Duration Of Cardiopulmonary Resuscitation Research Articles

Clinical Significance of Gray to White Matter Ratio after Cardiopulmonary Resuscitation in Children.

Cardiopulmonary resuscitation (CPR) successfully restores systemic circulation approximately 50% of the time; however, many successfully restored patients have severe neurologic damage. In adults, the gray matter to white matter attenuation ratio (GWR) in brain computed tomography (CT) correlates with the neurologic outcome. However, in children, the clinical significance of GWR still remains unclear. The aim of this study was to evaluate the clinical characteristics of children who underwent CPR for cardiac arrest according to the survival and to demonstrate the differentiation of grey/white matter by Hounsfield units of brain CT and to characterize the attenuations of grey and white matters. Methods: This is a retrospective single-center study. We enrolled those who underwent brain CT within 24 h after return of spontaneous circulation (ROSC) from January 2005 to June 2018. Brain CTs were taken within 24 h of ROSC. We measured the attenuation of grey and white matter in Hounsfield units and calculated GWR. They were compared with healthy controls. Patients were analyzed as follows: survivors vs. non-survivors and better neurologic outcome vs. worse neurologic outcome. Results: Among 100 pediatric patients who had CPR, 56 met inclusion criteria. There were 24 patients who survived and 32 non-survivors. Our study revealed that the incidence of seizure, duration of CPR, and instances of hypothermia were significantly different between survivors and non-survivors. In both survivors and non-survivors, the attenuation of the caudate nucleus, putamen, GWR-basal ganglia, and average GWR were significantly different from controls. In regression analyses, the medial cortex and average GWR were the significant variables to predict survival, and the receiver operating curves revealed areas under curve of 0.733 and 0.666, respectively. Also, the medial cortex 1 was the only variable that predicted the neurologic outcome. Conclusions: There was some predictive survival value of GWR and medial cortex at the centrum semiovale level in early brain CT within 24 h after cardiac arrest. Although we could not find the predictive value of GWR in the neurologic outcome of pediatric patients, we found that the absolute attenuation of the medial cortex was low in patients with worse neurologic outcomes. Further prospective, multicenter studies are needed to determine the predictive value of GWR and the medial cortex.

Time point for transport initiation in out-of-hospital cardiac arrest cases with ongoing cardiopulmonary resuscitation: anationwide cohort study in Japan.

AimThis study aimed to investigate the time point of the decision to initiate transport with ongoing cardiopulmonary resuscitation (CPR) in Japan.MethodsWe analyzed adult out‐of‐hospital cardiac arrest (OHCA) cases that achieved return of spontaneous circulation (ROSC) before hospital arrival from the All‐Japan Utstein Registry during 2015–2017. We constructed receiver operating characteristics (ROC) curves to illustrate the ability of achieving ROSC as a predictor of neurologically favorable outcomes as a function of increasing time points of resuscitation before ROSC. Furthermore, a multivariable logistic regression analysis was carried out to identify factors associated with outcomes.ResultsOf 373,993 OHCA patients with attempted resuscitation during 2015–2017, 22,067 patients with prehospital ROSC were included in our study. Patients were divided into the shockable initial rhythm (n = 5,580) and nonshockable initial rhythm (n = 16,487) cohorts. The ROC curves showed 10 min was the best test performance time point for a neurologically favorable outcome for shockable initial rhythm patients (sensitivity, 0.78; specificity, 0.53; area under the ROC curve [AUC], 0.70) and 8 min for nonshockable initial rhythm patients (sensitivity, 0.74; specificity, 0.77; AUC, 0.83). Multivariable logistic regression analyses revealed that CPR durations using the cut‐off value were independently associated with better outcomes for both shockable initial rhythm patients (odds ratio, 2.09; 95% confidence interval, 1.81–2.42) and nonshockable initial rhythm patients (odds ratio, 3.34; 95% confidence interval, 2.92–3.82).ConclusionWhen Japanese emergency medical service (EMS) providers attend OHCA cases, the decision to initiate transport with ongoing CPR should be made at approximately 10 min after EMS providers initiate CPR for shockable initial rhythm patients and at approximately 8 min for nonshockable initial rhythm patients.

Impact of Cardiopulmonary Resuscitation Duration on Survival of Out-of-Hospital Cardiac Arrest

Background: Patients experiencing cardiac arrest outside medical facilities are at greater risk of death and might have negative outcomes. Cardiopulmonary resuscitation duration affects survival of such patients, which suggests that duration of CPR may be vital to patient outcomes. Objectives: The study aims to evaluate the impact of cardiopulmonary resuscitation duration on survival of patients who have suffered out-of-hospital cardiac arrest.

