Resuscitation of patients suffering from sudden cardiac arrests in nursing homes is not futile

Background

Survival after out-of-hospital cardiac arrest (OHCA) has increased in recent years, and new data are therefore needed to avoid unsubstantiated statements when debating futility of resuscitation attempts following OHCA in nursing home (NH)-residents. We aimed to investigate the outcome and prognosis after OHCA in NH.

Methods

Consecutive Emergency Medical Service (EMS) attended OHCA-patients in Copenhagen during 2007–2011 were included. Utstein-criteria for pre-hospital data and review of individual patient charts for in-hospital post-resuscitation care were collected.

Results

A total of 2541 consecutive OHCA-patients were recorded, 245 (10%) of who were current NH-residents. NH-patients were older, more frequently female, had more witnessed arrests, fewer shockable primary rhythm and assumed cardiac aetiology, but shorter time to the return of spontaneous circulation (ROSC) compared to OHCA in non-nursing homes (non-NH). Overall 30-day survival rate was 9% in NH and 18% in non-NH, p < 0.001. Of the 245 NH-arrests 79 (32%) patients were admitted to hospital compared to 937 (41%) from non-NH (p < 0.001). Thirty-day survival rate in patients admitted to hospital were 27% for NH- and 42% for non-NH-patients, p < 0.001. OHCA in NH was, however, not associated with a significantly worse prognosis (HR = 0.88 (0.64–1.21), p = 0.4) after adjustment for known prognostic factors including co-morbidity.

Conclusions

Nursing home residents resuscitated from OHCA and admitted to hospital have similar survival rates as non-NH-patients when adjusting for known prognostic factors and pre-existing co-morbidity. A policy of not attempting resuscitation in nursing homes at all may therefore not be justified.     

Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest – A comparison with that for extracorporeal rescue for in-hospital cardiac arrest

Purpose

The aim was to investigate the effects of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) and compare the results with those of in-hospital cardiac arrest (IHCA).

Methods

We analyzed our extracorporeal membrane oxygenation (ECMO) results for patients who received ECPR for OHCA or IHCA in the last 5 years. Pre-arrest, resuscitation, and post-resuscitative data were evaluated.

Results

In the last 5 years, ECPR was used 230 times for OHCA (n = 31) and IHCA (n = 199). The basic demographic data showed significant differences in age, cardiomyopathy, and location of the initial CPR. Duration of ischemia was shorter in the IHCA group (44.4 ± 24.7 min vs. 67.5 ± 30.6 min, p < 0.05). About 50% of each group underwent a further intervention to treat the underlying etiology. ECMO was maintained for a shorter duration in the OHCA patients (61 ± 48 h vs. 94 ± 122 h, p < 0.05). Survival to discharge was similar in the two groups (38.7% for OHCA vs. 31.2% for IHCA, p > 0.05), as was the favorable outcome rate (25.5% for OHCA vs. 25.1% for IHCA, p > 0.05). Survival was acceptable (about 33%) in both groups when the duration of ischemia was no longer than 75 min.

Conclusions

In addition to having a beneficial effect in IHCA, ECPR can lead to survival and a positive neurological outcome in selected OHCA patients after prolonged resuscitation. Our results suggest that further investigation of the use of ECMO in OHCA is warranted.     

Myocardial infarction is a frequent cause of exercise-related resuscitated out-of-hospital cardiac arrest in a general non-athletic population

Background

Performing exercise is shown to prevent cardiovascular disease, but the risk of an out-of-hospital cardiac arrest (OHCA) is temporarily increased during strenuous activity. We examined the etiology and outcome after successfully resuscitated OHCA during exercise in a general non-athletic population.

Methods

Consecutive patients with OHCA were admitted with return of spontaneous circulation (ROSC) or on-going resuscitation at hospital arrival (2002–2011). Patient charts were reviewed for post-resuscitation data. Exercise was defined as moderate/vigorous physical activity.

