Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest

Introduction

We sought to compare characteristics of emergency medical services-treated out-of-hospital cardiac arrests resulting from suspected drug overdose with non-overdose cases and test the relationship between suspected overdose and survival to hospital discharge.

Methods

Data from emergency medical services-treated, non-traumatic out-of-hospital cardiac arrests from 2006 to 2008 and late 2009 to 2011 were obtained from four EMS agencies in the Pittsburgh, Pennsylvania metropolitan area. Case definition for suspected drug overdose was naloxone administration, indication on the patient care report and/or indication by a review of hospital records. Resuscitation parameters included chest compression fraction, rate, and depth and the administration of resuscitation drugs. Demographic and outcome variables compared by suspected overdose status included age, sex, and survival to hospital discharge.

Results

From 2342 treated out-of-hospital cardiac arrests, 180 were suspected overdose cases (7.7%) and were compared to 2162 non-overdose cases. Suspected overdose cases were significantly younger (45 vs. 65, p < 0.001), less likely to be witnessed by a bystander (29% vs. 41%, p < 0.005), and had a higher rate of survival to hospital discharge (19% vs. 12%, p = 0.014) than non-overdoses. Suspected overdose cases had a higher overall chest compression fraction (0.69 vs. 0.67, p = 0.018) and higher probability of adrenaline, sodium bicarbonate, and atropine administration (p < 0.001). Suspected overdose status was predictive of survival to hospital discharge when controlling for other variables (p < 0.001).

Conclusion

Patients with suspected overdose-related out-of-hospital cardiac arrest were younger, received different resuscitative care, and survived more often than non-overdose cases.     

Targeted temperature management after cardiac arrest with anaphylaxis

Fatal anaphylaxis is uncommon but not rare. Extrapolated mortality rates are 0.52% of total anaphylaxis patients Bock et al. (Jan. 2001) [1]. Nevertheless, compared with the incidence of the other cardiac arrest events, the incidence of cardiac arrest due to anaphylaxis is relatively small. As a result, the effect using targeted temperature management after anaphylaxis is not clearly understood. We report the case of a 63-year-old man who developed cardiac arrest after ingestion of two pieces of peach. He was resuscitated and his circulation returned spontaneously after approximately 11 min of cardiopulmonary resuscitation, but he was unresponsive and had fixed dilated pupils. We initiated therapeutic hypothermia on the basis of protocol for 24 h. The patient was gradually and successfully cooled and rewarmed. The patient opened his eyes spontaneously on day 5, obeyed commands on day 6, and was discharged on day 18. At the time of discharge, he had no neurologic deficiencies or other complications.     

Time to awakening and neurologic outcome in therapeutic hypothermia-treated cardiac arrest patients

Introduction

Therapeutic hypothermia (TH) has been shown to improve outcomes in comatose Post-Cardiac Arrest Syndrome (PCAS) patients. It is unclear how long it takes these patients to regain neurologic responsiveness post-arrest. We sought to determine the duration to post-arrest awakening and factors associated with times to such responsiveness.

Methods

We performed a retrospective chart review of consecutive TH-treated PCAS patients at three hospitals participating in a US cardiac arrest registry from 2005 to 2011. We measured the time from arrest until first documentation of “awakening”, defined as following commands purposefully.

Results

We included 194 consecutive TH-treated PCAS patients; mean age was 57 ± 16 years; 59% were male; 40% had an initial shockable rhythm. Mean cooling duration was 24 ± 8 h and mean rewarming time was 14 ± 13 h. Survival to discharge was 44%, with 78% of these discharged with a good neurologic outcome. Of the 85 patients who awakened, median time to awakening was 3.2 days (IQR 2.2, 4.5) post-cardiac arrest. Median time to awakening for a patient discharged in good neurological condition was 2.8 days (IQR 2.0, 4.5) vs. 4.0 days (IQR 3.5, 7.6) for those who survived to discharge without a good neurological outcome (p = 0.035). There was no significant association between initial rhythm, renal insufficiency, paralytic use, post-arrest seizure, or location of arrest and time to awakening.

Conclusion

In TH-treated PCAS patients, time to awakening after resuscitation was highly variable and often longer than three days. Earlier awakening was associated with better neurologic status at hospital discharge.     

