Cardiac Arrest Events Research Articles

Impact of Pre-Revascularization and Post-Revascularization Cardiac Arrest on Survival Prognosis in Patients With Acute Myocardial Infarction and Following Emergency Percutaneous Coronary Intervention

Objectives: To evaluate the effects of occurrence and timing of sudden cardiac arrest (SCA) on survival in patients with acute myocardial infarction (AMI) who underwent emergency percutaneous coronary intervention (PCI).Methods: We analyzed 1,956 consecutive patients with AMI with emergency PCI from 2014 to 2018. Patients with cardiac arrest events were identified, and their medical records were reviewed.Results: Patients were divided into non-cardiac arrest group (NCA group, n = 1,724), pre-revascularization cardiac arrest (PRCA group, n = 175), and post-revascularization SCA (POCA group, n = 57) according to SCA timing. Compared to NCA group, PRCA group and POCA group presented with higher brain natriuretic polypeptide (BNP), more often Killip class 3/4, atrial fibrillation, and less often completed recovery of coronary artery perfusion (all p < 0.05). Both patients with PRCA and POCA showed increased 30-day all-cause mortality when compared to patients with NCA (8.0 and 70.2% vs. 2.9%, both p < 0.001). However, when compared to patients with NCA, patients with PRCA did not lead to higher mortality during long-term follow-up (median time 917 days) (16.3 vs. 18.6%, p = 0.441), whereas patients with POCA were associated with increased all-cause mortality (36.3 vs. 18.6%, p < 0.001). Multivariate analysis identified Killip class 3/4, atrial fibrillation, high maximum MB isoenzyme of creatine kianse, and high creatinine as predictive factors for POCA. In Cox regression analysis, POCA was found as a strong mortality-increase predictor (HR, 8.87; 95% CI, 2.26–34.72; p = 0.002) for long-term all-cause death.Conclusions: POCA appeared to be a strong life-threatening factor for 30-day and long-term all-cause mortality among patients with AMI who admitted alive and underwent emergency PCI. However, PRCA experience did not lead to a poorer long-term survival in patients with AMI surviving the first 30 days.

Abstract 10520: Emerging Cardiovascular Side Effects of Selective and Non-Selective Immunotherapies in Cancer Patients: 2021 Results from the Global WHO Database

Introduction: Immune checkpoint inhibitors (ICIs), and adoptive cell transfer (ACT) - which involves collecting and using patient’s own immune cells to treat their cancer, are two rapidly emerging therapeutic modalities for various advanced stage cancers. Emerging cardiovascular side effects of ICIs and ACTs are currently being recognized. Objective: We analyzed the newly reported side-effect profiles of FDA-approved ICIs (anti-CTLA-4, anti-PD-1 and anti-PD-L1) and ACTs (also known as CAR-T therapy). Methods: We utilized the global data available in VigiBase®, World Health Organization’s global database for adverse drug reactions (ADRs), maintained by the Uppsala Monitoring Centre. We extracted information on reports of suspected ADRs, also called Individual Case Safety Reports (ICSRs). ICSRs of ICI and ACT therapy on cardiovascular system were extracted, and the side effect profile of the two groups of immunotherapies were systematically analyzed. Results: Based on the records obtained to-date, a total of 6,000 cardiovascular ADRs caused by ICIs (Ipilimumab, Nivolumab, Pembrolizumab, Cemiplimab, Atezolizumab, Avelumab and Durvalumab), and 500 ADRs by ACTs (Kymriah, Yescarta, Tecartus, Brevanzi and Abecma) have been reported. ICI therapies were predominantly associated with myocarditis (1098), cardiac failure (614), acute coronary syndrome (548) and pericarditis/pericardial effusion (516). ACT therapies were associated with tachyarrhythmia (263), cardiac arrest (44) and cardiorenal events (25). A propensity analysis demonstrated ICIs to be associated with autoimmunity-related ADRs, whereas ACTs were associated with acute cytokine release-related ADRs. Conclusions: Using a large-scale global WHO data platform, we have identified unique tendencies for cardiovascular ADRs resulting from non-selective (ICIs) and highly-selective (ACTs) immunotherapies for cancer: the former is associated with serious autoimmune effects, and the latter is associated with acute cytokine-release-related ADRs.

Abstract 9764: Prevalence of Inappropriate Defibrillation Attempts During Pediatric In-Hospital Cardiac Arrest

