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The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest. [ABSTRACT FROM AUTHOR]

Although most US emergency medical services (EMS) systems collect time-to-treatment data in their electronic prehospital patient care reports (PCRs), analysis of these data seldom appears in publications. We believe EMS agencies should routinely analyze the initial time-to-treatment data for various potentially life-threatening conditions. This not only assures that protocol-required treatments have been provided but can discover avoidable delays and drive protocol/treatment priority change. Our study purpose was to analyze the interval from 9-1-1 call receipt until the first administration of naloxone to adult opioid overdose victims to demonstrate the quality assurance importance of analyzing time-to-treatment data. Retrospective analysis of intervals from 9-1-1 call receipt to initial naloxone treatment in adult opioid overdose victims. We excluded victims <18 years of age and cases where a bystander, police, or a health care worker gave naloxone before EMS arrival. We compared data collected before and during the COVID-19 pandemic to determine its effect on the analysis. The mean patient age of 582 opioid overdose victims was 40.7 years [95% CI 39.6, 41.8] with 405 males (69.6%). EMS units' scene arrival was 6.7 minutes from the 9-1-1 call receipt. It took 1.8 minutes to reach the victim, and 8.6 additional minutes to administer the first naloxone regardless of administration route (70.4% intravenous, 26.1% intranasal, 2.7% intraosseous, 0.7% intramuscular). EMS personnel administered the first naloxone 17.1 minutes after the 9-1-1 call receipt, with 50.3% of the delay occurring after patient contact. There was no statistically significant difference in the times-to-treatment before vs. during the pandemic. The prepandemic interval from 9-1-1 call receipt until initial EMS administration of naloxone was substantial and did not change significantly during COVID-19. Our findings exemplify why EMS agencies should analyze initial time-to-treatment data, especially for life-threatening conditions, beyond assuring that protocol-required treatments have been provided. Based on our analysis, fire department crews now carry intranasal naloxone, and intranasal naloxone is given to "impaired" opioid overdose victims the first-arriving fire department or EMS personnel. We continue to collect data on intervals-to-treatment prospectively and monitor our critical process/treatment intervals using the plan-do-study-act model to improve our process/carry out change, and publish our results in a future publication. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the effects of the selective NLRP3 inflammasome inhibitor MCC950 on post-resuscitation myocardial function and survival in a rat model of cardiopulmonary resuscitation (CPR). Methods: Thirty-six Sprague Dawley rats were randomized into three groups: (1) MCC950, (2) control, and (3) sham. Each group consisted of a 6 h non-survival subgroup (n = 6) and a 48 h survival subgroup (n = 6). Ventricular fibrillation (VF) was induced and untreated for 6 min. CPR was initiated and continued for 8 min. Resuscitation was attempted with a 4 J defibrillation. MCC950 (10 mg/kg) or vehicle was administered via intraperitoneal injection immediately after the return of spontaneous circulation (ROSC). Myocardial function and sublingual microcirculation were measured after ROSC in the non-survival subgroups. Plasma levels of interleukin Iβ (IL-1β) and cardiac troponin I (cTnI) were measured at baseline and 6 h in the non-survival subgroups. Heart tissue was harvested to measure the NLRP3 inflammasome constituents, including NLRP3, apoptosis-associated speck-like protein (ASC), Caspase-1, and IL-1β. Survival duration and neurologic deficit score (NDS) were recorded and evaluated among survival groups. Results: Post-resuscitation myocardial function and sublingual microcirculation were improved in MCC950 compared with control (p < 0.05). IL-1β and cTnI were decreased in MCC950 compared to control (p < 0.01). The MCC950 treated groups showed significantly reduced ASC, caspase-1, and IL-1β compared with the control group (p < 0.05). Survival at 48 h after ROSC was greater in MCC950 (p < 0.05) with improved NDS (p < 0.05). Conclusion: Administration of MCC950 following ROSC mitigates post-resuscitation myocardial dysfunction and improves survival. [ABSTRACT FROM AUTHOR]

©2012 Wiley Periodicals Inc. New variables obtained from cardiopulmonary exercise testing (CPX) have received attention in recent years, in particular the partial pressure of end-tidal carbon dioxide (PETCO2). The purpose of this study was to therefore comprehensively assess the ability of resting and exercise PETCO2 to predict major cardiac events in a heart failure (HF) cohort referred for CPX. A total of 963 patients with systolic HF undergoing symptom-limited CPX were included in the analysis. Resting and exercise PETCO2 along with other CPX variables were determined, and patients were followed for major adverse events. With regard to resting measures, multivariate analysis revealed that left ventricular ejection fraction was the most robust prognostic marker ( P<.001) while resting PETCO2 added significant predictive value and was retained in the regression ( P<.001). When exercise data were considered, the multivariate analysis revealed that the PETCO2 apex during exercise added predictive value and was retained ( P<.05). In what is the largest evaluation of PETCO2 in the assessment of systolic HF patients to date, the authors substantiate prior (smaller) studies showing prognostic utility of PETCO2, both as a resting measure (an important potential screening tool) and during exercise. These data add to the rationale to incorporate PETCO2 as a routine monitoring component in HF management. [ABSTRACT FROM AUTHOR]

The article focuses on a study which evaluated the association between automated external defibrillators (AEDs) use and survival for in-hospital cardiac arrest. The researchers examined 11,695 hospitalized patients who experienced cardiac arrests between January 1, 2000 to August 26, 2008 at U.S. hospitals following the introduction of AEDs on general and hospital wards. Study results indicated that hospitalized patients with cardiac arrest and use of AED were not associated with improved survival.