In-Hospital Cardiac Arrest: Patient Characteristics and Factors Influencing Survival and Neurologic Outcomes

Objective: We aimed to determine the characteristics of in-hospital cardiac arrest (IHCA) patients, as well as the factors influencing survival to discharge and good neurologic outcome.Methods: We examined patients who experienced IHCA from January 1, 2011, to December 31, 2013, in Soonchunhyang University Seoul Hospital. They were divided into a survival group and non-survival group. The patient characteristics, including age, sex, comorbid disease, arrest time, arrest location, witnessed arrest, monitoring, arrest cause, arrest rhythm, and cardiopulmonary resuscitation (CPR) duration, were compared between the groups. Moreover, we assessed the factors associated with survival to discharge and good neurologic outcomes by using multivariate logistic regression analysis.Results: In total, 453 patients of IHCA were observed. The comorbidities in the survival group included neurologic disease (P < 0.001), arrhythmia (P = 0.001), and myocardial infarction (P = 0.032), pneumonia (P = 0.016). Other characteristics included cardiac arrest at daytime (P = 0.032), cardiogenic arrest cause (P = 0.019), and CPR duration < 15 minutes (P < 0.001). The factors associated with survival to discharge included comorbid neurologic disease (odds ratio [OR], 2.191; P = 0.031), arrhythmia (OR, 3.027; P = 0.009), pneumonia (OR, 3.243; P = 0.002), and CPR duration < 15 minutes (OR, 9.638; P < 0.001). The factors influencing good neurologic outcomes included age < 65 years (OR, 3.158; P = 0.007), comorbid disease as arrhythmia (OR, 4.921; P = 0.001), pneumonia (OR, 4.551; P = 0.001), hypotension (OR, 4.264; P = 0.021), and CPR duration < 15 minutes (OR, 6.652; P = 0.001).Conclusion: The factors influencing survival to discharge and good neurologic outcomes among IHCA patients included comorbidities, arrest cause, and CPR duration.

Outcomes of Trauma Victims with Cardiac Arrest Who Survived to Intensive Care Unit Admission in a Level 1 Apex Indian Trauma Centre: A Retrospective Cohort Study.

Background and aimsThe prognosis of patients with cardiac arrest following trauma is poor. Our objectives were: (1) to determine outcomes of patients following in-hospital cardiac arrest posttrauma and admitted to the intensive care unit (ICU) and (2) to identify characteristics associated with in-hospital mortality.Materials and methodsThis was a single-center retrospective analysis of patients admitted to ICU after resuscitation following in-hospital cardiac arrest between January 2017 and July 2018. Patients with isolated head injuries and multiple cardiac arrests were excluded. Bivariate analysis was done to determine a significant association between baseline characteristics and in-hospital mortality.ResultsA total of 37 patients were included. About 35.1% of trauma subjects survived hospital discharge. Bivariate analysis showed positive association between admission Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores with in-hospital mortality. Other characteristics, such as age, duration of cardiopulmonary resuscitation (CPR), and serum lactate levels on admission, were not associated with in-hospital mortality.ConclusionDespite being at lower survival following a cardiac arrest after trauma, approximately one-third of the patients survived hospital discharge. This implies that aggressive support of this population is not necessarily futile. Optimization of postresuscitation physiological factors and their impacts on outcomes for these patients need further studies.How to cite this articleSoni KD, Rai N, Aggarwal R, Trikha A. Outcomes of Trauma Victims with Cardiac Arrest Who Survived to Intensive Care Unit Admission in a Level 1 Apex Indian Trauma Centre: A Retrospective Cohort Study. Indian J Crit Care Med 2021;25(12):1408–1412.

