Post-cardiac Arrest Care Research Articles

The Utility of a Point-of-Care Transcranial Doppler Ultrasound Management Algorithm on Outcomes in Pediatric Asphyxial Out-of-Hospital Cardiac Arrest - An Exploratory Investigation.

BackgroundTranscranial Doppler ultrasound is a sensitive, real time tool used for monitoring cerebral blood flow; it could provide additional information for cerebral perfusion in cerebral resuscitation during post cardiac arrest care. The aim of the current study was to evaluate the utility of a point-of-care transcranial Doppler ultrasound management algorithm on outcomes in pediatric asphyxial out-of-hospital cardiac arrest.MethodsThis retrospective cohort study was conducted in two tertiary pediatric intensive care units between January 2013 and June 2018. All children between 1 month and 18 years of age with asphyxial out-of-hospital cardiac arrest and a history of at least 3 min of chest compressions, who were treated with therapeutic hypothermia and survived for 12 h or more after the return of circulation were eligible for inclusion.ResultsTwenty-one patients met the eligibility criteria for the study. Sixteen (76.2%) of the 21 children were male, and the mean age was 2.8 ± 4.1 years. Seven (33.3%) of the children had underlying disorders. The overall 1-month survival rate was 52.4%. Twelve (57.1%) of the children received point-of-care transcranial Doppler ultrasound. The 1-month survival rate was significantly higher (p = 0.03) in the point-of-care transcranial Doppler ultrasound group (9/12, 75%) than in the non-point-of-care transcranial Doppler ultrasound group (2/9, 22.2%).ConclusionsPoint-of-care transcranial Doppler ultrasound group was associated with a significantly better 1-month survival rate compared with no point-of-care transcranial Doppler ultrasound group in pediatric asphyxial out-of-hospital cardiac arrest.

Development, implementation, and refinement of a comprehensive postcardiac arrest care training course in Japan

AimIn Japan, no training course is dedicated to postcardiac arrest care (PCAC), including venoarterial extracorporeal membrane oxygenation (VA‐ECMO); thus, faculty members of the Japanese Circulation Society developed an original, comprehensive PCAC training course. This report reviews the development, implementation, and refinement of this PCAC training course.MethodsWe examined the preserved data from the Japanese Circulation Society PCAC training courses between 2014 and 2020. Data related to the learning content and number of the attendees and instructors were collected and summarized.ResultsSixteen courses were held between August 2014 and February 2020, before the coronavirus disease 2019 (COVID‐19) pandemic. A total of 677 health care providers participated: 351 doctors, 225 nurses, 62 perfusionists, five emergency medical professionals, and two pharmacists. Thirty‐two attendees’ data were missing. The core learning contents of all the courses included a standardized postcardiac arrest algorithm, targeted temperature management, VA‐ECMO cannulation skills, and postcannulation management. Concerning curriculum evolution, extracorporeal cardiopulmonary resuscitation simulation, postarrest neurological examination and monitoring, and ultrasound‐guided Seldinger technique training were added in the 4th, 5th, and 13th courses, respectively.ConclusionThe Japanese Circulation Society PCAC training course has been developed and refined to provide an organized, comprehensive opportunity for health care providers to acquire specific knowledge and skills in PCAC and VA‐ECMO.

Oxyhaemoglobin Level Measured Using Near-Infrared Spectrometer Is Associated with Brain Mitochondrial Dysfunction After Cardiac Arrest in Rats.

