In this June issue.

Use of mild therapeutic hypothermia to goal 32 34 °C, after return of spontaneous circulation (ROSC) in cardiac arrest patients, has been shown to increase the rates of survival and favorable neurological outcomes [1, 2]. The American Heart Association (AHA) recommends mild therapeutic hypothermia after ROSC for out-of-hospital cardiac arrest with an initial documented rhythm of ventricular fibrillation (class I, level of evidence B) [3]. International resuscitation guidelines also support mild therapeutic hypothermia as the best medical practice for shockable rhythms in patients resuscitated from cardiac arrest due to ventricular fibrillation and pulseless ventricular tachycardia after ROSC [4]. Herein, we wish to notify the readers on a case of therapeutic hypothermia after ROSC in a young man associated with favorable neurologic outcome and survival. A 34-yearold electrical worker is brought to the emergency department (ED) by co-workers having been injured by electrical strike at work. On arrival in the ED, he had a Glasgow coma score (GCS) of 3/15 and dilated sluggish pupils. Additionally, there were no heartbeats or respiration. Cardiac monitoring revealed ventricular fibrillation and the patient received treatment with 150-J biphasic waveform shock. Cardiopulmonary resuscitation (CPR) was immediately instituted after the shock. After 2 min of CPR, ROSC was achieved and his rhythm has restored to sinus rhythm. Neither epinephrine nor antidysrhythmic agents were administered. He was resuscitated succesufully but yet remained comatose after CPR at the ED, following vital signs: GCS 8, heart rate 110/min, and blood pressure 80/50 mm Hg. Advanced cardiac life support measures were initiated (i.e., controlled intravenous fluid support, administration of dopamine, adequate oxygenation, and support of respiration with bag ventilation) following ROSC in the ED. Furthermore, therapeutic hypothermia protocol was started immediately with ice packs in the ED to decrease the patient’s temperature below 34 °C. Two hours after admission to the ED, he was transferred to the intensive care unit (ICU) for optimal care. Therapeutic cooling was maintained for 24 h by gel-circulation cooling pads (temperature management system; Artric Sun® 5000) in the ICU, and the patient was discharged home with mild neurologic deficit on ICU day 20. Therapeutic hypothermia is associated with favorable neurologic outcome and survival in patients who have experienced cardiac arrest and resuscitated succesufully, as it was in the present case. This therapy should be started as quickly as possible in post-cardiac arrest care patients, particularly with shockable cardiac arrest rhythms.

The current report shows a comparison of changes in pre- and in-hospital procedures, treatments and outcomes of patients with out-of-hospital cardiac arrest (OHCA) during the SOS-KANTO study periods. This study included patients aged ≥18 years who experienced bystander-witnessed OHCA of cardiac etiology, which was confirmed by emergency medical service (EMS) providers at the scene, received cardiopulmonary resuscitation (CPR) from EMS providers, and were subsequently transported to the participating institutions.The primary outcome measure was patient survival with favorable neurological outcomes at 1 month from cardiac arrest. The secondary outcomes were the proportions of bystander CPR cases, advanced CPR procedures performed by EMS providers, pre-hospital return of spontaneous circulation (ROSC) rates, and post-resuscitation treatment administration. Data of 1,515 patients from the SOS-KANTO 2017 study and 2,189 patients from the 2012 study were analyzed. Bystander CPR and advanced CPR procedures were performed more frequently and reliably by EMS providers in the 2017 than in the 2012 study. The rate of pre-hospital ROSC to total ROSC was higher in the 2017 study (35.7% vs 29.0%), and in-hospital treatments and post-resuscitation care was provided more frequently in the 2017 study. However, the 2017 study showed no significant difference in the survival rate with favorable neurological outcomes at 1 month, compared with the 2012 study. (9.0% vs 8.5%). High quality of prior to ROSC and post-resuscitation care following ROSC was maintained in the 2017 study. However, the 2017 study showed no significant difference in the survival rate with favorable neurological outcomes at 1 month, compared with the 2012 study.

