Good Neurological Outcome In Patients Research Articles

Effect Size of Targeted Temperature Management in Pediatric Patients with Post-Cardiac Arrest Syndrome According to the Severity.

Few studies have investigated the differential effects of targeted temperature management (TTM) according to the severity of the condition in pediatric patients with post-cardiac arrest syndrome (PCAS). This study was aimed at evaluating the differential effects of TTM in pediatric patients with PCAS according to a risk classification tool developed by us, the rCAST. We used data from a nationwide prospective registry for out-of-hospital cardiac arrest (OHCA) patients in Japan. We classified eligible pediatric PCAS patients (aged ≤ 18 years) into quintiles based on their rCAST scores and evaluated the effect of TTM on the neurological outcomes in each severity group. Then, focusing on the severity group that appeared to benefit from TTM, we also evaluated the effect of TTM by propensity score analysis. Good neurological outcome was defined as a score on the Cerebral Performance Category or Pediatric Cerebral Performance Category scale of ≤2 at 30 days. Among 1526 OHCA pediatric patients enrolled in the registry, the data of 307 PCAS patients were analyzed. None of the patients in the fifth quintile (rCAST ≥ 18.5) showed a good neurological outcome, regardless of whether they received TTM or not (0% [0/20] vs. 0% [0/73]). The propensity score analysis showed that TTM was significantly associated with a good neurological outcome in patients with rCAST scores in the first to fourth quintile (odds ratio: 1.21 [1.04-1.40], p = 0.014). TTM was significantly associated with good neurological outcomes in pediatric PCAS patients with rCAST scores of ≤18.0.

Complete vs culprit-lesion-only myocardial revascularization in patients with out-of-hospital cardiac arrest: insights from the multicentric "Lombardia CARe" registry

Abstract Background Out-of-hospital Cardiac Arrest (OHCA) is a potentially devastating complication of patients with Myocardial Infarction (MI). Multivessel Disease (MVD) is a frequent occurrence in this setting, being present in nearly half patients undergoing Coronary Angiography (CAG). We previously reported that, in case of MI complicated by OHCA and evidence of MVD, a complete myocardial revascularization, as compared to culprit-lesion-only revascularization, was associated with an improved 1-year survival and favorable neurological outcomes. We aimed to validate and confirm these results on a multicentric scale with a larger patient cohort. Methods This is a multicentric, prospective, observational study. We considered all the consecutive patients with OHCA and MI enrolled in the Lombardia CARe Registry from January 1st 2015 to December 31st 2022 who underwent CAG in 6 centers in Northen Italy. Results A total of 623 patients were included; of these, 403 underwent CAG. Median age was 64 years, and about 80% had no previous history of ischemic heart disease. Median ejection fraction (EF) at presentation was 40%. MVD was present in 186 (46.1%) patients and was subsequently treated with either complete (32.3%) or incomplete (67.7%) coronary revascularization. Left anterior descendent (LAD) artery was the culprit lesion in almost 1/3 of patients. The 1-year survival rate was 78.3% in the complete revascularization group and 42.9% in the culprit-lesion-only revascularization group (p-value < 0.001). After correction for factors that were predictors on univariate analysis, complete revascularization strategy was independently associated with a reduced risk of death [HR: 0.27 (95% CI: 0.01 to 0.739; p = 0.01] and death or unfavorable neurological outcome [HR: 0.23 (95% CI: 0.08 to 0.67); p = 0.007]. Conclusions Complete revascularization strategy was confirmed to be associated with an improvement of 1-year survival and with a good neurological outcome in patients resuscitated from OHCA. These results highlight the independent impact on survival of a complete coronary intervention strategy in patients with OHCA plus MVD.

Abstract 147: Is Effect Size of Targeted Temperature Management Different for Pediatric Post-Cardiac Arrest Syndrome According to the Severity?

