No-flow Time Research Articles

Dispatcher-Assisted CPR in Italy: A Nationwide Survey of Current Practices and Future Challenges in Emergency Medical Communication Centers.

Background/Objectives: Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is widely recognized as a critical intervention that significantly reduces no-flow time, improving survival rates in out-of-hospital cardiac arrests (OHCAs). This study evaluates current practices and the organization of DA-CPR in Italian emergency medical communication centers (EMCCs) and identifies areas for improvement. Methods: A cross-sectional survey was conducted between April and May 2024 among all Italian EMCCs, achieving a 92.6% response rate (62 out of 67) and covering 95.5% of the population. Data were collected on the availability of DA-CPR, additional medical instructions provided, standardized protocols, integration into dispatch software, availability of video call systems, and follow-up programs. Results: All responding EMCCs provide DA-CPR, with 79.1% (n = 49) initiating these protocols more than five years ago. In adult cardiac arrest, 74.2% (n = 46) provide instructions for chest compressions only. Standardized protocols are used in 69.4% (n = 43) of EMCCs, and 53.2% (n = 33) have these protocols integrated into their dispatch software. Additionally, 93.5% (n = 58) provide dispatcher-assisted instructions for other medical conditions, including pediatric CPR (90.3%, n = 56), neonatal CPR (90.3%, n = 56), foreign body airway obstruction (85.5%, n = 53), labor (56.5%, n = 35), and massive bleeding (41.9%, n = 26). A training path for DA-CPR is available in 48 EMCCs (77.4%), and in most cases, it is included in the basic dispatcher course (56.5%, n = 36), with 50% conducting periodic retraining. Moreover, 33.9% (n = 21) utilize video call systems to support dispatcher-assisted instructions. Data on DA-CPR are collected by 46.8% of EMCCs (n = 29), primarily on relevant cases, but only 25.8% (n = 16) have a follow-up path for patients. Conclusions: This study highlights a widespread implementation of DA-CPR across Italian EMCCs. However, regional disparities, mainly in protocols and technological support, indicate areas requiring urgent attention. Enhancing training programs and standardizing protocols could improve DA-CPR effectiveness and patient outcomes, thus guaranteeing equitable care nationwide. Future initiatives should focus on integrating support tools like video calls, expanding retraining programs, and establishing follow-up and debriefing paths.

The association between the type of bystander and survival after an out-of-hospital cardiac arrest: A French nationwide study.

Early bystander interventions are associated with more favorable outcomes after out-of-hospital cardiac arrest (OHCA). The objective of the present study was to determine whether the type of bystander-patient relationship was associated with survival and neurological outcomes after OHCA in France. We analyzed data registered in the French National Cardiac Arrest Registry (RéAC) between July 1st, 2011, and April 30th, 2023. The study population comprised bystander-attended cases of OHCA managed by the emergency medical services. Bystanders were categorized as family members, other laypersons, off-duty professional first responders, or off-duty healthcare professionals. The primary outcome was 30-day survival with a favorable neurological outcome (Cerebral Performance Category 1 or 2). The secondary outcomes included the bystander cardiopulmonary resuscitation (CPR) initiation rate, return of spontaneous circulation, and survival upon admission to the hospital. Our statistical analyses were based on bivariate and multivariable logistic regressions analyses. Among the 89,861 OHCA cases analyzed, family members constituted the largest group of bystanders (69.2%). Compared with non-family-member bystanders, family bystander status was associated with a lower CPR initiation rate, a longer no-flow time, and lower 30-day survival rates. Specifically, cases of OHCA with non-family-member bystanders were 32% more likely to survive with a CPC of 1-2 at day 30 than cases with family member bystanders. Medically trained bystander status (off-duty professional first responders and healthcare professionals) was associated with higher CPR initiation and 30-day survival rates, relative to nontrained laypersons. Survival after an OHCA appears to be associated with the type of bystander. Although family members were the most common bystanders, they were less likely to initiate CPR and less likely to see the OHCA patient survive. Efforts to increase the post-OHCA survival rate should include targeted interventions (such as public education and training programs) that emphasize the importance of early CPR and automated external defibrillator use by family members.

Abstract Su607: Which would be major? witnessed collapse or bystander resuscitation?

