Cerebral Performance Category Research Articles

Cardiac arrest in an emergency department in Colombia during 2011-2020: A descriptive study.

Cardiac arrest is a public health problem related to high morbidity and mortality. In Colombia, objective data characterize in our population has been not available. The aim of this study has been to determined the epidemiological characteristics of patients with cardiorespiratory arrest treated in an emergency room. A retrospective observational cross-sectional cohort study was performed. We included adult patients admitted with a diagnostic of out-of-hospital cardiac arrest (OHCA) or who presented with in-hospital cardiac arrest while in the emergency department (ED). A total of 415 patients were included 232 were men, and the median age was 67 years. OHCA was presented in 383 patients. In this group, 80.2% required orotracheal intubation, 90.1% received Epinephrine, and and 52.6% received immediate resuscitation. Survival after discharge was 43.1% in patients with non-shockable rhythm registered. Return of spontaneous circulation was achieved in 49.6%. The survival after hospital discharge was 22.2%. Cerebral performance category score <=2 was 20.4%. In our study, the epidemiological characteristics and outcomes of patients seen in the ED with cardiac arrest are similar to those described in the literature.

Frailty and Neurologic Outcomes of Patients Resuscitated From Nontraumatic Out-of-Hospital Cardiac Arrest: A Prospective Observational Study.

To elucidate the clinical utility of the Clinical Frailty Scale score for predicting poor neurologic functions in patients resuscitated from out-of-hospital cardiac arrest (OHCA). This was a prospective, multicenter, observational study conducted between 2019 and 2021. The study included adults with nontraumatic OHCA admitted to the intensive care unit after return of spontaneous circulation (ROSC). Pre-arrest high Clinical Frailty Scale score was defined as 5 or more. Favorable neurologic outcomes defined as a Cerebral Performance Category score of 2 or less at 30 days after admission were compared between patients with and without high Clinical Frailty Scale scores. Multivariable logistic regression analyses fitted with generalized estimating equations were performed to adjust for patient characteristics, out-of-hospital information, and resuscitation content and account for within-institution clustering. Of 9,909 patients with OHCA during the study period, 1,216 were included, and 317 had a pre-arrest high Clinical Frailty Scale score. Favorable neurologic outcomes were fewer among patients with high Clinical Frailty Scale scores. The high Clinical Frailty Scale score group showed a lower percentage of favorable neurologic outcomes after OHCA than the low Clinical Frailty Scale score group (6.1% vs 24.4%; adjusted odds ratio, 0.45 [95% confidence interval 0.22 to 0.93]). This relationship remained in subgroups with cardiogenic OHCA, with ROSC after hospital arrival, and without a high risk of dying (Clinical Frailty Scale score of 7 or less), whereas the neurologic outcomes were comparable regardless of pre-arrest frailty in those with noncardiogenic OHCA and with ROSC before hospital arrival. Pre-arrest high Clinical Frailty Scale score was associated with unfavorable neurologic functions among patients resuscitated from OHCA. The Clinical Frailty Scale score would help predict clinical consequences following intensive care after ROSC.

Extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: a systematic review and meta-analysis of randomized clinical trials.

