Cerebral Performance Category Score Research Articles

Impact of sedation depth on neurological outcome in post-cardiac arrest patients – A retrospective cohort study

AimsWhether targeted temperature management (TTM) might improve neurologic prognosis in patients after cardiac arrest is currently under debate. Data concerning sedation depth during TTM is rare. This study aimed to compare the impact of different sedation depths on neurological outcomes in post-cardiac arrest patients undergoing TTM . MethodsIn this retrospective, before-and-after registry study, all patients receiving TTM on a medical ICU between 08/2016 and 03/2021 were included. This study evaluated the following sedation targets: RASS-target during TTM −5 until 08/2019 and RASS-target −4 since 09/2019. The primary endpoint was favorable neurological outcome at ICU discharge, defined as a Cerebral Performance Category (CPC) score of 1 or 2. Results403 patients were included (RASS-target −5: N = 285; RASS-target −4: N = 118). Favorable neurological outcome was documented in 54/118 (45.8 %) patients in the group with a RASS-target of −4 compared to 111/285 (38.9 %) in the group with a RASS-target of −5. After adjustment for age, sex, initial shockable rhythm, bystander CPR, duration of CPR and mean arterial pressure 12 h after CPR, favorable neurological outcome was associated with RASS-target −4 (OR 1.82 (95 % CI: 1.02–3.23); p = 0.042). ICU survival was similar in both groups while 30-day survival was associated with RASS-target −4 (OR 1.81 (1.01–3.26); p = 0.047). ConclusionLighter sedation strategies during TTM after cardiac arrest might improve outcome and should be further investigated.

Combined sonographic optic nerve sheath diameter and cerebral oximeterfor predicting neurological outcome after cardiac arrest.

Cardiac arrest (CA) remains a critical global health issue with high rates of mortality and morbidity. Accurate prediction of neurological outcomes in post-CA patients is essential for optimizing management strategies. Optic nerve sheath diameter (ONSD) and near-infrared spectroscopy (NIRS) are emerging as promising tools for evaluating brain oxygenation and intracranial pressure. However, the potential benefits of combining these methods for improved prognostic accuracy have not been thoroughly explored. This study investigates whether the combined use of ultrasonographic ONSD and NIRS measurements enhances the prediction of neurological outcomes after CA. In this prospective study, ONSD measurements were obtained three times at 24-hour intervals, while regional hemoglobin oxygen saturation (rSO2) using NIRS was recorded twice. Neurological outcomes were assessed using the Full Outline of Unresponsiveness (FOUR) and Cerebral Performance Categories (CPC) scores for both early and late evaluations. Results indicated that 47.5% of patients had poor outcomes and 52.5% had good outcomes based on the FOUR score, while 65% had poor outcomes and 35% had good outcomes according to the CPC score. The combination of ONSD and NIRS measurements showed superior prognostic performance compared to either method alone. While standalone NIRS measurements taken after 24 hours exhibited limited predictive value, combining ONSD and NIRS provided a more reliable approach for neurological assessment in the short term following CA. This integrated method may improve prognostic accuracy and support better clinical decision-making.

Delirium after cardiac arrest: incidence, risk factors, and association with neurologic outcome—insights from the Freiburg Delirium Registry

Abstract Aim Delirium in patients treated in the intensive care unit (ICU) is linked to adverse outcome, according to previous observations. However, data on patients recovering after cardiac arrest are sparse. The aim of this study was to assess incidence, risk factors, and outcome of patients with delirium after cardiac arrest in the Freiburg Delirium Registry (FDR). Methods In this retrospective registry study, all patients after cardiac arrest treated in the Freiburg University Medical Center medical ICU between 08/2016 and 03/2021 were included. Delirium was diagnosed using the Nursing Delirium screening scale (NuDesc), assessed three times daily. Favorable neurological outcome was defined as cerebral performance category (CPC) score at ICU discharge ≤ 2. Results Two hundred seventeen patients were included and among them, delirium was detected in one hundred ninety-nine (91.7%) patients. Age was independently associated with the incidence of delirium (p = 0.003), and inversely associated with the number of delirium-free days (p < 0.001). Favorable neurological outcome was present in 145/199 (72.9%) with, and 17/18 (94.4%) patients without delirium (p = 0.048). While the incidence of delirium was not independently associated with a favorable neurologic outcome, the number of delirium-free days strongly predicted the primary endpoint [OR 2.14 (1.73–2.64), p > 0.001]. Conclusion Delirium complicated the ICU course in almost all patients after cardiac arrest. The number of delirium-free days was associated with favorable outcome while incidence of delirium itself was not. Graphical abstract

