CPC Score Research Articles

Multidisciplinary shock team is associated with improved outcomes in patients undergoing ECPR

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) has been increasingly used in cardiopulmonary resuscitation (ECPR) in select patients. Few centers have published their experience or outcomes with ECPR. The aim of our study was to evaluate outcomes of adult patients in cardiac arrest placed on VA ECMO in the catheterization laboratory. We performed a retrospective analysis of adult patients in refractory cardiac arrest who underwent ECPR at the Minneapolis Heart Institute (MHI) at Abbott Northwestern Hospital from January 2012 to December 2017. Relevant data were obtained from electronic medical records, including arrest to ECMO flow time, total ECMO support time, and outcomes. Twenty-six adult patients underwent ECPR at the study site during the defined time period. Seven patients (27%) sustained cardiac arrest out of hospital, 19 patients arrested in-hospital with eight of those occurring in the catheterization laboratory. Seventeen (65%) patients had initial rhythm of ventricular fibrillation or tachycardia (VF/VT). All patients underwent mechanical CPR with LUCAS device. Overall 30 day and 6 month survival was 69%. Median time from arrest to ECMO flow was 46 mins (21,68) vs 61 mins (36,71) in survivors and non-survivors, respectively. Sixteen of 18 survivors discharged with a CPC score of 1 or 2. We demonstrate that adult patients in cardiac arrest initiated on VA ECMO in the cardiac catheterization laboratory and cared for by a multidisciplinary shock team in the critical care unit have superior long-term survival and functionally favorable neurologic recovery when compared to current literature.

Differences Between Included And Excluded Participants In An Exercise Study Following Resuscitation From Cardiac Arrest

INTRODUCTION: Survivors of cardiac arrest (CA) frequently experience both physical and cognitive impairment. Few receive outpatient rehabilitation services. We are conducting a randomized trial to determine if therapeutic exercise (TE) improves health related quality of life, physical, and cognitive function after cardiac arrest. We assessed characteristics of included/non-included patients during the first 32 months of enrollment to determine if these populations differ from one another. HYPOTHESIS: Those who participate in the TE study have less severe initial illness severity, better neurologic outcomes, and more favorable baseline demographic characteristics than non-participants. METHODS: CA patients treated between June 2016 and February 2019 were included. CA survivors were eligible between hospital discharge and 6 months post-CA. Patients were called 3 times before being considered “lost to follow up” (LTF). T-test and Wilcoxon Rank-Sum were used to compare baseline demographics, initial illness severity (measured by the Pittsburgh Cardiac Arrest Category-PCAC), and discharge dispositions (measured by CPC and mRS) between groups. RESULTS: Of 234 eligible patients, 12 were enrolled (5.13%). Primary exclusions were LTF (n = 71, 30.34%), enrolled and later dropped or excluded (n = 66, 28.21%), or were admitted to a hospital, skilled nursing, or inpatient rehabilitation facility at the time of eligibility (n=39, 16.67%). Included participants did not differ from excluded with regards to age, gender, cardiac arrest location, PCAC, primary rhythm, temperature management, hospital or ICU length of stay, discharge disposition, mRS, or CPC score. [Table] CONCLUSIONS: Demographic variables, illness severity, and outcome do not differ between participating and non-participating patients. Only 5% of eligible patients participated in the study. Further research to reduce LTF and increase study participation should be investigated.

P065: Out-of-hospital cardiac arrest patients eligible for extracorporeal cardiopulmonary resuscitation in Regina emergency departments

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) is a rapidly evolving technology for clinical use in patients with refractory cardiogenic arrest. Out-of-hospital cardiac arrest (OHCA) is a common cause of unexpected death and has a low survival rate. There is increasing evidence that suggests better outcomes for (OHCA) patients, including improved neurological outcomes and survival rates, who are started on extracorporeal corporeal membrane oxygenation (ECMO) versus traditional resuscitation methods. Methods: We conducted a retrospective chart review of 200 out-of-hospital cardiac arrest patients presenting to Regina emergency departments from January 1, 2017 to March 31, 2019. Eligibility for ECPR was assessed using different clinical criteria from different ECPR programs (University of British Columbia, University of Michigan, and a hypothetical “Regina” criteria created for this study). Outcomes of the eligible patients were compared using descriptive statistics with SPSS version 22. Results: Between four different criteria, 15%, 9.5%, 7.5%, and 3.5% of patients were respectively eligible to receive ECPR. Of patients who met eligibility for all four criteria, 80% were male, the average age was 61 years old, the average Cerebral Performance score was 4.46, and 83% died in hospital. There was a low survival rate of eligible patients, with rates of 16%, 17%, 20%, and 28% in each group. The survival rate for all patients was 21% and the average CPC score was 4.35. Conclusion: The significant percentage of patients were eligible for ECPR upon presentation to Regina Emergency Departments. Patients who were eligible had low survival rates and poor neurological outcomes, suggesting that ECPR could prove to be a valuable clinical tool that could improve patient outcomes in Saskatchewan. There were considerable differences in patient eligibility percentages based on different criterion. Differences in inclusion/exclusion criteria, modifying the expected annual number of ECPR eligible OHCA patients, could provide valuable information on required resources and planning for implementation of an ECPR program in a smaller centre, such as Regina.