Results

A total of 1393 OHCA-patients were included with 91(7%) arrests occurring during exercise. Exercise-related OHCA-patients were younger (60 ± 13 vs. 65 ± 15, p < 0.001) and predominantly male (96% vs. 69%, p < 0.001). The arrest was more frequently witnessed (94% vs. 86%, p = 0.02), bystander CPR was more often performed (88% vs. 54%, p < 0.001), time to ROSC was shorter (12 min (IQR: 5–19) vs. 15 (9–22), p = 0.007) and the primary rhythm was more frequently shock-able (91% vs. 49%, p < 0.001) compared to non-exercise patients. Cardiac etiology was the predominant cause of OHCA in both exercise and non-exercise patients (97% vs. 80%, p < 0.001) and acute coronary syndrome was more frequent among exercise patients (59% vs. 38%, p < 0.001). One-year mortality was 25% vs. 65% (p < 0.001), and exercise was even after adjustment associated with a significantly lower mortality (HR = 0.40 (95%CI: 0.23–0.72), p = 0.002).

Conclusions

OHCA occurring during exercise was associated with a significantly lower mortality in successfully resuscitated patients even after adjusting for confounding factors. Acute coronary syndrome was more common among exercise-related cardiac arrest patients.     

Prodromal symptoms of out-of-hospital cardiac arrests: A report from a large-scale population-based cohort study

Objective

Little is known about which symptoms are manifested before out-of-hospital cardiac arrest (OHCA). The objective of this study is to describe the prodromal symptoms of OHCA focusing on the onset of the symptom in relation of etiology of cardiac arrests, and to analyze the association between those symptoms and their outcomes after OHCA.

Methods

This prospective, population-based cohort study enrolled all persons aged 18 years or older who had experienced OHCA of presumed cardiac and non-cardiac origin that were witnessed by bystanders or emergency medical system (EMS) personnel in Osaka from 2003 through 2004.

Results

There were 1042 were presumed to be of cardiac origin and 424 of non-cardiac. Patients with non-cardiac origin were more likely to have prodromal symptoms than those with cardiac etiology (70.0% vs. 61.8%, p = 0.003). Over 40% of OHCA regardless of etiology had displayed symptoms at least several minutes before their arrest (40.2% [259/644] in those of cardiac origin and 45.5% [135/297] in those of non-cardiac origin). As to cardiac origin, the most frequent prodromal symptom was dyspnea (27.6%), followed by chest pain (20.7%) and syncope (12.7%). For non-cardiac origin, the most frequent symptom was also dyspnea (40.7%), but chest pain was rarely presented (3.4%). Although, prodromal symptoms themselves were not associated with better neurological outcomes (adjusted odds ratio [AOR], 2.03; 95% confidence interval [CI], 1.00–4.13), earlier contact to a patient yielded better neurological outcomes (AOR per every one-minute increase, 0.90; 95% CI, 0.82–0.99).

Conclusions

Many of OHCA regardless of etiology have prodromal symptoms before arrest. Prodromal symptoms induced early activation of the EMS system, and may thus improve outcomes after OHCA.     

Reduced in-hospital survival rates of out-of-hospital cardiac arrest victims with obstructive pulmonary disease

Aim

Out-of-hospital cardiac arrest (OHCA) due to sustained ventricular tachycardia/fibrillation (VT/VF) is common and often lethal. Patient's co-morbidities may determine survival after OHCA, and be instrumental in post-resuscitation care, but are poorly studied. We aimed to study whether patients with obstructive pulmonary disease (OPD) have a lower survival rate after OHCA than non-OPD patients.

Methods

We performed a community-based cohort study of 1172 patients with non-traumatic OHCA with ECG-documented VT/VF between 2005 and 2008. We compared survival to Emergency Room (ER), to hospital admission, to hospital discharge, and at 30 days after OHCA, of OPD-patients and non-OPD patients, using logistic regression analysis. We also compared 30-day survival of patients who were admitted to hospital, using multivariate logistic regression analysis.