Background: Witnessed collapse and bystander cardiopulmonary resuscitation (CPR) are two variables commonly used to predict outcomes in out-of-hospital cardiac arrest (OHCA). Some published studies have shown that bystander CPR were not significantly associated with outcomes after confounders adjusted. This may imply that witnessed collapse would be a superior prognostic factors beyond bystander CPR. Hypothesis: Witnessed collapse and bystander CPR may not contribute equally to prehospital return of spontaneous circulation (ROSC), and the former may be major. Aims: To investigate four prediction models for prehospital ROSC using stratification of the witnessed collapse and bystander CPR. Methods: The study enrolled OHCA patients treated by the emergency medical service (EMS) from January 2010 to December 2022 in three EMS systems in Taiwan. Data were extracted from the records of each medical service encounter, including patient demographics, dispatch timing, prehospital management, witnessed collapse and bystander CPR. The primary outcome was any prehospital ROSC. Patients were stratified into four groups by witnessed collapse (with/without) and bystander CPR (with/without) status, namely W+B+, W-B+, W+B- and W-B-. Prehospital ROSC prognostication were identified using multivariable logistic regression analysis. Results: The analysis comprised 17,323 patients, among whom 1,165 (6.7%) achieved prehospital ROSC. The W+B+ group demonstrated the highest prehospital ROSC rate at 13.0%, as compared with the other groups significantly (9.0%, 3.4%, and 4.1%, as depicted in Image 1). Stratification of the prehospital ROSC model (Image 2) indicated that the W+B+ group had several common predictors including age, traumatic arrest, no-flow time, public access defibrillation (PAD), and resuscitation events. However, certain predictors in other groups were removed during regression process. Notably, no-flow time significantly influenced prehospital ROSC only in the W+B+ and W+B- groups. Conversely, in the W-B- group, most variables had minimal impact on prehospital ROSC, reflecting the limited effectiveness of traditional predictors within this subgroup. Conclusion: The significance of witnessed collapse as a prognostic factor may be equal to or even greater than that of bystander CPR. Further studies are needed to confirm.

Abstract Su602: Categorizing Witnessed Out-of-Hospital Cardiac Arrest by Bystander Type

Witnessed out-of-hospital cardiac arrests (OHCA) are associated with improved outcomes with increased likelihood of rapid activation of the emergency response system thus decreasing no-flow or low-flow times. Current literature has largely treated witnessed cardiac arrest as binary (i.e. was a cardiac arrest witnessed Yes/No). We hypothesize there is a need to further delineate and categorize distinct bystander types; these differences may have important downstream contributions to outcomes and survival and targets for improving training and recognition. For example, a bystander who is a healthcare provider with formal training or has experience performing resuscitation may be associated with better outcomes than a non-medical layperson. We examined a national-level database of emergency medical services (EMS) activations in the United States (NEMSIS). Inclusion criteria were any adult (18+ years) cardiac arrest activation between January 2022 and December 2023. Cardiac arrests taking place after EMS arrival (EMS-witnessed) were excluded. Witnessed status was described as unwitnessed, witnessed by healthcare provider, witnessed by family member, or witnessed by bystander. Across basic demographic variables, we compared overall witnessed rates, family member witnessed rates, and healthcare worker witnessed rates. A total of 791,217 cardiac arrests met inclusion criteria. Overall, 62.5% of arrests were unwitnessed, 22.8% were witnessed by a family member, and 6.3% were witnessed by a healthcare provider. Across sex, cardiac arrests in male patients were more likely to be witnessed, however, cardiac arrests in female patients were more likely to be witnessed by a family member or healthcare provider (p<0.05). Significant differences in witnessed status were also seen across race/ethnicity. For instance, cardiac arrests in Black/African American patients were less likely to be witnessed by family members and cardiac arrests in Hispanic/Latino patients were less likely to be witnessed by healthcare workers (p<0.05). Our analysis of a large and nationally-representative database of cardiac arrest suggests differences in rates of witnessed cardiac arrest and – perhaps, more importantly – the existence of different types of bystanders. Moreover, when considering these differences, there is heterogeneity among demographic variables. Future research is needed to understand whether these differences in bystander type may contribute to differences in outcomes.

Abstract Su403: Iterative Simulation to Optimize Mechanical CPR Device Application

Mechanical chest compression devices (MCDs) are commonly used for in-hospital and emergency department (ED) cardiac arrest resuscitation. Manufacturer guidelines and educational materials demonstrate that in the prehospital setting, MCDs can be deployed with an interruption in CPR of less than 15 seconds. No similar materials exist for the in-hospital environment, where observational studies have noted median CPR interruptions of up to 40 seconds for MCD deployment. With the integration of extracorporeal CPR (eCPR) into OHCA systems of care, the need to transfer patients with ongoing CPR to MCDs in the ED is growing. To develop a hospital-specific procedure for receiving a patient in cardiac arrest and deploying the MCD with minimal no-flow time. We used an iterative participatory design process to develop a procedure for receiving patients in cardiac arrest from Emergency Medical Services (EMS). Tasks included transferring a patient, replacing defibrillator pads, and deploying the hospital MCD with minimal no-flow time. Participants including ED physicians, nurses, and respiratory therapists performed a series of simulations using a high-fidelity manikin, resuscitation equipment, and an MCD. Simulations were followed by focused debriefings, participant-directed modification of the working procedure, and repeat simulation until participants expressed satisfaction with the procedure. Participant roles were shuffled after each round. The primary outcome was the duration of CPR interruption required to deploy the MCD; change in this time over successive iterations was assessed using a Wilcoxon signed-rank test. The final procedure described a sequence of steps and responsibilities that participants deemed efficient and reproducible. Through seven simulation-debriefing cycles, CPR interruption associated with MCD deployment decreased from 19 to 10 seconds (p = 0.033). The most common failure modes that participants corrected during modifications involved needed equipment that was out of reach, obstructed provider positioning, and poorly defined roles. On subsequent days, two additional groups of on-shift ED providers deployed the MCD in less than 15 seconds following the developed procedure. Using an iterative design process, we created an MCD deployment procedure that minimized CPR interruptions and was acceptable to hospital staff. This represents an effective, low-cost methodology to design a process for transfer of care during CPR and MCD deployment.

