Journal: Resuscitation

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Abstract

Determinants of Change in Code Status among Patients with Cardiopulmonary Arrest Admitted to the Intensive Care Unit.

Ploch M, Ahmed T, Reyes S, Irizarry-Caro JA, ... Safavi Naeini P, Madjid M
Background
Patients with cardiopulmonary arrest often have a poor prognosis, prompting discussion with families about code status. The impact of socioeconomic factors, demographics, medical comorbidities and medical interventions on code status changes is not well understood.
Methods
This retrospective study included adult patients presenting with cardiac arrest to the intensive care unit of a hospital group between 5/1/2010 - 5/1/2020. We extracted chart data on socioeconomic factors, demographics, and medical comorbidities.
Results
We identified 1,254 patients, of which 57.5% were males. Age was different across the groups with (61.2±15.5 years) and without (61.2±15.5 years) code status change (p= <0.0001). Code status was changed in 583 patients (46.5%). Among patients with code status change, the highest prevalence was White patients (34.8%), followed by African Americans (30.9%), and Hispanics (25.4%). Compared to patients who did not have a code status change, those with a change in code status were older (66.7±14.8 years vs 61.2±15.5 years). They were also more likely to receive vasopressor/inotropic support (74.6% vs 58.5%), and broad-spectrum antibiotics (70.3% vs 57.7%). Insurance status, ethnicity, religion, education, and salary did not lead to statistically significant changes in code status.
Conclusions
In patients with cardiopulmonary arrest, code status change was more likely to be influenced by the presence of medical comorbidities and medical interventions during hospitalization rather than by socioeconomic factors.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 26 Sep 2022; epub ahead of print
Ploch M, Ahmed T, Reyes S, Irizarry-Caro JA, ... Safavi Naeini P, Madjid M
Resuscitation: 26 Sep 2022; epub ahead of print | PMID: 36174763
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Abstract

Maintaining normal temperature immediately after birth in late preterm and term infants: A systematic review and meta-analysis.

Ramaswamy VV, de Almeida MF, Dawson JA, Trevisanuto D, ... Liley HG, International Liaison Committee on Resuscitation Neonatal Life Support Task Force
Aim
Prevention of hypothermia after birth is a global problem in late preterm and term neonates. The aim of this systematic review and meta-analysis was to evaluate delivery room strategies to maintain normothermia and improve survival in late preterm and term neonates (≥ 34 weeks\' gestation).
Methods
Medline, Embase, CINAHL, CENTRAL and international clinical trial registries were searched. Randomized controlled trials (RCTs), quasi-RCTs and observational studies were eligible for inclusion. Risk of bias for each study and GRADE certainty of evidence for each outcome were assessed.
Results
25 RCTs and 10 non-RCTs were included. Room temperature of 23°C compared to 20°C improved normothermia [Risk Ratio (RR), 95% Confidence Interval (CI): 1.26, 1.11-1.42)] and body temperature [Mean Difference (MD), 95% CI: 0.30°C, 0.23-0.37°C), and decreased moderate hypothermia (RR, 95% CI: 0.26, 0.16-0.42). Skin to skin care (SSC) compared to no SSC increased body temperature (MD, 95% CI: 0.32, 0.10-0.52), reduced hypoglycemia (RR, 95% CI: 0.16, 0.05-0.53) and hospital admission (RR, 95% CI: 0.34, 0.14-0.83). Though plastic bag or wrap (PBW) alone or when combined with SSC compared to SSC alone improved temperatures, the risk-benefit balance is uncertain. Clinical benefit or harm could not be excluded for the primary outcome of survival for any of the interventions. Certainty of evidence was low to very low for all outcomes.
Conclusions
Room temperature of 23°C and SSC soon after birth may prevent hypothermia in late preterm and term neonates. Though PBW may be an effective adjunct intervention, the risk-benefit balance needs further investigation.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 26 Sep 2022; epub ahead of print
Ramaswamy VV, de Almeida MF, Dawson JA, Trevisanuto D, ... Liley HG, International Liaison Committee on Resuscitation Neonatal Life Support Task Force
Resuscitation: 26 Sep 2022; epub ahead of print | PMID: 36174764
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Abstract

End-tidal carbon dioxide (ETCO2) at intubation and its increase after 10 minutes resuscitation predicts survival with good neurological outcome in out-of-hospital cardiac arrest patients.

Baldi E, Luce Caputo M, Klersy C, Benvenuti C, ... Auricchio A, Savastano S
Aim
To evaluate whether end-tidal carbon dioxide (ETCO2) value at intubation and its early increase (10minutes) after intubation predict both the survival to hospital admission and the survival at hospital discharge, including good neurological outcome (CPC 1-2), in patients with out-of-hospital cardiac arrest (OHCA).
Methods
All consecutive OHCA patients of any etiology between 2015 and 2018 in Pavia Province (Italy) and Ticino Region (Switzerland) were considered. Patients died before ambulance arrival, with a \"do-not-resuscitate\" order, without ETCO2 value or with incomplete data were excluded.
Results
The study population consisted of 668 patients. An ETCO2 value at intubation > 20 mmHg and its increase 10 minutes after intubation were independent predictors (after correction for known predictors of OHCA outcome) of survival to hospital admission and survival at hospital discharge. Relative to hospital discharge with good neurological outcome, ETCO2 at intubation and its 10-minute change were confirmed predictors both individually and in a bivariable analysis (OR 1.83, 95%CI 1.02-3.3; p=0.04 and OR 3.9, 95%CI 1.97-7.74; p<0.001, respectively). This was confirmed also when accounting for gender, age, etiology and location. After further adjustment for bystander and CPR status, presenting rhythm and EMS arrival time, the ETCO2 change remained an independent predictor.
Conclusions
ETCO2 value > 20 mmHg at intubation and its increase during resuscitation improve the prediction of survival at hospital discharge with good neurological outcome of OHCA patients. ETCO2 increase during resuscitation is a more powerful predictor than ETCO2 at intubation. A larger prospective study to confirm this finding appears warranted.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 23 Sep 2022; epub ahead of print
Baldi E, Luce Caputo M, Klersy C, Benvenuti C, ... Auricchio A, Savastano S
Resuscitation: 23 Sep 2022; epub ahead of print | PMID: 36162612
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Abstract

Sex Differences in the Association Between Bystander CPR and Survival for Out-of-Hospital Cardiac Arrest.

Ok Ahn K, McNally B, Al-Araji R, Cisneros C, Chan PS
Background
Prior studies have identified socio-cultural barriers in laypersons performing high-quality cardiopulmonary resuscitation (CPR) in women. Whether the effect of layperson bystander CPR on survival from out-of-hospital cardiac arrest (OHCA) differs by patients\' sex is unknown.
Methods
Using data during 2013-2020 from an OHCA registry in the U.S., we identified adult patients with non-traumatic OHCA. The primary outcome was favorable neurological survival and the secondary outcome was survival to discharge. Multivariable logistic regression models evaluated the interaction between patients\' sex and bystander CPR with survival, adjusted for patient and cardiac arrest characteristics.
Results
Of 420,671 patients with OHCA, 151,145 (35.9%) occurred in women and 269,526 (64.1%) in men. Rates of layperson bystander CPR were similar between women (38.3%) and men (40.0%). Rates of favorable neurological survival were 11.4% in those with bystander CPR and 5.6% in those without, but the association between bystander CPR and favorable neurological survival was weaker for women than men (women: adjusted OR, 1.33 [95% CI: 1.27-1.39]; men: adjusted OR, 1.55 [95% CI: 1.51-1.61]; interaction p<0.001)]. Rates of survival to discharge were 13.1% and 7.3% in those with and without layperson bystander CPR, and the association between bystander CPR was weaker for women than men (women: adjusted OR, 1.21 [95% CI: 1.16-1.26]; men: adjusted OR, 1.43 [95% CI: 1.39-1.47]; interaction p<0.001).
Conclusions
For OHCA, bystander CPR was associated with higher survival in women and men. However, as currently practiced, the association between bystander CPR and higher survival was weaker for women as compared with men.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 23 Sep 2022; epub ahead of print
Ok Ahn K, McNally B, Al-Araji R, Cisneros C, Chan PS
Resuscitation: 23 Sep 2022; epub ahead of print | PMID: 36162613
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Abstract

ARE FIRST RESPONDERS FIRST? THE RALLY TO THE SUSPECTED OUT-OF-HOSPITAL CARDIAC ARREST.

Berglund E, Byrsell F, Forsberg S, Nord A, Jonsson M
Background
Time is the crucial factor in the \"chain of survival\" treatment concept for out-of-hospital cardiac arrest (OHCA). We aimed to measure different response time intervals by comparing emergency medical system (EMS), fire fighters and smartphone aided volunteer responders.
Methods
In two large Swedish regions, volunteer responders were timed from the alert until they arrived at the scene of the suspected OHCA. The first arriving volunteer responders who tried to fetch an automated external defibrillator (AED-responder) and who ran to perform bystander cardiopulmonary resuscitation (CPR-responder) were compared to both the first arriving EMS and fire fighters. Three-time intervals were measured, from call to dispatch, the unit response time (from dispatch to arrival) and the total response time.
Results
During 22 months, 2631 suspected OHCAs were included. The median time from call to dispatch was in minutes 1.8 (95% CI=1.7-1.8) for EMS, 2.9 (95% CI=2.8-3.0) for fire-fighters and 3.0 (95% CI=2.9-3.1) for volunteer responders. The median unit response time was 8.3 (95% CI=8.1-8.5) for EMS, 6.8 (95% CI=6.7-6.9) for fire fighters and 6.0 (95% CI=5.7-6.2) for AED-responders and 4.6 (95% CI=4.5-4.8) for CPR-responders. The total response time was 10.4 (95% CI=10.1-10.6) for EMS, 10.2 (95% CI=9.9-10.4) for fire fighters, 9.6 (95% CI=9.1-9.8) for AED-responders and 8.2 (95% CI= 8.0-8.3) for CPR-responders.
Conclusion
First arriving volunteer responders had the shortest unit response time when compared to both fire fighters and EMS, however this advantage was reduced by delays introduced at the dispatch center. Earlier automatic dispatch should be considered in further studies.

Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 23 Sep 2022; epub ahead of print
Berglund E, Byrsell F, Forsberg S, Nord A, Jonsson M
Resuscitation: 23 Sep 2022; epub ahead of print | PMID: 36162614
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Abstract

Race and Ethnicity Data in the Cardiac Arrest Registry to Enhance Survival: Insights from Medicare Self-Reported Data.

Chan PS, Merritt R, Chang A, Girotra S, ... Al-Araji R, McNally B
Background
For out-of-hospital cardiac arrest (OHCA), assignment of race/ethnicity data can be challenging. Validation of race/ethnicity in registry data with patients\' self-reported race/ethnicity would provide insights regarding misclassification.
Methods
Using recently linked 2013-2019 Cardiac Arrest Registry to Enhance Survival (CARES) data with Medicare files, we examined the concordance of race/ethnicity in CARES with self-reported race/ethnicity in Medicare.. Among patients with unknown race/ethnicity in CARES, race/ethnicity data from Medicare files were reported.
Results
Of 26,875 patients in the linked data, 5757 (21.4%) had unknown race/ethnicity in CARES. Of the remaining 21,118 patients, 14,284 (67.6%) were identified in CARES as non-Hispanic White, 4771 (22.6%) as non-Hispanic Black, 1213 (5.7%) as Hispanic, 760 (3.6%) as Asian or Pacific Islander, and 90 (0.4%) as American Indian or Alaskan Native. The concordance rate for race/ethnicity between CARES and Medicare was 93.4% for patients reported as non-Hispanic White in CARES, 89.1% for non-Hispanic Blacks, 74.6% for Hispanics, 69.6% for Asians and Pacific Islanders, and 37.8% for American Indian or Alaskan Natives. For the 5757 patients with unknown race/ethnicity in CARES, 3973 (69.0%) self-reported in Medicare as non-Hispanic White, 617 (10.7%) as non-Hispanic Black, 425 (7.4%) as Hispanic, 491 (8.5%) as Asian or Pacific Islander, and 52 (0.9%) as American Indian or Alaskan Native. Race/ethnicity remained unknown in 199 (3.5%) of patients.
Conclusion
Race/ethnicity in CARES was highly concordant with self-reported race/ethnicity in Medicare, especially for non-Hispanic White and Black individuals. For patients with unknown race/ethnicity data in CARES, the vast majority were of White race.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 22 Sep 2022; epub ahead of print
Chan PS, Merritt R, Chang A, Girotra S, ... Al-Araji R, McNally B
Resuscitation: 22 Sep 2022; epub ahead of print | PMID: 36156280
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Impact:
Abstract

Effect of life-sustaining treatment decision law on pediatric in-hospital cardiopulmonary resuscitation rate: A Korean population-based study.