Cerebral blood oxygenation (CBO), measured using near-infrared spectroscopy (NIRS), can play an important role in post-cardiac arrest (CA) care as this emerging technology allows for noninvasive real-time monitoring of the dynamic changes of tissue oxygenation. We recently reported that oxyhaemoglobin (oxy-Hb), measured using NIRS, may be used to evaluate the quality of chest compressions by monitoring the brain tissue oxygenation, which is a critical component for successful resuscitation. Mitochondria are the key to understanding the pathophysiology of post-CA oxygen metabolism. In this study, we focused on mitochondrial dysfunction, aiming to explore its association with CBO parameters such as oxy-Hb and deoxyhaemoglobin (deoxy-Hb) or tissue oxygenation index (TOI). Male Sprague-Dawley rats were used in the study. We applied NIRS between the nasion and the upper cervical spine. Following 10 min of CA, the rats underwent cardiopulmonary resuscitation (CPR) with a bolus injection of 20μg/kg epinephrine. At 10 and 20 min after CPR, brain, and kidney tissues were collected. We isolated mitochondria from these tissues and evaluated the association between CBO and mitochondrial oxygen consumption ratios. There were no significant differences in the mitochondrial yields (10 vs. 20 min after resuscitation: brain, 1.33±0.68 vs. 1.30±0.75mg/g; kidney, 19.5±3.2 vs. 16.9±5.3mg/g, respectively). State 3 mitochondrial oxygen consumption rates, known as ADP-stimulated respiration, demonstrated a significant difference at 10 vs. 20 min after CPR (brain, 170±26 vs. 115±17nmol/min/mg protein; kidney, 170±20 vs. 130±16nmol/min/mg protein, respectively), whereas there was no significant difference in ADP non-dependent state 4 oxygen consumption rates (brain, 34.0±6.7 vs. 31.8±10nmol/min/mg protein; kidney, 29.8±4.8 vs. 21.0±2.6nmol/min/mg protein, respectively). Consequently, the respiratory control ratio (RCR=state 3/state 4) showed a significant difference over time, but this was only noted in the brain (brain, 5.0±0.29 vs. 3.8±0.64; kidney, 5.8±0.53 vs. 6.2±0.25nmol/min/mg protein, respectively). The oxy-Hb levels had a dynamic change after resuscitation, and they had a significant association with the RCR of the brain mitochondria (r=0.8311, p=0.0102), whereas deoxy-Hb and TOI did not (r=-0.1252, p=0.7677; r=0.4186, p=0.302, respectively). The RCRs of the kidney mitochondria did not have a significant association with CBO (oxy-Hb, r=-0.1087, p=0.7977; deoxy-Hb, r=0.1565, p=0.7113; TOI, r=-0.1687, p=0.6896, respectively). The brain mitochondrial respiratory dysfunction occurred over time, and it was seen at the time points between 10 and 20 min after CPR. The oxy-Hb level was associated with brain mitochondrial dysfunction during the early post-resuscitation period.

Feasibility of early waking cardiac arrest patients whilst receiving therapeutic hypothermia: The therapeutic hypothermia and early waking (THAW) trial

AimTo determine the safety and feasibility of an early (12 h) waking and extubation protocol for out-of-hospital cardiac arrest (OHCA) patients receiving targeted temperature management (TTM). MethodsThis was a single-centre, prospective, non-randomised, observational, safety and feasibility pilot study which included successfully resuscitated OHCA patients, of presumed cardiac cause. Inclusion criteria were: OHCA patients aged over 18 years with a return of spontaneous circulation, who were going to receive TTM33 (TTM at 33 °C for 24 h and prevention of hyperthermia for 72 h) as part of their post cardiac arrest care. Clinical stability was measured against physiological and neurological parameters as well as clinical assessment. Results50 consecutive patients were included (median age 65.5 years, 82% male) in the study. Four (8%) patients died within the first twelve hours and were excluded from the final cohort (n = 46). Twenty-three patients (46%) were considered clinically stable and suitable for early waking based on the intention to treat analysis; 12 patients were extubated early based on a variety of clinical factors (21.4 ± 8.6 h) whilst continuing to receive TTM33 with a mean core temperature of 34.2 °C when extubated. Of these, five patients were discharged from the intensive care unit (ICU) <48 h after admission with a mean ICU length of stay 1.8 ± 0.4 days. Twenty-eight patients (56%) were discharged from the ICU with a modified Rankin Score of 0–2. The overall intra-hospital mortality was 50% (n = 25). ConclusionsIt is safe and feasible to wake selected comatose OHCA patients at 12 h, allowing for earlier positive neuro-prognostication and reduced ICU stay.

