In-hospital Cardiac Arrest Research Articles

Impact of Social Vulnerability on Cardiac Arrest Mortality in the United States, 2016 to 2020.

Cardiac arrest is 1 of the leading causes of morbidity and mortality, with an estimated 340 000 out-of-hospital and 292 000 in-hospital cardiac arrest events per year in the United States. Survival rates are lower in certain racial and socioeconomic groups. We performed a county-level cross-sectional longitudinal study using the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research multiple causes of death data set between 2016 and 2020 among individuals of all ages whose death was attributed to cardiac arrest. The Social Vulnerability Index is a composite measure that includes socioeconomic vulnerability, household composition, disability, individuals from racial and ethnic minority groups status and language, and housing and transportation domains. We examined the impact of social determinants on cardiac arrest mortality stratified by age, race, ethnicity, and sex in the United States. All age-adjusted mortality rate (cardiac arrest AAMRs) are reported as per 100 000. Overall cardiac arrest AAMR during the study period was 95.6. The cardiac arrest AAMR was higher for men compared with women (119.6 versus 89.9) and for the Black population compared with the White population (150.4 versus 92.3). The cardiac arrest AAMR increased from 64.8 in counties in quintile 1 of Social Vulnerability Index to 141 in quintile 5, with an average increase of 13% (95% CI, 9.8%-16.9%) in AAMR per quintile increase. Mortality from cardiac arrest varies widely, with a >2-fold difference between the counties with the highest and lowest social vulnerability, highlighting the differential burden of cardiac arrest deaths throughout the United States based on social determinants of health.

Serum urea increase during hospital stay is associated with worse outcomes after in-hospital cardiac arrest

BackgroundEvaluate the association between serum urea at admission and during hospital stay with return of spontaneous circulation (ROSC) and in-hospital mortality in patients with in-hospital cardiac arrest (IHCA). MethodsThis retrospective study included patients over 18 years with IHCA attended from May 2018 to December 2022. The exclusion criteria were the absence of exams to calculate delta urea and the express order of “do-not-resuscitate”. Data were collected from the electronic medical records. Serum admission urea and urea 24 hours before IHCA were also collected and used to calculate delta urea. ResultsA total of 504 patients were evaluated; 125 patients were excluded due to the absence of variables to calculate delta urea and 5 due to “do-not-resuscitate” order. Thus, we included 374 patients in the analysis. The mean age was 65.0 ± 14.5 years, 48.9% were male, 45.5% had ROSC, and in-hospital mortality was 91.7%. In logistic regression models, ROSC was associated with lower urea levels 24 hours before IHCA (OR: 0.996; CI95%: 0.992-1.000; p: 0.032). In addition, increased levels of urea 24 hours before IHCA (OR: 1.020; CI95%: 1.008-1.033; p: 0.002) and of delta urea (OR: 1.001; CI95%: 1.001-1.019; p: 0.023) were associated with in-hospital mortality. ROC curve analysis showed that the area under the ROC curve for mortality prediction was higher for urea 24 hours before IHCA (Cutoff > 120.1 mg/dL) than for delta urea (Cutoff > 34.83 mg/dL). ConclusionsIn conclusion, increased serum urea levels during hospital stay were associated with worse prognosis in IHCA.

Hospitalized patients’ attitudes towards participating in a randomized control trial in case of a cardiac arrest

BackgroundNo previous study has evaluated patients attitudes towards inclusion in an ongoing cardiac arrest clinical trial. The aim of this study was to assess patientś willingness and motives to participate in the ongoing randomized controlled drug trial “Vasopressin and Steroids in addition to Adrenaline in cardiac arrest” (VAST-A trial) in case of an in-hospital cardiac arrest (IHCA). ObjectivesHospitalized patients, men ≥ 18 and women ≥ 50 years, were asked for informed consent for inclusion in the VAST-A trial in case of an IHCA, the reason for approving or declining inclusion in the trial and baseline characteristics. MethodsPatients admitted to hospital were asked to give informed consent of inclusion in VAST-A in case of an IHCA during their hospital stay. Patients were also asked why they approved or declined inclusion as well as baseline characteristics questions. Results1,064 patients were asked about willingness to participate in the VAST-A trial, of these 902 (84.8%) patients approved inclusion. A subgroup of 411 patients were, except willingness, also asked about motives to participate or not and basic characteristics. The main reason for approving inclusion was to contribute to research (n = 328, 83.9%). The main reason for declining inclusion was concerns regarding testing the drug treatment (n = 6, 30%). ConclusionAmong hospitalized patients the vast majority gave informed consent to inclusion in an ongoing randomized cardiac arrest drug trial. The main reason for approving inclusion was to contribute to research.

