Post-cardiac Arrest Care Research Articles

Association between institutional volume of out-of-hospital cardiac arrest cases and short term outcomes

BackgroundOut-of-hospital cardiac arrest (OHCA) is a serious condition. The volume-outcome relationship and various post–cardiac arrest care elements are believed to be associated with improved neurological outcomes. Although previous studies have investigated the volume–outcome relationship, adjusting for post-cardiac arrest care, intra-class correlation for each institution, and other covariates may have been insufficient. ObjectiveTo investigate the volume-outcome relationships and favorable neurological outcomes among OHCA cases in each institution. MethodsWe conducted a prospective observational study of adult patients with non-traumatic OHCA using the OHCA registry in Japan. The primary outcome was 30-day favorable neurological outcomes, and the secondary outcome was 30-day survival. We set the cutoff values to trisect the number of patients as equally as possible and classified institutions into high-, middle-, and low-volume. Generalized estimating equations (GEE) were performed to adjust for covariates and within-hospital clustering.1Department of Emergency Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8606, Japan ResultsAmong the 9909 registry patients, 7857 were included. These patients were transported to either low- (2679), middle- (2657), or high- (2521) volume institutions. The median number of eligible patients per institution in 19 months of study periods was 82 (range, 1–207), 252 (range, 210–353), and 463 (range, 390–701), respectively. After multivariable GEE using the low-volume institution as a reference, no significant difference in odds ratios and 95% confidence intervals were noted for 30-day favorable neurological outcomes for middle volume [1.22 (0.69–2.17)] and high volume [0.80 (0.47–1.37)] institutions. Moreover, there was no significant difference for 30-day survival for middle volume [1.02 (0.51–2.02)] and high volume [1.09 (0.53–2.23)] institutions. ConclusionThe patient volume of each institution was not associated with 30-day favorable neurological outcomes. Although this result needs to be evaluated more comprehensively, there may be no need to set strict requirements for the type of institution when selecting a destination for OHCA cases.

Management of post-cardiac arrest syndrome

Background: Despite various advances in resuscitation science, the overall survival outcome remains very low in patients who sustain sudden cardiac death. Regardless of the cause of the collapse, multiple organ systems may be injured secondary to post-cardiac arrest syndrome. This column highlights the interventions that can be incorporated as a bundle of post-resuscitation care, to narrow the gap between return of spontaneous circulation (ROSC) and neurologically intact survival.Current Concepts: The post-cardiac arrest care algorithm presents treatment strategies and therapeutic goals to be considered in the initial stabilization stage, followed by investigating the cause of cardiac arrest and intensive care strategies to reduce additional brain damage. Immediately after ROSC, multimodal interventions required for post-ROSC care are bundled into a care regimen (treatment of the reversible cause, adequate seizure management, and glycemic control). It is also essential to establish definitive airway management to maintain normocapnic ventilation, prevent hyperoxia, and optimize hemodynamic management. Targeted temperature management after ROSC confers neuroprotection and leads to improved neurological outcomes.Discussion and Conclusion: Post-cardiac arrest care is also emphasized as a key element in the chain of survival. The interventions outlined could lead to more patients being discharged alive from the hospital, with good neurological function. In addition, continued management planning, such as secondary prevention and social rehabilitation for cardiac arrest survivors and neurological prognostication for patients who do not recover consciousness after a certain period, are included.

Is insomnia associated with self-reported health and life satisfaction in cardiac arrest survivors? A cross-sectional survey

BackgroundInsomnia symptoms seem to be common in cardiac arrest survivors but their associations with important outcomes such as self-reported health and life satisfaction have not previously been reported during the early post-event period. Therefore, the aim of the study was to investigate whether symptoms of insomnia are associated with self-reported health and life satisfaction in cardiac arrest survivors six months after the event. MethodsThis multicentre cross-sectional survey included cardiac arrest survivors ≥18 years. Participants were recruited six months after the event from five hospitals in southern Sweden, and completed a questionnaire including the Minimal Insomnia Symptom Scale, EQ-5D-5L, Health Index, Hospital Anxiety and Depression Scale, and Satisfaction With Life Scale. Data were analysed using the Mann-Whitney U test, linear regression, and ordinal logistic regression. The regression analyses were adjusted for demographic and medical factors. ResultsIn total, 212 survivors, 76.4% males, with a mean age of 66.6 years (SD = 11.9) were included, and of those, 20% reported clinical insomnia. Insomnia was significantly associated with all aspects of self-reported health (p < 0.01) and life satisfaction (p < 0.001), except mobility (p = 0.093), self-care (p = 0.676), and usual activities (p = 0.073). ConclusionInsomnia plays a potentially important role for both health and life satisfaction in cardiac arrest survivors. Screening for sleep problems should be part of post cardiac arrest care and follow-up to identify those in need of further medical examination and treatment.

