Post-cardiac Arrest Research Articles

Abstract 147: Is Effect Size of Targeted Temperature Management Different for Pediatric Post-Cardiac Arrest Syndrome According to the Severity?

Introduction: The beneficial effect of target temperature management (TTM) for pediatric post-cardiac arrest syndrome (PCAS) patients is controversial, and there are few studies on the differential effects of TTM according to the risk classification. Objective: The aim of this study was to evaluate the differential effects of TTM for pediatric PCAS patients according to a risk classification tool we previously developed, rCAST. Methods: We used data from the Japanese nationwide out-of-hospital cardiac arrest (OHCA) registry of the Japanese Association for Acute Medicine. We classified eligible pediatric PCAS patients (aged ≤18 years) who achieved return of spontaneous circulation (ROSC) according to the quintile of score points on the rCAST. The effect of TTM for their neurological outcome was evaluated for each severity group. And then, focusing on the severity group that appeared to benefit from TTM, we also evaluated the effect of TTM by the propensity score analysis with several adjustment factors. Good neurological outcome was defined as a Cerebral Performance Categories score or Pediatric Cerebral Performance Categories score ≤2 at 30 days. Results: Among 1,526 OHCA pediatric patients in the registry, data of 307 PCAS patients who achieved ROSC were analyzed. The proportion of patients with a good neurological outcome was higher among those who underwent TTM compared to those who did not in the first to forth quintile (TTM vs non-TTM; 81% [21/26] vs 58% [21/36] [p=0.10] in the first, 11% [2/19] vs 7% [2/31] [p=0.63] in the second, 12% [2/17] vs 0% [0/55] [p=0.053] in the third, and 11% [1/9] vs 0% [0/21] [p=0.30] in the fourth). In the group of the fifth quantile (rCAST ≥ 18.5), no patients showed good neurological outcome regardless of TTM (0% [0/20] vs 0% [0/73]). The propensity score analysis showed that TTM was significantly associated with their good neurological outcome in the patients classified into the first to fourth quantile group (Odds ratio; 1.21 [1.04-1.40], p = 0.014). Conclusions: TTM was significantly associated with a good neurological outcome in the pediatric PCAS patients with rCAST ≤ 18.0. All patients with rCAST ≥ 18.5 showed poor neurological outcomes even if they underwent TTM.

Abstract 253: The Recovery of Consciousness via Evidence-Based Medicine and Research Program: An Innovative Paradigm for Advancing Neuroprognostication After Cardiac Arrest

Introduction: Prognostication of neurologic recovery in post-cardiac arrest coma often dictates whether life-sustaining treatments are continued or withdrawn. However, the conventional approach to prognostication is fragmented and inconsistent, impeding clinical care, research and education. Goals: We sought to establish an innovative approach to prognostication -- the Re covery of Co nsciousness V ia E vidence-Based Medicine and R esearch (RECOVER) program -- that provides specialized, comprehensive, and longitudinal care. Methods: Inpatients with post-arrest coma are evaluated by a dedicated RECOVER consult service, which collects data per evidence-based guidelines and advises clinical teams and families. Patients are discussed in a weekly interdisciplinary conference (with neurology, physiatry, radiology, palliative care, social work, physical therapy, ethics, and others) to formulate holistic prognostic determinations and treatment plans. For surviving patients, the RECOVER program provides continuity through partnered post-acute facilities and outpatient clinics. This clinical infrastructure is leveraged to build a registry of clinical data and outcomes. Trainees are incorporated throughout. Results: Between August 2022 and June 2023, the RECOVER program evaluated 70 patients with post-arrest coma (mean age 55y [SD = 16]). Of those, 34 (49%) survived to hospital discharge without transition to hospice care. Of the 25 patients ≥3 months from discharge, four have returned to clinic (16%). Functional MRIs are interpreted with the aid of neuroradiology and ethics. Preliminary data suggest high caregiver satisfaction with the RECOVER program (mean of 4.7 on a 5-point Likert scale). Conclusion: The RECOVER program enables systematic, guideline-based and interdisciplinary care, provides continuity, and facilitates clinical translation of research in patients with post-arrest coma. The RECOVER program helps provide ongoing healthcare access to this vulnerable population, although clinic retention is low. The RECOVER program also promotes trainee education and serves as an effective platform for data collection. If adopted broadly, the RECOVER program may advance post-arrest care and facilitate multi-center research.

Clinical features and outcomes of in-hospital cardiac arrest in code blue events: a retrospective observational study.