Methylphenidate and amantadine to stimulate reawakening in comatose patients resuscitated from cardiac arrest

Background

Despite critical-care packages including therapeutic hypothermia (TH), neurologic injury is common after cardiac arrest (CA) resuscitation. Methylphenidate and amantadine have treated coma in traumatically-brain-injured patients with mixed success, but have not been explored in post-arrest patients.

Objective

Compare the outcome of comatose post-arrest patients treated with neurostimulants to a matched cohort.

Methods

Retrospective cohort study from 6/2008 to 12/2011 in a tertiary university hospital. We included adult patients treated with methylphenidate or amantadine after resuscitation from in-hospital or out-of-hospital CA (OHCA) of any rhythm, excluding patients with traumatic/surgical etiology of arrest, terminal re-arrest within 6 h, or withdrawal of care by family within 6 h. Primary outcome was following commands; secondary outcomes included survival to hospital discharge, cerebral performance category (CPC), and modified Rankin scale (mRS). We compared characteristics and outcomes to a control cohort matched on TH and 72 h FOUR score ± 1.

Results

Of 588 patients, 8 received methylphenidate, 6 received amantadine, and 2 both. Most were female suffering OHCA with median age 61 years. All received TH and a multi-modal neurological evaluation. Initial exam revealed median GCS 6 and FOUR 7, which was unchanged at 72 h. Six patients (38%) followed commands prior to discharge at median 2.5 days (range: 1–18 days) after treatment. Patients receiving neurostimulants trended toward improved rate of following commands, survival to hospital discharge, and distribution of CPC and mRS scores.

Conclusions

Neurostimulants may be considered to stimulate wakefulness in selected post-cardiac arrest patients, but a prospective trial is needed to evaluate this therapy.     

Thrombin-antithrombin levels are associated with survival in patients resuscitated from cardiac arrest

Background

Following successful resuscitation from cardiac arrest, a prothrombotic state may contribute to end-organ dysfunction. We examined whether the level of serum thrombin-antithrombin (TAT) in patients hospitalized after cardiac arrest was associated with survival or the development of multiple organ failure (MOF).

Methodology

A prospective cohort study of subjects with in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) treated between 1/1/2007 and 5/30/2010 at a single tertiary care referral center. TAT levels were measured at hospital arrival and 24 h after cardiac arrest. Logistic regression was used to determine associations between TAT levels and survival and development of MOF.

Results

Data were available for 86 subjects. TAT levels decreased over time. Initial TAT levels (OR 0.03; 95%CI 0.001, 0.62) and category of illness severity (OR 0.39; 95% CI 0.21, 0.73) were associated with survival. Male gender (OR 3.86; 95% CI 1.17, 12.75) and category of illness severity (OR 1.86; 95% CI 1.09, 3.20), but not TAT levels were associated with development of MOF. Neither the 24-h TAT level, nor the change in TAT from initial to 24 h was associated with survival when adjusted for category of illness severity.

Conclusions

Initial serum TAT levels and category of illness severity are associated with survival. TAT levels are not associated with development of MOF. Initial TAT levels may be a useful prognostic adjunct in the post arrest population.     

A structured educational intervention to improve targeted temperature management utilization after cardiac arrest

Purpose

Post-arrest targeted temperature management (TTM) has been shown to dramatically improve outcomes after resuscitation, yet studies have revealed inconsistent and slow adoption. Little is known about barriers to TTM implementation and methods to increase adoption. We hypothesized that a structured educational intervention might increase TTM use.

Materials and Methods

Subjects participated in mixed quantitative/qualitative surveys before and after attending a series of TTM educational courses from October 2010 to October 2011, to determine usage and barriers to implementation. A knowledge examination was also administered to participants before and after the course.

Results

Clinicians completed 227 surveys (129 pre-training and 98 post-training) and 343 exams (165 pre-training and 178 post-training). A ranking survey (score range 1-7; 7 as most challenging) found that communication challenges (mean score 4.7 ± 1.5) and lacking adequate education (4.3 ± 1.9) were the 2 most emphasized barriers to implementation. Post-survey results found that 95% (93/98) of respondents felt more confident initiating TTM post-intervention. There was a statistically significant increase in self-reported TTM usage after participation in the program (P < .01).

Conclusions

A focused TTM program led to increased confidence and usage among participants. Future work will focus on targeted training to address specific barriers and increase TTM utilization.     