Introduction: The beneficial effect of target temperature management (TTM) for pediatric post-cardiac arrest syndrome (PCAS) patients is controversial, and there are few studies on the differential effects of TTM according to the risk classification. Objective: The aim of this study was to evaluate the differential effects of TTM for pediatric PCAS patients according to a risk classification tool we previously developed, rCAST. Methods: We used data from the Japanese nationwide out-of-hospital cardiac arrest (OHCA) registry of the Japanese Association for Acute Medicine. We classified eligible pediatric PCAS patients (aged ≤18 years) who achieved return of spontaneous circulation (ROSC) according to the quintile of score points on the rCAST. The effect of TTM for their neurological outcome was evaluated for each severity group. And then, focusing on the severity group that appeared to benefit from TTM, we also evaluated the effect of TTM by the propensity score analysis with several adjustment factors. Good neurological outcome was defined as a Cerebral Performance Categories score or Pediatric Cerebral Performance Categories score ≤2 at 30 days. Results: Among 1,526 OHCA pediatric patients in the registry, data of 307 PCAS patients who achieved ROSC were analyzed. The proportion of patients with a good neurological outcome was higher among those who underwent TTM compared to those who did not in the first to forth quintile (TTM vs non-TTM; 81% [21/26] vs 58% [21/36] [p=0.10] in the first, 11% [2/19] vs 7% [2/31] [p=0.63] in the second, 12% [2/17] vs 0% [0/55] [p=0.053] in the third, and 11% [1/9] vs 0% [0/21] [p=0.30] in the fourth). In the group of the fifth quantile (rCAST ≥ 18.5), no patients showed good neurological outcome regardless of TTM (0% [0/20] vs 0% [0/73]). The propensity score analysis showed that TTM was significantly associated with their good neurological outcome in the patients classified into the first to fourth quantile group (Odds ratio; 1.21 [1.04-1.40], p = 0.014). Conclusions: TTM was significantly associated with a good neurological outcome in the pediatric PCAS patients with rCAST ≤ 18.0. All patients with rCAST ≥ 18.5 showed poor neurological outcomes even if they underwent TTM.

15-year survival of comatose OHCA patients according to initial rhythm

Abstract Introduction Long-term outcome of comatose survivors of out-of-hospital cardiac arrest (OHCA) is largely unknown. We therefore investigated 15-year survival of consecutive patients who were admitted to our hospital after reestablishment of spontaneous circulation (ROSC) on the field. Methods and results Between January 2003 and January 2022, 851 patients with shockable and 247 patients with non-shockable rhythms were admitted. Patients with shockable rhythm were significantly younger (61.5±13,3 versus 66.8±14.8 years), had more often bystander life support (64% versus 35%), shorter delay to emergency team arrival (7.3±5.1 versus 8.3±5.9 minutes), shorter time from advanced life support to ROSC (16.6±15.27 versus 18.5±14.3) and more aggressive hospital treatment including hypothermia (89% versus 74%), coronary angiography/PCI strategy (81% versus 52%) and more IABP/ECMO support (18% versus 10%). Survival with good neurological outcome in patients with shockable rhythm decreased from 51% at hospital discharge to 35% at 15 years (Figure 1). In patients with non-shockable rhythm, survival decreased from 14% at hospital discharge to 8% at 15 years. Conclusion If comatose OHCA patient survives to hospital discharge, annual death rate during the following 15 years is 1.07% for shockable and 0.40 for non-shockable rhythms indicating good long-term outcome. Funding Acknowledgement Type of funding sources: None.

Complete Revascularization and One-Year Survival with Good Neurological Outcome in Patients Resuscitated from an Out-of-Hospital Cardiac Arrest.

