Out-of-hospital Cardiac Arrest Patients Research Articles

Comparison of the impact of longitudinal body mass index changes on cardiac arrest risk between normal and overweight populations.

Being overweight is a key modifiable risk factor for cardiovascular disease. However, the impact of longitudinal changes in body mass index (BMI) on the risk of out-of-hospital cardiac arrests (OHCA) remains unclear, especially among overweight populations. This nested case-control study utilized data from the Korean National Health Information Database between 2009 and 2018. A total of 23453 OHCA patients, who underwent national health check-ups within 1 and 2-4years before OHCA occurrence, and 31686 controls, who underwent similar national health check-ups, were included. The study population was matched for sex, age and survival status. Conditional logistic regression was employed to analyse the odds ratios (ORs) and 95% confidence intervals (CIs) of each BMI per cent change in assessing the risk of OHCA occurrence within 1year. A reverse J-shaped association between BMI per cent change and OHCA risk was observed, even among overweight populations. Among the overweight populations, weight loss significantly increased OHCA risk, with ORs (95% CI) of 4.10 (3.23-5.20) for severe weight loss (BMI decrease>15%), 2.72 (2.33-3.17) for moderate weight loss (BMI decrease 10-15%) and 1.46 (1.35-1.59) for mild weight loss (BMI decrease 5-10%). Conversely, mild weight gain (BMI increase 5-10%) did not significantly increase OHCA risk. The impact of weight changes on the occurrence of OHCA differed by sex, being more prominent in males. Significant weight changes within a 4-year period increase the risk of OHCA with a reverse J-shaped association, even among overweight and obese individuals. Maintaining a stable weight could be a reliable public health strategy irrespective of the weight status, particularly for males.

Comparison of pre-hospital management of out-of-hospital cardiac arrest and its outcomes between the COVID-19 and pre-COVID-19 periods

Out-of-hospital cardiac arrest (OHCA) is a time-sensitive medical emergency that needs immediate interventions. COVID-19 affected the performance of the emergency medical service (EMS) system in pre-hospital care, including the management of cardiac arrest. This study aimed to identify the impact of the COVID-19 pandemic on pre-hospital management of out-of-hospital cardiac arrest and its outcome in Qom City, Iran. In this descriptive-analytical study, the data were collected from the electronic registration system of the EMS center in Qom, Iran. All OHCA patients who received resuscitation during COVID-19 and before COVID-19 were enrolled in the study. Data consisted of the characteristics of OHCA patients, EMS interventions and response times, and the outcome of OHCA. A P-value of <0.05 was deemed statistically significant. 630 OHCA patients in the COVID-19 period and 524 OHCA patients in the pre-COVID-19 period were included in the study. Endotracheal intubation and defibrillation were done more in the COVID-19 period than in the pre-COVID-19 period (50.2 % vs. 17 %, p<0.001 %, and 40.1 % vs. 22.5 %, p < 0.001, respectively). The EMS response time was longer during the COVID-19 pandemic (9.1 ± 3.9 min vs. 7.6 ± 1.4 min, p < 0.001). The rate of pre-hospital return of spontaneous circulation (ROSC) was lower in the COVID-19 period (15.6 % vs. 8.4 %, p < 0.001). According to univariate analysis, ROSC was predicted by COVID-19 (p < 0.001). However, COVID-19 was not the statistically significant independent predictor after multivariate analysis (p < 0.67). The COVID-19 pandemic period influenced OHCA and ROSC. Also, it affected pre-hospital management in the OHCA situation. The negative impact of COVID-19 on the EMS response reflected the need to know and remove barriers to managing crises such as COVID-19.

Impact of Bystander Cardiopulmonary Resuscitation on Out-of-Hospital Cardiac Arrest Outcome in Vietnam.

Patients experiencing an out-of-hospital cardiac arrest (OHCA) frequently do not receive bystander cardiopulmonary resuscitation (CPR), especially in low- and middle-income countries (LMIC). In this study we sought to determine the prevalence of OHCA patients in Vietnam who received bystander CPR and its effects on survival outcomes. We performed a multicenter, retrospective observational study of patients (≥18years) presenting with OHCA at three major hospitals in an LMIC from February 2014-December 2018. We collected data on the hospital and patient characteristics, the cardiac arrest events, the emergency medical services (EMS) system, the therapy methods, and the outcomes and compared these data, before and after pairwise 1:1 propensity score matching, between patients who received bystander CPR and those who did not. Upon admission, we assessed factors associated with good neurological survival at hospital discharge in univariable and multivariable logistic models. Of 521 patients, 388 (74.5%) were men, and the mean age was 56.7years (SD 17.3). Although most cardiac arrests (68.7%, 358/521) occurred at home and 78.8% (410/520) were witnessed, a low proportion (22.1%, 115/521) of these patients received bystander CPR. Only half of the patients were brought by EMS (8.1%, 42/521) or private ambulance (42.8%, 223/521), 50.8% (133/262) of whom had resuscitation attempts. Before matching, there was a significant difference in good neurological survival between patients who received bystander CPR (12.2%, 14/115) and patients who did not (4.7%, 19/406; P < .001). After matching, good neurological survival was absent in all OHCA patients who did not receive CPR from a bystander. The multivariable analysis showed that bystander CPR (adjusted odds ratio: 3.624; 95% confidence interval 1.629-8.063) was an independent predictor of good neurological survival. In our study, only 22.1% of total OHCA patients received bystander CPR, which contributed significantly to a low rate of good neurological survival in Vietnam. To improve the chances of survival with good neurological functions of OHCA patients, more people should be trained to perform bystander CPR and teach others as well. A standard program for emergency first-aid training is necessary for this purpose.