In-hospital cardiac arrest (IHCA) is a critical medical event with outcomes less researched compared to out-of-hospital cardiac arrest. This retrospective observational study aimed to investigate key aspects of IHCA epidemiology and prognosis in patients with Code Blue activation. This retrospective observational study enrolled patients with Code Blue events in our hospital between January 2010 and October 2019. Participant characteristics, including age and sex, and IHCA characteristics, including the time of cardiac arrest, witnessed event, bystander cardiopulmonary resuscitation (CPR), initial shockable rhythm, vital signs at 1 and 6 h before IHCA, survival to hospital discharge (SHD), and the cardiac arrest survival postresuscitation in-hospital (CASPRI) score were included in univariate and multivariate logistic regression analyses with SHD as the primary endpoint. From the 293 Code Blue events that were activated during the study period, 81 participants were enrolled. Overall, the SHD rate was 28.4%, the median CPR duration was 14 (interquartile range, 6-28) min, and the rate of initial shockable rhythm was 19.8%. There were significant intergroup differences between the SHD and non-SHD groups in the CPR duration, shockable rhythm, and CASPRI score on univariate logistic regression analysis. Multivariate logistic regression analysis showed that the CASPRI score was the most accurate predictive factor for SHD (OR = 0.98, p = 0.006). The CASPRI score is associated with SHD in patients with IHCA during Code Blue events. Therefore, the CASPRI score of IHCA patients potentially constitutes a simple, useful adjunctive tool for the management of post-cardiac arrest syndrome.

Managing Post Cardiac Arrest Syndrome

Four conditions occur after cardiac arrest resuscitation and are referred to as the post-cardiac arrest syndrome. Moreover, post-cardiac arrest brain injury has the greatest impact on outcomes. Brain injury can be primary as a result of global cerebral ischemia during cardiac arrest. It may be secondary(reperfusion injury)after initiation of cardiopulmonary resuscitation. After cardiac arrest resuscitation, the patient must be managed in the intensive care unit, and it is recommended to avoid hypotension(MAP<65 mmHg), hypoxemia, and hyperoxemia. Oxygen saturation should be maintained at 94%-98%, normal ventilation(35 mmHg-45 mmHg), and body temperature below 37.5℃ for 72 h after resuscitation. The administration of anticonvulsants for abnormal electroencephalograms did not significantly affect the outcome. Prognosis should be predicted within 24 h to 72 h combining physical examination, biomarkers, electrophysiology, and imaging being predictive of poor outcomes.

Cardiac power output is associated with cardiovascular related mortality in the ICU in post-cardiac arrest patients

AimAlthough brain injury is the main determinant of poor outcome following cardiac arrest (CA), cardiovascular failure is the leading cause of death within the first days after CA. However, it remains unclear which hemodynamic parameter is most suitable for its early recognition. We investigated the association of cardiac power output (CPO) with early mortality in intensive care unit (ICU) after CA and with mortality related to post-CA cardiovascular failure. MethodsRetrospective analysis of adult comatose survivors of CA admitted to the ICU of a University Hospital. Exclusion criteria were treatment with extracorporeal cardiopulmonary resuscitation, ECMO or intra-aortic balloon pump. We retrieved CA characteristics; we recorded mean arterial pressure, cardiac output, CPO (as derived parameter) and the vasoactive-inotropic score for the first 72 hours after ROSC, at intervals of 8 hours. ICU death was defined as related to post-CA cardiovascular failure when death occurred as a direct consequence of shock, secondary CA or fatal arrhythmia, or related to neurological injury if this led to withdrawal of life-sustaining therapy or brain death. ResultsAmong the 217 patients (median age 66 years, 65% male, 61.8% out-of-hospital CA), 142 (65.4%) died in ICU: 99 (69.7%) patients died from neurological injury and 43 (30.3%) from cardiovascular-related causes. Comparing the evolution over time of CPO between survivors and non-survivors, a statistically significant difference was found only at +8 hours after CA (p = 0.0042). In multivariable analysis, CPO at 8-hour was significantly associated with cardiovascular-related mortality (p = 0.007). ConclusionsIn post-CA patients, the 8-hour CPO is an independent factor associated with ICU cardiovascular-related mortality.