Different Stratification of Physiological Factors Affecting Cerebral Perfusion Pressure in Hypoxic-Ischemic Brain Injury after Cardiac Arrest According to Visible or Non-Visible Primary Brain Injury: A Retrospective Observational Study

We aimed to explore the stratification of physiological factors affecting cerebral perfusion pressure, including arterial oxygen tension, arterial carbon dioxide tension, mean arterial pressure, intracranial pressure (ICP), and blood-brain barrier (BBB) status, with respect to primary or secondary brain injury (PBI or SBI) after out-of-hospital cardiac arrest (OHCA). Among the retrospectively enrolled 97 comatose OHCA survivors undergoing post-cardiac arrest (PCA) care, 46 (47.4%) with already established PBI (high signal intensity (HSI) on diffusion-weighted imaging (DWI) had higher ICP (p = 0.02) and poorer BBB status (p < 0.01) than the non-HSI group. On subgroup analysis within the non-HSI group to exclude the confounding effect of already established PBI, 40 (78.4%) patients with good neurological outcomes had lower ICP at 24 h (11.0 vs. 16.0 mmHg, p < 0.01) and more stable BBB status (p = 0.17 in pairwise comparison) compared to those with poor neurological outcomes, despite the non-significant differences in other physiological factors. OHCA survivors with HSI on DWI showed significantly higher ICP and poorer BBB status at baseline before PCA care than those without HSI. Despite the negative DWI findings before PCA care, OHCA survivors have a cerebral penumbra at risk for potentially leading the poor neurological outcome from unsuppressed SBI, which may be associated with increased ICP and BBB permeability.

Abstract 10739: Simulation Based Assessment of Trainee’s Performance in Post-Cardiac Arrest Resuscitation

Up to 22% of patients survive to hospital admission following out-of-hospital cardiac arrest (OHCA). Post cardiac arrest is complex and requires a multidisciplinary approach. Our aim is to assess trainee’s performance in managing post-cardiac arrest care using a high-fidelity manikin-based simulation. We also sought to obtain evidence regarding the validity of our findings. Methods: In this prospective, observational, simulation based study, participants ranging from sub interns to attending physicians evaluated and managed a post cardiac arrest patient, complicated by refractory status epilepticus. Critical actions were developed by a modified Delphi approach based on relevant American Heart Association guidelines and the Neurocritical Care Society’s Emergency Neurological Life Support protocols. The primary outcome measure was the critical action item sum score. We sought validity evidence to support our findings by comparing trainees’ performance across four levels of training. Results: Forty-nine participants completed the simulation. The mean sum of critical actions completed by participants was 10/21(49%). Eleven(22%) participants verbalized a differential diagnosis for the arrest. Thirty-two(65%) recognized the abnormal electrocardiography, and consulted cardiology. Forty trainees(81%) independently decided to start target temperature management (TTM), but only 20(41%) insisted on TTM when asked to reconsider. There was an effect of level of training on critical action checklist sum scores (novice mean score [standard deviation (SD)] = 4.8 (1.8) vs. intermediate mean score (SD) = 10.4 (2.1) vs. advanced mean score (SD) = 11.6 (3.0) vs. expert mean score (SD) = 14.7 (2.2) Conclusions: High-fidelity manikin-based simulation holds promise as an assessment tool in the performance of post-cardiac arrest care. Areas for further educational initiatives to improve performance include diagnostic work-up of OHCA and implementation of TTM.

Abstract 14218: Post-Cardiac Arrest Care Delivery Varies Widely Across Institutions Belonging to the PediRES-Q Collaborative

Introduction: Despite national pediatric post-cardiac arrest care (PCAC) guidelines to improve survival and neurological outcomes, there are limited studies describing PCAC delivery in pediatric institutions. The objective of this study was to describe reported PCAC delivery in pediatric institutions. We hypothesized that there would be variability in PCAC processes across institutions. Methods: An IRB-approved REDCap survey was distributed electronically to the lead resuscitation investigator at each institution belonging to the international Pediatric Resuscitation Quality Improvement collaborative (PediRES-Q). Data were summarized using descriptive statistics. A chi-square test was used to compare categorical data. Results: Twenty-four of 47 centers completed the survey (51%). Most respondents (58%) belonged to large centers (≥1000 annual PICU admissions). Two-third (67%) of centers reported using no specific selection criteria to initiate PCAC with the other third employing order sets, paper forms, or institutional guidelines. Smaller centers (&lt;1000 annual PICU admissions) more frequently reported the use of attending-directed care for PCAC initiation/delivery (80%) versus larger centers (57%), p = 0.04. Common PCAC targets included temperature (96%), glucose (75%), and age-based blood pressure (88%). Most PCAC included EEG (75%) but neuroimaging was only included at 46% of centers. Duration of PCAC was either tailored to clinical improvement and neurological exam (54%) or time-based (45%). Only 25% of centers reported having a mechanism for evaluating PCAC adherence. Common barriers to effective PCAC implementation included lack of time and limited training opportunities (Figure 1). Conclusions: There is wide variation in PCAC delivery among surveyed pediatric institutions. Targeting common themes such as standardization of PCAC initiation and bundle components and implementing adherence evaluation could improve PCAC.

