Decrease in the occurrence of ventricular fibrillation as the initially observed arrhythmia after out-of-hospital cardiac arrest during 11 years in Sweden

Aim: To describe the change in the occurrence of ventricular fibrillation as initially observed arrhythmia among patients suffering from out-of-hospital cardiac arrest in Sweden. Patients: All patients included in the Swedish cardiac arrest registry between 1991 until 2001. The registry covers 85% of the population in Sweden. Methods: All patients with bystander witnessed out-of-hospital cardiac arrest included in the Swedish Cardiac Arrest Registry between 1991 and 2001 from the same ambulance organisation each year were included in the survey. Results: Over 11 years, among patients in Sweden with a bystander witnessed out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation (CPR) was attempted (n=9666), the occurrence of ventricular fibrillation as the initially obseved arrhythmia decreased from 45% in 1991 to 28% in 2001 (P<0.0001) if the arrest occurred at home, and from 57% to 41% if the arrest occurred outside home (P<0.0001). This was found despite the fact that the proportion who received bystander CPR increased from 29% in 1991 to 39% in 2001 if the arrest occurred at home (P<0.0001) and from 54% to 60% if the arrest occurred outside home (NS). There was a significant increase in age among patients with out-of-hospital cardiac arrest at home, no change in the estimated interval between collapse and call but an increase in the interval between call and arrival of the ambulance among patients with out-of-hospital cardiac arrest outside home. Conclusion: During 11 years in Sweden, there was a marked decrease in the proportion of patients found in ventricular fibrillation among patients with a bystander witnessed cardiac arrest regardless whether the arrest occurred at home or outside home. A modest increase in age and interval between call for, and arrival of, the ambulance was associated with these findings.     

Effects of intraaortic balloon augmentation in a porcine model of endotoxemic shock

Objective: Patients with septic shock commonly have myocardial dysfunction associated with lactic acid production and troponin I release. The purpose of this study was to evaluate the effects on intraaortic balloon pump (IABP) support on myocardial dysfunction. Design: Prospective, randomized controlled study. Setting: Animal research laboratory. Methods: Ten pigs had arterial, pulmonary arterial, and coronary catheters inserted. After receiving endotoxin infusion over 30 min, half the animals received IABP support. Results: Coronary sinus lactic acid levels (P<0.05 for both 90 min versus baseline and 60 min versus baseline) and arterial lactic acid levels (P<0.05 for both 90 min versus baseline and 60 min versus baseline) increased with time but did not differ between IABP and sham groups. While overall there was no difference with time in myocardial lactic acid consumption or production (calculated as arterial lactic acid level minus coronary sinus lactic acid level), the IABP group showed net myocardial lactic acid consumption at 90 min, while the sham group showed myocardial lactic acid production. Three of five animals in each group showed troponin I release. The levels were similar and did not differ between groups. Conclusion: IABP had no benefits in this porcine model of endotoxemic shock.     

Does race or socioeconomic status predict adverse outcome after out of hospital cardiac arrest: a multi-center study

Objective: To assess whether socioeconomic status (SES) or race is associated with adverse outcome after an out-of-hospital cardiac arrest (OHCA). Methods: A convenience sample of OHCA of presumed cardiac origin from seven suburban cities in Michigan, 1991–1996. Median household income (HHI), utilizing patient home address and 1990 census tract data, was dichotomized above and below 1990 state median income. Patient race was dichotomized as black or white. Outcome was defined as survival to hospital discharge (DC). Multiple logistic regression and Pearson’s χ² values were used for analysis. Results: Of 1317 cases with complete data for analysis, the average age was 67.3±16.0, 939 (71.1%) were white, 587 (44.4%) arrests were witnessed (WIT), and 65 (4.9%) were DC alive. There was no significant difference between races with respect to WIT arrests, V_T/V_F arrest rhythms, and a small difference in EMS response interval. Whites were more likely to be above median HHI (57.1 vs. 26.2%, P<0.001). Adjusted odds ratios for predictors of survival were WIT arrest (OR=3.76, 95% CI (1.7, 8.2)), V_T/V_F (OR=8.74, 95% CI (3.7, 10.8), but not race (OR=0.68, 95% CI (0.3, 1.4)) or SES (OR=1.51,95% CI 0.8, 2.8). Conclusion: In this population, neither race nor SES was independently associated with a worse outcome after OHCA.     