Abstract Su701: The Influence of Public Assistance Among Patients Who Received Extracorporeal Cardiopulmonary Resuscitation after Cardiac Arrest in Japan

Background: This study aimed to evaluate the influence of public assistance on patients with out-of-hospital cardiac arrest (OHCA) who received extracorporeal cardiopulmonary resuscitation (ECPR) in Japan. Methods: We conducted a secondary analysis of data from the SAVE-J II study, a retrospective, multicenter registry study involving 36 participating institutions in Japan. Patients with cardiac arrest who received ECPR were divided into two groups depending on whether or not they had received public assistance. The primary outcome was 30-day survival. Secondary outcomes were as follows: 30-day favorable neurological outcomes (cerebral performance category scores 1-2); survival at discharge; favorable neurological outcome at discharge; number of intensive care unit, hospital, ventilator, and extracorporeal membrane oxygenation days; medical expenses; proportion of percutaneous coronary intervention; target temperature management; mechanical circulatory support (MCS) device use; and withdrawal of life-sustaining therapy. Results: Of 2,157 patients registered in the SAVE-J II study, 1,885 patients were enrolled in this study; 99 patients (5.3%) received public assistance and 1,786 patients (94.7%) did not. Multivariable logistic regression analysis did not show a significant difference in 30-day survival (OR 1.22, 95% CI 0.77-1.95, p=0.40). The log-rank test for the Kaplan-Meiercurve on 30-day survival did not demonstrate a significant difference (p=0.46). Except for the use of MCS devices, there were no significant differences in secondary outcomes. Conclusions: The use of public assistance did not influence the prognoses of OHCA patients receiving ECPR. Treatment option during hospitalization may be affected by the use of public assistance.

Abstract Su804: Use of Machine Learning Models to Predict Neurologically Intact Survival for Advanced Age Adults Following Out-of-hospital Cardiac Arrest

Background: We recently published a multivariable logistic regression model that successfully predicted neurologic outcomes in advanced age adults (≥ 65 years old) who achieve return of spontaneous circulation following out-of-hospital cardiac arrest (OHCA). Prior to externally validating this model, we sought to compare the predictive performance of our logistic regression model against common machine learning (ML) algorithms using the same dataset. Methods: We performed a retrospective observational analysis of the Cardiac Arrest Registry to Enhance Survival database from 2013-2021. All non-traumatic OHCA occurring in adults (≥65 years) who survived to hospital admission were included. The primary outcome measure was neurologically intact survival defined as a cerebral performance category (CPC) score of 1 or 2 at hospital discharge. Our original logistic regression model was compared to Boosted Trees and Decision Tree ML algorithms and assessed using accuracy, Area Under the Receiver Operating Characteristic Curve (AUC-ROC) and Area Under the Precision-Recall Curve (AUC-PR). The model variables included age, gender, race/ethnicity, location, witnessed status, who initiated cardiopulmonary resuscitation, whether an automated external defibrillator was applied prior to emergency medical services arrival, and first monitored rhythm. Results: A total of 83,561 OHCA were included. Median age was 75 years (IQR 69-82), 58.9% were male, 53% were White, 67% experienced an OHCA at home, 52% were witnessed by a bystander, 44% received bystander CPR, and 34% were found in shockable rhythm. Neurologically intact survival (CPC 1 or 2) occurred in 23% of patients. The logistic regression model had an accuracy of 79.6%, AUC-PR 0.542, and AUC-ROC of 0.774. The Boosted Trees model had an accuracy of 79.2%, AUC-PR 0.555, and AUC-ROC of 0.774. The Decision Tree Model had an accuracy of 79.3%, AUC-PR 0.490, and AUC-ROC of 0.717. Conclusion: Boosted Trees and Decision Tree ML models performed comparably to the logistic regression model in predicting favorable versus unfavorable neurological outcomes following successful resuscitation from OHCA in advanced-age adults. Given their similar performance, logistic regression may be preferred for its simplicity and interpretability over alternative ML models. Future efforts to improve and ultimately externally validate the model are warranted.