Results

OPD patients (n = 178) and non-OPD patients (n = 994) had comparable survival to ER (75% vs. 78%, OR 0.9 [95% CI: 0.6–1.3]) and to hospital admission (56% vs. 57%, OR 1.0 [0.7–1.4]). However, survival to hospital discharge was significantly lower among OPD patients (21% vs. 33%, OR 0.6 [0.4–0.9]). Multivariate regression analysis among patients who were admitted to hospital (OPD: n = 100, no OPD: n = 561) revealed that OPD was an independent determinant of reduced 30-day survival rate (39% vs. 59%, adjusted OR 0.6 [0.4–1.0, p = 0.035]).

Conclusion

OPD-patients had lower survival rates after OHCA than non-OPD patients. Survival to ER and to hospital admission was not different between both groups. However, among OHCA victims who survived to hospital admission, OPD was an independent determinant of reduced 30-day survival rate.     

Use and benefits of public access defibrillation in a nation-wide network

Background

Automated External Defibrillators (AEDs) are known to increase survival after out-of-hospital cardiac arrest (OHCA). The aim of this study was to examine the use and benefit of public-access defibrillation (PAD) in a nation-wide network. We primarily sought to assess survival at 1 month but information about the circumstances of each OHCA is provided as well.

Methods

In this 28-month study, we assessed the use of 807 AEDs in Denmark. When an AED was deployed information about the circumstances of OHCA, the bystander, the AED and the victim's condition was obtained.

Results

An AED was connected to an OHCA victim prior to the arrival of Emergency Medical Services (EMS) in 48 instances. Ten percent of bystanders were off-duty healthcare professionals. Shockable arrests (N = 31, 70%) were significantly more likely to be witnessed (94% vs. 54%) to occur at sports facilities (74% vs. 31%), in relation to exercise (42% vs. 0%), and with improved 30-day survival (69% vs. 15%, p = 0.001). Among those presenting with a shockable rhythm, 20 (65%) had Return of Spontaneous Circulation upon arrival of EMS and 8 (26%) were conscious, which emphasizes the diagnostic value of ECG downloads from AEDs. Survival could be determined in 42 of 44 patients with OHCA of cardiac origin, and was 52% (n = 22, 95% CI [38–67]) and the Cerebral Performance Category was 1 (Good Cerebral Performance) in all survivors.

Conclusion

With a 30-day neurologically intact survival of 69% for patients with shockable rhythms, this study provides further evidence of the lifesaving potential of PAD.     

Aspects on the increase in bystander CPR in Sweden and its association with outcome

Aim

To describe changes in the proportion of bystanders performing cardiopulmonary resuscitation (CPR) in out of hospital cardiac arrest (OHCA) in Sweden and to study the impact of bystander CPR on ventricular fibrillation and on survival during various times.

Patients and methods

All patients who suffered from OHCA in Sweden in whom CPR was attempted and who were included in the Swedish cardiac arrest register (SCAR) between 1992 and 2005. Crew witnessed cases were excluded.

Results

In all 34,125 patients were included in the survey. Among witnessed OHCA the proportion of patients receiving bystander CPR increased from 40% in 1992 to 55% in 2005 (p < 0.0001). In non-witnessed OHCA the corresponding proportion increased from 22% to 44% (p < 0.0001). There was a significant increase in bystander CPR regardless of age, sex and place. The increase was only found when CPR was performed by lay persons (21% in 1992 to 40% in 2005; p < 0.0001). Bystander CPR was associated with an increased proportion of patients found in a shockable rhythm and a lower number of shocks to receive return of spontaneous circulation. Bystander CPR was associated with a similar increase in survival early and late in the evaluation.

Conclusion

There was a marked increase in bystander CPR in OHCA, when performed by lay persons, during the last 14 years in Sweden. Bystander CPR was associated with positive effects both on ventricular fibrillation and survival.     

