Favorable Neurological Survival Research Articles

Survival Differences in Asian and Hispanic Patients With In-Hospital Cardiac Arrest.

Although they are fast-growing populations in the United States, little is known about survival outcomes of Hispanic and Asian patients after in-hospital cardiac arrest. In Get With The Guidelines-Resuscitation, we identified Asian, Hispanic, and White adults with in-hospital cardiac arrest during 2005 to 2023. Using multivariable models, we compared rates of survival to discharge separately for Asian and Hispanic patients versus White patients, as well as rates of sustained return of spontaneous circulation for ≥20 minutes and favorable neurologic survival as secondary outcomes. Of 189 557 in-hospital cardiac arrests, 167 640 (88.4%), 16 800 (8.9%), and 5117 (2.7%) patients were White, Hispanic, and Asian, respectively. Compared with the survival rate to discharge for White patients (22.0%), rates were lower for Hispanic (19.4%; adjusted odds ratio [OR], 0.93 [95% CI, 0.89-0.97]; P<0.001) and Asian patients (17.8%; adjusted OR, 0.90 [95% CI, 0.83-0.97]; P=0.008), and these differences were attenuated after accounting for the hospital at which patients received care (adjusted OR: Hispanic patients, 0.95 [95% CI, 0.91-1.00]; Asian patients, 0.91 [95% CI, 0.84-0.99]). Although there were no differences in rates of return of spontaneous circulation between White (68.7%), Hispanic (69.0%), and Asian patients (69.7%), both Asian and Hispanic patients were less likely to have favorable neurologic survival (White: 18.3%; Hispanic: 15.4%; adjusted OR, 0.88 [95% CI, 0.84-0.93]; Asian: 13.2%; adjusted OR, 0.80 [95% CI, 0.73-0.87]). These differences were also attenuated after accounting for hospital site. Compared with White patients, Hispanic and Asian patients with in-hospital cardiac arrest had lower rates of overall survival and favorable neurologic survival. Some of these differences were associated with the hospital at which patients received care.

Abstract Su704: Body Mass Index and Outcomes of In-Hospital Cardiac Arrest

Background: Although previous studies have reported an association between a patient’s body mass index (BMI) and outcomes for various cardiovascular conditions, the relationship between BMI and survival for in-hospital cardiac arrest (IHCA), a condition for which emergent response is required, has not been fully described. Aims: Examine the association between BMI and survival outcomes for IHCA. Methods: Within the Get With The Guidelines®-Resuscitation, we identified 56,411 patients with IHCA and available BMI data during 2005-2012 when weight and height data were collected in the registry. BMI was classified as underweight [&lt;18.5 kg/m 2 ], normal [18.5 to 24.9 kg/m 2 ], overweight [25.0 to 29.9 kg/m 2 ], obese [30.0 to 34.9 kg/m 2 ], and very obese [≥35.0 kg/m 2 ]). Using multivariable hierarchical models with hospital as a random effect, we examined the association between BMI and survival to discharge, stratified by cardiac arrest rhythm type (shockable and non-shockable). As secondary outcomes, we examined rates of sustained return of spontaneous circulation for &gt; 20 minutes (ROSC) and favorable neurological survival (i.e., survival to discharge without severe neurological disability). Results: Among 10,219 patients with a shockable arrest rhythm, 3,964 (38.7%) survived to discharge. After multivariable adjustment, compared with overweight patients, those who were underweight, of normal weight, and very obese had lower survival rates, whereas obese patients had similar survival rates ( Table ). Underweight patients also had a lower rate of ROSC and favorable neurologic survival ( Table ). Among 46,192 patients with a non-shockable arrest rhythm, 7,331 (15.8%) survived to discharge. After multivariable adjustment, all BMI groups had similar rates of survival, ROSC, and favorable neurologic survival, except for underweight patients ( Table ). Conclusions: Although the association between BMI and survival outcomes for IHCA varied by initial rhythm, underweight patients consistently had lower survival rates of survival. Very obese patients generally had similar outcomes to other weight groups, underscoring that morbid obesity was not a negative predictor of survival outcomes for IHCA.

Heart rhythm at hospital admission: A factor for survival and neurological outcome among ECPR recipients?