Choi J, Choi AY, Park E, Son MH, Cho J
Aim
The 2018 life-sustaining treatment (LST) decision law is expected to improve end-of-life quality in Korea. This study evaluated the national effect of the LST decision law on the cardiopulmonary resuscitation (CPR) rate among pediatric patients who died during hospital admission.
Methods
This retrospective cohort study was based on the Korean National Health Insurance database. Pediatric admissions within 12 months before or after implementation of the LST decision law were compared, allowing a 1-month transition period (February 2018). The changes in mortality, CPR, and documentation of LST decision were evaluated.
Results
The CPR rate of patients who died in hospital decreased after establishment of the LST decision law (49.6 vs 43.4 %, P = 0.04), without change of in-hospital mortality between pre/post-LST decision law activation (0.83 vs 0.81 per 1000 admissions, P = 0.67). In addition, in-hospital CPR (0.73 vs 0.67 per 1000 admissions, P = 0.15) and survival to discharge after in-hospital CPR (43.6 vs 47.2 %, P = 0.27) were slightly improved, although there was no statistical significance. Patients with LST decision documentation were less frequently mechanically ventilated (69.8 % vs 80.4 %, P < 0.01) and used fewer inotropes (76.5 % vs 90.1 %, P < 0.01) and more frequent opioids (67.1 % vs 57.4 %, P = 0.04).
Conclusions
The legally guided process of LST decision can decrease the CPR rate of children who die in hospitals. This result highlights the possibility of improving end-of-life quality by reducing non-beneficial in-hospital CPR.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 19 Sep 2022; 180:38-44
Choi J, Choi AY, Park E, Son MH, Cho J
Resuscitation: 19 Sep 2022; 180:38-44 | PMID: 36176228
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Impact:
Abstract

Cost-effectiveness analysis of termination-of-resuscitation rules for patients with out-of-hospital cardiac arrest.

Shibahashi K, Konishi T, Ohbe H, Yasunaga H
Aim
To evaluate the cost-effectiveness of practices with and without termination-of-resuscitation (TOR) rules for out-of-hospital cardiac arrest (OHCA), using an analytic model based on a nationwide population-based registry in Japan.
Methods
A combined model using a decision tree and Markov model was developed to compare costs and treatment effectiveness of three scenarios: basic life support (BLS) TOR rules (BLS-rule scenario), advanced life support (ALS) TOR rules (ALS-rule scenario), and no TOR rules (No-rule scenario). A nationwide population-based OHCA registry from January 1 to December 31, 2019 and published data were used. Analyses were performed from healthcare payers\' perspectives. Life-time incremental cost-effectiveness ratio (ICER) was determined by the difference in cost between two scenarios, divided by the difference in quality adjusted life year (QALY).
Results
The OHCA registry included 126,271 patients (57.3% men; median age, 80 years). The BLS-rule scenario yielded lower cost and less QALY than the ALS-rule scenario and No-rule scenario. With reference to the BLS-rule scenario, the ICERs for the ALS-rule scenario and No-rule scenario were 81,000 and 98,762 USD per QALY, respectively. The BLS-rule scenario was cost-effective in 100% of simulations at the willingness-to-pay threshold in Japan (5 million JPY = 45,455 USD). The willingness-to-pay threshold higher than 80,000 and 204,000 USD were required for the ALS-rule scenario and No-rule scenarios, respectively, to be cost-effective.
Conclusion
No-rule scenario was not cost-effective compared with BLS-rule scenario within acceptable willingness-to-pay thresholds. Further research on health economics of TOR rules is warranted to support constructive discussion on implementing TOR rules.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 19 Sep 2022; 180:45-51
Shibahashi K, Konishi T, Ohbe H, Yasunaga H
Resuscitation: 19 Sep 2022; 180:45-51 | PMID: 36176229
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Abstract

Family Presence During Adult Resuscitation From Cardiac Arrest: A Systematic Review.

Considine J, Eastwood K, Webster H, Smyth M, ... Finn J, Bray J
Aim
****** OBJECTIVE: To conduct a systematic review of the published evidence related to family presence during adult resuscitation from cardiac arrest.
Methods
This review, registered with PROSPERO (CRD42021242384) and reported according to PRISMA guidelines, included studies of adult cardiac arrest with family presence during resuscitation that reported one or more patient, family or provider outcomes. Three databases (Medline, CINAHL and EMBASE) were searched from inception to 10/05/2022. Two investigators screened the studies, extracted data, and assessed risks of bias using the Mixed Method Appraisal Tool (MMAT). The synthesis approach was guided by Synthesis Without Meta-Analysis (SWiM) reporting guidelines and a narrative synthesis method.
Results
The search retrieved 9,459 citations of which 31 were included: 18 quantitative studies (including two RCTs), 12 qualitative studies, and one mixed methods study. The evidence was of very low or low certainty. There were four major findings. High-certainty evidence regarding the effect of family presence during resuscitation on patient outcomes is lacking. Family members had mixed outcomes in terms of depression, anxiety, post-traumatic stress disorder (PTSD) symptoms, and experience of witnessing resuscitation. Provider experience was variable and resuscitation setting, provider education, and provider experience were major influences on family presence during resuscitation. Finally, providers reported that a family support person and organisational guidelines were important for facilitating family presence during resuscitation.
Conclusion
The effect of family presence during resuscitation varies between individuals. There was variability in the effect of family presence during resuscitation on patient outcomes, family and provider outcomes and perceptions.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 07 Sep 2022; epub ahead of print
Considine J, Eastwood K, Webster H, Smyth M, ... Finn J, Bray J
Resuscitation: 07 Sep 2022; epub ahead of print | PMID: 36087636
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Impact:
Abstract

Quality of chest compressions during prehospital resuscitation phase from scene arrival to ambulance transport in out-of-hospital cardiac arrest.

Gyung Won Lee S, Jeong Hong K, Han Kim T, Choi S, ... Joo Park Y, Ho Park J
Aim
Prehospital cardiopulmonary resuscitation is performed from scene arrival to hospital arrival. The diverse prehospital resuscitation phases can affect the quality of chest compressions. This study aimed to evaluate the dynamic changes in chest compression quality during prehospital resuscitation.
Methods
Adult out-of-hospital cardiac arrest patients treated without prehospital return of spontaneous circulation were included in Seoul between July 2020 and September 2021. The chest compressions quality was assessed using a real-time chest compression feedback device. The prehospital phase was divided by key events during the prehospital resuscitation timeline (phase 1: first 2 min after initiation of chest compression, phase 2: from the end of phase 1 to 1 min prior to ambulance departure; phase 3: from 1 min before to 1 min after ambulance departure; phase 4: from the end of phase 3 to hospital arrival). The main outcome was no-flow fraction. The no-flow fraction between prehospital phases was compared using repeated-measure analysis of variance.
Results
In total, 788 patients were included. Mean no-flow fraction was the highest in phase 3 (phase 1: 11.3%±13.8, phase 2: 19.3%±12.3, phase 3: 33.0%±34.9, phase 4: 18.7%±23.7, p<0.001). The mean number of total no-flow events per minute was also the highest in Phase 3. The minute-by-minute analysis showed that the no-flow fraction rapidly increased before ambulance departure and decreased during ambulance transport.
Conclusion
Dynamic changes in chest compression quality were observed during prehospital resuscitation phase. The no-flow fraction was the highest from 1 min before to 1 min after ambulance departure.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 07 Sep 2022; epub ahead of print
Gyung Won Lee S, Jeong Hong K, Han Kim T, Choi S, ... Joo Park Y, Ho Park J
Resuscitation: 07 Sep 2022; epub ahead of print | PMID: 36087637
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Impact:
Abstract

Manual chest compression pause duration for ventilations during prehospital advanced life support - an observational study to explore optimal ventilation pause duration for mechanical chest compression devices.

van Schuppen H, Doeleman LC, Hollmann MW, Koster RW
Aim
Mechanical chest compression devices in the 30:2 mode generally provide a pause of three seconds to give two insufflations without evidence supporting this pause duration. We aimed to explore the optimal pause duration by measuring the time needed for two insufflations, during advanced life support with manual compressions.
Methods
Prospectively collected data in the AmsteRdam REsuscitation STudies (ARREST) registry were analysed, including thoracic impedance signal and waveform capnography from manual defibrillators of the Amsterdam ambulance service. Compression pauses were analysed for number of insufflations, time interval from start of the compression pause to the end of the second insufflation, chest compression pause duration and ventilation subintervals.
Results
During 132 out-of-hospital cardiac arrests, 1619 manual chest compression pauses to ventilate were identified. In 1364 (84%) pauses, two insufflations were given. In 28% of these pauses, giving two insufflations took more than three seconds. The second insufflation is completed within 3.8 seconds in 90% and within 5 seconds in 97.5% of these pauses. An increasing likelihood of achieving two insufflations is seen with increasing compression pause duration up to five seconds.
Conclusion
The optimal chest compression pause duration for mechanical chest compression devices in the 30:2 mode to provide two insufflations, appears to be five seconds, warranting further studies in the context of mechanical chest compression. A 5-second pause will allow providers to give two insufflations with a very high success rate. In addition, a 5-second pause can also be used for other interventions like rhythm checks and endotracheal intubation.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 06 Sep 2022; epub ahead of print
van Schuppen H, Doeleman LC, Hollmann MW, Koster RW
Resuscitation: 06 Sep 2022; epub ahead of print | PMID: 36084804
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Impact:
Abstract

Changes in Health Status and Health Related Quality of Life from Six Months to Five Years in Out-of-Hospital Cardiac Arrest Survivors - a NORCAST sub study.

Wimmer H, Šaltytė Benth J, Lundqvist C, Øystein Andersen G, ... Sunde K, Rostrup Nakstad E
Background
Brain injury in out-of-hospital cardiac arrest (OHCA) survivors affects health status and health-related quality of life (HRQoL). It is unknown how HRQoL evolves over time, and assessments at different time points may lead to different results.
Methods
In a NORCAST sub study, OHCA survivors eligible for health status (EQ-5D-3L) and HRQoL (SF-36) assessments were examinated six months and five years after OHCA. At five-year follow-up, survivors also retrospectively assessed their health status for each consecutive year following OHCA. The next of kin independently assessed health status and HRQoL of their respective OHCA survivors.
Results
Among 138 survivors alive after six months and 117 after five years, 80 (88% male) completed both follow-ups. Health status and HRQoL remained stable over time, except for increasing SF-36 mental summary score and decreasing physical functioning and physical component score. Anxiety and depression levels were generally low, although younger survivors stated more anxiety than older survivors. Retrospective assessment showed reduced health status for the first two years, which increased only from the third year. Explorative analyses revealed that younger age, longer time to return of spontaneous circulation (tROSC) and late awakening affected health status, particularly in the first two years post-arrest.
Conclusions
OHCA survivors showed stable health status and HRQoL with only minor differences between six months and five years. Younger survivors with long tROSC, late awakening, and more anxiety and depression symptoms at six months, had reduced health status the first two years with significant improvements towards the fourth year.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 06 Sep 2022; epub ahead of print
Wimmer H, Šaltytė Benth J, Lundqvist C, Øystein Andersen G, ... Sunde K, Rostrup Nakstad E
Resuscitation: 06 Sep 2022; epub ahead of print | PMID: 36084805
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Abstract

Factors predicting cardiac arrest in acute coronary syndrome patients under 50: a state-wide angiographic and forensic evaluation of outcomes.