Survival of In-Hospital Cardiopulmonary Arrest in Trauma Patients

IntroductionRelative to other hospitalized patients, trauma patients are younger with fewer comorbidities, but the incidence and outcomes of in-hospital cardiopulmonary arrest (IHCA) with cardiopulmonary resuscitation (CPR) in this population is unknown. Therefore, we aimed to investigate factors associated with survival in trauma patients after IHCA to test the hypothesis that compared to other hospitalized patients, trauma patients with IHCA have improved survival. MethodsRetrospective review of the Trauma Quality Improvement Program database 2017 to 2019 for patients who had IHCA with CPR. Primary outcome was survival to hospital discharge. Secondary outcomes were in-hospital complications, hospital length of stay, intensive care unit length of stay, and ventilator days. Data were compared with univariate and multivariate analyses at P < 0.05. ResultsIn 22,346,677 admitted trauma patients, 14,056 (0.6%) received CPR. Four thousand three hundred seventy-seven (31.1%) survived to discharge versus 26.4% in a national sample of all hospitalized patients (P < 0.001). In trauma patients, median age was 55 y, the majority were male (72.2%). Mortality was higher for females versus males (70.3% versus 68.3%, P = 0.026). Multivariate regression showed that older age 1.01 (95% confidence interval (CI) 1.01-1.02), Hispanic ethnicity 1.21 (95% CI 1.04-1.40), and penetrating trauma 1.51 (95% CI 1.32-1.72) were risk factors for mortality, while White race was a protective factor 0.36 (95% CI 0.14-0.89). ConclusionsThis is the first study to show that the incidence of IHCA with CPR is approximately six in 1000 trauma admissions and 31% survive to hospital discharge, which is higher than other hospitalized patients. Age, gender, racial, and ethnic disparities also influence survival.

Frequency, Prognosis, and Clinical Features of Unexpected versus Expected Cardiac Arrest in the Emergency Department: A Retrospective Analysis.

Background: Though out-of-hospital CA (OHCA) is widely reported, data on in-hospital CA (IHCA) and especially cardiac arrest (CA) in the emergency department (CAED) are scarce. This study aimed to determine the frequency, prevalence, and clinical features of unexpected CAED and compare the data with those of expected CAED. Methods: We defined unexpected CAED as CA occurring in patients in non-critical ED-care areas; classified as not requiring strict monitoring. This classification was the modified Japanese Triage and Acuity Scale and physician assessment. A retrospective analysis of cases from 2016 to 2018 was performed, in comparison to other patients experiencing CAED. Results: The 38 cases of unexpected CA in this study constituted 34.5% of CA diagnosed in the ED and 8.4% of all CA treated in the ED. This population did not differ significantly from other CAED regarding demographics, comorbidities, and survival rates. The commonest symptoms were dyspnoea, disorders of consciousness, generalised weakness, and chest pain. The commonest causes of death were acute myocardial infarction, malignant neoplasms with metastases, septic shock, pulmonary embolism, and heart failure. Conclusions: Unexpected CAED represents a group of potentially avoidable CA and deaths. These patients should be analysed, and ED management should include measures aimed at reducing their incidence.

The association of recent simulation training and clinical experience of team leaders with cardiopulmonary resuscitation quality during in-hospital cardiac arrest

ObjectiveWe aimed to investigate the association of recent team leader simulation training (<6 months) and years of clinical experience (≥4 years) with chest compression quality during in-hospital cardiac arrest (IHCA). MethodsThis cohort study of IHCA in four Danish hospitals included cases with data on chest compression quality and team leader characteristics. We assessed the impact of recent simulation training and experienced team leaders on longest chest compression pause duration (primary outcome), chest compression fraction (CCF), and chest compression rates within guideline recommendations using mixed effects models. ResultsOf 157 included resuscitation attempts, 45% had a team leader who recently participated in simulation training and 66% had an experienced team leader. The median team leader experience was 7 years [Q1; Q3: 4; 11]. The median duration of the longest chest compression pause was 16 s [10; 30]. Having a team leader with recent simulation training was associated with significantly shorter longest pause durations (difference: −7.11 s (95%-CI: −12.0; −2.2), p = 0.004), a higher CCF (difference: 3% (95%-CI: 2.0; 4.0%), p < 0.001) and with less guideline compliant chest compression rates (odds ratio: 0.4 (95%-CI: 0.19; 0.84), p = 0.02). Having an experienced team leader was not associated with longest pause duration (difference: −1.57 s (95%-CI: −5.34; 2.21), p = 0.42), CCF (difference: 0.7% (95%-CI: −0.3; 1.7), p = 0.17) or chest compression rates within guideline recommendations (odds ratio: 1.55 (95%-CI: 0.91; 2.66), p = 0.11). ConclusionRecent simulation training of team leaders, but not years of team leader experience, was associated with shorter chest compression pauses during IHCA.