Abstract 12989: Impact of Vasopressor Use on Brain Edema and Neurological Outcomes Among Resuscitated Cardiac Arrest Survivors

Introduction: Current guidelines in post cardiac arrest care recommend the use of vasopressors for hemodynamic optimization. The use of hypothermia can further challenge hemodynamics. The impact of vasopressors among cardiac arrest survivors on neurological outcomes is not well studied Hypothesis: We hypothesized that duration and use of vasopressor are not associated with poor neurological outcome and brain edema Methods: We enrolled cardiac arrest survivors from January 2012 - December 2016 that were able to survive for 24 hours or more. We examined associations of vasopressor use and duration with brain edema and poor neurological outcomes in adjusted logistic regression models (Fig 1). Poor neurological recovery was defined as cerebral performance score (CPC) of &gt;2 or modified Rankin score of &gt;3(unable to perform daily activities independently).Kaplan-Meier was used to depict relationship of brain edema with mortality. Results: Out of 981 cardiac arrest survivors (mean age 62.5±14.8 years, 39.3% female, 70.4% white, 34.7% shockable rhythm), 754 (76.6%) were treated with vasopressors. CT or MRI brain were performed among 931 (94.9%) of the patients and brain edema was present among 445 (47.8%) of the patients. Brian edema was independently associated with mortality (HR 2.50; 95% 2.06 - 3.04, p &lt;0.001). Vasopressor use was significantly associated with brain edema (OR 2.90; 95% CI 2.00 - 4.21, p &lt;0.001). Vasopressor duration was also an independent risk factor of brain edema (OR per hour of vasopressor use 1.031; 95% CI 1.002 - 1.061, p = 0.03). In addition to this, vasopressor use was associated with CPC &gt;2 (OR 1.04; 95% CI 1.01 - 1.07, p = 0.006) and with modified Rankin score &gt;3 (OR 1.04; 95% CI 1.01 - 1.07, p = 0.006). Conclusions: We observed that the duration and use of vasopressor were associated with poor neurological outcomes and brain edema among cardiac arrest survivors. Future studies should evaluate the mechanism of brain edema associated with vasopressor use.

Abstract 13114: Effectiveness of a Novel Decision Aid for Surrogate Decision Makers of Comatose Survivors of Cardiac Arrest: A Pilot Study of the “Tool to EMPOwer Surrogate Decision Makers” (TEMPO)

Introduction: Surrogate decision makers (SDMs) represent critical stakeholders in decision making for comatose survivors of cardiac arrest, yet these individuals are often unprepared for decision making and unfamiliar with the complexity of post-cardiac arrest care. To that end, we created a decision aid for SDMs intended to inform and support evidence-based decision making for comatose survivors of cardiac arrest. Methods: We conducted a pilot trial to measure real world effectiveness of the Tool to EMPOwer (TEMPO) Surrogate Decision Makers, by measuring knowledge and acceptability. Individuals were enrolled who self-identified as the SDM for a comatose survivor of OHCA admitted to an academic tertiary care hospital. Participants completed a pre-intervention survey prior to the provision of TEMPO, and a post-intervention survey approximately 24 hours after exposure to the intervention. Pre-survey questions included SDM demographics and an 8-question knowledge survey. Post-intervention surveys included the same knowledge questions, the Ottawa Acceptability of Decision Aid tool, and questions to measure if SDMs shared TEMPO with others. This study was approved by the Colorado Multiple Institutional Review Board and registered at Clinicaltrials.gov (NCT03908346). Results: Twenty SDMs were enrolled between 9/1/2020 and 6/7/2021. One subject did not complete the post-intervention survey therefore 19 subject responses were analyzed for the purpose of this report. Participants were 85.0% Female, 47.4 +/- 14.8 years, and 45.0% were the spouse of the patient. In the 8-question knowledge survey, results improved from 57.2% correct to 90.8% correct after exposure to TEMPO (p&lt;0.001). Using the Ottawa Acceptability Tool, 89.5% of participants stated TEMPO was useful in decision-making and 94.7% reported that TEMPO made their decision “easier”. Most (79.0%) participants reported they shared the DA with another family/friend in-person, while some (52.6%) reported they shared content with another person by telephone. Conclusion: Initial pilot data on the efficacy of the Tool to EMPOwer Surrogate Decision Makers of comatose survivors of cardiac arrest shows significant promise in improving knowledge and supporting decision-making.