Can successful treatment of cardiac arrest be a performance indicator for hospitals?

BACKGROUND: Although resuscitation from cardiac arrest prevents more deaths from acute myocardial infarction (MI) than any other treatment, results have not been audited widely nor performance standards proposed. METHODS: The Myocardial Infarction National Audit Project (MINAP) uses electronic transmission of a 53-item dataset to a central cardiac audit database (CCAD). From October 2000 to August 2002, transmission by 218 hospitals of data from 55,906 cases of MI with 4934 attempted resuscitations from a first arrest, allowed for examination of factors determining survival, and for possible future measurement of success in resuscitation as a performance indicator. We investigated two possible indicators: (i) numbers of survivors from arrest in ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) per 1000 cases of MI; and (ii) observed/expected (O/E) ratios for survival taking all VF/VT arrests rather than MI as the denominator, and adjusting for differing age structures and admission delays among individual hospitals. FINDINGS: Of the 4934 reported patients suffering a first arrest, 1778 (36%) survived to be discharged from hospital. The presenting rhythm was VF/VT in 2321 (47%) patients of whom 1461 (63%) survived. Survival for all 218 hospitals together had the relatively small 95% confidence limits of 26 (25-27) survivors from VF/VT per 1000 MI. However, the small numbers from individual hospitals made it impossible in most cases, whichever of the two indicators was used, to separate quality of performance and completeness of reporting from the factor of chance. INTERPRETATION: Audit of success in resuscitation is essential if performance in the treatment of MI is to be assessed. However, the relatively small numbers of arrests occurring in individual hospitals means that if year on year improvements are to be documented, audit must be carried out among groups of hospitals or on a national scale.     

Laryngeal mask airway in neonatal resuscitation: a survey of current practice and perceived role by anaesthesiologists and paediatricians

Objectives: To survey current practice and to compare the opinion of paediatricians and anaesthesiologists regarding laryngeal mask airway (LMA) in neonatal resuscitation. Design: A structured postal questionnaire on the use of the laryngeal mask airway in neonatal resuscitation was sent to the heads of department of the paediatric and anaesthesiology services. Setting: Forty-three hospitals in the Veneto Region, Italy. Results: During the year 2000, 1526 out of 33708 (4.5%) neonates in our region needed resuscitation. Of these cases, 101 (6.6%) were ventilated using the LMA. Laryngeal mask airway availability was significantly greater in the anaesthesiology department compared to the paediatric department (90% versus 50%; P=0.002). However, 52% of anaesthesiologists and 72% of paediatricians had never used the laryngeal mask airway in their practice. The laryngeal mask airway was considered as an essential device more frequently by the anaesthesiologists than by the paediatricians (27% versus 5%; P=0.015); both groups considered the laryngeal mask airway particularly useful in specific situations. Interestingly, while 16% of the paediatricians described the laryngeal mask airway as having no value, none of the anaesthesiologists did (P=0.002). Staff competence was considered low by 70% of anaesthesiology heads of department compared with 90% of their pediatric colleagues. In both specialties, use of the laryngeal mask airway was limited to medical staff. With regard to training, 35% of anaesthesiologists and 22.5% of paediatricians had attended a course on laryngeal mask airway use. Conclusions: Laryngeal mask airway availability and perceived value were higher amongst anaesthesiologists than their paediatric colleagues. However, educational level, competence and utilization rates of the LMA in neonatal resuscitation were low in both groups.     