BackgroundThe initial rhythm is a known predictor of survival in extracorporeal cardiopulmonary resuscitation (ECPR) patients. However, the effect of the rhythm at hospital admission on outcomes in these patients is less clear. MethodsThis observational, single-center study assessed the influence of the rhythm at hospital admission on 30-day survival and neurological outcomes at discharge in patients who underwent ECPR for out-of-hospital cardiac arrest (OHCA). ResultsBetween January 2012 and December 2023, 1,219 OHCA patients were admitted, and 210 received ECPR. Of these, 196 patients were analyzed. The average age was 52.9 years (±13), with 80.6 % male. The median time to ECPR initiation was 61 min (IQR 54–72). Patients with ventricular fibrillation as both the initial and admission rhythm had the highest 30-day survival rate (52 %: 35/67), while those with asystole in both instances had the lowest (6 %: 1/17, log-rank p < 0.00001). After adjusting for age, sex, initial rhythm, resuscitation time, location, bystander, and witnessed status, asystole at admission was linked to higher 30-day mortality (OR 4.03, 95 % CI 1.49–12.38, p = 0.009) and worse neurological outcomes (Cerebral Performance Category 3–5) at discharge (OR 4.61, 95 % CI 1.49–17.62, p = 0.013). ConclusionsThe rhythm at hospital admission affects ECPR outcomes. Patients presenting with and maintaining ventricular fibrillation have a higher chance of favorable neurological survival, whereas those presenting with or converting to asystole have poor outcomes. The rhythm at hospital admission appears to be a valuable criterion for deciding on ECPR initiation.

The association of intravenous vs. humeral-intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests

AimWhile intravenous (IV) vascular access for out-of-hospital cardiac arrest (OHCA) resuscitation is standard, humeral-intraosseous (IO) access is commonly used, despite few supporting data. We investigated the association between IV vs. humeral-IO and outcomes. MethodsWe utilized BC Cardiac Arrest Registry data, including adult OHCA where the first-attempted intra-arrest vascular access route performed by advanced life support (ALS)-trained paramedics was IV or humeral-IO. We fit a propensity-score adjusted model with inverse probability treatment weighting to estimate the association between IV vs. humeral-IO routes and favorable neurological outcomes (CPC 1–2) and survival at hospital discharge. We repeated models within subgroups defined by initial cardiac rhythm. ResultsWe included 2,112 cases; the first-attempted route was IV (n = 1,575) or humeral-IO (n = 537). Time intervals from ALS-paramedic on-scene arrival to vascular access (6.6 vs. 6.9 min) and epinephrine administration (9.0 vs. 9.3 min) were similar between IV and IO groups, respectively. Among IV and humeral-IO groups, 98 (6.2%) and 20 (3.7%) had favorable neurological outcomes. Compared to humeral-IO, an IV-first approach was associated with improved hospital-discharge favorable neurological outcomes (AOR 1.7; 95% CI 1.1–2.7) and survival (AOR 1.5; 95% CI 1.0–2.3). Among shockable rhythm cases, an IV-first approach was associated with improved favorable neurological outcomes (AOR 4.2; 95% CI 2.1–8.2), but not among non-shockable rhythm cases (AOR 0.73; 95% CI 0.39–1.4). ConclusionAn IV-first approach, compared to humeral-IO, for intra-arrest resuscitation was associated with an improved odds of favorable neurological outcomes and survival to hospital discharge. This association was seen among an initial shockable rhythm, but not non-shockable rhythm, subgroups.

The association of non-prescription drug use preceding out-of-hospital cardiac arrest and clinical outcomes

BackgroundClinicians may make prognostication decisions for out-of-hospital cardiac arrest (OHCA) using historical details pertaining to non-prescription drug use. However, differences in outcomes between OHCAs with evidence of non-prescription drug use, compared to other OHCAs, have not been well described. MethodsWe included emergency medical service-treated OHCA in the British Columbia Cardiac Arrest Registry (January/2019–June/2023). We classified cases as “non-prescription drug-associated cardiac arrests” (DA-OHCA) if there was evidence of non-prescription drug use preceding the OHCA, including witness accounts of use within 24 h or paraphernalia at the scene. We fit logistic regression models to investigate the association between DA-OHCA (vs. other cases) and favourable neurological outcome (Cerebral Performance Category [CPC] 1–2) and survival at hospital discharge, and return of spontaneous circulation (ROSC). ResultsOf 18,426 OHCA, 2,171 (12%) were classified as DA-OHCA. DA-OHCA tended to be younger, unwitnessed, occur during the evening or night, and present with a non-shockable rhythm, compared to other OHCA. DA-OHCA (221 [10%]) had a greater proportion (difference 1.8%; 95% CI 0.49–3.2) with favourable neurological outcomes compared to other OHCA (1,365 [8.4%]). Adjusted models did not identify an association of DA-OHCA with favourable neurological outcome (OR 1.08, 95% CI 0.87–1.33) or survival to hospital discharge (OR 1.13, 95% CI 0.93–1.38), but did demonstrate an association with ROSC (OR 1.13, 95% CI 1.004–1.27). ConclusionIn unadjusted models, DA-OHCA was associated with an improved odds of survival and favourable neurological outcomes at hospital discharge, compared to other OHCA. However, we did not detect an association in adjusted analyses.

