The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based ...on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
There are limited tools available following cardiac arrest to prognosticate neurologic outcomes. Prior retrospective and single center studies have demonstrated early EEG features are associated with ...neurologic outcome. This study aimed to evaluate the prognostic value of EEG for pediatric in-hospital cardiac arrest (IHCA) in a prospective, multicenter study.
This cohort study is a secondary analysis of the ICU-Resuscitation trial, a multicenter randomized interventional trial conducted at 18 pediatric and pediatric cardiac ICUs in the United States. Patients who achieved return of circulation (ROC) and had post-ROC EEG monitoring were eligible for inclusion. Patients < 90 days old and those with pre-arrest Pediatric Cerebral Performance Category (PCPC) scores > 3 were excluded. EEG features of interest included EEG Background Category, and presence of focal abnormalities, sleep spindles, variability, reactivity, periodic and rhythmic patterns, and seizures. The primary outcome was survival to hospital discharge with favorable neurologic outcome. Associations between EEG features and outcomes were assessed with multivariable logistic regression. Prediction models with and without EEG Background Category were developed and receiver operator characteristic curves compared.
Of the 1129 patients with an index cardiac arrest who achieved ROC in the parent study, 261 had EEG within 24 h of ROC, of which 151 were evaluable. The cohort included 57% males with a median age of 1.1 years (IQR 0.4, 6.8). EEG features including EEG Background Category, sleep spindles, variability, and reactivity were associated with survival with favorable outcome and survival, (all p < 0.001). The addition of EEG Background Category to clinical models including age category, illness category, PRISM score, duration of CPR, first documented rhythm, highest early post-arrest arterial lactate improved the prediction accuracy achieving an AUROC of 0.84 (CI 0.77–0.92), compared to AUROC of 0.76 (CI 0.67–0.85) (p = 0.005) without EEG Background Category.
This multicenter study demonstrates the value of EEG, in the first 24 h following ROC, for predicting survival with favorable outcome after a pediatric IHCA.
Abstract
Background
Out-of-hospital cardiac arrest (OHCA) is a leading cause of sudden cardiac death worldwide. Researchers have found significant pathophysiological differences between females and ...males and clinically significant sex differences related to medical services. However, conflicting results exist and there is no uniform agreement regarding sex differences in survival and prognosis after OHCA. Therefore, we investigated the relationship between the prognosis of OHCA and sex factors.
Methods
We comprehensively searched the PubMed, Embase, and Cochrane databases and obtained a total of 1042 articles, from which 33 studies were selected for inclusion. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a random-effects model.
Results
The meta-analysis included 1,268,664 patients. Compared with males, females were older (69.7 years vs. 65.4 years,
p
< 0.05) and more frequently suffered OHCA without witnesses (58.39% vs 62.70%,
p
< 0.05). Females were less likely to receive in-hospital interventions than males. There was no significant difference between females and males in the survival from OHCA to hospital admission (OR 0.99, 95% CI 0.89–1.1). However, females had lower chances for survival from hospital admission to discharge (OR 0.59, 95% CI 0.48–0.73), overall survival to hospital discharge (OR 0.73, 95% CI 0.62–0.86), and favorable neurological outcomes (OR 0.62, 95% CI 0.47–0.83) compared with males.
Conclusions
Our results indicate that the overall discharge survival rate of females is lower than that of males, and females face a poor prognosis of the nervous system. This is likely related to the pathophysiological characteristics of females, more conservative treatment measures compared with males, and different post-resuscitation care. However, these findings should be interpreted with caution due to the presence of several confounding factors.
After resuscitation from out-of-hospital cardiac arrest (OHCA) by Emergency Medical Services (EMS), the amount of time that should be dedicated to pre-transport stabilization is unclear. We examined ...whether the time spent on-scene after return of spontaneous circulation (ROSC) was associated with patient outcomes.
We examined consecutive adult EMS-treated OHCAs from the British Columbia Cardiac Arrest registry (January 1/2019-June 1/2021) that had on-scene ROSC (sustained to scene departure). The primary outcome was favourable neurological outcome (Cerebral Performance Category ≤ 2) at hospital discharge; secondary outcomes were re-arrest during transport and hospital-discharge survival. Using adjusted logistic regression models, we estimated the association between the post-resuscitation on-scene interval (divided into quartiles) and outcomes.
Of 1653 cases, 611 (37%) survived to hospital discharge, and 523 (32%) had favourable neurological outcomes. The median post-resuscitation on-scene interval was 18.8 minutes (IQR:13.0–25.5). Compared to the first post-resuscitation on-scene interval quartile, neither the second (adjusted odds ratio AOR 1.19; 95% CI 0.72–1.98), third (AOR 1.10; 95% CI 0.67–1.81), nor fourth (AOR 1.54; 95% CI 0.93–2.56) quartiles were associated with favourable neurological outcomes; however, the fourth quartile was associated with a greater odds of hospital-discharge survival (AOR 1.73; 95% CI 1.05–2.85), and both the third (AOR 0.40; 95% CI 0.22–0.72) and fourth (AOR 0.44;95% CI 0.24–0.81) quartiles were associated with a lower odds of intra-transport re-arrest.