A randomized trial of suprasternal palpation to determine endotracheal tube position in neonates

Objective: To compare suprasternal palpation, a previously described bedside technique, with standard chest radiography for correct positioning of the endotracheal tube (ETT) in newborn infants. Study design: A randomized single-blinded study in an academic medical center. Preterm and term newborn infants requiring intubation were eligible, provided that they had not had their initial chest roentgenogram (CXR). Infants were randomized to ETT palpation and non-adjustment (Controls), or to ETT palpation and adjustment (Treatment), following digital palpation of the ETT tip in the suprasternal notch. ETT position was considered correct when only the tip of the ETT was palpable in the suprasternal notch. ETT position by CXR was blindly assessed by an experienced pediatric radiologist. Results: Fifty-five infants were enrolled in the delivery room or neonatal intensive care unit. Correct tube placements improved from 48% pre-study to 85 and 93% in the Control and Treatment arms, respectively. The majority of incorrect estimations were that the ETT position using palpation was judged to be too low when it was, in fact, in correct position, as noted in 11 infants. ETT palpation had a 70% concordance with the position determined by CXR. No difficulties or complications were associated with the use of suprasternal palpation. Conclusions: Suprasternal palpation is a simple, safe, teachable, method of confirming ETT position in neonates when CXR is unavailable, and may especially helpful during neonatal resuscitation prior to surfactant administration.     

There is a difference in characteristics and outcome between women and men who suffer out of hospital cardiac arrest

Objective: To evaluate whether there is a difference in characteristics and outcome in relation to gender among patients who suffer out of hospital cardiac arrest. Design: Observational study. Setting: The community of Göteborg. Patients: All patients in the community of Göteborg who suffered out of hospital cardiac arrest between 1980 and 1996, and in whom cardiopulmonary resuscitation (CPR) was initiated. Main outcome measures: Factors at resuscitation and the proportion of patients being hospitalized and discharged from hospital. P values were corrected for age. Results: The women were older than the men (median of 73 vs. 69 years; P<0.0001), they received bystander-CPR less frequently (11 vs. 15%; P=0.003), they were found in ongoing ventricular fibrillation less frequently (28 vs. 44%; P<0.0001), and their arrests were judged to be of cardiac origin less frequently. In a multivariate analysis considering age, gender, arrest being due to a cardiac etiology, initial arrhythmia and by-stander initiated CPR, female gender appeared as an independent predictor for patients being brought to hospital alive (odds ratio 1.37; P=0.001) but not for patients being discharged from hospital. Conclusion: Among patients who suffer out of hospital cardiac arrest with attempted CPR women differ from men being older, receive bystander CPR less frequently, have a cardiac etiology less frequently and are found in ventricular fibrillation less frequently. Finally female gender is associated with an increased chance of arriving at hospital alive.     

Cardiopulmonary resuscitation (CPR) using periodic acceleration (pGz) in an older porcine model of ventricular fibrillation

Cardiopulmonary resuscitation (CPR) can be achieved by repetitive motion of the body headwards to footwards in the spinal axis, at 2 Hz and ±0.6 G in a juvenile pig model of ventricular fibrillation. Return of spontaneous circulation and normal neurological outcome occurred after a total of 22 min of ventricular fibrillation that included a 3-min noninterventional period [Resuscitation 56 (2003) 215; Resuscitation 51 (2001) 55]. Since older pigs have stiffer rib cages than juvenile pigs and their hemodynamic response to various stimuli might differ, this study was carried out to determine whether this method of CPR, termed pGz-CPR, was just as effective in older pigs. pGz-CPR was also compared to chest compression CPR using an automated mechanical device (CONV-CPR). Ventricular fibrillation was instituted in older pigs weighing 23–34 kg and a 3-min noninterventional period was observed, followed by 15 min pGz-CPR in eight pigs or 15 min CONV-CPR in eight pigs. Return of spontaneous circulation (ROSC) occurred after defibrillation in all eight pigs with pGz-CPR and in six of eight pigs with CONV-CPR. Two of eight pigs with CONV-CPR and none of the eight pigs with pGz-CPR had rib fractures. Hemodynamic instability 15 min after ROSC occurred in all animals with CONV-CPR whereas only three of eight pigs with pGz-CPR demonstrated hemodynamic instability (P<0.05). We conclude that pGz-CPR in older pigs produces similar ROSC reported by other investigators in pigs without the risk of rib fractures. Further, pGz-CPR is associated with a lower incidence of periods of hemodynamic instability following ROSC than CONV-CPR.     