Comparison of Clinical Outcomes between Rebound Hyperthermia and Non-Rebound Hypertherma Groups in Postcardiac Arrest Syndrome Patients Undergoing Targeted Temperature Management

Purpose : This retrospective study aims to provide basic data for intervention to improve clinical outcomes and identify the characteristics of the rebound hyperthermia (RHG) and non-rebound hyperthermia (NRHG) groups by checking body temperature in patients with post-cardiac arrest syndrome.Method : The study involved 118 patients who completed target temperature management (TTM) in an acute-care unit. Data were analyzed for frequency, percentages, mean, standard deviation, median, and quartiles, and compared using the chi-squared test and Mann–Whitney U-test.Results : Rebound hyperthermia (RH) was observed in 74 (62.7%) patients, predominantly male (69.5%), with an average age of 64.54 ± 15.98, and a body mass index of 23.22 ± 4.75kg/m&lt;sup&gt;2&lt;/sup&gt; (overweight). Hypertension (50%) was the most common co-morbidity, followed by diabetes and heart disease (33.1%). Neuron-specific enolase levels were higher in the NRHG 24, 48, and 72 hours after recovery of spontaneous circulation (p = .037, &lt;i&gt;p&lt;/i&gt;＜ .001, &lt;i&gt;p&lt;/i&gt;= .008). The APHCHE Ⅳ was also higher in the NRHG (&lt;i&gt;p&lt;/i&gt;＜ .001). RH occurred 25.49 (7.28–52.96) hours after TTM completion, lasting for 2 (1–3) hours. Temperature reduction strategies included notifying doctors, administering antipyretics, and nursing intervention, with the latter being the most common at 94.6%. Half of the subjects in the RHG and 77.3% in the NRHG fell into cerebral performance categories 3, 4, and 5 (&lt;i&gt;p&lt;/i&gt;= .003).Conclusion : RH is more likely a body mechanism related to CPR and TTM than a result of pathogenic infection. Therefore, we require an active intervention for hyperthermia, and a patient-specific nursing intervention protocol.

117 Clinicians' approach to predicting outcomes of post cardiac arrest patients enrolled in a United States clinical trial

117 Clinicians' approach to predicting outcomes of post cardiac arrest patients enrolled in a United States clinical trial

Induction of pre-hospital emergency anaesthesia i-PHEA: a national survey of UK HEMS practice

BackgroundPre-hospital emergency anaesthesia is a critical intervention undertaken by helicopter emergency medical teams. Previous studies informed current practice for induction regimes, using a standardized approach of fentanyl, ketamine and rocuronium. There may be a trend towards post-induction hypotension attributed to the induction regime used. Several new combinations of fentanyl, ketamine and rocuronium are emerging in clinical practice. There is currently no consensus on what induction regimes should be used.MethodsA semi-structured survey was distributed to the medical leads of all UK air ambulance organisations between December 2022 and February 2023. Responses that were returned within the study period were included. Exclusions included missing data, declined participation and failure to return the survey within the data collection period. The survey sought to establish provision of pre-hospital emergency anaesthesia and current induction regimes for stable, unstable and post-cardiac arrest patients. Data was extracted from Microsoft Forms into Excel. Descriptive statistics were used to analyse survey response rate, provision of PHEA and induction regimes. The survey was endorsed by the National HEMS Research and Audit Forum.Results19 air ambulance organisations responded (response rate 86%). The majority of organisations provide over 100 pre-hospital emergency anaesthetics per annum (79%, n = 15/19). A standard combination of fentanyl, ketamine and rocuronium is used as a primary induction regime in haemodynamically stable patients by 52% of services (n = 10/19). In haemodynamically compromised patients, fentanyl was omitted or pracititioner choice emphasized by 79% of services (n = 15/19). There was variability in the dose of rocuronium from 1 mg/kg to 2 mg/kg throughout services.ConclusionThere is variability in the approach to pre-hospital emergency anaesthesia. There is a growing dataset that would enable development of a registry to better understand induction regimes and the impact on patient physiology. Organisations are increasingly adopting a patient centered, practitioner choice model towards induction of anaesthesia.

113 Comparison of the outcome of post-cardiac arrest care pre- and post-covid-19 pandemic

113 Comparison of the outcome of post-cardiac arrest care pre- and post-covid-19 pandemic

143 Cardiac Power Output as a predictor of early mortality in postcardiac arrest cardiovascular failure

143 Cardiac Power Output as a predictor of early mortality in postcardiac arrest cardiovascular failure

367 “Mind Over Matter: The Power of Specialized Rehabilitation in Post-Cardiac Arrest Brain Recovery”

367 “Mind Over Matter: The Power of Specialized Rehabilitation in Post-Cardiac Arrest Brain Recovery”

263 Pre-hospital high-dose glucocorticoid treatment for post-cardiac arrest syndrome following resuscitated out-of-hospital cardiac arrest (the sterohca trial)

263 Pre-hospital high-dose glucocorticoid treatment for post-cardiac arrest syndrome following resuscitated out-of-hospital cardiac arrest (the sterohca trial)

In vivo cytosolic H2O2 changes and Ca2+ homeostasis in mouse skeletal muscle.