Temperature Management for Comatose Adult Survivors of Cardiac Arrest: A Science Advisory From the American Heart Association.

Targeted temperature management has been a cornerstone of post-cardiac arrest care for patients remaining unresponsive after return of spontaneous circulation since the initial trials in 2002 found that mild therapeutic hypothermia improves neurological outcome. The suggested temperature range expanded in 2015 in response to a large trial finding that outcomes were not better with treatment at 33° C compared with 36° C. In 2021, another large trial was published in which outcomes with temperature control at 33° C were not better than those of patients treated with a strategy of strict normothermia. On the basis of these new data, the International Liaison Committee on Resuscitation and other organizations have altered their treatment recommendations for temperature management after cardiac arrest. The new American Heart Association guidelines on this topic will be introduced in a 2023 focused update. To provide guidance to clinicians while this focused update is forthcoming, the American Heart Association's Emergency Cardiovascular Care Committee convened a writing group to review the TTM2 trial (Hypothermia Versus Normothermia After Out-of-Hospital Cardiac Arrest) in the context of other recent evidence and to present an opinion on how this trial may influence clinical practice. This science advisory was informed by review of the TTM2 trial, consideration of other recent influential studies, and discussion between cardiac arrest experts in the fields of cardiology, critical care, emergency medicine, and neurology. Conclusions presented in this advisory statement do not replace current guidelines but are intended to provide an expert opinion on novel literature that will be incorporated into future guidelines and suggest the opportunity for reassessment of current clinical practice.

Sex Difference on Neurological Outcomes and Post-Cardiac Arrest Care in Out-of-Hospital Cardiac Arrest Patients Treated with Targeted Temperature Management: Post-Hoc Study of a Prospective, Multicenter, Observational Cohort Study.

Conflicting results regarding sex-based differences in the outcomes of out-of-hospital cardiac arrest (OHCA) patients have been reported. We aimed to evaluate the association between sex and neurological outcome as well as various in-hospital process in OHCA patients treated with targeted temperature management. We retrospectively analyzed a prospective registry data collected between October 2015 and December 2018. To evaluate the effect of sex on patient outcomes, we created various multivariable logistic regression models. When the results were adjusted using resuscitation variables and in-hospital variables, there was no significant difference (OR = 1.22, 95% CI: 0.85-1.74; OR = 1.13, 95 CI: 0.76-1.68, respectively). Regarding the in-hospital course, the daily total SOFA score was similar in both sexes, whereas cardiovascular scores were higher in women on days 2 and 3. The adjusted effect of sex was not associated with the clinician's decision to perform early cardiac interventions, except for those men that had more extracorporeal membrane oxygenation (OR = 2.51, 95% CI: 1.11-5.66). The findings seems that men had more favorable 6-month neurological outcomes. However, after adjusting for confounders, there was no difference between the sexes. The results regarding in-hospital course were similar in men and women.

Impaired echocardiographic left ventricular global longitudinal strain after pediatric cardiac arrest children is associated with mortality