Increased survival for resuscitated Utstein-comparator group patients conveyed directly to cardiac arrest centres in a large rural and suburban population in England

AimThe cohort of patients in which cardiac arrest centres (CAC) in rural and suburban populations confer the greatest survival benefit remains unclear. The aim of this study was to assess whether the transfer of resuscitated Utstein-comparator out-of-hospital cardiac arrest (OHCA) patients direct to a CAC was associated with improved survival to hospital discharge compared to patients conveyed to non-specialist centres. MethodsA consecutive sample of adult (≥18 years old) Utstein-comparator patients (witnessed collapse and initial shockable rhythm) were included from the East of England Ambulance Service NHS Trust Utstein resuscitation registry; 2018–2022. Logistic regression was used to compare survival to discharge in patients transported to CACs compared with patients transported to non-specialist centres. ResultsDuring the study period, resuscitation was attempted in 18,276 OHCA patients. N = 2448 (13.4%) met the Utstein-comparator definition and 1151 patients were included in the final analysis; per protocol. Survival was greater for patients conveyed directly to a CAC (n = 768, 60.7%) compared to non-specialist centres (n = 383, 47.3%); adjusted OR 1.44 (95%CI 1.07–1.94),p = 0.017. Amongst the centres analysed in this study, there was significant inter-hospital variability in survival between CACs (p = 0.017). There was no association between patient volume and survival (p = 0.850). ConclusionDirect transport to a cardiac arrest centre was associated with a 44% increase in the odds of survival compared to conveyance to a non-specialist centre for resuscitated adult patients presenting with witnessed collapse and initial shockable OHCA rhythm.

A metabolic profile of xenon and metabolite associations with 6-month mortality after out-of-hospital cardiac arrest: A post-hoc study of the randomised Xe-Hypotheca trial.

Out-of-hospital cardiac arrest (OHCA) carries a relatively poor prognosis and requires multimodal prognostication to guide clinical decisions. Identification of previously unrecognized metabolic routes associated with patient outcome may contribute to future biomarker discovery. In OHCA, inhaled xenon elicits neuro- and cardioprotection. However, the metabolic effects remain unknown. In this post-hoc study of the randomised, 2-group, single-blind, phase 2 Xe-Hypotheca trial, 110 OHCA survivors were randomised 1:1 to receive targeted temperature management (TTM) at 33°C with or without inhaled xenon during 24 h. Blood samples for nuclear magnetic resonance spectroscopy metabolic profiling were drawn upon admission, at 24 and 72 h. At 24 h, increased lactate, adjusted hazard-ratio 2.25, 95% CI [1.53; 3.30], p<0.001, and decreased branched-chain amino acids (BCAA) leucine 0.64 [0.5; 0.82], p = 0.007, and valine 0.37 [0.22; 0.63], p = 0.003, associated with 6-month mortality. At 72 h, increased lactate 2.77 [1.76; 4.36], p<0.001, and alanine 2.43 [1.56; 3.78], p = 0.001, and decreased small HDL cholesterol ester content (S-HDL-CE) 0.36 [0.19; 0.68], p = 0.021, associated with mortality. No difference was observed between xenon and control groups. In OHCA patients receiving TTM with or without xenon, high lactate and alanine and decreased BCAAs and S-HDL-CE associated with increased mortality. It remains to be established whether current observations on BCAAs, and possibly alanine and lactate, could reflect neural damage via their roles in the metabolism of the neurotransmitter glutamate. Xenon did not significantly alter the measured metabolic profile, a potentially beneficial attribute in the context of compromised ICU patients. Trial Registry number: ClinicalTrials.gov Identifier: NCT00879892.