Continuous Quality Improvement Efforts Increase Survival with Favorable Neurologic Outcome after Out-of-hospital Cardiac Arrest

Objective: To assess system-wide implementation of specific therapies focused on perfusion during cardiopulmonary resuscitation (CPR) and cerebral recovery after Return of Spontaneous Circulation (ROSC). Methods: Before and after retrospective analysis of an out-of-hospital cardiac arrest database. Implementation trial in the urban/suburban community of Alameda County, California, USA, population 1.6 million, from November 2009–December 2012. Adult patients with non-traumatic out-of-hospital cardiac arrest (OHCA) who received CPR and/or defibrillation. The impedance threshold device was used throughout this study and there was an increased use of mechanical CPR (mCPR) and in-hospital therapeutic hypothermia (HTH). Results: Rates of ROSC, survival to hospital discharge and Cerebral Performance Category (CPC) scores were compared using univariate and multivariable analyses. A total of 2,926 adult non-traumatic patients with OHCA received CPR during the study period. From 2009–2011 to 2012, there was an increase in ROSC from 29.0% to 34.4% (p = 0.003) and a non-significant increase in hospital discharge from 10.2% to 12.0% (p = 0.16). There was a 76% relative increase in survival with favorable neurologic function between the two periods, as determined by CPC ≤ 2, from 4.5% to 7.9% (unadjusted OR = 1.80; CI = 1.31, 2.48; p < 0.001). After adjusting for witnessed arrest, bystander CPR, initial rhythm (VT/VF vs. others), placement of an advanced airway, EMS response time, drugs administered, and age, the OR was 1.61 (1.10, 2.36; p = 0.015). Using a stepwise multivariable logistic regression model, the independent predictors of CPC ≤ 2 were 2012 (vs. 2009–2011; p = 0.022), witnessed arrest (p < 0.001), initial rhythm VT/VF (p < 0.001), and advanced airway (inverse association p < 0.001). Additional analyses of the three prescribed therapies, separately and in combination, demonstrated that for those patients admitted to the hospital, mCPR with HTH had the biggest impact on survival to hospital discharge with CPC ≤ 2. Conclusions: Specific therapies within a system of care (mCPR, HTH), developed to enhance circulation during CPR and cerebral recovery after ROSC, significantly improved survival by 74% with favorable neurologic function following OHCA.     

Significant factors in predicting sustained ROSC in paediatric patients with traumatic out-of-hospital cardiac arrest admitted to the emergency department

BACKGROUND: Paediatric patients with out-of-hospital cardiac arrest (OHCA) due to trauma pose difficult challenges in resuscitation. Trauma is a major cause of OHCA in children. The aim of this study was to determine which factors were related to predicting a sustained return of spontaneous circulation (ROSC) in paediatric OHCA patients with trauma. METHOD: This retrospective study comprised 115 paediatric patients (56 traumatic and 59 non-traumatic OHCA patients) aged younger than 18 years who had been admitted to the emergency department (ED) from January 2000 to December 2004. We analysed the demographic data and the factors that may have influenced sustained ROSC in the group of OHCA paediatric patients with trauma. The non-trauma group was established as a control group. Survival analysis was used to compare differences in survival rate between trauma and non-trauma OHCA patients. Receiver operating characteristic (ROC) analysis was used to determine the significant in-hospital CPR duration related to sustained ROSC. RESULTS: Initial cardiac rhythm on arrival (P=0.005) and the duration of in-hospital CPR (P<0.001) were significant factors. Patients with PEA or VF had higher rate of sustained ROSC than those with asystole (PEA: P=0.003, VF: P=0.03). In the survival analysis, OHCA children with trauma had a lower chance of survival than non-trauma children as the interval from the scene to the ER increased (P=0.008). Based on the ROC analysis, the cut-off values of in-hospital CPR duration were 25min in OHCA paediatric patients with trauma. CONCLUSION: Several significant factors relating to sustained ROSC were determined in the OHCA paediatric patients with trauma; most importantly, we found that in-hospital CPR may have to be performed for at least 25min to enable a spontaneous circulation to return.     