Abstract 4135335: A randomized trial of expedited intra-arrest transfer versus more extended on-scene resuscitation for refractory out of hospital cardiac arrest: the EVIDENCE Study

Background: Refractory out-of-hospital cardiac arrest (OHCA) has poor outcomes. The benefit of expedited intra-arrest transport with ongoing resuscitation versus more extended on-scene resuscitation for refractory OHCA is not clear. Methods: In this Phase III, multi-center (15 hospitals), randomized, controlled trial conducted in Sydney, Australia, we assigned patients with refractory out-of-hospital cardiac arrest to receive either expedited intra-arrest transport, with mechanical cardiopulmonary resuscitation, to a cardiac catherization-capable hospital for coronary angiography and, where available, extracorporeal membrane oxygenation (ECMO) cardiopulmonary resuscitation (ECPR) or more extended on-scene conventional CPR (advanced cardiac life support). Eligible patients were between 18 and 70 years of age, had received bystander CPR, initial rhythm VT/VF/PEA, and did not have a return of spontaneous circulation after 15 minutes of CPR, or three rounds of resuscitation. The primary outcome was survival with a favorable neurologic outcome, defined as a Cerebral Performance Category score of 1 or 2 at hospital discharge. Analyses were performed on an intention-to-treat basis. Results: One hundred and ninety-seven (197) eligible patients were randomized (median age, 57.0 years; 77 [81%] men), 149 VT/VF (76%). Ninety-five were assigned to receive expedited transfer and 102 to receive conventional CPR. Ten patients in the expedited arms and 6 patients in the conventional arm received ECPR at hospital. At hospital discharge, 15 patients (14.7%) in the expedited transfer group (median on scene time 26 mins) were alive with a favorable neurologic outcome, as compared with 15 patients (15.8%) (median on-scene time 36 minutes). This treatment difference was small and statistically insignificant (risk difference -1.1% [95% CI: -12.2% to 10.0%]), adjusted relative risk 0.95 [p=0.87, 95% CI: 0.50 to 1.8]. Conclusions: Among patients with refractory out-of-hospital cardiac arrest, expedited intra-arrest transport did not significantly improve survival with neurologically favorable outcome at discharge compared with more extended on-scene resuscitation. However, clinically relevant differences could still be consistent with our results.

Abstract Su1204: Impact of Hypothermia vs. Normothermia Temperature Management Based on Body Temperature at Hospital Arrival on 30-Day Neurological Outcomes in Out-of-Hospital Cardiac Arrest Patients: A Nationwide, Retrospective Study in Japan

Introduction: Temperature management (TM) to prevent fever is crucial to mitigate neurological deterioration post-cardiac arrest. Whether hypothermic TM (h-TM) is superior or equal to normothermic TM (n-TM) after out-of-hospital cardiac arrest (OHCA) is debatable, prompting ongoing effects to identify patients who might benefit more from h-TM. We hypothesized that effect of TM would differ based on body temperature at hospital arrival. Aim: Explore which post-cardiac arrest patient subsets might benefit from h-TM by stratifying them based on body temperature at hospital arrival. Methods: This retrospective, observational study used data from the OHCA registry in Japan. Patients 18 years and older who experienced OHCA due to medical cause and received TM in the intensive care unit were included. Primary outcome measure was 30-day favorable neurological outcomes, defined as a Cerebral Performance Category score of 1 or 2. Patients were stratified into groups based on body temperature at hospital arrival: normothermia (36.0-38.0°C), hypothermia (<36.0°C), and hyperthermia (>38.0°C). Effect of TM post-cardiac arrest (h-TM [32-34°C] or n-TM [35-36°C]) was evaluated in each stratified group. Univariable and multivariable logistic regression analysis was used for comparison. Adjusted odds ratio (OR) for favorable neurological outcome with h-TM was calculated using n-TM as a reference. Hyperthermia was excluded from multivariable analyses due to small sample size. Results: We analyzed 3,044 patients, 1,273 in the normothermia group, 1,747 in the hypothermia group, and 24 in the hyperthermia group. Numbers of patients with favorable neurological outcomes were as follows: 530/1,273 (41.6%) in the normothermia group, 584/1,747 (33.4%) in the hypothermia group, and 4/24 (16.7%) in the hyperthermia group. There were no differences in favorable 30-day neurological outcomes between h-TM and n-TM in any stratified group in the univariable analysis: normothermia (h-TM 323/785 [41.2%] vs. n-TM 207/488 [42.4%], p=0.66); hypothermia (411/1,185 [34.7%] vs. 173/562 [30.8%], p=0.11); hyperthermia (3/13 [23.1%] vs. 1/11 [9.1%], p=0.59). Multivariable analysis also showed no differences: normothermia (OR: 0.96, 95% CI: 0.72-1.26), hypothermia (OR: 1.10, 95% CI: 0.85-1.42). Conclusion: TM (h-TM vs. n-TM) did not significantly affect 30-day neurological outcomes, regardless of initial temperature at hospital arrival.