Sonographic evaluation of intracranial hemodynamics and pressure after out-of-hospital cardiac arrest: An exploratory sub-study of the TAME trial

ObjectiveTargeted mild hypercapnia is a potential neuroprotective therapy after cardiac arrest. In this exploratory observational study, we aimed to explore the effects of targeted mild hypercapnia on cerebral microvascular resistance assessed by middle cerebral artery pulsatility index (MCA PI) and intracranial pressure estimated by optic nerve sheath diameter (ONSD) in resuscitated out-of-hospital cardiac arrest (OHCA) patients. Design, setting, participants and interventionsComatose adults resuscitated from OHCA were randomly allocated to targeted mild hypercapnia (PaCO2 50–55 mmHg) or targeted normocapnia (PaCO2 35–45 mmHg) for 24 h in the TAME trial. Main outcome measuresUsing transcranial Doppler and transorbital ultrasound, we obtained MCA PI and ONSD at 4, 24, and 48 h after randomization. Ultrasound parameters were compared between groups using a linear mixed effects model. ResultsTwelve consecutive patients were included, with seven patients in the mild hypercapnia group. MCA PI decreased from 4 to 24 h (p = 0.019) and was lower over the first 24 h in patients allocated to targeted mild hypercapnia compared with targeted normocapnia (p = 0.047). ONSD did not differ between groups or over time. ConclusionCerebral microvascular resistance assessed by MCA PI decreased over 24 h and was lower in OHCA patients treated with targeted mild hypercapnia compared with targeted normocapnia. Targeted mild hypercapnia did not exert substantial effect on intracranial pressure as estimated by ONSD.

Assessing feasibility of proposed extracorporeal cardiopulmonary resuscitation programmes for out-of-hospital cardiac arrest in Scotland via geospatial modelling

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) can improve survival for refractory out-of-hospital cardiac arrest (OHCA). We sought to assess the feasibility of a proposed ECPR programme in Scotland, considering both in-hospital and pre-hospital implementation scenarios. MethodsWe included treated OHCAs in Scotland aged 16–70 between August 2018 and March 2022. We defined those clinically eligible for ECPR as patients where the initial rhythm was ventricular fibrillation, ventricular tachycardia, or pulseless electrical activity, and where pre-hospital return of spontaneous circulation was not achieved. We computed the call-to-ECPR access time interval as the amount of time from emergency medical service (EMS) call reception to either arrival at an ECPR-ready hospital or arrival of a pre-hospital ECPR crew. We determined the number of patients that had access to ECPR within 45 min, and estimated the number of additional survivors as a result. ResultsA total of 6,639 OHCAs were included in the geospatial modelling, 1,406 of which were eligible for ECPR. Depending on the implementation scenario, 52.9–112.6 (13.8–29.4%) OHCAs per year had a call-to-ECPR access time within 45 min, with pre-hospital implementation scenarios having greater and earlier access to ECPR for OHCA patients. We further estimated that an ECPR programme in Scotland would yield 11.8–28.2 additional survivors per year, with the pre-hospital implementation scenarios yielding higher numbers. ConclusionAn ECPR programme for OHCA in Scotland could provide access to ECPR to a modest number of eligible OHCA patients, with pre-hospital ECPR implementation scenarios yielding higher access to ECPR and higher numbers of additional survivors.

Cardiopulmonary Resuscitation Without Aortic Valve Compression Increases the Chances of Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest: A Prospective Observational Cohort Study.

Following current cardiopulmonary resuscitation (CPR) guidelines, which recommend chest compressions at "the center of the chest," ~50% of patients experiencing out-of-hospital cardiac arrest (OHCA) undergo aortic valve (AV) compression, obstructing blood flow. We used resuscitative transesophageal echocardiography (TEE) to elucidate the impact of uncompressed vs. compressed AV on outcomes of adult patients experiencing OHCA. Prospective observational cohort study. Single center. This study included adult OHCA patients undergoing resuscitative TEE in the emergency department. Patients were categorized into AV uncompressed or AV compressed groups based on TEE findings. None. The primary outcome was sustained return of spontaneous circulation (ROSC). The secondary outcomes included end-tidal co2 (Et co2 ) during CPR, any ROSC, survival to ICU and hospital discharge, post-resuscitation withdrawal, and favorable neurologic outcomes at discharge. Additional analyses on intra-arrest arterial blood pressure (ABP) were also conducted. The sample size was pre-estimated at 37 patients/group. From October 2020 to January 2023, 76 patients were enrolled, 39 and 37 in the AV uncompressed and AV compressed groups, respectively. Intergroup baseline characteristics were similar. Compared with the AV compressed group, the AV uncompressed group had a higher probability of sustained ROSC (53.8% vs. 24.3%; adjusted odds ratio [aOR], 4.72; p = 0.010), any ROSC (56.4% vs. 32.4%; aOR, 3.30; p = 0.033), and survival to ICU (33.3% vs. 8.1%; aOR, 6.74; p = 0.010), and recorded higher initial diastolic ABP (33.4 vs. 11.5 mm Hg; p = 0.002) and a larger proportion achieving diastolic ABP greater than 20 mm Hg during CPR (93.8% vs. 33.3%; p < 0.001). The Et co2 , post-resuscitation withdrawal, and survival to discharge revealed no significant intergroup differences. No patients were discharged with favorable neurologic outcomes. Uncompressed AV seemed critical for sustained ROSC across all subgroups. Absence of AV compression during OHCA resuscitation is associated with an increased chance of ROSC and survival to ICU. However, its effect on long-term outcomes remains unclear.