Circulating glycocalyx shedding products as biomarkers for evaluating prognosis of patients with out-of-hospital cardiac arrest after return of spontaneous circulation

The endothelial glycocalyx is damaged in postcardiac arrest syndrome (PCAS), but the prognostic value is unknown. We aimed to observe the expression and prognostic value of glycocalyx shedding products, including syndecan-1 (SDC-1), hyaluronan (HA), and heparan sulfate (HS) in PCAS. Data on clinical and 28-day outcomes of seventy-one consecutive patients with out-of-hospital cardiac arrest (OHCA) after the return of spontaneous circulation (ROSC) were collected. SDC-1, HA, and HS were measured on days 0, 1, and 3 after ROSC. Thirty healthy individuals were controls. Glycocalyx shedding was observed in human umbilical vein endothelial cells (HUVECs) stimulated during hypoxia and reoxygenation in vitro. Within 4 h of ROSC, SDC-1 and HA levels, significantly increased. In the 28-day non-survivors, HA levels showed a gradual upward trend, SDC-1 remained at a high level, and HS levels first increased, then decreased. Kaplan–Meier curves and binary logistic regression analysis showed the prognostic value of SDC-1 levels on days 0, 1, and 3, HA levels on days 1 and 3, and HS levels on day 1. Only HS levels on day 1 showed a prognostic value for 28-day neurological outcomes. SDC-1 and HA levels were positively correlated with the no-flow time. In vitro, HUVECs showed shedding of SDC-1 and HS during a prolonged duration of hypoxia. After ROSC, SDC-1, HA, and HS levels may predict the 28-day survival after PCAS, and HS levels are associated with functional outcomes.

Differences in clinical features according to survival and gender in patients admitted for cardiac arrest

Abstract Funding Acknowledgements None. Introduction Cardiac arrest (CA) is a condition with poor vital and neurological prognosis. Although there are widely known clinical features modifying prognosis –such as time to return of spontaneous circulation (ROSC) and neuron-specific enolase values-, there is uncertainty around whether gender, ischemic etiology or classic cardiovascular risk factors may influence in the management and prognosis. Purpose The aim of this study was to analyze the differences in baseline characteristics and management between survivors and non survivors, among patients admitted for CA in an Intensive Cardiac Care Unit. Methods A prospective unicentric registry was performed from January 2010 to December 2021, including all consecutive cardiac arrest patients admitted to an intensive cardiac care unit of a university hospital. Patients were classified into survivors –to hospital discharge- and non-survivors –deceased during hospital admission, irrespective of time of death. Univariate analysis were performed using Chi-square and Student t tests, and logistic regression was used for a multivariate analysis to compare both groups. Results A total of 324 patients were included, mean age 59.7 (DE 12.2) years, 17.9% were women. In-hospital mortality was 42% (136 patients) and 188 patients survived to hospital discharge. Survivors were significantly younger (mean of 57,37 vs 62,98 years) and had less prevalence of diabetes (17 vs 33%) and previous myocardial infarction (15 vs 25%) than non-survivors. Among survivors, there was a higher prevalence of in-hospital CA (26,6 vs 12,5%), CA due to acute coronary syndrome (68,62 vs 57,78%) and shockable first rhythm (90,43 vs 72,06%). They also had shorter ROSC (mean 22,13 vs 34,25 minutes) and no flow times (mean 2,54 vs 5,67 minutes). Gender, arterial hypertension, dyslipidemia and smoking habit did not modify prognosis. When comparing genders, women had significantly less prevalence of smoking habit and previous ischemic heart disease, their time to ROSC was lower and they received less coronary angiographies than men. The multivariate analysis showed significant in-hospital mortality risk increase with age (OR 1,04 per year), ROSC (OR 1,04 per minute) and no-flow (OR 1,09 per minute) times, out of hospital CA (OR 2,26) and non shockable rhythm. Conclusions In a consecutive cohort of 324 patients admitted after cardiac arrest, survivors were significantly younger, and had less prevalence of diabetes mellitus and previous myocardial infarction. In-hospital arrest, shockable rhythm, and shorter ROSC and no-flow times were associated with better survival. No differences in survival were found between genders, although women had significantly shorter resuscitation times.Univariate analysisMultivariate analysis

Characterization and mid-term outcomes of current out-of-hospital cardiac arrest patients admitted to intensive cardiovascular care units