Extracorporeal cardiopulmonary resuscitation (ECPR) is currently recommended as a rescue therapy for selected patients in refractory out-of-hospital cardiac arrest (OHCA). However, there is conflicting evidence regarding its effect on survival and neurological outcomes. We conducted a systematic review and meta-analysis of randomized clinical trials (RCTs) to evaluate whether ECPR is superior to standard CPR in refractory OHCA. We performed a systematic search of electronic databases (PubMed, CENTRAL, and Scopus) until March 2023. Studies were eligible if they a) were RCTs, and b) compared ECPR vs. standard CPR for OHCA. Outcomes were defined as survival with a favorable neurological status (cerebral performance category 1 or 2) at both the shortest follow-up and at 6months, and in-hospital mortality. Meta-analyses using a random-effects model were undertaken. Three RCTs, with a total of four hundred and eighteen patients, were included. Compared with standard CPR, ECPR was associated with a non-statistically significant higher rate of survival with a favorable neurological outcome at the shortest follow-up (26.4% vs. 17.2%; RR 1.47 [95% CI 0.91-2.40], P = 0.12) and at 6months (28.3% vs. 18.6%; RR 1.48 [95% CI 0.88-2.49], P = 0.14). The mean absolute rate of in-hospital mortality was not significantly lower in the ECPR group (RR 0.89 [95% CI 0.74-1.07], P = 0.23). ECPR was not associated with a significant improvement in survival with favorable neurologic outcomes in refractory OHCA patients. Nevertheless, these results constitute the rationale for a well-conducted, large-scale RCT, aiming to clarify the effectiveness of ECPR compared to standard CPR.

Association between time-dependent changes in cerebrovascular autoregulation after cardiac arrest and outcomes: A prospective cohort study

This prospective observational single-center cohort study aimed to determine an association between cerebrovascular autoregulation (CVAR) and outcomes in hypoxic-ischemic brain injury post-cardiac arrest (CA), and assessed 100 consecutive post-CA patients in Japan between June 2017 and May 2020 who experienced a return of spontaneous circulation. Continuous monitoring was performed for 96 h to determine CVAR presence. A moving Pearson correlation coefficient was calculated from the mean arterial pressure and cerebral regional oxygen saturation. The association between CVAR and outcomes was evaluated using the Cox proportional hazard model; non-CVAR time percent was the time-dependent, age-adjusted covariate. The non-linear effect of target temperature management (TTM) was assessed using a restricted cubic spline. Of the 100 participants, CVAR was detected using the cerebral performance category (CPC) in all patients with a good neurological outcome (CPC 1–2) and in 65 patients (88%) with a poor outcome (CPC 3–5). Survival probability decreased significantly with increasing non-CVAR time percent. The TTM versus the non-TTM group had a significantly lower probability of a poor neurological outcome at 6 months with a non-CVAR time of 18%–37% (p < 0.05). Longer non-CVAR time may be associated with significantly increased mortality in hypoxic-ischemic brain injury post-CA.

The effect of sedation and time after cardiac arrest on coma outcome prognostication based on EEG power spectra.

Early prognostication of long-term outcome of comatose patients after cardiac arrest remains challenging. Electroencephalography-based power spectra after cardiac arrest have been shown to help with the identification of patients with favourable outcome during the first day of coma. Here, we aim at comparing the power spectra prognostic value during the first and second day after coma onset following cardiac arrest and to investigate the impact of sedation on prognostication. In this cohort observational study, we included comatose patients (N = 91) after cardiac arrest for whom resting-state electroencephalography was collected on the first and second day after cardiac arrest in four Swiss hospitals. We evaluated whether the average power spectra values at 4.6-15.2 Hz were predictive of patients' outcome based on the best cerebral performance category score at 3 months, with scores ranging from 1 to 5 and dichotomized as favourable (1-2) and unfavourable (3-5). We assessed the effect of sedation and its interaction with the electroencephalography-based power spectra on patient outcome prediction through a generalized linear mixed model. Power spectra values provided 100% positive predictive value (95% confidence intervals: 0.81-1.00) on the first day of coma, with correctly predicted 18 out of 45 favourable outcome patients. On the second day, power spectra values were not predictive of patients' outcome (positive predictive value: 0.46, 95% confidence intervals: 0.19-0.75). On the first day, we did not find evidence of any significant contribution of sedative infusion rates to the patient outcome prediction (P > 0.05). Comatose patients' outcome prediction based on electroencephalographic power spectra is higher on the first compared with the second day after cardiac arrest. Sedation does not appear to impact patient outcome prediction.

Aetiology and outcome in hospitalized cardiac arrest patients.