Validation of the Good Outcome Following Attempted Resuscitation (GO-FAR) score in an East Asian population

AimThe Good Outcome Following Attempted Resuscitation (GO-FAR) score is useful for identifying patients post-arrest with very poor neurologic outcomes and may thus be utilized when counseling family members on do-not-attempt-resuscitation (DNAR) order. We validated the GO-FAR score for neurologically intact survival in patients with in-hospital cardiac arrest (IHCA) in an East Asian country in which DNAR order not common. MethodsRetrospective study about patients who experienced IHCA from 2013 to 2017 with a primary outcome of neurologically intact survival, defined as a CPC score 1 or 2 at discharge. GO-FAR score categorizes the patients into 4 groups: a very low (<1%), low (1%–3%), average (>3%–15%), or higher than average (>15%) likelihood of neurologically intact survival. ResultsOf the 1011 included patients, the rates of survival discharge and neurologically intact survival at discharge were 25.4% and 16.0%, respectively. The area under the receiver operating characteristics curve of GO-FAR score for good neurological outcome was 0.81 (95% CI, 0.78–0.84). Patients with low or very low probability of survival had a likelihood of 0.9% (95% CI, 0.0–2.0), but for those under 40 years old, it was increased to 4.2% (95% CI, 0.0–12.2). Patients with average or above-average probabilities had likelihoods of of 18.5% (95% CI, 15.3–21.6) and 50.5% (95% CI, 40.6–60.5), respectively. ConclusionsThe GO-FAR score well-predicted the neurologically intact survival of East Asian patients with IHCA. This tool may be used as part of a shared decision regarding DNAR orders.

Abstract 186: Sex Differences in Outcomes for Out-Of-Hospital Cardiac Arrest

Introduction: Approximately 1,000 out-of-hospital cardiac arrest (OHCA) occur per day in the United States. Although survival rates remains low, the extent to which OHCA neurological outcomes differ between men and women remains poorly characterized. Methods: Within the national Cardiac Arrest Registry to Enhance Survival (CARES) registry, we identified 195,722 adult individuals with an OHCA between 2013-2017. Using multi-variable logistic regression models, we evaluated for sex differences in rates of survival to hospital discharge and favorable neurological outcome (survival with discharge CPC score of 1 or 2), adjusted for cardiac arrest characteristics, race, location, year of arrest, age, and use of targeted temperature management (TTM) and coronary angiography. Results: Overall, 70,767 (31%) patients were women. Median age was 64 and 62 years for women and men, respectively. An initial shockable rhythm (14.9% vs. 25.7%) and a witnessed arrest (40.9% vs. 45.6%) was more common in men. Bystander CPR was provided to 37% of women and 39% of men. Men were less likely to survive to hospital discharge than women (8.7% vs. 10.9%; adjusted OR 0.75, 95% CI 0.73, 0.78). Similarly, men were less likely to have favorable neurological outcome (6.6% vs. 9.2% for women; adjusted OR 0.78, 95% CI 0.74, 0.82). Further interaction analysis for the pre-hospital elements found small, but statistically significant sex differences in favorable neurological survival for witnessed status (among female OR 2.29, 95% CI 2.10, 2.49; among males OR 2.07, 95% CI 1.92, 2.23, p= 0.04) and for bystander CPR (among females OR 1.20, 95% CI 1.11, 1.29; among males OR 1.34, 95% CI 1.27, 1.42, p= 0.01). Interaction of sex with the hospital level variables of TTM and coronary angiography, for the subset of patients that survived to hospital admission, had no sex differences in favorable neurological outcome. Conclusion: Our analysis shows that for OHCA in the United States, women have better survival outcomes than men. There was a sex differences in the pre-hospital variable of BCPR, but not in the other modifiable variables of TTM and coronary angiography. Further study is needed to better understand sex differences in overall survival and neurological outcomes.