What factors are effective on the CPR duration of patients under extracorporeal cardiopulmonary resuscitation: a single-center retrospective study

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) is an alternative method for patients with reversible causes of cardiac arrest (CA) after conventional cardiopulmonary resuscitation (CCPR). However, cardiopulmonary resuscitation (CPR) duration during ECPR can vary due to multiple factors. Healthcare providers need to understand these factors to optimize the resuscitation process and improve outcomes. The aim of this study was to examine the different variables impacting the duration of CPR in patients undergoing ECPR.MethodsThis retrospective, single-center, observational study was conducted on adult patients who underwent ECPR due to in-hospital CA (IHCA) or out-of-hospital CA (OHCA) at Hamad General Hospital (HGH), the tertiary governmental hospital of Qatar, between February 2016 and March 2020. Univariate and multivariate binary logistic regression analyses were performed to identify the prognostic factors associated with CPR duration, including demographic and clinical variables, as well as laboratory tests.ResultsThe mean ± standard division age of the 48 participants who underwent ECPR was 41.50 ± 13.15 years, and 75% being male. OHCA and IHCA were reported in 77.1% and 22.9% of the cases, respectively. The multivariate analysis revealed that several factors were significantly associated with an increased CPR duration: higher age (OR: 1.981, 95%CI: 1.021–3.364, P = 0.025), SOFA score (OR: 3.389, 95%CI: 1.289–4.911, P = 0.013), presence of comorbidities (OR: 3.715, 95%CI: 1.907–5.219, P = 0.026), OHCA (OR: 3.715, 95%CI: 1.907–5.219, P = 0.026), and prolonged collapse-to-CPR time (OR: 1.446, 95%CI:1.092–3.014, P = 0.001). Additionally, the study found that the initial shockable rhythm was inversely associated with the duration of CPR (OR: 0.271, 95%CI: 0.161–0.922, P = 0.045). However, no significant associations were found between laboratory tests and CPR duration.ConclusionThese findings suggest that age, SOFA score, comorbidities, OHCA, collapse-to-CPR time, and initial shockable rhythm are important factors influencing the duration of CPR in patients undergoing ECPR. Understanding these factors can help healthcare providers better predict and manage CPR duration, potentially improving patient outcomes. Further research is warranted to validate these findings and explore additional factors that may impact CPR duration in this population.

Consciousness and the Dying Brain.

The near-death experience has been reported since antiquity and is often characterized by the perception of light, interactions with other entities, and life recall. Near-death experiences can occur in a variety of situations, but they have been studied systematically after in-hospital cardiac arrest, with an incidence of 10 to 20%. Long attributed to metaphysical or supernatural causes, there have been recent advances in understanding the neurophysiologic basis of this unique category of conscious experience. This article reviews the epidemiology and neurobiology of near-death experiences, with a focus on clinical and laboratory evidence for a surge of neurophysiologic gamma oscillations and cortical connectivity after cardiac and respiratory arrest.

Ransomware Cyberattack Associated With Cardiac Arrest Incidence and Outcomes at Untargeted, Adjacent Hospitals.

Healthcare ransomware cyberattacks have been associated with major regional hospital disruptions, but data reporting patient-oriented outcomes in critical conditions such as cardiac arrest (CA) are limited. This study examined the CA incidence and outcomes of untargeted hospitals adjacent to a ransomware-infected healthcare delivery organization (HDO). This cohort study compared the CA incidence and outcomes of two untargeted academic hospitals adjacent to an HDO under a ransomware cyberattack during the pre-attack (April 3-30, 2021), attack (May 1-28, 2021), and post-attack (May 29, 2021-June 25, 2021) phases. None. Emergency department and hospital mean daily census, number of CAs, mean daily CA incidence per 1,000 admissions, return of spontaneous circulation, survival to discharge, and survival with favorable neurologic outcome were measured. The study evaluated 78 total CAs: 44 out-of-hospital CAs (OHCAs) and 34 in-hospital CAs. The number of total CAs increased from the pre-attack to attack phase (21 vs. 38; p = 0.03), followed by a decrease in the post-attack phase (38 vs. 19; p = 0.01). The number of total CAs exceeded the cyberattack month forecast (May 2021: 41 observed vs. 27 forecasted cases; 95% CI, 17.0-37.4). OHCA cases also exceeded the forecast (May 2021: 24 observed vs. 12 forecasted cases; 95% CI, 6.0-18.8). Survival with favorable neurologic outcome rates for all CAs decreased, driven by increases in OHCA mortality: survival with favorable neurologic rates for OHCAs decreased from the pre-attack phase to attack phase (40.0% vs. 4.5%; p = 0.02) followed by an increase in the post-attack phase (4.5% vs. 41.2%; p = 0.01). Untargeted hospitals adjacent to ransomware-infected HDOs may see worse outcomes for patients suffering from OHCA. These findings highlight the critical need for cybersecurity disaster planning and resiliency.