Quality of evidence in studies evaluating neuroimaging for neurologic prognostication in adult patients resuscitated from cardiac arrest

Aim

Neuroimaging has been proposed as a predictor of neurologic outcome in comatose survivors of cardiac arrest. We reviewed the quality and level of evidence of the current neuroimaging literature for predicting neurologic outcome in cardiac arrest patients treated with or without therapeutic hypothermia (TH).

Data Sources

Medline, EMBASE, and Cochrane Databases were searched using the terms “cardiac arrest,” “cardiopulmonary resuscitation,” “brain hypoxia,” “brain anoxia,” “brain hypoxia-ischaemia,” “neuroimaging,” and “prognosis.” Eligible studies were reviewed and classified by level of evidence and methodological quality as defined by the International Liaison Committee on Resuscitation (ILCOR).

Results

928 studies were identified, 84 of which met inclusion criteria: 74 were supportive of neuroimaging to predict outcome, eight unsupportive, and two equivocal. Several studies investigated more than one imaging modality: 27 investigated computed tomography (CT), 46 magnetic resonance imaging (MRI), and 18 alternate imaging modalities, including positron emission tomography and single photon emission computed tomography. No randomized controlled trials were identified. Seven cohort and case control studies were identified, only one of which was graded “good” quality, two were “fair” and four were “poor.”

Conclusion

Neuroimaging is an evolving modality as a prognostic parameter in cardiac arrest survivors. However, the quality of the available literature is not robust, highlighting the need for higher quality studies before neuroimaging can be supported as a standard tool for prognostication in the patient population.     

Outcomes from out-of-hospital cardiac arrest in Detroit

OBJECTIVE: To determine the out-of-hospital cardiac arrest survival rate, and prevalence of modifiable factors associated with survival, in Detroit, Michigan, over a 6-month period of time in 2002. METHODS: A retrospective review of all out-of-hospital cardiac arrests responded to by the Detroit Fire Department, Division of Emergency Medical Services. All elements of the EMS runsheet were transcribed to a database for analysis. Patient hospital records were reviewed to determine survival to hospital admission. All survivors to hospital admission were surveyed later in the Michigan Department of Vital Records death registry search. RESULTS: During this study timeframe, there were 538 confirmed out-of-hospital cardiac arrests within the City of Detroit, of which 67 were excluded for being dead on scene [51 (12.5%)] or having no available hospital records [16 (3.0%)]. Of the remaining 471 patients, 443 (94.1%) died before hospital admission. Only 44 (9.9%) of the 471 patients had a first recorded rhythm of ventricular fibrillation (VF), and 339 (76.5%) were asystolic. Of the 28 patients who survived to hospital admission, only 2 (7.1%) were noted to have a first rhythm of VF, and 15 (53.6%) were asystolic. Only one patient survived to hospital discharge. CONCLUSIONS: In this urban setting, out-of-hospital cardiac arrest is an almost uniformly fatal event.     

Serum matrix metalloproteinases in patients resuscitated from cardiac arrest. The association with therapeutic hypothermia

Aim

To study the systemic levels of matrix metalloproteinases (MMP) -7, -8 and -9 and their inhibitor TIMP-1 in cardiac arrest patients and the association with mild therapeutic hypothermia treatment on the serum concentration of these enzymes.

Methods

MMP-7, -8 and -9 and tissue inhibitor of metalloproteinases-1 (TIMP-1) were analysed in blood samples obtained from 51 patients resuscitated from cardiac arrest. The samples were taken at 24 and 48 h from restoration of spontaneous circulation (ROSC). The biomarker levels were compared between patients (N = 51) and healthy controls (N = 10) and between patients who did (N = 30) and patients who did not (N = 21) receive mild therapeutic hypothermia.

Results

MMP-7 (median 0.47 ng/ml), MMP-8 (median 31.16 ng/ml) and MMP-9 (median 253.00 ng/ml) levels were elevated and TIMP-1 levels suppressed (median 78.50 ng/ml) in cardiac arrest patients as compared with healthy controls at 24 h from ROSC. Hypothermia treatment associated with attenuated elevation of MMP-9 (p = 0.001) but not MMP-8 (p = 0.02) or MMP-7 (p = 0.69). Concentrations of MMPs -7, -8 and -9 correlated with the leukocyte count but not with C-reactive protein (CRP) or neurone-specific enolase (NSE) levels.