BackgroundThe prognosis in refractory out-of-hospital cardiac arrest (OHCA) with ongoing cardiopulmonary resuscitation (CPR) at hospital arrival is often considered dismal. The use of extracorporeal cardiopulmonary resuscitation (eCPR) for perfusion enhancement during resuscitation has shown variable results. We aimed to investigate outcome in refractory OHCA patients managed conservatively without use of eCPR.MethodsWe included consecutive OHCA patients with refractory arrest or prehospital return of spontaneous circulation (ROSC) in the Copenhagen area in 2002–2011.ResultsA total of 3992 OHCA patients with resuscitation attempts were included; in 2599, treatment was terminated prehospital, and 1393 (35%) were brought to the hospital either with ROSC (n = 1285, 92%) or with refractory OHCA (n = 108, 8%). Of patients brought in with refractory OHCA, 56 (52%) achieved ROSC in the emergency department. There were no differences between patients with refractory OHCA or prehospital ROSC with regard to age, sex, comorbidities, or etiology of OHCA. Time to emergency medical services (EMS) arrival was similar, whereas time to ROSC (when ROSC was achieved) was longer in refractory OHCA patients (EMS, 6 (5–9] vs. 7 [5–10] min, p = 0.8; ROSC, 15 [9–22] vs. 27 [20–41] min, p < 0.001). Independent factors associated with transport with refractory OHCA instead of prehospital termination of therapy were OHCA in public (OR, 3.6 [95% CI, 2.2–5.8]; p < 0.001), witnessed OHCA (OR, 3.7 [2.0–7.1]; p < 0.001), shockable rhythm (OR, 3.0 [1.9–4.7]; p < 0.001), younger age (OR, 1.2 [1.1–1.2]; p < 0.001), and later calendar year (OR, 1.4 [1.2–1.6]; p < 0.001). Thirty-day survival was 20% in patients with refractory OHCA compared with 42% in patients with prehospital ROSC (p < 0.001). Four of 28 refractory OHCA patients with duration of resuscitation > 60 min achieved ROSC. No difference in favorable neurological outcome in patients surviving to discharge was found (prehospital ROSC 84% vs. refractory OHCA 86%; p = 0.7).ConclusionsSurvival after refractory OHCA with ongoing CPR at hospital arrival was significantly lower than among patients with prehospital ROSC. Despite a lower survival, the majority of survivors with both refractory OHCA and prehospital ROSC were discharged with a similar degree of favorable neurological outcome, indicating that continued efforts in spite of refractory OHCA are not in vain and may still lead to favorable outcome even without eCPR.

Frailty and Neurologic Outcomes of Patients Resuscitated From Nontraumatic Out-of-Hospital Cardiac Arrest: A Prospective Observational Study.

Transient return of spontaneous circulation related to favourable outcomes in out-of-hospital cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation: A secondary analysis of the SAVE-J II study