446 Relationship between out of hospital cardiac arrest and COVID-19 pandemic: impact on outcome

AimsDuring 2020, Italy was hit by the pandemic of the ‘Coronavirus disease 2019’ (COVID-19) with an incidence/100 000 citizens characterized by two peaks. An increase in out-of-hospital cardiac arrest (OHCA) mortality during the first pandemic peak has already been described, but there are few data on the whole year. The goal of our study is to evaluate the impact of the pandemic on post-OHCA mortality.MethodsWe considered patients with OHCA in Varese territory from January to December 2020 with medical aetiology according with Utstein 2014 classification. The primary endpoint of the study was the assessment of acute post-arrest mortality and which parameters influence this outcome. In particular, both the role of pandemic peaks (‘first peak’ from 11 March 2020 to 23rd May 2020 and ‘second peak’ from 7 October 2020 to 31 December 2020) and the average rescue times, i.e.: (i) interval between OHCA and call for first aid (delay in activation of assistance); (ii) the interval between the call and the arrival of the rescue vehicles (delay in the arrival of the first aid) and finally; (iii) the time between the arrival of the rescue vehicles and the end of Cardiopulmonary Resuscitation (CPR), interrupted due to death or Recovery of Spontaneous Circulation (ROSC). Finally, we performed a multivariate analysis to assess which of the variables considered had the greatest impact on the outcome.ResultsWe analysed 708 patients (mean age 76 + 14.09 years; 40% women). Overall mortality was 89%. During the peaks there was an increase in mortality compared to the pre-pandemic period (first peak 96% vs. 83%, OR 4.49; second peak 92% vs. 83%, OR 2.45) (Figure 1). The time between the collapse and the call for help was significantly higher during the first pandemic peak compared to the second peak and the pre-pandemic period (P = 0.003); the time between the call and the arrival on the patient was significantly longer during both pandemic peaks than in the previous period (P = 0.002) and there was no significant difference in CPR duration time between the periods analysed. In a multivariate model, the only time associated with an increase in mortality is the period between the call for help and the arrival on the patient, regardless of the COVID-19 pandemic.Figure 1446 ConclusionsDuring the COVID-19 pandemic there has been an increase in mortality of patients with OHCA. Among the variables considered, the increase in mortality is mainly associated with the delay in the arrival of emergency vehicles on site. This delay, although decreasing, was also maintained during the second peak of the pandemic.

Survival and Factors Associated with Survival with Extracorporeal Life Support During Cardiac Arrest: A Systematic Review and Meta-Analysis

The survival rate after cardiac arrest (CA) remains low. The utilization of extracorporeal life support is proposed to improve management. However, this resource-intensive tool is associated with complications and must be used in selected patients. We performed a meta-analysis to determine predictive factors of survival. Among the 81 studies included, involving 9256 patients, survival was 26.2% at discharge and 20.4% with a good neurologic outcome. Meta-regressions identified an association between survival at discharge and lower lactate values, intrahospital CA, and lower cardio pulmonary resuscitation (CPR) duration. After adjustment for age, intrahospital CA, and mean CPR duration, an initial shockable rhythm was the only remaining factor associated with survival to discharge (β = 0.02, 95% CI: 0.007-0.02; p = 0.0004).

Impact of chronic obstructive pulmonary disease on survival and neurologic outcomes in adults with in-hospital cardiac arrest.

BackgroundLittle data exists regarding the association of chronic obstructive pulmonary disease (COPD) on outcomes in the setting of in-hospital cardiac arrest (IHCA). We sought to assess the impact of COPD on mortality and neurologic outcomes in adults with IHCA.MethodsThe study population included 593 consecutive hospitalized patients with IHCA undergoing ACLS-guided resuscitation at an academic tertiary medical center from 2012–2018. The primary and secondary outcomes of interest were survival to discharge and favorable neurological outcome (defined as a Glasgow Outcome Score of 4–5) respectively.ResultsOf the 593 patients studied, 162 (27.3%) had COPD while 431 (72.7%) did not. Patients with COPD were older, more often female, and had higher Charlson Comorbidity score. Location of cardiac arrest, initial rhythm, duration of cardiopulmonary resuscitation, and rates of defibrillation and return of spontaneous circulation were similar in both groups. Patients with COPD had significantly lower rates of survival to discharge (10.5% vs 21.6%, p = 0.002) and favorable neurologic outcomes (7.4% vs 15.9%, p = 0.007). In multivariable analyses, COPD was independently associated with lower rates of survival to discharge [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.30–0.98, p = 0.041].ConclusionsIn this contemporary prospective registry of adults with IHCA, COPD was independently associated with significantly lower rates of survival to discharge.

