2) <60 mm Hg, highest PaO2 ⩾200 mm Hg, or every PaO2 60-199 mm Hg, respectively-and hypocapnia, hypercapnia, or normocapnia, defined as lowest arterial carbon dioxide tension/pressure (PaCO2) <30 mm Hg, highest PaCO2 ⩾50 mm Hg, or every PaCO2 30-49 mm Hg, respectively. Associations of oxygenation and carbon dioxide group with survival to hospital discharge were assessed using Poisson regression with robust error estimates. Results: The hypoxemia group was less likely to survive to hospital discharge, compared with the normoxemia group (adjusted relative risk [aRR] = 0.71; 95% confidence interval [CI] =  0.58-0.87), whereas survival in the hyperoxemia group did not differ from that in the normoxemia group (aRR = 1.0; 95% CI = 0.87-1.15). The hypercapnia group was less likely to survive to hospital discharge, compared with the normocapnia group (aRR = 0.74; 95% CI = 0.64-0.84), whereas survival in the hypocapnia group did not differ from that in the normocapnia group (aRR = 0.91; 95% CI = 0.74-1.12). Conclusions: Postarrest hypoxemia and hypercapnia were each associated with lower rates of survival to hospital discharge.

Cardiac arrest and post-discharge mortality in patients with myocardial infarction: A large-scale nationwide registry analysis

Background

Cardiac arrest is a serious complication of acute myocardial infarction. The implementation of contemporary approaches to acute myocardial infarction management, including urgent revascularization procedures, has led to significant improvements in short-term outcomes. However, the extent of post-discharge mortality in patients experiencing cardiac arrest during acute myocardial infarction remains uncertain. This study aimed to determine the post-discharge outcomes of patients with cardiac arrest.

Methods

We analysed data from the J-PCI OUTCOME registry, a Japanese prospectively planed, observational, multicentre, national registry of percutaneous coronary intervention involving consecutive patients from 172 institutions who underwent percutaneous coronary intervention and were discharged. Patients who underwent percutaneous coronary intervention for acute myocardial infarction between January 2017 and December 2018 and survived for 30 days were included. Mortality in patients with and without cardiac arrest from 30 days to 1 year after percutaneous coronary intervention for acute myocardial infarction was compared.

Results

Of the 26,909 patients who survived for 30 days after percutaneous coronary intervention for acute myocardial infarction, 1,567 (5.8%) had cardiac arrest at the onset of acute myocardial infarction. Patients with cardiac arrest were younger and more likely to be males than patients without cardiac arrest. The 1-year all-cause mortality was significantly higher in patients with cardiac arrest than in those without (11.9% vs. 2.8%, p < 0.001) for all age groups. Multivariable analysis showed that cardiac arrest was an independent predictor of all-cause long-term mortality (hazard ratio: 2.94; 95% confidence interval: 2.29-3.76).

Conclusions

Patients with acute myocardial infarction and concomitant cardiac arrest have a worse prognosis for up to 1 year after percutaneous coronary intervention than patients without cardiac arrest.

[Quality of life after in-hospital cardiac arrest : An 11-year experience from an university center]

BACKGROUND

Cardiac arrest is a life-threatening condition requiring urgent medical care and is one of the leading causes of death worldwide. Given that in-hospital cardiac arrest (IHCA) is still poorly investigated, data on health-associated quality of life thereafter remains scarce. The available evidence is mostly transferred from out-of-hospital cardiac arrest studies, but the epidemiology and determinants of success might be different. The aim of the study was to investigate the change in the quality of life after in-hospital cardiac arrest and to identify potential risk factors for a poor outcome.

MATERIAL AND METHODS

This retrospective analysis of data and prospective evaluation of quality of life included all patients surviving an IHCA and being treated by the emergency medical team between 2010 and 2020. The primary endpoint of the study was the quality of life after IHCA at the reference date. Secondary endpoints covered determination of risk factors and predictors of poor outcome after in-hospital cardiopulmonary resuscitation.

RESULTS

In total 604 patients were resuscitated within the period of 11 years and 61 (10%) patients survived until the interview took place. Finally, 48 (79%) patients fulfilled the inclusion criteria and 31 (65%) were included in the study. There was no significant difference in the quality of life before and after cardiac arrest (EQ-5D-5L utility 0.79 vs. 0.78, p = 0.567) and in the EQ-5D-5L visual analogue scale (VAS) score.

CONCLUSION

The quality of life before and after IHCA in survivors was good and comparable. The quality of life was mostly affected by reduced mobility and anxiety/depression. Future studies with larger patient samples should focus on potentially modifiable factors that could prevent, warn, and limit the consequences of in-hospital cardiac arrest. Moreover, research on outcomes of IHCA should include available tools for the quality of life assessment.

Noninvasive Positive Pressure Ventilation Use and In-Hospital Cardiac Arrest in Bronchiolitis

IMPORTANCE

A recent study showed an association between high hospital-level noninvasive positive pressure ventilation (NIPPV) use and in-hospital cardiac arrest (IHCA) in children with bronchiolitis.

OBJECTIVES

We aimed to determine if patient-level exposure to NIPPV in children with bronchiolitis was associated with IHCA.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort study at a single-center quaternary PICU in North America including children with International Classification of Diseases primary or secondary diagnoses of bronchiolitis in the Virtual Pediatric Systems database.

MAIN OUTCOMES AND MEASURES

The primary exposure was NIPPV and the primary outcome was IHCA.

MEASUREMENTS AND MAIN RESULTS

Of 4698 eligible ICU admissions with bronchiolitis diagnoses, IHCA occurred in 1.2% (57/4698). At IHCA onset, invasive mechanical ventilation (IMV) was the most frequent level of respiratory support (65%, 37/57), with 12% (7/57) receiving NIPPV. Patients with IHCA had higher Pediatric Risk of Mortality-III scores (3 [0-8] vs. 0 [0-2]; p < 0.001), more frequently had a complex chronic condition (94.7% vs. 46.2%; p < 0.001), and had higher mortality (21.1% vs. 1.0%; p < 0.001) compared with patients without IHCA. Return of spontaneous circulation (ROSC) was achieved in 93% (53/57) of IHCAs; 79% (45/57) survived to hospital discharge. All seven children without chronic medical conditions and with active bronchiolitis symptoms at the time of IHCA achieved ROSC, and 86% (6/7) survived to discharge. In multivariable analysis restricted to patients receiving NIPPV or IMV, NIPPV exposure was associated with lower odds of IHCA (adjusted odds ratio [aOR], 0.07; 95% CI, 0.03-0.18) compared with IMV. In secondary analysis evaluating categorical respiratory support in all patients, compared with IMV, NIPPV was associated with lower odds of IHCA (aOR, 0.35; 95% CI, 0.14-0.87), whereas no difference was found for minimal respiratory support (none/nasal cannula/humidified high-flow nasal cannula [aOR, 0.56; 95% CI, 0.23-1.36]).

CONCLUSIONS AND RELEVANCE

Cardiac arrest in children with bronchiolitis is uncommon, occurring in 1.2% of bronchiolitis ICU admissions. NIPPV use in children with bronchiolitis was associated with lower odds of IHCA.

Neurological outcomes in traffic accidents: A propensity score matching analysis of medical and non-medical origin cases of out-of-hospital cardiac arrest

AIM

This study aimed to comprehensively compare the characteristics of out-of-hospital cardiac arrest (OHCA) with medical and non-medical origins attributed to traffic accidents and explore the potential association between the cases with a medical origin and neurologically favorable outcomes.

METHODS

In this retrospective nationwide population-based study, baseline data were collected between January 2018 and December 2020. We analyzed 5091 OHCA associated with traffic accidents on the road scene. Only those encounters involving treatment or transport by prehospital emergency medical technicians were included. The characteristics of OHCA incidents and their outcomes were analyzed by categorizing patients into "medical origin" and "non-medical origin" groups.

RESULTS

Medical-origin cases exhibited several distinct characteristics, including higher frequencies of occurrence during the daytime (79.3% [706/890] vs. 68.9% [2895/4201], p < 0.001), a higher prevalence among male (77.8% [692/890] vs. 68.3% [2871/4201], p < 0.001) and younger patients (median [25-75%]: 63 years [42-77] vs. 66 years [50-76], p = 0.003), a higher proportion of shockable initial rhythms(10.5% [93/890] vs. 1.1% [45/4201], p < 0.001), an increased number of cases requiring advanced airway management (33.8% [301/890] vs. 28.5% [1199/4201], p = 0.002) and adrenaline administration by emergency medical teams (26.9% [239/890] vs. 21.7% [910/4201], p < 0.001), and shorter transport times (55.3% [492/890] vs. 60.9% [2558/4201], p = 0.002) compared to non-medical-origin cases. However, medical-origin cases also had lower witness rates (42.8% [381/890] vs. 27.2% [1142/4201], p < 0.001) and were less likely to be transported to higher-level hospitals (55.3% [492/890] vs. 60.9% [2558/4201], p = 0.002). Propensity score matching analysis identified factors associated with favorable neurological outcomes in medical-origin traffic accidents. The adjusted odds ratios were as follows: 8.46 (3.47-20.61) for cases with shockable initial rhythms, 2.36 (1.01-5.52) for cases involving traffic accidents due to medical origin, and 0.09 (0.01-0.67) for cases where advanced airway management was provided.