BackgroundGlobal longitudinal strain (GLS) is an echocardiographic method to identify left ventricular (LV) dysfunction after cardiac arrest that is less sensitive to loading conditions. We aimed to identify the frequency of impaired GLS following pediatric cardiac arrest, and its association with hospital mortality. MethodsThis is a retrospective single-center cohort study of children <18 years of age treated in the pediatric intensive care unit (PICU) after in- or out-of-hospital cardiac arrest (IHCA and OHCA), with echocardiogram performed within 24 hours of initiation of post-arrest PICU care between 2013 and 2020. Patients with congenital heart disease, post-arrest extracorporeal support, or inability to measure GLS were excluded. Echocardiographic LV ejection fraction (EF) and shortening fraction (SF) were abstracted from the chart. GLS was measured post hoc; impaired strain was defined as LV GLS ≥ 2 SD worse than age-dependent normative values. Demographics and pre-arrest, arrest, and post-arrest characteristics were compared between subjects with normal versus impaired GLS. Correlation between GLS, SF and EF were calculated with Pearson comparison. Logistic regression tested the association of GLS with mortality. Area under the receiver operator curve (AUROC) was calculated for discriminative utility of GLS, EF, and SF with mortality. ResultsGLS was measured in 124 subjects; impaired GLS was present in 46 (37.1%). Subjects with impaired GLS were older (median 7.9 vs. 1.9 years, p < 0.001), more likely to have ventricular tachycardia/fibrillation as initial rhythm (19.6% versus 3.8%, p = 0.017) and had higher peak troponin levels in the first 24 hours post-arrest (median 2.5 vs. 0.5, p = 0.002). There were no differences between arrest location or CPR duration by GLS groups. Subjects with impaired GLS compared to normal GLS had lower median EF (42.6% versus 62.3%) and median SF (23.3% versus 36.6%), all p < 0.001, with strong inverse correlation between GLS and EF (rho −0.76, p < 0.001) and SF (rho −0.71, p < 0.001). Patients with impaired GLS had higher rates of mortality (60% vs. 32%, p = 0.009). GLS was associated with mortality when controlling for age and initial rhythm [aOR 1.17 per 1% increase in GLS (95% CI 1.09–1.26), p < 0.001]. GLS, EF and SF had similar discrimination for mortality: GLS AUROC 0.69 (95% CI 0.60–0.79); EF AUROC 0.71 (95% CI 0.58–0.88); SF AUROC 0.71 (95% CI 0.61–0.82), p = 0.101. ConclusionsImpaired LV function as measured by GLS after pediatric cardiac arrest is associated with hospital mortality. GLS is a novel complementary metric to traditional post-arrest echocardiography that correlates strongly with EF and SF and is associated with mortality. Future large prospective studies of post-cardiac arrest care should investigate the prognostic utilities of GLS, alongside SF and EF.

Saline versus Plasma Solution-A in Initial Resuscitation of Patients with Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.

Although saline is commonly used during cardiopulmonary resuscitation (CPR) or post-cardiac arrest care, it has detrimental effects. This trial aimed to evaluate the efficacy of a balanced crystalloid solution (Plasma Solution-A [PS]) in out-of-hospital cardiac arrest (OHCA) patients and compare it with the efficacy of saline. A randomized, unblinded clinical trial was conducted using PS and saline for intravenous fluid administration during CPR and post-cardiac arrest care of non-traumatic OHCA patients admitted to the emergency department of a tertiary university hospital. Patients received saline (saline group) or PS (PS group) within 24 h of hospital arrival. The primary outcomes were changes in arterial pH, bicarbonate, base excess (BE), and chloride levels within 24 h. The secondary outcomes were clinical outcomes including mortality. Of the 364 patients, data from 27 and 26 patients in the saline and PS groups, respectively, were analyzed. Analysis using a linear mixed model revealed a significant difference in BE change over time between the groups (treatment-by-time p = 0.044). Increase in BE and bicarbonate levels from 30 min to 2 h was significantly greater (p = 0.044 and p = 0.024, respectively) and the incidence of hyperchloremia was lower (p < 0.001) in the PS group than in the saline group. However, there was no difference in clinical outcomes. Use of PS for resuscitation resulted in a faster improvement in BE and bicarbonate, especially in the early phase of post-cardiac arrest care, and lower hyperchloremia incidence than the use of saline, without differences in clinical outcomes, in OHCA patients.