Addition of ketamine to propofol–fentanyl anaesthesia can reduce post-operative pain and epidural analgesic consumption in upper abdominal surgery

The aim of this study was to confirm whether intravenous anaesthesia supplemented with the N-methyl- -aspartate (NMDA) antagonist ketamine could reduce post-operative pain after elective open cholecystectomy. Fifty patients were randomised double-blind to one of the following two groups: PF Group received propofol and fentanyl supplemented with saline infusion; PFK Group received propofol and fentanyl supplemented with ketamine (total dose 2 mg/kg). During the first 48 post-operative hours, epidural analgesia was provided for all patients with patient-controlled epidural analgesia (PCEA) using 0.125% bupivacaine and morphine (0.05 mg/ml). Pain assessments at rest and movement, and cumulative PCEA volume consumed, were recorded at 5, 24 and 48 h post-operatively. The visual analogue scale (VAS) scores at rest were significantly less in the PFK Group than in the PF Group at 5, 24 and 48 h (P<0.001, P<0.001 and P=0.02, respectively). The VAS score at movement were also significantly (P<0.001) less throughout this study than in the PF Group. The difference in PCEA analgesic consumption at 0–5 and 5–24 h reached statistical significance (P<0.001 and P=0.008, respectively). Our results show that an intra-operative ketamine dose provides advantages for post-operative analgesia beyond its duration of action after an open cholecystectomy.     

Recovery from near death following cerebral anoxia: A case report demonstrating superiority of median somatosensory evoked potentials over EEG in predicting a favorable outcome after cardiopulmonary resuscitation

An electroencephalogram disclosing electrocerebral silence (ECS) after cardiopulmonary resuscitation (CPR) is usually considered an unfavorable prognostic indicator associated with brain death or persistent vegetative state. I report a case of a comatose patient following cardiac arrest, whose initial electroencphalography (EEG) was isoelectric taken 5 h after onset. Median somatosensory evoked potentials (SSEP) obtained immediately after the initial EEG were normal. He then underwent gradual recovery of neurologic function with incremental improvement on serial EEG study, and eventually achieved full neurological recovery. SSEP proved to be a more reliable predictor of a neurological outcome that was ultimately favorable.     

Improving the rate of return of spontaneous circulation for out-of-hospital cardiac arrests with a formal, structured emergency resuscitation team

OBJECTIVE: To assess the impact of a formal, structured resuscitation team in the emergency department (ED) on the success rate of cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) patients. METHODS: This is a "three-phase" (organized, transitional, and re-organized), prospective study in which medical records of all OHCA patients who needed resuscitation in the ED during the three 6-month periods were reviewed and data were coded in out-of-hospital Utstein style formats. An organized resuscitation team existed in the organized and re-organized phases but not in the transitional phase. The study population consisted of adult patients with non-traumatic cardiac arrest (>18 years of age). RESULTS: The rates of return of spontaneous circulation (ROSC) were 51.3% for the organized phase, 31.0% for the transitional phase, and 53.1% for the re-organized phase ( P=0.013 ). The rates of ROSC from pulseless electrical activity (PEA)/asystole were significantly higher in periods with organized and re-organized teams ( P=0.007 ). The rates of ROSC for the ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) sub-groups were not significantly different in all three periods ( P=0.406 ). The chance of survival-to-discharge was 9.2% in the organized period, 11.2% in the transitional period, and 15.6% in the re-organized period ( P=0.496 ). The existence of a formal, structured emergency resuscitation team in the ED (odds ratio: 2.56, 95% confidence interval: 1.35-4.80) and witness at the scene (odds ratio: 2.45, 95% confidence interval: 1.34-4.45) were the only independent predictors of successful ROSC of OHCA patients by multiple logistic regression analysis. CONCLUSION: The establishment of a formal and structured emergency resuscitation team in the ED is associated with an increased rate of ROSC for OHCA patients.     

Survival rates in out-of-hospital cardiac arrest patients transported without prehospital return of spontaneous circulation: An observational cohort study

Background

Some Emergency Medical Services currently use just one component of the Universal Termination of Resuscitation (TOR) Guideline, the absence of prehospital return of spontaneous circulation (ROSC), as the single criteria to terminate resuscitation, which may deny transport to potential survivors.