Sudden cardiac arrest survival in HEARTSafe communities

BackgroundThe HEARTSafe Communities program promotes community efforts to improve systems for treating sudden cardiac arrest (SCA). The study hypothesis was that the rates of SCA survival to admission, discharge, and discharge with CPC score 1 or 2 are higher in HEARTSafe-designated communities than non-designated communities in Connecticut, USA. Secondary outcomes included bystander CPR and AED application. MethodsThe state Office of EMS supplied a list of towns that are HEARTSafe-designated, and dates of designation. The Cardiac Arrest Registry to Enhance Survival provided data for all SCA from 2013 to 2017 in the 70 participating towns. For each SCA, it was determined whether the town was HEARTSafe-designated at the time. ResultsOf 2922 SCA cases, 1569 (54%) occurred in towns that were HEARTSafe-designated.Patients in designated towns were 1.15 times more likely to have AEDs applied by bystanders, and 1.15 times more likely to have CPR started by bystanders, than were patients in non-designated towns, but these differences were not significance (p = 0.66 and 0.28). The likelihood of surviving to admission was 1.33 times higher (p = 0.02) in designated towns. The likelihood of surviving to discharge was 1.33 times higher, and of surviving to discharge with CPC 1 or 2 was 1.4 times higher, but these differences were not significant (p = 0.17 and 0.13). ConclusionSCA survival rates do not differ between HEARTSafe and non-HEARTSafe communities in Connecticut. SCA patients in HEARTSafe communities are no more likely to receive bystander AED application or bystander CPR.

P2671The addition of admission lactate to the CREST risk score to determine prognosis in out of hospital cardiac arrest: the C-AREST score

Abstract Introduction There has been an increasing focus on the development of scoring systems for patients admitted following resuscitation from out-of-hospital cardiac arrest (OHCA) to determine both prognosis and short-term management. One such system, the CREST score, has been shown to predict circulatory aetiology death in patients without ST-elevation myocardial infarction, however with an increasing number of OHCAs seen, general scoring systems to predict outcome in OHCA would be helpful. Aims We sought to determine whether the addition of an admission lactate ≥8 mmol/l to the existing CREST score was able to better predict in-hospital mortality in patients admitted with OHCA. Methods and results We retrospectively analysed the data of 500 patients admitted with an OHCA of presumed cardiac origin to our tertiary cardiac centre between June 2014 and Oct 2018. Mean age was 62.6y (±14.7), 379 (76%) were male and 250 (50%) were Caucasian. 313 (62.6%) were admitted with ST elevation myocardial infarction or equivalent. 48.6% (243/500) of patients died in hospital and of those that survived, 20.2% (52/257) were left with hypoxic brain injury (CPC score 3–4). When analysed independently, all individual factors other than history of Coronary artery disease (OR 1.47, p=0.084) significantly predicted in-hospital mortality: Admission lactate ≥8 mmol/l (OR 6.78, p&lt;0.0001), non-shockable Rhythm (OR 10.9, p&lt;0.0001), Ejection fraction &lt;30% (OR 5.84, p&lt;0.0001), Shock at presentation (OR 5.49, p&lt;0.0001) and ischaemic Time &gt;25 minutes (OR 12.8, p&lt;0.0001). When each factor was assigned one point and totalled, both increasing CREST and C-AREST scores were associated with increasing in-hospital mortality: CREST (0–5 points): 4.3%, 30.5%, 41.5%, 85.6%, 95.2%, 100% vs C-AREST (0–6 points): 9.1%, 28.3%, 41.9%, 62.8%, 97.6%, 96.4%, 100%. When analysed with stepwise logistic regression, the addition of admission lactate ≥8 mmol/l to the model improved the prediction of in-hospital mortality: CREST (40.8% of variance explained) vs C-AREST (43.3%), with admission lactate remaining an independently significant predictor (OR 3.67, p=0.002). Conclusion We describe a novel modification to the previously described CREST scoring system for OHCA: the C-AREST score. The addition of admission lactate ≥8 mmol/l may have a role in differentiating those in intermediate risk categories (score between 2 and 3) where the predicted in hospital mortality would otherwise vary greatly. Given the relative ease of obtaining admission lactate, this scoring system may further improve stratification of patients who may or may not benefit from invasive management.

Abstract 154: True Outcome Determination After In-Hospital Cardiac Arrest

Background/Objectives: A commonly reported measure for a successful resuscitation from in-hospital cardiac arrest is survival to discharge. But what does that really tell us? In the continuation of a previous study looking at whether hospital bed size impacted survival, we wanted to look even further to identify the true condition of those patients at discharge who survived, and their discharge destinations after an in-hospital cardiac arrest. Methods: By using data for the years 2013-2017 from Get With the Guidelines-Resuscitation for 75-199 &amp; 300-399 bed hospitals in the AHA Midwest Affiliate, we compared survival to discharge destination &amp; cerebral performance category, (CPC score), for patients who survived with and without shockable rhythms. All patients were included in a risk adjusted formula. Results: Although survival rates in the 75-199 bed hospitals were always higher, CPC scores were almost always lower for the 300-399 bed facilities indicating a better neurological outcome. Discharge destinations varied but in almost every case, the majority were sent to other healthcare facilities, (extended care, skilled nursing, rehab). A large percentage were discharged home however, verifying again that many patients survived with normal to nearly normal neurologic status. We also discovered that nearly 1 in 4 patients had no CPC score documented at discharge. Conclusions: After analyzing hospitals with 75-199 &amp; 300-399 beds, the data showed higher rates of survival to discharge in the smaller hospitals however, neurologic outcomes were better at larger facilities. This led us to conclude that survival rate alone may not be the most appropriate measure of a successful resuscitation. CPC score at discharge is another key component that should be included. Discharge destination can also be considered as an indicator of the patient’s condition. Additionally, hospitals should evaluate their process for documenting neurologic status at discharge and whether there are omissions in the medical record or an abstracting oversight in Get With the Guidelines-Resuscitation by not including a CPC score.