CONCLUSION

In this retrospective study, the occurrence of OHCAs of medical origin involving traffic accidents were associated with favorable neurological outcomes. These cases more frequently demonstrated favorable factors for survival compared to those classified as of non-medical origin. The findings have important implications for public health and EMS professionals, they will guide future research aimed at optimizing prehospital care strategies and improving survival rates for similar cases.

Improving response time and survival in ward based in-hospital cardiac arrest: A quality improvement initiative

BACKGROUND

Survival in cardiac arrest is associated with rapid initiation of high-quality cardiopulmonary resuscitation (CPR) and advanced life support. To improve ROSC rates and survival, we identified the need to reduce response times and implement coordinated resuscitation by dedicated cardiac arrest teams (CATs). We aimed to improve ROSC rates by 10% within 6 months, and subsequent survival to hospital discharge.

METHODS

We used the Model for Improvement to implement a ward-based cardiac arrest quality improvement (QI) initiative across 3 Plan-Do-Study-Act (PDSA) cycles. QI interventions focused on instituting dedicated CATs and resuscitation equipment, staff training, communications, audit framework, performance feedback, as well as a cardiac arrest documentation form. The primary outcome was the rate of ROSC, and the secondary outcome was survival to hospital discharge. Process measures were call center processing times, CAT response times and CAT nurses' knowledge and confidence regarding CPR. Balancing measures were the number of non-cardiac arrest activations and the number of cardiac arrest activations in patients with existing do-not-resuscitate orders.

RESULTS

After adjustments for possible confounders in the multivariate analysis, there was a significant improvement in ROSC rate post-intervention as compared to the pre-intervention period (OR 2.05 [1.04-4.05], p = 0.04). Median (IQR) call center processing times decreased from 1.8 (1.6-2.0) pre-intervention to 1.4 (1.4-1.6) minutes post-intervention (p = 0.03). Median (IQR) CAT response times decreased from 5.1 (4.5-7.0) pre-intervention to 3.6 (3.4-4.3) minutes post-intervention (p < 0.001). After adjustments for possible confounders in the multivariate analysis, there was no significant improvement in survival to hospital discharge post-intervention as compared to the pre-intervention period (OR 0.71 [0.25-2.06], p = 0.53).

CONCLUSION

Implementation of a ward-based cardiac arrest QI initiative resulted in an improvement in ROSC rates, median call center and CAT response times.

Optimal duration and timing of basic-life-support-only intervention for patients with out-of-hospital cardiac arrest

To elucidate the relationship between the interval from cardiopulmonary resuscitation initiation to return of spontaneous circulation (ROSC) and neurologically favourable 1-month survival in order to determine the appropriate duration of basic life support (BLS) without advanced interventions. This population-based cohort study included patients aged ≥ 18 years with 9132 out-of-hospital cardiac arrest of presumed cardiac origin who were bystander-witnessed and had achieved ROSC between 2018 and 2020. Patients were classified into two groups based on the resuscitation methods as the "BLS-only" and the "BLS with administered epinephrine (BLS-AE)" groups. Receiver operating characteristic (ROC) curve analysis indicated that administering BLS for 9 min yielded the best neurologically outcome for patients with a shockable rhythm [sensitivity, 0.42; specificity, 0.27; area under the ROC curve (AUC), 0.60] in the BLS-only group. Contrastingly, for patients with a non-shockable rhythm, performing BLS for 6 min yielded the best neurologically outcome (sensitivity, 0.65; specificity, 0.43; AUC, 0.63). After propensity score matching, multivariate analysis revealed that BLS-only resuscitation [6.44 (5.34-7.77)] was associated with neurologically favourable 1-month survival. This retrospective study revealed that BLS-only intervention had a significant impact in the initial minutes following CPR initiation. Nevertheless, its effectiveness markedly declined thereafter. The optimal duration for effective BLS-only intervention varied depending on the patient's initial rhythm. Consequently, advanced interventions should be administered within the first few minutes to counteract the diminishing effectiveness of BLS-only intervention.

Compliance with cardiopulmonary resuscitation guidelines in witnessed in-hospital cardiac arrest events and patient outcome on monitored versus non-monitored wards

BACKGROUND

Adherence to cardiopulmonary resuscitation (CPR) guidelines in treatment of in-hospital cardiac arrest (IHCA) have been associated with favourable patient outcome. The aim of this study was to evaluate if compliance with initial CPR guidelines and patient outcome of witnessed IHCA events were associated with the place of arrest defined as monitored versus non-monitored ward.

METHODS

A total of 956 witnessed IHCA events in adult patients at six hospitals during 2018 to 2019, were extracted from the Swedish Registry of Cardiopulmonary Resuscitation. Initial CPR guidelines were: ≤1 min from collapse to alert of the rapid response team, ≤1 min from collapse to start of CPR, ≤3 min from collapse to defibrillation of shockable rhythm.

RESULTS

The odds of compliance with guidelines was higher on monitored wards vs non-monitored wards, even after adjustment for factors that could affect staffing and resources. The place of arrest was not a significant factor for sustained return of spontaneous circulation, survival at 30 days, or neurological status at discharge, when adjusting for clinically relevant confounders. Compliance with initial CPR guidelines remained a significant factor for survival to 30 days and favourable neurological outcome at discharge regardless of other confounders.

CONCLUSION

Compliance with initial CPR guidelines was higher in witnessed IHCA events on monitored wards than on non-monitored wards, which indicates that healthcare professionals in monitored wards are quicker to recognize a cardiac arrest and initiate treatment. When initial CPR guidelines are followed, the place of arrest does not influence patient outcome.

How do survivors after out-of-hospital cardiac arrest perceive their health compared to the norm population? A nationwide registry study from Norway

Introduction

Self-perceived health status data is usually collected using patient-reported outcome measures. Information from the patients' perspective is one of the important components in planning person-centred care. The study aimed to compare EQ-5D-5L in survivors after out-of-hospital cardiac arrest (OHCA) with data for Norwegian population controls. Secondary aim included comparing characteristics of respondents and non-respondents from the OHCA population.

Methods

In this cross-sectional survey, 714 OHCA survivors received an electronic EQ-5D-5L questionnaire 3-6 months following OHCA. EQ-5D-5L assesses for five dimensions of health (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) with five-point descriptive scales and overall health on a visual analogue scale from 0 (worst) to 100 (best) (EQ VAS). Results are used to calculate the EQ index ranging from -0.59 (worst) to 1 (best). Patient responses were matched for age and sex with existing data from controls, collected through a postal survey (response rate 26%), and compared with Chi-square tests or t-tests as appropriate.

Results

Of 784 OHCA survivors, 714 received the EQ-5D-5L, and 445 (62%) responded. Respondents had higher rates of shockable first rhythm and better cerebral performance category scores than the non-respondents. OHCA survivors reported poorer health compared to controls as assessed by EQ-5D-5L dimensions, the EQ index (0.76 ± 0.24 vs 0.82 ± 0.18), and EQ VAS (69 ± 21 vs 79 ± 17), except for the pain/discomfort dimension.

Conclusions

Norwegian OHCA survivors reported poorer health than the general population as assessed by the EQ-5D-5L. PROMs use in this population can be used to inform follow-up and health care delivery.

Prognostic implication of heart failure stage and left ventricular ejection fraction for patients with in-hospital cardiac arrest: a 16-year retrospective cohort study

BACKGROUND

The 2022 AHA/ACC/HFSA guidelines for the management of heart failure (HF) makes therapeutic recommendations based on HF status. We investigated whether the prognosis of in-hospital cardiac arrest (IHCA) could be stratified by HF stage and left ventricular ejection fraction (LVEF).

METHODS

This single-center retrospective study analyzed the data of patients who experienced IHCA between 2005 and 2020. Based on admission diagnosis, past medical records, and pre-arrest echocardiography, patients were classified into general IHCA, at-risk for HF, pre-HF, HF with preserved ejection fraction (HFpEF), and HF with mildly reduced ejection fraction or HF with reduced ejection fraction (HFmrEF-or-HFrEF) groups.