Variability of day-to-day pulsatility index change in children with cerebral malaria.

Cerebral malaria (CM) is a devastating disease and better understanding of etiologies of the resulting neurologic injury is needed. The purpose of this study is to describe the day-to-day (DTD) pulsatility index (PI) change measured by transcranial Doppler ultrasound (TCD), a novel measure of cerebral and vascular changes, in children with CM. A retrospective analysis of 122 children in sub-Saharan Africa with CM and 3 or more sequential TCD measurements was performed. Variability of DTD PI change was calculated as a measure of changes in vasculature overtime. Neurologic outcome was determined by the Pediatric Cerebral Performance Category (PCPC) score, a measure of neurologic function. Of the 122 participants, 77.9% had a good neurologic outcome (no neurologic sequelae), and 22.1% had a poor outcome (neurologic sequelae or died). Patients who had a poor neurologic outcome had higher levels of variability of DTD PI change in the right middle cerebral artery (MCA) (0.14 ± 0.21) and left MCA (0.17 ± 0.41) compared to those who had a good neurologic outcome (0.1 ± 0.1 and 0.11 ± 0.19, respectively). A higher variability of both left and right MCA DTD PI change was also associated with higher brain volume assessed through neuroimaging. Variability of DTD PI change may provide early prognostic information regarding PCPC outcomes and brain volume changes seen in CM patients. Expanded research on pathophysiologic contributors to variability of DTD PI changes in children with CM is warranted.

Intraosseous and Intravenous Epinephrine Administration Routes in Out-of-Hospital Cardiac Arrest: Survival and Neurologic Outcomes.

The rate of survival after out-of-hospital cardiac arrest varies depending on the timeliness and effectiveness of prehospital interventions. This study was conducted to compare out-of-hospital cardiac arrest outcomes between intravenous and intraosseous routes and between upper and lower extremity routes for drug administration. We retrospectively analyzed data (collected using the Utstein template) from 1220 patients who had experienced out-of-hospital cardiac arrest in Taiwan's Taoyuan City between January 2021 and August 2023. The patients were stratified into intravenous and intraosseous groups by treatment approach and upper and lower extremity access groups by access site. The study outcomes were survival to discharge, favorable neurologic outcomes (Cerebral Performance Category score 1 or 2), and survival for >2 hours. The study groups were statistically compared before and after propensity score matching. Significant pre-propensity score matching differences were observed between intravenous and intraosseous groups, and the aforementioned study outcomes were better in the intravenous group than in the intraosseous group. However, the between-group differences became nonsignificant after propensity score matching. Furthermore, lower extremity access and delayed epinephrine administration were associated with worse outcomes. Survival rates fell below 12.6% when time to treatment exceeded 15 minutes, particularly in the cases of intraosseous access and lower extremity access. This study highlights the benefits of early intervention and upper extremity access for drug administration in patients with out-of-hospital cardiac arrest. Intraosseous access may serve as a viable alternative to intravenous access. Timely administration of essential drugs during resuscitation can improve clinical outcomes and thus has implications for emergency medical service training.

Optimal Timing of the Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio as Early Predictors of Neurological Outcomes in Postcardiac Arrest Patients.

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been recognized as predictors of various critical illnesses. Our study aimed to investigate whether the NLR and PLR measured at different timepoints could predict poor neurological outcomes at 6 months. This observational retrospective cohort study included adults who had experienced out-of-hospital cardiac arrest (OHCA) and received targeted temperature management between November 2015 and December 2020. Patients with an active infection, as confirmed by an initial blood culture, were excluded. Multivariate logistic regression models were used to determine the association between the NLR and PLR at 0, 24, and 48 h after return of spontaneous circulation and poor neurological outcomes, defined as a Cerebral Performance Category score of ≥3 at 6 months. The NLR at 24 h, but not the NLR or PLR at other timepoints, was significantly associated with poor neurological outcomes (odds ratio: 1.05; 95% CI: 1.01-1.09; p = 0.018). The NLR at 24 h showed moderate accuracy in predicting poor neurological outcomes, with an AUC of 0.619. A cutoff value of 9.0 achieved 72.5% sensitivity and 47.7% specificity. The NLR measured at 24 h after ROCS could be used for early neuroprognostication given its low cost and widespread availability.