Early goal-directed haemodynamic optimization of cerebral oxygenation in comatose survivors after cardiac arrest: the Neuroprotect post-cardiac arrest trial.

During the first 6-12 h of intensive care unit (ICU) stay, post-cardiac arrest (CA) patients treated with a mean arterial pressure (MAP) 65 mmHg target experience a drop of the cerebral oxygenation that may cause additional cerebral damage. Therefore, we investigated whether an early goal directed haemodynamic optimization strategy (EGDHO) (MAP 85-100 mmHg, SVO2 65-75%) is safe and could improve cerebral oxygenation, reduce anoxic brain damage, and improve outcome when compared with a MAP 65 mmHg strategy. A total of 112 out-of-hospital CA patients were randomly assigned to EGDHO or MAP 65 mmHg strategies during the first 36 h of ICU stay. The primary outcome was the extent of anoxic brain damage as quantified by the percentage of voxels below an apparent diffusion coefficient (ADC) score of 650.10-6 mm2/s on diffusion weighted magnetic resonance imaging (at day 5 ± 2 post-CA). Main secondary outcome was favourable neurological outcome (CPC score 1-2) at 180 days. In patients assigned to EGDHO, MAP (P < 0.001), and cerebral oxygenation during the first 12 h of ICU stay (P = 0.04) were higher. However, the percentage of voxels below an ADC score of 650.10-6 mm2/s did not differ between both groups [16% vs. 12%, odds ratio 1.37, 95% confidence interval (CI) 0.95-0.98; P = 0.09]. Also, the number of patients with favourable neurological outcome at 180 days was similar (40% vs. 38%, odds ratio 0.98, 95% CI 0.41-2.33; P = 0.96). The number of serious adverse events was lower in patients assigned to EGDHO (P = 0.02). Targeting a higher MAP in post-CA patients was safe and improved cerebral oxygenation but did not improve the extent of anoxic brain damage or neurological outcome.

Prolonged targeted temperature management reduces memory retrieval deficits six months post-cardiac arrest: A randomised controlled trial

BackgroundCognitive sequelae, most frequently memory, attention, and executive dysfunctions, occur commonly in out-of-hospital cardiac arrest (OHCA) survivors. Targeted temperature management (TTM) following OHCA is associated with improved cognitive function. However, the relationship between the duration of TTM and cognitive outcome remains unclear. We hypothesised that OHCA survivors that were subjected to prolonged TTM of 48 h (TTM48) would exhibit better cognitive functions compared to those subjected to standard TTM of 24 h (TTM24) six months post-OHCA. MethodsA predefined, cognitive post-hoc sub-study was conducted on the multicentre clinical trial: “Target Temperature Management for 48 vs. 24 h and Neurologic Outcome after out-of-hospital cardiac arrest: A Randomised Clinical Trial” (the TTH48 trial). OHCA survivors with perceived good cognitive outcome (CPC score ≤ 2) were invited to a neuropsychological assessment of memory, attention, and executive functions six months post-OHCA. ResultsIn total, 79 patients were included in the study. Multivariate regression analysis revealed that TTM48 was associated with a significant better performance on three of 13 cognitive tests specific to memory retrieval after adjusting for age at follow-up and time to return of spontaneous circulation. Overall, patients in the TTM24 group were almost three times more likely (RR = 2.9 (95% CI 1.1–7.4)), p = 0.02) to be cognitively impaired. ConclusionsThis study reports an association between the duration of TTM and cognitive outcome. In OHCA survivors with perceived good cognitive outcome (CPC ≤ 2), TTM48 was associated with reduced memory retrieval deficits and lower relative risk of cognitive impairment six months after OHCA compared to standard TTM24.ClinicalTrials.gov (identifier: NCT01689077).