Acute kidney injury after out-of-hospital cardiac arrest

BackgroundAcute kidney injury (AKI) is a significant risk factor associated with reduced survival following out-of-hospital cardiac arrest (OHCA). Whether the severity of AKI simply serves as a surrogate measure of worse peri-arrest conditions, or represents an additional risk to long-term survival remains unclear.MethodsThis is a sub-study derived from a randomized trial in which 789 comatose adult OHCA patients with presumed cardiac cause and sustained return of spontaneous circulation (ROSC) were enrolled. Patients without prior dialysis dependent kidney disease and surviving at least 48 h were included (N = 759). AKI was defined by the kidney disease: improving global outcome (KDIGO) classification, and patients were divided into groups based on the development of AKI and the need for continuous kidney replacement therapy (CKRT), thus establishing three groups of patients—No AKI, AKI no CKRT, and AKI CKRT. Primary outcome was overall survival within 365 days after OHCA according to AKI group. Adjusted Cox proportional hazard models were used to assess overall survival within 365 days according to the three groups.ResultsIn the whole population, median age was 64 (54–73) years, 80% male, 90% of patients presented with shockable rhythm, and time to ROSC was median 18 (12–26) min. A total of 254 (33.5%) patients developed AKI according to the KDIGO definition, with 77 requiring CKRT and 177 without need for CKRT. AKI CKRT patients had longer time-to-ROSC and worse metabolic derangement at hospital admission. Overall survival within 365 days from OHCA decreased with the severity of kidney injury. Adjusted Cox regression analysis found that AKI, both with and without CKRT, was significantly associated with reduced overall survival up until 365 days, with comparable hazard ratios relative to no AKI (HR 1.75, 95% CI 1.13–2.70 vs. HR 1.76, 95% CI 1.30–2.39).ConclusionsIn comatose patients who had been resuscitated after OHCA, patients developing AKI, with or without initiation of CKRT, had a worse 1-year overall survival compared to non-AKI patients. This association remains statistically significant after adjusting for other peri-arrest risk factors.Trial registration: The BOX trial is registered at ClinicalTrials.gov: NCT03141099.

OUTCOME OF OUT OF HOSPITAL CARDIAC ARREST: ARE THERE GENDER DIFFERENCES?

Abstract Background Despite advance in resuscitation science, out of hospital cardiac arrest (OHCA) has an average survival rate of only 10 %. Ventricular fibrillation (FV) is amenable to defibrillation, but deteriorates to non shockable rhythms over time. It’Known that immediate cardiopulmonary resuscitation and eraly defibrillation increase survival after OHCA. It remains unclear whether there is an association between gender and survival. It seems that women OHCA patients are older, are less likely to have a witness arrest and they had fewer arrest in pubblic location than men . However these data are controversial. Methods We considered consecutively 6995 OHCA survivors resuscitated from emergency medical System (EMS) or bystander (BS) In Piacenza between june 1999 to decembre 2022 and we evaluated the outcome, considering sex and gender disparities Results Out of 6995 suffered from OHCA, 2983 (43%) were females with average age 81 ±13 years and 4012 (57%) males with average age of 73 ±15 years (p&amp;lt;0,00001).We observed with advanced age an incresead rate of woman that suffered from OHCA in comparison to man (&amp;lt; 44 years 177 m vs 63 w; 45–60 y 594 m vs 152 w, 61–75 y 1261m vs 530w; &amp;gt; 75 y 1980 m vs 2239 w).The survival of our population was 270 patients At EMS arrival 6150 patients (88%), 2779 (45%) female and 3371 (55%) male presented a non schockable rhythms (NSR):asystole or pulseless electrical activity (PEA) whilst 845 patients(12%), 170(75%) males and 56 (25%) females, presented FV .In the group with FV as initial rhythm, the survival was 26% (56/206 f 27% vs 107/647 m 26% p= 0,06). Also in this group women were slightly older (73 years f vs 67 m, p&amp;lt;0,00001). In all population survival decreased in females vs males (66/2984 w 2% vs 200/4012 5%f vp&amp;lt;0,00001).Females appeared with more non schockable rhythms (93 % f vs 84 % m, p&amp;lt; 0,00001)Women suffered from OHCA were found more frequently at home (2785 w 93% vs 3379 84%m p &amp;lt; 0,0001).Furthermore 97% males and 98% female were treated by EMS and 3 % males and 1,3% females by BS(survival males 3,6% EMS vs 51% BS and females 2 EMS%vs 26%BS). Conclusions In our OHCA population, the survival was 4% with better results in man Female were older and they had less survival, because initial rhythm registered were non shockable rhythms. They were found at home,with a delay in the first aid. This can be due to a gender disparities with advanced age.