Background. The survival benefit of complete versus infarct-related artery (IRA)-only revascularization during the index hospitalization in patients resuscitated from an out-of-hospital cardiac arrest (OHCA) with multivessel disease is unknown. Methods. We considered all the OHCA patients prospectively enrolled in the Lombardia Cardiac Arrest Registry (Lombardia CARe) from 1 January 2015 to 1 May 2021 who underwent coronary angiography (CAG) at the Fondazione IRCCS Policlinico San Matteo (Pavia). Patients’ prehospital, angiographical and survival data were reviewed. Results. Out of 239 patients, 119 had a multivessel coronary disease: 69% received IRA-only revascularization, and 31% received a complete revascularization: 8 during the first procedure and 29 in a staged-procedure after a median time of 5 days [IQR 2.5–10.3]. The complete revascularization group showed significantly higher one-year survival with good neurological outcome than the IRA-only group (83.3% vs. 30.4%, p < 0.001). After correcting for cardiac arrest duration, shockable presenting rhythm, peak of Troponin-I, creatinine on admission and the need for circulatory support, complete revascularization was independently associated with the probability of death and poor neurological outcome [HR 0.3 (95%CI 0.1–0.8), p = 0.02]. Conclusions. This observation study shows that complete myocardial revascularization during the index hospitalization improves one-year survival with good neurological outcome in patients resuscitated from an OHCA with multivessel coronary disease.

Influence of circulatory shock at hospital admission on outcome after out-of-hospital cardiac arrest

Hypotension after cardiac arrest could aggravate prolonged hypoxic ischemic encephalopathy. The association of circulatory shock at hospital admission with outcome after cardiac arrest has not been well studied. The objective of this study was to investigate the independent association of circulatory shock at hospital admission with neurologic outcome, and to evaluate whether cardiovascular comorbidities interact with circulatory shock. 4004 adult patients with out-of-hospital cardiac arrest enrolled in the International Cardiac Arrest Registry 2006–2017 were included in analysis. Circulatory shock was defined as a systolic blood pressure below 90 mmHg and/or medical or mechanical supportive measures to maintain adequate perfusion during hospital admission. Primary outcome was cerebral performance category (CPC) dichotomized as good, (CPC 1–2) versus poor (CPC 3–5) outcome at hospital discharge. 38% of included patients were in circulatory shock at hospital admission, 32% had good neurologic outcome at hospital discharge. The adjusted odds ratio for good neurologic outcome in patients without preexisting cardiovascular disease with circulatory shock at hospital admission was 0.60 [0.46–0.79]. No significant interaction was detected with preexisting comorbidities in the main analysis. We conclude that circulatory shock at hospital admission after out-of-hospital cardiac arrest is independently associated with poor neurologic outcome.

Per-pass analysis of recanalization and good neurological outcome in thrombectomy for stroke: Systematic review and meta-analysis.

First pass effect (FPE) is defined as achieving a complete recanalization with a single thrombectomy device pass. Although clinically desired, FPE is reached in less than 30% of thrombectomy procedures. Multiple device passes are often necessary to achieve successful or complete recanalization. We performed a systematic review and meta-analysis to determine the recanalization rate after each pass of mechanical thrombectomy and its association with good neurological outcome. A literature search was performed for studies reporting the number of device passes required for either successful (mTICI 2b or higher) or complete (mTICI 2c or higher) recanalization. Using random-effect meta-analysis, we evaluated the likelihood of recanalization and good neurological outcome (measured with the modified Rankin Score <2 at 90 days) after each device pass. Thirteen studies comprising 4197 patients were included. Among cases with failed first pass, 24% of them achieved final complete recanalization and 45% of them achieved final successful recanalization. Independently to the total number of previously failed attempts, the likelihood of achieving successful recanalization was 30% per pass, and the likelihood to achieve complete recanalization was about 20% per pass. The likelihood of good neurological outcome in patients with final successful recanalization decreased after each device pass: 55% after the first pass, 48% after the second pass, 42% after the third pass, 36% after the fourth pass, and 26% for 5 passes or more. Each pass is associated with a stable likelihood of recanalization but a decreased likelihood of good neurological outcome.