Relationship between cardiopulmonary resuscitation duration and outcomes in children with drowning-induced cardiac arrest

BackgroundDue to the difficulty in making the decision to discontinue resuscitation efforts, clinicians often perform prolonged cardiopulmonary resuscitation (CPR) in children who have drowned. This study investigated the relationship between out-of-hospital CPR duration and neurological outcomes in children with drowning-induced cardiac arrest. MethodsThis retrospective cohort study used data from the All-Japan Utstein Registry from 2013 to 2021. We included patients aged ≤18 years with drowning-induced cardiac arrest who underwent CPR via emergency medical services. The study's primary outcome was a favorable neurological outcome (Cerebral Performance Category score of 1 or 2) at 1 month. We also calculated the dynamic proportion of 1-month outcomes as a function of out-of-hospital CPR duration. Moreover, we determined the sensitivity, specificity, and positive predictive value of 33 min of out-of-hospital CPR, which is the time point at which primary analysis showed a plateau in the neurological outcomes. ResultsOf 14,849 children included in the registry, 992 cases of drowning-induced cardiac arrest were analyzed. The median out-of-hospital CPR duration was 20 (range, 2–164) min, with only 35 (3.5 %) patients showing favorable neurological outcomes at 1 month. The proportion of favorable neurological outcomes decreased rapidly for up to 33 min of out-of-hospital CPR and then plateaued to 0.3 %; only three patients achieved favorable neurological outcomes after 33 min of CPR. An out-of-hospital CPR duration of >33 min was associated with poor neurological outcomes (sensitivity, 0.17 [95 % confidence interval: 0.15–0.20]; specificity, 0.91 [0.77–0.98]; and positive predictive value, 0.98 [0.95–1.00]). ConclusionsPrehospital EMS-initiated CPR duration for children with drowning-induced cardiac arrest was inversely associated with one-month favorable neurological outcomes. Favorable neurological outcomes after >33 min of out-of-hospital CPR were extremely rare, though accurately predicting the outcome remains challenging.

Cardiovascular etiologies and risk factors of survival outcomes after resuscitation for out-of-hospital cardiac arrest: data from the KoCARC registry

Abstract Background The outcomes and characteristics of out-of-hospital cardiac arrest (OHCA) vary across geographic regions. The etiologies and prognoses of OHCA in Asian populations remain less established. This study aimed to investigate the etiologies and clinical characteristics of patients successfully resuscitated after OHCA and identify predictors of survival outcomes. Methods Data were extracted from a South Korean multicenter prospective registry of OHCA that included 64 tertiary hospitals from 2015 to 2018 (n=7577). The primary outcome was in-hospital mortality, and secondary outcome was the grade-1 cerebral performance category (CPC) score at discharge. Results Of the 7577 patients, 2066 achieved return of spontaneous circulation (ROSC) and were hospitalized and 915 (44·2%) presented with ventricular arrhythmia (VA) as their initial rhythm or on admission. The leading cause was obstructive coronary artery disease (n=413; 20·0%). Sudden unexplained death syndrome (SUDS) accounted for 67·5% of survivors, which were significantly lower with VA (82·7% vs. 48·3%, p<0.001). VA was an independent predictor of in-hospital mortality (adjusted hazard ratio [aHR] 0·72, 95% confidence interval 0·60–0·87) and the grade-1 CPC score at discharge (aHR 3·63, 95% CI 2·56–5·15). Other predictors of the primary outcome included age, ROSC on arrival, total arrest time, alertness on admission, extracorporeal membrane oxygenation use, targeted temperature management, implantable cardioverter defibrillator use, and coronary vasospasm. Conclusions SUDS was common in patients with ROSC after OHCA and thus needs to be evaluated comprehensively. VA was independently associated with favorable survival outcomes at discharge. Further management may improve clinical outcomes in patients with OHCA, particularly those with VA.

Factors associated with neurological outcomes in patients experiencing out-of-hospital cardiac arrest and severe acidaemia: retrospective analysis of a nation-wide registry

Background and objectiveAcidaemia is common among individuals who experience out-of-hospital cardiac arrest (OHCA). While severe acidaemia is a strong predictor of unfavourable outcomes, a subset of patients exhibits dramatic recovery. Despite these conflicting outcomes, little is known about the factors associated with neurological outcomes in those who experience OHCA with severe acidaemia. MethodsThis retrospective analysis used data from a Japanese multicentre nationwide database, the Japanese Association for Acute Medicine OHCA Registry. The analysis included data from adult patients with OHCA for whom blood pH data were available upon arrival to hospital. The primary outcome was 30-day survival with favourable neurological outcomes, defined as a Glasgow-Pittsburgh cerebral performance category score of 1 or 2. Patients were categorised with severe acidaemia if their blood pH was ≤ 6.8. Factors associated with favourable outcomes were investigated using multiple logistic regression analysis. ResultsData from 49,044 patients were included in the analysis, of whom 16,620 exhibited severe acidaemia with a median pH of 6.70 (interquartile range [IQR] 6.61–6.76], and 0.5% (86/16,620) experienced a neurologically favourable outcome. After adjustment for important prognostic factors, witnessed status exhibited a strong association with favourable neurological outcome (adjusted odds ratio [aOR] 6.46 [95% confidence interval (CI) 2.64–15.8]), while initial blood pH exhibited no significant association (aOR 0.90 with every 0.1 unit increase [95% CI 0.71–1.14]). ConclusionAlthough the number is small, a notable number of patients with severe acidaemia exhibited good neurological recovery. Witness status was critical for the prognosis of these patients.