Background: Anaphylaxis is a life-threatening condition that can lead to out-of-hospital cardiac arrest (OHCA). Understanding the factors associated with neurological outcomes in anaphylaxis-induced OHCA may provide valuable clinical insights; however, evidence remains limited. Furthermore, the most effective treatments or the critical time window for achieving favorable neurological outcomes in anaphylaxis OHCA remain unclear. Hypothesis: We hypothesized that specific clinical factors, including prehospital treatments (e.g., advanced airway management and adrenaline administration), are associated with favorable neurological outcomes in anaphylaxis OHCA. We also hypothesized that the time window for achieving a favorable outcome is short. Aims: To identify clinical factors associated with favorable neurological outcomes and to describe the association between the CPR duration and probability of favorable outcome. Methods: We analyzed OHCA cases from a nationwide Japanese registry (2005–2023), including all patients with cardiac arrest due to anaphylaxis. Neurological outcomes were categorized as favorable (Cerebral Performance Category [CPC] 1–2) or poor (CPC 3–5). Logistic regression analyses were performed to identify factors associated with favorable outcomes. A cubic spline curve was used to estimate the relationship between cardiac arrest duration and the probability of favorable outcomes. Results: Among registered patients in adult, prevalence of anaphylaxis-induced OHCA was 0.16% (364/2,332,898). Among 364 patients, 106 (29.1%) achieved favorable neurological outcomes. These patients more frequently had witnessed arrests (91% vs. 73%, p&lt;0.01), and prehospital return of spontaneous circulation (ROSC) (74% vs. 28%, p&lt;0.01). Multivariable analysis showed that prehospital ROSC (adjusted odds ratio: 3.89, 95% confidence interval: 1.22–12.4) was significantly associated with favorable outcomes. However, prehospital airway management and adrenaline use were not significantly associated with favorable outcomes. Among patients with known cardiac arrest duration, the estimated durations corresponding to a 75%, 50%, and 25% probability of favorable outcome were 8, 13, and 18 minutes, respectively. Conclusions: Anaphylaxis-induced OHCA can result in favorable neurological outcomes, particularly when ROSC is achieved early. These findings highlight the importance of rapid recognition and timely resuscitation in this population.

The association of mechanical versus manual chest compressions with neurological outcomes at hospital discharge among out-of-hospital cardiac arrests treated with intra-arrest transport.

Cardiac arrest is associated with morbidity and mortality because of cerebral ischemia. Therefore, we tested the hypothesis that higher regional cerebral oxygenation during resuscitation is associated with improved return of spontaneous circulation, survival, and neurologic outcomes at hospital discharge. We further examined the validity of regional cerebral oxygenation as a test to predict these outcomes. Multicenter prospective study of in-hospital cardiac arrest. Five medical centers in the United States and the United Kingdom. Inclusion criteria are as follows: in-hospital cardiac arrest, age 18 years old or older, and prolonged cardiopulmonary resuscitation greater than or equal to 5 minutes. Patients were recruited consecutively during working hours between August 2011 and September 2014. Survival with a favorable neurologic outcome was defined as a cerebral performance category 1-2. Cerebral oximetry monitoring. Among 504 in-hospital cardiac arrest events, 183 (36%) met inclusion criteria. Overall, 62 of 183 (33.9%) achieved return of spontaneous circulation, whereas 13 of 183 (7.1%) achieved cerebral performance category 1-2 at discharge. Higher mean ± SD regional cerebral oxygenation was associated with return of spontaneous circulation versus no return of spontaneous circulation (51.8% ± 11.2% vs 40.9% ± 12.3%) and cerebral performance category 1-2 versus cerebral performance category 3-5 (56.1% ± 10.0% vs 43.8% ± 12.8%) (both p < 0.001). Mean regional cerebral oxygenation during the last 5 minutes of cardiopulmonary resuscitation best predicted the return of spontaneous circulation (area under the curve, 0.76; 95% CI, 0.69-0.83); regional cerebral oxygenation greater than or equal to 25% provided 100% sensitivity (95% CI, 94-100) and 100% negative predictive value (95% CI, 79-100); regional cerebral oxygenation greater than or equal to 65% provided 99% specificity (95% CI, 95-100) and 93% positive predictive value (95% CI, 66-100) for return of spontaneous circulation. Time with regional cerebral oxygenation greater than 50% during cardiopulmonary resuscitation best predicted cerebral performance category 1-2 (area under the curve, 0.79; 95% CI, 0.70-0.88). Specifically, greater than or equal to 60% cardiopulmonary resuscitation time with regional cerebral oxygenation greater than 50% provided 77% sensitivity (95% CI,:46-95), 72% specificity (95% CI, 65-79), and 98% negative predictive value (95% CI, 93-100) for cerebral performance category 1-2. Cerebral oximetry allows real-time, noninvasive cerebral oxygenation monitoring during cardiopulmonary resuscitation. Higher cerebral oxygenation during cardiopulmonary resuscitation is associated with return of spontaneous circulation and neurologically favorable survival to hospital discharge. Achieving higher regional cerebral oxygenation during resuscitation may optimize the chances of cardiac arrest favorable outcomes.