Blood-Pressure Management in Post-Cardiac Arrest Care: A Review of the BOX Trial

Blood-Pressure Management in Post-Cardiac Arrest Care: A Review of the BOX Trial

Preliminary Prognostication for Good Neurological Outcomes in the Early Stage of Post-Cardiac Arrest Care

We investigated prognostic strategies for predicting good outcomes in the early stage of post-cardiac-arrest care using multiple prognostic tests that are available until 24 h after the return of spontaneous circulation (ROSC). A retrospective analysis was conducted on 138 out-of-hospital cardiac-arrest patients who underwent prognostic tests, including the gray–white-matter ratio (GWR-BG), the Glasgow Coma Scale motor (GCS-M) score before sedative administration, and the neuron-specific enolase (NSE) level measured at 24 h after the ROSC. We investigated the prognostic performances of the tests as single predictors and in various combination strategies. Classification and regression-tree analysis were used to provide a reliable model for the risk stratification. Out of all the patients, 55 (44.0%) had good outcomes. The NSE level showed the highest prognostic performance as a single prognostic test and provided improved specificities (&gt;70%) and sensitivities (&gt;98%) when used in combination strategies. Low NSE levels (≤32.1 ng/mL) and high GCS-M (≥4) scores identified good outcomes without misclassification. The overall accuracy for good outcomes was 81.8%. In comatose patients with low NSE levels or high GCS-M scores, the premature withdrawal of life-sustaining therapy should be avoided, thereby complying with the formal prognostication-strategy algorithm after at least 72 h from the ROSC.

State of the Art Post-Cardiac Arrest Care: Evolution and future of post cardiac arrest care.

Out-of-hospital cardiac arrest is a leading cause of mortality. In the prehospital setting, bystander response with cardiopulmonary resuscitation and use of publicly available automated external defibrillators have been associated with improved survival. Early in-hospital treatment still focuses on emergency coronary angiography for selected patients. For patients remaining comatose, temperature control to avoid fever is still recommended, but former hypothermic targets have been abandoned. For patients without spontaneous awakening, the use of a multimodal prognostication model is key. After discharge, follow-up with screening for cognitive and emotional disabilities is recommended. There has been an incredible evolution of research within cardiac arrest. Two decades ago, the largest trials include a few hundred patients. Today, undergoing studies are planning to include 10-20 times as many patients, with improved methodology. This article describes the evolution and perspectives for the future in post-cardiac arrest care.

Post-cardiac arrest intensive care in Sweden: A survey of current clinical practice.

European guidelines recommend targeted temperature management (TTM) in post-cardiac arrest care. A large multicentre clinical trial, however, showed no difference in mortality and neurological outcome when comparing hypothermia to normothermia with early treatment of fever. The study results were valid given a strict protocol for the assessment of prognosis using defined neurological examinations. With the current range of recommended TTM temperatures, and applicable neurological examinations, procedures may differ between hospitals and the variation of clinical practice in Sweden is not known. The aim of this study was to investigate current practice in post-resuscitation care after cardiac arrest as to temperature targets and assessment of neurological prognosis in Swedish intensive care units (ICUs). A structured survey was conducted by telephone or e-mail in all Levels 2 and 3 (= 53) Swedish ICUs during the spring of 2022 with a secondary survey in April 2023. Five units were not providing post-cardiac arrest care and were excluded. The response rate was 43/48 (90%) of the eligible units. Among the responding ICUs, normothermia (36-37.7°C) was applied in all centres (2023). There was a detailed routine for the assessment of neurological prognosis in 38/43 (88%) ICUs. Neurological assessment was applied 72-96 h after return of spontaneous circulation in 32/38 (84%) units. Electroencephalogram and computed tomography and/or magnetic resonance imaging were the most common technical methods available. Swedish ICUs use normothermia including early treatment of fever in post-resuscitation care after cardiac arrest and almost all apply a detailed routine for the assessment of neurological prognosis. However, available methods for prognostic evaluation varies between hospitals.

Association Between Postresuscitation 12-Lead ECG Features and Early Mortality After Out-of-Hospital Cardiac Arrest: A Post Hoc Subanalysis of the PEACE Study.

