Comorbidity burden is not associated with higher mortality after out-of-hospital cardiac arrest*

Abstract

Objectives. We investigated whether comorbidity burden of comatose survivors of out-of-hospital cardiac arrest (OHCA) affects outcome and if comorbidity modifies the effect of target temperature management (TTM) on final outcome. Design. The TTM trial randomized 939 patients to 24?h of TTM at either 33 or 36?°C with no difference regarding mortality and neurological outcome. This post-hoc study of the TTM-trial formed a modified comorbidity index (mCI), based on available comorbidities from the Charlson comorbidity index (CCI). Results. Bystander cardiopulmonary resuscitation (CPR) decreased with higher comorbidity group, p?=?0.01. Comorbidity groups were univariately associated with higher mortality compared to mCI0 (HR_mCI1: 1.55, CI: 1.25–1.93, p?<?0.001, HR_mCI2: 2.01, CI: 1.55–2.62, p?<?0.001, HR_mCI ≥ 3: 2.16, CI: 1.57–2.97, p?<?0.001). When adjusting for confounders there was a consistent, nonsignificant association between level of comorbidity and mortality (HRm_C11: 1.17, CI: 0.92–1.48, p?=?0.21, HR_mCI2: 1.28, CI: 0.96–1.71, p?=?0.10, HR_mCI ≥ 3: 1.37, CI: 0.97–1.95, p?=?0.08). There was no interaction between comorbidity burden and level of TTM on outcome, p?=?0.61. Conclusion. Comorbidity burden was associated with higher mortality following OHCA, but when adjusting for confounders, the influence was no longer significant. The association between mCI and mortality was not modified by TTM. Comorbidity burden is associated with lower rates of bystander cardiopulmonary resuscitation after OHCA.     

Improved survival after an out-of-hospital cardiac arrest using new guidelines

Background: An out-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis. We hypothesized that the implementations of 2005 European Resuscitation Council resuscitation guidelines were associated with improved 30-day survival after OHCA.
Methods: We prospectively recorded data on all patients with OHCA treated by the Mobile Emergency Care Unit of Copenhagen in two periods: 1 June 2004 until 31 August 2005 (before implementation) and 1 January 2006 until 31 March 2007 (after implementation), separated by a 4-month period in which the above-mentioned change took place.
Results: We found that 30-day survival increased after the implementation from 31/372 (8.3%) to 67/419 (16%), P =0.001. ROSC at hospital admission, as well as survival to hospital discharge, were obtained in a significantly higher proportion from 23.4% to 39.1%, P <0.0001, and from 7.9% to 16.3%, P =0.0004, respectively. Treatment after implementation was confirmed as a significant predictor of better 30-day survival in a logistic regression analysis.
Conclusion: The implementation of new resuscitation guidelines was associated with improved 30-day survival after OHCA.     

Importance of comorbidities in comatose survivors of shockable and non-shockable out-of-hospital cardiac arrest treated with target temperature management

Objective. Comorbidity prior to out-of-hospital cardiac arrest (OHCA) and primary rhythm in relation to survival is not well established. We aimed to assess the prognostic importance of comorbidity in relation to primary rhythm in OHCA-patients treated with Target Temperature Management (TTM). Design. Consecutive comatose survivors of OHCA treated with TTM in hospitals in the Copenhagen area between 2002–2011 were included. Utstein-based pre- and in-hospital data collection was performed. Data on comorbidity was obtained from The Danish National Patient Register and patient charts, assessed by the Charlson Comorbidity Index (CCI). Results. A total of 666 patients were included. A third (n?=?233, 35%) presented with non-shockable rhythm, and they were less often male (64% vs. 82%, p?p?p?p?p?p?=?.34). No significant interaction between primary rhythm and comorbidity in terms of mortality was present. Conclusion. A higher comorbidity burden was independently associated with a higher 30-day mortality rate in patients presenting with non-shockable primary rhythm but not in patients with shockable rhythm.     

Auditory brainstem responses after out-of-hospital cardiac arrest: Are they useful for outcome prediction?

We evaluated whether we could predict the neurologic outcome in 55 out-of-hospital cardiac arrest patients using auditory brainstem responses (ABR). ABR patterns were classified into one of 3 types by evaluation of 5 components: type 1, with all 5 components; type 2, lack of at least one response between the 2nd and 5th components; type 3, with only the first component or no response. The relation between the ABR patterns on the 3rd day following resuscitation and the neurologic outcome on hospital discharge was evaluated. The specificity that the 5 awake patients had type-1 ABR was 38%. The sensitivity that the 10 brain dead patients had type-3 ABR was 60%. In the type-1 ABR patients, the negative predictive value that the patients were awake was 100%. In the type-3 ABR patients, the negative predictive value that the patients became brain dead was 90.9%. These results suggest that ABR on the 3rd post-resuscitation day may not be useful for predicting if patients are awake or become brain dead, although the loss of components may be a sign of morbidity, and the presence of the 2nd or later components indicates possible future prevention of brain death.     