To study aetiologies of in-hospital cardiac arrests (IHCAs) and their association with 30-day survival. Observational study with data from national registries. Specific aetiologies (n = 22) of IHCA patients between April 2018 and December 2020 were categorized into cardiac vs. non-cardiac and six main aetiology categories: myocardial ischemia, other cardiac causes, pulmonary causes, infection, haemorrhage, and other non-cardiac causes. Main endpoints were proportions in each aetiology, 30-day survival, and favourable neurological outcome (Cerebral Performance Category scale 1-2) at discharge. Among, 4320 included IHCA patients (median age 74 years, 63.1% were men), approximate 50% had cardiac causes with a 30-day survival of 48.4% compared to 18.7% among non-cardiac causes (P < 0.001). The proportion in each category were: myocardial ischemia 29.9%, pulmonary 21.4%, other cardiac causes 19.6%, other non-cardiac causes 11.6%, infection 9%, and haemorrhage 8.5%. The odds ratio (OR) for 30-day survival compared to myocardial ischemia for each category were: other cardiac causes OR 1.48 (CI 1.24-1.76); pulmonary causes OR 0.36 (CI 0.3-0.44); infection OR 0.25 (CI 0.18-0.33); haemorrhage OR 0.22 (CI 0.16-0.3); and other non-cardiac causes OR 0.56 (CI 0.45-0.69). IHCA caused by myocardial ischemia had the best favourable neurological outcome while those caused by infection had the lowest OR 0.06 (CI 0.03-0.13). In this nationwide observational study, aetiologies with cardiac and non-cardiac causes of IHCA were evenly distributed. IHCA caused by myocardial ischemia and other cardiac causes had the strongest associations with 30-day survival and neurological outcome.

Changes in pre- and in-hospital management and outcomes among children with out-of-hospital cardiac arrest between 2012 and 2017 in Kanto, Japan

Previously, the SOS-KANTO 2012 studies, conducted in the Kanto area of Japan, reported a summary of outcomes in patients with out-of-hospital cardiac arrest (OHCA). This sub-analysis of the SOS-KANTO study 2017 aimed to evaluate the neurological outcomes of paediatric OHCA patients, by comparing the SOS-KANTO 2012 and 2017 studies. All OHCA patients, aged < 18 years, who were transported to the participating hospitals by EMS personnel were included in both SOS-KANTO studies (2012 and 2017). The number of survival patients with favourable neurological outcomes (paediatric cerebral performance category 1 or 2) at 1 month did not improve between 2012 and 2017. There was no significant difference in achievement of pre-hospital return of spontaneous circulation (ROSC) [odds ratio (OR): 2.00, 95% confidence interval (95% CI): 0.50–7.99, p = 0.50] and favourable outcome at 1 month [OR: 0.67, 95% CI: 0.11–3.99, p = 1] between the two studies, matched by age, witnessed arrest, bystander CPR, aetiology of OHCA, and time from call to EMS arrival. Multivariable logistic regression showed no significant difference in the achievement of pre-hospital ROSC and favourable outcomes at 1 month between the two studies.

Lactate to Albumin Ratio for Predicting Clinical Outcomes after In-Hospital Cardiac Arrest.

In-hospital cardiac arrest (IHCA) is associated with high mortality and poor neurological outcomes. Our objective was to assess whether the lactate-to-albumin ratio (LAR) can predict the outcomes in patients after IHCA. We retrospectively screened 75,987 hospitalised patients at a university hospital between 2015 and 2019. The primary endpoint was survival at 30-days. Neurological outcomes were assessed at 30 days using the cerebral performance category scale. 244 patients with IHCA and return of spontaneous circulation (ROSC) were included in this study and divided into quartiles of LAR. Overall, there were no differences in key baseline characteristics or rates of pre-existing comorbidities among the LAR quartiles. Patients with higher LAR had poorer survival after IHCA compared to patients with lower LAR: Q1, 70.4% of the patients; Q2, 50.8% of the patients; Q3, 26.2% of the patients; Q4, 6.6% of the patients (p = 0.001). Across increasing quartiles, the probability of a favourable neurological outcome in patients with ROSC after IHCA decreased: Q1: 49.2% of the patients; Q2: 32.8% of the patients; Q3: 14.7% of the patients; Q4: 3.2% of the patients (p = 0.001). The AUCs for predicting 30-days survival using the LAR were higher as compared to using a single measurement of lactate or albumin. The prognostic performance of LAR was superior to that of a single measurement of lactate or albumin for predicting survival after IHCA.