Abstract 13412: Gender Based Differences in Duration of Cardiopulmonary Resuscitation in the Inpatient Setting

Introduction: The decision to terminate cardiopulmonary resuscitation (CPR) prior to return of spontaneous circulation (ROSC) may be impacted by resuscitation parameters or by patient demographics. Studies show that longer resuscitation efforts have a higher likelihood of ROSC and survival to discharge. It is unclear if gender of the code leader and the patient may be associated with duration of unsuccessful CPR attempt. Methods: Retrospective chart review of inpatient CA that occurred at the UC San Diego Health System between 2011-2019. All adult inpatients with an index cardiac arrest who expired within three days of admission were included. Exclusion criteria included patients who achieved ROSC, CA that occurred outside of the wards or ICU, those with active pre-arrest DNR status, and patients with CA > 3 days after admission (done to minimize provider bias based on prior knowledge of the patient). Data were identified from an internal cardiac arrest quality improvement database. Patient gender was self-reported and code leader gender was identified. Primary outcome was duration of resuscitation efforts. To determine differences in duration of CPR between code leader and patient gender a one-sided ANOVA test was used. A p value < 0.05 was considered statistically significant. Results: We identified 91 patients between 2011 and 2019 that met inclusion criteria. Thirty-eight patients (41.8%) identified as female, fifty-three identified as male (58.2%), the average age was 62.7 years old, and seventeen (18.7%) had initial shockable rhythm. Thirty (33%) of the code leaders identified as female and sixty-one (67%) identified as male. Average duration of CPR was 31.6 minutes (2 - 135 minutes) for male patients with male code leader, 32.2 minutes (9 - 71 minutes) for male patients with female code leader, 27.0 minutes (7 - 60 minutes) for female patients with female code leader, and 33.7 minutes (10 - 73 minutes) for female patients with male code leader. No significant difference in duration of unsuccessful CPR attempt associated with gender of code leader and gender of patient in ANOVA analysis was found (p = 0.512). Conclusions: We did not identify a significant association between code leader and patient gender on duration of CPR in the inpatient setting.

Abstract 12398: Cardiopulmonary Resuscitation Duration Determines Phenotype of Post-Arrest Brain Injury

Introduction: Patients resuscitated from out-of-hospital cardiac arrest (OHCA) have variable severity of brain injury. Signatures of severe injury on brain imaging and EEG including diffuse cerebral edema and burst suppression with identical bursts (BSIB). Current therapies for these patterns of injury are inadequate and patient outcomes are poor. Hypothesis: We hypothesize distinct phenotypes of brain injury are associated with increasing CPR duration. Methods: We identified from our prospective registry OHCA patients treated between January 2010 to July 2019. We abstracted CPR duration, best neurological examination < 6 hours from OHCA, initial brain CT grey-to-white ratio (GWR), and initial EEG pattern. We defined cerebral edema as GWR <1.20. We defined BSIB according to American Clinical Neurophysiology Society guidelines. We considered four phenotypes on presentation: awake; comatose with neither BSIB nor cerebral edema; BSIB; and cerebral edema. BSIB and cerebral edema were considered as non-mutually exclusive outcomes. We compared duration of CPR across groups using Kruskal-Wallis tests with Bonferroni correction for multiple hypothesis testing. We report the probability of presenting phenotype at the median CPR duration for each group using local regression. Results: We included 2,721 patients, of whom 582 (21%) were awake, 1,428 (52%) had coma without BSIB or edema, 372 (14%) had BSIB and 356 (13%) had cerebral edema. Only 47 (2%) had both BSIB and edema. Median CPR duration was 16 [IQR 8-28] minutes overall. Median CPR duration increased in a stepwise manner across groups: awake 6 [3-12] minutes; comatose without BSIB or edema 16 [9-27] minutes; BSIB 21 [14-30] minutes; cerebral edema 32 [22-46] minutes (all P <0.001). The probability of observing each phenotype at the median CPR duration for each was: awake (0.42); comatose without BSIB or edema (0.72); BSIB (0.34); cerebral edema (0.29). Conclusions: The brain injury phenotype is related to CPR duration, which is a surrogate for severity of ischemic injury. The sequence of most likely brain injury phenotype with progressively longer CPR duration is awake, coma without BSIB or edema, BSIB, and finally cerebral edema.

Cardiopulmonary Resuscitation Outcomes of Patients with COVID-19; a One-Year Survey.