Plasma glial fibrillary acidic protein and tau: predictors of neurological outcome after cardiac arrest

BackgroundThe purpose was to evaluate glial fibrillary acidic protein (GFAP) and total-tau in plasma as predictors of poor neurological outcome after out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA), including comparisons with neurofilament light (NFL) and neuron-specific enolase (NSE).MethodsRetrospective multicentre observational study of patients admitted to an intensive care unit (ICU) in three hospitals in Sweden 2014–2018. Blood samples were collected at ICU admission, 12 h, and 48 h post-cardiac arrest. Poor neurological outcome was defined as Cerebral Performance Category 3–5 at 2–6 months after cardiac arrest. Plasma samples were retrospectively analysed for GFAP, tau, and NFL. Serum NSE was analysed in clinical care. Prognostic performances were tested with the area under the receiver operating characteristics curve (AUC).ResultsOf the 428 included patients, 328 were OHCA, and 100 were IHCA. At ICU admission, 12 h and 48 h post-cardiac arrest, GFAP predicted neurological outcome after OHCA with AUC (95% CI) 0.76 (0.70–0.82), 0.86 (0.81–0.90) and 0.91 (0.87–0.96), and after IHCA with AUC (95% CI) 0.77 (0.66–0.87), 0.83 (0.74–0.92) and 0.83 (0.71–0.95). At the same time points, tau predicted outcome after OHCA with AUC (95% CI) 0.72 (0.66–0.79), 0.75 (0.69–0.81), and 0.93 (0.89–0.96) and after IHCA with AUC (95% CI) 0.61 (0.49–0.74), 0.68 (0.56–0.79), and 0.77 (0.65–0.90). Adding the change in biomarker levels between time points did not improve predictive accuracy compared to the last time point. In a subset of patients, GFAP at 12 h and 48 h, as well as tau at 48 h, offered similar predictive value as NSE at 48 h (the earliest time point NSE is recommended in guidelines) after both OHCA and IHCA. The predictive performance of NFL was similar or superior to GFAP and tau at all time points after OHCA and IHCA.ConclusionGFAP and tau are promising biomarkers for neuroprognostication, with the highest predictive performance at 48 h after OHCA, but not superior to NFL. The predictive ability of GFAP may be sufficiently high for clinical use at 12 h after cardiac arrest.

EFFECT OF PULMONARY ARTERY CATHETERIZATION IN PATIENTS WITH NONISCHEMIC CARDIOGENIC SHOCK: A NATIONWIDE ANALYSIS.

Background: Pulmonary artery catheterization (PAC) has been widely used in critically ill patients, yielding mixed results. Prior studies on cardiogenic shock (CS) predominantly included patients with acute myocardial infarction. This study aims to examine the effect of PAC use in patients with nonischemic CS. Methods: This retrospective cohort study employed data from the National Inpatient Sample database, including weighted hospitalizations of adult patients with nonischemic CS during 2017 to 2019. In-hospital outcomes were compared between groups using inverse probability of treatment weighting. Results: A total of 303,970 patients with nonischemic CS were included, of whom 17.5% received a PAC during their hospitalization. The median age was 67 years (interquartile range: 57-77) and 61% were male. After inverse probability of treatment weighting, patients in the PAC group had significantly lower in-hospital mortality (24.8% vs. 35.3%, P < 0.001), renal replacement therapy (10.7% vs. 12.4%, P = 0.002), in-hospital cardiac arrest (7.1% vs. 9.6%, P < 0.001), and mechanical ventilation (44.6% vs. 50.4%, P < 0.001) compared to non-PAC group. In contrast, the PAC group had higher use of intra-aortic balloon pump (15.4% vs. 3.4%, P < 0.001), percutaneous ventricular assist devices (12.6% vs. 2.6%, P < 0.001), extracorporeal membrane oxygenation (3.9% vs. 2.5%, P < 0.001), and heart transplantation (2.1% vs. 0.4%, P < 0.001). Conclusion: In the real-world setting, invasive hemodynamic monitoring with PAC in patients with nonischemic CS is associated with survival benefits and a reduction in adverse events, including reduced need for renal replacement therapy, mechanical ventilation and risk of in-hospital cardiac arrest.

Does post acute care reduce the mortality of octogenarian and nonagenarian patients undergoing hip fracture surgery?