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Consell Català de Resuscitació. Background Out-of-hospital cardiac arrest (OHCA) accounts the 50% of cardiovascular deaths. Being aware of characteristics and outcomes of our OHCA population is important in order to apply measures in the weaker areas to improve the results of the process. Purpose To investigate current outcomes, at 6-month follow-up, of patients admitted to an Intensive Cardiac Care Unit (ICCU) in a mediterranean area during the 2020s. Current characteristics, prehospital management and factors related to outcomes were also analyzed. Methods PCR-Cat was a prospective observational multicentre registry. OHCA patients admitted to the ICCU of 8 hospitals were included from October/2020 to December/2021. Those who survived with good neurological status, no disabilities, and remained independent for usual life activities, were classified as Good Outcome (GO). Those patients who died or had a poor neurological status, with high dependency or rested in permanent vegetative status were classified as Poor Outcome (PO). A multinomial logistic regression was done to analyze the factors independently related to PO. Results 288 patients were included, only 50 (17.36%) were women. At 6-month follow-up, 48.95% of patients had GO. Most events happened in the first month (Figure 1). The cause of death was neurological in 72.9%. Patients with PO were significantly older (63.74 vs. 58.88, p=0.003) and had more comorbidities (Table 1A). The most frequent location was on a public space (54.84%) and most were witnessed (88.93%). Cardiopulmonary resuscitation maneuvers were initiated by a bystander in 69.18% until EMS arrival, being only 20.79% done by an experienced bystander. The medium no-flow time was low (2 min) but total time until ROSC was of 28 min. First rhythm was shockable in 80%, but an automatic external defibrillator was only used in 58% of cases. Statistically significant lower values of first pH and higher values of first lactate, glucose and creatinine were related to PO (Table 1B). Patients with PO had a higher APACHE II (26 vs. 20, p<0.001) and SOFA (10.39 vs. 7.14, p<0.001) scores at admission, and required a longer time on mechanical ventilation (6 vs. 3.5 days, p=0.001). The main cause of the OHCA was acute coronary syndrome (53.82%), followed by chronic coronary syndrome (7.64%) and dilated myocardiopathy (7.64%). In the multinomial logistic regression, older age (p=0.005), male sex (p=0.016), previous stroke (p=0.046), longer ROSC time (p<0.001) and non-shockable first rhythm (p<0.001) were independently related to PO. Receiving cardiopulmonary resuscitation maneuvers by an experienced bystander was related to a reduction of 17 min of ROSC (p=0.001). Conclusions Less than a half of patients admitted to an ICCU because of an OHCA had GO at 6-month follow-up. Age, male sex, previous stroke, longer ROSC time and non-shockable first rhythm were factors independently related to PO. Interventions addressed to reduce ROSC time are urgently needed.

Sequential Normothermic Regional Perfusion and End-ischemic Ex Situ Machine Perfusion Allow the Safe Use of Very Old DCD Donors in Liver Transplantation.

In Italy, 20 min of continuous, flat-line electrocardiogram are required for death declaration. Despite prolonged warm ischemia time, Italian centers reported good outcomes in controlled donation after circulatory death (cDCD) liver transplantation by combining normothermic regional and end-ischemic machine perfusion (MP). The aim of this study was to evaluate the safety and feasibility of the use of septuagenarian and octogenarian cDCD donors with this approach. All cDCD older than 70 y were evaluated during normothermic regional perfusion and then randomly assigned to dual hypothermic or normothermic MP. In the period from April 2021 to December 2022, 17 cDCD older than 70 y were considered. In 6 cases (35%), the graft was not considered suitable for liver transplantation, whereas 11 (65%) were evaluated and eventually transplanted. The median donor age was 82 y, being 8 (73%) older than 80. Median functional warm ischemia and no-flow time were 36 and 28 min, respectively. Grafts were randomly assigned to ex situ dual hypothermic oxygenated MP in 6 cases (55%) and normothermic MP in 5 (45%). None was discarded during MP. There were no cases of primary nonfunction, 1 case of postreperfusion syndrome (9%) and 2 cases (18%) of early allograft dysfunction. At a median follow-up of 8 mo, no vascular complications or ischemic cholangiopathy were reported. No major differences were found in terms of postoperative hospitalization or complications based on the type of MP. The implementation of sequential normothermic regional and end-ischemic MP allows the safe use of very old donation after circulatory death donors.