Roles of cerebral metabolic rate for oxygen in evaluating the prognosis of cerebral function after cardiopulmonary resuscitation

Objective To investigate the roles of cerebral metabolic rate for oxygen (CMRO2) monitoring in the evaluation of cerebral function after cardiopulmonary resuscitation (CPR) through transcranial doppler (TCD) and SjvO2. Methods In this prospective/retrospective analysis, we included 46 cases admitted to the general intensive care unit (GICU) of the Second Affiliated Hospital of Soochow University from January 2012 to December 2014. Upon admission, TCD and SjvO2 were performed, and the patients’ characteristics were recorded. Based on the CPC score upon GICU discharge, the patients were divided into two groups with satisfactory cerebral function and poor cerebral function, respectively. Then the clinical symptoms, cerebral blood flow (CBF), a-vDO2, SjvO2 and CMRO2 were analyzed, followed by investigating their correlation with the prognosis of cerebral function. The measurement data that were normally distributed were presented by mean ± standard deviation. Student’s t test was utilized for the inter-group comparison. Correlation analysis was performed. ROC was plotted, followed by evaluating roles of each index in the specificity and sensitivity of nervous prognosis. Results No statistical differences were noted in the gender, age, initial monitoring indicators, ICU duration and initial GCS between the two groups (P>0.05). The CA-ROSC time and APACHE II score in the satisfactory cerebral function group were significantly shorter than those of the poor cerebral function group (P<0.05). The SjvO2 in the satisfactory cerebral function group was significantly lower than that of the poor function group (67.33±10.30 vs. 76.89±13.08, t=-3.579, P<0.05). The Vs and Vd as revealed by TCD in the satisfactory function group were higher than those of the poor function group, together with the CBF. Significant decrease was noted in the PI and RI in the satisfactory function group compared with that of the poor function group (P<0.05). Besides, the CMRO2 and a-vDO2 in the satisfactory function group showed significant increase compared with those of the poor function group (P<0.05). ROC indicated that CMRO2, CBF, a-vDO2 and SjvO2 could be utilized for the evaluation of cerebral function, among which CMRO2 showed the highest accuracy for the cerebral function prognosis. Conclusions CMRO2, CBF, a-vDO2 and SjvO2 were associated with cerebral function prognosis. CMRO2 was the most appropriate parameter to evaluate the oxygen metabolism in brain tissues, which could evaluate the prognosis of cerebral function. Key words: Cardiac arrest; Resuscitation; Jugular venous oxygen saturation; Transcranial Doppler; Cerebral metabolic rate for oxygen

Abstract 362: Early Signs of Life as a Prognostic Factor for Extracorporeal Cardiopulmonary Resuscitation in Refractory Out-of-Hospital Cardiac Arrest

Introduction: After 20 to 30 minutes of cardiopulmonary resuscitation (CPR) without return of spontaneous circulation (ROSC), cardiac arrest is considered as refractory (RCA). For RCA, extracorporeal CPR (ECPR) is one of the only treatments with a potential benefit on survival. Presence of gasping during CPR has been shown to be strongly associated with a favorable outcome. To our knowledge, signs of life during CPR (such as gasping, movements, pupillary response) has not been studied in the specific context of RCA treated with ECPR. Hypothesis: We assessed the relationship between survival with favorable neurologic outcomes and presence of early signs of life during or before CPR in RCA treated with ECPR. Methods: We carried out a multicenter observational study of patients with out-of-hospital RCA treated with ECPR in 3 cities in France. Primary outcome was favorable neurologic outcome at 30 days defined as CPC score ≤ 2. Signs of life were defined as gasping or recovery of normal breathing, any pupillary response or any movements during CPR. Patient selection for ECPR was decided according to french guidelines criteria such as initial rhythm, no-flow duration, expected transport time and EtCO2 &gt; 10 mmHg. A logistic regression analysis was performed. P -values &lt; 0.05 were considered statistically significant. Results: Overall, 437 patients treated with ECPR were included with 71 (16%) patients with CPC ≤ 2 at 30 days. Signs of life were observed in 261 (59%) patients, with 136 (31%) patients presenting gasping or respiratory movement, 155 (35%) a pupillary response, and 49 (11%) movements during CPR. Overall 63/261 (24.1%) patients with signs life survived with favorable neurologic outcome vs. 8/176 (4.5%) without signs of life, p&lt;0.0001. In multivariate analysis, factors associated with favorable outcome were: signs of life during CPR (OR 11.0, 95%CI 3.7-32.5; p&lt;0.001), first recorded rhythm VF/VT (OR 3.4, 95%CI 1.3-8.9; P=0.011), low-flow duration per min (OR 0.99, 95%CI 0.98-1.00; p=0.032). Conclusions: These results highlight the importance of signs of life before or during CPR on neurological outcomes for RCA treated with ECPR. These results could help select patients with good chance of survival in whom we should not give up resuscitation efforts too soon.