Cardiac Arrest Survival Postresuscitation In-Hospital (CASPRI) Score Predicts Neurological Favorable Survival in Emergency Department Cardiac Arrest

Background: This study was conducted to identify the predictive factors for survival and favorable neurological outcome in patients with emergency department cardiac arrest (EDCA). Methods: ED patients who suffered from in-hospital cardiac arrest (IHCA) from July 2014 to June 2019 were enrolled. The electronic medical records were retrieved and data were extracted according to the IHCA Utstein-style guidelines. Results: The cardiac arrest survival post-resuscitation in-hospital (CASPRI) score was associated with survival, and the CASPRI scores were lower in the survival group. Three components of the CASPRI score were associated with favorable neurological survival, and the CASPRI scores were lower in the favorable neurological survival group of patients who were successfully resuscitated. The independent predictors of survival were presence of hypotension/shock, metabolic illnesses, short resuscitation time, receiving coronary angiography, and TTM. Receiving coronary angiography and low CASPRI score independently predicted favorable neurological survival in resuscitated patients. The performance of a low CASPRI score for predicting favorable neurological survival was fair, with an AUROCC of 0.77. Conclusions: The CASPRI score can be used to predict survival and neurological status of patients with EDCA. Post-cardiac arrest care may be beneficial for IHCA, especially in patients with EDCA.

Post-cardiac arrest physiology and management in the neonatal intensive care unit

AimThe importance of high-quality post-cardiac arrest care is well-described in adult and paediatric populations, but data are lacking to inform post-cardiac arrest care in the neonatal intensive care unit (NICU). The objective of this study was to describe post-cardiac arrest physiology and management in a quaternary NICU. MethodsRetrospective descriptive study of post-cardiac arrest physiology and management. Data were abstracted from electronic medical records and an institutional resuscitation database. A cardiac arrest was defined as ≥1 minute of chest compressions. Only index arrests were analysed. Descriptive statistics were used to report patient, intra-arrest, and post-arrest characteristics. ResultsThere were 110 index cardiac arrests during the 5-year study period from 1/2017–2/2021. The majority (69%) were acute respiratory compromise leading to cardiopulmonary arrest (ARC-CPA) and 26% were primary cardiopulmonary arrests (CPA). Vital sign monitoring within 24 hours post-arrest was variable, especially non-invasive blood pressure frequency (median 5, range 1–44 measurements). There was a high prevalence of hypothermia (73% of arrest survivors). There was substantial variability in laboratory frequency within 24 hours post-arrest. Patients with primary CPA received significantly more lab testing and had a higher prevalence of acidosis (pH < 7.2) than those with ARC-CPA. ConclusionsWe identified significant variation in post-arrest management and a high prevalence of hypothermia. These data highlight the need for post-arrest management guidelines specific to neonatal physiology, as well as opportunities for quality improvement initiatives. Further research is needed to ascertain the impact of neonatal post-arrest management on long-term outcomes and survival.