Tertiary centres have improved survival compared to other hospitals in the Copenhagen area after out-of-hospital cardiac arrest

Aims

Out-of-hospital cardiac arrest (OHCA) has been reported to carry very varying morbidity and mortality. However, it remains unclear whether this is caused by intrinsic factors of the OHCA or due to the level of in-hospital care. The aim of this study is to compare 30-day and long-term mortality after OHCA at tertiary heart centres and non-tertiary university hospitals.

Methods and results

Data from the Copenhagen OHCA registry from June 2002 through December 2010 included a total of 1218 consecutive patients treated by the same mobile emergency care unit (MECU) with either return of spontaneous circulation (ROSC) or on-going resuscitation (n = 53) at hospital arrival. The MECU transported patients to the nearest hospital unless an ECG on scene suggested ST-segment elevation myocardial infarction, in which case patients were transported to the nearest tertiary centre for acute coronary angiography. Therefore, patients with ST-elevation myocardial infarction (n = 198) were excluded from the analysis. 30-day mortality was 56% vs. 76% and long term (up to 8 years) mortality was 78% vs. 94% for tertiary and non-tertiary hospitals, respectively, both p < 0.001. Multivariate analysis showed that admission to a non-tertiary hospital was independently associated with increased risk of death (HR = 1.32, 95% CI: 1.09–1.59, p = 0.004). Exclusion of patients with on-going resuscitation at admission resulted in HR = 1.34 (1.11–1.62), p = 0.003. A matched pair propensity score analysis of 255 patients confirmed the results of the proportional hazard analysis (HR = 1.35, 95% CI: 1.11–1.65 p = 0.003).

Conclusion

Admission to tertiary centres is associated with lower mortality rates after OHCA compared with non-tertiary hospitals.     

Predictive value of electrocardiogram in diagnosing acute coronary artery lesions among patients with out-of-hospital-cardiac-arrest

Aims

Acute coronary lesions are known to be the most common trigger of out of hospital cardiac arrest (OHCA). Aim of the present study was to assess the predictive value of ST-segment changes in diagnosing the presence of acute coronary lesions among OHCA patients

Methods

Findings of coronary angiography (CA) performed in patients resuscitated from OCHA were retrospectively reviewed and related to ST-segment changes on post-ROSC electrocardiogram (ECG)

Results

Ninety-one patients underwent CA after OHCA; 44% of patients had ST-segment elevation and 56% of patients had other ECG patterns on post-ROSC ECG. Significant coronary artery disease (CAD) was found in 86% of patients; CAD was observed in 98% of patients with ST-segment elevation and in 77% of patients with other ECG patterns on post-ROSC ECG (p = 0.004). Acute or presumed recent coronary artery lesions were diagnosed in 56% of patients, respectively in 85% of patients with ST-segment elevation and in 33% of patients with other ECG patterns (p < 0.001). ST-segment analysis on post-ROSC ECG has a good positive predictive value but a low negative predictive value in diagnosing the presence of acute or presumed recent coronary artery lesions (85% and 67%, respectively)

Conclusions

Electrocardiographic findings after OHCA should not be considered as strict selection criteria for performing emergent CA in patients resuscitated from OHCA without obvious extra-cardiac cause; even in the absence of ST-segment elevation on post-ROSC ECG, acute culprit coronary lesions may be present and considered the trigger of cardiac arrest     

Can experienced paramedics perform tracheal intubation at cardiac arrests? Five years experience of a regional air ambulance service in the UK

Aims

Paramedic tracheal intubation has been reported to carry a high failure rate and morbidity. A comparison between doctor and paramedic-led intubation at out-of-hospital cardiac arrests (OHCA) was conducted to assess whether this finding was observed in our clinical practice.

Methods

Retrospective review of all medical OHCA attended by the Warwickshire and Northamptonshire Air Ambulance (WNAA) over a 64-month period. Cases were identified and divided into doctor-led or paramedic-led groups. Self-reported intubation failure rate, morbidity and clinical outcome were observed and compared. Paramedic exposure to tracheal intubation was assessed.