Abstract 216: Renal Failure After Cardiac Arrest and the role of Targeted Temperature Management

Introduction: While Acute Kidney Injury (AKI) is a common complication of cardiac arrest (CA), the incidence of AKI and Chronic Kidney Disease (CKD) following resuscitation are not well studied. Further, the association of Targeted Temperature Management (TTM) with AKI and CKD incidence has not been extensively studied. Aim: We compared the incidence of post-arrest AKI and CKD among patients who received TTM and those who did not receive TTM. Methods: In this retrospective cohort study, we studied adult patients following resuscitation from out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). Serum creatinine (Cr) data for post-arrest patients were extracted from the electronic medical record. Baseline serum Cr was defined as the most recent pre-arrest Cr value or the lowest Cr value within 6 hrs of arrest. Using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria, AKI was defined as an increase in Cr by &gt; 0.3 mg/dL within 48 hrs or an increase in serum Cr by 1.5x the baseline value within a one-week period. CKD was defined as a GFR of &lt; 60 mL/min per 1.73 m 2 3 months post-arrest. Results: From 1/2005 to 12/2017, 1099 patients had serial post-arrest creatinine values available. Median age at arrest was 63 (IQR 25), 58% were male, survival to discharge was 20%, with a 17 % favorable CPC score of 1 or 2. Of these, 240 patients had documented TTM status (89 received TTM and 151 did not). Of the patients who received TTM, 31% developed AKI compared to 40 % who did not receive TTM (P=NS). The incidence of CKD was 56% in the TTM group and 45% in the non-TTM group. McNemar’s test for CKD at baseline and at 3 months post-arrest showed a significant increase in the incidence of CKD post arrest (45% vs. 49%, p = 0.031). Conclusions: Post cardiac arrest, AKI and CKD are common complications. The use of TTM was not associated with the incidence of AKI or CKD. Further research is needed to study factors that affect AKI and CKD in CA.

Extracorporeal cardiopulmonary resuscitation for refractory in-hospital cardiac arrest

Despite recent improvement in cardiac arrest management, in-hospital cardiac arrest (IHCA) remains associated with poor outcome. Whereas its usefulness for out-of-hospital cardiac arrest seems poor, extracorporeal cardiopulmonary resuscitation (e-CPR; i.e. veno-arterial extracorporeal membrane oxygenation (VA-ECMO) under cardiopulmonary resuscitation) could be a life-saving strategy for refractory IHCA. To describe the characteristics and outcomes of refractory IHCA patients supported by e-CPR in our institution. Retrospective cohort study of data prospectively collected. All patients implanted with a VA-ECMO for refractory IHCA from 2007 to 2017 were included. VA-ECMO was implanted at the cardiac arrest site by trained cardiac surgeons from our mobile circulatory assistance unit. After ECMO implantation, patients were all referred and managed in our ICU. A 1-yr follow-up phone call was given to each survivor. During the study period, 97 patients (mean age 50.9 ± 14.8 yrs) received e-CPR for refractory IHCA. 80.4% of IHCA had a cardiac origin. VA-ECMO was implanted in our ICU for 37% of them, in the cardiology department for 30%, in another hospital for 23%. Survival rate was 19.6% at hospital discharge, 15% at 1-yr follow-up, with a 1-yr CPC score of 1 [1–2]. Main causes of in-ICU deaths were multiple organ failure (71%) and post-anoxic encephalopathy (12%). Compared to 1-yr non-survivors, 1-yr survivors had similar no- and low-flow, their initial rhythm was more frequently shockable (69.2% versus 33.8%, respectively, P = 0.03) and their day-1 SOFA score was significantly lower (13 [10–14] versus 15 [12–17], respectively, P = 0.02). e-CPR in refractory IHCA is associated with a 15% 1-yr survival rate. Survivors have a good 1-year CPC score. Next step is to determine prognosis factors to select the patients the most likely to benefit from this technique.

Factors of importance to 30-day survival after in-hospital cardiac arrest in Sweden – A population-based register study of more than 18,000 cases

Background and objectiveIn-hospital cardiac arrest (IHCA) constitutes a major contributor to cardiovascular mortality. The aim of the present study was to investigate factors of importance to 30-day survival after IHCA in Sweden. MethodsA retrospective register study based on the Swedish Register of Cardiopulmonary Resuscitation (SRCPR) 2006–2015. Sixty-six of 73 hospitals in Sweden participated. The inclusion criterion was a confirmed cardiac arrest in which resuscitation was attempted among patients aged >18years. ResultsIn all, 18,069 patients were included, 39% of whom were women. The median age was 75years. Thirty-day survival was 28.3%, 93% with a CPC score of 1–2. One-year survival was 25.0%. Overall IHCA incidence in Sweden was 1.7 per 1000 hospital admissions. Several factors were found to be associated with 30-day survival in a multivariable analysis. They included cardiac arrest (CA) at working days during the daytime (08–20) compared with weekends and night-time (20–08) (OR 1.51 95% CI 1.39–1.64), monitored CA (OR 2.18 95% CI 1.99–2.38), witnessed CA (OR 2.87 95% CI 2.48–3.32) and if the first recorded rhythm was ventricular fibrillation/tachycardia, especially in combination with myocardial ischemia/infarction as the assumed aetiology of the CA (OR for interaction 4.40 95% CI 3.54–5.46). Conclusion30-day survival after IHCA is associated with the time of the event, the aetiology of the CA and the degree of monitoring and this should influence decisions regarding the appropriate level of monitoring and care.