Conclusion

We demonstrated that the systemic levels of MMP-7, -8 and -9 but not TIMP-1 are elevated in cardiac arrest patients in the 48 h post-resuscitation period relative to the healthy controls. Patients who received therapeutic hypothermia had lower MMP-9 levels compared to non-hypothermia treated patients, which generates hypothesis about attenuation of inflammatory response by hypothermia treatment.     

Naloxone in cardiac arrest with suspected opioid overdoses

Introduction

Naloxone's use in cardiac arrest has been of recent interest, stimulated by conflicting results in both human case reports and animal studies demonstrating antiarrhythmic and positive ionotropic effects. We hypothesized that naloxone administration during cardiac arrest, in suspected opioid overdosed patients, is associated with a change in cardiac rhythm.

Methods

From a database of 32,544 advanced life support (ALS) emergency medical dispatches between January 2003 and December 2007, a retrospective chart review was completed of patients receiving naloxone in cardiac arrest. Forty-two patients in non-traumatic cardiac arrest were identified. Each patient received naloxone because of suspicion by a paramedic of acute opioid use.

Results

Fifteen of the 36 (42%) (95% confidence interval [CI]: 26-58) patients in cardiac arrest who received naloxone in the pre-hospital setting had an improvement in electrocardiogram (EKG) rhythm. Of the participants who responded to naloxone, 47% (95% CI: 21-72) (19% [95% CI: 7-32] of all study subjects) demonstrated EKG rhythm changes immediately following the administration of naloxone.

Discussion

Although we cannot support the routine use of naloxone during cardiac arrest, we recommend its administration with any suspicion of opioid use. Due to low rates of return of spontaneous circulation and survival during cardiac arrest, any potential intervention leading to rhythm improvement is a reasonable treatment modality.     

Therapeutic benefits of mild hypothermia in patients successfully resuscitated from cardiac arrest: A meta-analysis

BACKGROUND:

Good neurological outcome after cardiac arrest (CA) is hard to achieve for clinicians. Experimental and clinical evidence suggests that therapeutic mild hypothermia is beneficial. This study aimed to assess the effectiveness and safety of therapeutic mild hypothermia in patients successfully resuscitated from CA using a meta-analysis.

METHODS:

We searched the MEDLINE (1966 to April 2012), OVID (1980 to April 2012), EMBASE (1980 to April 2012), Chinese bio-medical literature & retrieval system (CBM) (1978 to April 2012), Chinese medical current contents (CMCC) (1995 to April 2012), and Chinese medical academic conference (CMAC) (1994 to April 2012). Studies were included if 1) the study design was a randomized controlled trial (RCT); 2) the study population included patients successfully resuscitated from CA, and received either standard post-resuscitation care with normothermia or mild hypothermia; 3) the study provided data on good neurologic outcome and survival to hospital discharge. Relative risk (RR) and 95% confidence interval (CI) were used to pool the effect.

RESULTS:

The study included four RCTs with a total of 417 patients successfully resuscitated from CA. Compared to standard post-resuscitation care with normothermia, patients in the hypothermia group were more likely to have good neurologic outcome (RR=1.43, 95% CI 1.14–1.80, P=0.002) and were more likely to survive to hospital discharge (RR=1.32, 95% CI 1.08–1.63, P=0.008). There was no significant difference in adverse events between the normothermia and hypothermia groups (P>0.05), nor heterogeneity and publication bias.

CONCLUSION:

Therapeutic mild hypothermia improves neurologic outcome and survival in patients successfully resuscitated from CA.KEY WORDS: Cardiac arrest, Cardiopulmonary resuscitation, Return of spontaneous circulation, Mild hypothermia, Meta-analysis     

The effect of targeted temperature management on coagulation parameters and bleeding events after out-of-hospital cardiac arrest of presumed cardiac cause