Introduction:Assessing cardiopulmonary resuscitation (CPR) outcomes of patients with COVID-19 and employing effective strategies for their improvement are essential. This study is designed in this regard. Methods:This cross-sectional study was conducted between January 20, 2020 and January 20, 2021 in the emergency departments of two hospitals in Hamadan and Kermanshah, Iran. Participants were 487 patients with confirmed COVID-19 and cardiac arrest (CA) who had undergone CPR during the study period. Data were collected using the available CPR documentation forms developed based on the Utstein Style and analyses were performed using Chi-square, Fisher’s exact, and Mann-Whitney U tests and the logistic regression analysis.Results:Participants’ mean age was 69.31±14.73 years and most of them were male (61.8%) and suffered from at least one underlying disease (58.1%). The rate of total and in-hospital CA was 9.67% and 9.39%, respectively. The most prevalent first documented rhythm was asystole (67.9%) and the highest responsivity to CPR was for shockable rhythms. The rate of the return of spontaneous circulation (ROSC) was 9% and the rate of survival to hospital discharge was 2%. The significant predictors of CPR success were age (p = 0.035), epinephrine administration time interval (p = 0.00), CPR duration (p = 0.00), and First documented rhythm (p = 0.009).Conclusion:The rate of in-hospital CA among studied COVID-19 cases was 9.39% with 9% ROSC and 2% survival to hospital discharge rates after CPR. Primary CPR success among patients with COVID-19 was poor, particularly among those with asystole and bradycardia. It seems that old age and improper doses of epinephrine can reduce CPR success.

Patterns of retinal hemorrhage associated with cardiac arrest and cardiopulmonary resuscitation

Hypoxia and cardiopulmonary resuscitation (CPR) have been proposed as causes of retinal hemorrhage (RH) in children evaluated for abusive head trauma (AHT). We sought to determine the prevalence and characteristics of RH in children who underwent CPR after cardiac arrest. This was a prospective, single-center, consecutive observational study of 38 children (<18 years of age). Indirect ophthalmoscopic examination was completed by an ophthalmologist within 48 hours of CPR. Extensive medical records data were collected to assess for potential confounding factors. Outcomes included the presence and pattern of RH. Of the 38 children, 20 had in-hospital arrest; 18 had out-of-hospital arrest. The median duration of CPR was 10 minutes. Seven children had RH, of whom 6 had an RH pattern consistent with coexistent medical conditions: 4 AHT diagnosable with nonocular findings, including subdural and subarachnoid hemorrhage, rib fractures, abdominal injury (RH pattern: diffuse, numerous, intraretinal and/or multilayered RH); 1 septic shock (RH pattern: 1-2 posterior pole RH); 1 ruptured arteriovenous malformation (RH pattern: 4-8 peripapillary RH). The seventh child had unwitnessed cardiac arrest due to nonfatal drowning and a single superficial intraretinal peripapillary hemorrhage. CPR for cardiac arrest is rarely associated with RH, which, absent coexisting conditions causing retinal hemorrhage, are intraretinal, few in number, and located in the posterior pole. In children who have undergone CPR, when RH are multilayered, or are more than a few in number, or extend outside the posterior pole, another etiology for the RH should be sought.

Clinical spectrum and risk factors for mortality among seawater and freshwater critically ill drowning patients: a French multicenter study

BackgroundDrowning is a global threat and one of the leading causes of injury around the world. The impact of drowning conditions including water salinity on patients’ prognosis remains poorly explored in Intensive Care Units (ICUs) patients.MethodsWe conducted a retrospective multicenter study on patients admitted to 14 ICUs in the west of France from January 2013 to January 2020. We first compared demographic and clinical characteristics at admission as well as clinical courses of these patients according to the salinity of drowning water. Then, we aimed to identify variables associated with 28-day survival using a Cox proportional hazard model.ResultsOf the 270 consecutive included patients, drowning occurred in seawater in 199 patients (73.7%) and in freshwater in 71 patients (26.3%). Day-28 mortality was observed in 55 patients (20.4%). Freshwater was independently associated with 28-day mortality (Adjusted Hazard Ratio (aHR) 1.84 [95% Confidence Interval (CI) 1.03–3.29], p = 0.04). A higher proportion of freshwater patients presented psychiatric comorbidities (47.9 vs. 19.1%; p < 0.0001) and the etiology of drowning appeared more frequently to be a suicide attempt in this population (25.7 vs. 4.2%; p < 0.0001). The other factors independently associated with 28-day mortality were the occurrence of a drowning-related cardiac arrest (aHR 11.5 [95% CI 2.51–52.43], p = 0.0017), duration of cardiopulmonary resuscitation (aHR 1.05 [95% CI 1.03–1.07], p < 0.0001) and SOFA score at day 1 (aHR 1.2 [95% CI 1.11–1.3], p < 0.0001).ConclusionsIn this large multicenter cohort, freshwater drowning patients had a poorer prognosis than saltwater drowning patients. Reasons for such discrepancies include differences in underlying psychiatric comorbidity, drowning circumstances and severities. Patients with initial cardiac arrest secondary to drowning remain with a very poor prognosis.