Introduction: Shockable rhythms (ventricular fibrillation [VF] and ventricular tachycardia [VT]) occur in &lt;25% of pediatric in-hospital cardiac arrest (IHCA) events, yet the prevalence of inappropriate defibrillation attempts for non-VF/VT rhythms is unknown. We aim to describe the prevalence of inappropriate shocks across a large, multi-national pediatric cardiac arrest network. Methods: We included children &lt;18y reported to the pedi atric RES uscitation- Q uality (pediRES-Q) network from 2015-2019 with complete defibrillator files who received defibrillation attempts during IHCA (ZOLL R-Series, MA). Two pediatric cardiologists independently classified rhythms immediately prior to shock as: 1) appropriate (VF or wide complex ≥ 150/min), 2) indeterminate (narrow complex ≥150/min or wide complex 100-149/min), or 3) inappropriate (asystole, sinus, narrow complex &lt;150/min, or wide complex &lt;100/min). Rhythms that were undecipherable due to artifact were excluded from analysis (n=22). Disagreements were resolved by arbitration and consensus. Results: Of 896 IHCA events, 124 (14%) had defibrillation attempts. A total of 303 shocks were delivered: 87 (29%) in age &lt;1y, 84 (28%) in 1-8y, and 132 (44%) in 9-17y. Of shocks delivered, 206 (68%) were appropriate, 12 (4%) indeterminate, and 85 (28%) inappropriate. There was no difference in inappropriate shock delivery by age category: &lt;1y (24/87, 28%), 1-8y (26/84, 31%), 9-17y (35/132, 27%) ( p =0.4). Conclusions: Across a multi-national pediatric cardiac arrest network, a large proportion (28%) of defibrillation attempts were inappropriate, suggesting significant opportunity for improvement in rhythm identification in pediatric cardiac arrest. There was no difference in inappropriate shock delivery across age groups. Figure 1. Representation of rhythm classification and appropriateness of defibrillation attempts with exemplar rhythms.

Abstract 11233: A Trigger and Response System for Preventing Cardiac Arrest in the Intensive Care Unit

Background: Although patients in the ICU are closely monitored, some ICU cardiac arrest events may be preventable. In this study we sought to reduce the rate of ICU cardiac arrests. Methods: This was a prospective study of a novel clinical trigger and response tool deployed in the ICUs of a single, tertiary academic medical center. An interrupted time series approach was used to assess the impact of the tool on ICU cardiac arrests. Results: Forty-three patients experienced an ICU cardiac arrest in the pre-intervention epoch (6.79 arrests per 1000 discharges) and 59 patients experienced an ICU cardiac arrest in the intervention epoch (7.91 arrests per 1000 discharges). In the intervention epoch, the clinical trigger and response tool was activated 106 times over a 1-year period, most commonly due to unexpected new or worsening hypotension. There was no step change in arrest-rate (2.24 arrests/1000 patients, 95%CI -1.82, 6.28, p=0.28) or slope change (-0.02 slope of arrest rate, 95%CI -0.14, 0.11, p=0.79) comparing the pre-intervention and intervention time epochs (see Figure). Cardiac arrests occurring in the pre-intervention epoch were more likely to be deemed ‘potentially preventable’ than those in the intervention epoch (25.6% prior to the intervention vs. 12.3% during the intervention, OR 0.58, 95%CI 0.20, 0.88, p&lt;0.01). Conclusions: A trigger-and-response tool did not reduce the incidence of ICU cardiac arrest. Arrests occurring after introduction of the tool were less likely to be rated as ‘potentially preventable.’

Increased left and right atrial volume indices are associated with decreased survival times post-cardiac arrest

BackgroundLeft and right atrial volume indices (LAVI and RAVI) are markers of cardiac remodeling. LAVI and RAVI are associated with worse outcomes in other cardiac conditions. This study aimed to determine the associations of these atrial volume indices with survival time post-cardiac arrest. MethodsThis was a single center, retrospective study of patients with a sudden cardiac arrest event during index hospitalization from 2014-2018 based on pre-arrest parameters. The analysis was stratified based on whether a pulseless ventricular tachycardia/ventricular fibrillation (pVT/VF) event or a pulseless electrical activity (PEA)/asystole event occurred. Cox proportional hazards regression and model selection with best subsets approach evaluated the association of atrial volume parameters with survival times in the context of other covariates. ResultsOf 305 patients studied (64 ± 14 years, 37% female), the mean LAVI was 34.0 ± 15.8 mL/m2 (based on 162 reliable measurements), and mean RAVI was 25.0 ± 15.6 mL/m2 (based on 163 measurements). Increased atrial volume indices were most strongly associated with survival in patients who had sustained pVT/VF (LAVI HR 0.47, 95% CI 0.25–0.90, p = 0.020; RAVI HR 0.57, 95% CI 0.30–1.05, p = 0.074). In multivariable best subsets Cox regression with LAVI, RAVI, and 13 other scaled covariates, LAVI < 34 ml/m2 was by far the best single predictor of survival (p < 0.0001), and the next best predictor was the absence of pulmonary hypertension. ConclusionAmong patients with cardiac arrest from ventricular arrhythmias, those with no more than mild left atrial enlargement pre-arrest by LAVI measurement had the best prognosis. Additional studies are indicated to validate the importance of this finding for clinical management decisions. Condensed abstractIn patients with sudden cardiac arrest associated with ventricular arrhythmias, a left atrial volume index (LAVI) < 34 mL/m2 prior to the arrest had the strongest association with survival among fifteen candidate predictors. Pulmonary hypertension was more common in patients with an elevated right atrial volume index (RAVI), and the absence of pulmonary hypertension was the next best pre-arrest parameter predictive of survival. Larger studies are indicated to validate the use of LAVI for clinical management decisions in this condition.