RESULTS

This study included 2,466 patients, including 485 (19.7%), 546 (22.1%), 863 (35.0%), 342 (13.9%), and 230 (9.3%) patients with general IHCA, at-risk for HF, pre-HF, HFpEF, and HFmrEF-or-HFrEF, respectively. A total of 405 (16.4%) patients survived to hospital discharge, with 228 (9.2%) patients achieving favorable neurological recovery. Multivariable logistic regression analysis indicated that pre-HF and HFpEF were associated with better neurological (pre-HF, OR: 2.11, 95% confidence interval [CI]: 1.23-3.61, p = 0.006; HFpEF, OR: 1.90, 95% CI: 1.00-3.61, p = 0.05) and survival outcomes (pre-HF, OR: 2.00, 95% CI: 1.34-2.97, p < 0.001; HFpEF, OR: 1.91, 95% CI: 1.20-3.05, p = 0.007), compared with general IHCA.

CONCLUSION

HF stage and LVEF could stratify patients with IHCA into different prognoses. Pre-HF and HFpEF were significantly associated with favorable neurological and survival outcomes after IHCA. Further studies are warranted to investigate whether HF status-directed management could improve IHCA outcomes.

Relationship between stress hyperglycaemic ratio and incidence of in-hospital cardiac arrest in patients with acute coronary syndrome: a retrospective cohort study

BACKGROUND

The stress hyperglycaemic ratio (SHR), a new marker that reflects the true hyperglycaemic state of patients with acute coronary syndrome (ACS), is strongly associated with adverse clinical outcomes in these patients. Studies on the relationship between the SHR and in-hospital cardiac arrest (IHCA) incidence are limited. This study elucidated the relationship between the SHR and incidence of IHCA in patients with ACS.

METHODS

In total, 1,939 patients with ACS who underwent percutaneous coronary intervention (PCI) at the Affiliated Hospital of Zunyi Medical University were included. They were divided into three groups according to the SHR: group T1 (SHR ≤ 0.838, N = 646), group T2 (0.838< SHR ≤ 1.140, N = 646), and group T3 (SHR3 > 1.140, N = 647). The primary endpoint was IHCA incidence.

RESULTS

The overall IHCA incidence was 4.1% (N = 80). After adjusting for covariates, SHR was significantly associated with IHCA incidence in patients with ACS who underwent PCI (odds ratio [OR] =  2.6800; 95% confidence interval [CI] =  1.6200-4.4300; p<0.001), and compared with the T1 group, the T3 group had an increased IHCA risk (OR =  2.1800; 95% CI =  1.2100-3.9300; p =  0.0090). In subgroup analyses, after adjusting for covariates, patients with ST-segment elevation myocardial infarction (STEMI) (OR =  3.0700; 95% CI =  1.4100-6.6600; p =  0.0050) and non-STEMI (NSTEMI) (OR =  2.9900; 95% CI =  1.1000-8.1100; p =  0.0310) were at an increased IHCA risk. After adjusting for covariates, IHCA risk was higher in patients with diabetes mellitus (DM) (OR =  2.5900; 95% CI =  1.4200-4.7300; p =  0.0020) and those without DM (non-DM) (OR =  3.3000; 95% CI =  1.2700-8.5800; p =  0.0140); patients with DM in the T3 group had an increased IHCA risk compared with those in the T1 group (OR =  2.4200; 95% CI =  1.0800-5.4300; p =  0.0320). The restriction cubic spline (RCS) analyses revealed a dose-response relationship between IHCA incidence and SHR, with an increased IHCA risk when SHR was higher than 1.773. Adding SHR to the baseline risk model improved the predictive value of IHCA in patients with ACS treated with PCI (net reclassification improvement [NRI]: 0.0734 [0.0058-0.1409], p =  0.0332; integrated discrimination improvement [IDI]: 0.0218 [0.0063-0.0374], p =  0.0060).

CONCLUSIONS

In patients with ACS treated with PCI, the SHR was significantly associated with the incidence of IHCA. The SHR may be a useful predictor of the incidence of IHCA in patients with ACS. The addition of the SHR to the baseline risk model had an incremental effect on the predictive value of IHCA in patients with ACS treated with PCI.

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

OBJECTIVE

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

DESIGN

Retrospective cohort study.

SETTING

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

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Incidence and case ascertainment of treated in-hospital cardiac arrest events in a national quality registry - A comparison of reported and non-reported events

BACKGROUND

Approximately 2500 in-hospital cardiac arrest (IHCA) events are reported annually to the Swedish Registry of Cardiopulmonary Resuscitation (SRCR) with an estimated incidence of 1.7/1000 hospital admissions. The aim of this study was to evaluate the compliance in reporting IHCA events to the SRCR and to compare reported IHCA events with possible non-reported events, and to estimate IHCA incidence.

METHODS

Fifteen diagnose codes, eight Classification of Care Measure codes, and two perioperative complication codes were used to find all treated IHCAs in 2018-2019 at six hospitals of varying sizes and resources. All identified IHCA events were cross-checked against the SRCR using personal identity numbers. All non-reported IHCA events were retrospectively reported and compared with the prospectively reported events.

RESULTS

A total of 3638 hospital medical records were reviewed and 1109 IHCA events in 999 patients were identified, with 254 of the events not found in the SRCR. The case completeness was 77% (range 55-94%). IHCA incidence was 2.9/1000 hospital admissions and 12.4/1000 admissions to intensive care units. The retrospectively reported events were more often found on monitored wards, involved patients who were younger, had less comorbidity, were often found in shockable rhythm and more often achieved sustained spontaneous circulation, compared with in prospectively reported events.

CONCLUSION

IHCA case completeness in the SRCR was 77% and IHCA incidence was 2.9/1000 hospital admissions. The retrospectively reported IHCA events were found in monitored areas where the rapid response team was not alerted, which might have affected regular reporting procedures.

Associations Between End-Tidal Carbon Dioxide During Pediatric Cardiopulmonary Resuscitation, Cardiopulmonary Resuscitation Quality, and Survival

BACKGROUND

Supported by laboratory and clinical investigations of adult cardiopulmonary arrest, resuscitation guidelines recommend monitoring end-tidal carbon dioxide (ETCO2) as an indicator of cardiopulmonary resuscitation (CPR) quality, but they note that "specific values to guide therapy have not been established in children."

METHODS

This prospective observational cohort study was a National Heart, Lung, and Blood Institute-funded ancillary study of children in the ICU-RESUS trial (Intensive Care Unit-Resuscitation Project; NCT02837497). Hospitalized children (≤18 years of age and ≥37 weeks postgestational age) who received chest compressions of any duration for cardiopulmonary arrest, had an endotracheal or tracheostomy tube at the start of CPR, and evaluable intra-arrest ETCO2 data were included. The primary exposure was event-level average ETCO2 during the first 10 minutes of CPR (dichotomized as ≥20 mm Hg versus <20 mm Hg on the basis of adult literature). The primary outcome was survival to hospital discharge. Secondary outcomes were sustained return of spontaneous circulation, survival to discharge with favorable neurological outcome, and new morbidity among survivors. Poisson regression measured associations between ETCO2 and outcomes as well as the association between ETCO2 and other CPR characteristics: (1) invasively measured systolic and diastolic blood pressures, and (2) CPR quality and chest compression mechanics metrics (ie, time to CPR start; chest compression rate, depth, and fraction; ventilation rate).

RESULTS

Among 234 included patients, 133 (57%) had an event-level average ETCO2 ≥20 mm Hg. After controlling for a priori covariates, average ETCO2 ≥20 mm Hg was associated with a higher incidence of survival to hospital discharge (86/133 [65%] versus 48/101 [48%]; adjusted relative risk, 1.33 [95% CI, 1.04-1.69]; P=0.023) and return of spontaneous circulation (95/133 [71%] versus 59/101 [58%]; adjusted relative risk, 1.22 [95% CI, 1.00-1.49]; P=0.046) compared with lower values. ETCO2 ≥20 mm Hg was not associated with survival with favorable neurological outcome or new morbidity among survivors. Average 2 ≥20 mm Hg was associated with higher systolic and diastolic blood pressures during CPR, lower CPR ventilation rates, and briefer pre-CPR arrest durations compared with lower values. Chest compression rate, depth, and fraction did not differ between ETCO2 groups.

CONCLUSIONS

In this multicenter study of children with in-hospital cardiopulmonary arrest, ETCO2 ≥20 mm Hg was associated with better outcomes and higher intra-arrest blood pressures, but not with chest compression quality metrics.