Prehospital Ground and Helicopter-Based Extracorporeal Cardiopulmonary Resuscitation (ECPR) Reduce Barriers to ECPR: A GIS Model

Introduction Evidence suggests that Extracorporeal Cardiopulmonary Resuscitation (ECPR) can improve survival rates for nontraumatic out-of-hospital cardiac arrest (OHCA). However, when ECPR is indicated over 50% of potential candidates are unable to qualify in the current hospital-based system due to geographic limitations. This study employs a Geographic Information System (GIS) model to estimate the number of ECPR eligible patients within the United States in the current hospital-based system, a prehospital ECPR ground-based system, and a prehospital ECPR Helicopter Emergency Medical Services (HEMS)-based system. Methods We constructed a GIS model to estimate ground and helicopter transport times. Time-dependent rates of ECPR eligibility were derived from the Resuscitation Outcome Consortium (ROC) database, while the Cardiac Arrest Registry to Enhance Survival (CARES) registry determined the number of OHCA patients meeting ECPR criteria within designated transportation times. Emergency Medical Services (EMS) response time, ECPR candidacy determination time, and on-scene time were modeled based on data from the EROCA trial. The combined model was used to estimate the total ECPR eligibility in each system. Results The CARES registry recorded 736,066 OHCA patients from 2013 to 2021. After applying clinical criteria, 24,661 (3.4%) ECPR-indicated OHCA were identified. When considering overall ECPR eligibility within 45 min from OHCA to initiation, only 11.76% of OHCA where ECPR was indicated were eligible in the current hospital-based system. The prehospital ECPR HEMS-based system exhibited a four-fold increase in ECPR eligibility (49.3%), while the prehospital ground-based system showed a more than two-fold increase (28.4%). Conclusions The study demonstrates a two-fold increase in ECPR eligibility for a prehospital ECPR ground-based system and a four-fold increase for a prehospital ECPR HEMS-based system compared to the current hospital-based ECPR system. This novel GIS model can inform future ECPR implementation strategies, optimizing systems of care.

The association between prehospital post-return of spontaneous circulation core temperature and survival after out-of-hospital cardiac arrest.

Following the return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), a low body temperature on arrival at the hospital and on admission to the ICU is reportedly associated with increased mortality. Whether this association exists in the prehospital setting, however, is unknown. The objective of this study was to investigate whether the initial, prehospital core temperature measured post-ROSC is independently associated with survival to hospital discharge in adult patients following OHCA. This retrospective observational study was conducted at East Anglian Air Ambulance, a physician-paramedic staffed Helicopter Emergency Medical Service in the East of England, UK. Adult OHCA patients attended by East Anglian Air Ambulance from 1 February 2015 to 30 June 2023, who had post-ROSC oesophageal temperature measurements were included. The primary outcome measure was survival to hospital discharge. Core temperature was defined as the first oesophageal temperature recorded following ROSC. Multivariable logistic regression evaluated the adjusted association between core temperature and survival to hospital discharge. Resuscitation was attempted in 3990 OHCA patients during the study period, of which 552 patients were included in the final analysis. The mean age was 61 years, and 402 (72.8%) patients were male. Among them, 194 (35.1%) survived to hospital discharge. The mean core temperature was lower in nonsurvivors compared with those who survived hospital discharge; 34.6 and 35.2 °C, respectively (mean difference, -0.66; 95% CI, -0.87 to -0.44; P < 0.001). The adjusted odds ratio for survival was 1.41 (95% CI, 1.09-1.83; P = 0.01) for every 1.0 °C increase in core temperature between 32.5 and 36.9 °C. In adult patients with ROSC following OHCA, early prehospital core temperature is independently associated with survival to hospital discharge.

Explorative study on lower inflection point dynamics during cardiopulmonary resuscitation: Potential implications for airway management

IntroductionIn patients undergoing cardiopulmonary resuscitation (CPR) after an Out-of-Hospital Cardiac Arrest (OHCA), intrathoracic airway closure can impede ventilation, adversely affecting patient outcomes. This explorative study investigates the evolution of intrathoracic airway closure by analyzing the lower inflection point (LIP) during the inspiration phase of CPR, aiming to identify the potential thresholds for alveolar recruitment. Methods and materialsEleven OHCA patients undergoing CPR with endotracheal intubation and manual bag ventilation were included. Flow and pressure measurements were obtained using Sensirion SFM3200AW and Wika CPT2500 sensors attached to the endotracheal tube, connected to a Surface Go Tablet for data collection. Flow data was analyzed in Microsoft Excel, while pressure data was processed using the Wika USBsoft2500 application. Analysis focused on the inspiration phase of the first 6–8 breaths, with an additional 2 breaths recorded and analyzed at the end of CPR. ResultsAcross the cohort, the median tidal volume was 870.00 milliliter (mL), average flow was 31.90 standard liters per minute (slm), and average pressure was 17.21 cmH2O. The calculated average LIP was 31.47 cmH2O. Most cases (72.7%) exhibited a negative trajectory in LIP evolution during CPR, with 2 cases (18.2%) showing a positive trajectory and 1 case remaining inconclusive. The average LIP in the first 8 breaths was significantly higher than in the last 2 breaths (p = 0.018). No significant correlation was found between average LIP and return of spontaneous circulation (ROSC), compression depth, frequency, or end-tidal CO2 (EtCO2). However, a significant negative correlation was observed between the average LIP of the last 2 breaths and CPR duration (p = 0.023). Validation: LIP calculation in low-flow ventilations using the novel mathematical method yielded values consistent with those reported in the literature. Discussion/conclusionThese explorative data demonstrate a predominantly negative trajectory in LIP evolution during CPR, suggesting potential challenges in maintaining airway patency. Limitations include a small sample size and sensor recording issues. Further research is warranted to explore the evolution of LIP and its implications for personalized ventilation strategies in CPR.