Improvement of Pediatric Advanced Airway Management in General Emergency Departments After a Collaborative Intervention Program.

In general emergency departments, advanced airway management of pediatric patients who are critically ill has been associated with increased adverse events given the varying exposure to pediatric patients and limited resources. Previous studies have shown significant improvement of simulated pediatric airway management in general emergency departments. The aim of this retrospective study was to determine the effect of an in situ simulation-based collaborative intervention program on the actual care of pediatric airway management in general emergency departments. This was a retrospective study of pediatric subjects who were critically ill and required intubation at a diverse set of general emergency departments before referral to the academic medical center. The primary outcome was the quality of clinical care measured by adherence to best practices via a critical action checklist. Secondary outcomes included tracheal intubation associated adverse events and clinical outcomes. A total of 135 pediatric subjects (48 pre- and 87 post-intervention) who were transferred to the academic medical center from 9 general emergency departments between May 2014 and August 2019 were included in the analysis. The use of a cuffed endotracheal tube improved, from 44% to 72% (P = .001), whereas there was no significant change in the appropriate endotracheal tube size. Overall, severe tracheal intubation associated adverse events decreased, from 18.8% to 9.2% (P = .03), and post-intubation cardiac arrest events decreased, from 6.3% to 0% (P = .02). A simulation-based collaborative intervention program led to improvement in pediatric airway management and subject outcomes in general emergency departments. This model demonstrated the transfer of improvement from a simulated setting to a clinical setting and may be targeted in other clinical settings.

Reducing failure to rescue rates in a paediatric in-patient setting: A 9-year quality improvement study.

Annually in England, over 1.5 million children and young people (CYP) are admitted to hospital. However, a proportion of these CYP will experience failure to rescue (FtR), a failure to recognize, respond and escalate clinical deterioration, which can result in significant harm or death. To identify and quantify FtR episodes from emergency events at a 110-bedded tertiary children's hospital located within a University Teaching Hospital and evaluate the impact of targeted interventions on reducing FtR. A quality improvement approach was adopted. From 170 446 patients admitted between 2011 and 2019, all emergency event calls were systematically reviewed to identify FtR episodes. Root-cause analysis was performed to identify practice deficiencies. The Plan-Do-Study-Act fundamentals were used. A total of 520 emergency events were reviewed over the 9-year period. One hundred and thirty-two (n=132; 25%) were cardiac arrest events, with the majority occurring within the PCCU setting. Three hundred and twelve (60%) of the events were in children who had been inpatient for more than 48 hours. FtR trend declined over the study period from 23.6% in 2011 when the project commenced to 2.5% or less over the following 8 years. Identifying rates of FtR events from routinely collected emergency events data can be used as a patient safety measure to identify emergency concerns. This enables dynamic problem solving through delivery of strategic and targeted interventions. The proposed interventions outlined in this quality improvement study have application to critical care nursing as mechanisms for reducing unplanned admissions to paediatric critical care unit (PCCU), patient mortality, and PCCU and non-PCCU cardiac arrests. This study emphasises the importance in understanding the antecedence of emergency events for paediatric inpatient populations. This intelligence can be used to direct targeted interventions to significantly reduce failure to rescue rates.

A Trigger and Response System for Preventing Cardiac Arrest in the ICU.

Prospective, observational study. ICUs of a single tertiary care center. Patients hospitalized in the ICUs between August 2017 and November 2019. A comprehensive trigger and response tool. Forty-three patients experienced an ICU cardiac arrest in the preintervention epoch (6.79 arrests per 1,000 discharges), and 59 patients experienced an ICU cardiac arrest in the intervention epoch (7.91 arrests per 1,000 discharges). In the intervention epoch, the clinical trigger and response tool was activated 106 times over a 1-year period, most commonly due to unexpected new/worsening hypotension. There was no step change in arrest rate (2.24 arrests/1,000 patients; 95% CI, -1.82 to 6.28; p = 0.28) or slope change (-0.02 slope of arrest rate; 95% CI, -0.14 to 0.11; p = 0.79) comparing the preintervention and intervention time epochs. Cardiac arrests in the preintervention epoch were more likely to be "potentially preventable" than that in the intervention epoch (25.6% vs 12.3%, respectively; odds ratio, 0.58; 95% CI, 0.20-0.88; p < 0.01). A novel trigger-and-response tool did not reduce the frequency of ICU cardiac arrest. Additional investigation is needed into the optimal approach for ICU cardiac arrest prevention.