Survival With Favorable Neurologic Outcome and Quality of Cardiopulmonary Resuscitation Following In-Hospital Cardiac Arrest in Children With Cardiac Disease Compared With Noncardiac Disease

OBJECTIVES

To assess associations between outcome and cardiopulmonary resuscitation (CPR) quality for in-hospital cardiac arrest (IHCA) in children with medical cardiac, surgical cardiac, or noncardiac disease.

DESIGN

Secondary analysis of a multicenter cluster randomized trial, the ICU-RESUScitation Project (NCT02837497, 2016-2021).

SETTING

Eighteen PICUs.

PATIENTS

Children less than or equal to 18 years old and greater than or equal to 37 weeks postconceptual age receiving chest compressions (CC) of any duration during the study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 1,100 children with IHCA, there were 273 medical cardiac (25%), 383 surgical cardiac (35%), and 444 noncardiac (40%) cases. Favorable neurologic outcome was defined as no more than moderate disability or no worsening from baseline Pediatric Cerebral Performance Category at discharge. The medical cardiac group had lower odds of survival with favorable neurologic outcomes compared with the noncardiac group (48% vs 55%; adjusted odds ratio [aOR] [95% CI], aOR 0.59 [95% CI, 0.39-0.87], p = 0.008) and surgical cardiac group (48% vs 58%; aOR 0.64 [95% CI, 0.45-0.9], p = 0.01). We failed to identify a difference in favorable outcomes between surgical cardiac and noncardiac groups. We also failed to identify differences in CC rate, CC fraction, ventilation rate, intra-arrest average target diastolic or systolic blood pressure between medical cardiac versus noncardiac, and surgical cardiac versus noncardiac groups. The surgical cardiac group had lower odds of achieving target CC depth compared to the noncardiac group (OR 0.15 [95% CI, 0.02-0.52], p = 0.001). We failed to identify a difference in the percentage of patients achieving target CC depth when comparing medical cardiac versus noncardiac groups.

CONCLUSIONS

In pediatric IHCA, medical cardiac patients had lower odds of survival with favorable neurologic outcomes compared with noncardiac and surgical cardiac patients. We failed to find differences in CPR quality between medical cardiac and noncardiac patients, but there were lower odds of achieving target CC depth in surgical cardiac compared to noncardiac patients.

Clinical Implications of the Lung Ultrasound Score in Patients after Cardiopulmonary Resuscitation

Background

Lung ultrasound score (LUS) is a clinical index used to measure lung injury, but its clinical value in patients after cardiopulmonary resuscitation (CPR) remains relatively unknown. The purpose of this study was to investigate the clinical value of LUS in patients after CPR.

Methods

This retrospective study included a total of 34 patients older than 18 years with a nontraumatic cause of in-hospital cardiac arrest, who received standard resuscitation and achieved return of spontaneous circulation (ROSC). All patients underwent bedside lung ultrasound examination within half an hour once ROSC was achieved, and LUSs were calculated. The study included patient death as the endpoint event.

Results

Compared with the group with lower LUSs, the patients with higher LUSs had a lower oxygenation index, longer duration of CPR, and lower 72 h survival rate. The initial LUS had good clinical value in predicting the secondary outcomes of CPR (adjusted odds ratio (aOR): 1.353, 95% confidence interval (CI): 1.018-1.797, and P = 0.037) and 72 h survival rate of patients who underwent CPR (aOR: 1.145, 95% CI: 1.014-1.294, and P = 0.029).

Conclusions

LUS was shown to be helpful and had a prognostic value in patients after CPR.

Explainable Artificial Intelligence Warning Model Using an Ensemble Approach for In-Hospital Cardiac Arrest Prediction: Retrospective Cohort Study

BACKGROUND

Cardiac arrest (CA) is the leading cause of death in critically ill patients. Clinical research has shown that early identification of CA reduces mortality. Algorithms capable of predicting CA with high sensitivity have been developed using multivariate time series data. However, these algorithms suffer from a high rate of false alarms, and their results are not clinically interpretable.

OBJECTIVE

We propose an ensemble approach using multiresolution statistical features and cosine similarity-based features for the timely prediction of CA. Furthermore, this approach provides clinically interpretable results that can be adopted by clinicians.

METHODS

Patients were retrospectively analyzed using data from the Medical Information Mart for Intensive Care-IV database and the eICU Collaborative Research Database. Based on the multivariate vital signs of a 24-hour time window for adults diagnosed with heart failure, we extracted multiresolution statistical and cosine similarity-based features. These features were used to construct and develop gradient boosting decision trees. Therefore, we adopted cost-sensitive learning as a solution. Then, 10-fold cross-validation was performed to check the consistency of the model performance, and the Shapley additive explanation algorithm was used to capture the overall interpretability of the proposed model. Next, external validation using the eICU Collaborative Research Database was performed to check the generalization ability.

RESULTS

The proposed method yielded an overall area under the receiver operating characteristic curve (AUROC) of 0.86 and area under the precision-recall curve (AUPRC) of 0.58. In terms of the timely prediction of CA, the proposed model achieved an AUROC above 0.80 for predicting CA events up to 6 hours in advance. The proposed method simultaneously improved precision and sensitivity to increase the AUPRC, which reduced the number of false alarms while maintaining high sensitivity. This result indicates that the predictive performance of the proposed model is superior to the performances of the models reported in previous studies. Next, we demonstrated the effect of feature importance on the clinical interpretability of the proposed method and inferred the effect between the non-CA and CA groups. Finally, external validation was performed using the eICU Collaborative Research Database, and an AUROC of 0.74 and AUPRC of 0.44 were obtained in a general intensive care unit population.

CONCLUSIONS

The proposed framework can provide clinicians with more accurate CA prediction results and reduce false alarm rates through internal and external validation. In addition, clinically interpretable prediction results can facilitate clinician understanding. Furthermore, the similarity of vital sign changes can provide insights into temporal pattern changes in CA prediction in patients with heart failure-related diagnoses. Therefore, our system is sufficiently feasible for routine clinical use. In addition, regarding the proposed CA prediction system, a clinically mature application has been developed and verified in the future digital health field.

A classification system for identifying patients dead on ambulance arrival: a prehospital medical record review

BACKGROUND

Patients dead before arrival of the ambulance or before arrival at hospital may be in- or excluded in mortality analyses, making comparison of mortality difficult. Often only physicians are allowed to declare death, thereby impeding uniform registration of prehospital death. Many studies do not report detailed definitions of prehospital mortality. Our aim was to define criteria to identify and categorize prehospital patients' vital status, and to estimate the proportion of these groups, primarily the proportion of patients dead on ambulance arrival.

METHODS

Prehospital medical records review for patients receiving an ambulance in the North Denmark Region from 2019 to 2021 and registered dead on the same or the following day. We defined three vital status categories: (1) Dead on Ambulance Arrival (DOAA), (2) Out-of-Hospital Cardiac Arrest (OHCA) divided into OHCA Basic Life Support (OHCA BLS) and OHCA Advanced treatment, and 3) Alive on Ambulance Arrival.

RESULTS

Among 3 174 dead patients, DOAA constituted 28.8%, OHCA BLS 13.4%, OHCA Advanced treatment 31.3%, and Alive on Ambulance Arrival 26.6%.

CONCLUSION

We defined exhaustive and mutually exclusive criteria to define vital status, DOAA, OHCA, and Alive on Ambulance Arrival based on prehospital medical records. More than one out of four patients receiving an ambulance and registered dead on the same or the following day were dead already at ambulance arrival. Adding OHCA BLS where resuscitation was terminated without defibrillation or other treatment, increased the proportion of patients dead on ambulance arrival to 42%. We recommend reporting similar categories of vital status to improve valid comparisons of prehospital mortality rates.

The role of point-of-care testing in cardiac arrest patients

BACKGROUND

Point-of-care testing (POCT) provides real time information to the clinical team, leading to early diagnosis and treatment. Whether POCT plays a role in improving outcomes in patients with out of hospital cardiac arrest (OHCA) remains unknown. The objective of this study was to describe use of POCT in OHCA and to explore its association with outcomes.

METHODS

We conducted a retrospective chart review on patients transferred by emergency medical services (EMS) to the ED for out-of-hospital cardiac arrest (OHCA) in 2019. Data collected from patient charts included baseline information, the Utstein criteria for cardiac arrest, whether POCT was used, whether POCT was abnormal, and what treatment was given, if any, as a result of the abnormal POCT. Outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge. Outcomes in patients with and without POCT were compared using chi-square and t-tests.