A Scoping Review on The Use of Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-Of-Hospital Cardiac Arrest

Aim of the review: To provide an overview of studies that have published data regarding region and population size, procedure location, team composition, inclusion and exclusion criteria, outcome parameters, and cost–benefit analyses on extracorporeal membrane oxygenation use for refractory out-of-hospital cardiac arrest. Data sources: A structured systematic literature search of articles published prior to April 27, 2021, was performed in online databases (PubMed, EMBASE, ClinicalTrials.gov, the EU Clinical Trials Register, and Cochrane Library). Results: Sixty-three articles were included based on predefined eligibility criteria. The included articles were published between 2011 and 2021, with the highest number of articles in 2020 and 2021 (50%). Of the 58 articles that reported data on organisational topics, 47 reported transporting the patients to the hospital for cannulation, 10 reported initiating extracorporeal cardiopulmonary resuscitation (ECPR) on-scene, and one reported doing both. The most common inclusion criterion was a lower age limit of 18 years (in 86% of the articles). Other inclusion criteria were witnessed collapse (67%) and initial ventricular fibrillation/tachycardia (43%), asystole (3%), pulseless electrical activity (5%), pulmonary embolism (2%), and signs of life during CPR (5%). The most common exclusion criterion was a do-not-resuscitate order (38%). Of the 44 studies reporting outcomes, 77% reported survival to hospital discharge and 50%, a cerebral performance category score of 1-2. Other outcome parameters were sparsely reported. Conclusion: There is a variation in regional size, team composition, inclusion and exclusion criteria and reported outcomes. These discrepancies make it challenging to determine how to effectively use ECPR.

Resuscitation of older adults in Norway; a comparison of survival and outcome after out-of-hospital cardiac arrest in healthcare institutions and at home

BackgroundPerceptions about expected outcome after out-of-hospital cardiac arrest (OHCA) influence treatment decisions, and there is a need for updated evidence about outcomes for the elderly. MethodWe conducted a cross-sectional study of cases reported to the Norwegian Cardiac Arrest Registry from 2015 through 2021 of patients 60 years and older, suffering cardiac arrest in healthcare institutions or at home. We examined reasons for emergency medical service (EMS) withholding or withdrawing resuscitation. We compared survival and neurological outcome for EMS-treated patients and explored factors associated with survival using multivariate logistic regression. ResultWe included 12,191 cases and the EMS started resuscitation in 10,340 (85%). The incidence per capita of OHCA the EMS were alerted to was 267/100,000 in healthcare institutions and 134/100,000 at home. Resuscitation was most frequently withdrawn due to medical history (n = 1251). In healthcare institutions, 72 of 1503 (4.8%) patients survived to 30 days compared to 752 of 8837 (8.5%) at home (P <.001). We found survivors in all age cohorts both in healthcare institutions and at home, and most of the 824 survivors had a good neurological outcome with a Cerebral Performance Category ≤2 (88%). ConclusionMedical history was the most frequent reason for EMS not to start or continue resuscitation, indicating a need for a discussion about, and documentation of, advance directives in this age group. When EMS attempted resuscitation, most survivors had a good neurological outcome, both in healthcare institutions and at home.