Hydrogen peroxide (H2O2) and calcium ions (Ca2+) are functional regulators of skeletal muscle contraction and metabolism. Although H2O2 is one of the activators of the type-1 ryanodine receptor (RyR1) in the Ca2+ release channel, the interdependence between H2O2 and Ca2+ dynamics remains unclear. This study tested the following hypotheses using an in vivo model of mouse tibialis anterior (TA) skeletal muscle. 1. Under resting conditions, elevated cytosolic H2O2 concentration ([H2O2]cyto) leads to a concentration-dependent increase in cytosolic Ca2+concentration ([Ca2+]cyto) through its effect on RyR1. 2. In hypoxia (cardiac arrest) and muscle contractions (electrical stimulation), increased [H2O2]cyto induce Ca2+ accumulation. Cytosolic H2O2 (HyPer7) and Ca2+ (Fura-2) dynamics were resolved by TA bioimaging in C57BL/6J male mice under four conditions: Elevated exogenous H2O2, Cardiac arrest, Twitch and Tetanic contractions. Exogenous H2O2 (0.1-100mM) induced a concentration-dependent increase in [H2O2]cyto (+55%,0.1mM; +280%,100mM) and an increase in [Ca2+]cyto (+3%,1.0mM; +8%,10mM). This increase in [Ca2+]cyto was inhibited by pharmacological inhibition of RyR1 by dantrolene. Cardiac arrest-induced hypoxia increased [H2O2]cyto (+33%) and [Ca2+]cyto (+20%) 50min post-cardiac arrest. Compared to exogenous 1.0mM H2O2 condition, [H2O2]cyto after tetanic contractions rose less than one-tenth as much, while [Ca2+]cyto was 4.7-fold higher. In conclusion, substantial increases in [H2O2]cyto levels evoke only modest Ca2+ accumulation via their effect on the sarcoplasmic reticulum RyR1. On the other hand, contrary to hypoxia secondary to cardiac arrest, increases in [H2O2]cyto from contractions are small, indicating that H2O2 generation is unlikely to be a primary factor driving the significant Ca2+ accumulation after, especially tetanic, muscle contractions.

Hemoglobin as a prognostic marker for neurological outcomes in post-cardiac arrest patients: a meta-analysis

The aim of this study was to investigate the relationship between serum level of hemoglobin and neurological outcomes following cardiac arrest. Relevant studies were identified by searching electronic databases including PubMed, Web of Science, Cochrane Library, and Embase from June 2012 through April 2023. Articles were rigorously reviewed for their study inclusion and exclusion criteria. Pooled effect date was determined using the standardized mean difference (SMD) and 95% confidence intervals (CI). The Newcastle–Ottawa Scale was used to evaluate study quality. Subgroup analyses were conducted to determine confounding factors affecting patient outcomes. Study heterogeneity, sensitivity, and publication bias were also determined.This meta-analysis included 11 studies involving 2519 patients. Our results suggest that high serum level of hemoglobin may improve neurological prognosis(SMD = 0.60, 95%CI = 0.49–0.71, I2 = 10.85). The findings of this study indicate that serum level of hemoglobin may be associated with better neurological prognosis, perhaps an appropriate increase in serum haemoglobin levels can improve the neurological prognosis of patients in cardiac arrest.

Effect of percutaneous ventricular assisted device on post-cardiac arrest myocardial dysfunction in swine model with prolonged cardiac arrest