Survival and neurological outcome in the elderly after in-hospital cardiac arrest

BackgroundThere have been few studies of the outcome in elderly patients who have suffered in-hospital cardiac arrest (IHCA) and the association between cardiac arrest characteristics and survival. AimThe aim of this large observational study was to investigate the survival and neurological outcome in the elderly after IHCA, and to identify which factors were associated with survival. MethodsWe investigated elderly IHCA patients (≥70years of age) who were registered in the Swedish Cardiopulmonary Resuscitation Registry 2007–2015. For descriptive purposes, the patients were grouped according to age (70–79, 80–89, and ≥90years). Predictors of 30-day survival were identified using multivariable analysis. ResultsAltogether, 11,396 patients were included in the study. Thirty-day survival was 28% for patients aged 70–79 years, 20% for patients aged 80–89 years, and 14% for patients aged ≥90years. Factors associated with higher survival were: patients with an initially shockable rhythm, IHCA at an ECG-monitored location, IHCA was witnessed, IHCA during daytime (8 a.m.–8 p.m.), and an etiology of arrhythmia. A lower survival was associated with a history of heart failure, respiratory insufficiency, renal dysfunction and with an etiology of acute pulmonary oedema. Patients over 90 years of age with VF/VT as initial rhythm had a 41% survival rate.We found a trend indicating a less aggressive care with increasing age during cardiac arrest (fewer intubations, and less use of adrenalin and anti-arrhythmic drugs) but there was no association between age and delay in starting cardiopulmonary resuscitation (CPR). In survivors, there was no significant association between age and a favourable neurological outcome (CPC score: 1–2) (92%, 93%, and 88% in the three age groups, respectively). ConclusionsIncreasing age among the elderly is associated with a lower 30-day survival after IHCA. Less aggressive treatment and a worse risk profile might contribute to these findings. Relatively high survival rates among certain subgroups suggest that discussions about advanced directives should be individualized. Most survivors have good neurological outcome, even patients over 90 years of age.

A Pre-Hospital Extracorporeal Cardio Pulmonary Resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: An observational study and propensity analysis

BackgroundOut of hospital cardiac arrest (OHCA) mortality rates remain very high with poor neurological outcome in survivors. Extracorporeal cardiopulmonary resuscitation (ECPR) is one of the treatments of refractory OHCA. This study used data from the mobile intensive care unit (MOICU) as part of the emergency medical system of Paris, and included all consecutive patients treated with ECPR (including pre-hospital ECPR) from 2011 to 2015 for the treatment of refractory OHCA, comparing two historical ECPR management strategies. MethodsWe consecutively included refractory OHCA patients. In Period 1, ECPR was indicated in selected patients after 30min of advanced life support; in- or pre-hospital implementation depended on estimated transportation time and ECPR team availability. In Period 2, patient care relied on early ECPR initiation after 20min of resuscitation, stringent patient selection, epinephrine dose limitation and deployment of ECPR team with initial response team. Primary outcome was survival with good neurological function Cerebral Performance Category score (CPC score) 1 and 2 at ICU discharge or day 28. FindingsA total of 156 patients were included. (114 in Period 1 and 42 in Period 2). Baseline characteristics were similar. Mean low-flow duration was shorter by 20min (p<0.001) in Period 2. Survival was significantly higher in Period 2: 29% vs 8% (P<0.001), as confirmed by the multivariate analysis and propensity score. When combining stringent patient selection with an aggressive strategy, the survival rate increased to 38%. Pre-hospital ECPR implementation in itself was not an independent predictor of improved survival, but it was part of the strategy in Period 2. InterpretationOur data suggest that ECPR in specific settings in the management of refractory OHCA is feasible and can lead to a significant increase in neurological intact survivors. These data, however, need to be confirmed by a large RCT.

Public access defibrillation and outcomes after pediatric out-of-hospital cardiac arrest