Prognostic effects of cardiopulmonary resuscitation (CPR) start time and the interval between CPR to extracorporeal cardiopulmonary resuscitation (ECPR) on patient outcomes under extracorporeal membrane oxygenation (ECMO): a single-center, retrospective observational study

BackgroundThe impact of the chronological sequence of events, including cardiac arrest (CA), initial cardiopulmonary resuscitation (CPR), return of spontaneous circulation (ROSC), and extracorporeal cardiopulmonary resuscitation (ECPR) implementation, on clinical outcomes in patients with both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA), is still not clear. The aim of this study was to investigate the prognostic effects of the time interval from collapse to start of CPR (no-flow time, NFT) and the time interval from start of CPR to implementation of ECPR (low-flow time, LFT) on patient outcomes under Extracorporeal Membrane Oxygenation (ECMO).MethodsThis single-center, retrospective observational study was conducted on 48 patients with OHCA or IHCA who underwent ECMO at Hamad General Hospital (HGH), the tertiary governmental hospital of Qatar, between February 2016 and March 2020. We investigated the impact of prognostic factors such as NFT and LFT on various clinical outcomes following cardiac arrest, including 24-hour survival, 28-day survival, CPR duration, ECMO length of stay (LOS), ICU LOS, hospital LOS, disability (assessed using the modified Rankin Scale, mRS), and neurological status (evaluated based on the Cerebral Performance Category, CPC) at 28 days after the CA.ResultsThe results of the adjusted logistic regression analysis showed that a longer NFT was associated with unfavorable clinical outcomes. These outcomes included longer CPR duration (OR: 1.779, 95%CI: 1.218–2.605, P = 0.034) and decreased survival rates for ECMO at 24 h (OR: 0.561, 95%CI: 0.183–0.903, P = 0.009) and 28 days (OR: 0.498, 95%CI: 0.106–0.802, P = 0.011). Additionally, a longer LFT was found to be associated only with a higher probability of prolonged CPR (OR: 1.818, 95%CI: 1.332–3.312, P = 0.006). However, there was no statistically significant connection between either the NFT or the LFT and the improvement of disability or neurologically favorable survival after 28 days of cardiac arrest.ConclusionsBased on our findings, it has been determined that the NFT is a more effective predictor than the LFT in assessing clinical outcomes for patients with OHCA or IHCA who underwent ECMO. This understanding of their distinct predictive abilities enables medical professionals to identify high-risk patients more accurately and customize their interventions accordingly.

High Variability in the Duration of Chest Compression Interruption is Associated With Poor Outcomes in Pediatric Extracorporeal Cardiopulmonary Resuscitation.

To determine the association between chest compression interruption (CCI) patterns and outcomes in pediatric patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR). Cardiopulmonary resuscitation (CPR) data were collected using defibrillator-electrode and bedside monitor waveforms from pediatric ECPR cases between 2013 and 2021. Duration and variability of CCI during cannulation for ECPR was determined and compared with survival to discharge using Fishers exact test and logistic regressions with cluster-robust se s for adjusted analyses. Quaternary care children's hospital. Pediatric patients undergoing ECPR. None. Of 41 ECPR events, median age was 0.7 years (Q1, Q3: 0.1, 5.4), 37% (15/41) survived to hospital discharge with 73% (11/15) of survivors having a favorable neurologic outcome. Median duration of CPR from start of ECPR cannulation procedure to initiation of extracorporeal membrane oxygenation (ECMO) flow was 21 minutes (18, 30). Median duration of no-flow times associated with CCI during ECMO cannulation was 11 seconds (5, 28). Following planned adjustment for known confounders, survival to discharge was inversely associated with maximum duration of CCI (odds ratio [OR] 0.91 [0.86-0.95], p = 0.04) as well as the variability in the CCI duration (OR 0.96 [0.93-0.99], p = 0.04). Cases with both above-average CCI duration and higher CCI variability ( sd > 30 s) were associated with lowest survival (12% vs. 54%, p = 0.009). Interaction modeling suggests that lower variability in CCI is associated with improved survival, especially in cases where average CCI durations are higher. Shorter duration of CCI and lower variability in CCI during cannulation for ECPR were associated with survival following refractory pediatric cardiac arrest.

Improved Extracorporeal Cardiopulmonary Resuscitation (ECPR) Outcomes Is Associated with a Restrictive Patient Selection Algorithm.

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality. Despite decades of intensive research and several technological advancements, survival rates remain low. The integration of extracorporeal cardiopulmonary resuscitation (ECPR) has been recognized as a promising approach in refractory OHCA. However, evidence from recent randomized controlled trials yielded contradictory results, and the criteria for selecting eligible patients are still a subject of debate. This study is a retrospective analysis of refractory OHCA patients treated with ECPR. All adult patients who received ECPR, according to the hospital algorithm, from 2013 to 2021 were included. Two different algorithms were used during this period. A "permissive" algorithm was used from 2013 to mid-2016. Subsequently, a revised algorithm, more "restrictive", based on international guidelines, was implemented from mid-2016 to 2021. Key differences between the two algorithms included reducing the no-flow time from less than three minutes to zero minutes (implying that the cardiac arrests must occur in the presence of a witness with immediate CPR initiation), reducing low-flow duration from 100 to 60 min, and lowering the age limit from 65 to 55 years. The aim of this study is to compare these two algorithms (permissive (1) and restrictive (2)) to determine if the use of a restrictive algorithm was associated with higher survival rates. A total of 48 patients were included in this study, with 23 treated under Algorithm 1 and 25 under Algorithm 2. A significant difference in survival rate was observed in favor of the restrictive algorithm (9% vs. 68%, p < 0.05). Moreover, significant differences emerged between algorithms regarding the no-flow time (0 (0-5) vs. 0 (0-0) minutes, p < 0.05). Survivors had a significantly shorter no-flow and low-flow time (0 (0-0) vs. 0 (0-3) minutes, p < 0.01 and 40 (31-53) vs. 60 (45-80) minutes, p < 0.05), respectively. The present study emphasizes that a stricter selection of OHCA patients improves survival rates in ECPR.