RESULTS

There were 119 study patients. Their mean (SD) age was 65 (18) years and 65% were male. Cardiac arrest was witnessed in 48% and initial rhythm was asystole in 66%. The rates of ROSC and survival were 22.7% (95%CI, 16.1-31.1) and 3.4% (95%CI, 1.3-8.3). POCT was used in 66 patients (55.4%; 95%CI, 46.5-64.1) all of whom had at least one abnormality. The results of POCT led to administration of a therapy in 60 patients (91.0%; 95%CI, 81.6-95.8). The rates of ROSC in patients with and without POCT were 22.6% vs 22.7% respectively. The rates of survival to discharge in patients with and without POCT were 0% vs 3.8% respectively.

CONCLUSIONS

POCT is commonly used in the ED for patients with OHCA and its results often lead to changes in therapies. However, use of POCT was not associated with ROSC or survival to discharge.

Resuscitative endovascular balloon occlusion of the aorta in out-of-hospital cardiac arrest - A Delphi consensus study for uniform data collection

Background

Evolving research on resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct treatment for out-of-hospital cardiac arrest mandates uniform recording and reporting of data. A consensus on which variables need to be collected may enable comparing and merging data from different studies. We aimed to establish a standard set of variables to be collected and reported in future REBOA studies in out-of-hospital cardiac arrest.

Methods

A four-round stepwise Delphi consensus process first asked experts to propose without restraint variables for future REBOA research in out-of-hospital cardiac arrest. The experts then reviewed the variables on a 5-point Likert scale and ≥75% agreement was defined as consensus. First authors of published papers on REBOA in out-of-hospital cardiac arrest over the last five years were invited to join the expert panel.

Results

The data were collected between May 2022 and December 2022. A total of 28 experts out of 34 primarily invited completed the Delphi process, which developed a set of 31 variables that might be considered as a supplement to the Utstein style reporting of research in out-of-hospital cardiac arrest.

Conclusions

This Delphi consensus process suggested 31 variables that enable future uniform reporting of REBOA in out-of-hospital cardiac arrest.

Prediction Models for Return of Spontaneous Circulation in Patients with Cardiac Arrest: A Systematic Review and Critical Appraisal

Objectives

Prediction models for the return of spontaneous circulation (ROSC) in patients with cardiac arrest play an important role in helping physicians evaluate the survival probability and providing medical decision-making reference. Although relevant models have been developed, their methodological rigor and model applicability are still unclear. Therefore, this study aims to summarize the evidence for ROSC prediction models and provide a reference for the development, validation, and application of ROSC prediction models.

Methods

PubMed, Cochrane Library, Embase, Elsevier, Web of Science, SpringerLink, Ovid, CNKI, Wanfang, and SinoMed were systematically searched for studies on ROSC prediction models. The search time limit was from the establishment of the database to August 30, 2022. Two reviewers independently screened the literature and extracted the data. The PROBAST was used to evaluate the quality of the included literature.

Results

A total of 8 relevant prediction models were included, and 6 models reported the AUC of 0.662-0.830 in the modeling population, which showed good overall applicability but high risk of bias. The main reasons were improper handling of missing values and variable screening, lack of external validation of the model, and insufficient information of overfitting. Age, gender, etiology, initial heart rhythm, EMS arrival time/BLS intervention time, location, bystander CPR, witnessed during sudden arrest, and ACLS duration/compression duration were the most commonly included predictors. Obvious chest injury, body temperature below 33°C, and possible etiologies were predictive factors for ROSC failure in patients with TOHCA. Age, gender, initial heart rhythm, reason for the hospital visit, length of hospital stay, and the location of occurrence in hospital were the predictors of ROSC in IHCA patients.

Conclusion

The performance of current ROSC prediction models varies greatly and has a high risk of bias, which should be selected with caution. Future studies can further optimize and externally validate the existing models.

Identification of post-cardiac arrest blood pressure thresholds associated with outcomes in children: an ICU-Resuscitation study

INTRODUCTION

Though early hypotension after pediatric in-hospital cardiac arrest (IHCA) is associated with inferior outcomes, ideal post-arrest blood pressure (BP) targets have not been established. We aimed to leverage prospectively collected BP data to explore the association of post-arrest BP thresholds with outcomes. We hypothesized that post-arrest systolic and diastolic BP thresholds would be higher than the currently recommended post-cardiopulmonary resuscitation BP targets and would be associated with higher rates of survival to hospital discharge.

METHODS

We performed a secondary analysis of prospectively collected BP data from the first 24 h following return of circulation from index IHCA events enrolled in the ICU-RESUScitation trial (NCT02837497). The lowest documented systolic BP (SBP) and diastolic BP (DBP) were percentile-adjusted for age, height and sex. Receiver operator characteristic curves and cubic spline analyses controlling for illness category and presence of pre-arrest hypotension were generated exploring the association of lowest post-arrest SBP and DBP with survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). Optimal cutoffs for post-arrest BP thresholds were based on analysis of receiver operator characteristic curves and spline curves. Logistic regression models accounting for illness category and pre-arrest hypotension examined the associations of these thresholds with outcomes.

RESULTS

Among 693 index events with 0-6 h post-arrest BP data, identified thresholds were: SBP > 10th percentile and DBP > 50th percentile for age, sex and height. Fifty-one percent (n = 352) of subjects had lowest SBP above threshold and 50% (n = 346) had lowest DBP above threshold. SBP and DBP above thresholds were each associated with survival to hospital discharge (SBP: aRR 1.21 [95% CI 1.10, 1.33]; DBP: aRR 1.23 [1.12, 1.34]) and survival to hospital discharge with favorable neurologic outcome (SBP: aRR 1.22 [1.10, 1.35]; DBP: aRR 1.27 [1.15, 1.40]) (all p < 0.001).

CONCLUSIONS

Following pediatric IHCA, subjects had higher rates of survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome when BP targets above a threshold of SBP > 10th percentile for age and DBP > 50th percentile for age during the first 6 h post-arrest.

Association between post-cardiac arrest treatments and clinical outcomes according to scene time interval in out-of-hospital cardiac arrest: Retrospective cross-sectional study

BACKGROUND

Previous studies have reported that Post-Cardiac arrest (PCA) treatments including targeted temperature management (TTM), coronary reperfusion therapy (CRT), and extracorporeal membrane oxygenation (ECMO) are time-sensitive; however, there are no reports of the clinical outcomes of PCA treatment according to the scene time interval (STI). Our study aimed to investigated the clinical outcomes of PCA treatment according to the STI.

METHODS

We used a Korean nationwide OHCA cohort database from January 2017 to December 2020. The inclusion criteria were all adult OHCA patients with a presumed cardiac etiology, bystander-witnessed arrest, and prehospital return of spontaneous circulation (ROSC). The outcomes were survival to discharge and good neurological recovery. The main exposure of interest was PCA treatment. We compared the outcomes using multivariable logistic regression, and interaction terms were included in the final model to assess whether the STI modified the effect of PCA treatment on clinical outcomes of OHCA.

RESULTS

TTM and CRT were associated with high survival to discharge and good neurological recovery. In the interaction analysis, ECMO had an interaction effect with the STI on a good CPC among patients with OHCA [short STI (0 to 11 min) (1.16 (0.77-1.75)), middle STI (12 to 15 min) (0.66 (0.41-1.06)), and long STI (16 to 30 min) (0.59 (0.40-0.88)) (p for interaction <0.05)].

CONCLUSION

In adult bystander-witnessed patients with OHCA with prehospital ROSC, an STI of >16 min was a risk factor for poor neurological outcome in those patients who underwent ECMO.

Prediction of Return of Spontaneous Circulation in a Pediatric Swine Model of Cardiac Arrest Using Low-Resolution Multimodal Physiological Waveforms

Monitoring physiological waveforms, specifically hemodynamic variables (e.g., blood pressure waveforms) and end-tidal CO2 (EtCO2), during pediatric cardiopulmonary resuscitation (CPR) has been demonstrated to improve survival rates and outcomes when compared to standard depth-guided CPR. However, waveform guidance has largely been based on thresholds for single parameters and therefore does not leverage all the information contained in multimodal data. We hypothesize that the combination of multimodal physiological features improves the prediction of the return of spontaneous circulation (ROSC), the clinical indicator of short-term CPR success. We used machine learning algorithms to evaluate features extracted from eight low-resolution (4 samples per minute) physiological waveforms to predict ROSC. The waveforms were acquired from the 2nd to 10th minute of CPR in pediatric swine models of cardiac arrest (N = 89, 8-12 kg). The waveforms were divided into segments with increasing length (both forward and backward) for feature extraction, and machine learning algorithms were trained for ROSC prediction. For the full CPR period (2nd to 10th minute), the area under the receiver operating characteristics curve (AUC) was 0.93 (95% CI: 0.87-0.99) for the multivariate model, 0.70 (0.55-0.85) for EtCO2 and 0.80 (0.67-0.93) for coronary perfusion pressure. The best prediction performances were achieved when the period from the 6th to the 10th minute was included. Poor predictions were observed for some individual waveforms, e.g., right atrial pressure. In conclusion, multimodal waveform features carry relevant information for ROSC prediction. Using multimodal waveform features in CPR guidance has the potential to improve resuscitation success and reduce mortality.