CETUXIMAB: A POTENTIALLY UNDER RECOGNIZED ETIOLOGY OF SUDDEN CARDIAC DEATH

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Certain medications have been linked to an increased risk of sudden cardiac death through varying mechanisms. Herein, we describe a case of a cardiac arrest where cetuximab was presumed the culprit. CASE PRESENTATION: A 58-year-old female with a history relevant for TxN3bM0 squamous cell carcinoma of the neck on chemoradiation therapy was transferred to the hospital after having a cardiac arrest while receiving cetuximab. She presented earlier to the cancer center with no complaints. During cetuximab infusion, she had a cardiac arrest (pulseless electrical activity). She was resuscitated per ACLS guidelines and had a return of spontaneous circulation (ROSC) within eight minutes. Post ROSC, she was hemodynamically stable, with appropriate oxygenation and ventilation. An electrocardiogram showed normal sinus rhythm with no signs of ischemia. Point of care ultrasonography (POCUS) showed a normal left ventricular ejection fraction, with no evidence of wall motion abnormalities, right ventricular strain, or pericardial effusion. POCUS also ruled out deep vein thrombosis and pneumothorax. Cardiac enzymes, brain natriuretic peptide, potassium, calcium, and magnesium, were normal. Post-cardiac arrest care was provided, including targeted temperature management. The next day, she was following commands and meeting extubation criteria. She was extubated and transferred to the floor one day after. Formal echocardiography confirmed POCUS findings. In the absence of another explanation for her cardiac arrest, cetuximab was to blame. DISCUSSION: Cetuximab is a monoclonal antibody that binds the epidermal growth factor receptor (EGFR), competitively inhibiting the binding of EGF and resulting in inhibition of cell growth and induction of apoptosis. Cetuximab is indicated for locoregionally advanced squamous cell carcinoma of the head and neck (SCCHN) in combination with radiation therapy. The addition of cetuximab in this population increased median overall survival by 20 months1. In patients with SCCHN treated with cetuximab and radiation therapy, 2% had sudden death1. Cardiac arrest also occurred in 3% of SCCHN patients treated with cetuximab in combination with platinum-based therapy and fluorouracil2. As a result, cetuximab's package has "sudden death" as a black box warning. Of note, 50% of patients treated with cetuximab may develop hypomagnesemia, and weekly monitoring of electrolytes is recommended. In our patient, electrolytes were normal, and the exact mechanism of cetuximab-induced cardiac arrest remains unclear. CONCLUSIONS: Cetuximab-induced cardiac arrest occurs in 2%-3% of treated patients in controlled studies. Real-world incidence may be higher. We report this case to add to the literature what we believe is a case of cetuximab-related cardiac arrest. REFERENCE #1: 1. Bonner JA, et. al. New England Journal of Medicine. 2006 Feb 9;354(6):567-78. REFERENCE #2: 2. Vermorken JB, et al. New England Journal of Medicine. 2008 Sep 11;359(11):1116-27. DISCLOSURES: No relevant relationships by Tony Abdo, source=Web Response No relevant relationships by Ammaar Azeem, source=Web Response No relevant relationships by SYED HUSSAIN, source=Web Response

The evolution of hypothermia for neuroprotection after cardiac arrest: a history in the making.

While much has been observed regarding hypothermia by way of environmental exposure, it is modern day medicine that deployed hypothermia as a therapeutic. From the early 1930s, when Temple Fay deployed "refrigeration" to treat pain, to the work of Wilfred Bigelow and Charles Drew, who utilized hypothermia in open heart surgery-the opportunities seemed endless. However, questions arose surrounding appropriate temperatures to achieve best outcomes and how to minimize adverse events, such as coagulopathy and infection. In the 1980s, hypothermia underwent a resurgence through Peter Safar's critical studies in large animals, which quickly translated into feasibility studies and the landmark trials of 2002 that paved the way for postcardiac arrest care as we currently know it. Through clinical and observational trials, modern-day targeted temperature management continues to adapt, striving to improve patient outcomes. While hypothermia has come a long way from the writings of Hippocrates, the ideal therapy has not yet been defined, and more work is needed. While the history is long, there is more to be written and advances to be achieved as we optimize the neuroprotective effects of hypothermia for comatose survivors of cardiac arrest.

Beyond return of spontaneous circulation: update on post-cardiac arrest management in the intensive care unit.

A well-functioning chain of survival is critical for good outcomes following out-of-hospital cardiac arrest, a major public health concern in Singapore. While the percentage of survivors to hospital admission has increased over the years, the percentage of survivors to hospital discharge and the number of patients with good neurological recovery can be greatly improved. This underscores the urgent need to focus on 'post-cardiac arrest care', the fifth link in the chain of survival, to improve the outcomes of patients who are admitted to the intensive care unit (ICU) after return of spontaneous circulation. This review builds on earlier recommendations of the Singapore National Targeted Temperature Management Workgroup in 2017 to provide a focused update on post-cardiac arrest management and a practical guide for physicians managing resuscitated patients with cardiac arrest in the ICU.

Extracorporeal life support in adult patients with out-of-hospital cardiac arrest.

