Abstract Aim of the study To evaluate the relationship between cause and outcome of in-hospital cardiac arrest. Methods Retrospective analysis of resuscitation data, causes of cardiac arrest and ...outcome with a follow-up to 6 months of a cardiac arrest registry in an emergency department of a tertiary care hospital, covering a 17.5-year period. Results Of 1041 patients, 653 were male (63%), the median age was 64 years (IQR 53–73), 51% suffered cardiac arrest in the emergency department. The first recorded rhythm showed PEA in 432 (41%), ventricular fibrillation in 404 (39%) and asystole in 205 (20%) patients. Cardiac arrest of cardiac origin occurred in 63% of all patients, with 35% of them due to acute myocardial infarction. Non-cardiac causes were mostly due to pulmonary causes (15% of all patients). Aortic dissection/rupture, exsanguination, intoxication and adverse drug reactions, metabolic, cerebral, sepsis and accidental hypothermia each ranged between 1 and 4% of the cohort. Of all patients, 376 (36%) were discharged in good neurologic condition. Overall, patients with cardiac causes had a significantly better outcome than those with non-cardiac causes (44% vs. 23%, p < 0.01). Patients with pulmonary causes survived in 24%. The other subgroups showed widely divergent survival results (3–65%). Patients who had suffered cardiac arrest in the emergency department had a better outcome then patients of the regular ward or radiology department. Conclusion In hospital cardiac arrest is caused mainly by cardiac and pulmonary causes, outcome depends on the cause, with a big variability.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Whether admission C-reactive protein (aCRP) concentrations are associated with neurological outcome after out-of-hospital cardiac arrest (OHCA) is controversial. Based on established kinetics of CRP, ...we hypothesized that aCRP may reflect the pre-arrest state of health and investigated associations with neurological outcome. Prospectively collected data from the Vienna Clinical Cardiac Arrest Registry of the Department of Emergency Medicine were analysed. Adults (≥ 18 years) who suffered a non-traumatic OHCA between January 2013 and December 2018, without return of spontaneous circulation or extracorporeal cardiopulmonary resuscitation therapy were eligible. The primary endpoint was a composite of unfavourable neurologic function or death (defined as Cerebral Performance Category 3-5) at 30 days. Associations of CRP levels drawn within 30 min of hospital admission were assessed using binary logistic regression. ACRP concentrations were overall low in our population (n = 832), but higher in the unfavourable outcome group median: 0.44 (quartiles 0.15-1.44) mg/dL vs. 0.26 (0.11-0.62) mg/dL, p < 0.001. The crude odds ratio for higher aCRP concentrations was 1.19 (95% CI 1.10-1.28, p < 0.001, per mg/dL) to have unfavourable neurological outcome. After multivariate adjustment for traditional prognostication markers the odds ratio of higher aCRP concentrations was 1.13 (95% CI 1.04-1.22, p = 0.002). Sensitivity of aCRP was low, but specificity for unfavourable neurological outcome was 90% for the cut-off at 1.5 mg/dL and 97.5% for 5 mg/dL CRP. In conclusion, high aCRP levels are associated with unfavourable neurological outcome at day 30 after OHCA.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Out-of-hospital cardiac arrest (OHCA) survival varies greatly between communities. The Utstein template was developed and promulgated to improve the comparability of OHCA outcome reports, but it has ...undergone limited empiric validation. We sought to assess how much of the variation in OHCA survival between emergency medical services (EMS) across the globe is explained by differences in the Utstein factors. We also assessed how accurately the Utstein factors predict OHCA survival.
We performed a retrospective analysis of patient-level prospectively collected data from 12 OHCA registries from 12 countries for the period 1 Jan 2006 through 31 Dec 2011. We used generalized linear mixed models to examine the variation in survival between EMS agencies (n=232).
Twelve registries contributed 86,759 cases. Patient arrest characteristics, EMS treatment and patient outcomes varied across registries. Overall survival to hospital discharge was 10% (range, 6% to 22%). Overall survival with Cerebral Performance Category of 1 or 2 (available for 8/12 registries) was 8% (range, 2% to 20%). The area-under-the-curve for the Utstein model was 0.85 (Wald CI: 0.85–0.85). The Utstein factors explained 51% of the EMS agency variation in OHCA survival.