Emergency Medical Service Agency Practices and Cardiac Arrest Survival

Survival for out-of-hospital cardiac arrest (OHCA) varies widely across emergency medical service (EMS) agencies in the US. However, little is known about which EMS practices are associated with higher agency-level survival. To identify resuscitation practices associated with favorable neurological survival for OHCA at EMS agencies. This cohort study surveyed EMS agencies participating in the Cardiac Arrest Registry to Enhance Survival (CARES) with 10 or more OHCAs annually during January 2015 to December 2019; data analyses were performed from April to October 2023. Survey of resuscitation practices at EMS agencies. Risk-standardized rates of favorable neurological survival for OHCA at each EMS agency were estimated using hierarchical logistic regression. Multivariable linear regression then examined the association of EMS practices with rates of risk-standardized favorable neurological survival. Of 577 eligible EMS agencies, 470 agencies (81.5%) completed the survey. The mean (SD) rate of risk-standardized favorable neurological survival was 8.1% (1.8%). A total of 7 EMS practices across 3 domains (training, cardiopulmonary resuscitation [CPR], and transport) were associated with higher rates of risk-standardized favorable neurological survival. EMS agencies with higher favorable neurological survival rates were more likely to use simulation to assess CPR competency (β = 0.54; P = .05), perform frequent reassessment (at least once every 6 months) of CPR competency in new staff (β = 0.51; P = .04), use full multiperson scenario simulation for ongoing skills training (β = 0.48; P = .01), perform simulation training at least every 6 months (β = 0.63; P < .001), and conduct training in the use of mechanical CPR devices at least once annually (β = 0.43; P = .04). EMS agencies with higher risk-standardized favorable neurological survival were also more likely to use CPR feedback devices (β = 0.58; P = .007) and to transport patients to a designated cardiac arrest or ST-segment elevation myocardial infarction receiving center (β = 0.57; P = .003). Adoption of more than half (≥4) of the 7 practices was more common at EMS agencies in the highest quartile of favorable neurological survival rates (70 of 118 agencies [59.3%]) vs the lowest quartile (42 of 118 agencies [35.6%]) (P < .001). In a national registry for OHCA, 7 practices associated with higher rates of favorable neurological survival were identified at EMS agencies. Given wide variability in neurological survival across EMS agencies, these findings provide initial insights into EMS practices associated with top-performing EMS agencies in OHCA survival. Future studies are needed to validate these findings and identify best practices for EMS agencies.

Prognostic Impact of Heart Rhythm Shockability Trajectory in Out-of-Hospital Cardiac Arrest: A Multicenter Retrospective Study.

This study aimed to investigate the association between the temporal transitions in heart rhythms during cardiopulmonary resuscitation (CPR) and outcomes after out-of-hospital cardiac arrest. This was an analysis of the prospectively collected databases in 3 academic hospitals in northern and central Taiwan. Adult patients with out-of-hospital cardiac arrest transported by emergency medical service between 2015 and 2022 were included. Favorable neurological recovery and survival to hospital discharge were the primary and secondary outcomes, respectively. Time-specific heart rhythm shockability was defined as the probability of shockable rhythms at a particular time point during CPR. The temporal changes in the time-specific heart rhythm shockability were calculated by group-based trajectory modeling. Multivariable logistic regression analyses were performed to examine the association between the trajectory group and outcomes. Subgroup analyses examined the effects of extracorporeal CPR in different trajectories. The study comprised 2118 patients. The median patient age was 69.1 years, and 1376 (65.0%) patients were male. Three distinct trajectories were identified: high-shockability (52 patients; 2.5%), intermediate-shockability (262 patients; 12.4%), and low-shockability (1804 patients; 85.2%) trajectories. The median proportion of shockable rhythms over the course of CPR for the 3 trajectories was 81.7% (interquartile range, 73.2%-100.0%), 26.7% (interquartile range, 16.7%-37.5%), and 0% (interquartile range, 0%-0%), respectively. The multivariable analysis indicated both intermediate- and high-shockability trajectories were associated with favorable neurological recovery (intermediate-shockability: adjusted odds ratio [aOR], 4.98 [95% CI, 2.34-10.59]; high-shockability: aOR, 5.40 [95% CI, 2.03-14.32]) and survival (intermediate-shockability: aOR, 2.46 [95% CI, 1.44-4.18]; high-shockability: aOR, 2.76 [95% CI, 1.20-6.38]). The subgroup analysis further indicated extracorporeal CPR was significantly associated with favorable neurological outcomes (aOR, 4.06 [95% CI, 1.11-14.81]) only in the intermediate-shockability trajectory. Heart rhythm shockability trajectories were associated with out-of-hospital cardiac arrest outcomes, which may be a supplementary factor in guiding the allocation of medical resources, such as extracorporeal CPR.