The use of extracorporeal life support in cardiopulmonary resuscitation (CPR) of adult patients experiencing out-of-hospital cardiac arrest by the application of veno-arterial extracorporeal membrane oxygenation (ECMO) during cardiac arrest has been increasing over the past decade. This can be attributed to the encouraging results of extracorporeal CPR (ECPR) in multiple observational studies. To date, only one randomised controlled trial has compared ECPR to conventional advanced life support measures. Patient selection is crucial for the success of ECPR programmes. A rapid and organised approach is required for resuscitation, i.e. cannula insertion with ECMO pump initiation in combination with other aspects of post-cardiac arrest care such as targeted temperature management and early coronary reperfusion. The provision of an ECPR service can be costly, resource intensive and technically challenging, as limited studies have reported on its cost-effectiveness.

Variation in Post-Cardiac Arrest Care Within a Regional EMS System

Objective: Within Emergency Medical Systems (EMS) regional systems, there may be significant differences in the approach to patient care despite efforts to promote standardization. Identifying hospital-level factors that contribute to variations in care can provide opportunities to improve patient outcomes. The purpose of this analysis was to evaluate variation in post-cardiac arrest care within a large EMS system and explore the contribution of hospital-level factors. Methods: This was a retrospective analysis from a regional cardiac system serving over 10 million persons. Patients with out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) are transported to 36 cardiac arrest centers with 24/7 emergent coronary angiography (CAG) capabilities and targeted temperature management (TTM) policies based on regional guidelines. We included adult patients ≥18 years with non-traumatic OHCA from 2016-2018. Patients with a Do-Not-Resuscitate order and those who died in the emergency department (ED) were excluded. For the TTM analysis, we also excluded patients who were alert in the ED. The primary outcome was receiving CAG or TTM after cardiac arrest. The secondary outcome was neurologic recovery (dichotomized to define a “good” outcome as cerebral performance category (CPC) 1 or 2). We used generalized estimating equations including patient-level factors (age, sex, witnessed arrest, initial rhythm) and hospital-level factors (academic status, hospital size based on licensed beds, annual OHCA patient volume) to estimate the odds ratios associated with these variables. Results: There were 7831 patients with OHCA during the study period; 4694 were analyzed for CAG and 3903 for TTM. The median and range for treatment with CAG and TTM after OHCA was 23% (12-49%) and 58% (17-92%) respectively. Hospital size was associated with increased likelihood of CAG, adjusted odds ratio 1.71, 95% CI 1.05-2.86, p = 0.03. Academic status approached significance in its association with TTM, adjusted odds ratio 1.69, 95% CI 0.98-2.91, p = 0.06. Overall, 28% of patients survived with good neurologic outcome, ranging from 17 to 43% across hospitals. Conclusion: Within this regional cardiac system, there was significant variation in use of CAG and TTM after OHCA, which was not fully explained by patient-level factors. Hospital size was associated with increased CAG.

Quantitative Electroencephalogram in Pediatric Intensive Care Unit in Three Different Clinical Scenarios

AbstractAlthough clinical judgement and sedation scales are primarily used in intensive care units (ICUs) to manage sedation, adjunctive data are needed to direct therapy with sedative and hypnotic agents to prevent side effects and long-term sequelae. In this case report, we described three cases where we used quantitative electroencephalogram (qEEG) data in a pediatric ICU (PICU); to manage these specific clinical situations and to identify the limitations of the qEEG data, two patients were admitted for post–cardiac arrest care and the third was admitted for status epilepticus. In post–cardiac arrest patients, qEEG was mainly used for monitoring depth of sedation and drug titration. Unnecessary use of high-drug doses was prevented, and monitoring also helped to guide clinical intervention for the management of seizure activity. In the patient with status epilepticus, qEEG data on burst suppression and depth of sedation were used. In this report, we describe three different cases where we used qEEG data in a PICU, to give insight on the use of data in specific clinical situations and to describe the limitations of the qEEG data monitoring system.