Background Once the return of spontaneous circulation after out-of-hospital cardiac arrest is achieved, a 12-lead ECG is strongly recommended to identify candidates for urgent coronary angiography. ECG has no apparent role in mortality risk stratification. We aimed to assess whether ECG features could be associated with 30-day survival in patients with out-of-hospital cardiac arrest. Methods and Results All the post-return of spontaneous circulation ECGs from January 2015 to December 2018 in 3 European centers (Pavia, Lugano, and Vienna) were collected. Prehospital data were collected according to the Utstein style. A total of 370 ECGs were collected: 287 men (77.6%) with a median age of 62 years (interquartile range, 53-70 years). After correction for the return of spontaneous circulation-to-ECG time, age >62 years (hazard ratio [HR], 1.78 [95% CI, 1.21-2.61]; P=0.003), female sex (HR, 1.5 [95% CI, 1.05-2.13]; P=0.025), QRS wider than 120 ms (HR, 1.64 [95% CI, 1.43-1.87]; P<0.001), the presence of a Brugada pattern (HR, 1.49 [95% CI, 1.39-1.59]; P<0.001), and the presence of ST-segment elevation in >1 segment (HR, 1.75 [95% CI, 1.59-1.93]; P<0.001) were independently associated with 30-day mortality. A score ranging from 0 to 26 was created, and by dividing the population into 3 tertiles, 3 classes of risk were found with significantly different survival rate at 30 days (score 0-4, 73%; score 5-7, 66%; score 8-26, 45%). Conclusions The post-return of spontaneous circulation ECG can identify patients who are at high risk of mortality after out-of-hospital cardiac arrest earlier than other forms of prognostication. This provides important risk stratification possibilities in postcardiac arrest care that could help to direct treatments and improve outcomes in patients with out-of-hospital cardiac arrest.

Use of Prognostication Instruments in Prognostication Procedures of Postanoxic Coma Patients over Time: A Retrospective Study.

Many survivors of cardiovascular arrest remain in a postanoxic coma. The neurologist's task is to provide the most accurate assessment of the patient's neurologic prognosis through a multimodal approach of clinical and technical tests. The aim of this study is to analyze differences and developments in the concept of neurological prognosis assessment and in-hospital outcome of patients over a five year-period. This retrospective observational study included 227 patients with postanoxic coma treated in the medical intensive care unit of the University Hospital, Mannheim from January 2016 to May 2021. We retrospectively analyzed patient characteristics, post-cardiac arrest care, and the use of clinical and technical tests for neurological prognosis assessment and patient outcome. Over the observation period, 215 patients received a completed neurological prognosis assessment. Regarding the multimodal prognostic assessment, patients with poor prognosis (54%) received significantly fewer diagnostic modalities than patients with very likely poor (20.5%), indeterminate (24.2%), or good prognosis (1.4%; p = 0.001). The update of the DGN guidelines in 2017 had no effect on the number of performed prognostic parameters per patient. The finding of bilaterally absent pupillary light reflexes or severe anoxic injury on CT contributed most to a poor prognosis category (OR 8.38, 95%CI 4.01-7.51 and 12.93, 95%CI 5.55-30.13, respectively), whereas a malignant EEG pattern and NSE > 90 µg/L at 72 h resulted in the lowest OR (5.11, 95%CI 2.32-11.25, and 5.89, 95%CI 3.14-11.06, respectively) for a poor prognosis category. Assessment of baseline NSE significantly increased over the years (OR 1.76, 95%CI 1.4-2.22, p < 0.001), and assessment of follow-up NSE at 72 h trended to increase (OR 1.19, 95%CI 0.99-1.43, p = 0.06). In-hospital mortality was high (82.8%), remained unchanged over the observation period, and corresponded to the number of patients in whom life-sustaining measures were discontinued. Among comatose survivors of cardiac arrest, the prognosis remains poor. Prognostication of a poor outcome led nearly exclusively to withdrawal of care. Prognostic modalities varied considerably with regard to their contribution to a poor prognosis category. Increasing enforcement of a standardized prognosis assessment and standardized evaluation of diagnostic modalities are needed to avoid false-positive prognostication of poor outcomes.

Neuromonitoring after Pediatric Cardiac Arrest: Cerebral Physiology and Injury Stratification.