Results

286 cases of medical OHCA were identified, 199 (69.6%) were doctor-led and 87 (30.4%) paramedic-led. Paramedic and doctor-led crews intubated an equivalent proportion of cases (Para-led 60.7% [37] vs. Dr-led 62.8% [98]; p = 0.89) and no significant difference in failure rate was observed (Para-led 2.7% [1 case, 95% CI 0.0–7.9%] vs. Dr-led 3.1% [3 cases, 95% CI 0.0–6.5%]; p = 1). No morbidity from failure-to-intubate was recorded, and equal rates of return of spontaneous circulation (ROSC) were observed (Para-led 20.7% [18] vs. Dr-led 20.6% [41]; p = 0.89). Paramedics operating with the WNAA were found to have a higher exposure to tracheal intubation (WNAA 0.03 TT/shift vs. unselected paramedics 0.004 TT/shift).

Conclusions

Experienced paramedics regularly operating with physicians have a low tracheal intubation failure rate at OHCA, whether practicing independently or as part of a doctor-led team. This is likely due to increased and regular clinical exposure.     

Comparison of Medical Priority Dispatch (MPD) and Criteria Based Dispatch (CBD) relating to cardiac arrest calls

Background

Prompt emergency medical service (EMS) system activation with rapid delivery of pre-hospital treatment is essential for patients suffering out-of-hospital cardiac arrest (OHCA). The two most commonly used dispatch tools are Medical Priority Dispatch (MPD) and Criteria Based Dispatch (CBD). We compared cardiac arrest call processing using these two dispatch tools in two different dispatch centres.

Methods

Observational study of adult EMS confirmed (non-EMS witnessed) OHCA calls during one year in Richmond, USA (MPD) and Oslo, Norway (CBD). Patients receiving CPR prior to call, interrupted calls or calls where the caller did not have access to the patients were excluded from analysis. Dispatch logs, ambulance records and digitalized dispatcher and caller voice recordings were compared.

Results

The MPDS-site processed 182 cardiac arrest calls and the CBD-site 232, of which 100 and 140 calls met the inclusion criteria, respectively. The recognition of cardiac arrest was not different in the MPD and CBD systems; 82% vs. 77% (p = 0.42), and pre-EMS arrival CPR instructions were offered to 81% vs. 74% (p = 0.22) of callers, respectively. Time to ambulance dispatch was median (95% confidence interval) 15 (13, 17) vs. 33 (29, 36) seconds (p < 0.001) and time to chest compression delivery; 4.3 (3.7, 4.9) vs. 3.7 (3.0, 4.1) min for the MPD and CBD systems, respectively (p = 0.05).

Conclusion

Pre-arrival CPR instructions were offered faster and more frequently in the CBD system, but in both systems chest compressions were delayed 3–4 min. Earlier recognition of cardiac arrest and improved CPR instructions may facilitate earlier lay rescuer CPR.     

New treatment bundles improve survival in out-of-hospital cardiac arrest patients: A historical comparison

Introduction

Before the introduction of the new international cardiac arrest treatment guidelines in 2005, patients with out-of-hospital cardiac arrest (OHCA) of cardiac origin in Northern Italy had very poor prognosis. Since 2006, a new bundle of care comprising use of automated external defibrillators (AEDs) and therapeutic hypothermia (TH) was started, while extracorporeal CPR program (ECPR) for selected refractory CA and dispatcher-assisted cardio-pulmonary resuscitation (CPR) was started in January 2010.

Objectives

We hypothesized that a program of bundled care might improve outcome of OHCA patients.

Methods

We analyzed data collected in the OHCA registry of the MB area between September 2007 and August 2011 and compared this with data from 2000 to 2003.

Results

Between 2007 and 2011, 1128 OHCAs occurred in the MB area, 745 received CPR and 461 of these had a CA of presumed cardiac origin. Of these, 125 (27%) achieved sustained ROSC, 60 (13%) survived to 1 month, of whom 51 (11%) were discharged from hospital with a good neurological outcome (CPC ≤ 2), and 9 with a poor neurological outcome (CPC > 2).Compared with data from the 2000 to 2003 periods, survival increased from 5.6% to 13.01% (p < 0.0001). In the 2007–2011 group, low-flow time and bystander CPR were independent markers of survival.