With the increasing number of elderly individuals worldwide, a greater number of people aged 80years and older sustain fragility fracture due to osteopenia and osteoporosis. This retrospective study included 158 older adults, with a median age of 85 (range: 80-99) years, who sustained hip fragility fracture and who underwent surgery. The patients were divided into two groups, one including patients who joined the post-acute care (PAC) program after surgery and another comprising patients who did not. The mortality, complication, comorbidity, re-fracture, secondary fracture, and readmission rates and functional status (based on the Barthel index score, numerical rating scale score, and Harris Hip Scale score) between the two groups were compared. The patients who presented with fragility hip fracture and who joined the PAC rehabilitation program after the surgery had a lower rate of mortality, readmission rate, fracture (re-fracture and secondary fracture), and complications associated with fragility fracture, such as urinary tract infection, cerebrovascular accident, and pneumonia (acute coronary syndrome, out-of-hospital cardiac arrest, or in-hospital cardiac arrest. PAC is associated with a lower rate of mortality and complications such as urinary tract infection, bed sore, and pneumonia in octogenarian and nonagenarian patients with hip fragility fracture.

Effectiveness of team-focused CPR on in-hospital CPR quality and outcomes

ObjectiveWe sought to identify changes in neurological outcome over time following initial training and subsequent implementation of team-focused CPR in an inpatient setting where responders practice specific roles with emphasis on minimally interrupted chest compressions and early defibrillation. MethodsThis retrospective pre- vs post-intervention study was conducted at an urban 900-bed teaching hospital and Level I Cardiac Resuscitation Center. We included adult patients suffering in-hospital cardiac arrest occurring in non-emergency department and non-intensive care unit areas who received CPR and/or defibrillation. We compared survival with good neurological outcome at time of hospital discharge in the one-year periods before and after implementation of team-focused CPR. To investigate skill degradation, we compared cumulative survival with good neurological outcome in 3-month intervals against the before team-focused CPR baseline. Trained research associates abstracted explicitly defined variables from electronic health records using a standardized form and data dictionary to achieve consistency between collaborators. ResultsOf 296 IHCAs, 207 patients met inclusion criteria and were analyzed. In 104 patients before team-focused CPR initiation, survival with good neurological outcome was 21%. In the 12-month period following team-focused CPR initiation, survival with good neurological outcome was 31% in 101 patients, risk difference 9.9% (95% CI −2 to 22%; p = 0.14). By quarterly time intervals, following team-focused CPR implementation, the cumulative survival with good neurological outcome at 3 months was 42%; at 6 months 37%; at 9 months 31%; and at 12 months 31%. ConclusionIn our single-institution implementation of team-focused CPR for in-hospital cardiac arrest, outcomes significantly improved at 6 months before declining towards baseline.

Association Between Chest Compression Pause Duration and Survival After Pediatric In-Hospital Cardiac Arrest.

The association between chest compression (CC) pause duration and pediatric in-hospital cardiac arrest survival outcomes is unknown. The American Heart Association has recommended minimizing pauses in CC in children to <10 seconds, without supportive evidence. We hypothesized that longer maximum CC pause durations are associated with worse survival and neurological outcomes. In this cohort study of index pediatric in-hospital cardiac arrests reported in pediRES-Q (Quality of Pediatric Resuscitation in a Multicenter Collaborative) from July of 2015 through December of 2021, we analyzed the association in 5-second increments of the longest CC pause duration for each event with survival and favorable neurological outcome (Pediatric Cerebral Performance Category ≤3 or no change from baseline). Secondary exposures included having any pause >10 seconds or >20 seconds and number of pauses >10 seconds and >20 seconds per 2 minutes. We identified 562 index in-hospital cardiac arrests (median [Q1, Q3] age 2.9 years [0.6, 10.0], 43% female, 13% shockable rhythm). Median length of the longest CC pause for each event was 29.8 seconds (11.5, 63.1). After adjustment for confounders, each 5-second increment in the longest CC pause duration was associated with a 3% lower relative risk of survival with favorable neurological outcome (adjusted risk ratio, 0.97 [95% CI, 0.95-0.99]; P=0.02). Longest CC pause duration was also associated with survival to hospital discharge (adjusted risk ratio, 0.98 [95% CI, 0.96-0.99]; P=0.01) and return of spontaneous circulation (adjusted risk ratio, 0.93 [95% CI, 0.91-0.94]; P<0.001). Secondary outcomes of any pause >10 seconds or >20 seconds and number of CC pauses >10 seconds and >20 seconds were each significantly associated with adjusted risk ratio of return of spontaneous circulation, but not survival or neurological outcomes. Each 5-second increment in longest CC pause duration during pediatric in-hospital cardiac arrest was associated with lower chance of survival with favorable neurological outcome, survival to hospital discharge, and return of spontaneous circulation. Any CC pause >10 seconds or >20 seconds and number of pauses >10 seconds and >20 seconds were significantly associated with lower adjusted probability of return of spontaneous circulation, but not survival or neurological outcomes.