Ferritin Levels on Hospital Admission Predict Hypoxic-Ischemic Encephalopathy in Patients After Out-of-Hospital Cardiac Arrest: A Prospective Observational Single-Center Study.

Out-of-hospital cardiac arrest (OHCA) is a major health concern in Western societies. Poor outcome after OHCA is determined by the extent of hypoxic-ischemic encephalopathy (HIE). Dysregulation of iron metabolism has prognostic relevance in patients with ischemic stroke and sepsis. The aim of this study was to determine whether serum iron parameters help to estimate outcomes after OHCA. In this prospective single-center study, 70 adult OHCA patients were analyzed. Serum ferritin, iron, transferrin (TRF), and TRF saturation (TRFS) were measured in blood samples drawn on day 0 (admission), day 2, day 4, and 6 months after the return of spontaneous circulation (ROSC). The association of 4 iron parameters with in-hospital mortality, neurological outcome (cerebral performance category [CPC]), and HIE was investigated by receiver operating characteristics and multivariate regression analyses. OHCA subjects displayed significantly increased serum ferritin levels on day 0 and lowered iron, TRF, and TRFS on days 2 and 4 after ROSC, as compared to concentrations measured at a 6-month follow-up. Iron parameters were not associated with in-hospital mortality or neurological outcomes according to the CPC. Ferritin on admission was an independent predictor of features of HIE on cranial computed tomography and death due to HIE. OHCA is associated with alterations in iron metabolism that persist for several days after ROSC. Ferritin on admission can help to predict HIE.

Oxygen targets following immediate percutaneous coronary intervention in comatose survivors of out-of-hospital cardiac arrest - a BOX sub-study

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Novo Nordisk Foundation The Lundbeck Foundation. Background Treatment with supplemental oxygen in patients with acute myocardial infarction (AMI) has previously been associated with poorer outcomes. However, in patients with AMI resuscitated from out-of-hospital cardiac arrest (OHCA) and undergoing immediate revascularization, evidence regarding specific oxygen targets is sparse. Purpose To assess the impact of a restrictive versus a liberal oxygen target on infarct size in OHCA patients undergoing immediate percutaneous coronary intervention (PCI). Methods The current study is a sub-study of the BOX trial, a randomized trial with a 2-by-2 factorial design, in which comatose OHCA patients with a presumed cardiac cause of arrest were randomly assigned to either a restrictive oxygen target (partial pressure of arterial oxygen (Pao2) of 9 to 10 kPa) or a liberal oxygen target (Pao2 of 13 to 14 kPa). In this sub-study we included patients who underwent immediate revascularization with PCI. The primary outcome was myocardial infarct size as assessed by the cardiac enzyme troponin-T (TnT). TnT was measured repeatedly during the first 72 hours and analyzed with a repeated measures variance component model with baseline adjustment. Secondary outcome was one-year all-cause mortality assessed by Kaplan-Meier and Cox proportional hazards analyses. Results A total of 329 patients underwent immediate PCI, whereof 172 patients were randomized to the restrictive oxygen target and 157 to the liberal oxygen target. The oxygen intervention was successful with a significantly higher PaO2 in the liberal oxygen target group during the first 72 hours (p&amp;lt;0.0001). Baseline characteristics and findings on coronary angiography (CAG) were similar in the two oxygen target groups. Thus, median age was 63 (interquartile range (IQR) 55–71), 81% were male, and estimated left ventricular ejection fraction on arrival to hospital was 35% (IQR 25–45%). Further, 74% of the patients had an initial postresuscitation electrocardiogram with ST-segment elevations, and the left anterior descending artery was deemed as culprit lesion in 49% of the patients. There was no difference in peak TnT between the restrictive and liberal oxygen target group (median 2540 (IQR 925–6420) versus 3410 (792–8630), ng/l, p=0.23), nor did TnT differ between the groups during the first 72 hours after admission (Figure 1, p=1.00). Within one year from admission, 120 patients (36.5%) had died. There was no difference in mortality between the restrictive (34%) and liberal (39%) oxygen target group (hazard ratio, 0.80; 95% CI, 0.56-1.14; p=0.21) (Figure 2). Conclusion Targeting a restrictive versus a liberal oxygen level in comatose survivors of OHCA who underwent immediate revascularization did not affect infarct size nor did it result in a significant difference in one-year mortality rate.Figure 1:Troponin-T levelsFigure 2:Kaplan-Meier curves