Repolarization and ventricular arrhythmia during targeted temperature management post cardiac arrest

BackgroundTargeted temperature management (TTM) following out-of-hospital cardiac arrest (OHCA) prolongs the QT-interval but our knowledge of different temperatures and risk of arrhythmia is incomplete. ObjectiveTo assess whether the QTc, QT-peak (QTp) and T-peak to T-end interval (TpTe) may be useful markers of ventricular arrhythmia in contemporary post cardiac arrest treatment. MethodsAn ECG-substudy of the TTM-trial (TTM at 33 °C vs. 36 °C) with serial ECGs from 680 (94%) patients. Bazett’s (B) and Fridericia’s (F) formula were used for heart rate correction of the QT, QTp and TpTe. Ventricular arrhythmia (VT/VF) were registered during the first three days of post cardiac arrest care. ResultsThe QT, QTc and QTp intervals were prolonged more at 33 °C compared to 36 °C and restored to similar and lower levels after rewarming. The TpTe-interval remained between 92–100 ms throughout TTM in both groups.The QTc intervals were associated with ventricular arrhythmia, but not after adjustment for cardiac arrest characteristics. The QTp-interval was not associated with risk of ventricular arrhythmia. Heart rate corrected TpTe-intervals were associated with higher risk of arrhythmia (Odds ratio (OR): TpTe(B): 1.12 (1.02–1.23, p = 0.01 TpTe(F): 1.12 (1.02–1.23, p = 0.02) per 20 ms). Further a prolonged TpTe-interval ≥ 90 ms was consistently associated with higher risk (ORadjusted: TpTe(B): 2.05 (1.25–3.37), p < 0.01, TpTe(F): 2.14 (1.32–3.49), p < 0.01). ConclusionsTTM prolongs the QT-interval by prolongation of the QTp-interval without association to increased risk. The TpTe-interval is not significantly affected by core temperature, but heart rate corrected TpTe intervals are robustly associated with risk of ventricular arrhythmia. Trial registrationThe TTM-trial is registered and accessible at ClinicalTrials.gov (Identifier: NCT01020916).

Interaction Effect Between Prehospital Mechanical Chest Compression Device Use and Post-Cardiac Arrest Care on Clinical Outcomes After Out-Of-Hospital Cardiac Arrest.

Prehospital application of a mechanical chest compression device (MCD) and post-cardiac arrest (PCA) care including coronary reperfusion therapy (CRT) or targeted temperature management (TTM) could affect the clinical outcome in out-of-hospital cardiac arrest (OHCA). This study aimed to assess whether the effect of PCA care including CRT or TTM differs according to prehospital MCD use in patients with OHCA. Adult OHCA cases with a presumed cardiac etiology and with survival to admission from 2016 to 2017 were enrolled from the Korean nationwide OHCA registry. The main exposures were CRT and TTM during PCA care. The primary outcome was good neurologic recovery defined by a cerebral performance category score of 1 or 2 at hospital discharge. We conducted interaction analyses between MCD use and PCA care including CRT or TTM. Four thousand three hundred sixty-six OHCA cases were enrolled and 7.9% underwent MCD application. TTM and CRT were performed in 11.2% and 17.9% of the study population. In the interaction analysis, the adjusted odds ratios of TTM and CRT for good neurologic recovery were 2.41 (1.90-3.06) and 3.40 (2.79-4.14) in patients without MCD use and 1.89 (0.97-3.68), and 1.54 (0.79-3.01) in patients with MCD use. The effect of PCA care on neurologic outcomes was different according to MCD use in OHCA. The association of good neurologic outcome and PCA care was not observed in the prehospital MCD use group compared with that in the MCD nonuse group.

Feline cardiopulmonary resuscitation: Getting the most out of all nine lives.

Cardiopulmonary arrest (CPA) can occur in any veterinary or animal care setting and is a particular risk in scenarios involving ill, injured or anesthetized patients. Education of all staff on the prevention and recognition of CPA, as well as the performance of cardiopulmonary resuscitation (CPR), is vital to influencing outcome. While there is a plethora of information regarding CPA and CPR in human medicine, there are comparably few studies in the veterinary literature. Many of the current veterinary guidelines are extrapolated from human medicine or studies based on animal models. Ongoing work is needed to tailor guidelines and recommendations to our domestic feline (and canine) patients in a clinical setting. The aim of this article, which is intended for veterinarians in all areas of small animal practice, is to provide an evidence-based review of CPA and CPR in feline patients. The authors have drawn heavily on detailed recommendations published by the Reassessment Campaign on Veterinary Resuscitation (RECOVER) initiative - one of the few resources specific to the veterinary clinical setting - as well as reviewing the available peer-reviewed literature studies, in constructing this article. Among the topics discussed are recognizing and preventing CPA, staff training and clinic preparedness, basic life support and advanced life support interventions, and appropriate post-cardiac arrest care.