BackgroundUse of automated external defibrillators (AEDs) has been recommended for pediatric out-of-hospital cardiac arrest (OHCA). However, there are no conclusive studies that elucidated the effectiveness of public-access defibrillation (PAD) in children. MethodsThis was a nationwide, population-based, propensity score-matched study of pediatric OHCA in Japan from 2011 to 2012, based on data from the All-Japan Utstein Registry. We included pediatric OHCA patients (aged 1–17 years) who received bystander cardiopulmonary resuscitation. The primary outcome was a favorable neurological state 1 month after OHCA (defined as a CPC score of 1–2). ResultsA total of 1193 patients were included in the final cohort; 57 received PAD and 1136 did not. Among 1193 patients, 188 (15.8%) survived with a favorable neurological status 1 month after OHCA. The odds of neurologically favorable survival were significantly higher for patients receiving PAD after adjusting for potential confounders: propensity score matching, OR 3.17 (95% CI 1.40–7.17), and multivariable logistic regression modeling, ORadjusted 5.10 (95% CI 2.01–13.70). Similar findings were observed for the secondary outcomes (i.e., neurologically favorable survival with a CPC score of 1, one-month survival, and prehospital return of spontaneous circulation). In subgroup analyses, there were no significant differences in neurologically favorable survival between the PAD group and non-PAD group in the unwitnessed cohort (ORadjusted 7.76 [0.75–81.90]) or the non-cardiac etiology cohort (ORadjusted 6.65 [0.64–66.24]). ConclusionsPAD was associated with an increased chance of neurologically favorable survival in pediatric OHCA (aged 1–17 years) who received bystander CPR, except for in cases of unwitnessed or non-cardiac etiology.

Abstract 13806: Association Between Coronary Angiography With or Without Percutaneous Coronary Intervention and Outcomes After Out-of-Hospital Cardiac Arrest

Introduction: Coronary angiography (CA) is recommended after out-of-hospital cardiac arrest (OHCA) when ST-elevation is present but the ideal timing and benefit of CA when ST-elevation is not present are unknown. Methods: Prospective observational study of adult (age &gt;17) OHCA of presumed cardiac etiology from 1/01/2010-12/31/2014 who were admitted to one of 40 recognized cardiac receiving centers within a state resuscitation center network. DNR patients, those who did not achieve ROSC, and/or those who died in the ED were excluded since the likelihood of percutaneous coronary intervention (PCI) impacting outcome in these patients is low. An in-hospital database was linked with a statewide OHCA database. Results: Among 6,615 cases, 1,247 remained for analysis after exclusion [DNR (1254); failed to achieve ROSC/died in ED (4,020); missing prehospital variable (92); and missing outcome (2)]. Median age was 63 and 70% were male. There were 62% witnessed arrests, 54% received bystander CPR and the initial rhythm was VF/VT in 55%. Sixty-four percent survived to hospital discharge, 82% of which had a CPC score of 1 or 2. Of the 326 STEMI cases, 298 (91%) underwent CA with resultant PCI in 206 (63%). Of the 849 non-STEMI cases, 361 (43%) underwent CA with resultant PCI in 107 (13%). Overall survival was: 54% in cases without CA; 73% in cases with CA but without PCI; and 73% in those with PCI. Survival in non-STEMI cases was: 55% in cases without CA; 82% in cases with CA but without PCI; and 80% in those with PCI. In non-STEMI cases, the adjusted odds of survival for CA without PCI vs no CA was 2.70 (95% CI: 1.81, 4.02) and for PCI versus no CA it was 2.01 (95% CI: 1.16, 3.48). Conclusion: In this statewide analysis over 90% of OHCA cases with STEMI underwent CA. In cases that were not STEMI, CA was strongly and independently associated with survival regardless of whether PCI was performed. Since there is no reason to believe that CA without PCI confers a survival benefit, these findings suggest a component of selection bias in those without STEMI who undergo CA.

Breath‐print analysis by e‐nose may refine risk stratification for adverse outcomes in cirrhotic patients

The spectrum of volatile organic compounds in the exhaled breath (breath-print, BP) has been shown to characterize patients with cirrhosis and with worse hepatic function. However, the association of different BPs with clinically relevant outcomes has not been described yet. Hence, we aimed to evaluate the association between BPs, mortality and hospitalization in cirrhotic patients and to compare it with that of the "classical" prognostic indices (Child-Pugh Classification [CPC] and MELD). Eighty-nine cirrhotic patients (M/F 59/30, mean age 64.8±11.3, CPC A/B/C 37/33/19) were recruited and followed up for a median time of 23months. Clinical and biochemical data were collected. Breath collection and analysis were obtained through Pneumopipe® and BIONOTE e-nose respectively. Four different BP clusters (A, B, C, D) were identified. BP clusters A and D were associated with a significantly increased risk of mortality (HR 2.9, 95% confidence intervals [CI] 1.5-5.6) and hospitalization (HR 2.6, 95% CI 1.4-4.6), even in multiple adjusted models including CPC and MELD score (adjusted [a]HR 2.8, 95% CI 1.1-7.0 for mortality and aHR 2.2, 95% CI 1.1-4.2 for hospitalization). CPC C maintained the strongest association with both mortality (aHR 17.6, 95% CI 1.8-174.0) and hospitalization (aHR 12.4, 95% CI 2.0-75.8). This pilot study demonstrates that BP clusters are associated with significant clinical endpoints (mortality and hospitalization) even independently from "classical" prognostic indices. Even though further studies are warranted on this topic, our findings suggest that the e-nose may become an adjunctive aid to stratify the risk of adverse outcomes in cirrhotic patients.