The association between early hypotension and neurologic outcome after pediatric cardiac ECPR in children with cardiac disease

ObjectiveExplore the relationship between early hypotension after ECPR and survival to hospital discharge (SHD) with favorable neurologic outcome (FNO) in children with cardiac disease. MethodsRetrospective cohort study of patients undergoing ECPR at a single center pediatric cardiac intensive care unit. Hypotension was defined as MAP < 5th percentile for age. Primary and secondary exposure variables were presence and burden of hypotension respectively, during the first 6 h after ECPR. Our primary outcome was SHD with FNO defined by Pediatric Cerebral Performance Category score of 1–3 or no change from baseline. Secondary outcomes included acute central nervous system (CNS) injury via neuroimaging and EEG. Univariate and multivariable logistic regression analyses were performed. ResultsWe analyzed 82 index ECPR events from 2010 to 2022. Hypotension was observed for at least one MAP value in 36/82 (43.9%) of the cohort. The median [IQR] burden of hypotension was 0 [0,14.3]%. Patients with SHD with FNO had shorter CPR duration, lower number of epinephrine and calcium doses, and lower maximum lactate levels when compared to patients who died or had SHD without FNO. After controlling for potential confounders, there was no association between presence of hypotension or burden of hypotension and SHD, SHD with FNO, or acute CNS injury via neuroimaging and EEG. ConclusionIn children with cardiac disease, there was no association between early hypotension after ECPR and SHD with FNO. Multicenter studies are needed to better understand how early hypotension after ECPR affects neurologic outcomes in children with cardiac disease.

Validating the GO-FAR score: predicting in-hospital cardiac arrest outcomes in the Middle East

Introduction and aimExternal validations of the Good Outcome Following Attempted Resuscitation (GO-FAR) score have been in populations where Do Not Attempt Resuscitation (DNAR) is practised. We aim to externally validate the GO-FAR score in a population without a DNAR order.MethodsWe studied patients ≥ 18 years old who had an In-hospital cardiac arrest (IHCA) with known outcomes at Al Ain Hospital from January 2017 to December 2019, excluding those who died in the emergency department. Studied variables included demography, location, response time, code duration, initial rhythm, primary diagnosis, admission vital signs, GO FAR score variables, discharge status, and functional outcomes as determined by the cerebral performance category score ranging from 1 (good cerebral performance) to 5 (brain death).Results366 patients were studied; 66.7% were males. The median (IQR) age was 70 (55–81) years. Cardiac and respiratory causes were the primary diagnoses in 89 (24.6%) and 67 (18.5%), respectively. IHCA occurred in critical areas such as the intensive care unit, high dependency unit and coronary care unit in 206 (80.8%) patients. The majority, 308 (91.8%), had a non-shockable rhythm, and a return of spontaneous circulation was achieved in 159 (43.4%) of the patients. Thirty-one (8.5%) patients survived to hospital discharge, and 20 (5.5%) patients had cerebral performance category scores of 1 and 2. The area under the curve of the ROC for survival to discharge with good functional outcome was 0.74 (95% CI 0.59–0.88). The best cut-off point for predicting survival with a good neurological outcome was a GO-FAR score of < 4, having a sensitivity of 0.81, a specificity of 0.7, a positive likelihood ratio of 2.7 and a negative likelihood ratio of 0.27.ConclusionsA GO-FAR score of less than 4 predicts survival with a good neurological outcome in a healthcare system with an all-inclusive patient population with no DNAR practice.

Effects of Perfusion, Coronary Artery Disease Burden, and Revascularization in Establishing Organized Cardiac Rhythm During Extracorporeal Cardiopulmonary Resuscitation for Shockable Refractory Out-of-Hospital Cardiac Arrest.