Paratz ED, van Heusden A, Smith K, Brennan A, ... Stub D, EndUCD Investigators
Background
An uncertain proportion of patients with acute coronary syndrome (ACS) also experience out-of-hospital cardiac arrest (OHCA). Predictors of OHCA in ACS remain unclear and vulnerable to selection bias as pre-hospital deceased patients are usually not included.
Methods
Data on patients aged 18-50 years from a percutaneous coronary intervention (PCI) and OHCA registry were combined to identify all patients experiencing OHCA due to ACS (not including those managed medically or who proceeded to cardiac surgery). Clinical, angiographic and forensic details were collated. In-hospital and post-discharge outcomes were compared between OHCA survivors and non-OHCA ACS patients.
Results
OHCA occurred in 6.0% of ACS patients transported to hospital and 10.0% of all ACS patients. Clinical predictors were non-diabetic status (p=0.015), non-obesity (p=0.004), ST-elevation myocardial infarction (p<0.0001) and left main (p<0.0002) or left anterior descending (LAD) coronary artery (p<0.0001) as culprit vessel. OHCA patients had poorer in-hospital clinical outcomes, including longer length of stay and higher pre-procedural intubation, cardiogenic shock, major adverse cardiovascular events, bleeding, and mortality (p<0.0001 for all). At 30 days, OHCA survivors had equivalent cardiac function and return to premorbid independence but higher rates of anxiety/depression (p=0.029).
Conclusion
OHCA complicates approximately 10% of ACS in the young. Predictors of OHCA are being non-diabetic, non-obese, having a STEMI presentation, and left main or LAD coronary culprit lesion. For OHCA patients surviving to PCI, higher rates of in-hospital complications are observed. Despite this, recovery of pre-morbid physical and cardiac function is equivalent to non-OHCA patients, apart from higher rates of anxiety/depression.

Crown Copyright © 2022. Published by Elsevier B.V. All rights reserved.

Resuscitation: 25 Aug 2022; epub ahead of print
Paratz ED, van Heusden A, Smith K, Brennan A, ... Stub D, EndUCD Investigators
Resuscitation: 25 Aug 2022; epub ahead of print | PMID: 36031075
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Impact:
Abstract

Continuous Assessment of Ventricular Fibrillation Prognostic Status during CPR: Implications for Resuscitation.

Coult J, Kwok H, Eftestøl T, Bhandari S, ... Kudenchuk PJ, Rea TD
Background
Ventricular fibrillation (VF) waveform measures reflect myocardial physiologic status. Continuous assessment of VF prognosis using such measures could guide resuscitation, but has not been possible due to CPR artifact in the ECG. A recently-validated VF measure (termed VitalityScore), which estimates the probability (0-100%) of return-of-rhythm (ROR) after shock, can assess VF during CPR, suggesting potential for continuous application during resuscitation.
Objective
We evaluated VF using VitalityScore to characterize VF prognostic status continuously during resuscitation.
Methods
We characterized VF using VitalityScore during 60 seconds of CPR and 10 seconds of subsequent pre-shock CPR interruption in patients with out-of-hospital VF arrest. VitalityScore utility was quantified using area under the receiver operating characteristic curve (AUC). VitalityScore trends over time were estimated using mixed-effects models, and associations between trends and ROR were evaluated using logistic models. A sensitivity analysis characterized VF during protracted (100-second) periods of CPR.
Results
We evaluated 724 VF episodes among 434 patients. After an initial decline from 0-8 seconds following VF onset, VitalityScore increased slightly during CPR from 8-60 seconds (slope: 0.18 %/min). During the first 10 seconds of subsequent pre-shock CPR interruption, VitalityScore declined (slope: -14 %/min). VitalityScore predicted ROR throughout CPR with AUCs 0.73-0.75. Individual VitalityScore trends during 8-60 seconds of CPR were marginally associated with subsequent ROR (adjusted odds ratio for interquartile slope change (OR)=1.10, p=0.21), and became significant with protracted (≥100 seconds) CPR duration (OR=1.28, p=0.006).
Conclusion
VF prognostic status can be continuously evaluated during resuscitation, a development that could translate to patient-specific resuscitation strategies.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 25 Aug 2022; epub ahead of print
Coult J, Kwok H, Eftestøl T, Bhandari S, ... Kudenchuk PJ, Rea TD
Resuscitation: 25 Aug 2022; epub ahead of print | PMID: 36031076
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Impact:
Abstract

Socioeconomic status and outcomes after in-hospital cardiac arrest.

Stankovic N, Holmberg MJ, Granfeldt A, Andersen LW
Aim
To investigate the association between socioeconomic status and outcomes after in-hospital cardiac arrest in Denmark.
Methods
We conducted an observational cohort study based on nationwide registries and prospectively collected data on in-hospital cardiac arrest from 2017 and 2018 in Denmark. Unadjusted and adjusted analyses using regression models were performed to assess the association between socioeconomic status and outcomes after in-hospital cardiac arrest. Outcomes included return of spontaneous circulation (ROSC), survival to 30 days, survival to one year, and the duration of resuscitation among patients without ROSC.
Results
A total of 3,223 patients with in-hospital cardiac arrest were included in the study. In the adjusted analyses, high household assets were associated with 1.20 (95%CI: 0.96, 1.51) times the odds of ROSC, 1.49 (95%CI: 1.14, 1.96) times the odds of survival to 30 days, 1.40 (95%CI: 1.04, 1.90) times the odds of survival to one year, and 2.8 (95%CI: 0.9, 4.7) minutes longer duration of resuscitation among patients without ROSC compared to low household assets. Similar albeit attenuated associations were observed for education. While high household income was associated with better outcomes in the unadjusted analyses, these associations largely disappeared in the adjusted analyses.
Conclusions
In this study of patients with in-hospital cardiac arrest, we found that high household assets were associated with a higher odds of survival and a longer duration of resuscitation among patients without ROSC compared to low household assets. However, the effect size may potentially be small. The results varied based on socioeconomic status measure, outcome of interest, and across adjusted analyses.

Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 24 Aug 2022; epub ahead of print
Stankovic N, Holmberg MJ, Granfeldt A, Andersen LW
Resuscitation: 24 Aug 2022; epub ahead of print | PMID: 36029912
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Impact:
Abstract

The immunology of the post-cardiac arrest syndrome.

Cunningham CA, Coppler PJ, Skolnik AB
Patients successfully resuscitated from cardiac arrest often have brain injury, myocardial dysfunction, and systemic ischemia-reperfusion injury, collectively termed the post-cardiac arrest syndrome (PCAS). To improve outcomes, potential therapies must be able to be administered early in the post-arrest course and provide broad cytoprotection, as ischemia-reperfusion injury affects all organ systems. Our understanding of the immune system contributions to the PCAS has expanded, with animal models detailing biologically plausible mechanisms of secondary injury, the protective effects of available immunomodulatory drugs, and how immune dysregulation underlies infection susceptibility after arrest. In this narrative review, we discuss the dysregulated immune response in PCAS, human trials of targeted immunomodulation therapies, and future directions for immunomodulation following cardiac arrest.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 23 Aug 2022; epub ahead of print
Cunningham CA, Coppler PJ, Skolnik AB
Resuscitation: 23 Aug 2022; epub ahead of print | PMID: 36028143
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Impact:
Abstract

Firefighters as first-responders in out-of-hospital cardiac arrest- a retrospective study of a time-gain selective dispatch system in the Skåne Region, Sweden.

Andréll C, Dankiewicz J, Todorova L, Olanders K, Ullén S, Friberg H
Aim
To analyze the impact of a time-gain selective, first-responder dispatch system on the presence of a shockable initial rhythm (SIR), return of spontaneous circulation (ROSC) and 30-day survival after out-of-hospital cardiac arrest (OHCA).
Method
A retrospective observational study comprising OHCA registry data and dispatch data in the Skåne Region, Sweden (2010-2018). Data were categorized according to dispatch procedures, two ambulances (AMB-only) versus two ambulances and firefighter first-responders (DUAL-dispatch), based on the dispatcher\'s estimation of a time-gain. Dual dispatch was sub-categorized by arrival of first vehicle (first-responder or ambulance). Logistic regressions were used, additionally with groups matched (1:1) for age, witnessed event, bystander cardiopulmonary resuscitation and ambulance response time. Adjusted and conditional odds-ratios (aOR, cOR) with 95% confidence intervals (CI) are presented.
Results
Of 3,245 eligible cases, 43% were DUAL-dispatches with first-responders first on scene (FR-first) in 72%. Despite a five-minute median reduction in response time in the FR-first group, no association with SIR was found (aOR 0.83, 95%CI 0.64-1.07) nor improved 30-day survival (aOR 1.03, 95%CI 0.72-1.47). A positive association between ROSC and the FR-first group (aOR 1.25, 95%CI 1.02-1.54) disappeared in the matched analysis (cOR 1.12, 95%CI 0.87-1.43). Time to first monitored rhythm was 7:06 minutes in the FR-first group versus 3:01 in the combined AMB-only/AMB-first groups.
Conclusion
In this time-gain selective first-responder dispatch system, a shorter response time was not associated with increased SIR, improved ROSC rate or survival. Process measures differed between the study groups which could account for the observed findings and requires further investigation.

Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 23 Aug 2022; epub ahead of print
Andréll C, Dankiewicz J, Todorova L, Olanders K, Ullén S, Friberg H
Resuscitation: 23 Aug 2022; epub ahead of print | PMID: 36028144
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Impact:
Abstract

External validation of the simple NULL-PLEASE clinical score in predicting outcomes of out-of-hospital cardiac arrest in the Danish population - a nationwide registry-based study.

Byrne C, Barcella CA, Lukacs Krogager M, Pareek M, ... Kragholm K, Lip GYH
Aim
The NULL-PLEASE score (Nonshockable rhythm, Unwitnessed arrest, Long no-flow or Long low-flow period, blood pH <7.2, Lactate >7.0 mmol/L, End-stage renal disease on dialysis, Age ≥85 years, Still resuscitation, and Extracardiac cause) may identify patients with out-of-hospital cardiac arrest (OHCA) unlikely to survive. We aimed to validate the NULL-PLEASE score in a nationwide setting.
Methods
We used Danish nationwide registry data from 2001-2019 and identified OHCA survivors with return of spontaneous circulation (ROSC) or ongoing cardiopulmonary resuscitation at hospital arrival. The primary outcome was 1-day mortality. Secondary outcomes were 30-day mortality and the combined outcome of 1-year mortality or anoxic brain damage. The risks of outcomes were estimated using logistic regression with a NULL-PLEASE score of 0 as reference (range 0-14). The predictive ability of the score was examined using the area under the receiver operating characteristics (AUCROC) curve.
Results
A total of 3,881 patients were included in the analyses. One-day mortality was 35%, 30-day mortality was 61%, and 68% experienced the combined outcome. For a NULL-PLEASE score ≥9 (n=244) the absolute risks were: 1-day mortality: 80.7% (95% confidence interval [CI]: 75.8-85.7%); 30-day mortality: 98.0% (95% CI: 96.2-99.7%); and the combined outcome: 98.4% (95% CI: 96.8-100.0%). Corresponding AUCROC values were 0.800 (95% CI: 0.786-0.814) for 1-day mortality, 0.827 (95% CI: 0.814-0.840) for 30-day mortality, and 0.828 (95% CI: 0.815-0.841) for the combined outcome.
Conclusions
In a nationwide OHCA-cohort, AUCROC values for the predictive ability of NULL-PLEASE were high for all outcomes. However, some survived even with high NULL-PLEASE scores.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 22 Aug 2022; epub ahead of print
Byrne C, Barcella CA, Lukacs Krogager M, Pareek M, ... Kragholm K, Lip GYH
Resuscitation: 22 Aug 2022; epub ahead of print | PMID: 36007857
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Impact:
Abstract

Duration of Resuscitation and Long-Term Outcome After In-Hospital Cardiac Arrest: A Nationwide Observational Study.