BackgroundIt remains unclear if percutaneous left ventricular assist device (pLVAD) reduces post-cardiac arrest myocardial dysfunction. MethodsThis is a prespecified analysis of a subset of swine that achieved return of spontaneous circulation (ROSC) in a study comparing pLVAD, transient aortic occlusion (AO), or both during cardiopulmonary resuscitation (CPR). Devices were initiated after 24 minutes of ventricular fibrillation cardiac arrest (8 min no-flow and 16 min mechanical CPR). AO was discontinued post-ROSC, and pLVAD support or standard care were continued. Beginning 60 minutes post-ROSC, pLVAD support was weaned to < 1.0 L/min and subsequently removed at 240 minutes. The primary outcome was cardiac index (CI), stroke volume index (SVI), and left ventricular ejection fraction (LVEF) at 240 minutes post-ROSC. Data are shown as mean (standard error). ResultsSeventeen swine achieved ROSC without complication and were included in this analysis (pLVAD group, n = 11 and standard care group, n = 6). For the primary outcomes, the pLVAD group had significantly higher CI of 4.2(0.3) vs. 3.1(0.4) L/min/m2 (p = 0.043) and LVEF 60(3) vs. 49(4) % (p = 0.029) at 240 minutes after ROSC when compared with the standard care group, while SVI was not statistically significantly different (32[3] vs. 23[4] mL/min/m2, p = 0.054). During the first 60 minutes post-ROSC, the pLVAD group had significantly higher coronary perfusion pressure, lower LV stroke work index, and total pulmonary resistance index. ConclusionThese results suggest that early pLVAD support after ROSC is associated with better recovery myocardial function compared to standard care after prolonged cardiac arrest.

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.

Prediction of the neurological outcomes post-cardiac arrest: A prospective validation of the CAST and rCAST

IntroductionThe neurologic prognosis of out-of-hospital cardiac arrest (OHCA) patients in whom return of spontaneous circulation (ROSC) is achieved remains poor. The aim of this study was to externally and prospectively validate two scoring systems developed by us: the CAST score, a scoring system to predict the neurological prognosis of OHCA patients undergoing targeted temperature management (TTM), and a simplified version of the same score developed for improved ease of use in clinical settings, the revised CAST (rCAST) score. MethodsThis study was a prospective, multicenter, observational study conducted using the SOS KANTO 2017 registry, an OHCA registry involving hospitals in the Kanto region (including Tokyo) of Japan. The primary outcome was favorable neurological outcome (defined as Cerebral Performance Category score of 1 or 2) at 30 days and the secondary outcomes were favorable neurological outcome at 90 days and survival at 30 and 90 days. The predictive accuracies of the original CAST (oCAST) and rCAST scores were evaluated by using area under the receiver operating characteristic curve (AUC). ResultsOf 9909 OHCA patients, 565 showed ROSC and received TTM. Of these, we analyzed the data of 259 patients in this study. The areas under the receiver operating characteristic curve (AUCs) of the oCAST and rCAST scores for predicting a favorable neurological outcome at 30 days were 0.86 and 0.87, respectively, and those for predicting a favorable neurological outcome at 90 days were 0.87 and 0.88, respectively. The rCAST showed a higher predictive accuracy for the neurological outcome as compared with the NULL-PLEASE score. The patients with a favorable neurological outcome who had been classified into the high severity group based on the rCAST tended to have hypothermia at hospital arrival and to not show any signs of loss of gray-white matter differentiation on brain CT. Neurological function at 90 days was correlated with the rCAST (r = 0.63, p < 0.001). ConclusionsrCAST showed high predictive accuracy for the neurological prognosis of OHCA patients managed by TTM, comparable to that of the oCAST score. The scores on the rCAST were strongly correlated with the neurological functions at 90 days, implying that the rCAST is a useful scale for assessing the severity of brain injury after cardiac arrest.

Correlation of immature/total granulocyte ratio with return of spontaneous circulation and early mortality in nontraumatic out-of-hospital cardiac arrest

Objective: Aim of this study was to examine immature granulocyte/total granulocyte (IG/TG) ratio for prediction of return of spontaneous circulation (ROSC) and early mortality in post cardiac arrest survivors.&#x0D; Methods: The study was carried out prospectively between January 2021 and January 2022. Non-traumatic out-of-hospital cardiac arrest (OHCA), over the age of 18 and non-pregnant were included. Patients’ whose IG levels were not studied, with hematological disease and who receiving immunosuppressive therapy were excluded. A palpable pulsation of the main arteries for at least 15 minutes was considered ROSC. Data were compared between the&lt;4 hour and ≥4 hour survival groups and patients with and without ROSC.&#x0D; Results: Total of 254 OHCA patients were included in the study. ROSC was achieved in 84 (33.1%) of these patients and 170 (66.9%) patients were died. There were 28 patients (33.3%) with survival of &lt;4 hours and 56 patients (66.7%) with survival of ≥4 hours in patients with ROSC. The IG count and IG/TG ratio did not differ significantly between the ROSC groups and between the groups separated by survival time (P&gt;0.05).&#x0D; Conclusion: We found no significant differences between subgroups defined according to survival duration. Similarly, no differences found between OHCA patients with and without sustained ROSC.