Impact of clinical variables on outcomes in refractory cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation.

In the past two decades, extracorporeal resuscitation (ECPR) has been increasingly used in the management of refractory cardiac arrest (CA) patients. Decision algorithms have been used to guide the care such patients, but the effectiveness of such decision-making tools is not well described. The aim of this study was to compare the rate of survival with a good neurologic outcome of patients treated with ECPR meeting all criteria of a clinical decision-making tool for the initiation of ECPR to those for whom ECPR was implemented outside of the algorithm. All patients who underwent E-CPR between January 2014 and December 2021 at the Montreal Heart Institute were included in this retrospective analysis. We dichotomized the cohort according to adherence or non-adherence with the ECPR decision-making tool, which included the following criteria: age ≤65 years, initial shockable rhythm, no-flow time <5 min, serum lactate <13 mmol/L. Patients were included in the "IN" group when they met all criteria of the decision-making tool and in the "OUT" group when at least one criterion was not met. The primary outcome was survival with intact neurological status at 30 days, defined by a Cerebral Performance Category (CPC) Scale 1 and 2. A total of 41 patients (IN group, n = 11; OUT group, n = 30) were included. A total of 4 (36%) patients met the primary outcome in the IN group and 7 (23%) in the OUT group [odds ratio (OR): 1.88 (95% CI, 0.42-8.34); P = 0.45]. However, survival with a favorable outcome decreased steadily with 2 or more deviations from the decision-making tool [2 deviations: 1 (11%); 3 deviations: 0 (0%)]. Most patients supported with ECPR fell outside of the criteria encompassed in a clinical decision-making tool, which highlights the challenge of optimal selection of ECPR candidates. Survival rate with a good neurologic outcome did not differ between the IN and OUT groups. However, survival with favorable outcome decreased steadily after one deviation from the decision-making tool. More studies are needed to help select proper candidates with refractory CA patients for ECPR.

Hemodynamic Effect of Repeated Epinephrine Doses Decreases With Cardiopulmonary Resuscitation Cycle Progression.

Epinephrine is administered to increase coronary perfusion pressure during advanced life support and promote short-term survival. Recent cardiopulmonary resuscitation (CPR) guidelines recommend an epinephrine dosing interval of 3 to 5 minutes during resuscitation; however, scientific evidence supporting this recommendation is lacking. Therefore, we aimed to investigate the hemodynamic effects of repeated epinephrine doses during CPR by monitoring augmented blood pressure after its administration in a swine model of cardiac arrest. A secondary analysis of data from a published study was performed using a swine cardiac arrest model. The epinephrine dose was fixed at 1 mg, and the first dose of epinephrine was administered after no-flow and low-flow times of 2 minutes and 8 minutes, respectively, and subsequently administered every 4 minutes. Four cycles of dosing intervals were defined because a previous study was terminated 26 minutes after the induction of ventricular fibrillation. Augmented blood pressures and corresponding timelines were determined. Augmented blood pressure trends following cycles and the epinephrine effect duration were also monitored. Among the 140 CPR cycles, the augmented blood pressure after epinephrine administration was the highest during the first cycle of CPR and decreased gradually with further cycle repetitions. The epinephrine effect duration did not differ between repeated cycles. The maximum blood pressure was achieved 78 to 97 seconds after epinephrine administration. Hemodynamic augmentation with repeated epinephrine administration during CPR decreased with cycle progression. Further studies are required to develop an epinephrine administration strategy to maintain its hemodynamic effects during prolonged resuscitation.

Automated and app-based activation of first responders for prehospital cardiac arrest: an analysis of 16.500 activations of the KATRETTER system in Berlin

