To assess the association of diastolic blood pressure cutoffs (≥ 25 mm Hg in infants and ≥ 30 mm Hg in children) during cardiopulmonary resuscitation with return of spontaneous circulation and ...survival in surgical cardiac versus medical cardiac patients. Secondarily, we assessed whether these diastolic blood pressure targets were feasible to achieve and associated with outcome in physiology unique to congenital heart disease (single ventricle infants, open chest), and influenced outcomes when extracorporeal cardiopulmonary resuscitation was deployed.
Multicenter, prospective, observational cohort analysis.
Tertiary PICU and cardiac ICUs within the Collaborative Pediatric Critical Care Research Network.
Patients with invasive arterial catheters during cardiopulmonary resuscitation and surgical cardiac or medical cardiac illness category.
None.
Hemodynamic waveforms during cardiopulmonary resuscitation were analyzed on 113 patients, 88 surgical cardiac and 25 medical cardiac. A similar percent of surgical cardiac (51/88; 58%) and medical cardiac (17/25; 68%) patients reached the diastolic blood pressure targets (p = 0.488). Achievement of diastolic blood pressure target was associated with improved survival to hospital discharge in surgical cardiac patients (p = 0.018), but not medical cardiac patients (p = 0.359). Fifty-three percent (16/30) of patients with single ventricles attained the target diastolic blood pressure. In patients with an open chest at the start of chest compressions, 11 of 20 (55%) attained the target diastolic blood pressure. In the 33 extracorporeal cardiopulmonary resuscitation patients, 16 patients (48%) met the diastolic blood pressure target with no difference between survivors and nonsurvivors (p = 0.296).
During resuscitation in an ICU, with invasive monitoring in place, diastolic blood pressure targets of greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in children can be achieved in patients with both surgical and medical heart disease. Achievement of diastolic blood pressure target was associated with improved survival to hospital discharge in surgical cardiac patients, but not medical cardiac patients. Diastolic blood pressure targets were feasible to achieve in 1) single ventricle patients, 2) open chest physiology, and 3) extracorporeal cardiopulmonary resuscitation patients.
Given the relative independence of ventilator settings from gas exchange and plasticity of blood gas values during extracorporeal cardiopulmonary resuscitation (ECPR), do mechanical ventilation ...parameters and blood gas values influence survival?
Observational cohort study of 7488 adult patients with ECPR from the Extracorporeal Life Support Organization (ELSO) Registry. We performed case-mix adjustment for severity of illness and patient type using generalized estimating equation logistic regression to determine factors associated with hospital survival accounting for clustering by center, standardizing variables by 1 standard deviation (SD) of their values. We examined non-linear relationships between ventilatory and blood gas values with hospital survival.
Hospital survival was decreased with higher PaO2 on ECMO (OR 0.69, per 1SD increase 95% CI 0.64, 0.74; p < 0.001) and with any relative changes in PaCO2 (pre-arrest to on-ECMO) in a non-linear fashion. Survival was worsened with any peak inspiratory pressure >20 cmH20 (OR 0.69, per 1SD 0.64, 0.75; p < 0.001) and above 40% fraction of inspired oxygen (OR 0.75, per 1SD 0.69, 0.82; p < 0.001), and with higher dynamic driving pressure (OR 0.72, per 1 SD increase 0.65, 0.79; <0.001). Ventilation settings and blood gas values varied widely across hospitals, but were not associated with annual hospital ECPR case volume.
Lower ventilatory pressures, avoidance of hyperoxia, and relatively unchanged CO2 (pre- to on-ECMO) were all associated with survival in patients after ECPR, yet varied across hospitals. Our findings represent potential targets for prospective trials for this rapidly growing therapy to test if these associations have causality.
During out-of-hospital cardiac arrest, it is unclear how long prehospital resuscitation efforts should be continued to maximize lives saved.
Between 2005 and 2012, we enrolled 282 183 adult patients ...with bystander-witnessed out-of-hospital cardiac arrest from the All-Japan Utstein Registry. Prehospital resuscitation duration was calculated as the time interval from call receipt to return of spontaneous circulation in cases achieving prehospital return of spontaneous circulation or from call receipt to hospital arrival in cases not achieving prehospital return of spontaneous circulation. In each of 4 groups stratified by initial cardiac arrest rhythm (shockable versus nonshockable) and bystander resuscitation (presence versus absence), we calculated minimum prehospital resuscitation duration, defined as the length of resuscitation efforts in minutes required to achieve ≥99% sensitivity for the primary end point, favorable 30-day neurological outcome after out-of-hospital cardiac arrest. Prehospital resuscitation duration to achieve prehospital return of spontaneous circulation ranged from 1 to 60 minutes. Longer prehospital resuscitation duration reduced the likelihood of favorable neurological outcome (adjusted odds ratio, 0.84; 95% confidence interval, 0.838-0.844). Although the frequency of favorable neurological outcome was significantly different among the 4 groups, ranging from 20.0% (shockable/bystander resuscitation group) to 0.9% (nonshockable/bystander resuscitation group; P<0.001), minimum prehospital resuscitation duration did not differ widely among the 4 groups (40 minutes in the shockable/bystander resuscitation group and the shockable/no bystander resuscitation group, 44 minutes in the nonshockable/bystander resuscitation group, and 45 minutes in the nonshockable/no bystander resuscitation group).