Conclusions

OHCA survival has improved in our region. An increased bystander CPR rate associated with dispatcher-assisted CPR was the most significant cause of increased survival, but duration of CA remains critical for patient outcome.     

Out-of-hospital cardiac arrest frequency and survival: Evidence for temporal variability

Aim

Some cardiac phenomena demonstrate temporal variability. We evaluated temporal variability in out-of-hospital cardiac arrest (OHCA) frequency and outcome.

Methods

Prospective cohort study (the Resuscitation Outcomes Consortium) of all OHCA of presumed cardiac cause who were treated by emergency medical services within 9 US and Canadian sites between 12/1/2005 and 02/28/2007. In each site, Emergency Medical System records were collected and analyzed. Outcomes were individually verified by trained data abstractors.

Results

There were 9667 included patients. Median age was 68 (IQR 24) years, 66.7% were male and 8.3% survived to hospital discharge. The frequency of cardiac arrest varied significantly across time blocks (p < 0.001). Compared to the 0001-0600 hourly time block, the odds ratios and 95% CIs for the occurrence of OHCA were 2.02 (1.90, 2.15) in the 0601-1200 block, 2.01 (1.89, 2.15) in the 1201-1800 block, and 1.73 (1.62, 1.85) in the 1801-2400 block. The frequency of all OHCA varied significantly by day of week (p = 0.03) and month of year (p < 0.001) with the highest frequencies on Saturday and during December. Survival to hospital discharge was lowest when the OHCA occurred during the 0001-0600 time block (7.3%) and highest during the 1201-1800 time block (9.6%). Survival was highest for OHCAs occurring on Mondays (10.0%) and lowest for those on Wednesdays (6.8%) (p = 0.02).

Conclusion

There is temporal variability in OHCA frequency and outcome. Underlying patient, EMS system and environmental factors need to be explored to offer further insight into these observed patterns.     

Chest compression-only cardiopulmonary resuscitation performed by lay rescuers for adult out-of-hospital cardiac arrest due to non-cardiac aetiologies

Objective

Bystander CPR improves survival in patients with out-of-hospital cardiac arrest (OHCA). For adult sudden collapse, bystander chest compression-only CPR (COCPR) is recommended in some circumstances by the American Heart Association and European Resuscitation Council. However, adults who arrest from non-cardiac causes may also receive COCPR. Because rescue breathing may be more important for individuals suffering OHCA secondary to non-cardiac causes, COCPR is not recommended for these cases. We evaluated the relationship of lay rescuer COCPR and survival after OHCA from non-cardiac causes.

Methods

Analysis of a statewide Utstein-style registry of adult OHCA, during a large scale campaign endorsing COCPR for OHCA from presumed cardiac cause. The relationship between lay rescuer CPR (both conventional CPR and COCPR) and survival to hospital discharge was evaluated.

Results

Presumed non-cardiac aetiologies of OHCA accounted for 15% of all cases, and lay rescuer CPR was provided in 29% of these cases. Survival to hospital discharge occurred in 3.8% after conventional CPR, 2.7% after COCPR, and 4.0% after no CPR (p = 0.85). The proportion of patients receiving COCPR was much lower in the cohort of OHCA from respiratory causes (8.3%) than for those with presumed cardiac OHCA (18.0%; p < 0.001).

Conclusions

In the setting of a campaign endorsing lay rescuer COCPR for cardiac OHCA, bystanders were less likely to perform COCPR on OHCA victims who might benefit from rescue breathing.     

Out-of-hospital cardiac arrests in young adults in Melbourne, Australia

Background

Characteristics and outcomes of out-of-hospital cardiac arrest (OHCA) in young adults are not well described in Australia.

Methods

A 10-year retrospective case review of all OHCA in young adults (aged 16-39) and not witnessed by EMS, was performed using data from the Victorian Ambulance Cardiac Arrest Registry (VACAR).