Medical futility in asystolic out-of-hospital cardiac arrest

Objectives: To study the factors associated with short- and long-term survival after asystolic out-of-hospital cardiac arrest, with a reference to medical futility.
Methods: This is a retrospective observational study conducted in Helsinki, Finland during 1 January 1997 to 31 December 2005. All out-of-hospital cardiac arrests were prospectively registered in the cardiac arrest database. Of 3291 arrests, 1455 had asystole as the first registered rhythm. These patients represent the study population.
Results: A short time interval to the initiation of advanced life support (ALS) was associated with a long-term benefit, but a short first responding unit (FRU) response time had only a short-term benefit. Conversion of asystole into a shockable rhythm provided only a short-term benefit. The prognosis was poor if the FRU response time was over 10 min or the ALS response time was over 11 min in bystander-witnessed arrests, and if the duration of resuscitation was over 8 min in emergency medical services (EMS)-witnessed arrests. Bystander-CPR was associated with increased 30-day mortality. The 30-day survival rate after an unwitnessed arrest ( n =548) was 0.5%. All survivors in this group were either hypothermic or were victims of near-drowning.
Conclusions: Resuscitation should be withheld in cases of unwitnessed asystole, excluding cases of hypothermia and near-drowning. The prognosis is poor if the FRU response time is over 10 min or the ALS response time is over 10–15 min in bystander-witnessed arrests. The decision of whether or not to attempt resuscitation should not be influenced by the presence of bystander-CPR. Early initiation of ALS should be prioritised in the treatment of out-of-hospital asystole.     

An unexpected cause of cardiac arrest during laparoscopy in an infant with supravalvar aortic stenosis

Patients with congenital supravalvar aortic stenosis (SVAS) with associated biventricular outflow tract obstruction and coronary artery abnormalities have a tenuous myocardial oxygen supply/demand relationship. They are at increased risk of acute myocardial ischemia and sudden death, especially during anesthesia. Furthermore, resuscitation during cardiac arrest is frequently unsuccessful. We report a case of perioperative cardiac arrest due to an unexpected cause in a 2 month old with SVAS during a laparoscopic Nissen fundoplication.     

Helicopter emergency medical service in out-of-hospital cardiac arrest--a 10-year population-based study

BACKGROUND: In 1988, Norway established a countrywide, physician staffed helicopter emergency medical service (HEMS). The medical benefit remains controversial. The aim of this study was to estimate the population incidence of HEMS involvement in out-of-hospital cardiac arrest, report the patient outcome and evaluate the contribution of HEMS to survival. METHODS: We studied HEMS operations in central Norway (population 364,000) during a 10-year period (1988-1997). Missions were classified according to type and quality of intervention done by the primary care providers. HEMS witnessed cardiac arrests were not considered. Patient outcome was determined as survival to hospital discharge with cerebral performance category (CPC) score. The contribution made by HEMS in each survivor was assessed from the timing of return of spontaneous circulation (ROSC) and from subsequent need for advanced medical intervention. The relation between survival and HEMS response time was investigated by ordinal correlation. RESULTS: A total of 541 requests (14.9 per 100,000 inhabitants per year) were identified, of which 424 missions were completed. Overall survival to discharge was 36/541 (6.6%), yielding a population survival incidence of 1 per 100,000 per year. Ninety-five percent of survivors made a favourable cerebral outcome (CPC 1 or 2). General practitioners/ambulance personnel resuscitated 29 out of 36 survivors. The remainder achieved ROSC after HEMS arrival. Case by case, HEMS assistance was considered possibly important in 17 survivors. We found no relation between survival and HEMS response time (P=0.77). DISCUSSION: Survival following out-of-hospital cardiac arrest assisted by HEMS in this region is low, but not negligible. While primary care is most important, HEMS may possibly contribute to the additional survival of 0.19 to 0.46 patients per 100,000 per year. This benefit appears to be independent of HEMS response time.     

Ubiquitin C-terminal hydrolase L1 after out-of-hospital cardiac arrest

Background

We studied the prognostic ability of serum ubiquitin C-terminal hydrolase L1 (UCH-L1) after out-of-hospital cardiac arrest (OHCA), compared to that of neuron-specific enolase (NSE).