Objective

This study aimed to report the survival to hospital discharge rate in non-traumatic, adult out-of-hospital cardiac arrest (OHCA) patients transported to hospital without a prehospital ROSC.

Methods

An observational study of OHCA patients without a prehospital ROSC who met the Universal TOR Guideline for transport to hospital with ongoing resuscitation. Multivariable logistic regression was used to determine the association of each variable with survival to hospital discharge.

Results

Of 20,207 OHCA treated by EMS, 3374 (16.4%) did not have a prehospital ROSC but met the Universal TOR guideline for transport to hospital with ongoing resuscitation. Of these patients, 122 (3.6%) survived to hospital discharge. Survival to discharge was associated with initial shockable VF/VT rhythms (OR 5.07; 95% CI 2.77–9.30), EMS-witnessed arrests (OR 3.51; 95% CI 1.73–7.15), bystander-witnessed arrests (OR 2.11; 95% CI 1.18–3.77), and public locations (OR 1.57; 95% CI 1.02–2.40).

Conclusion

In OHCA patients without a prehospital ROSC who met the Universal TOR Guideline for transport with ongoing resuscitation survival rates were above the 1% futility rate. Employing only the lack of ROSC as criteria for termination of resuscitation may miss survivors after OHCA.     

A comparison of vertical force and temporal parameters produced by an in-shoe pressure measuring system and a force platform

Objective. To investigate the ability of Pedar in-shoe system to measure vertical force accurately, by comparing it with the Kistler force platform.

Design. In vivo experiment in normal subjects.

Background. It has been suggested Pedar is highly reliable, but absolute accuracy of the system with regard to force measurement has not been comprehensively tested.

Methods. Sampling at 99 Hz, using five healthy subjects, simultaneous data were collected barefoot, and in three types of shoes (Trainers, Oxfords, Slip-on Deck Type). Six variables obtained from the force/time curve from each footstep were compared.

Results. The temporal data recorded by Pedar correlated well with that obtained using Kistler, with significant differences only in overall duration of the step in Deck shoes (P<0.001) and Oxford shoes (P<0.01), and peak to peak barefoot (P<0.01). Pedar recorded a lower first peak force and mid-peak force in all cases (P<0.001). However, the magnitude of the 2nd peak force recorded by both systems was significantly different only in Trainers (P<0.05) and Oxford shoes (P<0.001). The impulse data obtained with Oxford shoes was not significantly different, although barefoot, Trainers and Deck shoes were significantly lower (P<0.001) for Pedar.

Conclusions. In most cases, comparison of data recorded by the two systems provided good evidence for the accuracy and reliability of temporal measurements and second peak force measurements taken with the Pedar in-shoe system.Relevance

In-shoe pressure data provides evidence for clinical decisions if the systems utilised are proven to be valid, repeatable and accurate. Comparison with an established force platform enables some assessment of these factors.     

The effect of hydrocortisone on the outcome of out-of-hospital cardiac arrest patients: a pilot study

OBJECTIVE: Several studies have disclosed the importance of serum adrenocorticotropic hormone and cortisol levels in resuscitation. The objective of this study was to observe the effect of hydrocortisone on the outcome of out-of-hospital cardiac arrest (OHCA) patients. DESIGN: Prospective, nonrandomized, open-labeled clinical trial. SETTING: Emergency department (ED) of National Taiwan University Hospital. PATIENTS AND PARTICIPANTS: Ninety-seven nontraumatic adult OHCA victims. INTERVENTIONS: Serum adrenocorticotropic hormone and total cortisol levels were examined in all patients. The hydrocortisone group (n = 36) received 100 mg intravenous hydrocortisone during resuscitation, and the nonhydrocortisone group (n = 61) received 0.9% saline as placebo. MEASUREMENTS AND RESULTS: Comparison of return of the spontaneous circulation (ROSC) rates between the 2 groups was analyzed. The hydrocortisone group had a significantly higher ROSC rate than the nonhydrocortisone group (61% vs 39%, P = .038). Hydrocortisone administration within 6 minutes after ED arrival led to an increased ROSC rate (90% vs 50%, P = .045). The hydrocortisone and nonhydrocortisone groups did not differ in the development of electrolyte disturbances, gastrointestinal tract bleeding, or infection during early postresuscitation period (gastrointestinal bleeding: 41% vs 46%, P = .89; infection: 50% vs 75%, P = .335). There was no significant difference between the hydrocortisone and nonhydrocortisone groups in terms of 1- and 7-day survival and hospital discharge rates. CONCLUSIONS: Hydrocortisone treatment during resuscitation, particularly when administrated within 6 minutes of ED arrival, may be associated with an improved ROSC rate in OHCA patients.     