Cardiac arrest in patients hospitalized for COVID-19: a tertiary medical center retrospective cohort study

Background/IntroductionPatients with COVID-19 are at increased risk for mortality during hospitalization. Better definition of the incidence, predictors, and outcomes of cardiac arrest during hospitalization for COVID-19 may support early identification and intervention.PurposeTo estimate the incidence of in-hospital cardiac arrest in patients with COVID-19, describe the temporal trends in incidence of and survival after cardiac arrest, summarise characteristics of those who experienced a cardiac arrest, and compare the characteristics of survivors versus non-survivors of cardiac arrest.MethodsWe conducted a retrospective cohort study of patients admitted for COVID-19 to a tertiary medical center comprising three hospitals between March and November 2020. Data entry is ongoing for more than 2000 patients admitted through 2021. Clinical variables extracted via review of electronic medical records included age, sex, race/ethnicity, body mass index, history of cardiovascular disease (ie., coronary artery disease, congestive heart failure, atrial fibrillation, or cerebrovascular event), other comorbidities included in the Charlson comorbidity index, date of admission, duration of hospitalization, all cardiac arrest events during hospitalization, presenting rhythm during first cardiac arrest, and death. Data were described using summary statistics. Multivariable logistic regression was used to evaluate associations.ResultsAmong 1666 patients, 107 (6.4%) experienced at least one in-hospital cardiac arrest event during hospitalization for COVID-19, of which 25 (23%) survived to hospital discharge. From March to October 2020, there was a decrease in estimated cardiac arrest incidence in-hospital from 8.2% to 3%, whereas estimated survival to hospital discharge after an arrest remained similar at approximately 20% (Figure). Compared to those who did not, patients who experienced in-hospital cardiac arrest were older and more likely to have existing cardiovascular disease, as well as other comorbidities. Similar factors were associated with lower chance of survival after cardiac arrest (Table). Patients with pulseless ventricular tachycardia/fibrillation (VT/VF) as presenting rhythm in cardiac arrest had better survival to hospital discharge compared to those with other rhythms (OR 3.3, p=0.02). Younger age (per 10 years, OR=0.7, p=0.03) and fewer comorbidities (per one fewer comorbidity, OR=1.5, p=0.05) were associated with better survival after cardiac arrest in multivariable logistic regression.ConclusionThere was a decline in estimated incidence of cardiac arrest during hospitalization for COVID-19 since beginning of pandemic, with survival to hospital discharge after cardiac arrest estimated to be stable at around 20%. Younger age and fewer comorbidities especially cardiovascular disease were associated with better survival after an in-hospital cardiac arrest.Funding AcknowledgementType of funding sources: Public hospital(s). Main funding source(s): Rush University Medical Center Figure 1Table 1

Does patient age and BMI affect temporal changes in depth-force relationship during CPR?

Abstract Introduction A strong non-linear relationship exists between chest compression (CC) force and depth during cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest events. A decrease in the depth-force (DF) relationship over time and cumulative number of CC has been described for both human and animal subjects. The effect of patient demographics such as age and body mass index (BMI) in the DF relationship during CPR is not as widely explored. Purpose The aim of the present study was to analyse the temporal effect of patient demographics (i.e. age and BMI) in the DF relationship during the performance of CPR. Methods Data were collected from a first responder group based in Texas, USA. Responders were instructed to use a CPR depth feedback device (Laerdal CPRmeter) and an automated external defibrillator (AED; HeartSine SAM 350P) when attending sudden cardiac arrest events. The AED was configured with a shock protocol separated by 2-minute episodes of CPR and rescuer CC depth and rate were guided by the CPR depth feedback device. Patient demographic data was captured at the cardiac arrest scene. CC depth and force data were extracted from Laerdal CPRmeter and processed for 171 patient events. The depth-force ratio (DFR) was calculated as mean depth local maxima divided by mean force local maxima (mm/kgf). Data processing and statistical analyses were performed with R version 3.7.3. Patient age was available for 169 events (median (IQR) = 63 (53–76) years). Age was categorised in two groups: 18–64 (n=87) and 65+ years (n=82). Patient BMI was estimated for 149 patients (median (IQR) = 25.84 (22.58–31.05) kg/m2). BMI was categorised as: Underweight (gUW, BMI &amp;lt;18.5, n=13), Normal (gN, 18.5 ≤ BMI &amp;lt;25, n=54), Overweight (gOW, 25 ≤ BMI &amp;lt;30, n=37) and Obese (gOB, BMI ≥30, n=45). Results No statistically significant differences in mean event duration were found in the age groups (t-test, p=0.368) or the BMI groups (ANOVA, p=0.309). A multiple linear regression model was applied to the data to assess the effect of time and age or BMI on the DFR. At the beginning of the events, no statistically significant differences were found in DFR between age groups (p=0.092). Time had no effect on the change in DFR for 18–64 age group (p=0.110) but the rate of change between the 18–64 and 65+ age groups was significantly different (p&amp;lt;0.010). For BMI and using gN as reference, there were significant differences in DFR between all BMI groups except gUW at the beginning of the events. Time had a significant effect in DFR during events for gUW, gN and gOB (p&amp;lt;0.050), but no common trend in temporal change was identified. Conclusions Temporal changes in DFR appear to be significantly affected by patient age. Tailoring CC force or depth to patient demographics during CPR events may be required for some patients. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): HeartSine Technologies Ltd, Belfast, UK

Clinical characteristics and natural history of pre-adolescent non-syndromic hypertrophic cardiomyopathy