Significant long-term neurologic disability occurs in survivors of pediatric cardiac arrest, primarily due to hypoxic-ischemic brain injury. Postresuscitation care focuses on preventing secondary injury and the pathophysiologic cascade that leads to neuronal cell death. These injury processes include reperfusion injury, perturbations in cerebral blood flow, disturbed oxygen metabolism, impaired autoregulation, cerebral edema, and hyperthermia. Postresuscitation care also focuses on early injury stratification to allow clinicians to identify patients who could benefit from neuroprotective interventions in clinical trials and enable targeted therapeutics. In this review, we provide an overview of postcardiac arrest pathophysiology, explore the role of neuromonitoring in understanding postcardiac arrest cerebral physiology, and summarize the evidence supporting the use of neuromonitoring devices to guide pediatric postcardiac arrest care. We provide an in-depth review of the neuromonitoring modalities that measure cerebral perfusion, oxygenation, and function, as well as neuroimaging, serum biomarkers, and the implications of targeted temperature management. For each modality, we provide an in-depth review of its impact on treatment, its ability to stratify hypoxic-ischemic brain injury severity, and its role in neuroprognostication. Potential therapeutic targets and future directions are discussed, with the hope that multimodality monitoring can shift postarrest care from a one-size-fits-all model to an individualized model that uses cerebrovascular physiology to reduce secondary brain injury, increase accuracy of neuroprognostication, and improve outcomes.

Efficacy of inhaled hydrogen on neurological outcome following brain ischaemia during post-cardiac arrest care (HYBRID II): a multi-centre, randomised, double-blind, placebo-controlled trial

Inhaled molecular hydrogen gas (H2) has been shown to improve outcomes in animal models of cardiac arrest (CA). H2 inhalation is safe and feasible in patients after CA. We investigated whether inhaled H2 would improve outcomes after out-of-hospital CA (OHCA). HYBRID II is a prospective, multicentre, randomised, double-blind, placebo-controlled trial performed at 15 hospitals in Japan, between February 1, 2017, and September 30, 2021. Patients aged 20-80 years with coma following cardiogenic OHCA were randomly assigned (1:1) using blinded gas cylinders to receive supplementary oxygen with 2% H2 or oxygen (control) for 18h. The primary outcome was the proportion of patients with a 90-day Cerebral Performance Category (CPC) of 1 or 2 assessed in a full-analysis set. Secondary outcomes included the 90-day score on a modified Rankin scale (mRS) and survival. HYBRID II was registered with the University Hospital Medical Information Network (registration number: UMIN000019820) and re-registered with the Japan Registry for Clinical Trials (registration number: jRCTs031180352). The trial was terminated prematurely because of the restrictions imposed on enrolment during the COVID-19 pandemic. Between February 1, 2017, and September 30, 2021, 429 patients were screened for eligibility, of whom 73 were randomly assigned to H2 (n=39) or control (n=34) groups. The primary outcome, i.e., a CPC of 1 or 2at 90 days, was achieved in 22 (56%) and 13 (39%) patients in the H2 and control groups (relative risk compared with the control group, 0.72; 95% CI, 0.46-1.13; P=0.15), respectively. Regarding the secondary outcomes, median mRS was 1 (IQR: 0-5) and 5 (1-6) in the H2 and control groups, respectively (P=0.01). An mRS score of 0 was achieved in 18 (46%) and 7 (21%) patients in the H2 and control groups, respectively (P=0.03). The 90-day survival rate was 85% (33/39) and 61% (20/33) in the H2 and control groups, respectively (P=0.02). The increase in participants with good neurological outcomes following post-OHCA H2 inhalation in a selected population of patients was not statistically significant. However, the secondary outcomes suggest that H2 inhalation may increase 90-day survival without neurological deficits. Taiyo Nippon Sanso Corporation. For the Japanese translation of the abstract see Supplementary Materials section.

