Bystander-initiated cardiopulmonary resuscitation can curb the deterioration of regional cerebral oxygen saturation on hospital arrival in patients with cardiac arrest

Abstract

Bystander-initiated cardiopulmonary resuscitation (B-CPR) plays a key role in the chain of survival for out-of-hospital cardiac arrest (OHCA) patients. However, the effects of B-CPR for cerebral perfusion have not been demonstrated in humans, and the implementation rate of B-CPR is still low.1Berg R.A. Hemphill R. Abella B.S. et al.Part 5: adult basic life support: 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.Circulation. 2010; 122: S685-S705Crossref PubMed Scopus (606) Google Scholar We have previously reported that low regional cerebral oxygen saturation (rSO2) on hospital arrival is a predictor of poor neurological outcome at hospital discharge in OHCA patients and that post-resuscitation care preserving an rSO2 of ≥25% potentially improves neurological outcomes at hospital discharge.2Ito N. Nanto S. Nagao K. et al.Regional cerebral oxygen saturation predicts poor neurological outcome in patients with out-of-hospital cardiac arrest.Resuscitation. 2010; 81: 1736-1737Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 3Ito N. Nanto S. Nagao K. Hatanaka T. Nishiyama K. Kai T. Regional cerebral oxygen saturation on hospital arrival is a potential novel predictor of neurological outcomes at hospital discharge in patients with out-of-hospital cardiac arrest.Resuscitation. 2012; 83: 46-50Abstract Full Text PDF PubMed Scopus (45) Google Scholar Here we assessed the effects of B-CPR on cerebral perfusion through the measurement of rSO2 that is a neurological parameter reflecting the degree of cerebral perfusion.In a prospective cohort study, 186 consecutive patients with nontraumatic cardiac arrest on arrival (CAOA) among 418 OHCA patients were enrolled from April 2009 to March 2011. The CAOA patients were categorized into the B-CPR group (n = 76) and the no-B-CPR group (n = 110). Within 3 min after hospital arrival, rSO2 was monitored at least for 1 min with the sensors of a near-infrared spectrometer (INVOS™, Covidien, Boulder, CO) placed on the patient's forehead, and the lower of two rSO2 readings was used.4Yao F.S. Tseng C.C. Ho C.Y. Levin S.K. Illner P. Cerebral oxygen desaturation is associated with early postoperative neuropsychological dysfunction in patients undergoing cardiac surgery.J Cardiothorac Vasc Anesth. 2004; 18: 552-558Abstract Full Text Full Text PDF PubMed Scopus (295) Google Scholar Regardless of the rSO2 readings, all patients received the best available therapy.3Ito N. Nanto S. Nagao K. Hatanaka T. Nishiyama K. Kai T. Regional cerebral oxygen saturation on hospital arrival is a potential novel predictor of neurological outcomes at hospital discharge in patients with out-of-hospital cardiac arrest.Resuscitation. 2012; 83: 46-50Abstract Full Text PDF PubMed Scopus (45) Google ScholarThe primary endpoint was rSO2 on hospital arrival, and the secondary endpoint was neurological outcome at hospital discharge according to the Glasgow-Pittsburgh cerebral performance categories at hospital discharge.5Jacobs I. Nadkarni V. Bahr J. et al.Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa).Circulation. 2004; 110: 3385-3397Crossref PubMed Scopus (1136) Google Scholar This study was approved by institutional ethics committee, and written informed consent was waved.Patient characteristics were similar between the study groups. Of 186 CAOA patients, 18 (9.7%) had good neurological outcome. rSO2 on hospital arrival and the proportions of patients with good neurological outcome were significantly greater in the B-CPR group than in the no-B-CPR group (33 ± 20% vs 22 ± 13%, P = 0.00003; 21% vs 2%, P = 0.00005, respectively) (Table 1).Table 1Characteristics and neurological outcomes of CAOA patients among OHCA patients.CharacteristicsB-CPR group (N = 76)No-B-CPR group (N = 110)P-valueAge, years69 ± 1371 ± 130.5661Male, no. (%)57 (74%)72 (65%)0.1651Location of arrest, no. (%)0.3994 Home44 (58%)65 (59%) Nursing home/assisted living11 (14%)12 (11%) Public building8 (11%)15 (14%) Street7 (9%)15 (14%) Others6 (8%)3 (2%)First documented rhythms in the scene of cardiac arrest, no. (%)0.3899 VF/pulseless VT20 (26%)23 (21%) Non-VF/pulseless VT56 (74%)87 (79%)Prehospital