AimsTargeted temperature management (TTM) is part of the standard treatment of comatose patients after out-of-hospital cardiac arrest (OHCA) to attenuate neurological injury. In other clinical settings, hypothermia promotes coagulopathy leading to an increase in bleeding and thrombosis tendency. Thus, concern has been raised as to whether TTM can be applied safely, as acute myocardial infarction requiring primary percutaneous coronary intervention (PCI) with the need of effective antiplatelet therapy is frequent following OHCA. This study investigated the influence of TTM at 33 or 36 °C on various laboratory and coagulation parameters.Methods and resultsIn this single-center predefined substudy of the TTM trial, 171 patients were randomized to TTM at either 33 or 36 °C in the postresuscitation phase. The two subgroups were compared regarding standard laboratory coagulation parameters, thrombelastography (TEG), bleeding, and stent thrombosis events. Platelet counts were lower in the TTM33-group compared to TTM36 (p = 0.009), but neither standard coagulation nor TEG-parameters showed any difference between the groups. TEG revealed a normocoagulable state in the majority of patients, while approximately 20% of the population presented as hypercoagulable. Adverse events included 38 bleeding events, one stent thrombosis, and one reinfarction, with no significant difference between the groups.ConclusionsThere was no evidence supporting the assumption that TTM at 33 °C was associated with impaired hemostasis or increased the frequency of adverse bleeding and thrombotic events compared to TTM at 36 °C. We found that TTM at either temperature can safely be applied in the postresuscitation phase after acute myocardial infarction and primary PCI.     

Outcomes of patients with trauma and intraoperative cardiac arrest

Background

Although the occurrence of intraoperative cardiac arrest is rare, it is a severe adverse event with a high mortality rate. Trauma patients have additional causes for intraoperative arrest, and we hypothesised that the survival of trauma patients who experienced intraoperative cardiac arrest would be worse than nontrauma patients who experienced intraoperative cardiac arrest.

Objectives

The aim of the present study was to compare the outcomes of trauma and nontrauma patients after intraoperative cardiac arrest.

Methods

In a tertiary university hospital and trauma centre, the intraoperative cardiac arrest cases were evaluated from January 2007 to December 2009, excluding patients submitted to cardiac surgery. Data were prospectively collected using the Utstein-style. Outcomes among the patients with trauma were compared to the patients without trauma.

Results

We collected data from 81 consecutive intraoperative cardiac arrest cases: 32 with trauma and 49 without trauma. Patients in the trauma group were younger than the patients in the nontrauma group (44 ± 23 vs. 63 ± 17, p < 0.001). Hypovolaemia (63% vs. 35%, p = 0.022) and metabolic/hydroelectrolytic disturbances (41% vs. 2%, p < 0.001) were more likely to cause the cardiac arrest in the trauma group. The first documented arrest rhythm did not differ between the groups, and pulseless electrical activity was the most prevalent rhythm (66% vs. 53%, p = 0.698). The return of spontaneous circulation (47% vs. 63%, p = 0.146) and survival to discharge with favourable neurological outcome (16% vs. 14%, p = 0.869) did not differ between the two groups.

Conclusions

The outcomes did not differ between patients with trauma and nontrauma intraoperative cardiac arrest.     

Pyrexia and neurologic outcomes after therapeutic hypothermia for cardiac arrest

Objective

Therapeutic hypothermia, also known as targeted temperature management (TTM), improves clinical outcomes in patients resuscitated from cardiac arrest. Hyperthermia after discontinuation of active temperature management (“rebound pyrexia”) has been observed, but its incidence and association with clinical outcomes is poorly described. We hypothesized that rebound pyrexia is common after rewarming in post-arrest patients and is associated with poor neurologic outcomes.

Methods

Retrospective multicenter US clinical registry study of post-cardiac arrest patients treated with TTM at 11 hospitals between 5/2005 and 10/2011. We assessed the incidence of rebound pyrexia (defined as temperature >38 °C) in post-arrest patients treated with TTM and subsequent clinical outcomes of survival to discharge and “good” neurologic outcome at discharge, defined as cerebral performance category (CPC) 1–2.

Results

In this cohort of 236 post-arrest patients treated with TTM, mean age was 58.1 ± 15.7 y and 106/236 (45%) were female. Of patients who survived at least 24 h after TTM discontinuation (n = 167), post-rewarming pyrexia occurred in 69/167 (41%), with a median maximum temperature of 38.7 (IQR 38.3–38.9). There were no significant differences between patients experiencing any pyrexia and those without pyrexia regarding either survival to discharge (37/69 (54%) v 51/98 (52%), p = 0.88) or good neurologic outcomes (26/37 (70%) v 42/51 (82%), p = 0.21). We compared patients with marked pyrexia (greater than the median pyrexia of 38.7 °C) versus those who experienced no pyrexia or milder pyrexia (below the median) and found that survival to discharge was not statistically significant (40% v 56% p = 0.16). However, marked pyrexia was associated with a significantly lower proportion of CPC 1–2 survivors (58% v 80% p = 0.04).