On the basis of time intervals from the shockable arrest groups, prehospital resuscitation efforts should be continued for at least 40 minutes in all adults with bystander-witnessed out-of-hospital cardiac arrest.
URL: http://www.umin.ac.jp/ctr/. Unique identifier: 000009918.
Objective
To evaluate physicians' reasoning, considerations and possible difficulties in end-of-life decision-making for patients in European intensive care units (ICUs).
Design
A prospective ...observational study.
Setting
Thirty-seven ICUs in 17 European countries.
Patients and participants
A total of 3,086 patients for whom an end-of-life decision was taken between January 1999 and June 2000. The dataset excludes patients who died after attempts at cardiopulmonary resuscitation and brain-dead patients.
Measurements and results
Physicians indicated which of a pre-determined set of reasons for, considerations in, and difficulties with end-of-life decision-making was germane in each case as it arose. Overall, 2,134 (69%) of the decisions were documented in the medical record, with inter-regional differences in documentation practice. Primary reasons given by physicians for the decision mostly concerned the patient's medical condition (79%), especially unresponsive to therapy (46%), while chronic disease (12%), quality of life (4%), age (2%) and patient or family request (2%) were infrequent. Good medical practice (66%) and best interests (29%) were the commonest primary considerations reported, while resource allocation issues such as cost effectiveness (1%) and need for an ICU bed (0%) were uncommon. Living wills were considered in only 1% of cases. Physicians in central Europe reported no significant difficulty in 81% of cases, while in northern and southern regions there was no difficulty in 92–93% of cases.
Conclusions
European ICU physicians do not experience difficulties with end-of-life decisions in most cases. Allocation of limited resources is a minor consideration and autonomous choices by patient or family remain unusual. Inter-regional differences were found.
Prognostication of refractory out-of-hospital cardiac arrest (OHCA) is essential for selecting the population that may benefit from extracorporeal cardiopulmonary resuscitation (ECPR).
We aimed to ...examine the prognostic value of signs of life before or throughout conventional CPR for individuals undergoing ECPR for refractory OHCA.
Pooling the original data from three cohort studies, we estimated the prevalence of signs of life, for individuals with refractory OHCA resuscitated with ECPR. We performed multivariable logistic regression to examine the independent associations between the occurrence of signs of life and 30-day survival with a CPC score ≤ 2.
The analytical sample consisted of 434 ECPR recipients. The prevalence of any sign of life was 61%, including pupillary light reaction (48%), gasping (32%), or increased level of consciousness (13%). Thirty-day survival with favorable neurological outcome was 15% (63/434). In multivariable analysis, the adjusted odds ratios of 30-day survival with favorable neurological outcome were 7.35 (95% confidence interval CI, 2.71–19.97), 5.86 (95% CI, 2.28–15.06), 4.79 (95% CI, 2.16–10.63), and 1.75 (95% CI, 0.95–3.21) for any sign of life, pupillary light reaction, increased level of consciousness, and gasping, respectively.
The assessment of signs of life before or throughout CPR substantially improves the accuracy of a multivariable prognostic model in predicting 30-day survival with favorable neurological outcome. The lack of any sign of life might obviate the provision of ECPR for patients without shockable cardiac rhythm.
Abstract Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a feasible and effective rescue strategy for prolonged cardiac arrest (CA). However, prolonged total body ischemia and ...reperfusion can cause microvascular occlusion that prevents organ reperfusion and recovery of function. One hypothesized mechanism of microvascular “no-reflow” is leukocyte adhesion and formation of neutrophil extracellular traps. In this study we tested the hypothesis that a leukocyte filter (LF) or leukocyte modulation device (L-MOD) could reduce NETosis and improve recovery of heart and brain function in a swine model of prolonged cardiac arrest treated with ECPR. Thirty-six swine (45.5 ± 2.5 kg, evenly distributed sex) underwent 8 min of untreated ventricular fibrillation CA followed by 30 min of mechanical CPR with subsequent 8 h of ECPR. Two females were later excluded from analysis due to CPR complications. Swine were randomized to standard care (Control group), LF, or L-MOD at the onset of CPR. NET formation was quantified by serum dsDNA and citrullinated histone as well as immunofluorescence staining of the heart and brain for citrullinated histone in the microvasculature. Primary outcomes included recovery of cardiac function based on cardiac resuscitability score (CRS) and recovery of neurologic function based on the somatosensory evoked potential (SSEP) N20 cortical response. In this model of prolonged CA treated with ECPR we observed significant increases in serum biomarkers of NETosis and immunohistochemical evidence of microvascular NET formation in the heart and brain that were not reduced by LF or L-MOD therapy. Correspondingly, there were no significant differences in CRS and SSEP recovery between Control, LF, and L-MOD groups 8 h after ECPR onset (CRS = 3.1 ± 2.7, 3.7 ± 2.6, and 2.6 ± 2.6 respectively; p = 0.606; and SSEP = 27.9 ± 13.0%, 36.7 ± 10.5%, and 31.2 ± 9.8% respectively, p = 0.194). In this model of prolonged CA treated with ECPR, the use of LF or L-MOD therapy during ECPR did not reduce microvascular NETosis or improve recovery of myocardial or brain function. The causal relationship between microvascular NETosis, no-reflow, and recovery of organ function after prolonged cardiac arrest treated with ECPR requires further investigation.