Among resuscitated OHCAs, increased post-resuscitation on-scene time was not associated with improved neurological outcomes, but was associated with improved survival to hospital discharge and decreased intra-transport re-arrest.
Objective
Sex differences in patients presenting with out‐of‐hospital cardiac arrest (OHCA) and shockable rhythm might be associated with disparities in clinical outcomes.
Methods
We conducted a ...retrospective cohort study and compared characteristics and short‐term outcomes between male and female adult patients who presented with OHCA and shockable rhythm at two large metropolitan health services in Melbourne, Australia between the period of 2014–2018. Logistic regression was used to assess the effect of sex on clinical outcomes.
Results
Of 212 patients, 166 (78%) were males and 46 (22%) were females. Both males and females presented with similar rates of ST‐elevation myocardial infarction (44% vs 36%, P = 0.29), although males were more likely to have a history of coronary artery disease (32% vs 13%) and a final diagnosis of a cardiac cause for their OHCA (89% vs 72%), both P = 0.01. Rates of coronary angiography (81% vs 71%, P = 0.23) and percutaneous coronary intervention (51% vs 42%, P = 0.37) were comparable among males and females. No differences in rates of in‐hospital mortality (38% vs 37%, P = 0.90) and 30‐day major adverse cardiac and cerebrovascular events (composite of all‐cause mortality, myocardial infarction, coronary revascularization and nonfatal stroke) (39% vs 41%, P = 0.79) were observed between males and females, respectively. Female sex was not associated with worse in‐hospital mortality when adjusted for other variables (odds ratio 0.66, 95% confidence interval 0.28–1.60, P = 0.36).
Conclusion
Among patients presenting with OHCA and a shockable rhythm, baseline sex and sex differences were not associated with disparities in short‐term outcomes in contemporary systems of care.
A significant focus of post-resuscitation research over the last decade has included optimising oxygenation. This has primarily occurred due to an improved understanding of the possible harmful ...biological effects of high oxygenation, particularly the neurotoxicity of oxygen free radicals. Animal studies and some observational research in humans suggest harm with the occurrence of severe hyperoxaemia (PaO2 > 300 mmHg) in the post-resuscitation phase. This early data informed in a change in treatment recommendations, with the International Liaison Committee on Resuscitation (ILCOR) recommending the avoidance of hyperoxaemia. However, the optimal oxygenation level for maximal survival has not yet been determined. Recent Phase 3 randomised control trials (RCTs) provide further insight into when oxygen titration should occur. The EXACT RCT suggested that decreasing oxygen fraction post-resuscitation in the prehospital setting, with limited ability to titrate and measure oxygenation, is too soon. The BOX RCT, suggests delaying titration to a normal level in intensive care may be too late. While further RCTs are currently underway in ICU cohorts, titration of oxygen early after arrival at hospital should be considered.
BackgroundDespite concerted global efforts to enhance CPR and post-resuscitation care, out-of-hospital cardiac arrest (OHCA) remains a significant cause of mortality. Current guidelines promote the ...concept of Cardiac Arrest Centres (CACs), offering advanced post-resuscitation management with the aim of improving survival rates. However, it remains uncertain whether directly transporting OHCA patients from the scene to these centres would enhance their prognosis.ObjectiveThis study aimed to assess whether direct transport of intubated OHCA patients to a higher-level cardiac arrest centre in the Northwest of England yielded better outcomes compared to initial resuscitation in smaller local emergency departments followed by transfer.MethodConducted as a retrospective analysis, the audit examined OHCA patients presenting at a single cardiac arrest centre between October 2018 and April 2022. Only intubated patients were included. The study compared two groups based on the route of admission: direct admission to the cardiac arrest centre from the field by emergency medical service providers versus indirect admission via inter-hospital transfer to the centre. The primary outcomes assessed were inpatient survival and 30-day survival. Statistical analysis employed Student’s T-test and Chi-square test for clinical significance.ResultsThe audit included 214 patients, with 112 (52.34%) in the direct group and 102 (47.66%) in the indirect group. Baseline characteristics between the groups were similar, including age, gender, downtime, bystander CPR, haemodynamic status, initial presenting rhythm (VT/VF), post-ROSC ECG (STEMI), comorbidities, and procedural outcomes (table 1). However, the direct group exhibited significantly shorter average arrival times at the cardiac arrest centre (72 minutes vs. 190 minutes, p=0.017), along with improved in-hospital survival (52.68% vs. 41.18%, p=0.009) and 30-day survival rates (52.68% vs. 