Abstract Background The clinical presentation and natural history of pre-adolescent sarcomeric hypertrophic cardiomyopathy (HCM) has not been systematically characterised. The aim of this study was to describe the clinical characteristics and outcomes of a large, international, multicentre cohort of children diagnosed with non-syndromic HCM below the age of 12. Methods Data from the International Paediatric Hypertrophic Cardiomyopathy Consortium on 639 children meeting diagnostic criteria for HCM below 12 years of age (pre-adolescent) were collected and compared with 568 diagnosed aged 12–16 years. Patients with syndromic and metabolic HCM were excluded. Results Of 639 (male n=417, 65.3%) children with pre-adolescent HCM, 339 (53.1%) had a family history of HCM and 57 (8.9%) a family history of sudden cardiac death (SCD). At the time of baseline assessment; 132 (20.7%) had heart failure symptoms and 39 (6.1%) reported unexplained syncope. Median maximal left ventricular wall thickness on echocardiogram was 13.6mm (IQR 10–19) with a corresponding median z-score of 8.7 (5.3–14.4). 145 (22.7%) had left ventricular outflow tract obstruction (LVOTO) (maximal LVOT gradient≥30mmHg) and 35 (5.5%) had severe LVOTO (gradient≥90mmHg). Over a median follow up 5.6 years (IQR 2.3–10), 10.5% underwent a myectomy and 23.2% implantable cardiac defibrillator (ICD) implantation for primary (81.8%) or secondary (14.2%) prevention. 42 (6.7%) patients died [SCD 4.9%, heart failure death 0.8%, other 1%] and 21 (3.3%) underwent cardiac transplantation. 69 (10.8%) patients had an arrhythmic event (SCD n=31, resuscitated cardiac arrest n=17, appropriate ICD therapy n=14, sustained VT with haemodynamic compromise n=7). Compared to those presenting after 12 years, those under 12 were less likely to have a family history of SCD (8.9% vs 13%, p:0.047) or report unexplained syncope (6.1% vs 12.3%, p&amp;lt;0.00). The degree of hypertrophy did not differ but a higher proportion of pre-adolescent patients had LVOTO (22.7% vs 14.4%, p&amp;lt;0.00). A higher proportion of pre-adolescent underwent a myectomy (10.5% vs 7.2%, p:0.045) but a lower proportion received a primary prevention ICD (18.9% vs 30.1%, p:0.041). The overall proportion of patients reaching the mortality or arrhythmic end-points did not differ, but SCD and resuscitated cardiac arrest events were more frequent in pre-adolescent patients (4.9% vs 3.9% and 2.7 vs 1.6% respectively). Conclusion Pre-adolescent HCM is associated with a high symptom burden and variable cardiac phenotype, comparable to those presenting later in childhood. Despite baseline similarities and equal overall survival, younger patients were less likely to receive a primary prevention ICD despite being more likely to experience a SCD or resuscitated cardiac arrest. This study suggests that younger patients should not be considered a distinct entity for risk stratification and that similar management strategies to older HCM patients should be employed. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): BHF (British Heart Foudnation) MRC (Medical Research Council)

Rocuronium Reversal in the Emergency Department: Retrospective Evaluation of Hemodynamic Instability Following Administration of Sugammadex Versus Neostigmine With Glycopyrrolate

Background: Rocuronium is an intermediate-acting non-depolarizing neuromuscular blocking agent frequently used in the emergency department for rapid sequence intubation. The prolonged effects of rocuronium may prevent the ability to conduct a meaningful neurological examination, thereby delaying appropriate diagnosis and treatment. Sugammadex and neostigmine are pharmacologic agents commonly used to reverse rocuronium. The safety of sugammadex versus neostigmine with glycopyrrolate for the reversal of rocuronium in the emergency department has not been well described. Objective: Evaluate the occurrence of hemodynamic instability post-administration of sugammadex versus neostigmine with glycopyrrolate in the emergency department for the reversal of rocuronium. Methods: A retrospective cohort study conducted among adult patients that received sugammadex or neostigmine with glycopyrrolate in the emergency department for the reversal of rocuronium. The primary outcome was occurrence of hemodynamic instability that required escalation of treatment. Secondary outcomes included occurrence of hypotensive, bradycardic, or cardiac arrest events. Results: A total of 37 patients met inclusion criteria (n = 10, sugammadex; n = 27, neostigmine). There was no difference between the two groups in regard to hemodynamic instability that required escalation of treatment within 30 minutes after receiving either sugammadex or neostigmine with glycopyrrolate (P = .557). Conclusion: There was no difference between the two groups in regard to occurrence of hemodynamic instability that required escalation of treatment. Given the small sample size, future studies are warranted to further delineate the safety of sugammadex and neostigmine with glycopyrrolate for the reversal of rocuronium in the emergency department.