Despite the frequent use of both advanced airway management (AAM) and epinephrine during resuscitation, no studies have evaluated the optimal sequencing of these interventions in paediatric out-of-hospital cardiac arrest (OHCA). We therefore aimed to investigate the association between the sequence of AAM and epinephrine administration and outcomes in paediatric patients with OHCA with non-shockable rhythms. This retrospective observational study analysed data from a multicentre OHCA registry in Japan from 2014 to 2022. We included paediatric patients (aged <18 years) with non-shockable OHCA who received AAM (endotracheal intubation or supraglottic airway device placement) and/or epinephrine administration. The primary outcome was 1-month survival, and the secondary outcomes were 1-month favourable neurological outcome (defined as a paediatric cerebral performance category of 1-3) and the return of spontaneous circulation (ROSC). Inverse probability of treatment weighting (IPTW) was applied based on propensity scores to address imbalances in patient characteristics. Of the 952 paediatric patients with non-shockable OHCA (median age (IQR) 2 (0-14) years), 577 (61%) were male. Of these, 455 and 497 belonged to the AAM-first and epinephrine-first groups, respectively. After IPTW, all covariates were well balanced between the AAM-first and epinephrine-first groups (standardised mean difference ≤0.10). Compared with the epinephrine-first group, the AAM-first group showed similar 1-month survival (adjusted OR (aOR), 1.09; 95% CI 0.61 to 1.86), favourable neurological outcome at 1 month (aOR, 0.79; 95% CI 0.12 to 5.07) and ROSC (aOR, 0.98; 95% CI 0.72 to 1.35). The sequence of AAM and epinephrine administration was not associated with 1-month survival, favourable neurological outcome at 1 month or ROSC in paediatric patients with non-shockable OHCA.

We aimed to assess the association between base excess (BE) levels and neurological outcomes in patients with out-of-hospital cardiac arrest (OHCA), accounting for the time from cardiac arrest onset to blood sampling. This multicentre study was conducted in Osaka, Japan, and enrolled consecutive patients with OHCA who were transported to 16 medical centres between 2012 and 2021. Patients aged≥18years with witnessed OHCA and available BE measurements upon hospital arrival were examined. Patients were stratified into Q1 (BE≤-21.1mmol/L), Q2 (-21.1<BE≤-15.7mmol/L), Q3 (-15.7<BE≤-10.4mmol/L) and Q4 (BE>-10.4mmol/L) groups based on BE levels. The primary outcome was 1-month survival with a favourable neurological outcome (Cerebral Performance Category scale score: 1 or 2). Among the 23,854 patients with OHCA, only 6066 were included in the final analysis. Approximately 3.2%, 4.7%, 9.9% and 23.7% of patients in the Q1, Q2, Q3 and Q4 groups, respectively, achieved favourable neurological outcomes at 1month. Compared with Q4, the adjusted odds ratio for a favourable neurological outcome in Q1 was 0.13. Subgroup analysis revealed a significant interaction between prehospital return of spontaneous circulation (ROSC) and neurological outcomes; neurological outcomes worsened as BE decreased in patients with ROSC but not in those without ROSC. Lower BE levels upon hospital arrival are associated with poorer neurological outcomes and may serve as prognostic indicators in patients with OHCA who achieved prehospital ROSC.

Characteristics of out-of-hospital cardiac arrest due to cerebrovascular disorders: a nationwide, retrospective, observational study.