Association between shockable rhythm conversion and outcomes in patients with out-of-hospital cardiac arrest and initial non-shockable rhythm, according to the cause of cardiac arrest

ObjectiveConversion to shockable rhythm from an initial non-shockable rhythm is associated with good neurologic prognoses in patients with out-of-hospital cardiac arrest (OHCA). We aimed to investigate whether conversion to shockable rhythm has an association with good neurologic outcomes, according to the etiology of cardiac arrest. MethodsWe conducted a nationwide, population-based, cohort study using the OHCA data from the Korea Centers for Disease Control and Prevention database in 2012–2016. We included patients with OHCA and an initial non-shockable rhythm. The primary outcome was good neurologic outcome at discharge, etiologies of arrest were categorized to medical, non-medical cause. We analyzed the effect of conversion to a shockable rhythm on outcome according to causes of cardiac arrest using multiple regression analysis. ResultsOf 114,628 patients with an initial non-shockable rhythm, 25,042 (21.8%) experienced conversion to a shockable rhythm; 83,437 (72.8%) had medical causes and 31,191(27.2%) had non-medical causes. In all patients with OHCA and initial non-shockable rhythm, adjusted odds ratio (OR) of conversion for good neurologic outcome was 2.051 (95% confidence interval [CI] 1.181–2.297). The medical cause group showed an adjusted OR 1.789 (95% CI 1.586–2.019) of conversion for good neurologic outcome. In non-medical cause group, the adjusted OR of conversion was 0.644 (95% CI 0.372–1.114). ConclusionConversion to shockable rhythm had an association with good neurologic outcome in patients with OHCA with initial non-shockable rhythms, especially due to cardiac cause. However, rhythm conversion was not associated with better outcome in patients with non-medical causes.

Which patients benefit from transport with ongoing cardiopulmonary resuscitation? : Retrospective analysis of 70patients with refractory preclinical cardiac arrest

Mortality in patients with out-of-hospital cardiac arrest (OHCA) remains very high despite advances in resuscitation algorithms. Most of these patients die at the scene and do not reach hospital. It is currently the subject of discussion whether transport to hospital with ongoing cardiopulmonary resuscitation (CPR) improves survival and neurological outcome in patients with OHCA. The aim of this study was to identify predictors of survival and good neurological outcome in patients after OHCA who were transported to hospital with ongoing CPR. Atotal of 70consecutive patients with refractory OHCA (mean age 54.7 ± 15years) transported to hospital with ongoing CPR were retrospectively analyzed. Neurological outcome was assessed after 30days based on the Glasgow-Pittsburgh cerebral performance category (CPC). After 30days 82.9% of the patients enrolled in the trial died (CPC score of5), 8patients (11.4%) showed agood neurological recovery with CPC scores of 1-2 and 4patients (5.7%) had apoor neurological outcome with CPC scores of 3-4. Predictors of good neurological outcome were witnessed arrest, initial defibrillatable rhythm and serum lactate levels on admission. In all patients with good outcome, the index event for OHCA was from cardiac causes. Selected patient collectives can benefit from transport to hospital with ongoing cardiopulmonary resuscitation (CPR).

Effects of empowering a community-wide bystander defibrillation program on good neurological outcome in out-of-hospital cardiac arrest

Purpose: We examined the effect of empowering a community-wide bystander defibrillation program on good neurological outcome in patients after out-of-hospital cardiac arrest during a four-year prospective follow-up period.

A study assessing the post operative outcome in patients of acoustic schwannoma operated through retrosigmoid approach at tertiary care institutions- An experience of one year