#3538 SURVIVAL OUTCOMES FOLLOWING CARDIOPULMONARY RESUSCITATION IN ADULTS RECEIVING KIDNEY REPLACEMENT THERAPY: A SYSTEMATIC REVIEW AND NARRATIVE SYNTHESIS

Abstract Background and Aims Individuals receiving kidney replacement therapy (KRT) are at higher risk of cardiac arrest than the general population. The aim of this systematic review was to evaluate survival outcomes in individuals on different forms of KRT (haemodialysis, peritoneal dialysis or kidney transplantation) following cardiopulmonary resuscitation (CPR) within healthcare settings (hospital or outpatient clinics). Method A comprehensive literature search of EMBASE, MEDLINE, CINAHL, Web of Science and Central was carried using a pre-defined search strategy with no date or language restrictions. Retrospective and prospective observational studies reporting outcomes following CPR in adults on kidney replacement therapy were included. The study protocol was prospectively registered on PROSPERO: CRD42022336363. Results Thirteen eligible studies were identified. Due to the heterogeneity of study populations, lack of a standardised outcome set and inconsistent use of control groups, a narrative review was conducted, and a meta-analysis was not performed. Crude unadjusted survival rate to discharge from hospital was reported in 11 studies and ranged from 0%—75%. Only two studies reported neurological outcome at discharge, with rates of a favourable cerebral performance category score (CPC 1 or 2) on discharge between 17–20%. Conclusion The current evidence is insufficient to guide clinical decision-making regarding resuscitation due to a lack of up-to-date data, uncertainty about outcomes and inconsistent reporting of neurological status after CPR. Additionally, there is a lack of data comparing survival outcomes for people on different types of KRT. There remain unanswered questions regarding the likelihood of favourable outcomes for the KRT population and whether these can be accurately predicted using clinical and demographic features.

Time-course relationship between cerebrospinal fluid and serum concentrations of midazolam and albumin in patients with cardiac arrest undergoing targeted temperature management

AimTo understand the serum and cerebrospinal fluid (CSF) distribution of midazolam is important for proper timing of neurological prognostication of targeted temperature management(TTM) patients. Midazolam binds extensively to albumin in serum although non protein bound form exist in CSF. We investigated the time-course of CSF, serum concentrations of midazolam and albumin in patients with cardiac arrest who underwent TTM. MethodsThis prospective, single-center, observational study was conducted between May 2020 and April 2022. Midazolam and albumin concentrations in CSF and serum were quantified 0, 24, 48, and 72 h after the return of spontaneous circulation for comparison between the good (Cerebral Performance Category (CPC) 1 and 2) and poor (CPC 3, 4, and 5) neurologic outcome groups. The CSF/serum (C/S) ratios of midazolam and albumin concentrations were determined, along with their correlation coefficients. ResultsOf the 19 enrolled patients, 13 experienced poor outcomes. At 0 h, serum midazolam concentrations were the lowest, whereas serum albumin levels were the highest; in the CSF, the concentrations of both peaked at 24 h. There were no significant inter-group differences in midazolam concentrations in CSF or serum. The C/S ratios of midazolam and albumin significantly differed between the groups. Moderate to strong positive correlations were observed between the midazolam and albumin C/S ratios. ConclusionIn CSF, midazolam and albumin concentrations peaked 24 h post-cardiac arrest. Midazolam and albumin C/S ratios were significantly higher in the poor outcome group and positively correlated with each other, suggesting blood–brain barrier disruption 24 h post-cardiac arrest.

Association between the COVID-19 pandemic in 2020 and out-of-hospital cardiac arrest outcomes and bystander resuscitation efforts for working-age individuals in Japan: a nationwide observational and epidemiological analysis

BackgroundImproving out-of-hospital cardiac arrest (OHCA) prognosis within the working-age population is important, but no studies have investigated the effects of COVID-19 pandemic specifically on the working-age population with OHCAs. We...