Long-term function, quality of life and healthcare utilization among survivors of pediatric out-of-hospital cardiac arrest

BackgroundSurvival following pediatric out-of-hospital cardiac arrest (OHCA) has improved over the past 2 decades but data on survivors’ long-term outcomes are limited. We aimed to evaluate long-term outcomes in pediatric OHCA survivors more than one year after cardiac arrest. MethodsOHCA survivors <18 years old who received post-cardiac arrest care in the PICU at a single center between 2008–2018 were included. Parents of patients <18 years and patients ≥18 years at least one year after cardiac arrest completed a telephone interview. We assessed neurologic outcome (Pediatric Cerebral Performance Category [PCPC]), activities of daily living (Pediatric Glasgow Outcomes Scale-Extended, Functional Status Scale (FSS)), HRQL (Pediatric Quality of Life Core and Family Impact Modules), and healthcare utilization. Unfavorable neurologic outcome was defined as PCPC > 1 or worsening from pre-arrest baseline to discharge. FindingsForty four patients were evaluable. Follow-up occurred at a median of 5.6 years [IQR 4.4, 8.9] post-arrest. Median age at arrest was 5.3 [1.3,12.6] years; median CPR duration was 5 [1.5, 7] minutes. Survivors with unfavorable outcome at discharge had worse FSS Sensory and Motor Function scores and higher rates of rehabilitation service utilization. Parents of survivors with unfavorable outcome reported greater disruption to family functioning. Healthcare utilization and educational support requirements were common among all survivors. ConclusionsSurvivors of pediatric OHCA with unfavorable outcome at discharge have more impaired function multiple years post-arrest. Survivors with favorable outcome may experience impairments and significant healthcare needs not fully captured by the PCPC at hospital discharge.

One-Year Review in Cardiac Arrest: The 2022 Randomized Controlled Trials.

Cardiac arrest, one of the leading causes of death, accounts for numerous clinical studies published each year. This review summarizes the findings of all the randomized controlled clinical trials (RCT) on cardiac arrest published in the year 2022. The RCTs are presented according to the following categories: out-of- and in-hospital cardiac arrest (OHCA, IHCA) and post-cardiac arrest care. Interestingly, more than 80% of the RCTs encompassed advanced life support and post-cardiac arrest care, while no studies focused on the treatment of IHCA, except for one that, however, explored the temperature control after resuscitation in this population. Surprisingly, 9 out of 11 RCTs led to neutral results demonstrating equivalency between the newly tested interventions compared to current practice. One trial was negative, showing that oxygen titration in the immediate pre-hospital post-resuscitation period decreased survival compared to a more liberal approach. One RCT was positive and introduced new defibrillation strategies for refractory cardiac arrest. Overall, data from the 2022 RCTs discussed here provide a solid basis to generate new hypotheses to be tested in future clinical studies.

Diaphragmatic rupture and massive pneumoperitoneum after cardiopulmonary resuscitation

Introduction:Although cardiopulmonary resuscitation is an emergency life‐saving procedure, the intervention itself can cause major and often fatal injuries, with diaphragmatic rupture being very rare. This report describes a patient who experienced bilateral pneumothoraces, left diaphragmatic rupture, and pneumoperitoneum after extended cardiopulmonary resuscitation.Case presentation:A 90‐year‐old woman experienced a cardiac arrest. Spontaneous circulation was restored after 49 min of cardiopulmonary resuscitation performed by a bystander, emergency medical service providers, and emergency department staff. Imaging showed bilateral pneumothoraces, left diaphragmatic rupture, and massive pneumoperitoneum. The patient's guardian refused to permit surgery for the diaphragmatic rupture, and the patient died despite chest and abdominal decompression and post‐cardiac arrest care.Discussion and conclusion:Procedures to restore spontaneous circulation in patients experiencing cardiac arrest may result in fatal cardiopulmonary resuscitation–related injuries. Clinicians providing post‐cardiac arrest care should plan management for these iatrogenic injuries.

A novel cardiac arrest severity score for the early prediction of hypoxic-ischemic brain injury and in-hospital death