体外心肺复苏启动前因素对患者预后的影响

目的:分析体外心肺复苏（extracorporeal cardiopulmonary resuscitation,ECPR）启动前因素对患者预后的影响,以探讨ECPR的干预时机和改进策略。方法:回顾性分析2018年7月至2021年4月在湖南师范大学附属第一医院（湖南省人民医院）行ECPR的29例患者。按患者是否存活出院分为生存组( n=13)及死亡组( n=16),分析两组常规心肺复苏（conventional cardiopulmonary resuscitation,CCPR）时间（开始心肺复苏到体外膜肺氧合运转的时间）、ECPR前初始心律、院外及院内心搏骤停的构成比、外院转运病例构成比。按CCPR时间分为≤45 min组、45~60 min组及>60 min组分别比较其出院存活率及持续自主循环恢复（sustained return of spontaneous circulation,ROSC）率。本院院内心搏骤停患者按心搏骤停（cardiac arrest,CA）发生地点分为本科室亚组和其他科室亚组,比较其存活率。 结果:29例患者总体生存率44.83%,体外膜肺氧合（extracorporeal membrane oxygenation,ECMO）平均辅助时长114（33.5,142.5） h,CCPR平均时长60（44.5,80） min。生存组ECMO辅助时间（140.15±44.80）h较死亡组长（ P=0.001）,生存组CCPR时间明显低于死亡组（ P=0.010）。初始心律为可除颤心律组生存率更高（ P=0.010）。OHCA较IHCA患者病死率高（ P=0.020）。外院转运病例病死率高于本院病例（ P=0.025）。CCPR时间≤45min、45~60 min、>60 min三组患者出院生存率依次递减（ P=0.001）,ROSC率依次递减（ P=0.001)。本院院内心搏骤停患者,CA发生地点在本科室（急诊医学科）组与其他科室组生存率差异无统计学意义（ P=0.54）。 结论:ECPR出院存活率高于国内外报道的CCPR存活率,ECPR对难治性心搏骤停是有效的。ECPR的预后跟CCPR时间、CA初始心律、CA发生地点明显相关,提高ECPR存活率需加强宣教及团队建设。     

The effect of different relieving methods on the outcome of out-of-hospital cardiac arrest patients with nontraumatic hemopericardium in the ED

Aims

This study aimed to assess the impact of different methods of draining nontraumatic hemopericardium on outcome from patients with out-of-hospital cardiac arrest (OHCA), identify independent predictors of return of spontaneous circulation (ROSC), and examine the ineffective rate of decompression based on subxiphoid pericardiotomy (SP) and percutaneous pericardial catheter drainage (PCD).

Methods

Adult patients with OHCA who presented to the ED between May 1, 2000, and October 30, 2006, with moderate to massive nontraumatic hemopericardium were recruited and stratified into 4 groups according to the relieving methods of hemopericardium. Charts were reviewed for various demographic data, resuscitation records, management, and outcome. Patient outcome was recorded as survival to hospital discharge and ROSC, as primary end points. Effective decompression was recorded as a secondary end point. We compared the outcome between the groups.

Results

A total of 1491 OHCA resuscitation records were prospective collected. There were 23 OHCA patients with moderate to massive nontraumatic hemopericardium. The overall ROSC rate was 39.1% (9/23). There was a clear difference in the ROSC rate between 4 groups (P < .05). The overall rate of survival to hospital discharge was 4.3% (1/23). There was no significant difference in the rate of survival to hospital discharge between the groups. Relieving methods was an independent predictor of ROSC in OHCA patients with nontraumatic hemopericardium (odds ratio, 0.17; 95% confidence interval, 0.4-0.70). There was a significant statistical difference in adequate relief of hemopericardium based on SP and PCD (P < .01).