Analysis of the factors influencing prognosis of the adult in-hospital cardiac arrest

To explore the factors influencing prognosis of patients with in-hospital cardiac arrest (IHCA). A retrospective observational study was conducted. The clinical data of patients who developed IHCA and underwent cardiopulmonary resuscitation (CPR) at the Second Xiangya Hospital of Central South University from January 1, 2016, to December 31, 2022 were analyzed. The patients' information, including gender, age, medical history, pre-cardiac arrest related parameters [1-hour pre-cardiac arrest neurological function, 24-hour pre-cardiac arrest hemoglobin (Hb) levels, 1-hour pre-cardiac arrest vital signs], initial CPR-related factors (implementation time and location, initial rhythm, ventilation method, defibrillation and resuscitation drugs) as well as restoration of spontaneous circulation (ROSC) related parameters (vital signs at ROSC and 1 hour after ROSC, 24-hour post-cardiac arrest Hb, and IHCA events), were collected through the hospital's electronic medical record system. The clinical data were compared between ROSC and non-ROSC patients as well as between patients with favorable neurological function [cerebral performance category (CPC) grades 1-2] and unfavorable neurological function (CPC grades 3-5) at 28 days. The factors with statistical significance in univariate analysis and clinical significance were enrolled in a binary multivariate Logistic regression model to analyze the influencing factors of ROSC and neurological function at 28 days after ROSC. The predictive value of factors influencing neurological function at 28 days was assessed using receiver operator characteristic curve (ROC curve). A total of 277 IHCA-CPR patients were enrolled, of which 230 achieved ROSC (83.0%) and 47 were not achieved (17.0%). Compared with non-ROSC patients, ROSC patients had lower prevalence of cerebrovascular disease history and proportion of adrenaline usage, but a higher proportion of initial shockable rhythms. In the multivariate Logistic regression analysis, it was found that using a bag-mask ventilation+endotracheal intubation (compared with a bag-mask ventilation alone) was beneficial for achieving ROSC in IHCA-CPR patients [odds ratio (OR) = 2.895, 95% confidence interval (95%CI) was 1.204-6.962, P = 0.018], while a initial non-shockable rhythm was not conducive to achieving ROSC in IHCA-CPR patients (OR = 0.349, 95%CI was 0.147-0.831, P = 0.017). Among the 230 ROSC patients, 42 had good neurological function at 28 days (18.3%), and 188 had poor neurological function (81.7%). Compared with the patients with good neurological function, the patients with the poor neurological function were older and had a higher prevalence of 1-hour pre-cardiac arrest neurological dysfunction and low perfusion, initial non-shockable rhythms, endotracheal intubation, and usage of adrenaline, vasopressors and sodium bicarbonate, a lower proportion of defibrillation and antiarrhythmic medication usage as well as lower 24-hour post-cardiac arrest Hb levels. The multivariate Logistic regression analysis revealed that female (OR = 6.449, 95%CI was 1.837-22.642, P = 0.004), older age (OR = 1.054, 95%CI was 1.017-1.093, P = 0.004), 1-hour pre-cardiac arrest neurological dysfunction (OR = 25.044, 95%CI was 2.737-229.169, P = 0.004), 1-hour pre-cardiac arrest low perfusion (OR = 3.880, 95%CI was 1.306-11.524, P = 0.028), endotracheal intubation (compared with a bag-mask ventilation; OR = 8.712, 95%CI was 1.402-54.141, P = 0.020) and face mask+endotracheal intubation during CPR (compared with a bag-mask ventilation; OR = 11.089, 95%CI was 3.482-35.320, P = 0.000), IHCA events > 1 time (OR = 4.221, 95%CI was 1.249-14.226, P = 0.020) were positively associated with poor neurological function at 28 days, which were independent risk factors those were not conducive to 28-day neurological function recovery after ROSC in IHCA-CPR patients. In contrast, usage of antiarrhythmic medication (OR = 0.345, 95%CI was 0.134-0.890, P = 0.028) and 24-hour post-cardiac arrest Hb (OR = 0.983, 95%CI was 0.966-0.999, P = 0.043) were negatively associated with poor neurological function at 28 days, which were protective factors those were beneficial for the recovery of neurological function. ROC curve analysis showed that the area under the ROC curve (AUC) of 24-hour post-cardiac arrest Hb for predicting poor neurological function at 28 days after ROSC in IHCA-CPR patients was 0.659 (95%CI was 0.577-0.742), with a cut-off value of 99.5 g/L (sensitivity was 76.2%, specificity was 57.8%). Defibrillation and tracheal intubation during CPR are crucial for IHCA patients. It was also observed that patients with low Hb (< 99.5 g/L should be of high concern), older age, 1-hour pre-cardiac arrest neurological function and hypoperfusion, and IHCA events > 1 time were significantly related to unfavorable neurological outcome in adult resuscitated patients with IHCA.