Yonis H, Porsborg Andersen M, Helen Anna Mills E, Gregers Winkel B, ... Torp-Pedersen C, Hay Kragholm K
Background
Prior studies have investigated the association between duration of resuscitation and short-term outcomes following in-hospital cardiac arrest (IHCA). However, it remains unknown whether there is an association between duration of resuscitation and long-term survival and functional outcomes.
Method
We linked data from the Danish in-hospital cardiac arrest registry with nationwide registries and identified 8,727 patients between 2013 and 2019. Patients were stratified into four groups (A-D) according to quartiles of duration of resuscitation. Standardized average probability of outcomes was estimated using logistic regression.
Results
Of 8,727 patients, 53.1% (n=4,604) achieved return of spontaneous circulation. Median age was 74 (1st-3rd quartile [Q1-Q3] 65-81 years) and 63.1% were men. Among all IHCA patients the standardized 30-day survival was 62.0% (95% CI 59.8%-64.2%) for group A (< 5 minutes), 32.7% (30.8%-34.6%) for group B (5-11 minutes), 14.4% (12.9%-15.9%) for group C (12-20 minutes) and 8.1% (7.0%-9.1%) for group D (21 minutes or more). Similarly, 1-year survival was also highest for group A (50.4%; 48.2%-52.6%) gradually decreasing to 6.6% (5.6%-7.6%) in group D. Among 30-day survivors, survival without anoxic brain damage or nursing home admission within one-year post-arrest was highest for group A (80.4%; 78.2%-82.6%), decreasing to 73.3% (70.0%-76.6%) in group B, 67.2% (61.7%-72.6%) in group C and 73.3% (66.9%-79.7%) in group D.
Conclusion
Shorter duration of resuscitation attempt during an IHCA is associated with higher 30-day and 1-year survival. Furthermore, we found that the majority of 30-day survivors were still alive 1-year post-arrest without anoxic brain damage or nursing home admission despite prolonged resuscitation.

Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 22 Aug 2022; epub ahead of print
Yonis H, Porsborg Andersen M, Helen Anna Mills E, Gregers Winkel B, ... Torp-Pedersen C, Hay Kragholm K
Resuscitation: 22 Aug 2022; epub ahead of print | PMID: 36007858
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Impact:
Abstract

Prehospital care for traumatic cardiac arrest in the US: A cross-sectional analysis and call for a national guideline.

Ordoobadi AJ, Peters GA, MacAllister S, Anderson GA, Panchal AR, Cash RE
Aim
We describe emergency medical services (EMS) protocols and prehospital practice patterns related to traumatic cardiac arrest (TCA) management in the U.S.
Methods
We examined EMS management of TCA by 1) assessing variability in recommended treatments in state EMS protocols for TCA and 2) analyzing EMS care using a nationwide sample of EMS activations. We included EMS activations involving TCA in adult (≥18 years) patients where resuscitation was attempted by EMS. Descriptive statistics for recommended and actual treatments were calculated and compared between blunt and penetrating trauma using χ2 and independent 2-group Mann-Whitney U tests.
Results
There were 35 state EMS protocols publicly available for review, of which 16 (45.7%) had a specific TCA protocol and 17 (48.5%) had a specific termination of resuscitation protocol for TCA. Recommended treatments varied. We then analyzed 9,565 EMS activations involving TCA (79.1% blunt, 20.9% penetrating). Most activations (93%) were managed by advanced life support. Return of spontaneous circulation was achieved in 25.5% of activations, and resuscitation was terminated by EMS in 26.4% of activations. Median prehospital scene time was 16.4 minutes; scene time was shorter for penetrating mechanisms than blunt (12.0 vs. 17.0 min, p<0.001). Endotracheal intubation was performed in 32.0% of activations, vascular access obtained in 66.6%, crystalloid fluids administered in 28.8%, and adrenaline administered in 60.1%.
Conclusion
Actual and recommended approaches to EMS treatment of TCA vary nationally. These variations in protocols and treatments highlight the need for a standardized approach to prehospital management of TCA in the U.S.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 12 Aug 2022; epub ahead of print
Ordoobadi AJ, Peters GA, MacAllister S, Anderson GA, Panchal AR, Cash RE
Resuscitation: 12 Aug 2022; epub ahead of print | PMID: 35970396
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Impact:
Abstract

Use of torsades de pointes risk drugs among patients with out-of-hospital cardiac arrest and likelihood of shockable rhythm and return of spontaneous circulation: a nationwide study.

Krøll J, H B Jespersen C, Lund Kristensen S, Fosbøl EL, ... Tfelt-Hansen J, Weeke PE
Aim
Treatment with certain drugs can augment the risk of developing malignant arrhythmias (e.g. torsades de pointes [TdP]). Hence, we examined the overall TdP risk drug use before out-of-hospital cardiac arrest (OHCA) and possible association with shockable rhythm and return of spontaneous circulation (ROSC).
Methods
Patients ≥18 years with an OHCA of cardiac origin from the Danish Cardiac Arrest Registry (2001-2014) and TdP risk drug use according to www.CredibleMeds.org were identified. Factors associated with TdP risk drug use and secondly how use may affect shockable rhythm and ROSC were determined by multivariable logistic regression.
Results
We identified 27481 patients with an OHCA of cardiac origin (median age: 72 years [interquartile range 62.0, 80.0 years]). A total of 37% were in treatment with TdP risk drugs 0-30 days before OHCA compared with 33% 61-90 days before OHCA (p<0.001). Most commonly used TdP risk drugs were citalopram (36.1%) and roxithromycin (10.7%). Patients in TdP risk drug treatment were older (75 vs. 70 years) and more comorbid compared with those not in treatment. Subsequently, TdP risk drug use was associated with less likelihood of the presenting rhythm being shockable (odds ratio [OR]=0.63, 95%confidence interval [CI]:0.58-0.69) and ROSC (OR=0.73, 95%CI:0.66-0.80).
Conclusion
TdP risk drug use increased in the time leading up to OHCA and was associated with reduced likelihood of presenting with a shockable rhythm and ROSC in an all-comer OHCA setting. However, patients in TdP risk drug treatment were older and more comorbid than patients not in treatment.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 11 Aug 2022; epub ahead of print
Krøll J, H B Jespersen C, Lund Kristensen S, Fosbøl EL, ... Tfelt-Hansen J, Weeke PE
Resuscitation: 11 Aug 2022; epub ahead of print | PMID: 35964772
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Impact:
Abstract

Feasibility of Handheld Ultrasound to Assess Heart Rate in Newborn Nursery.

Manzar S, Bhat R
Background:
and objectives
Heart rate (HR) assessment is important during neonatal resuscitation. The most reliable ways of assessing HR at birth are pulse oximetry (PO) and/or electrocardiograph (ECG). However, delayed recording time due to poor perfusion or probe and electrode placement has been a concern. Point-of-care ultrasound (POCUS) provides a real-time instant view of the heart. The aim of this study was to look at the feasibility of POCUS in assessing the heart rate of stable, healthy, term neonates.
Methods
The study was approved by the institutional review board, and informed consent was obtained from the subject\'s mother. A real-time video image was obtained from the POCUS probe using the app on the smartphone. The principal investigator (PI) counted the heart beats for six seconds using a stopwatch, which was then multiplied by 10 to give the HR per minute. The assistant recorded the simultaneous HR using the PO. The HRs obtained from both methods were recorded and then compared using the Pearson correlation and Bland-Altman plot.
Results
A total of 30 HR observations were made using the POCUS and PO simultaneously. The correlation coefficient (r) was noted to be 0.75 with a p-value of < 0.0001 for pairwise correlation. A strong agreement was noted between the two methods using Bland-Altman Plot.
Conclusion
We were able to demonstrate the feasibility of using handheld POCUS in assessing the HR of stable NB infants in the newborn nursery. A follow-up study is planned to evaluate its feasibility in the delivery room.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 06 Aug 2022; epub ahead of print
Manzar S, Bhat R
Resuscitation: 06 Aug 2022; epub ahead of print | PMID: 35944817
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Impact:
Abstract

Patient Characteristics and Survival Outcomes of Cardiac Arrest in the Cardiac Catheterization Laboratory: Insights from Get with The Guidelines®-Resuscitation Registry.

Elkaryoni A, Tran AT, Saad M, Darki A, ... Chan PS, American Heart Association\'s Get With the Guidelines®-Resuscitation Investigators
Background
Characteristics and outcomes of patients with in-hospital cardiac arrest (IHCA) in the cardiac catheterization laboratory (CCL) have not been well-described. Thus, we compared the outcomes of patients with an IHCA in the CCL versus those in the intensive care unit (ICU) and operating rooms (OR).
Methods
Within the American Heart Association\'s Get With the Guidelines®-Resuscitation registry, we identified patients ≥18 years old with IHCA in the CCL, ICU, or OR between 2000-2019. Using hierarchical multivariable logistic regression, we compared rates of survival to discharge for patients with IHCA in the CCL versus ICU and OR.
Results
Across 428 hospitals, 193,950 patients had IHCA, of whom 6865, 181,905 and 5180 were in the CCL, ICU and OR, respectively. Overall, 2614 (38.1%) patients with IHCA in the CCL survived to discharge, whereas 30,830 (16.9%) and 2096 (40.5%) survived to discharge from the ICU and OR, respectively. After adjustment, patients with IHCA in CCL were more likely to survive to discharge as compared to those with IHCA in the ICU (odds ratio, 1.37 [95%CI: 1.29-1.46], p<0.001). In contrast, those who had IHCA in the CCL were less likely to survive to discharge as compared to patients with IHCA in the OR (odds ratio, 0.81 [95%CI: 0.69-0.94], p=0.006).
Conclusion
IHCA in the CCL is not uncommon and has a lower survival rate when compared with IHCA in the OR. The reasons for this difference deserve further study given that cardiac arrest in both settings is witnessed and response time should be similar.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 06 Aug 2022; epub ahead of print
Elkaryoni A, Tran AT, Saad M, Darki A, ... Chan PS, American Heart Association's Get With the Guidelines®-Resuscitation Investigators
Resuscitation: 06 Aug 2022; epub ahead of print | PMID: 35944818
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Impact:
Abstract

Trends in EMS-attended Out-of-Hospital Cardiac Arrest Survival, United States 2015-2019.

Odom E, Nakajima Y, Vellano K, Al-Araji R, ... Merritt R, McNally B
Aim
Everyday, nearly 1000 U.S. adults experience out-of-hospital cardiac arrest (OHCA). Survival to hospital discharge varies across many factors, including sociodemographics, location of arrest, and whether bystander intervention was provided. The current study examines recent trends in OHCA survival by location of arrest using a cohort of emergency medical service (EMS) agencies that contributed data to the Cardiac Arrest Registry to Enhance Survival.
Methods
The 2015 CARES cohort (N=122,613) includes EMS agencies contributing data across five consecutive years, 2015-2019. We assessed trends in EMS-attended OHCA survival for the 2015 CARES cohort by location of arrest - public, residential, nursing home. Unadjusted and adjusted percentages were estimated using 3-level hierarchical logistic regression models among cases aged 18-65 years.
Results
Overall, survival from EMS-attended OHCA significantly increased from 12.5% in 2015 to 13.8% in 2019 (p=0.001). Survival from bystander witnessed arrests also increased significantly from 17.8% in 2015 to 19.7% in 2019 (p=0.004). The trend for survival increased overall and for bystander witnessed OHCAs occurring in public places and nursing homes.
Conclusion
Increasing trends for EMS-attended OHCA survival were observed in the overall and bystander witnessed groups. No change in the trend for survival was observed among OHCAs in the groups most likely to have a desirable outcome - bystander witnessed, with a shockable rhythm, and receiving bystander intervention. Reporting and monitoring of OHCA may be an important first step in improving outcomes. Additional community interventions focused on bystander CPR and AED use may be warranted.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 06 Aug 2022; epub ahead of print
Odom E, Nakajima Y, Vellano K, Al-Araji R, ... Merritt R, McNally B
Resuscitation: 06 Aug 2022; epub ahead of print | PMID: 35944819
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Impact:
Abstract

Assessment of Intensive Care Unit-Free and Ventilator-Free Days as Alternative Outcomes in the Pragmatic Airway Resuscitation Trial.