Abstract Aims This study aimed to evaluate the effects of esmolol treatment for patients with refractory ventricular fibrillation (RVF) in out-of-hospital cardiac arrest (OHCA). Methods This ...single-centre retrospective pre-post study evaluated patients who were treated between January 2012 and December 2015. Some patients had received esmolol (loading dose: 500 μg/kg, infusion: 0–100 μg/kg/min) for RVF (≥3 defibrillation attempts), after obtaining consent from the patient's guardian. Results Twenty-five patients did not receive esmolol (the control group), and 16 patients received esmolol. Sustained return of spontaneous circulation (ROSC) was significantly more common in the esmolol group, compared to the control group (56% vs. 16%, p = 0.007). Survival and good neurological outcomes at 30 days, 3months and at 6 months were > 2-fold better in the esmolol group, compared to the control group, although these increases were not statistically significant. Conclusions The findings of our study suggest that administration of esmolol may increase the rate of sustained ROSC and ICU survival among patients with RVF in OHCA. Further larger-scale, prospective studies are necessary to determine the effect of esmolol for RVF in OHCA.
Dispatcher-assisted cardiopulmonary resuscitation (CPR) instructions can increase bystander CPR and thereby increase the rate of survival from cardiac arrest. The risk of bystander CPR for patients ...not in arrest is uncertain and has implications for how assertive dispatch is in instructing CPR. We determined the frequency of dispatcher-assisted CPR for patients not in arrest and the frequency and severity of injury related to chest compressions.
The investigation was a prospective cohort study of adult patients not in cardiac arrest for whom dispatchers provided CPR instructions in King County, Washington, between June 1, 2004, and January 31, 2007. The study focused on those who received chest compressions. Information was collected through review of the audio and written dispatch report, written emergency medical services report, hospital record, and telephone survey. Of the 1700 patients for whom dispatcher CPR instructions were initiated, 55% (938 of 1700) were in arrest, 45% (762 of 1700) were not in arrest, and 18% (313 of 1700) were not in arrest and received bystander chest compressions. Of the 247 not in arrest who received chest compressions and had complete outcome ascertainment, 12% (29 of 247) experienced discomfort, and 2% (6 of 247) sustained injuries likely or possibly caused by bystander CPR. Only 2% (5 of 247) suffered a fracture, and no patients suffered visceral organ injury.
In this prospective study, the frequency of serious injury related to dispatcher-assisted bystander CPR among nonarrest patients was low. When coupled with the established benefits of bystander CPR among those with arrest, these results support an assertive program of dispatcher-assisted CPR.
IntroductionAn out-of-hospital cardiac arrest occurs at a rate of 67–170 cases per 100 000 inhabitants per year in Europe. The early recognition of the occurrence of a cardiac arrest, placing an ...emergency call, performing cardiopulmonary resuscitation (CPR) and performing defibrillation are the most important response measures. The objective of this systematic review and meta-analysis is to assess the effects of laypersons’ CPR training with respect to CPR initiation rates, cardiovascular mortality rates, survival rate and the use of an automated external defibrillator.Methods and analysisThe literature search will be performed in the following databases: MEDLINE, Web of Science, the Cochrane Central Register of Controlled Studies, CINAHL, HBI, TESEO and NTX. Intervention studies and quasi-experimental studies in which CPR training interventions were performed will be included. We will exclude studies in which the participants do not meet the inclusion criteria, without a control group and in which the methodology of the intervention applied is unclear. There will be no restrictions on publication date or language of publication. The risk of bias will be assessed using the Risk of Bias in Non-randomized Studies of Interventions tool for randomised controlled trials (RCT), non-RCT and quasi-experimental trials. Data analysis and synthesis will be performed using RevMan V.5.4.1 software. The findings will be reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance.Ethics and disseminationEthical approval is not required, as only secondary data will be used. The findings will be published in a journal and presented at conferences.PROSPERO registration numberCRD42022365288.
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