Epidemiologic investigation of cardiac arrest and current research status on its risk factors analysis

Cardiac arrest most commonly occurs outside of the hospital, known as out-of-hospital cardiac arrest (OHCA), and is an important global health problem. Approximately 40% of cardiac arrest has no clear cause. Hereditary arrhythmias and cardiomyopathies factors contribute to cardiac arrest. The identification of genetic factors for cardiac arrest after its occurrence is of great value not only for the individual, but also for relatives who may be at risk for the disease in their family. In the United States, there are over 350 000 cases of OHCA and over 200 000 cases of in-hospital cardiac arrest (IHCA) each year, and in Western Europe, cardiac arrest accounts for 15%-20% of all adult natural deaths and 50% of all cardiovascular deaths. In order to reduce the burden caused by cardiac arrest within society, it is essential to further understand its etiological factors, such as incidence in different regions, risk factors, and populations at higher risk. For each individual, cardiac arrest is the result of a complex interaction of genetic and acquired factors. Understanding the complex interplay of pathogenic factors in cardiac arrest and the development of individualized prevention and treatment approaches requires the collection of clinical data from cardiac arrest populations and multimodal analysis in order to identify epidemiological features and risk factors for cardiac arrest. Recently, cardiac arrest-related data are being collected and integrated in Europe in different regions and populations. As a result of the commitment to the creation of large datasets of clinical information on cardiac arrest populations, the knowledge of the pathology of cardiac arrest pathogenesis as well as risk factors is steadily increasing. This article reviews the epidemiologic data of cardiac arrest in recent years and the associated risk factors, thus providing ideas for developing better strategies for the prevention and treatment of cardiac arrest.

Cardiac arrest, stony heart, and cardiopulmonary resuscitation: An updated revisit.

The post-resuscitation period is recognized as the main predictor of cardiopulmonary resuscitation (CPR) outcomes. The first description of post-resuscitation syndrome and stony heart was published over 50 years ago. Major manifestations may include but are not limited to, persistent precipitating pathology, systemic ischemia/reperfusion response, post-cardiac arrest brain injury, and finally, post-cardiac arrest myocardial dysfunction (PAMD) after successful resuscitation. Why do some patients initially survive successful resuscitation, and others do not? Also, why does the myocardium response vary after resuscitation? These questions have kept scientists busy for several decades since the first successful resuscitation was described. By modifying the conventional modalities of resuscitation together with new promising agents, rescuers will be able to salvage the jeopardized post-resuscitation myocardium and prevent its progression to a dismal, stony heart. Community awareness and staff education are crucial for shortening the resuscitation time and improving short- and long-term outcomes. Awareness of these components before and early after the restoration of circulation will enhance the resuscitation outcomes. This review extensively addresses the underlying pathophysiology, management, and outcomes of post-resuscitation syndrome. The pattern, management, and outcome of PAMD and post-cardiac arrest shock are different based on many factors, including in-hospital cardiac arrest vs out-of-hospital cardiac arrest (OHCA), witnessed vs unwitnessed cardiac arrest, the underlying cause of arrest, the duration, and protocol used for CPR. Although restoring spontaneous circulation is a vital sign, it should not be the end of the game or lone primary outcome; it calls for better understanding and aggressive multi-disciplinary interventions and care. The development of stony heart post-CPR and OHCA remain the main challenges in emergency and critical care medicine.

Extracorporeal cardiopulmonary resuscitation for in- and out-of-hospital cardiac arrest: The race against time

ObjectivesExtracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used due to its beneficial outcomes and results compared to conventional CPR. Cardiac arrests can be categorized depending on location: in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA). Despite this distinction, studies comparing the two are scarce, especially in comparing outcomes after ECPR. This study compared patient characteristics, cardiac arrest characteristics, and outcomes. MethodsBetween 2016 and 2022, patients who underwent ECPR for cardiac arrest at our institution were retrospectively analyzed, depending on the arrest location: IHCA and OHCA. We compared periprocedural characteristics and used multinomial regression analysis to indicate parameters contributing to a favorable outcome. ResultsA total of n = 157 patients (100%) were analyzed (OHCA = 91; IHCA = 66). Upon admission, OHCA patients were younger (53.2 ± 12.4 vs. 59.2 ± 12.6 years) and predominantly male (91.1% vs. 66.7%, p=<0.001). The low-flow time was significantly shorter in IHCA patients (41.1 ± 27.4 mins) compared to OHCA (63.6 ± 25.1 mins). Despite this significant difference, in-hospital mortality was not significantly different in both groups (IHCA = 72.7% vs. OHCA = 76.9%, p = 0.31). Both groups' survival-to-discharge factors were CPR duration, low flow time, and lactate values upon ECMO initiation. ConclusionSurvival-to-discharge for ECPR in IHCA and OHCA was around 25%, and there was no statistically significant difference between the two cohorts. Factors predicting survival were lower lactate levels before cannulation and lower low-flow time. As such, OHCA patients seem to tolerate longer low-flow times and thus metabolic impairments compared to IHCA patients and may be considered for ECMO cannulation on a broader time span than IHCA.

Abstract 43: Development and Internal Validation of Risk Scores to Predict Survival to Discharge Following Pediatric In-Hospital Cardiac Arrest

Introduction: In-hospital cardiac arrest (IHCA) in the pediatric population is associated with poor survival and neurological outcomes. We aimed to develop and internally validate a risk score to predict survival to discharge in pediatric IHCA patients. Methods: For model development and validation, we included pediatric IHCA patients captured in the Get With The Guidelines® registry (provided by the American Heart Association) between 2005 and 2021. We used logistic regression (LR), classification and regression trees (CART), and artificial neural networks (ANN) to develop models using 70% of the data and validate them using the remaining 30% of the data. The discrimination of the models was compared based on the area under the receiver operating characteristic curve (AUC), calibration based on the ratio of observed to expected (O: E), and predictive accuracy based on percent survival in each risk group. Results: We included 6141 pediatric patients (mean age 4.82 years, 41.3% infants, 54.7% male). Most patients survived to hospital discharge (60.9%). We developed separate models for infants vs. older children using LR, CART, and ANN. The least absolute shrinkage and selection operator (LASSO) identified age, illness category, acyanotic cardiac malformation, hepatic insufficiency, hypotension/hypoperfusion, metabolic/electrolyte abnormality, metastatic/hematologic malignancy, renal insufficiency, septicemia, and pediatric cerebral performance score on admission as important predictor variables for analysis. Table 1 shows a comparison of model parameters. Logistic regression models were found to be better at classifying survivors into risk categories with higher specificity and discrimination. Conclusion: Pediatric patients experiencing IHCA can be classified into low, moderate, and high-risk categories using a simple risk score and easily identified pre-arrest variables. These risk scores can support clinical decisions, facilitate research, and help monitor the quality of medical services.

Risk Factors and Outcomes for Recurrent Pediatric In-Hospital Cardiac Arrest: Retrospective Cohort Study from the American Heart Association's Get with the Guidelines-Resuscitation Registry

Abstract Objective We aimed to describe the risk factors and outcomes of recurrent in-hospital cardiac arrest (IHCA) in a large pediatric cohort. Methods A retrospective cohort study of patients ≤18 years from the American Heart Association's Get With The Guidelines®-Resuscitation Registry with single or recurrent IHCA who achieved return of spontaneous circulation and were not placed on extracorporeal membrane oxygenation with their initial IHCA were included. Patients were categorized into two groups for analysis: (1) single IHCA or (2) recurrent ICHA. Initial IHCAs from each category were analyzed and compared. Continuous variables were expressed as medians with interquartile ranges and compared via rank sum test. Categorical variables were expressed as percentages and compared via chi square test. Outcomes were assessed in a matched cohort. Results A total of 10,019 patients, 2,225 (22.2%) experienced a recurrent IHCA. Recurrent IHCA patients were more likely to be medical cardiac (21.3 vs. 19%; p = 0.01) or trauma patients (7.5 vs. 5.3%; p &lt; 0.001) and have higher acuity (27.8 vs. 22.7%; p &lt; 0.001). Initial IHCA for recurrent IHCA patients were more likely to occur in the pediatric intensive care unit (44.2 vs. 39.6%; p &lt; 0.001) or cardiac intensive care unit (11.5 vs. 9.5%; p = 0.006) versus other inpatient locations. There was no difference in initial IHCA duration between groups. After matching, patients with a recurrent IHCA had a lower rate of survival to hospital discharge (42.1 vs. 65.3%; p &lt; 0.001). Conclusion In a matched cohort, patients with recurrent IHCA had lower rates of survival compared with those with a single IHCA. Higher acuity and intensive care unit location during initial IHCA event were associated with increased risk for recurrent IHCA.