Wang H, Panchal A, Madison Hyer J, Nichol G, ... Idris A, Wei L
Objective
We sought to evaluate the utility and validity of ICU-free days and ventilator-free days as candidate outcomes for OHCA trials.
Methods
We conducted a secondary analysis of the Pragmatic Airway Resuscitation Trial. We determined ICU-free (days alive and out of ICU during the first 30 days) and ventilator-free days (days alive and without mechanical ventilation). We determined ICU-free and ventilator-free day distributions and correlations with Modified Rankin Scale (MRS). We tested associations with trial interventions (laryngeal tube (LT), endotracheal intubation (ETI)) using continuous (t-test), non-parametric (Wilcoxon Rank-Sum test - WRS), count (negative binomial - NB) and survival models (Cox proportional hazards (CPH) and competing risks regression (CRR)). We conducted bootstrapped simulations to estimate statistical power.
Main results
ICU-free days was skewed; median 0 days (IQR 0, 0), survivors only 24 (18, 27). Ventilator-free days was skewed; median 0 (IQR 0, 0) days, survivors only 27 (IQR 23, 28). ICU-free and ventilator-free days correlated with MRS (Spearman\'s ρ= -0.95 and -0.97). LT was associated with higher ICU-free days using t-test (p=0.001), WRS (p=0.003), CPH (p=0.02) and CRR (p=0.04), but not NB (p=0.13). LT was associated with higher ventilator-free days using t-test (p=0.001), WRS (p=0.001) and CRR (p=0.03), but not NB (p=0.13) or CPH (p=0.13). Simulations suggested that t-test and WRS would have had the greatest power to detect the observed ICU- and ventilator-free days differences.
Conclusion
ICU-free and ventilator-free days correlated with MRS and differentiated trial interventions. ICU-free and ventilator-free days may have utility in the design of OHCA trials.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 05 Aug 2022; epub ahead of print
Wang H, Panchal A, Madison Hyer J, Nichol G, ... Idris A, Wei L
Resuscitation: 05 Aug 2022; epub ahead of print | PMID: 35940492
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Impact:
Abstract

Early Withdrawal of Life Sustaining Therapy in Extracorporeal Cardiopulmonary Resuscitation (ECPR): Results from the Extracorporeal Life Support Organization Registry.

Carlson JM, Etchill E, Whitman G, Soo Kim B, ... Geocadin R, Cho SM
Aims
Although extracorporeal cardiopulmonary resuscitation (ECPR) improves survival outcomes in refractory cardiac arrest, morbidity and mortality remain significantly high. Information on causes of death in ECPR is limited; however, some evidence suggests withdrawal of life sustaining therapy (WLST) is a major factor in ECPR-associated mortality. We sought to describe the patients experiencing WLST after ECPR.
Methods
The international Extracorporeal Life Support Organization (ELSO) Registry was retrospectively queried for patients more than 18 years old supported with ECPR who underwent WLST due to family request from 2007-2017. These patients were split into groups for descriptive and multivariable analysis: early (WLST <72 hours from cannulation) and routine WLST.
Results
Overall, 411 ECPR patients experienced WLST (median age 42 years IQR=28-51; 31.7% female) over the 10-year period. 55.5% (n=228) underwent early WLST with a median ECPR duration of 24 hours (IQR=7-48) versus routine WLST (median=147 hours; IQR=105-238). In multivariable regression analysis, lower arterial blood gas pH (aOR=-3.1; 95% CI=2.18-2.8; p=0.04), arterial oxygen saturation (aOR=1.12; 95% CI=1.01-1.23; p=0.02), and higher peak inspiratory pressure (aOR=0.84; 95% CI=0.71-1.00; p=0.05) were independently associated with early WLST. Early WLST patients experienced higher rates of all ECMO-related complications except for infections.
Conclusions
More than half of ECPR patients experienced early WLST within 72 hours. The patients with early WLST had worse markers of severe critical illness at 24 hours and experienced higher rates of complications. Further research should include an appropriate control group to better adjust confounders for ECPR-associated death and focus on prognostication.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 04 Aug 2022; epub ahead of print
Carlson JM, Etchill E, Whitman G, Soo Kim B, ... Geocadin R, Cho SM
Resuscitation: 04 Aug 2022; epub ahead of print | PMID: 35934132
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Impact:
Abstract

Post-Cardiac Arrest PCI is Underutilized Among Cancer Patients: Machine Learning Augmented Nationally Representative Case-Control Study of 30 Million Hospitalizations.

Wan Kim J, Monlezun D, Kun Park J, Chauhan S, ... Marmagkiolis K, Iliescu C
Background
Cancer patients are less likely to undergo percutaneous coronary intervention (PCI) after cardiac arrest, although they demonstrate improved mortality benefit from the procedure. We produced the largest nationally representative analysis of mortality of cardiac arrest and PCI for patients with cancer versus non-cancer.
Methods
Propensity score adjusted multivariable regression for mortality was performed in this case-control study of the United States\' largest all-payer hospitalized dataset, the 2016 National Inpatient Sample. Regression models of mortality and PCI weighted by the complex survey design were fully adjusted for age, race, income, cancer metastases, NIS-calculated mortality risk by Diagnosis Related Group (DRG), acute coronary syndrome, and likelihood of undergoing PCI
Results:
Of the 30,195,722 hospitalized adult patients, 15.43% had cancer, and 0.79% of the whole sample presented with cardiac arrest (of whom 20.57% underwent PCI). In fully adjusted regression analysis among patients with cardiac arrest, PCI significantly reduced mortality (OR 0.15, 95%CI 0.13-0.19; p<0.001) among patients with cancer greater than those without it (OR 0.21, 95%CI 0.20-0.23; p<0.001).
Conclusions
This nationally representative study suggests that post-cardiac arrest PCI is underutilized among patients with cancer despite its significant mortality reduction for such patients (independent of clinical acuity).

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 03 Aug 2022; epub ahead of print
Wan Kim J, Monlezun D, Kun Park J, Chauhan S, ... Marmagkiolis K, Iliescu C
Resuscitation: 03 Aug 2022; epub ahead of print | PMID: 35933056
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Impact:
Abstract

Head and thorax elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival.

Moore JC, Pepe PE, Scheppke KA, Lick C, ... Debaty GP, Labarère J
Background
Survival after out-of-hospital cardiac arrest (OHCA) remains poor. A physiologically distinct cardiopulmonary resuscitation (CPR) strategy consisting of 1) active compression-decompression CPR and/or automated CPR, 2) an impedance threshold device, and 3) automated controlled elevation of the head and thorax (ACE) has been shown to improve neurological survival significantly versus conventional (C) CPR in animal models. This resuscitation device combination, termed ACE-CPR, is now used clinically.
Objectives
To assess the probability of OHCA survival to hospital discharge after ACE-CPR versus C-CPR.
Methods
As part of a prospective registry study, 227 ACE-CPR OHCA patients were enrolled 04/2019 to 07/2020 from 6 pre-hospital systems in the United States. Individual C-CPR patient data (n=5,196) were obtained from three large published OHCA randomized controlled trials from high-performing pre-hospital systems. The primary study outcome was survival to hospital discharge. Secondary endpoints included return of spontaneous circulation (ROSC) and favorable neurological survival. Propensity-score matching with a 1:4 ratio was performed to account for imbalances in baseline characteristics.
Results
Irrespective of initial rhythm, ACE-CPR (n=222) was associated with higher adjusted odds ratios (OR) of survival to hospital discharge relative to C-CPR (n=860), when initiated in <11 minutes (3.28, 95% confidence interval [CI], 1.55 to 6.92) and <18 minutes (1.88, 95% CI, 1.03 to 3.44) after the emergency call, respectively. Rapid use of ACE-CPR was also associated with higher probabilities of ROSC and favorable neurological survival.
Conclusions
Compared with C-CPR controls, rapid initiation of ACE-CPR was associated with a higher likelihood of survival to hospital discharge after OHCA.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 03 Aug 2022; epub ahead of print
Moore JC, Pepe PE, Scheppke KA, Lick C, ... Debaty GP, Labarère J
Resuscitation: 03 Aug 2022; epub ahead of print | PMID: 35933057
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Impact:
Abstract

Racial/Ethnic and Gender Disparities of the Impact of the COVID-19 Pandemic in Out-of-Hospital Cardiac Arrest (OHCA) in Texas.

Chavez S, Huebinger R, Kit Chan H, Schulz K, ... Al-Araji R, Bobrow B
Introduction
Prior research shows a greater disease burden, lower BCPR rates, and worse outcomes in Black and Hispanic patients after OHCA. Female OHCA patients have lower rates of BCPR compared to men and other survival outcomes vary. The influence of the COVID-19 pandemic on OHCA incidence and outcomes in different health disparity populations is unknown.
Methods
We used data from the Texas Cardiac Arrest Registry to Enhance Survival (CARES). We determined the association of both prehospital characteristics and survival outcomes with the pandemic period in each study group through Pearson\'s χ2 test or Fisher\'s exact tests. We created mixed multivariable logistic regression models to compare odds of cardiac arrest care and outcomes between 2019 and 2020 for the study groups.
Results
Black OHCA patients (aOR = 0.73; 95% CI: 0.65 - 0.82) had significantly lower odds of BCPR compared to White OHCA patients, were less likely to achieve ROSC (aOR = 0.86; 95% CI: 0.74 - 0.99) or have a good CPC score (aOR = 0.47; 95% CI: 0.29 - 0.75). Compared to White patients with OHCA, Hispanic persons were less likely to have a field TOR (aOR = 0.86; 95% CI: 0.75 - 0.99) or receive BCPR (aOR = 0.78; 95% CI: 0.69 - 0.87). Female OHCA patients had higher odds of surviving to hospital admission compared to males (aOR = 1.29; 95% CI: 1.15 - 1.44).
Conclusion
Many OHCA outcomes worsened for Black and Hispanic patients. While some aspects of care worsened for women, their odds of survival improved compared to males.

Published by Elsevier B.V.

Resuscitation: 03 Aug 2022; epub ahead of print
Chavez S, Huebinger R, Kit Chan H, Schulz K, ... Al-Araji R, Bobrow B
Resuscitation: 03 Aug 2022; epub ahead of print | PMID: 35933059
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Impact:
Abstract

Pre-arrest Prediction of Survival Following In-hospital Cardiac Arrest: A Systematic Review of Diagnostic Test Accuracy Studies.

Lauridsen KG, Djärv T, Breckwoldt J, Tjissen JA, ... Implementation, Team Task Force of the International Liaison Committee on Resuscitation ILCOR
Aim
To evaluate the test accuracy of pre-arrest clinical decision tools for in-hospital cardiac arrest survival outcomes.
Methods
We searched Medline, Embase, and Cochrane Library from inception through January 2022 for randomized and non-randomized studies. We used the Quality Assessment of Diagnostic Accuracy Studies framework to evaluate risk of bias, and Grading of Recommendations Assessment, Development and Evaluation methodology to evaluate certainty of evidence. We report sensitivity, specificity, positive predictive outcome, and negative predictive outcome for prediction of survival outcomes. PROSPERO CRD42021268005.
Results
We searched 2517 studies and included 23 studies using 13 different scores: 12 studies investigating 8 different scores assessing survival outcomes and 11 studies using 5 different scores to predict neurological outcomes. All were historical cohorts/ case control designs including adults only. Test accuracy for each score varied greatly. Across the 12 studies investigating 8 different scores assessing survival to hospital discharge/ 30-day survival, the negative predictive values (NPVs) for the prediction of survival varied from 55.6% to 100%. The GO-FAR score was evaluated in 7 studies with NPVs for survival with cerebral performance category (CPC) 1 ranging from 95.0% to 99.2%. Two scores assessed survival with CPC ≤2 and these were not externally validated. Across all prediction scores, certainty of evidence was rated as very low.
Conclusions
We identified very low certainty evidence across 23 studies for 13 different pre-arrest prediction scores to outcome following IHCA. No score was sufficiently reliable to support its use in clinical practice. We identified no evidence for children.

Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 03 Aug 2022; epub ahead of print
Lauridsen KG, Djärv T, Breckwoldt J, Tjissen JA, ... Implementation, Team Task Force of the International Liaison Committee on Resuscitation ILCOR
Resuscitation: 03 Aug 2022; epub ahead of print | PMID: 35933060
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Impact:
Abstract

A pilot study of methods for prediction of poor outcome by head computed tomography after cardiac arrest.

Lang M, Nielsen N, Ullén S, Abul-Kasim K, ... Cronberg T, Moseby-Knappe M
Introduction
In Sweden, head computed tomography (CT) is commonly used for prediction of neurological outcome after cardiac arrest, as recommended by guidelines. We compare the prognostic ability and interrater variability of routine and novel CT methods for prediction of poor outcome.
Methods
Retrospective study including patients from Swedish sites within the Target Temperature Management after out-of-hospital cardiac arrest trial examined with CT. Original images were assessed by two independent radiologists blinded from clinical data with eye-balling without pre-specified criteria, and with a semi-quantitative assessment. Grey-white-matter ratios (GWR) were quantified using models with 4-20 manually placed regions of interest. Prognostic abilities and interrater variability were calculated for prediction of poor outcome (modified Rankin Scale 4-6 at six months) for early (<24h) and late (≥24h) examinations.
Results
68/106 (64%) of included patients were examined <24h post-arrest. Eye-balling predicted poor outcome with 89-100% specificity and 15-78% sensitivity. GWR <24h predicted neurological outcome with unsatisfactory to satisfactory Area Under the Receiver Operating Characteristics Curve (AUROC: 0.54-0.64). GWR ≥24h yielded very good to excellent AUROC (0.80-0.93). Sensitivities increased >2-3 fold in examinations performed after 24h compared to early examinations. Combining eye-balling with GWR<1.15 predicted poor outcome without false positives with sensitivities remaining acceptable.
Conclusion
In our cohort, qualitative and quantitative CT methods predicted poor outcome with high specificity and low to moderate sensitivity. Sensitivity increased relevantly after the first 24 hours after CA. Interrater variability poses a problem and indicates the need to standardise brain CT evaluation to increase the methodś safety.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 02 Aug 2022; epub ahead of print
Lang M, Nielsen N, Ullén S, Abul-Kasim K, ... Cronberg T, Moseby-Knappe M
Resuscitation: 02 Aug 2022; epub ahead of print | PMID: 35931271
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Impact:
Abstract

Effect of Calcium vs. Placebo on Long-Term Outcomes in Patients with Out-of-hospital Cardiac Arrest A Randomized Clinical Trial.

Fink Vallentin M, Granfeldt A, Meilandt C, Ling Povlsen A, ... Kirkegaard H, Andersen LW
Objective
The Calcium for Out-of-hospital Cardiac Arrest (COCA) trial was a randomized, placebo-controlled, double-blind trial of calcium for out-of-hospital cardiac arrest. The primary and secondary outcomes have been reported previously. This article describes the long-term outcomes of the trial.
Methods
Patients aged ≥ 18 years were included if they had a non-traumatic out-of-hospital cardiac arrest during which they received adrenaline. The trial drug consisted of calcium chloride (5 mmol) or saline placebo given after the first dose of adrenaline and again after the second dose of adrenaline for a maximum of two doses. This article presents pre-specified analyses of 6-month and 1-year outcomes for survival, survival with a favorable neurological outcome (modified Rankin Scale of 3 or less), and health-related quality of life.
Results
A total of 391 patients were analyzed. At 1 year, 9 patients (4.7%) were alive in the calcium group while 18 (9.1%) were alive in the placebo group (risk ratio 0.51; 95% confidence interval 0.24, 1.09). At 1 year, 7 patients (3.6%) were alive with a favorable neurological outcome in the calcium group while 17 (8.6%) were alive with a favorable neurological outcome in the placebo group (risk ratio 0.42; 95% confidence interval 0.18, 0.97). Outcomes for health-related quality of life likewise suggested harm of calcium but results were imprecise with wide confidence intervals.
Conclusions
Effect estimates remained constant over time suggesting harm of calcium but with wide confidence intervals. The results do not support calcium administration during out-of-hospital cardiac arrest. Trial registration ClinicalTrials.gov-number, NCT04153435.

Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Jul 2022; epub ahead of print
Fink Vallentin M, Granfeldt A, Meilandt C, Ling Povlsen A, ... Kirkegaard H, Andersen LW
Resuscitation: 30 Jul 2022; epub ahead of print | PMID: 35917866
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Abstract

Neurological Pupil Index and its association with other prognostic tools after cardiac arrest: A post hoc analysis.

Peluso L, Oddo M, Minini A, Citerio G, ... Sandroni C, Silvio Taccone F
Introduction
We evaluated the concordance of the Neurological pupil Index (NPi) with other predictors of outcome after cardiac arrest (CA).
Methods
Post hoc analysis of a prospective, international, multicenter study including adult CA patients. Predictors of unfavorable outcome (UO, Cerebral Performance Category of 3-5 at 3 months) included: a) worst NPi ≤2; b) presence of discontinuous encephalography (EEG) background; c) bilateral absence of N20 waves on somatosensory evoked potentials (N20ABS); d) peak neuron-specific enolase (NSE) blood levels >60 mcg/L; e) myoclonus, which were all tested in a subset of patients who underwent complete multimodal assessment (MMM).
Results
A total of 269/456 (59%) patients had UO and 186 (41%) underwent MMM. The presence of myoclonus was assessed in all patients, EEG in 358 (78%), N20 in 186 (41%) and NSE measurement in 228 (50%). Patients with discontinuous EEG, N20ABS or high NSE had a higher proportion of worst NPi≤2. The accuracy for NPi to predict a discontinuous EEG, N20ABS, high NSE and the presence of myoclonus was moderate. Concordance with NPi ≤2 was high for NSE, and moderate for discontinuous EEG and N20ABS. Also, the higher the number of concordant predictors of poor outcome, the lower the observed NPi.
Conclusions
In this study, NPi≤ 2 had moderate to high concordance with other unfavorable outcome prognosticators of hypoxic-ischemic brain injury. This indicates that NPi measurement could be considered as a valid tool for coma prognostication after cardiac arrest.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 29 Jul 2022; epub ahead of print
Peluso L, Oddo M, Minini A, Citerio G, ... Sandroni C, Silvio Taccone F
Resuscitation: 29 Jul 2022; epub ahead of print | PMID: 35914656
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Impact:
Abstract

Early risk stratification for progression to death by neurological criteria following out-of-hospital cardiac arrest.

Coppler PJ, Flickinger KL, Darby JM, Doshi A, ... Callaway CW, Elmer J
Background
Some patients resuscitated from out-of-hospital cardiac arrest (OHCA) progress to death by neurological criteria (DNC). We hypothesized that initial brain imaging, electroencephalography (EEG), and arrest characteristics predict progression to DNC.
Methods
We identified comatose OHCA patients from January 2010 to February 2020 treated at a single quaternary care facility in Western Pennsylvania. We abstracted demographics and arrest characteristics; Pittsburgh Cardiac Arrest Category, initial motor exam and pupillary light reflex; initial brain CT grey-to-white ratio (GWR), sulcal or basal cistern effacement; initial EEG background and suppression ratio. We used two modeling approaches: fast and frugal tree (FFT) analysis to create an interpretable clinical risk stratification tool and ridge regression for comparison. We used bootstrapping to randomly partition cases into 80% training and 20% test sets and evaluated test set sensitivity and specificity.
Results
We included 1,569 patients, of whom 147 (9%) had diagnosed DNC. Across bootstrap samples, >99% of FFTs included three predictors: sulcal effacement, and in cases without sulcal effacement, the combination of EEG background suppression and GWR ≤ 1.23. This tree had mean sensitivity and specificity of 87% and 81%. Ridge regression with all available predictors had mean sensitivity 91% and mean specificity 83%. Subjects falsely predicted as likely to progress to DNC generally died of rearrest or withdrawal of life sustaining therapies due to poor neurological prognosis. Two of these cases awakened from coma during the index hospitalization.
Conclusions
Sulcal effacement on presenting brain CT or EEG suppression with GWR ≤ 1.23 predict progression to DNC after OHCA.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 29 Jul 2022; epub ahead of print
Coppler PJ, Flickinger KL, Darby JM, Doshi A, ... Callaway CW, Elmer J
Resuscitation: 29 Jul 2022; epub ahead of print | PMID: 35914657
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Abstract

Continuous Heart Rate Dynamics Preceding In-Hospital Pulseless Electrical Activity or Asystolic Cardiac Arrest of Respiratory Etiology.

Shan R, Yang J, Kuo A, Lee R, ... Boyle N, Do DH
Introduction
Respiratory failure is a common cause of pulseless electrical activity (PEA) and asystolic cardiac arrest, but the changes in heart rate (HR) pre-arrest is not well described. We describe HR dynamics prior to in-hospital cardiac arrest (IHCA) among PEA/asystole arrest patients with respiratory etiology.
Methods
In this retrospective study, we evaluated 139 patients with 3-24 hours of continuous electrocardiogram data recorded preceding PEA/asystole IHCA from 2010-2017. We identified respiratory failure cases by chart review and evaluated electrocardiogram data to identify patterns of HR changes, sinus bradycardia or sinus arrest, escape rhythms, and development right ventricular strain prior to IHCA.
Results
A higher proportion of respiratory cases (58/73, 79%) fit a model of HR response characterized by tachycardia followed by rapid HR decrease prior to arrest, compared to non-respiratory cases (30/66, 45%, p<0.001). Among the 58 respiratory cases fitting this model, 36 (62%) had abrupt increase in HR occurring 64 (IQR 23-191) minutes prior to arrest, while 22 (38%) had stable tachycardia until time of HR decrease. Mean peak HR was 123±21 bpm. HR decrease occurred 3.0 (IQR 2.0-7.0) minutes prior to arrest. Sinus arrest occurred during the bradycardic phase in 42/58 of cases; escape rhythms were present in all but 2/42 (5%) cases. Right ventricular strain ECG pattern, when present, occurred at a median of 2.2 (IQR -0.05-17) minutes prior to onset of HR decrease.
Conclusion
IHCAs of respiratory etiology follow a model of HR increase from physiologic compensation to hypoxia, followed by rapid HR decrease prior to arrest.

Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 26 Jul 2022; epub ahead of print
Shan R, Yang J, Kuo A, Lee R, ... Boyle N, Do DH
Resuscitation: 26 Jul 2022; epub ahead of print | PMID: 35905864
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Impact:
Abstract

Evaluation of Telephone-Assisted Cardiopulmonary Resuscitation Recommendations for Out-Of-Hospital Cardiac Arrest.