The Utstein factors explained 51% of the variation in survival to hospital discharge among multiple large geographically separate EMS agencies. This suggests that quality improvement and public health efforts should continue to target modifiable Utstein factors to improve OHCA survival. Further study is required to identify the reasons for the variation that is incompletely understood.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Introduction The neutrophil lymphocyte ratio(NLR) is a marker of systemic inflammation. We hypothesized that admission NLR is related to mortality and that epinephrine application during ...resuscitation influences NLR in patients after successful resuscitation from out of hospital cardiac arrest (OHCA). Methods This retrospective cohort study is based on a registry including all OHCA patients who had a presumed cardiac cause of cardiac arrest and achieved sustained ROSC prior to admission between 2005 and 2014. Patients were categorized into three groups according to the calculated NLR at admission (NLR <6, ≥6, and ‘abnormal differential’ indicating no differential blood cell count on patients report due to exceedance of machine predefined parameter limits). The primary outcome measure was long-term mortality after OHCA. Cox proportional hazards models were used for multivariable analysis. Results Out of 2273 OHCA patients during the study period a total of 1188(52%) patients were eligible for analysis, of those 274(23%) were female and mean age was 64 (25–75 IQR:52-72). Compared to a NLR < 6 (n = 442), adjusted hazard ratio for long-term mortality was significantly higher in patients with a NLR ≥ 6 (n = 447; 1.52 (95%CI 1.03–2.24)) and in patients with abnormal differential (n = 299; 3.16 (95%CI 2.02-4.97)). Epinephrine application during resuscitation did not explain the effect of NLR on mortality. Conclusion In this large retrospective cohort study of altogether >1000 OHCA patients, hospital admission NLR < 6 compared to abnormal differential or NLR ≥ 6 was associated with mortality independently from epinephrine application.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
6.
Therapeutic Hypothermia After Cardiac Arrest Peacock, W. Frank; Sterz, Fritz R
JAMA : the journal of the American Medical Association,
02/2017, Volume:
317, Issue:
6
Journal Article
OBJECTIVE:Only a few patients survive cardiac arrest with favorable neurologic recovery. Our objective was to assess whether induced hypothermia improves neurologic recovery in survivors of primary ...cardiac arrest.
DATA SOURCE:Studies were identified by a computerized search of MEDLINE, EMBASE, CINAHL, PASCAL, the Cochrane Controlled Trial Register, and BIOSIS.
STUDY SELECTION:We included randomized and quasi-randomized, controlled trials of adults who were successfully resuscitated, where therapeutic hypothermia was applied within 6 hrs after arrival at the emergency department and where the neurologic outcome was compared. We excluded studies without a control group and studies with historical controls.
DATA EXTRACTION:All authors of the identified trials supplied individual patient data with a predefined set of variables.
DATA SYNTHESIS:We identified three randomized trials. The analyses were conducted according to the intention-to-treat principle. Summary odds ratios were calculated using a random effects model and translated into risk ratios. More patients in the hypothermia group were discharged with favorable neurologic recovery (risk ratio, 1.68; 95% confidence interval, 1.29–2.07). The 95% confidence interval of the number-needed-to-treat to allow one additional patient to leave the hospital with favorable neurologic recovery was 4–13. One study followed patients to 6 months or death. Being alive at 6 months with favorable functional neurologic recovery was more likely in the hypothermia group (risk ratio, 1.44; 95% confidence interval, 1.11–1.76).
CONCLUSIONS:Mild therapeutic hypothermia improves short-term neurologic recovery and survival in patients resuscitated from cardiac arrest of presumed cardiac origin. Its long-term effectiveness and feasibility at an organizational level need further research.
Current guidelines recommend targeted temperature management to improve neurological outcome after cardiac arrest. Evidence regarding an ideal sedative/analgesic regimen including skeletal muscle ...paralysis is limited.
Patients were randomized to either a continuous administration of rocuronium (continuous-NMB-group) or to a continuous administration of saline supplemented by rocuronium bolus administration if demanded (bolus-NMB-group).
The primary outcome was the number of shivering episodes. Secondary outcomes included survival and neurological status one year after cardiac arrest, time to awakening, length of stay as well as required cumulative dose of rocuronium, midazolam and fentanyl.