Background: The most common tumors of the cerebellopontine angle (CPA) is Acoustic schwannoma (80–90%). Cerebellopontine Angle tumors may be asymptomatic or may present with symptoms which could be due to tumor mass or due to raised intracranial pressure (ICP). The Suboccipital retrosigmoid approach has become an increasingly popular method of excising CPA tumors.Aims and Objectives: To assess the post operative outcome and incidence of post operative complications in patients operated for CPA tumor through retrosigmoid approach.Materials and Methods: The present “Prospective study” was carried out in 10 patients admitted to the Department Of Neurosurgery, NRSMCH, Kolkata with a clinicoradiological diagnosis of CPA tumor and were operated between Feruary 2016 to March 2017.Results: The maximum number of cases i.e 38.46%(n=5) were of 31 to 40 years of age. The male to female ratio was 0.3:1.The most common symptom were ipsilateral sensorineural hearing loss (SNHL) and tinnitus, headache associated with papilloedema. The gross total resection was done in 84.61% cases &amp; subtotal done in 15.38% cases.CSF leakage was present in 23.07 % cases. Facial Nerve function of grade 1 was present in 53.84%. Out of all cases Grade 2 and grade 5 function was present in 1 patient. Grade 3&amp; Grade 4 dysfunction were present in 2 patients. Transient lower cranial nerve paresis was present in 46.15%.One patient expired in postoperatively.Conclusion: Ventriculo-peritoneal shunting followed by excision of tumor by retrosigmoid approach can bring good neurological outcome in patients with CPA tumors.Asian Journal of Medical Sciences Vol.8(4) 2017 44-49

Early Lactate Clearance Is Associated With Improved Outcomes in Patients With Postcardiac Arrest Syndrome: A Prospective, Multicenter Observational Study (SOS-KANTO 2012 Study)

To determine whether early lactate reduction is associated with improved survival and good neurologic outcome in patients with out-of-hospital cardiac arrest. Ad hoc data analysis of a prospective, multicenter observational study. Out-of-hospital cardiac arrest patients at 67 emergency hospitals in Kanto, Japan between January 2012 and March 2013. Adult patients with out-of-hospital cardiac arrest admitted to the hospital after successful resuscitation were identified. Blood lactate concentrations were measured at hospital admission and 6 h after hospital admission. Early lactate clearance was defined as the percent change in lactate level 6 h after a baseline measurement. The 543 patients (mean age, 65 ± 16 yr; 72.6% male) had a mean lactate clearance of 42.4% ± 53.7%. Overall 30-day survival and good neurologic outcome were 47.1% and 27.4%, respectively. The survival proportion increased with increasing lactate clearance (quartile 1, 29.4%; quartile 2, 42.6%; quartile 3, 51.5%; quartile 4, 65.2%; p < 0.001). Multivariate logistic regression analysis showed that lactate clearance quartile was an independent predictor of the 30-day survival and good neurologic outcome. In the Cox proportional hazards model, the frequency of mortality during 30 days was significantly higher for patients with lactate clearance in quartile 1 (hazard ratio, 3.12; 95% CI, 2.14-4.53), quartile 2 (hazard ratio, 2.13; 95% CI, 1.46-3.11), and quartile 3 (hazard ratio, 1.49; 95% CI, 1.01-2.19) than those with lactate clearance in quartile 4. Furthermore, multivariate logistic regression analysis revealed that lactate clearance was a significant predictor of good neurologic outcome at 30 days after hospital admission. Effective lactate reduction over the first 6 hours of postcardiac arrest care was associated with survival and good neurologic outcome independently of the initial lactate level.

Predictors of good neurologic outcome after resuscitation beyond 30min in out-of-hospital cardiac arrest patients undergoing therapeutic hypothermia.

Neurologically intact survival after cardiac arrest is possible even after prolonged resuscitation efforts. However, the factors associated with good neurologic outcome in these patients remain unknown. This study identifies predictors associated with good neurologic outcome after resuscitation beyond 30min in out-of-hospital cardiac arrest (OHCA) patients treated with targeted temperature management (TTM). This multicenter, registry-based, retrospective cohort study conducted in 24 hospitals across South Korea between 2007 and 2012 includes adult (≥18years) non-traumatic OHCA patients with prolonged (>30min) downtime who underwent TTM treatment. Good neurologic outcomes were defined as cerebral performance category scores of≤2. Of the 930 comatose adult cardiac arrest patients treated with TTM, 423 patients with prolonged downtime were included. A total of 76 (18.0%) had good neurologic outcome. Multivariable analysis reveal that age<65years (OR 7.91, 95% CI 3.18-19.68), initial shockable rhythm (OR 6.31, 95% CI 3.40-11.74), and witnessed arrest (OR 3.81, 95% CI 1.73-8.45) are associated with good neurologic outcome. The sensitivity and specificity for good neurologic outcome in patients with age<65years, shockable rhythm, and witnessed arrest are 90.8% and 41.2, 67.6 and 79.5%, and 81.6 and 41.2%, respectively. In prolonged cardiac arrest patients, initial shockable rhythm, age<65years, or witnessed arrest are predictors for neurologic intact survival.