Guerrero A, Blewer AL, Joiner AP, Sh Leong B, ... Kuchibhatla M, Eh Ong M
Aim of the study
While out-of-hospital cardiac arrest (OHCA) is associated with poor survival, early bystander CPR (B-CPR) and telephone CPR (T-CPR) improves survival from OHCA. American Heart Association (AHA) Scientific Statements outline recommendations for T-CPR. We assessed these recommendations and hypothesized that meeting performance standards is associated with increased likelihood of survival. Additional variables were analyzed to identify future performance measurements.
Methods
We conducted a retrospective cohort study of non-traumatic, adult, OHCA using the Singapore Pan-Asian Resuscitation Outcomes Study. The primary outcome was likelihood of survival; secondary outcomes were pre-hospital Return of Spontaneous Circulation (ROSC) and B-CPR.
Results
From 2012-2016, 2,574 arrests met inclusion criteria. Mean age was 68±15; of 2,574, 1,125 (44%) received T-CPR with 5% (135/2574) survival. T-CPR cases that met the Lerner et al. performance metrics analyzed, demonstrated no statistically significant association with survival. Cases which met the Kurz et al. criteria, \"Time for Dispatch to Recognize Need for CPR\" and \"Time to First Compression,\" had adjusted odds ratios of survival of 1.01 (95% CI:1.00, 1.02; p=<0.01) and 0.99 (95% CI:0.99, 0.99; p=<0.01), respectively. Identified barriers to CPR decreased the odds of T-CPR and B-CPR being performed. Patients with prehospital ROSC had higher odds of B-CPR being performed. EMS response time < 8 minutes was associated with increased survival among patients receiving T-CPR.
Conclusion
AHA scientific statements on T-CPR programs serve as ideal starting points for increasing the quality of T-CPR systems and patient outcomes. More work is needed to identify other system performance measures.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 20 Jul 2022; epub ahead of print
Guerrero A, Blewer AL, Joiner AP, Sh Leong B, ... Kuchibhatla M, Eh Ong M
Resuscitation: 20 Jul 2022; epub ahead of print | PMID: 35870555
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Impact:
Abstract

Coronary Angiographic Findings For Out-of-Hospital Cardiac arrest Survivors Presenting With Nonshockable Rhythms and no ST Elevation Post Resuscitation.

Harhash AA, Kluge MA, Muthukrishnan A, Noc M, ... Hsu CH, Kern KB
Background
Recent guidelines suggest that coronary angiography (CAG) should be considered for out-of-hospital cardiac arrest (OHCA) survivors, including those without ST elevation (STE) and without shockable rhythms. However, there is no prospective data to support CAG for survivors with nonshockable rhythms and no STE post resuscitation.
Methods
This was a re-analysis of the PEARL study (randomized OHCA survivors without STE to early CAG versus not). Patients were subdivided by initial rhythm as nonshockable (Nsh) vs shockable (Sh). The primary outcome was coronary angiographic evidence of acute culprit lesion, with secondary outcomes being survival to hospital discharge and neurological recovery.
Results
The PEARL study included 99 patients with OHCA from a presumed cardiac etiology, 24 with nonshockable and 75 with shockable rhythms. There was no difference in the frequency of CAG between the two groups [71% (Nsh) and 75% (Sh); p=0.79], presence of CAD [81% (Nsh) and 68% (sh); p=0.37, or culprit lesions identified in each group [50% (Nsh) and 45% (Sh); p=0.78. Nonshockable patients had worse discharge survival [33% (Nsh) vs. 57% (Sh); p=0.04] and those survived, had worse neurological recovery [30% (Nsh) vs. 54% (Sh); p=0.02] compared to shockable patients.
Conclusions
OHCA survivors presenting with nonshockable rhythms and no STE post resuscitation had similar prevalence of culprit coronary lesions to those with shockable rhythms. CAG may be considered in patients with OHCA without STE regardless of initial presenting rhythm. There was no benefit of emergent CAG both in shockable and non-shockable rhythms.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 20 Jul 2022; epub ahead of print
Harhash AA, Kluge MA, Muthukrishnan A, Noc M, ... Hsu CH, Kern KB
Resuscitation: 20 Jul 2022; epub ahead of print | PMID: 35870556
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Impact:
Abstract

Resuscitative endovascular occlusion of the aorta (REBOA) as a mechanical method for increasing the coronary perfusion pressure in non-traumatic out-of-hospital cardiac arrest patients.

Jang DH, Keon Lee D, Hwan Jo Y, Min Park S, Taeck Oh Y, Woo Im C
Aim
of the study Resuscitative endovascular balloon occlusion of the aorta (REBOA), originally designed to block blood flow to the distal part of the aorta by placing a balloon in trauma patients, has recently been shown to increase coronary perfusion in cardiac arrest patients. This study evaluated the effect of REBOA on aortic pressure and coronary perfusion pressure (CPP) in non-traumatic out of-hospital cardiac arrest (OHCA) patients.
Methods
Adult OHCA patients with cerebral performance category 1 or 2 prior to cardiac arrest, and without evidence of aortic disease, were enrolled from January to December 2021. Aortic pressure and right atrial pressure were measured before and after balloon occlusion. The CPP was calculated using the measured aortic and right atrial pressures, and the values before and after the balloon occlusion were compared.
Results
Fifteen non-traumatic OHCA patients were enrolled in the study. The median call to balloon time was 46.0 (IQR, 38.0-54.5) min. The median CPP before and after balloon occlusion was 13.5 (IQR, 5.8-25.0) and 25.2 (IQR, 12.0-44.6) mmHg, respectively (P = 0.001). The median increase in the estimated CPP after balloon occlusion was 86.7%.
Conclusions
The results of this study suggest that REBOA may increase the CPP during cardiopulmonary resuscitation in patients with non-traumatic OHCA. Additional studies are needed to investigate the effect on clinical outcomes.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 20 Jul 2022; epub ahead of print
Jang DH, Keon Lee D, Hwan Jo Y, Min Park S, Taeck Oh Y, Woo Im C
Resuscitation: 20 Jul 2022; epub ahead of print | PMID: 35870557
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Impact:
Abstract

Impact of trained intensivist coverage on survival outcomes after in-hospital cardiopulmonary resuscitation: A nationwide cohort study in South Korea.

Kyu Oh T, Cho M, Song IA
Aim
We aimed to investigate whether trained intensivist coverage affects survival outcomes following in-hospital cardiopulmonary resuscitation (ICPR) for in-hospital cardiac arrest (IHCA).
Methods
All adult patients who received ICPR for IHCA between January 1, 2016 and December 31, 2019 in South Korea were included. Patients who received ICPR in hospitals with trained intensivist coverage for ICU staffing were defined as the intensivist group, whereas other patients were considered the non-intensivist group.
Results
In total 68,286 adult patients (36,025 [52.8%] in the intensivist group and 32,261 [47.2%] in the non-intensivist group) were included in the analysis. After propensity score (PS) matching 40,988 patients (20,494 in each group) were included. In logistic regression after PS matching, the intensivist group showed a 17% (odds ratio: 1.17; 95% confidence interval [CI]: 1.12-1.22; P < 0.001) higher live discharge rate after ICPR than the non-intensivist group. In Cox regression after PS matching, the 6-month and the 1-year mortality rates in the intensivist group after ICPR were 11% (hazard ratio [HR]: 0.89; 95% CI: 0.87-0.91; P < 0.001) and 10% (HR: 0.90; 95% CI: 0.88-0.92; P < 0.001) lower than those in the non-intensivist group, respectively. In Kaplan-Meir estimation the median survival time after ICPR in the intensivist group was 12.0 days (95% CI: 11.6-12.4) while that in the non-intensivist group was 8.0 days (95% CI: 7.7-8.3).
Conclusions
Trained intensivist coverage in the ICU was associated with improvements in both short and long-term survival outcomes after ICPR for IHCA.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 20 Jul 2022; epub ahead of print
Kyu Oh T, Cho M, Song IA
Resuscitation: 20 Jul 2022; epub ahead of print | PMID: 35870558
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Impact:
Abstract

Predicting neurological outcomes after in-hospital cardiac arrests for patients with Coronavirus Disease 2019.

Mayampurath A, Bashiri F, Hagopian R, Venable L, ... Churpek M, American Heart Association\'s Get With The Guidelines®-Resuscitation Investigators
Background
Machine learning models are more accurate than standard tools for predicting neurological outcomes in patients resuscitated after cardiac arrest. However, their accuracy in patients with Coronavirus Disease 2019 (COVID-19) is unknown. Therefore, we compared their performance in a cohort of cardiac arrest patients with COVID-19.
Methods
We conducted a retrospective analysis of resuscitation survivors in the Get With The Guidelines®-Resuscitation (GWTG-R) COVID-19 registry between February 2020 and May 2021. The primary outcome was a favorable neurological outcome, indicated by a discharge Cerebral Performance Category score ≤ 2. Pre- and peri-arrest variables were used as predictors. We applied our published logistic regression, neural network, and gradient boosted machine models developed in patients without COVID-19 to the COVID-19 cohort. We also updated the neural network model using transfer learning. Performance was compared between models and the Cardiac Arrest Survival Post-Resuscitation In-Hospital (CASPRI) score.
Results
Among the 4,125 patients with COVID-19 included in the analysis, 484 (12%) patients survived with favorable neurological outcomes. The gradient boosted machine, trained on non-COVID-19 patients was the best performing model for predicting neurological outcomes in COVID-19 patients, significantly better than the CASPRI score (c-statistic: 0.75 vs. 0.67, P < 0.001). While calibration improved for the neural network with transfer learning, it did not surpass the gradient boosted machine in terms of discrimination.
Conclusion
Our gradient boosted machine model developed in non-COVID patients had high discrimination and adequate calibration in COVID-19 resuscitation survivors and may provide clinicians with important information for these patients.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 19 Jul 2022; epub ahead of print
Mayampurath A, Bashiri F, Hagopian R, Venable L, ... Churpek M, American Heart Association's Get With The Guidelines®-Resuscitation Investigators
Resuscitation: 19 Jul 2022; epub ahead of print | PMID: 35868590
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Impact:
Abstract

Investigating the Airway Opening Index during Cardiopulmonary Resuscitation.

Bhandari S, Coult J, Counts CR, Bulger NE, ... Rea TD, Johnson NJ
Introduction
Chest compressions during CPR induce oscillations in capnography (ETCO2) waveforms. Studies suggest ETCO2 oscillation characteristics are associated with intrathoracic airflow dependent on airway patency. Oscillations can be quantified by the Airway Opening Index (AOI). We sought to evaluate multiple methods of computing AOI and their association with return of spontaneous circulation (ROSC).
Methods
We conducted a retrospective study of 307 out-of-hospital cardiac arrest (OHCA) cases in Seattle, WA during 2019. ETCO2 and chest impedance waveforms were annotated for the presence of intubation and CPR. We developed four methods for computing AOI based on peak ETCO2 and the oscillations in ETCO2 during CCs (ΔETCO2). We examined the feasibility of automating ΔETCO2 and AOI calculation and evaluated differences in AOI across the methods using nonparametric testing (p=0.05).
Results
Median [interquartile range] AOI across all cases using Methods 1-4 was 28.0% [17.9-45.5%], 20.6% [13.0-36.6%], 18.3% [11.4-30.4%], and 22.4% [12.8-38.5%], respectively (p<0.001). Cases with ROSC had a higher median AOI than those without ROSC across all methods, though not statistically significant. Cases with ROSC had a significantly higher median [interquartile range] ΔETCO2 of 7.3 mmHg [4.5-13.6 mmHg] compared to those without ROSC (4.8 mmHg [2.6-9.1 mmHg], p<0.001).
Conclusion
We calculated AOI using four proposed methods resulting in significantly different AOI. Additionally, AOI and ΔETCO2 were larger in cases achieving ROSC. Further investigation is required to characterize AOI\'s ability to predict OHCA outcomes, and whether this information can improve resuscitation care.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 15 Jul 2022; epub ahead of print
Bhandari S, Coult J, Counts CR, Bulger NE, ... Rea TD, Johnson NJ
Resuscitation: 15 Jul 2022; epub ahead of print | PMID: 35850376
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Impact:
Abstract

Is frailty associated with long-term survival, neurological function and patient-reported outcomes after in-hospital cardiac arrest? - A Swedish cohort study.