Sixty-three patients (32 continuous-NMB-group; 31 bolus-NMB-group) were enrolled. Differences in baseline characteristics were not significant. Shivering episodes were detected in 94% of the patients in the bolus-NMB-group compared to 25% of the patients receiving continuous rocuronium infusion (p<0.01). The continuous-NMB-group received significant lower doses of midazolam (4.3±0.8mg/kg vs. 5.1±0.9mg/kg, p<0.01) and fentanyl (62±14μg/kg vs. 71±7μg/kg, p<0.01), but higher cumulative doses of rocuronium (7.8±1.8mg/kg vs. 2.3±1.6mg/kg, p<0.01). Earlier awakening (2 IQR 2;3 vs. 4 IQR 2;7.5 days, p=0.04) and decreased length of stay at the ICU (6 IQR 3;5.9 vs. 10 IQR 5;15 days, p=0.03) were observed in the continuous-NMB-group. There were no significant differences in survival and quality of life 12 months after cardiac arrest.
Continuous neuromuscular blockade during the first day after resuscitation reduced shivering, midazolam and fentanyl requirement, time to awakening and discharge from intensive care unit. There were no differences in overall survival, cooling rate and time to target temperature.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Abstract Aim Cardiac arrest centers have been associated with improved outcome for patients after cardiac arrest. Aim of this study was to investigate the effect on outcome depending on admission to ...high-, medium- or low volume centers. Methods Analysis from a prospective, multicenter registry for out of hospital cardiac arrest patients treated by the emergency medical service of Vienna, Austria. The frequency of cardiac arrest patients admitted per center/year (low <50; medium 50–100; high >100) was correlated to favorable outcome (30-day survival with cerebral performance category of 1 or 2). Results Out of 2238 patients (years 2013–2015) with emergency medical service resuscitation, 861 (32% female, age 64 (51;73) years) were admitted to 7 different centers. Favorable outcome was achieved in 267 patients (31%). Survivors were younger (58 vs. 66 years; p < 0.001), showed shockable initial heart rhythm more frequently (72 vs. 35%; p < 0.001), had shorter CPR durations (22 vs. 29 min; p < 0.001) and were more likely to be treated in a high frequency center (OR 1.6; CI: 1.2–2.1; p = 0.001). In multivariate analysis, age below 65 years (OR 15; CI: 3.3–271.4; p = 0.001), shockable initial heart rhythm (OR 10.1; CI: 2.4–42.6; p = 0.002), immediate bystander or emergency medical service CPR (OR 11.2; CI: 1.4–93.3; p = 0.025) and admission to a center with a frequency of >100 OHCA patients/year (OR 5.2; CI: 1.2–21.7; p = 0.025) was associated with favorable outcome. Conclusions High frequency of post-cardiac arrest treatment in a specialized center seems to be an independent predictor for favorable outcome in an unselected population of patients after out of hospital cardiac arrest.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background The outcome of patients after out-of-hospital cardiac arrest (OHCA) is poor and gets worse after prolonged resuscitation. Recently introduced attempts like an early installed ...emergency extracorporeal life support (E-ECLS) in patients with persisting cardiac arrest at the emergency department (ED) are tried. The “Vienna Cardiac Arrest Registry” (VICAR) was introduced August 2013 to collect Utstein-style data. The aim of this observational study was to identify the incidence of patients which fulfil “load&go”-criteria for E-ECLS at the ED. Methods VICAR was retrospectively analyzed for following criteria: age <75 years; witnessed OHCA; basic life support; ventricular fibrillation/ventricular tachycardia; no return-of-spontaneous-circulation (ROSC) within 15 min of advanced-life-support, which were supposed as potential optimal criteria for “load&go” plus successful E-ECLS treatment at the ED. The observation period was from August 1, 2013 to July 31, 2014. Results Over 948 OHCA patients registered during the study period; data were exploitable for 864 patients. Of all patients, “load&go”-criteria were fulfilled by 55 (6%). However, 96 (11%) were transported with on-going CPR to the ED. Of these 96 patients, only 16 (17%) met the “load&go”-criteria. Similarly, among the 96 patients, 12 adults were treated with E-ECLS at the ED, with only 5 meeting the criteria. Among these 12 patients, favourable neurological outcome (CPC 1/2) was obtained in 1 patient without criteria. Conclusion Further promotion of these criteria within the ambulance crews is needed. May be these criteria could serve as a decision support for emergency physicians/paramedics, which patients to transport with on-going CPR to the ED for E-ECLS.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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