Conclusions

Rebound pyrexia occurred in 41% of TTM-treated post-arrest patients, and was not associated with lower survival to discharge or worsened neurologic outcomes. However, among patients with pyrexia, higher maximum temperature (>38.7 °C) was associated with worse neurologic outcomes among survivors to hospital discharge.     

An underrecognized source of organ donors: patients with brain death after successfully resuscitated cardiac arrest

Objective To identify predictors of brain death after successful resuscitation of out-of-hospital cardiac arrest (OHCA), with the goal of improving the detection of brain death, and to evaluate outcomes of solid organs harvested from these patients. Design and setting Prospective observational cohort study in a medical and surgical unit of a nonuniversity hospital. Patients Patients with successfully resuscitated OHCA were prospectively included in a database over a 7-year period. We looked for early predictors of brain death and compared outcomes of organ transplants from these patients to those from patients with brain death due to head injury or stroke. Results Over the 7-year period 246 patients were included. No early predictors of brain death were found. Of the 40 patients (16%) who met criteria for brain death, after a median ICU stay of 2.5 days (IQR 2.0–4.2), 19 donated 52 solid organs (29 kidneys, 14 livers, 7 hearts, and 2 lungs). Outcomes of kidneys and livers did not differ between donors with and without resuscitated cardiac arrest. Conclusions Brain death may occur in about one-sixth of patients after successfully resuscitated OHCA, creating opportunities for organ donation. C. A. received a grant from the publicly funded organization Agence de Biomédecine which manages organ donor data in France.     

The association between blood lactate concentration on admission, duration of cardiac arrest, and functional neurological recovery in patients resuscitated from ventricular fibrillation

Objective: To assess the association between arterial lactate concentration on admission and the duration of human ventricular fibrillation cardiac arrest, and to what degree the arterial lactate concentration on admission is an early predictor of functional neurological recovery in human cardiac arrest survivors. Design: Cohort study. Arterial lactate concentrations and out-of-hospital data concerning cardiac arrest and cardiopulmonary resuscitation were collected retrospectively according to a standardized protocol. Functional neurological recovery was assessed prospectively at regular intervals for 6 months. Setting: Emergency department of an urban tertiary care hospital. Patients: A total of 167 primary survivors of witnessed out-of-hospital ventricular fibrillation cardiac arrest. Measurements: The association between arterial lactate concentration on admission, the duration of cardiac arrest, and functional neurological recovery was assessed. Further, we assessed whether admission concentrations of arterial lactate and duration of cardiac arrest can predict unfavorable functional neurological recovery. Functional neurological recovery was measured in cerebral performance categories (CPC). No or minimal functional impairment (CPC 1 and 2) was defined as favorable outcome; the remaining categories (CPC 3, 4 and 5) were defined as unfavorable functional neurological recovery. Results: In 167 patients, a weak association between total duration of cardiac arrest and admission levels of lactate (r = 0.49, P < 0.001) could be shown. With increasing admission concentrations of arterial lactate functional neurological recovery was more likely to be unfavorable (OR 1.15 per mmol/l increase, 95 % CI 1.04–1.27). Nevertheless, only at very high levels of lactate (16.3 mmol/l) could unfavorable neurological recovery be detected with 100 % specificity, yielding a very low sensitivity of 16 %. Conclusions: The arterial admission lactate concentration after out-of-hospital ventricular fibrillation cardiac arrest is a weak measure of the duration of ischemia. High admission lactate levels are associated with severe neurological impairment. However, this parameter has poor prognostic value for individual estimation of the severity of subsequent functional neurological impairment. Received: 13 March 1997 / Accepted: 7 August 1997     