BackgroundBystander CPR is one of the main independent factors contributing to better survival after out-of-hospital cardiac arrest. Simultaneously, the rate of bystander CPR in Germany is below the European average. First responder applications (apps) contribute to reducing the time period without CPR (no-flow time) until professional help can arrive on-scene.MethodsThe KATRETTER app was introduced in Berlin as one of the first apps in Europe which do not require any medical qualifications to register as a first responder. The activation of volunteer first responders for suspected cardiac arrest cases through the Berlin Emergency Medical Services integrated control center was evaluated based on data collected between 16 Oct 2020 and 16 Oct 2022. Our descriptive analysis includes the number of registered first responders, number of activations, the number and percentages of accepted activations, as well as all reports where first responders arrived at the scene.ResultsAs of 15 Oct 2022, a total of 10,102 first responders were registered in the state of Berlin. During this specified period, there were 16.505 activations of the system for suspected out-of-hospital cardiac arrest. In 38.4% of the accepted cases, first responders documented patient contact, and in 34.6% of cases with patient contact, CPR was performed. Only 2% of registered first responders did not have any medical qualifications.ConclusionsSmartphone-based first responder applications should not be understood as a means of alerting professional help, but rather like a digitally amplified “call for help” in the vicinity of an emergency location. A large number of first responders can be recruited within 24 months, without large-scale public relations work necessary. No qualifications were required to become a first responder, contributing to a low-threshold registration process with the effect of a more widespread distribution of the app and cost reduction during implementation.

Building an Extracorporeal Cardiopulmonary Resuscitation Program at a High-volume Extracorporeal Membrane Oxygenation Center

Extracorporeal Cardiopulmonary Resuscitation (ECPR) is an emerging approach to cardiac arrest. We present two contrasting cases from a high-volume extracorporeal membrane oxygenation (ECMO) center (defined as greater than 30 ECMO cases per year) without a 24/7 ECPR program to highlight how to establish an ECPR program with a focus on patient selection and outcome optimization. In one case, a patient presented with cardiac arrest during initial triage for chest pain within the emergency department, and in the other case, a patient experienced an out-of-hospital cardiac arrest with prolonged no-flow and low-flow time. Despite the lack of a 24/7 ECPR program at the presenting center, both patients received an ECPR evaluation, as both patients presented while all services necessary for ECMO cannulation were available. The in-hospital cardiac arrest patient was successfully cannulated for ECMO during cardiopulmonary resuscitation and survived with few complications. The out-of-hospital cardiac arrest patient was deemed a poor candidate for ECPR and expired soon after presentation. These two cases highlight the complex decision-making in ECPR and further illustrate how to create ECPR protocols at a high-volume ECMO center before resources are available for a 24/7 ECPR program.

Abstract 318: Glibenclamide May Have a Neuroprotective and Cardioprotective Role Beyond Cerebral Edema in an Asphyxial Model of Cardiac Arrest

Background: Cardiac arrest (CA) is a leading cause of mortality and long-term disability. There are no therapeutics approved for neuro- and cardio-protection. Novel therapeutics are urgently needed to improve patient outcomes. Glibenclamide is a second-generation sulfonylurea drug and inhibitor of SUR1-TRPM4. Little is known about its role in cardioprotection and synaptic density. Aims: To evaluate the effect of glibenclamide on coronary flow reserve (CFR), blood-brain barrier (BBB) permeability, and synaptic density in an asphyxial mouse model of CA. Methods: We used an asphyxial mouse model of CA; potassium chloride was injected into the right internal jugular vein, resulting in asystole. Chest compressions and epinephrine were administered following 12 minutes of no-flow time. Successfully resuscitated mice (n=24) were randomized to receive intravenous glibenclamide or vehicle; the glibenclamide group received a loading dose of 10 μg/kg immediately upon return of spontaneous circulation followed by 1.6 μg every 12 hours up to day 3. Pulse Doppler Velocity (PWV) was used to monitor the CFR and left carotid artery velocity. Synaptic density was quantified with ex vivo autoradiographs after injection of 18 F-SynVesT-2 in the brain (3, 24, and 72 hrs). Evans blue staining and general neurologic deficit scores were assessed 24 hours post-resuscitation. Results: Treatment with glibenclamide resulted in an increase in CFR (1.37±0.11 vs. 1.17±0.06, p=0.01) and carotid peak velocity (61.38±12.81 cm/s vs. 46.83±6.3 cm/s, p&lt;0.05). Whole brain synaptic density was increased in the mice treated with glibenclamide, suggesting a reduction in synaptic density loss. BBB disruption in the cerebrum was significantly lower in Glibenclamide treated mice (0.00022±0.000014/mg vs. 0.000471±0.000088/mg, p&lt;0.01). Mice treated with Glibenclamide had lower neurologic deficit scores (1.83±2.89 vs 4.75±3.84, p&lt;0.05). Conclusions: Glibenclamide given immediately following the return of spontaneous circulation improved CFR, decreased BBB disruption, reduced synaptic density loss, and improved neurologic deficit scores, suggesting both cardio- and neuro-protective effects.