procedures, no. (%) Airway securement with advanced devices64 (84%)98 (89%)0.3291 Intravenous adrenaline60 (79%)75 (68%)0.1057 Defibrillation21 (28%)27 (25%)0.6363Emergency call to hospital arrival, min41 ± 1443 ± 190.8385Rhythms at rSO2 measurement, no. (%)0.1364 VF/pulseless VT20 (26%)19 (17%) Non-VF/pulseless VT56 (74%)91 (83%)OutcomesrSO2 on hospital arrival, mean, %33 ± 2022 ± 130.00003CPC categories at hospital discharge, no. (%)0.00005 CPC 1/216 (21%)2 (2%) CPC 3/46 (8%)7 (6%) CPC 554 (71%)101 (92%)Data are expressed as mean ± SD. CAOA, cardiac arrest on arrival; CPC, cerebral performance category; B-CPR, bystander-initiated cardiopulmonary resuscitation; No-B-CPR, no-bystander-initiated cardiopulmonary resuscitation; OHCA, out-of-hospital cardiac arrest; PEA, pulseless electrical activity; rSO2, regional cerebral oxygen saturation; SD, standard deviation; VF, ventricular fibrillation; and VT, ventricular tachycardia. Open table in a new tab To the best of our knowledge, our study is the first to demonstrate that B-CPR curbed the deterioration of cerebral perfusion on hospital arrival in CAOA patients as evidenced by a single measurement of rSO2 on hospital arrival—a variable useful to determine the degree of cerebral perfusion—and that B-CPR increased the proportion of “CPC 1/2” CAOA patients although comparable prehospital procedures and the same best available therapy were provided.Since rSO2 was ≥25% in patients with good neurological outcome at hospital discharge, the sustainment thereof in the prehospital phase was suggested to be a probable cardinal requisite for successful CPR.2Ito N. Nanto S. Nagao K. et al.Regional cerebral oxygen saturation predicts poor neurological outcome in patients with out-of-hospital cardiac arrest.Resuscitation. 2010; 81: 1736-1737Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 3Ito N. Nanto S. Nagao K. Hatanaka T. Nishiyama K. Kai T. Regional cerebral oxygen saturation on hospital arrival is a potential novel predictor of neurological outcomes at hospital discharge in patients with out-of-hospital cardiac arrest.Resuscitation. 2012; 83: 46-50Abstract Full Text PDF PubMed Scopus (45) Google Scholar We speculate that B-CPR presumably favored adequate cerebral perfusion, facilitated its sustainment after the onset of cardiac arrest through to the measurement of rSO2, and prevented irreversible brain ischemia or ameliorated the intensity of brain ischemia.To the best of our knowledge, this letter is the first description on a study that examined the relationship between B-PCR and rSO2 measured in the emergency medicine setting. Our study provides clinical evidence for encouraging the general population to perform B-CPR.Conflict of interest statementAll authors had no conflicts of interest. Bystander-initiated cardiopulmonary resuscitation (B-CPR) plays a key role in the chain of survival for out-of-hospital cardiac arrest (OHCA) patients. However, the effects of B-CPR for cerebral perfusion have not been demonstrated in humans, and the implementation rate of B-CPR is still low.1Berg R.A. Hemphill R. Abella B.S. et al.Part 5: adult basic life support: 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.Circulation. 2010; 122: S685-S705Crossref PubMed Scopus (606) Google Scholar We have previously reported that low regional cerebral oxygen saturation (rSO2) on hospital arrival is a predictor of poor neurological outcome at hospital discharge in OHCA patients and that post-resuscitation care preserving an rSO2 of ≥25% potentially improves neurological outcomes at hospital discharge.2Ito N. Nanto S. Nagao K. et al.Regional cerebral oxygen saturation predicts poor neurological outcome in patients with out-of-hospital cardiac arrest.Resuscitation. 2010; 81: 1736-1737Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 3Ito N. Nanto S. Nagao K. Hatanaka T. Nishiyama K. Kai T. Regional cerebral oxygen saturation on hospital arrival is a potential novel predictor of neurological outcomes at hospital discharge in patients with out-of-hospital cardiac arrest.Resuscitation. 