Biomarkers for neuroprognostication after standard versus extracorporeal cardiopulmonary resuscitation – A sub-analysis of Prague-OHCA study

BackgroundLimited evidence exists for prognostic performance of biomarkers in patients resuscitated from out-of-hospital cardiac arrest (OHCA) with extracorporeal CPR (ECPR). We hypothesized that (1) the time course and (2) prognostic performance of biomarkers might differ between CPR and ECPR in a sub-analysis of Prague-OHCA study. MethodsPatients received either CPR (n = 164) or ECPR (n = 92). The primary outcome was favorable neurologic survival at 180 days [cerebral performance category (CPC) 1–2]. Secondary outcomes included biomarkers of neurologic injury, inflammation and hemocoagulation. ResultsFavorable neurologic outcome was not different between groups: CPR 29.3% vs. ECPR 21.7%; p = 0.191. Biomarkers exhibited similar trajectories in both groups, with better values in patients with CPC 1–2. Procalcitonin (PCT) was higher in ECPR group at 24–72 h (all p < 0.01). Neuron-specific enolase (NSE), C-reactive protein and neutrophil-to-lymphocyte ratio did not differ between groups. Platelets, D-dimers and fibrinogen were lower in ECPR vs. CPR groups at 24–72 h (all p < 0.001). ROC analysis (24–48–72 h) showed the best performance of NSE in both CPR and ECPR groups (AUC 0.89 vs. 0.78; 0.9 vs. 0.9; 0.91 vs. 0.9). PCT showed good performance specifically in ECPR (0.72 vs. 0.84; 0.73 vs. 0.87; 0.73 vs. 0.86). Optimal cutoff points of NSE and PCT were higher in ECPR vs. CPR. ConclusionsBiomarkers exhibited similar trajectories although absolute values tended to be higher in ECPR. NSE had superior performance in both groups. PCT showed a good performance specifically in ECPR. Additional biomarkers may have modest incremental value. Prognostication algorithms should reflect the resuscitation method.

Extracorporeal cardiopulmonary resuscitation versus conventional CPR in cardiac arrest: an updated meta-analysis and trial sequential analysis

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) may reduce mortality and improve neurological outcomes in patients with cardiac arrest. We updated our existing meta-analysis and trial sequential analysis to further evaluate ECPR compared to conventional CPR (CCPR).MethodsWe searched three international databases from 1 January 2000 through 1 November 2023, for randomised controlled trials or propensity score matched studies (PSMs) comparing ECPR to CCPR in both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). We conducted an updated random-effects meta-analysis, with the primary outcome being in-hospital mortality. Secondary outcomes included short- and long-term favourable neurological outcome and survival (30 days–1 year). We also conducted a trial sequential analysis to evaluate the required information size in the meta-analysis to detect a clinically relevant reduction in mortality.ResultsWe included 13 studies with 14 pairwise comparisons (6336 ECPR and 7712 CCPR) in our updated meta-analysis. ECPR was associated with greater precision in reducing overall in-hospital mortality (OR 0.63, 95% CI 0.50–0.79, high certainty), to which the trial sequential analysis was concordant. The addition of recent studies revealed a newly significant decrease in mortality in OHCA (OR 0.62, 95% CI 0.45–0.84). Re-analysis of relevant secondary outcomes reaffirmed our initial findings of favourable short-term neurological outcomes and survival up to 30 days. Estimates for long-term neurological outcome and 90-day–1-year survival remained unchanged.ConclusionsWe found that ECPR reduces in-hospital mortality, improves neurological outcome, and 30-day survival. We additionally found a newly significant benefit in OHCA, suggesting that ECPR may be considered in both IHCA and OHCA.

TREATMENT OF COMATOSE SURVIVORS OF IN-HOSPITAL CARDIAC ARREST WITH EXTENDED ENDOVASCULAR COOLING METHOD FOR 72 H: A PROPENSITY SCORE-MATCHED ANALYSIS.

Aims: Targeted temperature management is recommended for at least 24 h in comatose survivors of in-hospital cardiac arrest (IHCA) after the return of spontaneous circulation; however, whether an extension for 72 h leads to better neurological outcomes is uncertain. Methods: We included data from the Qilu Hospital of Shandong University between July 20, 2019, and June 30, 2022. Unconscious patients who had return of spontaneous circulation lasting >20 consecutive min and received endovascular cooling (72 h) or normothermia treatment were compared in terms of survival-to-discharge and favorable neurological survival. Propensity score matching was used to formulate balanced 1:3 matched patients. Results: In total, 2,084 patients were included. Sixteen patients received extended endovascular cooling and 48 matched controls received normothermia therapy. Compared with the normothermia group, patients who received prolonged endovascular cooling had a higher survival-to-discharge rate. However, good neurological outcomes did not differ significantly. Before matching, Cox regression analysis, using mortality as the event, showed that extended endovascular cooling independently affected the survival of IHCA patients. Conclusions: Among comatose patients who had been resuscitated from IHCA, the use of endovascular cooling for 72 h might confer a benefit on survival-to-discharge.