Anti-N-Methyl-d-Aspartate Receptor Encephalitis in Adult Patients Requiring Intensive Care.

Encephalitis caused by anti-N-methyl-d-aspartate receptor (NMDAR) antibodies is the leading cause of immune-mediated encephalitis. There are limited data on intensive care unit (ICU) management of these patients. To identify prognostic factors of good neurologic outcome in patients admitted to an ICU with anti-NMDAR encephalitis. This was an observational multicenter study of all consecutive adult patients diagnosed with anti-NMDAR encephalitis at the French National Reference Centre, admitted to an ICU between 2008 and 2014. The primary outcome was a good neurologic outcome at 6 months after ICU admission, defined by a modified Rankin Scale score of 0-2. Seventy-seven patients were included from 52 ICUs. First-line immunotherapy consisted of steroids (n = 61/74; 82%), intravenous immunoglobulins (n = 71/74; 96%), and plasmapheresis (n = 17/74; 23%). Forty-five (61%) patients received second-line immunotherapy (cyclophosphamide, rituximab, or both). At 6 months, 57% of patients had a good neurologic outcome. Independent factors of good neurologic outcome were early (≤8 d after ICU admission) immunotherapy (odds ratio, 16.16; 95% confidence interval, 3.32-78.64; for combined first-line immunotherapy with steroids and intravenous immunoglobulins vs. late immunotherapy), and a low white blood cell count on the first cerebrospinal examination (odds ratio, 9.83 for <5 vs. >50 cells/mm3; 95% confidence interval, 1.07-90.65). Presence of nonneurologic organ failures at ICU admission and occurrence of status epilepticus during ICU stay were not associated with neurologic outcome. The prognosis of adult patients with anti-NMDAR encephalitis requiring intensive care is good, especially when immunotherapy is initiated early, advocating for prompt diagnosis and early aggressive treatment.

282 Prognostic Factors for Good Neurologic Outcome in Patients With Prolonged Resuscitation Efforts

Neurologically intact survival after cardiac arrest can still occur in patients with prolonged downtime. It is unknown which factors associated with outcome in prolonged downtime patients treated with targeted temperature management (TTM). The present study aimed to determine the factors associated with neurologic intact survival in prolonged downtime, defined as >20 minutes, out-of-hospital cardiac arrest (OHCA) patients. Multicenter, registry-based, retrospective cohort study conducted in 24 hospitals across South Korea between January 2007 and December 2012. We included adult (≥18 years) non-traumatic OHCA patients who had prolonged downtime and treated with TTM. We defined downtime as the length of time between the patient being recognized as pulseless and return of spontaneous circulation. Good neurologic outcome defined as a cerebral performance category score of 1 or 2. Of the 930 OHCA patients treated with TTM, 254 were excluded, leaving 676 patients with prolonged downtime entering analysis. Mean age was 56.9 years and 150 patients (22.2%) had good neurologic outcome. After multivariable logistic regression analysis, age <60 years (OR 2.92, 95% CI 1.64 – 5.19), initial shockable rhythm (OR 6.75, 95% CI 4.02 – 11.33), no comorbidity (OR 2.12, 95% CI 1.26 – 3.58), downtime intervals [ORs and 95% CIs 0.59 (0.33 – 1.04), 0.43 (0.21 – 0.87), 0.17 (0.06 – 0.47), and 0.14 (0.03 – 0.52) for 30-39 min, 40-49 min, 50-59 min, and ≥ 60 min, respectively], and witnessed arrest (OR 1.88, 95% CI 1.05 – 3.35) were associated with good neurologic outcome. Chance of good neurologic outcome in OHCA patients with prolonged downtime decreased as downtime increases. However young age, shockable rhythm, no previous comorbidity, and witnessed arrest were prognostic factors for good neurologic outcome in patients with prolonged resuscitation efforts.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Targeted temperature management processes and outcomes after out-of-hospital cardiac arrest: an observational cohort study*.