Two hundred eighty-nine consecutive patients in refractory shockable OHCA were placed on ECMO followed by coronary angiogram (n=289) and PCI (n=165). Patients were grouped based on the extracorporeal cardiopulmonary resuscitation stage where a sustained organized rhythm was achieved. Survival outcomes were evaluated by using the Cerebral Performance Category. Logistic regression analysis was performed to determine the relationship between Cerebral Performance Category and timing of organized rhythm. Standard advanced cardiac life support before hospital arrival resulted in 148 of 289 (51%) patients attaining an organized rhythm while 87 of 289 (30%) achieved an organized rhythm post ECMO cannulation but before PCI, and 37 of 289 (13%) achieved an organized rhythm following PCI. Obstructive coronary artery disease was observed in 192 of 289 (66%) patients. A total of 144 of 192 (75%) patients with obstructive coronary artery disease converted to an organized rhythm before PCI and 37 of 192 (19%) following PCI. Cerebral Performance Category score 1 or 2 was significantly more likely in patients with cardiac arrest and obstructive coronary artery disease who achieved an organized rhythm before PCI (odds ratio [OR], 3.9 [95% CI, 1.2-12.0], P=0.024). Most patients undergoing extracorporeal cardiopulmonary resuscitation for refractory OHCA due to shockable rhythms achieved an organized rhythm before PCI independent of coronary artery disease burden. Also, neurologically favorable survival was more prevalent in those attaining an organized rhythm before PCI.

Short-term neurologic outcomes in pediatric extracorporeal membrane oxygenation are proportional to bleeding severity graded by a novel bleeding scale.

This study aimed to characterize the severity of bleeding and its association with short-term neurologic outcomes in pediatric ECMO. Multicenter retrospective cohort study of pediatric ECMO patients at 10 centers utilizing the Pediatric ECMO Outcomes Registry (PEDECOR) database from December 2013-February 2019. Subjects excluded were post-cardiac surgery patients and those with neonatal pathologies. A novel ECMO bleeding scale was utilized to categorize daily bleeding events. Poor short-term neurologic outcome was defined as an unfavorable Pediatric Cerebral Performance Category (PCPC) or Pediatric Overall Performance Category (POPC) (score of >3) at hospital discharge. This study included 283 pediatric ECMO patients with a median (interquartile range [IQR]) age of 1.3years [0.1, 9.0], ECMO duration of 5days [3.0, 9.5], and 44.1% mortality. Unfavorable PCPC and POPC were observed in 48.4% and 51.3% of patients at discharge, respectively. Multivariable logistic regression analysis included patient's age, cannulation type, duration of ECMO, need for cardiopulmonary resuscitation, acute kidney injury, new infection, and vasoactive-inotropic score. As the severity of bleeding increased, there was a corresponding increase in the likelihood of poor neurologic recovery, shown by increasing odds of unfavorable neurologic outcome (PCPC), with an adjusted odds ratio (aOR) of 0.77 (confidence interval [CI] 0.36-1.62), 1.87 (0.54-6.45), 2.97 (1.32-6.69), and 5.56 (0.59-52.25) for increasing bleeding severity (grade 1 to 4 events, respectively). Similarly, unfavorable POPC aOR (CI) was 1.02 (0.48-2.17), 2.05 (0.63-6.70), 5.29 (2.12-13.23), and 5.11 (0.66-39.64) for bleeding grade 1 to 4 events. Short-term neurologic outcomes in pediatric ECMO are proportional to the severity of bleeding events. Strategies to mitigate bleeding events could improve neurologic recovery in pediatric ECMO.