Perfusion index and mean arterial pressure after return of spontaneous circulation in out-of hospital cardiac arrest (OHCA) and their relationship with perfusion and survival

Abstract Funding Acknowledgements None. Background Current guidelines for post-cardiac arrest care recommend targeting mean arterial pressure (MAP) to restore adequate perfusion indicated by adequate urine output (UO) and normal or decreasing lactate, avoiding hypotension (MAP &amp;lt; 65 mmHg). The peripheral perfusion index (PI) is the ratio of the pulsatile blood flow to the non-pulsatile blood flow measured peripherally by a standard pulse-oximeter, and it represents a promising non-invasive tool to assess perfusion. The goal of this study is to assess whether prehospital PI and MAP measurements are associated with lactate clearance (LC), adequate UO and 30-days survival with good neurological outcome. Methods A retrospective analysis of prospectively collected data (January 2018 - March 2023) in two cardiac arrest registries located in Italy and Belgium was performed. PI was automatically and continuously measured by the manual monitor/defibrillator. The mean PI value of each minute after ROSC was extracted from the monitor data report and the mean value of 30 min of PI monitoring (MPI30) was calculated and categorized in tertiles (MPI30 T1-T3). The lowest prehospital value for MAP recording was considered. LC was defined by a serum lactate level &amp;lt;2 mmol/L at 6 hours. Inadequate UO was defined as &amp;lt; 0.5mL/kg/h averaged at 12 hours. Neurological outcome was assessed with the Cerebral Performance Category (CPC) at 30 days. Results Out of the 397 OHCA patients admitted to the ICU after ROSC enrolled over the study period 206 had a MPI30 value available and were included in this study; MAP value was available in 186 patients. In the subgroup of patients with hypotension, patients with MPI30 in T1 showed higher incidence of inadequate UO at 12 hours (78.9% vs 25.8%, p&amp;lt;0.001). At multivariable logistic regression, after adjusting for MAP, shockable rhythm, age, and dosage of adrenaline administered, MPI30 was independently associated with inadequate UO (OR 0.68, 95% CI 0.50-0.91, p=0.01). Patients with hypotension and MPI30 in T1 showed lower LC at 6h (15.8% vs 43.4%, p=0.02) when compared to the remaining population. At multivariable Cox proportional-hazard regression, after correction for shockable rhythm, age, and total amount of adrenaline administered, patients with hypotension and MPI30 in T1 showed lower survival with CPC 1-2 at 30 days (HR 2.61, 95% CI 1.52-4.51, p=&amp;lt;0.001) when compared to patients without hypotension or with hypotension but MPI30 in T2-T3. No difference in LC, adequate UO and survival with good neurological outcome was found between patients with hypotension and MPI30 in T2-T3 compared to patients without hypotension. Conclusion PI is a useful indicator of perfusion in patients with hypotension after OHCA. Patients with hypotension and reduced PI showed higher incidence of inadequate UO and lower incidence of LC, as well as association with lower survival at 30 days with CPC 1-2.Lactate clearenceSurvival at 30days with CPC 1-2

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&amp;lt;0.001) and SOFA (10.39 vs. 7.14, p&amp;lt;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&amp;lt;0.001) and non-shockable first rhythm (p&amp;lt;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.

Modulation of cytokine response in post-cardiac arrest syndrome through prehospital high-dose glucocorticoid treatment

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Novo Nordisk Foundation Research Foundation of Rigshospitalet. Background Post-cardiac arrest syndrome (PCAS) following out-of-hospital cardiac arrest (OHCA) is a life-threatening condition, characterized by a cascade of pathological events, including the development of a severe cytokine response. This inflammatory response may be associated with secondary brain injury and multi-organ dysfunction. In the randomized STEROHCA trial, high-dose glucocorticoid was administered immediately following resuscitation in the prehospital setting. The intervention exhibited a significant decrease in interleukin (IL) 6 levels, but its effect on other cytokines has yet to be assessed. Purpose We aimed to investigate the effects of high-dose glucocorticoid treatment in mitigating the cytokine response observed in PCAS after OHCA. Methods The modified intention-to-treat population of the double-blind, randomized STEROHCA trial consisted of 137 OHCA patients, who were randomized to a single prehospital injection of methylprednisolone 250 mg or placebo. Of these, this sub-study included 112 patients who were comatose and admitted to an ICU. Cytokine profiling was performed with a 17-plex assay, including pro- and anti-inflammatory cytokines, which were measured at 0, 24, 48, and 72h after admission. We applied mixed-model analyses to assess the effect of the intervention over time with log-transformed data. To maintain an exploratory approach, we chose not to correct for multiple testing. Results The intervention induced a reduction in the levels of several cytokines, with a significant treatment over time effect for IL-4, IL-8, IL-10, Monocyte Chemoattractant Protein-1 (MCP-1), Macrophage Inflammatory Protein-1 Beta (MIP-1β), and Tumor Necrosis Factor Alpha (TNF-α), all p&amp;lt;0.01. These cytokines, except for IL-10, exhibited lower values in the glucocorticoid group after 24h, Figure 1. Higher levels of IL-10 were observed in the glucocorticoid group at 0h. We found no differences in cytokine levels after 48-, and 72h between the two groups. Conclusion High-dose glucocorticoid treatment administered promptly after resuscitation from OHCA reduced several pro-inflammatory cytokines after 24h. TNF-α has previously been associated with poor outcomes following OHCA, whereas the exact role of the other cytokines following OHCA is unclear.Cytokines at 0-, 24-, 48-, and 72 hours