Identifying individuals satisfying the termination of resuscitation rule but having potential to achieve favourable neurological outcome following out-of-hospital cardiac arrest

AimTo develop a simple scoring model that identifies individuals satisfying the termination of resuscitation (TOR) rule but having potential to achieve favourable neurological outcome following out-of-hospital cardiac arrest (OHCA). MethodsThis study analysed the All-Japan Utstein Registry from 1 January 2010 to 31 December 2019. We identified patients satisfying basic life support (BLS) and advanced life support (ALS) TOR rules and determined factors associated with favourable neurological outcome (cerebral performance category scale of 1 or 2) for each cohort using multivariable logistic regression analysis. Scoring models were derived and validated to identify patient subgroups that might benefit from continued resuscitation efforts. ResultsAmong 1,695,005 eligible patients, 1,086,092 (64.1%) and 409,498 (24.2%) satisfied BLS and ALS TOR rules, respectively. One month post-arrest, 2038 (0.2%) and 590 (0.1%) patients in the BLS and ALS cohorts, respectively, achieved favourable neurological outcome. A scoring model derived for the BLS cohort (2 points for age <17 years or ventricular fibrillation/ventricular tachycardia rhythm; 1 point for age <80 years, pulseless electrical activity rhythm, or transport time <25 min) effectively stratified the probability of achieving 1-month favourable neurological outcome, with patients scoring <4 having a probability of <1%, whereas those scoring 4, 5, and 6 having probabilities of 1.1%, 7.1%, and 11.1%, respectively. In the ALS cohort, the probability increased with scores; however, it remained <1%. ConclusionA simple scoring model comprising age, first documented cardiac rhythm, and transport time effectively stratified the likelihood of achieving favourable neurological outcome in patients satisfying the BLS TOR rule.

Association between Case Volumes of Extracorporeal Life Support and Clinical Outcome in Out-of-Hospital Cardiac Arrest

Aim Extracorporeal life support (ECLS) for out-of-hospital cardiac arrest (OHCA) is increasing. There is little evidence identifying the association between hospital ECLS case volumes and outcomes in different populations receiving ECLS or conventional cardiopulmonary resuscitation (CPR). The goal of this investigation was to identify the association between ECLS case volumes and clinical outcomes of OHCA patients. Methods This cross-sectional observational study used the National OHCA Registry for adult OHCA cases in Seoul, Korea between January 2015 and December 2019. If the ECLS volume during the study period was >20, the institution was defined as a high-volume ECLS center. Others were defined as low-volume ECLS centers. Outcomes were good neurologic recovery (cerebral performance category 1 or 2) and survival to discharge. We performed multivariate logistic regression and interaction analyses to assess the association between case volume and clinical outcome. Results Of the 17,248 OHCA cases, 3,731 were transported to high-volume centers. Among the patients who underwent ECLS, those at high-volume centers had a higher neurologic recovery rate than those at low-volume centers (17.0% vs. 12.0%), and the adjusted OR for good neurologic recovery was 2.22 (95% confidence interval (CI): 1.15–4.28) in high-volume centers compared to low-volume centers. For patients who received conventional CPR, high-volume centers also showed higher survival-to-discharge rates (adjusted OR of 1.16, 95%CI: 1.01–1.34). Conclusions High-volume ECLS centers showed better neurological recovery in patients who underwent ECLS. High-volume centers also had better survival-to-discharge rates than low-volume centers for patients not receiving ECLS.

Association between optic nerve sheath diameter/eyeball transverse diameter ratio and neurological outcomes in patients with aneurysmal subarachnoid hemorrhage.