HOSPITALIZATIONS OF IDIOPATHIC PULMONARY ARTERIAL HYPERTENSION IN THE UNITED STATES: A NATIONAL PERSPECTIVE A DECADE APART (2007 VS 2017)

TOPIC: Pulmonary Vascular Disease TYPE: Original Investigations PURPOSE: Idiopathic pulmonary arterial hypertension (IPAH) related hospitalizations contribute to morbidity, mortality and incur substantial healthcare costs. Several advances in management have been achieved over the last decade. The objective of this study is to compare hospitalization related to IPAH between 2007 and 2017 using Nationwide In-patient Sample Database (NIS). METHODS: Retrospective, observational, population-based cohort analysis. NIS is the largest and most comprehensive all-payer database of inpatient hospitalizations in the US. IPAH was identified using the ICD9-CM (416.0) and ICD-10 codes (I27.0) for 2007 and 2017 respectively. We included patients 18 years or older from the years 2007 and 2017. Total hospitalizations, demographics, primary payer, bed size, location/teaching status of the hospital, region of hospital, comorbidities, all-cause mortality, the median length of stay, and median charges were analyzed. RESULTS: IPAH diagnosis was associated with 0.05% of all hospitalizations reviewed in 2007 and 0.03% in 2017. Hospitalizations occurred mostly in females compared to males (11,542 (65.2%) in 2007 vs. 6380 (68.4%) in 2017), but latter carried a higher mortality. Whites continued to have a higher total number of hospitalizations for IPAH than other races in 2007 and 2017 (67.4% vs. 64.1%). The number of IPAH hospitalizations did decrease from 17,713 in 2007 to 9,330 in 2017 (p<0.001) with most being at large bed hospitals (2007(11,820 (66.8%)) vs. 2017( 5,665 (60.7%)). Regional variations in trends were also noted. There was no significant difference in the median length of stay between the 2 years. Medicare was the primary payer in most admissions in both years (11,931 (67.4%) in 2007 vs 5795 (62.3%) in 2017). Total all-cause mortality (IPAH Hospitalization) decreased in 2017 (4.8%) compared to 2007 (6.4%) (p<0.001). Multivariate analysis of factors associated with inpatient mortality revealed the following: • Age group 45-64 (OR 2.09, P<0.001) and over 65 (OR 4.09, P < .0001) had a greater rate of mortality compared to the age group 18-44. • Males had higher mortality (OR 1.18, p=0.015) than females. • Blacks (OR 0.79, p=0.014) and Hispanics (OR 0.65, p=0.003) had lower mortality than whites. • Fewer patients had cardiac arrest in 2017 vs 2007 (145 (1%) vs 169(1.6%)) • Increased risk of death in the event of cardiac arrest was noted (OR 27.22, p<0.001) • Total charges in United States Dollars (USD) increased substantially in 2017 compared to 2007 ($26,016 vs. $46,450). CONCLUSIONS: NIS based hospitalization data comparing 2007 to 2017 revealed the following findings:1. Significant reduction in IPAH related hospitalizations2. Reduced all-cause mortality related to hospitalization3. Increased healthcare costs CLINICAL IMPLICATIONS: IPAH is linked to an increased risk of morbidity and mortality. Further epidemiological studies are needed to understand the nuances in IPAH related hospitalizations and outcomes. DISCLOSURES: Clinical Research - PI relationship with United Therapeutics Please note: 3 years by Vijay Balasubramanian, source=Web Response, value=Grant/Research Support Speaker relationship with Bayer Please note: 3 years by Vijay Balasubramanian, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: $1001 - $5000 by Vijay Balasubramanian, source=Web Response, value=Honoraria No relevant relationships by Rupak Desai, source=Web Response Advisory Committee Member relationship with United Therapeutics, Acceleron Please note: $5001 - $20000 Added 12/03/2020 by Jean Elwing, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Liquidia, Altavant, Bayer, Gossamer Bio Please note: $1001 - $5000 Added 12/03/2020 by Jean Elwing, source=Web Response, value=Consulting fee Research - Paid directly to employer relationship with Acceleron, Actelion, Reata, United Therapeutics, Liquidia Please note: $1-$1000 Added 04/27/2021 by Jean Elwing, source=Web Response, value=Grant/Research Research - Paid directly to employer relationship with Phase Bio, Complexa, Gossamer Bio, Bayer Please note: $1-$1000 Added 12/03/2020 by Jean Elwing, source=Web Response, value=Grant/Research Support No relevant relationships by Bisharah Rizvi, source=Web Response

Impact of air temperature on occurrence of bath-related cardiac arrest.

The mortality of the bath-related cardiac arrest (BRCA) is extremely high. While air temperature is reported to be associated with the BRCA occurrence, it is unclear whether daily minimum temperatures or the difference between maximum and minimum air temperatures influences BRCA occurrence the most.A retrospective cohort study of adult patients was conducted between January 2015 and February 2020 at Hirosaki University Hospital Emergency Department. The following data were collected: age, sex, day of cardiac arrest event, location of the event, initial cardiac rhythm, presence of return of spontaneous circulation, and overall mortality (status at 1 month after cardiac arrest event). Based on the day of the event and the location in which the event occurred, daily minimum and maximum temperatures were obtained from the Japan Meteorological Agency database.A total of 215 eligible cardiac arrest cases were identified, including 25 cases of BRCA. Comparing BRCA and non-BRCA, initial shockable cardiac rhythm (4.0% vs 44.7%), presence of return of spontaneous circulation (8.0% vs 34.7%), and overall mortality (96.0% vs 71.6%) differed significantly (P < .05 each). Daily minimum and maximum temperatures showed no significant relationships with BRCA or non-BRCA. Daily minimum temperature was a risk factor of BRCA occurrence after adjusting for age and temperature difference (risk ratio, 0.937; 95% confidence interval, 0.882–0.995).Daily minimum temperature represents a potential risk factor for BRCA occurrence.