Abstract Funding Acknowledgements Type of funding sources: None. Background Out-of-hospital cardiac arrest (OHCA) outcomes are unsatisfactory despite postcardiac arrest care. Early prediction of prognoses might help stratify patients and provide tailored therapy. Purpose In this study, we derived and validated a novel scoring system to predict hypoxic-ischaemic brain injury (HIBI) and in-hospital death (IHD). Methods We retrospectively analysed Korean Hypothermia Network prospective registry data collected from in Korea between 2015 and 2018. Patients without neuroprognostication data were excluded, and the remaining patients were randomly divided into derivation and validation cohorts. HIBI was defined when at least one prognostication predicted a poor outcome. IHD meant all deaths regardless of cause. In the derivation cohort, stepwise multivariate logistic regression was conducted for HIBI and IHD scores, and model performance was assessed. We then classified patients into four categories and analysed associations between the categories and cerebral performance categories (CPCs) at hospital discharge. Finally, we validated our models in the internal validation cohort. Results Among 1373 patients, 240 were excluded, and 1133 were randomised into derivation (n=754) and validation cohorts (n=379). In the derivation cohort, 7 and 8 predictors were selected for HIBI (0–8) and IHD scores (0–11), respectively, and the area under the curve (AUC) was 0.85 (95% CI 0.82–0.87) and 0.80 (95% CI 0.77–0.82), respectively. Applying optimum cutoff values of ≥6 points for HIBI and ≥7 points for IHD, patients were classified as follows: HIBI (-)/IHD (-), Category 1 (n=424); HIBI (-)/IHD (+), Category 2 (n=100); HIBI (+)/IHD (-), Category 3 (n=21); and HIBI (+)/IHD (+), Category 4 (n=209). CPCs at discharge were significantly different in each category (p&amp;lt;0.001). In the validation cohort, the model showed moderate discrimination (AUC 0.83, 95% CI 0.79–0.87 for HIBI and AUC 0.77, 95% CI 0.72–0.81 for IHD) with good calibration. Each category of the validation cohort showed a significant difference in discharge outcomes (p&amp;lt;0.001) and a similar trend to the derivation cohort. Conclusions We presented a novel approach for assessing illness severity after OHCA. Although external prospective studies are warranted, risk stratification for HIBI and IHD could help provide OHCA patients with appropriate treatment.

Sex difference in neurological outcome and post-cardiac arrest care in out-of-hospital cardiac arrest patients treated with targeted temperature management

Abstract Funding Acknowledgements Type of funding sources: None. Objectives Conflicting results regarding sex-based differences in the outcomes of out-of-hospital cardiac arrest (OHCA) patients have been reported. Furthermore, no study has examined whether differences in in-hospital interventions and courses are driven by sex differences. This study evaluated the effect of sex on the in-hospital course of these patients as well as the survival rates and long-term neurological outcomes of comatose OHCA patients treated with targeted temperature management (TTM). Methods We retrospectively analyzed the Korean Hypothermia Network prospective registry composed of data collected from 22 hospitals in Korea between October 2015 and December 2018. To evaluate the effect of sex on patient outcomes, we created various multivariate logistic regression models including baseline characteristics, resuscitation, and in-hospital care variables with an interaction term (age × sex). We also performed a stratified analysis of different age groups (less than 50 years of age and older). Regarding the difference in in-hospital courses, we compared daily total and SOFA sub-scores between the sexes and analyzed whether the decision regarding early cardiac interventions and limitations in in-hospital care were associated with sex. Results Among 1339 patients included in the study, 952 were men and 387 were women. There were no differences in age or modified comorbidity index values between the gender groups. Women were more likely to experience cardiac arrest at home and unwitnessed arrests, whereas men were more likely to have shockable initial rhythm, cardiac cause arrest, and ST-segment elevation myocardial infarction (STEMI) on initial electrocardiography and undergo early coronary interventions. The rate of survival to discharge was similar, but men showed better 6-month neurological outcomes. After adjusting for confounders, the male sex was not associated with survival to discharge or good 6-month neurological outcomes. There was no association between sex and outcome in patients of reproductive age and no interaction between age and sex. Regarding the in-hospital course, the daily total and SOFA sub-scores were similar in both sexes. The adjusted effect of sex was not associated with the clinician’s decision to perform early cardiac interventions. The decision to discontinue life-sustaining treatment was determined by poor prognostic factors, not by sex. Conclusions The findings suggested that men had more favorable 6-month survivals and good neurological outcomes compared to women since they had more favorable resuscitation variables. However, after adjusting for confounders, there was no difference between the sexes. This result was consistent with the data in patients of reproductive age. The results regarding in-hospital course showed that daily patient severity scores, early cardiac interventions, resource consumption, and the rates of withdrawal/withholding of in-hospital care were similar in men and women.