The relationship between the level of NMLR on admission and the prognosis of patients after cardiopulmonary resuscitation: a retrospective observational study

BackgroundThe inflammatory immune response is involved in the pathophysiology of the post-cardiac arrest syndrome and leads to high mortality. The admission (neutrophil + monocyte) to lymphocyte ratio (NMLR) can help us to assess the immune inflammatory status of patients. We aimed to identify factors that affect the prognosis and explore the association between NMLR and the prognosis of patients after cardiopulmonary resuscitation (CPR).MethodsThis is a retrospective study based on the MIMIC-IV database. We assessed patients admitted to the ICU after cardiopulmonary resuscitation, included demographic characteristics, peripheral blood cell count and blood gas indicators for the first time after admission to the ICU, developed a multivariate COX proportional-hazards model to explore prognostic factors, and divided patients into High NMLR and Low NMLR groups by cutoff values of NMLR. Propensity score matching (PSM) was used to adjust confounding factors.ResultsA total of 955 patients were included in the analysis, with 497 surviving and 458 dying during the follow-up period. In a multivariate Cox proportional-hazards model, age (RR 1.007, p = 0.0411), NMLR levels (RR 1.003, p = 0.0381), lactate (RR 1.097, p < 0.001) and hematocrit (RR 1.101, p < 0.001) were independent risk factors for patient death following CPR. Patients were divided into a high NMLR group (> 14.2) and a low NMLR group (≤ 14.2) based on the optimal threshold for NMLR. Compared to low NMLR group, high NMLR group had higher total vasoactive drugs and lower 28-day survival. After PSM, there were no differences in baseline characteristics. The high NMLR group still had a higher mortality rate (p = 0.001), lower 28-day survival (p = 0.001) and shorter length of stay (p = 0.005) compared to the low NMLR group.ConclusionsAge, NMLR levels, lactate levels and hematocrit were independent risk factors for death in patients after CPR. NMLR > 14.2 was associated with higher mortality and was a potential predictor of clinical outcome in patients after CPR.

Identification of post-cardiac arrest blood pressure thresholds associated with outcomes in children: an ICU-Resuscitation study

IntroductionThough early hypotension after pediatric in-hospital cardiac arrest (IHCA) is associated with inferior outcomes, ideal post-arrest blood pressure (BP) targets have not been established. We aimed to leverage prospectively collected BP data to explore the association of post-arrest BP thresholds with outcomes. We hypothesized that post-arrest systolic and diastolic BP thresholds would be higher than the currently recommended post-cardiopulmonary resuscitation BP targets and would be associated with higher rates of survival to hospital discharge.MethodsWe performed a secondary analysis of prospectively collected BP data from the first 24 h following return of circulation from index IHCA events enrolled in the ICU-RESUScitation trial (NCT02837497). The lowest documented systolic BP (SBP) and diastolic BP (DBP) were percentile-adjusted for age, height and sex. Receiver operator characteristic curves and cubic spline analyses controlling for illness category and presence of pre-arrest hypotension were generated exploring the association of lowest post-arrest SBP and DBP with survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1–3 or no change from baseline). Optimal cutoffs for post-arrest BP thresholds were based on analysis of receiver operator characteristic curves and spline curves. Logistic regression models accounting for illness category and pre-arrest hypotension examined the associations of these thresholds with outcomes.ResultsAmong 693 index events with 0–6 h post-arrest BP data, identified thresholds were: SBP > 10th percentile and DBP > 50th percentile for age, sex and height. Fifty-one percent (n = 352) of subjects had lowest SBP above threshold and 50% (n = 346) had lowest DBP above threshold. SBP and DBP above thresholds were each associated with survival to hospital discharge (SBP: aRR 1.21 [95% CI 1.10, 1.33]; DBP: aRR 1.23 [1.12, 1.34]) and survival to hospital discharge with favorable neurologic outcome (SBP: aRR 1.22 [1.10, 1.35]; DBP: aRR 1.27 [1.15, 1.40]) (all p < 0.001).ConclusionsFollowing pediatric IHCA, subjects had higher rates of survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome when BP targets above a threshold of SBP > 10th percentile for age and DBP > 50th percentile for age during the first 6 h post-arrest.