A descriptive analysis of obstacles to fulfilling the end of life care goals among cardiac arrest patients

Background and ObjectivesPerforming cardiopulmonary resuscitation (CPR) on cardiac arrest patients with Do Not Resuscitate (DNR) orders does not respect patients’ autonomy. We aimed to 1) determine the frequency of patients who wished to be DNR prior to cardiac arrest; 2) determine what proportion received CPR; and 3) explain why DNR patients received CPR. MethodsThis was a retrospective chart review study of cardiac arrest patients at an emergency department. We reported the frequency and proportion of patients who 1) had valid DNR orders presented at the time of cardiac arrest; 2) had valid DNR orders that were unavailable at the time of arrest 3) had Advanced Directives but no DNR orders; 4) had their DNR orders rescinded; and 5) wished to be DNR but did not have any documents in place. ResultsOf 419 patients, 65 (15.51%) wished to be DNR. Out of these 65 patients, 38 (58.46 %) patients were resuscitated. Among the 38 patients, 23 (60.52%) received CPR accordingly and 15 (39.47%) patients were inappropriately resuscitated. ConclusionIn our sample of 419 patients, 65 (15.51%) did not want CPR in the event of cardiac arrest and 38 (9.06%) received CPR against their wishes. This was due to failure to document DNR orders, lack of recognition of documented valid DNR orders, and use of non-actionable Advanced Directives to relay patients’ wishes.

Prior beta-blocker treatment improves outcomes in out-of-hospital cardiac arrest patients with non-shockable rhythms

The prognosis of out of cardiac arrest is poor and most cardiac arrest patients suffered from the non-shockable rhythm especially in patients without pre-existing cardiovascular diseases and medication prescription. Beta-blocker (ß-blocker) therapy has been shown to improve outcomes in cardiovascular diseases such as heart failure, ischemia related cardiac, and brain injuries. Therefore, we investigated whether prior ß-blockers use was associated with reduced mortality in patients with cardiac arrest and non-shockable rhythm. We conducted a population-based retrospective cohort study using multivariate propensity score–based regression to control for differences among patients with cardiac arrest. A total of 104,568 adult patients suffering a non-traumatic and non-shockable rhythm cardiac arrest between 2005 and 2011 were identified. ß-blocker prescription at least 30 days prior to the cardiac arrest event was defines as the ß-blockers group. We chose 12.5 mg carvedilol as the cut-off value and defined greater or equal to carvedilol 12.5 mg per day and its equivalent dose as high-dose group. After multivariate propensity score–based logistic regression analysis, patients with prior ß-blockers use were associated with better 1-year survival [adjusted odds ratio (OR), 1.15, 95% confidence interval (CI) 1.01–1.30; P = 0.031]. Compared to non-ß-blocker use group and prior low-dose ß-blockers use group, prior high-dose ß-blockers use group was associated with higher mechanical ventilator wean success rate (adjusted OR 1.19, 95% CI 1.01–1.41, P = 0.042). In conclusion, prior high dose ß-blockers use was associated with a better 1-year survival and higher weaning rate in patients with non-shockable cardiac arrest.

Transition of Hospital Based Endoscopy Nurses to an Ambulatory Setting

<h3>Background Information</h3> Our endoscopy services was adjacent to an Emergency Department (ED) and relied on it for support during medical emergencies. As the ED was transitioning to an Urgent Care, endoscopy realized a need to create plans for responding to emergencies without the support of the ED. <h3>Objectives of Project</h3> • Assess emergency preparedness of physicians and nursing staff • Identify knowledge gaps emergency situations • Provide Simulation activities responsiveness. • Build upon teamwork and closed loop communication skills through debriefing. Our goal was to improve staff comfort in identifying patient emergencies, increase knowledge of appropriate interventions and timely activation of community Emergency Response systems (911) in order to facilitate transport of patients to tertiary care. <h3>Process of Implementation</h3> • Pre/post assessment using a Likert scale to assess staff knowledge and comfort in identifying and treating emergency situations. • Nurse educators developed emergency simulations likely to occur in the endoscopy unit ○ cardiac arrest, bowel perforation, laryngospasm, allergic reaction and psychotic events • Endoscopy staff were divided into groups of four participants for three simulation activities and debriefed after each simulation • The exercise was repeated with on subsequent days in order to capture most of the staff. <h3>Statement of Successful Practice</h3> Nurses completed a post survey using Likert scale that was analyzed for improvement of comfort level. The pre/post assessment showed no increase in confidence: however, staff had rated themselves high on all elements in the pre-assessment. Anecdotally, they noted how much they learned an appreciated the opportunity to practice with the EMS provider. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Teamwork and communication are essential in effectively intervening in emergency situations. Simulation was a valuable tool that provided an opportunity to practice and enhance confidence in a safe learning environment. Debriefing sessions provided an opportunity for discussion and reflection. Staff stated increased confidence in handling emergencies in endoscopy.