Methods

In this post-hoc analysis of the FINNRESUSCI study, we measured serum concentrations of UCH-L1 in 249 OHCA patients treated in 21 Finnish intensive care units in 2010–2011. We evaluated the ability of UCH-L1 to predict unfavourable outcome at 12 months (defined as cerebral performance category 3–5) by assessing the area under the receiver operating characteristic curve (AUROC), in comparison with NSE.

Results

The concentrations of UCH-L1 were higher in patients with unfavourable outcome than for those with favourable outcome: median concentration 10.8 ng/mL (interquartile range, 7.5–18.5 ng/mL) versus 7.8 ng/mL (5.9–11.8 ng/mL) at 24 h (p < .001), and 16.2 ng/mL (12.2–27.7 ng/mL) versus 11.5 ng/mL (9.0–17.2 ng/mL) (p < .001) at 48 h after OHCA. For UCH-L1 as a 12-month outcome predictor, the AUROC was 0.66 (95% confidence interval, 0.60–0.73) at 24 h and 0.66 (0.59–0.74) at 48 h. For NSE, the AUROC was 0.66 (0.59–0.73) at 24 h and 0.72 (0.65–0.80) at 48 h. The prognostic ability of UCH-L1 was not different from that of NSE at 24 h (p = .82) and at 48 h (p = .23).

Conclusion

Concentrations of UCH-L1 in serum were higher in patients with unfavourable outcome than in those with favourable outcome. However, the ability of UCH-L1 to predict unfavourable outcome after OHCA was only moderate and not superior to that of NSE.     

Pneumopericardium: an unusual cause for cardiac arrest

A 1-year-old boy breathing via a T-piece system and recovering from meningococcal septicaemia in the intensive care unit suffered a severe bout of coughing and developed bilateral pneumothoraces and tension pneumopericardium resulting in electromechanical dissociation and asystole. Conventional cardiopulmonary resuscitation and adrenaline boluses were unsuccessful. Administration of 20 ml.kg⁻¹ of colloid and 3 mmol.kg⁻¹ of sodium bicarbonate solutions produced instantaneous return of cardiac output. The deleterious effects of cardiac tamponade appeared to decrease with increasing cardiac filling pressures. The patient was managed conservatively and he made a full recovery with no signs of residual neurological deficit.     

The functional status and perceived quality of life in long-term survivors of out-of-hospital cardiac arrest

BACKGROUND: Limited data exist on how long-term survivors after pre-hospital cardiac arrest lead their lives. This study assessed functional status and perceived quality of life in patients surviving for 15 years after successful resuscitation from witnessed out-of-hospital cardiac arrest as a result of ventricular fibrillation. METHODS: A 15-year follow-up study of 59 1-year survivors after successful pre-hospital resuscitation who were thoroughly evaluated at 3 and 12 months after out-of-hospital cardiac arrest. Eleven patients were still alive 15 years later. Ten of them were reached and underwent a comprehensive neuropsychological and neurological examination. Cognitive performance was evaluated and compared with individual results 15 years earlier and with an age-matched control group. The cause and time of death of the non-survivors were established. RESULTS: All 10 evaluated long-term survivors lived at home and were independent in their activities of daily living. Their mean age was 72 years. In nine patients there was no change in the present neurological status compared with the status at 1 year after resuscitation, and in one patient it had improved. Five patients were cognitively intact. In four patients mild cognitive problems had emerged or slightly progressed. All but one were satisfied with their perceived quality of life. By the time of examination, the mean survival time for the 1-year survivors was 7 years, and the mean age at the time of death was 70 years. CONCLUSION: Once good outcome after cardiac arrest is achieved, it can be maintained for more than 10 years.     

Association between spinal immobilization and survival at discharge for on-scene blunt traumatic cardiac arrest: A nationwide retrospective cohort study