Targeted temperature management has been shown to improve survival with good neurological outcome in patients after out-of-hospital cardiac arrest. The optimal approach to inducing and maintaining targeted temperature management, however, remains uncertain. The objective of this study was to evaluate these processes of care with survival and neurological function in patients after out-of-hospital cardiac arrest. An observational cohort study evaluating the association of targeted temperature management processes with survival and neurological function using bivariate and generalized estimating equation analyses. Thirty-two tertiary and community hospitals in eight urban and rural regions of southern Ontario, Canada. Consecutive adult (≥ 18 yr) patients admitted between November 1, 2007, and January 31, 2012, and who were treated with targeted temperature management following nontraumatic out-of-hospital cardiac arrest. Evaluate the association of targeted temperature management processes with survival and neurologic function using bivariate and generalized estimating equation analyses. There were 5,770 consecutive out-of-hospital cardiac arrest patients, of whom 747 (12.9%) were eligible and received targeted temperature management. Among patients with available outcome data, 365 of 738 (49.5%) survived to hospital discharge and 241 of 675 (35.7%) had good neurological outcomes. After adjusting for the Utstein variables, a higher temperature prior to initiation of targeted temperature management was associated with improved neurological outcomes (odds ratio, 1.27 per °C; 95% CI, 1.08-1.50; p = 0.004) and survival (odds ratio, 1.26 per °C; 95% CI, 1.09-1.46; p = 0.002). A slower rate of cooling was associated with improved neurological outcomes (odds ratio, 0.74 per °C/hr; 95% CI, 0.57-0.97; p = 0.03) and survival (odds ratio, 0.73 per °C/hr; 95% CI, 0.54-1.00; p = 0.049). A higher baseline temperature prior to initiation of targeted temperature management and a slower rate of cooling were associated with improved survival and neurological outcomes. This may reflect a complex relationship between the approach to targeted temperature management and the extent of underlying brain injury causing impaired thermoregulation in out-of-hospital cardiac arrest patients.

An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study.

IntroductionProlonged conventional cardiopulmonary resuscitation (CCPR) is associated with a poor prognosis in out-of-hospital cardiac arrest (OHCA) patients. Alternative methods can be needed to improve the outcome in patients with prolonged CCPR and extracorporeal cardiopulmonary resuscitation (ECPR) can be considered as an alternative method. The objectives of this study were to estimate the optimal duration of CPR to consider ECPR as an alternative resuscitation method in patients with CCPR, and to find the indications for predicting good neurologic outcome in OHCA patients who received ECPR.MethodsThis study is a retrospective analysis based on a prospective cohort. We included patients ≥ 18 years of age without suspected or confirmed trauma and who experienced an OHCA from May 2006 to December 2013. First, we determined the appropriate cut-off duration for CPR based on the discrimination of good and poor neurological outcomes in the patients who received only CCPR, and then we compared the outcome between the CCPR group and ECPR group by using propensity score matching. Second, we compared CPR related data according to the neurologic outcome in matched ECPR group.ResultsOf 499 patients suitable for inclusion, 444 and 55 patients were enrolled in the CCPR and ECPR group, respectively. The predicted duration for a favorable neurologic outcome (CPC1, 2) is < 21 minutes of CPR in only CCPR patients. The matched ECPR group with ≥ 21 minutes of CPR duration had a more favorable neurological outcome than the matched CCPR group at 3 months post-arrest. In matched ECPR group, younger age, witnessed arrest without initial asystole rhythm, early achievement of mean arterial pressure ≥ 60 mmHg, low rate of ECPR-related complications, and therapeutic hypothermia were significant factors for expecting good neurologic outcome.ConclusionsECPR should be considered as an alternative method for attaining good neurological outcomes in OHCA patients who required prolonged CPR, especially of ≥ 21 minutes. Younger or witnessed arrest patients without initial asystole were good candidates for ECPR. After implantation of ECPR, early hemodynamic stabilization, prevention of ECPR-related complications, and application of therapeutic hypothermia may improve the neurological outcome.