Impaired echocardiographic left ventricular global longitudinal strain after pediatric cardiac arrest children is associated with mortality

BACKGROUND

Global longitudinal strain (GLS) is an echocardiographic method to identify left ventricular (LV) dysfunction after cardiac arrest that is less sensitive to loading conditions. We aimed to identify the frequency of impaired GLS following pediatric cardiac arrest, and its association with hospital mortality.

METHODS

This is a retrospective single-center cohort study of children <18 years of age treated in the pediatric intensive care unit (PICU) after in- or out-of-hospital cardiac arrest (IHCA and OHCA), with echocardiogram performed within 24 hours of initiation of post-arrest PICU care between 2013 and 2020. Patients with congenital heart disease, post-arrest extracorporeal support, or inability to measure GLS were excluded. Echocardiographic LV ejection fraction (EF) and shortening fraction (SF) were abstracted from the chart. GLS was measured post hoc; impaired strain was defined as LV GLS ≥ 2 SD worse than age-dependent normative values. Demographics and pre-arrest, arrest, and post-arrest characteristics were compared between subjects with normal versus impaired GLS. Correlation between GLS, SF and EF were calculated with Pearson comparison. Logistic regression tested the association of GLS with mortality. Area under the receiver operator curve (AUROC) was calculated for discriminative utility of GLS, EF, and SF with mortality.

RESULTS

GLS was measured in 124 subjects; impaired GLS was present in 46 (37.1%). Subjects with impaired GLS were older (median 7.9 vs. 1.9 years, p < 0.001), more likely to have ventricular tachycardia/fibrillation as initial rhythm (19.6% versus 3.8%, p = 0.017) and had higher peak troponin levels in the first 24 hours post-arrest (median 2.5 vs. 0.5, p = 0.002). There were no differences between arrest location or CPR duration by GLS groups. Subjects with impaired GLS compared to normal GLS had lower median EF (42.6% versus 62.3%) and median SF (23.3% versus 36.6%), all p < 0.001, with strong inverse correlation between GLS and EF (rho -0.76, p < 0.001) and SF (rho -0.71, p < 0.001). Patients with impaired GLS had higher rates of mortality (60% vs. 32%, p = 0.009). GLS was associated with mortality when controlling for age and initial rhythm [aOR 1.17 per 1% increase in GLS (95% CI 1.09-1.26), p < 0.001]. GLS, EF and SF had similar discrimination for mortality: GLS AUROC 0.69 (95% CI 0.60-0.79); EF AUROC 0.71 (95% CI 0.58-0.88); SF AUROC 0.71 (95% CI 0.61-0.82), p = 0.101.

CONCLUSIONS

Impaired LV function as measured by GLS after pediatric cardiac arrest is associated with hospital mortality. GLS is a novel complementary metric to traditional post-arrest echocardiography that correlates strongly with EF and SF and is associated with mortality. Future large prospective studies of post-cardiac arrest care should investigate the prognostic utilities of GLS, alongside SF and EF.

The association of arterial blood pressure waveform-derived area duty cycle with intra-arrest hemodynamics and cardiac arrest outcomes

AIM

Develop a novel, physiology-based measurement of duty cycle (Arterial Blood Pressure-Area Duty Cycle [ABP-ADC]) and evaluate the association of ABP-ADC with intra-arrest hemodynamics and patient outcomes.

METHODS

This was a secondary retrospective study of prospectively collected data from the ICU-RESUS trial (NCT02837497). Invasive arterial waveform data were used to derive ABP-ADC. The primary exposure was ABP-ADC group (<30%; 30-35%; >35%). The primary outcome was systolic blood pressure (sBP). Secondary outcomes included intra-arrest physiologic goals, CPR quality targets, and patient outcomes. In an exploratory analysis, adjusted splines and receiver operating characteristic (ROC) curves were used to determine an optimal ABP-ADC associated with improved hemodynamics and outcomes using a multivariable model.

RESULTS

Of 1129 CPR events, 273 had evaluable arterial waveform data. Mean age is 2.9 years + 4.9 months. Mean ABP-ADC was 32.5% + 5.0%. In univariable analysis, higher ABP-ADC was associated with lower sBP (p < 0.01) and failing to achieve sBP targets (p < 0.01). Other intra-arrest physiologic parameters, quality metrics, and patient outcomes were similar across ABP-ADC groups. Using spline/ROC analysis and clinical judgement, the optimal ABP-ADC cut point was set at 33%. On multivariable analysis, sBP was significantly higher (point estimate 13.18 mmHg, CI95 5.30-21.07, p < 0.01) among patients with ABP-ADC < 33%. Other intra-arrest physiologic and patient outcomes were similar.

CONCLUSIONS

In this multicenter cohort, a lower ABP-ADC was associated with higher sBPs during CPR. Although ABP-ADC was not associated with outcomes, further studies are needed to define the interactions between CPR mechanics and intra arrest patient physiology.

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action

Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents' families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.

Outcomes and characteristics of cardiac arrest in children with pulmonary hypertension: A secondary analysis of the ICU-RESUS clinical trial

BACKGROUND

Previous studies have identified pulmonary hypertension (PH) as a relatively common diagnosis in children with in-hospital cardiac arrest (IHCA), and preclinical laboratory studies have found poor outcomes and low systemic blood pressures during CPR for PH-associated cardiac arrest. The objective of this study was to determine the prevalence of PH among children with IHCA and the association between PH diagnosis and intra-arrest physiology and survival outcomes.

METHODS

This was a prospectively designed secondary analysis of patients enrolled in the ICU-RESUS clinical trial (NCT02837497). The primary exposure was a pre-arrest diagnosis of PH. The primary survival outcome was survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category score 1-3 or unchanged from baseline). The primary physiologic outcome was event-level average diastolic blood pressure (DBP) during CPR.

RESULTS

Of 1276 patients with IHCAs during the study period, 1129 index IHCAs were enrolled; 184 (16.3%) had PH and 101/184 (54.9%) were receiving inhaled nitric oxide at the time of IHCA. Survival with favorable neurologic outcome was similar between patients with and without PH on univariate (48.9% vs. 54.4%; p = 0.17) and multivariate analyses (aOR 0.82 [95%CI: 0.56, 1.20]; p = 0.32). There were no significant differences in CPR event outcome or survival to hospital discharge. Average DBP, systolic BP, and end-tidal carbon dioxide during CPR were similar between groups.

CONCLUSIONS

In this prospective study of pediatric IHCA, pre-existing PH was present in 16% of children. Pre-arrest PH diagnosis was not associated with statistically significant differences in survival outcomes or intra-arrest physiologic measures.

The outcomes of cardiopulmonary resuscitation and their predictors during the coronavirus 2019 pandemic in Iran

BACKGROUND

Coronavirus disease 2019 (COVID-19) can negatively affect different healthcare-related outcomes. Nonetheless, there is limited information about its effects on different healthcare-related outcomes. This study aimed at evaluating the outcomes of cardiopulmonary resuscitation (CPR) and their predictors during the COVID-19 pandemic in Iran.

METHODS

This cross-sectional study was conducted on 1253 patients who had undergone CPR in the emergency wards of teaching hospitals in the west of Iran from the beginning of the first wave to the end of the third epidemic wave of COVID-19 in Iran, between February 20, 2020, and January 20, 2021. Data were collected using the National CPR Documentation Forms developed based on the Utstein Style and routinely used for all patients with cardiac arrest (CA). The SPSS (v. 20.0) program was used to analyze the data through the Chi-square, Fisher's exact, and Mann-Whitney U tests and logistic regression analysis.

RESULTS

Participants' age mean was 64.62 ± 17.54 years. Age mean among participants with COVID-19 was eight years more than other participants. Most participants were male (64.09%) and had at least one underlying disease (64.99%). The total rates of the return of spontaneous circulation (ROSC) and CPR-discharge survival were respectively 15.3% and 3.8% among all participants, 20.25% and 5.17% among participants without COVID-19, and 8.96% and 2.04% among participants with COVID-19. The significant predictors of ROSC were age, affliction by COVID-19, affliction by underlying diseases, baseline rhythm, delay in epinephrine administration, and epinephrine administration time interval, while the significant predictors of CPR-discharge survival were age and baseline rhythm.