255例院前心搏骤停患者心肺复苏影响因素分析

目的了解6年来心肺复苏(CPR)现状,分析其影响因素,研究如何提高CPR水平。方法对本院2001-01～2007-01院前发生的255例心搏骤停(cardiacarrest,CA)患者的资料进行分析,比较自主循环恢复(ROSC)成功组和失败组的CPR开始时间、CPR持续时间、除颤次数、肾上腺素用量等。结果全部病例ROSC成功率为38.03%,脑复苏成功率仅为2.74%。两组CPR开始时间(从心脏停搏至CPR开始时间)、人工气道开始建立时间、是否安装临时起搏器、肾上腺素用量比较差异有统计学意义(P≤0.01),在CPR持续时间、除颤次数方面比较差异无统计学意义(P>0.05)。CPR成功率与CPR开始时间和急救水平高低有密切关系。结论CA患者CPR成功率较低,与"生命链"未彻底落实及急救水平低有关。普及全民急救知识,加强完善急救医疗体系建设,是提高CPR成功率的关键措施。     

End stage renal disease modifies the effect of targeted temperature management after out-of-hospital cardiac arrest

IntroductionKidney function can affect the permeability of the blood-brain barrier; thus, end-stage renal disease (ESRD) may alter the effects of targeted temperature management (TTM) on the neurological outcomes of out-of-hospital cardiac arrest (OHCA) patients. We aimed to investigate whether the interaction effect of TTM on outcomes after OHCA was observed among patients with and without ESRD.MethodsAdult OHCA patients with presumed cardiac etiology who attained sustained return of spontaneous circulation from 2013 to 2017 were included using nationwide OHCA registry. The main exposure variable was TTM. The primary endpoint was survival with good neurological recovery. Multivariable logistic regression analysis was performed after adjustment for potential confounders. To compare the effect of ESRD on TTM, an interaction term (TTM × ESRD) was added to the model.ResultsA total of 21,250 patients were included in the analysis; 2693 (12.7%) patients underwent TTM. ESRD was observed in 128 (4.8%) in the TTM group and 767 (4.1%) in the no-TTM group. The TTM group showed better outcomes than the no-TTM group (32.4% vs. 17.2%, p < 0.01). The adjusted odds ratio of TTM for good neurological recovery in the entire study group was 1.15 (95% CI, 1.03–1.29). In the interaction model, the adjusted odds ratio of TTM for good neurological recovery was 0.47 (95% CI, 0.23–0.98) in the ESRD group vs. 1.54 (95% CI, 1.00–2.39) in the no-ESRD group.ConclusionsThe interaction effect between ESRD and TTM on neurologic outcome was positive in adult OHCA initial survivors with presumed cardiac etiology.     

Hypocalcemia following resuscitation from cardiac arrest revisited

Objective

Hypocalcemia associated with cardiac arrest has been reported. However, mechanistic hypotheses for the decrease in ionized calcium (iCa) vary and its importance unknown. The objective of this study was to assess the relationships of iCa, pH, base excess (BE), and lactate in two porcine cardiac arrest models, and to determine the effect of exogenous calcium administration on post-resuscitation hemodynamics.

Methods

Swine were instrumented and VF was induced either electrically (EVF, n = 65) or spontaneously, ischemically induced (IVF) with balloon occlusion of the LAD (n = 37). Animals were resuscitated after 7 min of VF. BE, iCa, and pH, were determined prearrest and at 15, 30, 60, 90, 120 min after ROSC. Lactate was also measured in 26 animals in the EVF group. Twelve EVF animals were randomized to receive 1 g of CaCl₂ infused over 20 min after ROSC or normal saline.

Results

iCa, BE, and pH declined significantly over the 60 min following ROSC, regardless of VF type, with the lowest levels observed at the nadir of left ventricular stroke work post-resuscitation. Lactate was strongly correlated with BE (r = −0.89, p < 0.0001) and iCa (r = −0.40, p < 0.0001). In a multivariate generalized linear mixed model, iCa was 0.005 mg/dL higher for every one unit increase in BE (95% CI 0.003-0.007, p < 0.0001), while controlling for type of induced VF. While there was a univariate correlation between iCa and BE, when BE was included in the regression analysis with lactate, only lactate showed a statistically significant relationship with iCa (p = 0.02). Post-resuscitation CaCl₂ infusion improved post-ROSC hemodynamics when compared to saline infusion (LV stroke work control 8 ± 5 g m vs 23 ± 4, p = 0.014, at 30 min) with no significant difference in tau between groups.

Conclusions

Ionized hypocalcemia occurs following ROSC. CaCl₂ improves post-ROSC hemodynamics suggesting that hypocalcemia may play a role in early post-resuscitation myocardial dysfunction.