Outcomes Following In-Hospital Cardiopulmonary Resuscitation in People Receiving Maintenance Dialysis

Rationale & ObjectivePrevious studies showing poor cardiopulmonary resuscitation (CPR) outcomes in the dialysis population have largely been derived from claims data and are somewhat limited by a lack of detailed characterization of CPR events. We aimed to analyze CPR-related outcomes in individuals receiving maintenance dialysis.Study DesignRetrospective chart review.Setting & ParticipantsUsing electronic medical records from a single academic health care system, we identified all hospitalized adult patients receiving maintenance dialysis who had undergone in-hospital CPR between 2006 and 2014.ExposureInitial in-hospital CPR.OutcomesOverall survival, predictors of unsuccessful CPR, predictors of death during the same hospitalization among initial survivors, predictors of discharge-to-home status.Analytical ApproachWe provide descriptive statistics for the study variables and used t tests, χ2 tests, or Fisher exact tests to compare differences between the groups. We built multivariable logistic regression models to examine the CPR-related outcomes.ResultsA total of 184 patients received in-hospital CPR: 51 (28%) did not survive the initial CPR event, and 77 CPR survivors died (additional 42%) later during the same hospitalization (overall mortality 70%). Only 18 (10%) were discharged home, with the remaining 32 (17%) discharged to a rehabilitation facility or a nursing home. In the multivariable model, the only predictor of unsuccessful CPR was CPR duration (OR, 1.41; 95% CI, 1.24-1.61; P < 0.001). Predictors of death during the same hospitalization after surviving the initial CPR event were CPR duration (OR, 1.15; 95% CI 1.04-1.27; P = 0.007) and older age (OR, 1.64; 95% CI, 1.23-2.2; P < 0.001). Older people also had lower odds of discharge-to-home status (OR, 0.25; 95% CI, 0.11-0.54; P < 0.001).LimitationsRetrospective study design, single-center study, no information on functional status.ConclusionsPatients receiving maintenance dialysis experience high mortality following in-hospital CPR and only 10% are discharged home. These data may help clinicians provide useful prognostic information while engaging in goals of care conversations.

Risk factors and outcomes for recurrent paediatric in-hospital cardiac arrest: Retrospective multicenter cohort study

Aim of studyRecurrent in-hospital cardiac arrest (IHCA) is associated with morbidity and mortality in adults. We aimed to describe the risk factors and outcomes for paediatric recurrent IHCA. MethodsRetrospective cohort study of patients ≤18 years old with single or recurrent IHCA. Recurrent IHCA was defined as ≥2 IHCA within the same hospitalization. Categorical variables expressed as percentages and compared via Chi square test. Continuous variables expressed as medians with interquartile ranges and compared via rank sum test. Outcomes assessed in a propensity match cohort. ResultsFrom July 1, 2015 to January 26, 2021, 139/894 (15.5%) patients experienced recurrent IHCA. Compared to patients with a single IHCA, recurrent IHCA patients were more likely to be trauma and less likely to be surgical cardiac patients. Median duration of cardiopulmonary resuscitation (CPR) was shorter in the recurrent IHCA (5 vs. 11 min; p < 0.001) with no difference in IHCA location or immediate cause of CPR. Patients with recurrent IHCA had worse survival to intensive care unit (ICU) discharge (31% vs. 52%; p < 0.001), and worse survival to hospital discharge (30% vs. 48%; p < 0.001) in unadjusted analyses and after propensity matching, patients with recurrent IHCA still had worse survival to ICU (34% vs. 67%; p < 0.001) and hospital (31% vs. 64%; p < 0.001) discharge. ConclusionWhen examining those with a single vs. a recurrent IHCA, event and patient factors including more pre-existing conditions and shorter duration of CPR were associated with risk for recurrent IHCA. Recurrent IHCA is associated with worse survival outcomes following propensity matching.

Clinical outcomes in COVID-19 patients with in-hospital cardiac arrest – an insight from multi-centre data