Abstract 394: Epinephrine Administration Before Defibrillation in Children With an Initially Shockable In-Hospital Cardiac Arrest Rhythm

Background: Contrary to current guidelines, administration of epinephrine before first defibrillation for shockable in-hospital cardiac arrest (IHCA) is common in adults and associated with lower survival. Whether these findings are also present in pediatric IHCA remains unknown. Methods: We used 2000-2020 data from the Get With the Guidelines®—Resuscitation registry to identify children (&lt;18 years) with index IHCA due to an initial shockable rhythm of ventricular fibrillation or pulseless ventricular tachycardia and at least 1 defibrillation attempt. Study outcomes were event survival, defined as return of spontaneous circulation for &gt; 20 minutes, survival to hospital discharge and favorable neurologic survival. Inverse probability of treatment weighting (IPTW) using propensity scores was used to adjust for confounding . Results: Among 492 pediatric IHCA index events (median [IQR] age, 7 years [0.75 to 14 years]; 351 [71%] in the ICU), 142 (29%) children with an initial shockable rhythm received epinephrine before defibrillation. Subjects receiving epinephrine before defibrillation had longer times to defibrillation compared to those receiving defibrillation first (median [IQR]: 4 minutes [2 to 8] vs. 1 minute [0 to 2]). Rates of event survival (72.7% vs. 82.8%), survival to hospital discharge (36.4% vs. 47.9%), and favorable neurologic survival (18.9% vs. 33.1%) were lower in the epinephrine before defibrillation group, Table). However, in adjusted analyses using IPTW, epinephrine before defibrillation was not associated with survival outcomes (Table). Conclusions: Nearly one in three pediatric IHCA with initial shockable rhythm receives epinephrine before defibrillation in contrast with recommended guidelines. However, unlike adults with IHCA, we did not identify a clear association between epinephrine before defibrillation and survival.

Abstract 150: Non-Linear Association Between the Time of Reaching the Targeted Temperature and the Neurological Outcome in Patients Undergoing Targeted Temperature Management After Out-of-Hospital Cardiac Arrest Observational Multicenter Cohort Study

Background: We aimed to identify the most favourable time from the introduction of targeted temperature management (TTM) to achieving the targeted temperature in patients experiencing out-of-hospital cardiac arrest. Methods: This multicenter cohort study was performed using the Comprehensive Registry of Intensive Care for OHCA Survival study, we collected patients’ information, including that on in-hospital care. We enrolled all consecutive patients transported to participating institutions in Osaka, Japan from 1 July 2012 through 31 December 2017. Eligible were persons aged ≥18 years whose cardiac arrest was of cardiac etiology and who received in-hospital TTM. Primary outcome was favourable neurological survival with a Cerebral Performance Category scale of 1 or 2 one-month after cardiac arrest, which was designated as “one-month favourable neurological survival”. After adjusting for several factors, a non-linear multivariable logistic regression analysis assessed the time from the introduction of TTM to reaching the targeted temperature and the probability of the primary outcome. Also, we subdivided patients according to five quintiles based on the time from the introduction of TTM to achieving the targeted temperature. To compare the probability of the primary outcome among quintiles, a multivariable logistic regression analysis calculated adjusted odds ratios and 95% confidence intervals. Results: We analyzed 483 patients. p for non-linearity was &lt;0.01 in the non-linear multivariable logistic regression analysis. In the first quintile (&lt;26.7 minutes), second quintile (26.8-89.9 minutes), third quintile (90.0-175.1 minutes), fourth quintile (175.2-352.1 minutes), and fifth quintile (≥352.2 minutes), one-month favourable neurological survival was 32.6% (31/95), 40.0% (36/90), 53.5% (53/99), 57.4% (54/94), and 37.9% (36/95), respectively. Adjusted odds ratios with 95% CI for the primary outcome in the first, second, third, and fifth quintiles, compared with the fourth quintile as the reference, were 0.38 (0.20 to 0.72), 0.43 (0.23 to 0.81), 0.77 (0.41 to 1.44), and 0.46 (0.25 to 0.87), respectively. Conclusions: Time to reaching the targeted temperature was associated with favourable outcome in patients with cardiac arrest.