Conclusion

The early effective decompression method is associated with an increased rate of ROSC for OHCA patients with nontraumatic hemopericardium. Subxiphoid pericardiotomy has a better effective decompression of hemopericardium than PCD.     

The effect of mild therapeutic hypothermia on renal function after cardiopulmonary resuscitation in men

Background: Mild therapeutic hypothermia (MTH) improves neurological outcome in patients after cardiac arrest. From animal and human studies it appears that hypothermia impairs renal function. The aim of this study was to examine the effects of MTH on renal function in humans. Methods: Patients were participants recruited in one of the centres of the hypothermia after cardiac arrest-multicenter trial. We measured serum creatinine and creatinine clearance (C_Cr) within 24 h of MTH, at 4 hourly intervals. Patients were followed for acute renal failure and need for renal supportive therapy for 28 days. Results: We included 60 patients (32 hypothermic, 28 normothermic). Median serum creatinine on admission was [{119 μmol/l (IQR 108–133)} {1.35 mg/dl (IQR 1.22–1.50)}] in hypothermic and [{114 μmol/l (IQR 99–131)} {1.29 mg/dl (IQR 1.12–1.48)}] in normothermic patients, and decreased to [{69 μmol/l (IQR 62–84)} {0.78 mg/dl (IQR 0.70–0.95)}] in the hypothermic group and to [{88 μmol/l (IQR 71–123)} {1.00 mg/dl (IQR 0.80–1.39)}] in the normothermic group within 24 h. C_Cr was decreased on admission. Within 24 h C_Cr improved to normal values in normothermic patients [1.53 ml/s (IQR 1.15–2.35) {92 ml/min (IQR 69–141)}] and remained low in hypothermic patients [0.88 ml/s (IQR 0.63–1.38) {53 ml/min (IQR 38–83)}] (P=0.0006). No difference was found between the groups in the development of acute renal failure or the need for renal supportive therapy. Conclusion: Twenty four hours of MTH was associated with a delayed improvement in renal function. This was not reflected in the serum creatinine values, which were low in the hypothermic group. This transient impaired renal function appeared to be completely reversible within 4 weeks.     

Cardiac arrest survival is rare without prehospital return of spontaneous circulation

Abstract Background. Emergency medical services (EMS) are crucial in the management of out-of-hospital cardiac arrest (OHCA). Despite accepted termination-of-resuscitation criteria, many patients are transported to the hospital without achieving field return of spontaneous circulation (ROSC). Objective. We examine field ROSC influence on OHCA survival to hospital discharge in two large urban EMS systems. Methods. A retrospective analysis of prospectively collected data was conducted. Data collection is a component of San Antonio Fire Department's comprehensive quality assurance/quality improvement program and Cincinnati Fire Department's participation in the Cardiac Arrest Registry to Enhance Survival (CARES) project. Attempted resuscitations of medical OHCA and cardiac OHCA for San Antonio and Cincinnati, respectively, from 2008 to 2010 were analyzed by city and in aggregate. Results. A total of 2,483 resuscitation attempts were evaluated. Age and gender distributions were similar between cities, but ethnic profiles differed. Cincinnati had 17% (p = 0.002) more patients with an initial shockable rhythm and was more likely to initiate transport before field ROSC. Overall survival to hospital discharge was 165 of 2,483 (6.6%). More than one-third (894 of 2,483, 36%) achieved field ROSC. Survival with field ROSC was 17.2% (154 of 894) and without field ROSC was 0.69% (11 of 1,589). Of the 11 survivors transported prior to field ROSC, nine received defibrillation by EMS. No asystolic patient survived to hospital discharge without field ROSC. Conclusion. Survival to hospital discharge after OHCA is rare without field ROSC. Resuscitation efforts should focus on achieving field ROSC. Transport should be reserved for patients with field ROSC or a shockable rhythm.