Abstract Background In general, rates of in-hospital cardiac arrest are reportedly 9 to 10 arrests per 1000 admissions, with survival rates of approximately 20–25%. Data regarding clinical characteristics and outcomes in patients with COVID-19 who received in-hospital CPR (cardiopulmonary resuscitation) are limited. This information can help guide end-of-life care conversations between families and health care workers based on real-world experience. Purpose To observe the outcomes (survival to discharged alive from the hospital) in critically sick COVID-19 patients who experienced in-hospital cardiac arrest. Methods This is a multi-centre institutional review board (IRB) approved retrospective study. The RT-PCR confirmed adult COVID-19 patients consecutively admitted from March 1st to April 30, 2020, were included. Data were extracted manually using the hospital's electronic medical record. The final date of follow-up to monitor clinical outcomes was January 2021. Results A total of 721 patients were admitted to the hospital. Of these, only 64 (8.87%) patients had “no CPR” orders.Cardiac arrest occurred in 141 (19.5%) patients. The mean duration of beginning of resuscitation was less than a minute and the mean duration of CPR was 19 minutes. The median age was 65 years; 62.4% were male. The most common co-morbidities were hypertension (66%) and diabetes mellitus (56%). The initial rhythm was non-shockable in 93.7% of patients [asystole in 48.4% and Pulseless Electrical Activity (PEA) in 45.3% of patients]. Only six (4.2%) patients had pulseless ventricular tachycardia and three (2.1%) patients had ventricular fibrillation. A total of eight patients (5.6%) survived and were discharged from the hospital; six (4.25%) had non-shockable and two (0.82%) had shockable initial rhythms. The median age of those who survived was 60 years (Figure 1). Conclusions Our study showed that critically sick patients with COVID-19 have a high rate of cardiac arrest and poor outcomes in those who received CPR. A non-shockable initial rhythm indicates that non-cardiac reasons might be playing a major role. These include acute respiratory insufficiency, severe sepsis, or multiorgan failure. These data should inform end-of-life care discussions between providers and patients' families. Funding Acknowledgement Type of funding sources: None.

42 Improving Patient Selection in International Pediatric ECPR Cohorts

To examine the efficacy of duration of cardiopulmonary resuscitation (CPR) and duration of extracorporeal membrane oxygenation (ECMO) as predictors of survival in pediatric extracorporeal cardiopulmonary resuscitation (ECPR) patients outside the United States. We searched EMBASE, PubMed, SCOPUS, and the Cochrane Library from the years 2010 to 2020 for pediatric ECPR performed arrest outside the United States comparing survivor data to non-survivor data. Primary outcomes of interest were duration of CPR and duration of ECMO. Secondary outcomes of interest were age, sex, weight, pre-ECPR pH, and pre-ECPR lactate. 17 studies (n = 1848) were included. The average survival rate was 39.9%. In international ECPR cohorts, longer CPR duration (n = 508, 10 studies) was demonstrated to be a significant predictor of survival, with the average survivor having 37.0 ± 28 minutes of CPR and the average non-survivor having 52.6 ± 48 minutes of CPR (Standardized Mean Difference (SMD) = -0.47 [95% CI: -0.77 - -0.17], I2 = 43%). ECMO duration (n = 1563, 12 studies) was not significantly associated with survival, with the average survivor having 98.0 ± 140 minutes and the average non-survivor having 114.3 ± 114 minutes of ECMO (SMD = -0.16 [-0.37 - 0.05], I2 = 49%). Age (p = 0.46) and female sex (p = 0.056) were additionally not significantly associated with survival. Increased weight (p = 0.047), elevated pre-ECPR lactate levels (p = 0.01), and elevated pre- ECPR pH (p < 0.01) were significantly associated with increased mortality. In this cohort of international pediatric ECPR patients from the last ten years, the primary outcome of elevated CPR duration was significantly associated with increased risk of mortality. This suggests ECPR programs should prioritize ECPR initiation earlier in cardiac arrest cases to minimize CPR duration prior to ECPR commencement. In addition, increased weight, elevated, pre-ECPR lactate levels, and elevated pre- ECPR pH were associated with increased risk of mortality. Elevated ECMO duration, age, and sex were not associated with increased risk of mortality. These factors can help provide clinicians with more information on the potential prognosis of patients, appropriate patient selection, and ECPR program effectiveness.