The optic nerve sheath diameter (ONSD)/eyeball transverse diameter (ETD) ratio is a more reliable marker of intracranial pressure than the ONSD alone. We aimed to investigate the predictive value of the ONSD/ETD ratio (OER) for neurological outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). Adult patients with aSAH who visited the emergency department of a tertiary hospital connected to a South Korean university between January 2015 and December 2021 were included. Data on patient characteristics and brain computed tomography scan findings, including the ONSD and ETD, were collected using a predefined protocol. According to the neurological outcome at hospital discharge, the patients were divided into the unfavorable neurological outcome (UNO; cerebral performance category [CPC] score 3-5) and the favorable neurological outcome (FNO; CPC score 1-2) groups. The primary outcome was the association between the OER and neurological outcomes in patients with aSAH. A total of 171 patients were included in the study, of whom 118 patients (69%) had UNO. Neither the ONSD (p=0.075) nor ETD (p=0.403) showed significant differences between the two groups. However, the OER was significantly higher in the UNO group in the univariate analysis (p=0.045). The area under the receiver operating characteristic curve of the OER for predicting UNO was 0.603 (p=0.031). There was no independent relationship between the OER and UNO in the multivariate logistic regression analysis (adjusted odds ratio, 0.010; p=0.576). The OER was significantly higher in patients with UNO than in those with FNO, and the OER was more reliable than the ONSD alone. However, the OER had limited utility in predicting UNO in patients with aSAH.

Specific thresholds of quantitative pupillometry parameters predict unfavorable outcome in comatose survivors early after cardiac arrest

AimQuantitative pupillometry is the guideline-recommended method for assessing pupillary light reflex for multimodal prognostication in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). However, threshold values predicting an unfavorable outcome have been inconsistent across studies; therefore, we aimed to identify specific thresholds for all quantitative pupillometry parameters. MethodsComatose post-OHCA patients were consecutively admitted to the cardiac arrest center at Copenhagen University Hospital Rigshospitalet from April 2015 to June 2017. The parameters of quantitatively assessed pupillary light reflex (qPLR), Neurological Pupil index (NPi), average/max constriction velocity (CV/MCV), dilation velocity (DV), and latency of constriction (Lat) were recorded on the first three days after admission. We evaluated the prognostic performance and identified thresholds achieving zero percent false positive rate (0% PFR) for an unfavorable outcome of 90-day Cerebral Performance Category (CPC) 3–5. Treating physicians were blinded for pupillometry results. ResultsOf the 135 post-OHCA patients, the primary outcome occurred for 53 (39%) patients.On any day during hospitalization, a qPLR < 4%, NPi < 2.45, CV < 0.1 mm/s, and an MCV < 0.335 mm/s predicted 90-day unfavorable neurological outcome with 0% FPR (95%CI: 0–0%), with sensitivities of 28% (17–40%), 9% (2–19%), 13% (6–23%), and 17% (8–26%), respectively on day 1. ConclusionWe found that specific thresholds of all quantitative pupillometry parameters, measured at any time following hospital admission until day 3, predicted a 90-day unfavorable outcome with 0% FPR in comatose patients resuscitated from OHCA. However, at 0% FPR, thresholds resulted in low sensitivity. These findings should be further validated in larger multicenter clinical trials.

Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with cardiac arrest: a comparative meta-analysis and trial sequential analysis