CONCLUSIONS

The total rates of ROSC and CPR-discharge survival were respectively 15.3% and 3.8% among all participants. The rates of ROSC and CPR to discharge survival among patients without COVID-19 are respectively 2.26 and 2.53 times more than the rates among patients with COVID-19.

Inappropriate Shock Delivery Is Common During Pediatric In-Hospital Cardiac Arrest

OBJECTIVES

To characterize inappropriate shock delivery during pediatric in-hospital cardiac arrest (IHCA).

DESIGN

Retrospective cohort study.

SETTING

An international pediatric cardiac arrest quality improvement collaborative Pediatric Resuscitation Quality [pediRES-Q].

PATIENTS

All IHCA events from 2015 to 2020 from the pediRES-Q Collaborative for which shock and electrocardiogram waveform data were available.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed 418 shocks delivered during 159 cardiac arrest events, with 381 shocks during 158 events at 28 sites remaining after excluding undecipherable rhythms. We classified shocks as: 1) appropriate (ventricular fibrillation [VF] or wide complex ≥ 150/min); 2) indeterminate (narrow complex ≥ 150/min or wide complex 100-149/min); or 3) inappropriate (asystole, sinus, narrow complex < 150/min, or wide complex < 100/min) based on the rhythm immediately preceding shock delivery. Of delivered shocks, 57% were delivered appropriately for VF or wide complex rhythms with a rate greater than or equal to 150/min. Thirteen percent were classified as indeterminate. Thirty percent were delivered inappropriately for asystole (6.8%), sinus (3.1%), narrow complex less than 150/min (11%), or wide complex less than 100/min (8.9%) rhythms. Eighty-eight percent of all shocks were delivered in ICUs or emergency departments, and 30% of those were delivered inappropriately.

CONCLUSIONS

The rate of inappropriate shock delivery for pediatric IHCA in this international cohort is at least 30%, with 23% delivered to an organized electrical rhythm, identifying opportunity for improvement in rhythm identification training.

Clinician-reported physiologic monitoring of cardiopulmonary resuscitation quality during pediatric in-hospital cardiac arrest: A propensity-weighted cohort study

AIMS

The primary objective was to determine the association between clinician-reported use of end-tidal CO2 (ETCO2) or diastolic blood pressure (DBP) to monitor cardiopulmonary resuscitation (CPR) quality during pediatric in-hospital cardiac arrest (pIHCA) and survival outcomes.

DESIGN

A retrospective cohort study was performed in two cohorts: (1) Patients with an invasive airway in place at the time of arrest to evaluate ETCO2 use, and (2) patients with an arterial line in place at the time of arrest to evaluate DBP use. The primary exposure was clinician-reported use of ETCO2 or DBP. The primary outcome was return of spontaneous circulation (ROSC). Propensity-weighted logistic regression evaluated the association between monitoring and outcomes.

SETTING

Hospitals reporting to the American Heart Association's Get With The Guidelines®- Resuscitation registry (2007-2021).

PATIENTS

Children with index IHCA with an invasive airway or arterial line at the time of arrest.

RESULTS

Between January 2007 and May 2021, there were 15,280 pediatric CPR events with an invasive airway or arterial line in place at the time of arrest. Of 7159 events with an invasive airway, 6829 were eligible for analysis. Of 2978 events with an arterial line, 2886 were eligible. Clinicians reported using ETCO2 in 1335/6829 (20%) arrests and DBP in 1041/2886 (36%). Neither exposure was associated with ROSC. ETCO2 monitoring was associated with higher odds of 24-hour survival (aOR 1.17 [1.02, 1.35], p = 0.03).

CONCLUSIONS

Neither clinician-reported ETCO2 monitoring nor DBP monitoring during pIHCA were associated with ROSC. Monitoring of ETCO2 was associated with 24-hour survival.

Association between cardiopulmonary resuscitation audit results with in-situ simulation and in-hospital cardiac arrest outcomes and key performance indicators

INTRODUCTION

In-situ simulation (ISS) is a method to evaluate the performance of hospital units in performing cardiopulmonary resuscitation (CPR). It is conducted by placing a high-fidelity mannequin at hospital units with simulated scenarios and having each unit's performance evaluated. However, little is known about its impact on actual patient outcomes. Therefore, we aimed to evaluate the association between the ISS results and actual outcomes of patients with in-hospital cardiac arrest (IHCA).

METHODS

This retrospective study was conducted by reviewing Siriraj Hospital's CPR ISS results in association with the data of IHCA patients between January 2012 and January 2019. Actual outcomes were determined by patients' outcomes (sustained return of spontaneous circulation (ROSC) and survival to hospital discharge) and arrest performance indicators (time-to-first-epinephrine and time-to-defibrillation). These outcomes were investigated for association with the ISS scores in multilevel regression models with hospital units as clusters.

RESULTS

There were 2146 cardiac arrests included with sustained ROSC rate of 65.3% and survival to hospital discharge rate of 12.9%. Higher ISS scores were significantly associated with improved sustained ROSC rate (adjusted odds ratio 1.32 (95%CI 1.04, 1.67); p = 0.01) and a decrease in time-to-defibrillation (-0.42 (95%CI -0.73, -0.11); p = 0.009). Although higher scores were also associated with better survival to hospital discharge and a decrease in time-to-first-epinephrine, most models for these outcomes failed to reach statistical significance.

CONCLUSION

CPR ISS results were associated with some important patient outcomes and arrest performance indicators. Therefore, it may be an appropriate performance evaluation method that can guide the direction of improvement.

Pediatric in-hospital cardiac arrest: respiratory failure characteristics and association with outcomes

AIMS

To characterize respiratory failure prior to pediatric in-hospital cardiac arrest (IHCA) and to associate pre-arrest respiratory failure characteristics with survival outcomes.

METHODS

This is a single-center, retrospective cohort study from a prospectively identified cohort of children <18 years in intensive care units (ICUs) who received cardiopulmonary resuscitation (CPR) for ≥ 1 minute between January 1, 2017 and June 30, 2021, and were receiving invasive mechanical ventilation (IMV) in the hour prior to IHCA. Patient characteristics, ventilatory support and gas exchange immediately pre-arrest were described and their association with the return of spontaneous circulation (ROSC) was measured.

RESULTS

In the 187 events among 154 individual patients, the median age was 0.9 [0.2, 2.4] years, and CPR duration was 7.5 [3, 29] minutes. Respiratory failure was acute prior to 106/187 (56.7%) events, and the primary indication for IMV was respiratory in nature in 107/187 (57.2%) events. Immediately pre-arrest, the median positive end-expiratory pressure was 8 [5,10] cmH₂O; mean airway pressure was 13 [10,18] cmH₂O; peak inspiratory pressure was 28 [24, 35] cmH₂O; and fraction of inhaled oxygen (FiO2) was 0.40 [0.25, 0.80]. Pre-arrest FiO2 was lower in patients with ROSC vs. without ROSC (0.30 vs 0.99; p<0.001). Patients without ROSC had greater severity of pre-arrest oxygenation failure (p<0.001) as defined by oxygenation index, oxygen saturation index, P/F ratio or S/F ratio.

CONCLUSIONS

There was substantial heterogeneity in respiratory failure characteristics and ventilatory requirements pre-arrest. Higher pre-arrest oxygen requirement and greater degree of oxygenation failure were associated with worse survival outcomes.

Prevalence and Geographic Features of Patients Eligible for Extracorporeal Cardiopulmonary Resuscitation

OBJECTIVE

This study sought to identify Out of Hospital Cardiac Arrests (OHCA) eligible for Extracorporeal Cardiopulmonary Resuscitation (ECPR), use Geographic Information Systems (GIS) to investigate geographic patterns, and investigate if correlation between ECPR candidacy and Social Determinants of Health (SDoH) exist.

METHODS

This study is of emergency medical service (EMS) runs for OHCA to an urban medical center from January 1, 2016 to December 31, 2020. All runs were filtered to inclusion criteria for ECPR: age 18-65, initial shockable rhythm, and no return of spontaneous circulation within initial defibrillations. Address level data were mapped in a GIS. Cluster detection assessed for granular areas of high concentration. The Center for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI) was overlaid. The SVI ranges from 0-1 with higher values indicating increasing social vulnerability.