SODIUM BICARBONATE USE IN IN-HOSPITAL CARDIAC ARRESTS: A RETROSPECTIVE ANALYSIS

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Sodium Bicarbonate has been used during advanced cardiac life support as one of the supportive measures to fight the build-up of acidosis during prolonged CPR. We aim to investigate the influence of bicarbonate administration on outcomes of cardiopulmonary resuscitation (CPR). METHODS: This was a retrospective observational study in a single medical center and included adult patients who had suffered an in-hospital cardiac arrest between 2016 and 2020. The mean age was 67.2 years (SD 15.5, range 18-95 years), with 109 males (60.2%). We used multivariable logistic regression analysis to evaluate the associations between independent variables and outcomes. The main variable for analysis was the use of bicarbonate during CPR vs no bicarbonate usage. Other factors analyzed were age, gender, comorbidities (heart failure, diabetes, hypertension, COPD, coronary artery disease, and sepsis), as well timing of CPR and total dose of epinephrine used during CPR. Favorable neurological outcome was based on clinical documentation. Kruskal-Wallis rank-sum tests and Pearson's Chi-squared tests were used to calculate p values. RESULTS: 181 patients were included in this analysis. After adjusting for comorbidities, duration of CPR, and confounding medications, the results indicated that sodium bicarbonate usage during CPR was a predictor of poor outcome, there was a significant reduction in the odds of discharge when a patient was given bicarbonate (OR = 0.18 – CI 0.09-0.37, p=<0.0001), such that there is an 82% reduction in the odds of discharge if bicarbonate is given. A likelihood ratio test was used to adjust for different dosing intervals of epinephrine and analyze outcomes for patients who received bicarbonate versus patients who did not, and bicarbonate continued to be a significant predictor of the odds of discharge, again with an 82% reduction in the odds of being discharged if bicarbonate is received (OR = 0.18 – CI 0.09-0.38, p=<0.0001). The odds of neurological recovery at 30 days were reduced by 76% for patients who were given bicarbonate during CPR (OR 0.24, CI 0.11-0.48, p<0.0001). CONCLUSIONS: Sodium Bicarbonate usage during CPR for in-hospital cardiac arrests was seen as a predictor of poor outcomes, including higher in-hospital mortality, and lesser chances of significant neurological recovery. This effect might be partly due to the fact that bicarbonate is used mainly during prolonged CPR situations, which is itself a predictor of poor outcomes. CLINICAL IMPLICATIONS: Sodium bicarbonate usage during CPR was seen to be associated with poorer neurological and mortality outcomes. Larger RCTs are needed to validate these findings. DISCLOSURES: No relevant relationships by Rahul Bollam, source=Web Response No relevant relationships by Waliul Chowdhury, source=Web Response No relevant relationships by Kainat Saleem, source=Web Response No relevant relationships by Syed Arsalan Zaidi, source=Web Response

Successful use of extended cardiopulmonary resuscitation followed by extracorporeal oxygenation after venlafaxine-induced takotsubo cardiomyopathy and cardiac arrest: a case report

BackgroundSevere venlafaxine intoxication may cause arrhythmias, cardiac failure, and even cardiac arrest.Case presentationA 48-year-old caucasian male with an extensive psychiatric history ingested a high dose of venlafaxine causing a serum venlafaxine concentration of 12.6 mg/L 24 hours after ingestion. Seven hours post-ingestion, he experienced tonic–clonic seizures, and 8 hours later, takotsubo cardiomyopathy was recognized followed by cardiac arrest. The patient was resuscitated with prolonged cardiopulmonary resuscitation including ongoing automatic external compressions during helicopter transportation to a tertiary hospital for extracorporeal membrane oxygenation treatment. Despite a cardiopulmonary resuscitation duration of 2 hours, 36 hours of extracorporeal membrane oxygenation, and a total of 30 days of intensive care, the patient made a full recovery.ConclusionIn cases of intoxication-induced cardiac arrests among otherwise young and healthy patients, prolonged cardiopulmonary resuscitation and extracorporeal circulation can be a life-saving bridge to recovery.

Treatment and survival following in-hospital cardiac arrest: does patient ethnicity matter?

Previous research on racial/ethnic disparities in relation to cardiac arrest has mainly focused on black vs. white disparities in the USA. The great majority of these studies concerns out-of-hospital cardiac arrest (OHCA). The current nationwide registry study aims to explore whether there are ethnic differences in treatment and survival following in-hospital cardiac arrest (IHCA), examining possible disparities towards Middle Eastern and African minorities in a European context. In this retrospective registry study, 24 217 patients from the IHCA part of the Swedish Registry of Cardiopulmonary Resuscitation were included. Data on patient ethnicity were obtained from Statistics Sweden. Regression analysis was performed to assess the impact of ethnicity on cardiopulmonary resuscitation (CPR) delay, CPR duration, survival immediately after CPR, and the medical team's reported satisfaction with the treatment. Middle Eastern and African patients were not treated significantly different compared to Nordic patients when controlling for hospital, year, age, sex, socioeconomic status, comorbidity, aetiology, and initial heart rhythm. Interestingly, we find that Middle Eastern patients were more likely to survive than Nordic patients (odds ratio = 1.52). Overall, hospital staff do not appear to treat IHCA patients differently based on their ethnicity. Nevertheless, Middle Eastern patients are more likely to survive IHCA.