Although outcomes of patients after cardiac arrest remain poor, studies have suggested that extracorporeal cardiopulmonary resuscitation (ECPR) might improve survival and neurological outcomes. We aimed to investigate any potential benefits of using ECPR over conventional cardiopulmonary resuscitation (CCPR) in patients with out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). In this systematic review and meta-analysis, we searched MEDLINE via PubMed, Embase, and Scopus from Jan 1, 2000, to April 1, 2023, for randomised controlled trials and propensity-score matched studies. We included studies comparing ECPR with CCPR in adults (aged ≥18 years) with OHCA and IHCA. We extracted data from published reports using a prespecified data extraction form. We did random-effects (Mantel-Haenszel) meta-analyses and rated the certainty of evidence using the Grading of Recommendations, Assessments, Developments, and Evaluations (GRADE) approach. We rated the risk of bias of randomised controlled trials using the Cochrane risk-of-bias 2.0 tool, and that of observational studies using the Newcastle-Ottawa Scale. The primary outcome was in-hospital mortality. Secondary outcomes included complications during extracorporeal membrane oxygenation, short-term (from hospital discharge to 30 days after cardiac arrest) and long-term (≥90 days after cardiac arrest) survival with favourable neurological outcomes (defined as cerebral performance category scores 1 or 2), and survival at 30 days, 3 months, 6 months, and 1 year after cardiac arrest. We also did trial sequential analyses to evaluate the required information sizes in the meta-analyses to detect clinically relevant reductions in mortality. We included 11 studies (4595 patients receiving ECPR and 4597 patients receiving CCPR) in the meta-analysis. ECPR was associated with a significant reduction in overall in-hospital mortality (OR 0·67, 95% CI 0·51-0·87; p=0·0034; high certainty), without evidence of publication bias (pegger=0·19); the trial sequential analysis was concordant with the meta-analysis. When considering IHCA only, in-hospital mortality was lower in patients receiving ECPR than in those receiving CCPR (0·42, 0·25-0·70; p=0·0009), whereas when considering OHCA only, no differences were found (0·76, 0·54-1·07; p=0·12). Centre volume (ie, the number of ECPR runs done per year in each centre) was associated with reductions in odds of mortality (regression coefficient per doubling of centre volume -0·17, 95% CI -0·32 to -0·017; p=0·030). ECPR was also associated with an increased rate of short-term (OR 1·65, 95% CI 1·02-2·68; p=0·042; moderate certainty) and long-term (2·04, 1·41-2·94; p=0·0001; high certainty) survival with favourable neurological outcomes. Additionally, patients receiving ECPR had increased survival at 30-day (OR 1·45, 95% CI 1·08-1·96; p=0·015), 3-month (3·98, 1·12-14·16; p=0·033), 6-month (1·87, 1·36-2·57; p=0·0001), and 1-year (1·72, 1·52-1·95; p<0·0001) follow-ups. Compared with CCPR, ECPR reduced in-hospital mortality and improved long-term neurological outcomes and post-arrest survival, particularly in patients with IHCA. These findings suggest that ECPR could be considered for eligible patients with IHCA, although further research into patients with OHCA is warranted. None.

What Is the True Meaning of a "Good" Pediatric Cerebral Performance Category Score at Hospital Discharge in Pediatric Cardiac Arrest Survivors?

Albrecht, Marijn MD; Dulfer, Karolijn PhD; Hunfeld, Maayke MD, PhD; de Jonge, Rogier C. J. MD, PhD; Buysse, Corinne M. P. MD, PhD Author Information

Extracorporeal membrane oxygenation-facilitated resuscitation in out-of-hospital cardiac arrest: a meta-analysis of randomized controlled trials.

It remains unclear whether extracorporeal cardiopulmonary resuscitation (ECPR) could improve neurological outcomes in patients with out-of-hospital cardiac arrest (OHCA) compared with conventional cardiopulmonary resuscitation (CCPR). We conducted a systemic search for randomized controlled trials (RCTs) comparing the efficacy of ECPR versus CCPR for OHCA until February 2023. The main end points were 6-month survival, and 6-month and short-term (in-hospital or 30-day) survival with favorable neurological outcome, defined as a Glasgow-Pittsburg cerebral performance category (CPC) score of 1 or 2. We identified four RCTs including a total of 435 patients. In the included RCTs, the initial cardiac rhythms were ventricular fibrillation in most cases (75%). There was a tendency towards improved 6-month survival and 6-month survival with favorable neurological outcome in ECPR although it did not reach statistical significance [odds ratio (OR): 1.50; 95% confidence interval (CI): 0.67 to 3.36, I2 = 50%, and OR: 1.74; 95% CI: 0.86 to 3.51, I2 = 35%, respectively]. ECPR was associated with a significant improvement in short-term favorable neurological outcomes without heterogeneity (OR: 1.84; 95% CI: 1.14 to 2.99, I2 = 0%). Our meta-analysis of RCTs revealed that there was a tendency towards better mid-term neurological outcomes in ECPR and that ECPR was associated with a significant improvement in short-term favorable neurological outcomes compared with CCPR.