Treatment and Outcomes of ST Segment Elevation Myocardial Infarction and Out-of-Hospital Cardiac Arrest in a Regionalized System of Care Based on Presence or Absence of Initial Shockable Cardiac Arrest Rhythm

The aim of this study was to evaluate the treatment and outcomes of patients with ST-segment elevation myocardial infarctions complicated by out-of-hospital cardiac arrest in a regional system of care. In this retrospective study, the effect of the absence of an initial shockable arrest rhythm was analyzed. The primary end point of survival with good neurologic outcome in patients with and without an initial shockable arrest rhythm was adjusted for age, witnessed arrest, bystander cardiopulmonary resuscitation, and treatment with therapeutic hypothermia and percutaneous coronary intervention. One-hundred sixty-eight of 348 patients (49%) survived to hospital discharge. Patients with a shockable initial rhythm were more likely to receive therapeutic hypothermia (48% vs 37%, risk ratio 1.2, 95% confidence interval [CI] 1.0 to 1.5) and to be treated in the cardiac catheterization laboratory (80% vs 43%, risk ratio 2.8, 95% CI 2.0 to 3.8). The likelihood of survival with good neurologic outcome in patients with a shockable initial rhythm compared with those presenting without a shockable rhythm was 4.8 (95% CI 2.7 to 8.7). In patients who underwent percutaneous coronary intervention, the likelihood of survival with good neurologic outcome was higher (risk ratio 2.7, 95% CI 1.1 to 6.8) in those with a shockable rhythm. In conclusion, the absence of an initial shockable rhythm in patients with ST-segment elevation myocardial infarctions plus out-of-hospital cardiac arrest is associated with significantly worse survival and neurologic outcome. These differences persist despite application of therapies including therapeutic hypothermia and percutaneous coronary intervention within a regionalized system of care.

A history of smoking is associated with improved survival in patients treated with mild therapeutic hypothermia following cardiac arrest

ObjectivesTo assess the association between smoking and survival with a good neurologic outcome in patients following cardiac arrest treated with mild therapeutic hypothermia (TH). MethodsWe conducted a retrospective observational study of a prospectively collected cohort of 188 consecutive patients following cardiac arrest treated with TH between May 2007 and January 2012. Smoking status was retrospectively collected via chart review and was classified as “ever” or “never”. Primary endpoint was survival to hospital discharge with a good neurologic outcome and was compared between smokers and nonsmokers. Logistic regression analysis was used to assess the association between smoking status and neurologic outcome at hospital discharge; adjusting for age, initial rhythm, time to return of spontaneous circulation (ROSC), bystander CPR, and time to initiation of TH. ResultsSmokers were significantly more likely to survive to hospital discharge with good neurologic outcome compared to nonsmokers (50% vs. 28%, p=0.003). After adjusting for age, initial rhythm, time to ROSC, bystander CPR, and time to initiation of TH, a history of smoking was associated with increased odds of survival to hospital discharge with good neurologic outcome (OR 3.54, 95% CI 1.41–8.84, p=0.007). ConclusionsSmoking is associated with improved survival with good neurologic outcome in patients following cardiac arrest. We hypothesize that our findings reflect global ischemic conditioning caused by smoking.