Jonsson H, Piscator E, Israelsson J, Lilja G, Djärv T
Background
Frailty is associated with poor 30-days survival after in-hospital cardiac arrests (IHCA). The aim was to assess how pre-arrest frailty was associated with long-term survival, neurological function and patient-reported outcomes in elderly survivors after IHCA.
Methods
Patients aged ≥65 years with IHCA at Karolinska University Hospital between 2013-2021 were studied. Frailty was assessed by the Clinical Frailty Scale (CFS) based on clinical records and categorised into non-frail (1-4) or frail (5-7). Survival was assessed in days. Neurological function was assessed by the Cerebral Performance Category scale (CPC). A telephone interview was performed six months post-IHCA and included the questionnaires EuroQoL-5 Dimensions-5 Levels and Hospital Anxiety and Depression Scale.
Results
Totally, 232 (28%) out of 817 eligible patients survived to 30-days. Out of 232, 65 (28%) were frail. Long-term survival was better for non-frail than frail patients (6months (92% versus 75%, p-value <0.01), 3 years (74% vs 22%, p-value <0.01)). The vast majority of both non-frail and frail patients had unchanged CPC from admittance to discharge from hospital (87% and 85%, respectively). The 121 non-frail patients reported better health compared to 27 frail patients (EQ-VAS median 70 versus 50 points, p-value <0.01) and less symptoms of depression than frail (16% and 52%, respectively, p-value <0.01).
Conclusion
Frail patients suffering IHCA survived with largely unchanged neurological function. Although one in five frail patients survived to three years, frailty was associated with a marked decrease in long-term survival as well as increased symptoms of depression and poorer general health.

Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 14 Jul 2022; epub ahead of print
Jonsson H, Piscator E, Israelsson J, Lilja G, Djärv T
Resuscitation: 14 Jul 2022; epub ahead of print | PMID: 35843406
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Impact:
Abstract

Quality of Life and Functional Outcomes after In-Hospital Cardiopulmonary Resuscitation. A Systematic Review.

Kobewka D, Young T, Adewole T, Fergusson D, ... Kimura M, Wegier P
Aim
Our aim was to determine the association of cardiopulmonary resuscitation (CPR) for in hospital cardiac arrest (IHCA) with quality of life after discharge.
Methods
We performed a systematic review using available databases for studies that measured any quality-of-life or functional outcome both before and after CPR for IHCA. All screening and data abstraction was performed in duplicate.
Results
We screened 10,927 records and included 24 papers representing 20 unique studies. Fifteen studies measured Cerebral Performance Category. Survival ranged from 11.8% - 39.5%. The risk of impaired cerebral function after discharged ranged from -16.1% (lower risk) to 44.7% increased risk of poor cerebral function after surviving to discharge. Four studies measured discharge to an institutional environment finding that the risk was increased by 18.2% - 72.2% among survivors. One study measured EQ-5D and found no difference pre and post CPR. One study measured performance of activities of daily living finding that survivors needed assistance with more activities after discharge.
Conclusion
Our review is limited by the lack of adjustment for confounders, including the baseline level of each outcome, in all included studies. Therefore, although risk for most outcomes was increased after discharge vs pre-admission we cannot be certain if this is a causal relationship.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 12 Jul 2022; epub ahead of print
Kobewka D, Young T, Adewole T, Fergusson D, ... Kimura M, Wegier P
Resuscitation: 12 Jul 2022; epub ahead of print | PMID: 35840012
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Impact:
Abstract

Cost-effectiveness of extracorporeal cardiopulmonary resuscitation for adult out-of-hospital cardiac arrest: A systematic review.

Addison D, Cheng E, Forrest P, Livingstone A, Morton RL, Dennis M
Objective
The use of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrests (OHCA) has increased dramatically over the past decade. ECPR is resource intensive and costly, presenting challenges for policymakers. We sought to review the cost-effectiveness of ECPR compared with conventional cardiopulmonary resuscitation (CCPR) in OHCA.
Methods
We searched Medline, Embase, Tufts CEA registry and NHS EED databases from database inception to 2021 or 2015 for NHS EED. Cochrane Covidence was used to screen and assess studies. Data on costs, effects and cost-effectiveness of included studies were extracted by two independent reviewers. Costs were converted to USD using purchasing power parities [1]. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist [2] was used for reporting quality and completeness of cost-effectiveness studies; the review was registered on PROSPERO, and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Results
Four studies met the inclusion criteria; three cost-effectiveness studies reported an incremental cost-effectiveness ratio (ICER) for OHCA compared with conventional care, and one reported the mean operating cost of ECPR. ECPR was more costly, accrued more life years (LY) and quality-adjusted life years (QALYs) than CCPR and was more cost-effective when compared with CCPR and other standard therapies. Overall study quality was rated as moderate.
Conclusion
Few studies have examined the cost-effectiveness of ECPR for OHCA. Of those, ECPR for OHCA was cost-effective. Further studies are required to validate findings and assess the cost-effectiveness of establishing a new ECPR service or alternate ECPR delivery models. PROSPERO Registration Number: CRD42021284506.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 11 Jul 2022; epub ahead of print
Addison D, Cheng E, Forrest P, Livingstone A, Morton RL, Dennis M
Resuscitation: 11 Jul 2022; epub ahead of print | PMID: 35835249
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Abstract

Contribution of chest compressions to end-tidal carbon dioxide levels generated during out-of-hospital cardiopulmonary resuscitation.

Gutiérrez JJ, Sandoval CL, Leturiondo M, Russell JK, ... Daya MR, de Gauna SR
Aim
Characterise how changes in chest compression depth and rate affect variations in end-tidal CO2 (ETCO2) during manual cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA).
Methods
Retrospective analysis of adult OHCA monitor-defibrillator recordings having concurrent capnogram, compression depth, transthoracic impedance and ECG, and with ⩾1,000 compressions. Within each patient, during no spontaneous circulation, nearby segments with changes in chest compression depth and rate were identified. Average ETCO2 within each segment was standardised to compensate for ventilation rate variability. Contributions of relative variations in depth and rate to relative variations in standardised ETCO2 were characterised using linear and non-linear models. Normalisation between paired segments removed intra and inter-patient variation and made coefficients of the model independent of the scale of measurement and therefore directly comparable.
Results
A total of 394 pairs of segments from 221 patients were analysed (33% female, median (IQR) age 66(55-74) years). Chest compression depth and rate were 50.4(43.2-57.0)mm and 111.1(106.5-116.1)compressions per minute. ETCO2 before and after standardization was 32.1(23.0-41.4)mmHg and 28.5(19.4-38.7)mmHg. Linear model coefficient of determination was 0.89. Variation in compression depth mainly explained ETCO2 variation (coefficient 0.95, 95% confidence interval (CI): 0.93-0.98) while changes in compression rate did not (coefficient 0.04, 95% CI: 0.01-0.07). Non-linear trend analysis confirmed the results.
Conclusion
This study quantified the relative importance of chest compression characteristics in terms of their impact on CO2 production during CPR. With ventilation rate standardised, variation in chest compression depth explained variations in ETCO2 better than variation in chest compression rate.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 11 Jul 2022; epub ahead of print
Gutiérrez JJ, Sandoval CL, Leturiondo M, Russell JK, ... Daya MR, de Gauna SR
Resuscitation: 11 Jul 2022; epub ahead of print | PMID: 35835250
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Abstract

Utilizing Community Level Factors to Improve Prediction of Out of Hospital Cardiac Arrest Outcome using Machine Learning.

Harford S, Darabi H, Heinert S, Weber J, ... Vanden Hoek T, Del Rios M
Objectives
To evaluate the impact of community level information on the predictability of out-of-hospital cardiac arrest (OHCA) survival.
Methods
We used the Cardiac Arrest Registry to Enhance Survival (CARES) to geocode 9,595 Chicago incidents from 2014-2019 into community areas. Community variables including crime, healthcare, and economic factors from public data were merged with CARES. The merged data were used to develop ML models for OHCA survival. Models were evaluated using Area Under the Receiver Operating Characteristic curve (AUROC) and features were analyzed using SHapley Additive exPansion (SHAP) values.
Results
Baseline results using CARES data achieved an AUROC of 84%. The final model utilizing community variables increased the AUROC to 88%. A SHAP analysis between high and low performing community area clusters showed the high performing cluster is positively impacted by good health related features and good community safety features positively impact the low performing cluster.
Conclusion
Utilizing community variables helps predict neurologic outcomes with better performance than only CARES data. Future studies will use this model to perform simulations to identify interventions to improve OHCA survival.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 08 Jul 2022; epub ahead of print
Harford S, Darabi H, Heinert S, Weber J, ... Vanden Hoek T, Del Rios M
Resuscitation: 08 Jul 2022; epub ahead of print | PMID: 35817268
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Abstract

Low Frequency Power in Cerebral Blood Flow is a Biomarker of Neurologic Injury in the Acute Period after Cardiac Arrest.

White BR, Ko TS, Morgan RW, Baker WB, ... Licht DJ, Kilbaugh TJ
Aim
Cardiac arrest often results in severe neurologic injury. Improving care for these patients is difficult as few noninvasive biomarkers exist that allow physicians to monitor neurologic health. The amount of low-frequency power (LFP, 0.01-0.1 Hz) in cerebral haemodynamics has been used in functional magnetic resonance imaging as a marker of neuronal activity. Our hypothesis was that increased LFP in cerebral blood flow (CBF) would be correlated with improvements in invasive measures of neurologic health.
Methods
We adapted the use of LFP for to monitoring of CBF with diffuse correlation spectroscopy. We asked whether LFP (or other optical biomarkers) correlated with invasive microdialysis biomarkers (lactate-pyruvate ratio - LPR - and glycerol concentration) of neuronal injury in the 4 hours after return of spontaneous circulation in a swine model of paediatric cardiac arrest (Sus scrofa domestica, 8-11 kg, 51% female). Associations were tested using a mixed linear effects model.
Results
We found that higher LFP was associated with higher LPR and higher glycerol concentration. No other biomarkers were associated with LPR; cerebral haemoglobin concentration, oxygen extraction fraction, and one EEG metric were associated with glycerol concentration.
Conclusion
Contrary to expectations, higher LFP in CBF was correlated with worse invasive biomarkers. Higher LFP may represent higher neurologic activity, or disruptions in neurovascular coupling. Either effect may be harmful in the acute period after cardiac arrest. Thus, these results suggest our methodology holds promise for development of new, clinically relevant biomarkers than can guide resuscitation and post-resuscitation care. Institutional protocol number: 19-001327.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 08 Jul 2022; epub ahead of print
White BR, Ko TS, Morgan RW, Baker WB, ... Licht DJ, Kilbaugh TJ
Resuscitation: 08 Jul 2022; epub ahead of print | PMID: 35817269
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Abstract

ECPR: Expert Consensus on PeRcutaneous cannulation for Extracorporeal CardioPulmonary Resuscitation.

Schmitzberger FF, Haas NL, Coute RA, Bartos J, ... Yannopoulos D, Peterson WJ
Aim
Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a promising resuscitation strategy for select patients suffering from refractory out-of-hospital cardiac arrest (OHCA), though limited data exist regarding the best practices for ECPR initiation after OHCA.
Methods
We utilized a modified Delphi process consisting of two survey rounds and a virtual consensus meeting to systematically identify detailed best practices for ECPR initiation following adult non-traumatic OHCA. A modified Delphi process builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. Consensus was achieved when items reached a high level of agreement, defined as greater than 80% responses for a particular item rated a 4 or 5 on a 5-point Likert scale.
Results
Snowball sampling generated a panel of 14 content experts, composed of physicians from four continents and five primary specialties. Seven existing institutional protocols for ECPR cannulation following OHCA were identified and merged into a single comprehensive list of 207 items. The panel reached consensus on 101 items meeting final criteria for inclusion: Prior to Patient Arrival (13 items), Inclusion Criteria (8), Exclusion Criteria (7), Patient Arrival (8), ECPR Cannulation (21), Go On Pump (18), and Post-Cannulation (26).
Conclusion
We present a list of items for ECPR initiation following adult nontraumatic OHCA, generated using a modified Delphi process from an international panel of content experts. These findings may benefit centers currently performing ECPR in quality assurance and serve as a template for new ECPR programs.

Copyright © 2022. Published by Elsevier B.V.

Resuscitation: 08 Jul 2022; epub ahead of print
Schmitzberger FF, Haas NL, Coute RA, Bartos J, ... Yannopoulos D, Peterson WJ
Resuscitation: 08 Jul 2022; epub ahead of print | PMID: 35817270
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This program is still in alpha version.