Results

Between 2000 and 2009 there were 30,006 adult cardiac arrests of which 3912 (13%) were in this age group. The median (IQR) age was 30 (25-35) years for both sexes with a 3:1 male to female ratio. Overdose was the most common precipitant (33.5%) followed by presumed cardiac (20%). Bystander CPR occurred in 21.2%, EMS median response time was 7 min and resuscitation was attempted in 36% of OHCAs. The presenting rhythm was asystole in 84.6%, PEA in 8.8% and VF/VT in 6.6%. Survival to hospital discharge, for all cause OHCA where resuscitation was attempted, was similar for young adult and older adults (8.8% vs 8.4%, p = 0.2). However, for presumed cardiac aetiology OHCA, young adults had a greater proportion of survivors (14.8% vs 9.0%, p < 0.001). Cardiac arrest with shockable rhythm (VF/pulseless VT) had a survival rate of 31.2% for young adults compared to 18.5% for older adults (p < 0.001).

Conclusion

Survival to hospital discharge rates from OHCA due to a ‘presumed cardiac’ precipitant in young adults is much better than older adults, however, all cause OHCA survival is similar. Multi agency novel upstream preventive strategies aimed at tackling drug overdose may reduce this aetiology of OHCA and save lives.     

A 5-year experience with cardiopulmonary resuscitation using extracorporeal life support in non-postcardiotomy patients with cardiac arrest

Background

Cardiopulmonary resuscitation (CPR) using extracorporeal life support (ECLS) system has been successfully used to support patients with in- and out-of-hospital cardiac arrest (IHCA, OHCA) when conventional measures have failed. The purpose of the current study is to report on our experience with extracorporeal CPR in non-postcardiotomy patients.

Methods

We retrospectively analysed a total of 85 consecutive adult patients, who have been treated with ECLS between January 2007 and January 2012.

Results

The mean CPR duration was 40 min (20–70 min). The mean ECLS support duration was 49 h (12–92 h). Twenty-eight patients (33%) had ECLS related complications. Forty patients (47%) were successfully weaned and 29 patients (34%) survived to hospital discharge. Among survivors, 93% were without severe neurologic deficit. Duration of CPR was shorter for survivors than for non-survivors [(25: 20–50 min) vs. (50: 25–86 min); p = 0.003]. Immediately after ECLS start, the mean blood lactate level was lower (p = 0.003), and the mean pH value was higher in the survivors’ group (p < 0.0001) compared to the non-survivors’ group. The CPR duration for the IHCA group (25: 20–50 min) was shorter compared to the OHCA group (70: 55–110 min; p < 0.0001). The survival rate in this group was higher compared to the OHCA group (42% vs. 15%; p < 0.02).

Conclusions

CPR using modern miniaturized ECLS systems should be established in the treatment of prolonged cardiac arrest and unsuccessful conventional CPR in selected patients. CPR with ECLS for OHCA has worse outcomes compared to IHCA. Duration of CPR was independent risk factor for mortality after extracorporeal CPR.     

OSA Symptoms Associated With and Predictive of Anxiety in Middle-Aged Men: Secondary Analysis of NHANES Data

Object

This population-based study examined obstructive sleep apnea (OSA) symptoms predictive of anxiety in middle-aged men.

Method

Secondary analyses were conducted on the National Health and Nutrition Examination Survey (NHANES) 2007–2008 data using weighted samples and complex sample analysis techniques (unweighted N = 1,217).

Findings

Nonrefreshing sleep (χ² = 69.333, p < 0.001), excessive daytime sleepiness (χ² = 47.766, p < 0.001), and sleep fragmentation (χ² = 30.692, p < 0.001) were significantly associated with anxiety. Nonrefreshing sleep (OR 3.582, p < 0.001) and awakenings due to apneic episodes (OR 2.047, p = 0.001) were predictive of anxiety.

Conclusion

Comorbid anxiety and OSA symptoms are common and have implications for activities of daily living, social responsibilities, and quality of life. Screening for anxiety among men with OSA symptoms is recommended.     