Part 6: Defibrillation

Background: Little is known about the association between serum potassium levels on hospital arrival and favorable neurological outcome after out-of-hospital cardiac arrest. Objective: The purpose of this study was to assess whether serum potassium levels on hospital arrival had prognostic indications for patients with out-of-hospital cardiac arrest (OHCA). Methods: The prospective, multicenter observational study conducted in Osaka, Japan (the CRITICAL study) enrolled all consecutive OHCA patients transported to 14 participating institutions from July 2012 through December 2015. We included adult patients aged ≥ 18 years with OHCA of cardiac origin who achieved return of spontaneous circulation (ROSC) and whose serum potassium level on hospital arrival was available. Based on the serum potassium level on hospital arrival, patients were divided into five quintiles (Q1-Q5), namely, Q1 (&lt;3.7mEq/l), Q2 (3.7-4.2mEq/l), Q3 (4.2-5.0mEq/l), Q4 (5.0-6.1mEq/l), and Q5 (&gt;6.1mEq/l). The primary outcome was one-month survival with favorable neurological outcome, which was defined as cerebral performance category scale 1 or 2. Results: During the study period, a total of 7373 patients were registered and 1148 of them were eligible for our analyses. The highest proportion of favorable neurological outcome was 42.2% (113/268) in the Q1, followed by 37.6% (76/202), 20.6% (50/243), 6.9% (15/216), and 2.7% (6/219) in the Q2, Q3, Q4, and Q5 (p&lt;0.001). In the multivariable logistic regression analysis, the adjusted proportion of favorable neurological outcome decreased as serum potassium level increased (p for trend &lt;0.001). In the subgroup analyses stratified by the first documented rhythm and estimated glomerular filtration rate, the adjusted proportions of favorable neurological outcome indicated similar tendency with those in the main analysis. Conclusion: Higher serum potassium level was significantly and independently associated with poor neurological outcome. Serum potassium on hospital arrival may be effective as a prognostic indication for out-of-hospital cardiac arrest achieving ROSC.

Changes in ventricular repolarisation, observed as QTc prolongation, are frequently observed following cardiac arrest. The T-peak to T-end (TpTe) interval represents a period of increased susceptibility to ventricular arrhythmia. We posit that TpTe prolongation may be associated with adverse clinical outcomes in patients resuscitated from cardiac arrest. We included patients aged ≥18 years with both out-of-hospital and in-hospital cardiac arrest following return of spontaneous circulation (ROSC) who had an electrocardiogram (ECG) obtained within 24 h following ROSC. The first ECG obtained was evaluated to determine the QTc and TpTe intervals. Hierarchical logistic regression was used to evaluate the association between prolongation of the QTc and TpTe intervals and clinical outcomes (in-hospital mortality and favourable neurologic outcome at hospital discharge). We included 443 patients, with a median age of 61 years (IQR: 50-72 years), 60.5% male, 65.7% OHCA, and 29.8% with initial shockable rhythm. Overall, 310 patients had QTc prolongation (70.0%), and 284 had TpTe prolongation (64.1%). Patients with TpTe prolongation had a greater incidence of initial shockable rhythm (35.6% vs. 19.5%, P < 0.001) and higher initial lactate (8.6 vs. 7.4 mmol/L, P = 0.03). QTc prolongation was not associated with in-hospital mortality [odds ratio (OR):1.27, 95% confidence interval (CI): 0.75-2.14, P = 0.37] or favourable neurologic outcome (OR: 0.88, 95% CI: 0.50-1.54, P = 0.65). TpTe prolongation was independently associated with in-hospital mortality (OR: 1.69, 95% CI: 1.01-2.85, P = 0.05) but not favourable neurologic outcome (OR: 0.78, 95% CI: 0.45-1.37, P = 0.39). TpTe interval prolongation, but not QTc interval prolongation, was associated with increased in-hospital mortality in patients resuscitated from cardiac arrest.

Effect of cardiopulmonary resuscitation training for layperson bystanders on outcomes of out-of-hospital cardiac arrest: A prospective multicenter observational study