2012; 83: 46-50Abstract Full Text PDF PubMed Scopus (45) Google Scholar Here we assessed the effects of B-CPR on cerebral perfusion through the measurement of rSO2 that is a neurological parameter reflecting the degree of cerebral perfusion. In a prospective cohort study, 186 consecutive patients with nontraumatic cardiac arrest on arrival (CAOA) among 418 OHCA patients were enrolled from April 2009 to March 2011. The CAOA patients were categorized into the B-CPR group (n = 76) and the no-B-CPR group (n = 110). Within 3 min after hospital arrival, rSO2 was monitored at least for 1 min with the sensors of a near-infrared spectrometer (INVOS™, Covidien, Boulder, CO) placed on the patient's forehead, and the lower of two rSO2 readings was used.4Yao F.S. Tseng C.C. Ho C.Y. Levin S.K. Illner P. Cerebral oxygen desaturation is associated with early postoperative neuropsychological dysfunction in patients undergoing cardiac surgery.J Cardiothorac Vasc Anesth. 2004; 18: 552-558Abstract Full Text Full Text PDF PubMed Scopus (295) Google Scholar Regardless of the rSO2 readings, all patients received the best available therapy.3Ito N. Nanto S. Nagao K. Hatanaka T. Nishiyama K. Kai T. Regional cerebral oxygen saturation on hospital arrival is a potential novel predictor of neurological outcomes at hospital discharge in patients with out-of-hospital cardiac arrest.Resuscitation. 2012; 83: 46-50Abstract Full Text PDF PubMed Scopus (45) Google Scholar The primary endpoint was rSO2 on hospital arrival, and the secondary endpoint was neurological outcome at hospital discharge according to the Glasgow-Pittsburgh cerebral performance categories at hospital discharge.5Jacobs I. Nadkarni V. Bahr J. et al.Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa).Circulation. 2004; 110: 3385-3397Crossref PubMed Scopus (1136) Google Scholar This study was approved by institutional ethics committee, and written informed consent was waved. Patient characteristics were similar between the study groups. Of 186 CAOA patients, 18 (9.7%) had good neurological outcome. rSO2 on hospital arrival and the proportions of patients with good neurological outcome were significantly greater in the B-CPR group than in the no-B-CPR group (33 ± 20% vs 22 ± 13%, P = 0.00003; 21% vs 2%, P = 0.00005, respectively) (Table 1). Data are expressed as mean ± SD. CAOA, cardiac arrest on arrival; CPC, cerebral performance category; B-CPR, bystander-initiated cardiopulmonary resuscitation; No-B-CPR, no-bystander-initiated cardiopulmonary resuscitation; OHCA, out-of-hospital cardiac arrest; PEA, pulseless electrical activity; rSO2, regional cerebral oxygen saturation; SD, standard deviation; VF, ventricular fibrillation; and VT, ventricular tachycardia. To the best of our knowledge, our study is the first to demonstrate that B-CPR curbed the deterioration of cerebral perfusion on hospital arrival in CAOA patients as evidenced by a single measurement of rSO2 on hospital arrival—a variable useful to determine the degree of cerebral perfusion—and that B-CPR increased the proportion of “CPC 1/2” CAOA patients although comparable prehospital procedures and the same best available therapy were provided. Since rSO2 was ≥25% in patients with good neurological outcome at hospital discharge, the sustainment thereof in the prehospital phase was suggested to be a probable cardinal requisite for successful CPR.2Ito N. Nanto S. Nagao K. et al.Regional cerebral oxygen saturation predicts poor neurological outcome in patients with out-of-hospital cardiac arrest.Resuscitation. 2010; 81: 1736-1737Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 3Ito N. Nanto S. Nagao K. Hatanaka T. Nishiyama K. Kai T. Regional cerebral oxygen saturation on hospital arrival is a potential novel predictor of neurological outcomes at hospital discharge in patients with out-of-hospital cardiac arrest.Resuscitation. 2012; 83: 46-50Abstract Full Text PDF PubMed Scopus (45) Google Scholar We speculate that B-CPR presumably favored adequate cerebral perfusion, facilitated its sustainment after the onset of cardiac arrest through to the measurement of rSO2, and prevented irreversible brain ischemia or ameliorated the intensity of brain ischemia. To the best of our knowledge, this letter is the first description on a study that examined the relationship between B-PCR and rSO2 measured in the emergency medicine setting. Our study provides clinical evidence for encouraging the general population to perform B-CPR. Conflict of interest statementAll authors had no conflicts of interest. All authors had no conflicts of interest.