Heart disease is a major cause of morbidity and mortality in the United States, with coronary artery disease (CAD) representing more than half of all cardiovascular events. Stable patients presenting with symptoms suggestive of CAD are likely to undergo an exercise electrocardiogram (ECG) and/ or imaging study as a first-line diagnostic assessment. A cardiopulmonary exercise test (CPX) is an ECG stress test plus ventilatory gas analysis. Recently, CPX has been used to detect exercise-induced myocardial ischemia (EIMI) suggestive of underlying CAD. Two CPX variables, oxygen pulse (VO2/HR) and the slope of oxygen consumption versus work rate (ΔVO2/ ΔWR), have been identified to be especially indicative of EIMI. Currently, there are a number of diagnostic tests available for the identification of CAD, with the most widely used being stress ECG, stress myocardial perfusion imaging (MPI) and echocardiography, and cardiac catheterization. Exercise ECG, although inexpensive, has a number of well-recognized limitations, including low sensitivity resulting in false-negative results. Stress (exercise or pharmaceutically induced) MPI and catheterization are more accurate but also more invasive and expensive. It appears that CPX may improve the diagnostic accuracy of exercise ECG. This review will address the potential utility of CPX in patients with suspected or confirmed myocardial ischemia. [ABSTRACT FROM PUBLISHER]

This study tested the hypothesis that increasing levels of maximal dyspnea on exertion (DOE) during cardiopulmonary exercise testing (CPX) is associated with heart failure (HF) disease severity and worsening prognosis. Three hundred seventy-six HF patients underwent CPX where ventilatory efficiency (minute ventilation/carbon dioxide production; VE/VCO2 slope), peak oxygen consumption (VO2), and maximal DOE were determined. A subgroup of 243 patients underwent echocardiography with tissue Doppler imaging to measure the ratio between mitral early (E) to mitral annular (E′) velocity as well as other variables. Maximal DOE was significantly correlated with E/E′ (rs=.49; P<.001). In the multivariate Cox regression, the VE/VCO2 slope was the strongest prognostic marker obtained from CPX (Multivariate chi-square, 48.0; P<.001) while maximal DOE (residual chi-square, 17.4; P<.001) and peak VO2 (residual chi-square, 7.5; P=.006) added predictive value. These results suggest that increasing DOE reflects the degree of disease severity and adds prognostic value to established CPX variables. [ABSTRACT FROM AUTHOR]

Peak oxygen consumption (VO2) and ventilatory efficiency (minute ventilation/carbon dioxide output [VE/VCO2] slope) are prognostically important in heart failure (HF). The purpose of the present study was to compare the prognostic characteristics of these variables between Caucasian and African American patients. A total of 662 HF patients (455 Caucasian/207 African American) underwent cardiopulmonary exercise testing and were tracked for major cardiac events. The VE/VCO2 slope was the strongest prognostic marker (chi-square ≥18.9, P<.001), irrespective of race. While peak VO2 was a significant univariate predictor in both Caucasian (chi-square 42.0, P<.001) and African American (5.2, P=.02) subgroups, it was only retained in the Caucasian multivariate regression. The lack of predictive value of peak VO2 in the African American subgroup was due to its lack of prognostic significance in female patients. While the VE/VCO2 slope was the most robust prognostic marker in both Caucasian and African American patients, the predictive ability of peak VO2 seems to be influenced by race and sex. [ABSTRACT FROM AUTHOR]

The article focuses on research which examined whether outcomes after in-hospital cardiac arrest differ during nights and weekends compared with days, evenings and weekdays. The research examined rates of survival and involved 58,593 cases of cardiac arrest during day time and 28,155 cases during night hours. Researchers found that survival rates from in-hospital cardiac arrest are lower during nights and weekends, even when adjusted for potentially confounding patient, event and hospital characteristics.

The article discusses the use of an automated load-distributing band-cardiopulmonary resuscitation device (LDB-CPR) for resuscitating patients who have out-of-hospital cardiac arrest (OHCA). The study was designed for a patient population serviced by an urban emergency medical services (EMS) system that switched from manual CPR. Outcome measures included return to spontaneous circulation (ROSC) and survival to hospital discharge. Research methods for the study in Richmond, Virginia are mentioned. The authors found improved survival when the LDB-CPR device was used on EMS ambulances.