Development and evaluation of a virtual reality basic life support for undergraduate students in Thailand: a project by Mae Fah Luang University (MFU BLiS VR)

BackgroundIn traditional basic life support training for university students or the public, trainees practice simulations only once or twice during the course, potentially limiting their competence. In contrast, virtual reality allows trainees to independently study and practice as often as needed, enhancing their skills. This research and development project aimed to develop and evaluate a novel learning device, virtual reality basic life support for undergraduate students of Mae Fah Luang University (MFU BLiS VR).MethodsThis study employed a two-group, pre- and post-test design, involving seventy students (n = 35 in each group) from Mae Fah Luang University, Thailand. Data were collected from March 2022 to January 2023. The experimental group received the MFU BLiS VR, in addition to traditional teaching, while the control group received only traditional teaching. Data analysis employed descriptive statistics, Chi-square, Mann-Whitney U test, and Wilcoxon signed ranks test.Results“MFU BLiS VR” provided a learning experience in out-of-hospital basic life support for adult patients in four scenarios: (1) a person who was not breathing but had a pulse; (2) a person who was not breathing, had no pulse, and required defibrillation; (3) a person who was not breathing, had no pulse, and did not require defibrillation; and (4) a person with normal breathing and pulse but was unconscious. Each scenario was presented sequentially from scenario one to scenario four. The scenarios encompassed common and complex situations requiring prompt and effective bystander responses to save lives. The results revealed that the experimental group had a significantly shorter no-flow time compared to the control group (Z = -5.02, p < .001) and achieved significantly higher knowledge scores than the control group (Z = -3.39, p < .01) as well as superior practical skills (Z = -7.26, p < .001). Both groups reported the highest satisfaction levels in all aspects, with no significant differences.ConclusionMFU BLiS VR is an effective training approach for teaching and learning basic life support and the use of an automated electronic defibrillator. It captures students’ attention and enhances their understanding of these essential life support skills, which are crucial for everyone.

Temporal trends in out-of-hospital cardiac arrest with an initial non-shockable rhythm in Singapore

AimOut-of-hospital cardiac arrest (OHCA) with an initial non-shockable rhythm is the predominant form of OHCA in adults. We evaluated its 10-year trends in epidemiology and management in Singapore. MethodsUsing the national OHCA registry we studied the trends of 20,844 Emergency Medical Services-attended adult OHCA from April 2010 to December 2019. Survival to hospital discharge was the primary outcome. Trends and outcomes were analyzed using linear and logistic regression, respectively. ResultsIncidence rates of adult OHCAs increased during the study period, driven by non-shockable OHCA. Compared to shockable OHCA, non-shockable OHCAs were significantly older, had more co-morbidities, unwitnessed and residential arrests, longer no-flow time, and received less bystander cardiopulmonary resuscitation (CPR) and in-hospital interventions (p < 0.001). Amongst non-shockable OHCA, age, co-morbidities, residential arrests, no-flow time, time to patient, bystander CPR and epinephrine administration increased during the study period, while presumed cardiac etiology decreased (p < 0.05). Unlike shockable OHCA, survival for non-shockable OHCA did not improve (p < 0.001 for trend difference). The likelihood of survival for non-shockable OHCA significantly increased with witnessed arrest (adjusted odds ratio (aOR) 2.02) and bystander CPR (aOR 3.25), but decreased with presumed cardiac etiology (aOR 0.65), epinephrine administration (aOR 0.66), time to patient (aOR 0.93) and age (aOR 0.98). Significant two-way interactions were observed for no-flow time and residential arrest with bystander CPR (aOR 0.96 and 0.40 respectively). ConclusionThe incidence of non-shockable OHCA increased between 2010 and 2019. Despite increased interventions, survival did not improve for non-shockable OHCA, in contrast to the improved survival for shockable OHCA.

Cardiac arrest related lung edema: examining the role of downtimes in transpulmonary thermodilution analysis.

Pulmonary edema and its association with low flow times has been observed in postcardiac arrest patients. However, diagnosis of distinct types of lung pathology is difficult.The aim of this study was to investigate pulmonary edema by transpulmonary thermodilution (TPTD) after out-of-hospital cardiac arrest (OHCA), and the correlation to downtimes. In this retrospective single-center study consecutive patients with return of spontaneous circulation (ROSC) following OHCA, age ≥ 18, and applied TPTD were enrolled. According to downtimes, patients were divided into a short and a long no-flow-time group, and data of TPTD were analysed. We identified 45 patients (n = 25 short no-flow time; n = 20 long no-flow time) who met the inclusion criteria. 24h after ROSC, the extra vascular lung water index (EVLWI) was found to be lower in the group with short no-flow time compared to the group with long no-flow time (10.7 ± 3.5ml/kg vs. 12.8 ± 3.9ml/kg; p = 0.08) and remained at a similar level 48h (10.9 ± 4.3ml/kg vs. 12.9 ± 4.9ml/kg; p = 0.25) and 72h (11.1 ± 5.0ml/kg vs. 13.9 ± 7.7ml/kg; p = 0.27) post-ROSC. We found a statistically significant and moderate correlation between no-flow duration and EVLWI 48h (r = 0.51; p = 0.002) and 72h (r = 0.54; p = 0.004) post-ROSC. Pulmonary vascular permeability index (PVPI) was not correlated with downtimes. Our observation underlines the presence of cardiac arrest-related lung edema by determination of EVLWI. The duration of no-flow times is a relevant factor for increased extravascular lung water index.