IntroductionSpinal immobilization has been indicated for all blunt trauma patients suspected of having cervical spine injury. However, for traumatic cardiac arrest (TCA) patients, rapid transportation without compromising potentially reversible causes is necessary. Our objective was to investigate the temporal trend of spinal immobilization for TCA patients and to examine the association between spinal immobilization and survival.MethodsWe conducted a retrospective cohort study using the Japan Trauma Data Bank 2004–2015 registry data. Our study population consisted of adult blunt TCA patients encountered at the scene of a trauma. The primary outcome was the survival proportion at hospital discharge, and the secondary outcome was the proportion achieving return of spontaneous circulation (ROSC). We examined the association between spinal immobilization and these outcomes using a logistic regression model based on imputed data sets with the multiple imputation method to account for missing data.ResultsAmong 4313 patients who met the inclusion criteria, 3307 (76.7%) were immobilized. The proportion of patients that underwent spinal immobilization gradually decreased from 82.7% in 2004–2006 to 74.0% in 2013–2015. 1.0% of immobilized and 0.9% of non-immobilized patients had severe cervical spine injury. Spinal immobilization was significantly associated with lower survival at discharge (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.42 to 0.98) and ROSC by admission (OR, 0.48; 95%CI, 0.27 to 0.87). There was no significant sub-group difference of the association between spinal immobilization and survival at discharge by patients with or without cervical spine injury (p for interaction 0.73).ConclusionSpinal immobilization is widely used even for blunt TCA patients, even though it is associated with a lower rate of survival at discharge and ROSC by admission. According to these results, we suggest that spinal immobilization should not be routinely recommended for all blunt TCA patients.     

Therapeutic hypothermia after out-of-hospital cardiac arrest: experiences with patients treated with percutaneous coronary intervention and cardiogenic shock

BACKGROUND: Therapeutic hypothermia has been shown to increase survival after out-of-hospital cardiac arrest (OHCA). The trials documenting such benefit excluded patients with cardiogenic shock and only a few patients were treated with percutaneous coronary intervention prior to admission to an intensive care unit (ICU). We use therapeutic hypothermia whenever cardiac arrest patients do not wake up immediately after return of spontaneous circulation. METHODS: This paper reports the outcome of 50 OHCA patients with ventricular fibrillation admitted to a tertiary referral hospital for immediate coronary angiography and percutaneous coronary intervention when indicated. Patients were treated with intra-aortic balloon counterpulsation (IABP) (23 of 50 patients) if indicated. All patients who were still comatose were treated with therapeutic hypothermia at 32-34 degrees C for 24 h before rewarming. The end-points were survival and cerebral performance category (CPC: 1, best; 5, dead) after 6 months. RESULTS: Forty-one patients (82%) survived until 6 months. Thirty-four patients (68%) were in CPC 1 or 2, and seven (14%) were in CPC 3. Of the 23 patients treated with IABP, 14 (61%) survived with CPC 1 or 2. In patients not treated with IABP, 20 patients (74%) survived with CPC 1 or 2. Forty patients (80%) developed myocardial infarction. Percutaneous coronary intervention was performed in 36 patients (72%). CONCLUSION: In OHCA survivors who reached our hospital, the survival rate was high and the neurological outcome acceptable. Our results indicate that the use of therapeutic hypothermia is justified even in haemodynamically unstable patients and those treated with percutaneous coronary intervention.     

Incidence of regurgitation and pulmonary aspiration of gastric contents in survivors from out-of-hospital cardiac arrest

Background:  The regurgitation of gastric contents and subsequent pulmonary aspiration remain serious adverse events in cardiac arrest and cardiopulmonary resuscitation. The aim of this study was to determine the association between clinical signs of regurgitation and radiological findings consistent with aspiration in resuscitated out-of-hospital cardiac arrest (OHCA) patients admitted to hospital.
Methods:  The incidence of regurgitation was studied in 182 successfully resuscitated OHCA patients. The inclusion criterion was the restoration of spontaneous circulation after OHCA not caused by trauma or drug overdose.
Results:  The incidence of regurgitation was 20%. Regurgitation was associated with radiological findings consistent with aspiration with a high specificity (81%) and a low sensitivity (46%).
Conclusions:  Although there was a strong association between clinical regurgitation and radiological findings consistent with aspiration, our data suggest that regurgitation is not invariably followed by radiological findings compatible with aspiration. Radiological findings consistent with aspiration are relatively infrequent without preceding signs of regurgitation in resuscitated patients.     

急性心肌梗死合并心肺骤停护理措施及预防多脏器衰竭的价值

目的：探讨急性心肌梗死合并心肺骤停护理措施,并分析其预防多脏器衰竭的临床价值。方法选择患者80例,分为两组,各40例,观察组实施本研究护理干预方法,对照组则实施常规护理,比较两组心跳恢复时间、呼吸恢复时间,并统计两组发生的并发症及整体抢救成功率。结果观察组心跳恢复时间和呼吸恢复时间均显著快于对照组（P ＜0.05）,观察组发生肋骨骨折、急性肾功能衰竭及脑梗死的比例显著低于对照组（P ＜0.05）,且抢救成功率显著高于对照组（P ＜0.05）。结论有效的护理配合对于提高患者抢救成功率,减少全身重要脏器损伤具有积极意义。