Context: Cardiac arrests in adults are often due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), which are associated with better outcomes than asystole or pulseless electrical activity (PEA). Cardiac arrests in children are typically asystole or PEA. Objective: To test the hypothesis that children have relatively fewer in-hospital cardiac arrests associated with VF or pulseless VT compared with adults and, therefore, worse survival outcomes. Design, Setting, and Patients: A prospective observational study from a multicenter registry (National Registry of Cardiopulmonary Resuscitation) of cardiac arrests in 253 US and Canadian hospitals between January 1, 2000, and March 30, 2004. A total of 36 902 adults ( 18 years) and 880 children (<18 years) with pulseless cardiac arrests requiring chest compressions, defibrillation, or both were assessed. Cardiac arrests occurring in the delivery department, neonatal intensive care unit, and in the out-of-hospital setting were excluded. Main Outcome Measure: Survival to hospital discharge. Results: The rate of survival to hospital discharge following pulseless cardiac arrest was higher in children than adults (27% [236/880] vs 18% [6485/36 902]; adjusted odds ratio [OR], 2.29; 95% confidence interval [CI], 1.95-2.68). Of these survivors, 65% (154/236) of children and 73% (4737/6485) of adults had good neurological outcome. The prevalence of VF or pulseless VT as the first documented pulseless rhythm was 14% (120/880) in children and 23% (8361/36 902) in adults (OR, 0.54; 95% CI, 0.44-0.65; P<.001). The prevalence of asystole was 40% (350) in children and 35% (13 024) in adults (OR, 1.20; 95% CI, 1.10-1.40; P = .006), whereas the prevalence of PEA was 24% (213) in children and 32% (11 963) in adults (OR, 0.67; 95% CI, 0.57-0.78; P<.001). After adjustment for differences in preexisting conditions, interventions in place at time of arrest, witnessed and/or monitored status, time to defibrillation of VF or pulseless VT, intensive care unit location of arrest, and duration of cardiopulmonary resuscitation, only first documented pulseless arrest rhythm remained significantly associated with differential survival to discharge (24% [135/563] in children vs 11% [2719/24 987] in adults with asystole and PEA; adjusted OR, 2.73; 95% CI, 2.23-3.32). Conclusions: In this multicenter registry of in-hospital cardiac arrest, the first documented pulseless arrest rhythm was typically asystole or PEA in both children and adults. Because of better survival after asystole and PEA, children had better outcomes than adults despite fewer cardiac arrests due to VF or pulseless VT. [ABSTRACT FROM AUTHOR]

This article focuses on a study which investigated the effect of heat failure (HF) etiology on the prognostic applications of peak oxygen consumption and minute ventilation/carbon dioxide production slope. Two hundred sixty-eight subjects underwent symptom-limited cardiopulmonary exercise testing (CPX). The population was divided into ischemic and nonischemic subgroups. The occurrence of cardiac-related events over the year following CPX was compared between groups using receiver operating characteristic curve analysis. Baseline and exercise characteristics were different between ischemic and nonischemic patients with HF. However, the prognostic power of the major CPX variables was strikingly similar.

Background: The minute ventilation (VE)-carbon dioxide output (VCO[sub 2]) relationship has recently been demonstrated to have prognostic significance in the heart failure (HF) population. However, the method by which the VE/VCO[sub 2] slope is expressed has been inconsistent. Methods: One hundred eighty-eight subjects, who had received diagnoses of HF, underwent exercise testing. Two VE/VCO[sub 2] slope calculations were made, one using exercise data prior to the ventilatory threshold (VT), and one using all data points from rest to peak exercise. Four separate peak exercise VE/VCO[sub 2] slope calculations also were derived with unaveraged, 10-s, 30-s, and 60-s ventilatory expired gas sampling intervals. Results: Although univariate Cox regression analysis demonstrated pre-VT and peak V[sub E]/VCO[sub 2] slope calculations to both be significant predictors of cardiac-related mortality and hospitalization (p < 0.001), the peak classification scheme was significantly better (p < 0.01). The ventilatory expired gas-sampling interval that was used did not impact the predictive ability of the peak VE/VCO[sub 2] slope. Conclusion: Although both the pre-VT and peak VE/VCO[sub 2] slope calculations were prognostically significant, the peak expression was superior. The sampling interval did not appear to have a significant impact on prognostic utility. We hope that the results of the present study will contribute to the standardization of the VE/VCO[sub 2] slope and will enhance its clinical application. [ABSTRACT FROM AUTHOR]

The author reflects on changes which have been seen in the resuscitation methods which are used on cardiac arrest patients. He suggests that a new approach which is used on cardiac arrest patients highlights the importance of high quality, minimally interrupted chest compressions to maximize tissue oxygen delivery and intracellular high energy phosphate levels. He argues that improvements in CPR are a meaningful development in the evolution of resuscitation science.

The article presents a reply to a letter to the editor discussing the article "Survival from in-hospital cardiac arrest during nights and weekends," by MA Peberdy, JP Ornato, and GL Larkin et al, published in a previous issue.