Prognostic value of electroencephalography (EEG) after out-of-hospital cardiac arrest in successfully resuscitated patients used in daily clinical practice

Background

Out-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis and predicting outcome is complex with neurophysiological testing and repeated clinical neurological examinations as key components of the assessment. In this study we examine the association between different electroencephalography (EEG) patterns and mortality in a clinical cohort of OHCA-patients.

Methods

From 2002 to 2011 consecutive patients were admitted to an intensive-care-unit after resuscitation from OHCA. Utstein-criteria for pre-hospital data and review of individual patients’ charts for post-resuscitation care were used. EEG reports were analysed according to the 2012 American Clinical Neurophysiology Society's guidelines.

Results

A total of 1076 patients were included, and EEG was performed in 20% (n = 219) with a median of 3(IQR 2–4) days after OHCA. Rhythmic Delta Activity (RDA) was found in 71 patients (36%) and Periodic Discharges (PD) in 100 patients (45%). Background EEG frequency of Alpha+ or Theta was noted in 107 patients (49%), and change in cerebral EEG activity to stimulation (reactivity) was found in 38 patients (17%). Suppression (all activity <10 μV) was found in 26 (12%) and burst-suppression in 17 (8%) patients. A favourable EEG pattern (reactivity, favourable background frequency and RDA) was independently associated with reduced mortality with hazard ratio (HR) 0.43 (95%CI: 0.24–0.76), p = 0.004 (false positive rate: 31%) and a non-favourable EEG pattern (no reactivity, unfavourable background frequency, and PD, suppressed voltage or burst-suppression) was associated with higher mortality (HR = 1.62(1.09–2.41), p = 0.02) after adjustment for known prognostic factors (false positive rate: 9%).

Conclusion

EEG may be useful in work-up in prognostication of patients with OHCA. Findings such as Rhythmic Delta Activity (RDA) seem to be associated with a better prognosis, whereas suppressed voltage and burst-suppression patterns were associated with poor prognosis.     

Post-hypothermia fever is associated with increased mortality after out-of-hospital cardiac arrest

Objective

Post-cardiac arrest fever has been associated with adverse outcome before implementation of therapeutic hypothermia (TH), however the prognostic implications of post-hypothermia fever (PHF) in the era of modern post-resuscitation care including TH has not been thoroughly investigated.The aim of the study was to assess the prognostic implication of PHF in a large consecutive cohort of comatose survivors after out-of-hospital cardiac arrest (OHCA) treated with TH.

Methods

In the period 2004–2010, a total of 270 patients resuscitated after OHCA and surviving a 24-h protocol of TH with a target temperature of 32–34 °C were included. The population was stratified in two groups by median peak temperature (≥38.5 °C) within 36 h after rewarming: PHF and no-PHF. Primary endpoint was 30-days mortality and secondary endpoint was neurological outcome assessed by Cerebral Performance Category (CPC) at hospital discharge.

Results

PHF (≥38.5 °C) was associated with a 36% 30-days mortality rate compared to 22% in patients without PHF, p_log-rank = 0.02, corresponding to an adjusted hazard rate (HR) of 1.8 (95% CI: 1.1–2.7), p = 0.02). The maximum temperature (HR = 2.0 per °C above 36.5 °C (95% CI: 1.4–3.0), p = 0.0005) and the duration of PHF (HR = 1.6 per 8 h (95% CI: 1.3–2.0), p < 0.0001) were also independent predictors of 30-days mortality in multivariable models. Good neurological outcome (CPC1-2) versus unfavourable outcome (CPC3-5) at hospital discharge was found in 61% vs. 39% in the PHF group compared to 75% vs. 25% in the No PHF group, p = 0.02.

Conclusions

Post-hypothermia fever ≥38.5 °C is associated with increased 30-days mortality, even after controlling for potential confounding factors. Avoidance of PHF as a therapeutic target should be evaluated in prospective randomized trials.