Abstract 186: Regional Cerebral Oxygen Saturation to Predict Neurologic Outcome During Out-of-Hospital-Cardiac -Arrest: An Ancillary Analysis of a Prospective Interventional Study

Background: Very few prognosis markers are available to help emergency medical services decide whether to continue or terminate cardiopulmonary resuscitation (CPR). ETCO 2 has been described to predict return of spontaneous circulation (ROSC) but its ability to predict neurologic outcome is poor. Cerebral tissue oxygen saturation (RSO 2 ) during CPR, as measured by near-infrared spectroscopy (NIRS) represents hemoglobin oxygenation within the cerebral tissue. The measure is feasible during CPR. It has been associated with the probability of ROSC. The aim of this study was to assess the predictive value of RSO2 regarding 30 days favorable neurologic outcome after out-of-hospital cardiac arrest (OHCA). Method: Data were collected during a prospective single center before-after interventional study comparing conventional CPR (C-CPR) with Automated head and thorax elevation CPR (AHUP). C-CPR was performed manually and AHUP-CPR was delivered using a LUCAS Active Decompression (Stryker Medical, USA), an EleGARD Patient Positioning System (AdvancedCPR Solutions, USA), and an impedance threshold device (ResQPOD-16, Zoll, USA). The study was carried out in four fire stations and one physician staffed advanced life support emergency medical services in France. ETCO2 (using an EMMA, Massimo or Lifepack 15, Stryker, USA) and RSO2 (H500, Nonin, USA) were collected as soon as possible during CPR. Favorable neurologic outcome was defined as MRS score of 0 to 3 at 30 days. Results are presented as mean ± standard deviation. Results: ETCO 2 was collected in 118 patients (11 with good neurologic outcome) and RSO 2 in 69 patients (6 with good neurologic outcome). Maximum ETCO 2 during CPR was 43±19mmHg in favorable neurologic outcome patients vs. 35±16mmHg (p=0.13). ETCO 2 alone had an AUC of 0,63 (IC95% 0.46-0.79). Maximum RSO2 during CPR was 68±13% for favorable neurologic outcome patients vs. 49±13% (p&lt;0.001). For survival with favorable neurologic outcome, rSO 2 alone had an AUC of 0.85 (IC95% 0.71-0.99). With a maximum RSO 2 value below 51% there was no patient with favorable neurologic outcome. Conclusion: In this prospective interventional study, unlike EtCO 2 , RSO 2 values were significantly associated with favorable neurological survival at 30 days.

How effective is extracorporeal life support for patients with out-of-hospital cardiac arrest initiated at the emergency department? A systematic review and meta-analysis.

Extracorporeal cardiopulmonary resuscitation (ECPR) is commonly initiated for adults experiencing cardiac arrest within the cardiac catheterization lab or the intensive care unit. However, the potential benefit of ECPR for these patients in the emergency department (ED) remains undocumented. This study aims to assess the benefit of ECPR initiated in the ED for patients with out-of-hospital cardiac arrest (OHCA). We conducted a systematic review and meta-analysis of studies comparing ECPR initiated in the ED versus conventional CPR. Relevant articles were identified by searching several databases including PubMed, EMBASE, Web of Science, and Cochrane collaborations up to July 31, 2022. Pooled estimates were calculated using the inverse variance heterogeneity method, while heterogeneity was evaluated using Q and I2 statistics. The risk of bias in included studies was evaluated using validated bias assessment tools. The primary outcome was a favorable neurological outcome at hospital discharge, and the secondary outcome was survival to hospital discharge or 30-day survival. Sensitivity analyses were performed to explore the benefits of ED-initiated ECPR in studies utilizing propensity score (PPS) analysis. Publication bias was assessed using Doi plots and the Luis Furuya-Kanamori (LFK) index. The meta-analysis included a total of eight studies comprising 51,173 patients. ED-initiated ECPR may not be associated with a significant increase in favorable neurological outcomes (odds ratio [OR] 1.43, 95% confidence interval [CI] 0.30-6.70, I2 = 96%). However, this intervention may be linked to improved survival to hospital discharge (OR 3.34, 95% CI 2.23-5.01, I2 = 17%). Notably, when analyzing only PPS data, ED-initiated ECPR demonstrated efficacy for both favorable neurological outcomes (OR 1.89, 95% CI 1.26-2.83, I2 = 21%) and survival to hospital discharge (OR 3.37, 95% CI 1.52-7.49, I2 = 57%). Publication bias was detected for primary (LFK index 2.50) and secondary (LFK index 2.14) outcomes. The results of this study indicate that ED-initiated ECPR may not offer significant benefits in terms of favorable neurological outcomes for OHCA patients. However, it may be associated with increased survival to hospital discharge. Future studies should prioritize randomized trials with larger sample sizes and strive for homogeneity in patient populations to obtain more robust evidence in this area.