Neurologic Recovery at Discharge and Long-Term Survival After Cardiac Arrest

Brain injury is the leading cause of death following cardiac arrest and is associated with severe neurologic disabilities among survivors, with profound implications for patients and their families, as well as broader societal impacts. How these disabilities affect long-term survival is largely unknown. To investigate whether complete neurologic recovery at hospital discharge after cardiac arrest is associated with better long-term survival compared with moderate or severe neurologic disabilities. This cohort study used data from 4 mandatory national registers with structured and predefined data collection and nationwide coverage during a 10-year period in Sweden. Participants included adults who survived in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) beyond 30 days and who underwent predefined neurologic assessment conducted by health care professionals at hospital discharge using the Cerebral Performance Category (CPC) scale between January 2010 and December 2019. Patients were divided into 3 categories: complete recovery (CPC 1), moderate disabilities (CPC 2), and severe disabilities (CPC 3-4). Statistical analyses were performed in December 2023. CPC score at hospital discharge. The primary outcome was long-term survival among patients with CPC 1 compared with those with CPC 2 or CPC 3 or 4. A total of 9390 cardiac arrest survivors (median [IQR] age, 69 .0 [58.0-77.0] years; 6544 [69.7%] male) were included. The distribution of functional neurologic outcomes at discharge was 7374 patients (78.5%) with CPC 1, 1358 patients (14.5%) with CPC 2, and 658 patients (7.0%) with CPC 3 or 4. Survival proportions at 5 years were 73.8% (95% CI, 72.5%-75.0%) for patients with CPC 1, compared with 64.7% (95% CI, 62.4%-67.0%) for patients with CPC 2 and 54.2% (95% CI, 50.6%-57.8%) for patients with CPC 3 or 4. Compared with patients with CPC 1, there was significantly higher hazard of death for patients with CPC 2 (adjusted hazard ratio [aHR], 1.57 [95% CI, 1.40-1.75]) or CPC 3 or 4 (aHR, 2.46 [95% CI, 2.13-2.85]). Similar associations were seen in the OHCA and IHCA groups. In this cohort study of patients with cardiac arrest who survived beyond 30 days, complete neurologic recovery, defined as CPC 1 at discharge, was associated with better long-term survival compared with neurologic disabilities at the same time point.

Assessing variations in care delivered to rural out of hospital cardiac arrest patients in the interfacility transfer setting.

There is significant variation in out-of-hospital cardiac arrest (OHCA) outcomes between different regions. We sought to evaluate outcomes of OHCA patients in the interfacility transfer (IFT) setting, between critical care transport (LifeFlight) and community Emergency Medical Services (EMS), in the state of Maine. This was a retrospective analysis of our institution's electronic medical record and the Maine EMS database. Data were collected from January 1, 2019, to December 31, 2021. Only adult OHCA encounters requiring an IFT for definitive post-cardiac-arrest care were included. Demographics, EMS agency, IFT vital signs, targeted temperature management (TTM) medications, cerebral performance category (CPC) scores, survival to discharge, and other descriptive variables were collected. Ninety-three patients met inclusion criteria, with LifeFlight transferring 30 of them (32.3%). LifeFlight was more likely to initiate TTM compared to other EMS agencies (p=0.012), have run-sheets reported (p=0.001), and serve rural areas (p=0.036). LifeFlight was associated with more epinephrine (0.034) and norepinephrine (<0.001) use. Only 37% of IFTs had physician orders, with none (0.0%) of them defining vital sign targets. No difference in survival to discharge or CPC scores was observed between LifeFlight and other EMS agencies. No significant variation in comorbidities or vital signs was observed. There was no difference in survival to discharge or CPC scores between LifeFlight and ad hoc EMS agency. LifeFlight was associated with more TTM and vasopressor utilization during IFT. Most IFT encounters did not have dedicated physician orders, and none of the orders included vital sign targets.

Outcomes of in-hospital cardiac arrest managed with and without a specialized code team: A retrospective observational study

Background In-hospital cardiac arrest (IHCA) still has a poor prognosis despite medical advancements in recent decades. Early and high-quality cardiopulmonary resuscitation (CPR), as well as good teamwork, are important prognostic factors. There are no clear guidelines regarding the composition of a dedicated hospital CPR team. We compared outcomes of IHCA treated by a dedicated hospital CPR team compared to ward medical staff with advanced cardiac life support (ACLS) training. Methods A single-center retrospective observational study based on the cardiopulmonary resuscitation database of Soroka University Medical Center from January 2016 until December 2019. We compared the results of resuscitations conducted by regular ward medical staff, certified in ACLS, versus those conducted by the dedicated hospital’s CPR team. Results Of the 360 CPR events analyzed, 141 (39.1%) ended in return of spontaneous circulation, 70 (19.4%) patients were alive after 24 hours, 23 (6.4%) survived for 30 days, and 18 (5%) survived to discharge. Of those who survived to discharge, 11 (61.1%) had a cerebral performance category (CPC) score of 1–2, and 7 (38.9%) had a score of 3–4 (mean 2.09). Survival-to-discharge was significantly higher in the CPR-team group compared to the ward-team group (7.6% vs. 1.9%, p = 0.013). However, with propensity score analysis the difference in survival became insignificant (RR = 1.97, 95% CI: 0.40–9.63, p = 0.40). Conclusion We found no difference in survival between IHCA treated by a dedicated hospital CPR team compared to a standard ward team, both trained with biennial ACLS training. Nevertheless, crude survival-to-discharge was significantly higher in the CPR-team group.