Advanced airway management in the prehospital setting during traumatic out-of-hospital cardiac arrest following traffic collision in Japan, 2013-2019

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Okinaka Memorial Institute for Medical Research; Toranomon Hospital. Background The European guideline on management of major bleeding and coagulopathy following trauma (sixth edition) recommend that endotracheal intubation or alternative airway management be performed without delay to facilitate adequate ventilation and oxygenation during trauma resuscitation. However, controversy remains as to whether advanced airway management should be provided for out-of-hospital cardiac arrest (OHCA) in the prehospital setting. Purpose This study aimed to examine the association of prehospital advanced airway management with outcomes after traumatic OHCA. Methods This observational study analyzed the Japanese government-led nationwide population-based registry data of OHCA patients. Patients with traumatic OHCA following traffic collision who received advanced life support in the prehospital setting from 2013 to 2019 were included. Propensity score matching was used to examine the association of advanced airway management with outcomes after traumatic OHCA following traffic collision. The primary outcome was one-month survival. Results A total of 5,617 patients (mean [SD] age, 60.1 [21.6] years; 68.6% male) were included. 3,822 (68.0%) received advanced airway management, and 1,795 (32.0%) did not. After adjusting for potential confounders using propensity score matching, advanced airway management was associated with decreased chance of one-month survival (23/1452 [1.6%] vs 43/1452 [3.0%]; RR, 0.53; 95%CI, 0.32-0.88; P=0.0128). Similar association was observed for prehospital return of spontaneous circulation (88/1452 [6.1%] vs 139/1452 [9.6%]; RR, 0.63; 95%CI, 0.49-0.82; P=0.0004). Conclusion Among patients with traumatic OHCA following traffic collision, advanced airway management was associated with decreased chance of one-month survival and prehospital return of spontaneous circulation.

Oxygen delivery and consumption in comatose out-of-hospital cardiac arrest patients are affected by blood pressure targets

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Grosserer L. F. Foghts Fond Background Hemodynamic instability is common after resuscitated out-of-hospital cardiac arrest (OHCA). Preventing inadequate oxygen delivery (DO2) to the cells and thus not meeting oxygen demand is crucial to prevent further organ dysfunction. Additionally, oxygen uptake in the cells may be impaired. Oxygen consumption (VO2; the amount of oxygen consumed by the body per minute) could thus also be affected in OHCA. Purpose This study aimed to describe the effect of different mean arterial blood pressure (MAP) and partial arterial oxygen pressure (PaO2) targets on DO2 and VO2. Methods This post-hoc study is based on the BOX trial, a 2x2 factorial design that randomized OHCA patients to a MAP of either 63 mmHg (MAP63) or 77 mmHg (MAP77) and a partial pressure of arterial oxygen of 9 to 10 kPa or a liberal oxygen target of a PaO2 of 13 to 14 kPa at two cardiac centers in Denmark. Pulmonary artery catheters were placed to evaluate cardiac output and collect mixed venous blood samples at prespecified time points. Oxygen blood contents were calculated for arterial (CaO2) and mixed venous blood (CvO2) as Hgb (mg/dl) x 10 x 1.39 x Saturation O2 (proportion) + 0.0225 x PaO2. DO2 = CO x CaO2, and VO2 = CO x (CaO2-CvO2). Results This study included 715 patients (90% of the total cohort with a pulmonary catheter) for analysis. A restrictive or liberal oxygen supplement did not affect DO2 or VO2 during the initial 48 hours. The MAP77 group exhibited on average 11% higher DO2 (95%CI: 6%-15%) and on average a 6% higher VO2 in the first 48 hours (95%CI: 3%-10%) compared to the MAP63 group (see Figure 1). Conclusion Targeting a PaO2 of either 9 to 10 kPa or 13 to 15 kPa resulted in no significant changes in the provision of oxygen to the cells, nor did it increase the consumption of oxygen. In contrast, targeting a MAP of 77 mmHg resulted in an increase in both the provision of oxygen and consumption of oxygen compared to a MAP target of 63 mmHg.Figure 1