The association of tibial vs. humeral intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests

AimHumeral and tibial intraosseous (IO) vascular access can deliver resuscitative medications for out-of-hospital cardiac arrest (OHCA), however the optimal site is unclear. We examined the association between IO tibia vs. humerus as the first-attempted vascular access site with OHCA outcomes. MethodsWe used prospectively-collected data from the British Columbia Cardiac Arrest registry, including adult OHCAs treated with IO humerus or IO tibia as the first-attempted intra-arrest vascular access. We fit logistic regression models on the full study cohort and a propensity-matched cohort, to estimate the association between IO site and both favorable neurological outcomes (Cerebral Performance Category 1–2) and survival at hospital discharge. ResultsWe included 1041 (43%) and 1404 (57%) OHCAs for whom IO humerus and tibia, respectively, were the first-attempted intra-arrest vascular access. Among humerus and tibia cases, 1010 (97%) and 1369 (98%) had first-attempt success, and the median paramedic arrival-to-successful access interval was 6.7 minutes (IQR 4.4–9.4) and 6.1 minutes (IQR 4.1–8.9), respectively. In the propensity-matched cohort (n = 2052), 31 (3.0%) and 44 (4.3%) cases had favourable neurological outcomes in the IO humerus and IO tibia groups, respectively; compared to IO humerus, we did not detect an association between IO tibia with favorable neurological outcomes (OR 1.44; 95% CI 0.90–2.29) or survival to hospital discharge (OR 1.29; 95% CI 0.83–2.01). Results using the full cohort were similar. ConclusionsWe did not detect an association between the first-attempted intra-arrest IO site (tibia vs. humerus) and clinical outcomes. Clinical trials are warranted to test differences between vascular access strategies.

236 Favourable neurological survival following out-of-hospital cardiac arrest in children treated by helicopter emergency medical service in Switzerland: a retrospective observational study

236 Favourable neurological survival following out-of-hospital cardiac arrest in children treated by helicopter emergency medical service in Switzerland: a retrospective observational study

Etiology-Based Prognosis of Extracorporeal CPR Recipients After Out-of-Hospital Cardiac Arrest: A Retrospective Multicenter Cohort Study

BackgroundA better understanding of the relative contributions of various factors to patient outcomes is essential for optimal patient selection for extracorporeal cardiopulmonary resuscitation (ECPR) therapy for patients with out-of-hospital cardiac arrest (OHCA). However, evidence on the prognostic comparison based on the etiologies of cardiac arrest is limited. Research QuestionWhat is the etiology-based prognosis of patients undergoing ECPR for OHCA? Study Design and MethodsThis retrospective multicenter registry study involved 36 institutions in Japan and included all adult patients with OHCA who underwent ECPR between January 2013 and December 2018. The primary etiology for OHCA was determined retrospectively from all hospital-based data at each institution. We performed a multivariable logistic regression model to determine the association between etiology of cardiac arrest and two outcomes: favorable neurological outcomes and survival at hospital discharge. ResultsWe identified 1,781 eligible patients, of whom 1,405 (78.9%) had cardiac arrest due to the cardiac causes. Multivariable logistic regression analysis for favorable neurological outcomes showed that accidental hypothermia (adjusted OR = 5.12; 95% CI = 2.98-8.80, P < 0.001) was associated with a significantly higher rate of favorable neurological outcomes than cardiac causes. Multivariable logistic regression analysis for survival showed that accidental hypothermia (adjusted OR = 5.19; 95% CI = 3.15-8.56, P < 0.001) had significantly higher rates of survival than cardiac causes. Acute aortic dissection/aneurysm (adjusted OR = 0.07, 95% CI = 0.02-0.28, P < 0.001) and primary cerebral disorders (adjusted OR = 0.12, 95% CI = 0.03-0.50, P = 0.004) had significantly lower rates of survival than cardiac causes. InterpretationIn this retrospective multicenter cohort study, although most OHCA patients underwent ECPR for cardiac causes, accidental hypothermia was associated with favorable neurological outcomes and survival; in contrast, acute aortic dissection/aneurysm and primary cerebral disorders were associated with non-survival than cardiac causes.