RESULTS

There were 670 EMS transports for OHCA during the study period. 12.7% (85/670) met inclusion criteria for ECPR. 90% (77/85) had appropriate addresses for geocoding. Three geographic clusters of events were detected. Two were residential areas and one was concentrated over a public use area of downtown Cleveland. The SVI for these locations was 0.79, indicative of high social vulnerability. Nearly half (32/77, 41.5%) occurred in neighborhoods with the highest level of social vulnerability (SVI ≥0.9).

CONCLUSION

A significant proportion of OHCAs were eligible for ECPR based on prehospital criteria. Utilizing GIS to map and analyze ECPR patients provided insights into the locations of these events and the SDoH that may be driving risk in these places.

Association of Degree of Urbanization and Survival in Out-of-Hospital Cardiac Arrest

Background Survival from out-of-hospital cardiac arrest (OHCA) varies across regions. The aim of this study was to evaluate the association between urbanization (rural, suburban, and urban areas), bystander interventions (cardiopulmonary resuscitation and defibrillation), and 30-day survival from OHCAs in Denmark. Methods and Results We included OHCAs not witnessed by ambulance staff in Denmark from January 1, 2016, to December 31, 2020. Patients were divided according to the Eurostat Degree of Urbanization Tool in rural, suburban, and urban areas based on the 98 Danish municipalities. Poisson regression was used to estimate incidence rate ratios. Logistic regression (adjusted for ambulance response time) tested differences between the groups with respect to bystander interventions and survival, according to degree of urbanization. A total of 21 385 OHCAs were included, of which 8496 (40%) occurred in rural areas, 7025 (33%) occurred in suburban areas, and 5864 (27%) occurred in urban areas. Baseline characteristics, as age, sex, location of OHCA, and comorbidities, were comparable between groups. The annual incidence rate ratio of OHCA was higher in rural areas (1.54 [95% CI, 1.48-1.58]) compared with urban areas. Odds for bystander cardiopulmonary resuscitation were lower in suburban (0.86 [95% CI, 0.82-0.96]) and urban areas (0.87 [95% CI, 0.80-0.95]) compared with rural areas, whereas bystander defibrillation was higher in urban areas compared with rural areas (1.15 [95% CI, 1.01-1.31]). Finally, 30-day survival was higher in suburban (1.13 [95% CI, 1.02-1.25]) and urban areas (1.17 [95% CI, 1.05-1.30]) compared with rural areas. Conclusions Degree of urbanization was associated with lower rates of bystander defibrillation and 30-day survival in rural areas compared with urban areas.

Discrepancies in the late auditory potentials of post-anoxic patients: watch out for focal brain lesions, a pilot retrospective study

AIMS

Late auditory evoked potentials, and notably mismatch negativity (MMN) and P3 responses, can be used as part of the multimodal prognostic evaluation in post-anoxic disorders of consciousness (DOC). MMN response preferentially stems from the temporal cortex and the arcuate fasciculus. Situations with discrepant evaluations, for example MMN absent but P3 present, are frequent and difficult to interpret. We hypothesize that discrepant MMN-/P3+ results could reflect a higher prevalence of lesions in MMN generating regions. This study presents correlations between neurophysiological and neuroradiological results.

METHODS

This retrospective study was conducted on 38 post-anoxic DOC patients. Brain lesions were analyzed on 3T MRI both anatomically and through computation of the local arcuate fasciculus fractional anisotropy values on Diffusion Tensor Imaging sequences. Neurophysiological data and outcome were also analyzed.

RESULTS

Our cohort included 8 MMN-/P3+, 7 MMN+/P3+, 21 MMN-/P3- and 2 MMN-/P3+ patients, assessed at a median delay of 20.5 days since cardiac arrest. Our results show that MMN-/P3+ patients tended to have fewer temporal and basal ganglia lesions than MMN-/P3- patients, and more than MMN+/P3+ patients (p-values for trend: p=0.02 for temporal and p=0.02 for basal ganglia lesions). There was a statistical difference across groups for mean fractional anisotropy values in the arcuate fasciculus (p=0.008). The percentage of patients regaining consciousness at three months in MMN-/P3+ patients was higher than in MMN-/P3- patients and lower than in MMN+/P3+ patients.

CONCLUSION

This study suggests that discrepancies in late auditory evoked potentials may be linked to focal post-anoxic brain lesions, visible on brain MRI.

Calcium use during paediatric in-hospital cardiac arrest is associated with worse outcomes

AIM

To evaluate associations between calcium administration and outcomes among children with in-hospital cardiac arrest and among specific subgroups in which calcium use is hypothesized to provide clinical benefit.

METHODS

This is a secondary analysis of observational data collected prospectively as part of the ICU-RESUScitation project. Children 37 weeks post-conceptual age to 18 years who received chest compressions in one of 18 intensive care units from October 2016-March 2021 were eligible. Data included child and event characteristics, pre-arrest laboratory values, pre- and intra-arrest haemodynamics, and outcomes. Outcomes included sustained return of spontaneous circulation (ROSC), survival to hospital discharge, and survival to hospital discharge with favourable neurologic outcome. A propensity score weighted cohort was used to evaluate associations between calcium use and outcomes. Subgroups included neonates, and children with hyperkalaemia, sepsis, renal insufficiency, cardiac surgery with cardiopulmonary bypass, and calcium-avid cardiac diagnoses.

RESULTS

Of 1,100 in-hospital cardiac arrests, median age was 0.63 years (IQR 0.19, 3.81); 450 (41%) received calcium. Among the weighted cohort, calcium use was not associated with sustained ROSC (aOR, 0.87; CI95 0.61-1.24; p = 0.445), but was associated with lower rates of both survival to hospital discharge (aOR, 0.68; CI95 0.52-0.89; p = 0.005) and survival with favourable neurologic outcome at hospital discharge (aOR, 0.75; CI95 0.57-0.98; p = 0.038). Among subgroups, calcium use was associated with lower rates of survival to hospital discharge in children with sepsis and renal insufficiency.

CONCLUSIONS

Calcium use was common during paediatric in-hospital cardiac arrest and associated with worse outcomes at hospital discharge.

PHYSICIANS’ MORAL DUTIES DURING PANDEMICS

Background

Pandemics with devastating morbidity and mortality have occurred repeatedly throughout recorded history. Each new scourge seems to surprise governments, medical experts, and the public. The SARS CoV-2 (COVID-19) pandemic, for example, arrived as an unwelcome surprise to an unprepared world.

Discussion

Despite humanity's extensive experience with pandemics and their associated ethical dilemmas, no consensus has emerged on preferred normative standards to deal with them. In this article, we consider the ethical dilemmas faced by physicians who work in these risk-prone situations and propose a set of ethical norms for current and future pandemics. As front-line clinicians for critically ill patients during pandemics, emergency physicians will play a substantial role in making and implementing treatment allocation decisions.

Conclusion

Our proposed ethical norms should help future physicians make morally challenging choices during pandemics.

The physiologic response to epinephrine and pediatric cardiopulmonary resuscitation outcomes

BACKGROUND

Epinephrine is provided during cardiopulmonary resuscitation (CPR) to increase systemic vascular resistance and generate higher diastolic blood pressure (DBP) to improve coronary perfusion and attain return of spontaneous circulation (ROSC). The DBP response to epinephrine during pediatric CPR and its association with outcomes have not been well described. Thus, the objective of this study was to measure the association between change in DBP after epinephrine administration during CPR and ROSC.

METHODS

This was a prospective multicenter study of children receiving ≥ 1 min of CPR with ≥ 1 dose of epinephrine and evaluable invasive arterial BP data in the 18 ICUs of the ICU-RESUS trial (NCT02837497). Blood pressure waveforms underwent compression-by-compression quantitative analysis. The mean DBP before first epinephrine dose was compared to mean DBP two minutes post-epinephrine. Patients with ≥ 5 mmHg increase in DBP were characterized as "responders."

RESULTS

Among 147 patients meeting inclusion criteria, 66 (45%) were characterized as responders and 81 (55%) were non-responders. The mean increase in DBP with epinephrine was 4.4 [- 1.9, 11.5] mmHg (responders: 13.6 [7.5, 29.3] mmHg versus non-responders: - 1.5 [- 5.0, 1.5] mmHg; p < 0.001). After controlling for a priori selected covariates, epinephrine response was associated with ROSC (aRR 1.60 [1.21, 2.12]; p = 0.001). Sensitivity analyses identified similar associations between DBP response thresholds of ≥ 10, 15, and 20 mmHg and ROSC; DBP responses of ≥ 10 and ≥ 15 mmHg were associated with higher aRR of survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category score of 1-3 or no worsening from baseline).

CONCLUSIONS

The change in DBP following epinephrine administration during pediatric in-hospital CPR was associated with return of spontaneous circulation.