Outcomes of Cardiopulmonary Resuscitation in the Pediatric Intensive Care of a Tertiary Center.

Understanding the factors affecting survival and modifying the preventable factors may improve patient outcomes following cardiopulmonary resuscitation (CPR). The aim of this study was to assess the prevalence and outcomes of cardiac arrest and CPR events in a tertiary pediatric intensive care unit (PICU). Outcomes of interest were the return of spontaneous circulation (ROSC) lasting more than 20 minutes, survival for 24 hours post-CPR, and survival to hospital discharge. We analyzed data from the PICU CPR registry from January 1, 2011 to January 1, 2018. All patients who underwent at least 2 minutes of CPR in the PICU were included. CPR was administered in 65 PICU instances, with a prevalence of 1.85%. The mean patient age was 32.7 months. ROSC occurred in 38 (58.5%) patients, 30 (46.2%) achieved 24-hour survival, and 21 (32.3%) survived to hospital discharge. Younger age ( p < 0.018), respiratory cause ( p < 0.001), bradycardia ( p < 0.018), and short duration of CPR ( p < 0.001) were associated with better outcomes, while sodium bicarbonate, norepinephrine, and vasopressin were associated with worse outcome ( p < 0.009). The off-hour CPR had no impact on the outcome. The patients' cumulative predicted survival declined by an average of 8.7% for an additional 1 minute duration of CPR ( p = 0.001). The study concludes that the duration of CPR, therefore, remains one of the crucial factors determining CPR outcomes and needs to be considered in parallel with the guideline emphasis on CPR quality. The lower survival rate post-ROSC needs careful consideration during parental counseling. Better anticipation and prevention of CPR remain ongoing challenges.

Computer simulation of the effectiveness of novel cardiac arrest response systems

AimsTo use a computer simulation model to predict the response time and survival impact of a sample of novel cardiac arrest response systems, such as those that use cellphone apps to dispatch citizen mobile responders and those that use drones to deliver an AED to the cardiac arrest location. MethodsWe developed a model which applies a Monte Carlo approach to simulate the response time and predicted survival for cardiac arrest events within a specific region. We used the model to compare the performance of 4 different novel response systems, along with simulated EMS performance, in Bellevue, Washington. We estimated the 10 year cost for each system, which was utilized together with the system performance predictions in a cost-benefit analysis. ResultsThe best performing systems in the simulation were a mobile responder system capable of providing both CPR and defibrillation, similar to the PulsePoint verified responder program, as well as a drone AED delivery system with bystander application. Both systems showed an incremental improvement in survival of 10% over the simulated EMS survival. The systems that provided the best cost-benefit ratio were the mobile responder system providing only CPR (PulsePoint Respond) and drone systems with bystander application. ConclusionsOur simulation results suggest that these novel response systems have the potential to substantially improve survival at an efficient cost.

Usefulness of a Novel Risk Score to Predict In-Hospital Mortality in Patients ≥ 60 Years of Age with ST Elevation Myocardial Infarction

Numerous algorithms are available to predict short-term mortality in ST elevation myocardial infarction (STEMI) but none are focused on elderly patients or include invasive hemodynamics. A simplified risk score (LASH score) including left ventricular end diastolic pressure > 20 mm Hg, age > 75 years, systolic blood pressure < 100 mm Hg and heart rate > 100 bpm was tested in a retrospective, single-center study of 346 patients ≥ 60 years old who underwent primary percutaneous coronary intervention (PPCI). The median age was 70 years [IQR: 64, 79], 60.1% were men, and 77.8% identified as White. In-hospital all-cause mortality was 10.1%. Patients with a LASH score ≥ 3 (n=34) had an in-hospital mortality rate of 44.1% compared to 6.4% for LASH score ≤ 2 (p < 0.0001). The odds ratio for in-hospital mortality for patients with LASH score ≥ 3 was 13.2 (95% CI 5.3-33.1) compared to patients with a LASH score ≤ 2 when adjusted for sex, cardiac arrest, heart failure, and prior cerebrovascular event. The LASH score had an area under the ROC curve for predicting in-hospital mortality of 0.795 [CI 0.716-0.872], as compared to TIMI-STEMI (0.881, CI 0.829-0.931; p=0.01), GRACE (0.849, CI 0.778-0.920; p=0.19), shock index (0.769, CI 0.667-0.871; p=0.51) and modified shock index (0.765, CI 0.716-0.873; p=0.48). In summary, a simplified, easy to calculate risk score that incorporates age and invasive hemodynamics predicts in-hospital mortality in patients ≥ 60 years old undergoing PPCI for STEMI.