Prehospital predicting factors using a decision tree model for patients with witnessed out-of-hospital cardiac arrest and an initial shockable rhythm

The effect of prehospital factors on favorable neurological outcomes remains unclear in patients with witnessed out-of-hospital cardiac arrest (OHCA) and a shockable rhythm. We developed a decision tree model for these patients by using prehospital factors. Using a nationwide OHCA registry database between 2005 and 2020, we retrospectively analyzed a cohort of 1,930,273 patients, of whom 86,495 with witnessed OHCA and an initial shockable rhythm were included. The primary endpoint was defined as favorable neurological survival (cerebral performance category score of 1 or 2 at 1 month). A decision tree model was developed from randomly selected 77,845 patients (development cohort) and validated in 8650 patients (validation cohort). In the development cohort, the presence of prehospital return of spontaneous circulation was the best predictor of favorable neurological survival, followed by the absence of adrenaline administration and age. The patients were categorized into 9 groups with probabilities of favorable neurological survival ranging from 5.7 to 70.8% (areas under the receiver operating characteristic curve of 0.851 and 0.844 in the development and validation cohorts, respectively). Our model is potentially helpful in stratifying the probability of favorable neurological survival in patients with witnessed OHCA and an initial shockable rhythm.

Comparison of Out-of-Hospital Cardiac Arrest Outcomes Between Asian and White Individuals in the United States.

Background Disparities in bystander cardiopulmonary resuscitation (CPR) and survival have been reported for Black and Hispanic individuals with out-of-hospital cardiac arrest (OHCA). Whether Asian individuals have lower rates of bystander CPR and survival for OHCA, as compared with White individuals, remains unknown. Methods and Results Within the US-based CARES (Cardiac Arrest Registry to Enhance Survival), we identified 278 989 OHCAs in Asian and White individuals during 2013 to 2021. Using hierarchical Poisson logistic regression with emergency medical service agency modeled as a random effect and patient and OHCA characteristics as fixed effects, we compared rates of bystander CPR, survival to discharge, and favorable neurological survival between Asian and White individuals with OHCA. Overall, 14 835 (5.3%) OHCAs occurred in Asian individuals. Compared with White individuals with OHCA, Asian individuals were older (67.0±17.6 versus 62.8±16.9 years) and were less likely to have drug overdose as the cause of OHCA (1.3% versus 6.6%) and a shockable arrest rhythm (19.2% versus 22.4%). Layperson bystander CPR rates were similar between Asian and White individuals (42.6% versus 42.1%; adjusted relative risk for Asian individuals, 0.99 [95% CI, 0.97-1.02]; P=0.69). However, rates of survival to discharge were lower in Asian individuals with OHCA (8.2% versus 10.3%; adjusted relative risk 0.92 [0.86-0.98] P=0.006). Similarly, the rate of favorable neurological survival was lower for Asian individuals (6.5% versus 8.7%; adjusted relative risk, 0.85 [0.79-0.91]; P<0.001). Conclusions Despite similar rates of bystander CPR, Asian individuals with OHCA have lower survival rates than White individuals with OHCA. The reasons for the lower survival rate deserve further study to determine whether there are disparities in resuscitation care between Asian and White individuals with OHCA.

Pre-hospital airway management and neurological status of patients with out-of-hospital cardiac arrest: A retrospective cohort study

PurposeLittle is known about whether pre-hospital advanced airway management (AAM) under the presence of a physician could improve outcome of patients with cardiac arrest, compared with pre-hospital AAM under the absence of a physician. MethodsThis retrospective multicentre-cohort study enrolled consecutive patients who were transported to participating hospitals after out-of-hospital cardiac arrest in Japan between 1 June 2014 and 31 December 2019. We included patients who underwent pre-hospital AAM and resuscitation after arrival at hospital, and who were ≥18 years of age, with medical aetiologies. The primary outcome was favourable neurological survival (Cerebral Performance Category score of 1 or 2) one month after cardiac arrest. The primary outcome was called one-month favourable neurological survival. The first confirmed cardiac rhythm was defined using 3-lead electrocardiogram monitor or an automated external defibrillator and by determining whether the carotid artery was pulsating. Previous research found that the presence of a pre-hospital physician was associated with improved patients’ outcomes, after the type of first confirmed cardiac rhythm was considered. Therefore, the first confirmed cardiac rhythm in current study was subdivided into non-shockable or shockable groups. A multivariable logistic regression analysis was performed on propensity score-matched patients. ResultsWe analysed 16,703 patients. Among the 2,346 patients in the non-shockable group, 1.2% (N = 29) achieved the primary outcome. The adjusted odds ratio of pre-hospital AAM with or without a physician for the primary outcome in the results of the non-shockable group was 4.64 (95% confidence interval: 1.81–14.4). Among the 826 patients in the shockable group, 16.9% (N = 140) achieved the primary outcome and the adjusted odds ratio of pre-hospital AAM with or without a physician for the primary outcome in the results of the shockable group was 1.05 (95% confidence interval: 0.67–1.63). ConclusionsThis retrospective multicentre-cohort study found that pre-hospital AAM under the presence of a physician was significantly associated with increased neurological outcome in specific patients with cardiac arrest, compared with pre-hospital AAM under the absence of a physician.