37.25%, p=0.002).ConclusionThe direct admission of intubated OHCA patients to a cardiac arrest center, as observed in this audit, was associated with improved outcomes attributed to expedited admission times. The study’s design limitations, including its non-randomized nature and single-centre approach, underscore the need for further research.Abstract 60 Table 1Summary of audit for intubated out-of-hospital cardiac arrest (OHCA), comparing admission to Cardiac Arrest Centre (CAC) directly versus indirectly Category Direct Indirect P value Overall Total (n) 214 Admission Route (n) 112 (52.34%) 102 (47.66%) Baseline characteristics Male (n) 81 (72.30%) 81 (79.41%) 0.226 162 (75.70%) Age (year) Average (year) 61 64 0.084 62.59 Min (year) 30 30 30 Max (year) 88 88 88 Smoker (n) 30 (26.79%) 17 (16.67%) 0.925 47 (21.96%) Diabetes Mellitus (n) 13 (13.55%) 16 (15.69%) 0.971 29 (13.55%) CKD (n) 2 (1.79%) 3 (2.94%) 0.779 5 (2.34%) HTN (n) 37 (33.03%) 27 (26.47%) 0.252 64 (29.91%) Known IHD (n) 11 (9.65%) 14 (13.73%) 0.393 25 (11.68%) Arrest characteristics Initial Rhythm VF/VT (n) 91 (81.25%) 85 (83.33%) 0.886 176 (82.24%) ECG Post Arrest STEMI (n) 91 (81.25%) 85 (83.33%) 0.886 176 (82.24%) Cardiogenic shock (n) 46 (41.07%) 47 (46.08%) 0.236 93 (43.46%) Bystander CPR (n) 93 (83.04%) 85 (83.33%) 0.870 178 (83.18%) Downtime (min) Average (min) 24 31 0.074 28 Min (min) 3 1 3 Max (min) 90 90 90 Time to Arrival to CAC Average (min) 72 190 0.017 129 Min (min) 17 15 15 Max (min) 408 693 693 Procedural outcomes Cath Performed (n) 103 (91.96%) 100 (98.04%) 0.650 203 (94.86%) Abnormal (n) 86 (83.5%) 79 (79%) 0.710 165 (81.3%) Successful PCI (%) 77.91% 81.01% 0.822 79.39% Survivals In-Hospital Survival (n) 59 (52.68%) 42 (41.18%) 0.009 101 (47.20%) 30-Day Survival (n) 59 (52.68%) 38 (37.25%) 0.002 97 (45.33%) Conflict of InterestNone
Early coronary angiography (CAG) has been reported in individual studies and systematic reviews to significantly improve outcomes of patients with return of spontaneous circulation (ROSC) after ...cardiac arrest (CA).
We undertook a systematic review and meta-analysis to evaluate the impact of early CAG on key clinical outcomes in comatose patients after ROSC following out-of-hospital CA of presumed cardiac origin. We searched the PubMED, EMBASE, CINAHL, ERIC and Cochrane Central Register of Controlled Trials databases from 1990 until April 2020. Eligible studies compared patients undergoing early CAG to patients with late or no CAG. When randomized controlled trials (RCTs) existed for a specific outcome, we used their results to estimate the effect of the intervention. In the absence of randomized data, we used observational data. We excluded studies at high risk of bias according to the Robins-I tool from the meta-analysis. The GRADE system was used to assess certainty of evidence at an outcome level.
Of 3738 citations screened, 3 randomized trials and 41 observational studies were eligible for inclusion. Evidence certainty across all outcomes for the RCTs was assessed as low. Randomized data showed no benefit from early as opposed to late CAG across all critical outcomes of survival and survival with favourable neurologic outcome for undifferentiated patients and for patient subgroups without ST-segment-elevation on post ROSC ECG and shockable initial rhythm.
These results do not support routine early CAG in undifferentiated comatose patients and patients without STE on post ROSC ECG after OHCA.
PROSPERO — CRD42020160152.
This study examined the association between admission to a cardiac arrest centre and survival to hospital discharge for adults following out-of-hospital cardiac arrest (OHCA).
We undertook a ...multicentre retrospective observational study of patients transferred to hospital after OHCA of presumed cardiac aetiology in three ambulance services in England. We used propensity score matching to compare rates of survival to hospital discharge in patients admitted to OHCA centres (defined as either 24/7 PPCI availability or >100 OHCA admissions per year) to rates of survival of patients admitted to non-centres.
Between January 2017 and December 2018, 10,650 patients with OHCA were included in the analysis. After propensity score matching, admission to a hospital with 24/7 PPCI availability or a high volume centre was associated with an absolute improvement in survival to hospital discharge of 2.5% and 2.8%, respectively. The corresponding odds ratios and 95% confidence intervals were 1.69 (1.28–2.23) and 1.41 (1.14–1.75), respectively. The results were similar when missing values were imputed. In subgroup analyses, the association between admission to an OHCA centre and improved rates of survival was mainly seen in patients with OHCA due to shockable rhythms, with no or minimal potential benefit for patients with OHCA and asystole as first presenting rhythm.
Following OHCA, admission to a cardiac arrest centre is associated with a moderate improvement in survival to hospital discharge. A corresponding bypass policy would need to consider the resulting increased workload for OHCA centres.
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