Search

This study aimed to investigate the effect of the head-up position implemented during cardiopulmonary resuscitation (CPR) on cerebral blood flow (CBF) using near-infrared spectroscopy in out-of-hospital cardiac arrest patients.Baseline characteristics (age, sex, cerebral performance category before cardiac arrest, witnessed cardiac arrest, bystander CPR, first monitored rhythm, no-flow time, prehospital low-flow time, CPR duration in the emergency department (ED), and reason for stopping CPR in the ED) were recorded. The changes of CBF were derived from the optical oscillation waveform measured by near-infrared spectroscopy in adult patients with out-of-hospital cardiac arrest by alternating head-up and supine positions at 4-minute intervals while performing CPR. The CBF velocity according to the head position was also evaluated using the time derivative of the oscillation waveform.During the study period, 28 patients were enrolled. The median increase in CBF in the prefrontal area in the head-up position was 14.6% (Interquartile range, 8.8-65.0), more than that in the supine position. An increase in CBF was observed in the head-up position compared with the supine position in 83.3% of the patients included in the analysis.CBF increased when the head-up position was used during CPR in non-traumatic out-of-hospital cardiac arrest patients.

Resuscitative endovascular balloon occlusion of the aorta (REBOA), originally designed to block blood flow to the distal part of the aorta by placing a balloon in trauma patients, has recently been shown to increase coronary perfusion in cardiac arrest patients. This study evaluated the effect of REBOA on aortic pressure and coronary perfusion pressure (CPP) in non-traumatic out of-hospital cardiac arrest (OHCA) patients.Adult OHCA patients with cerebral performance category 1 or 2 prior to cardiac arrest, and without evidence of aortic disease, were enrolled from January to December 2021. Aortic pressure and right atrial pressure were measured before and after balloon occlusion. The CPP was calculated using the measured aortic and right atrial pressures, and the values before and after the balloon occlusion were compared.Fifteen non-traumatic OHCA patients were enrolled in the study. The median call to balloon time was 46.0 (IQR, 38.0-54.5) min. The median CPP before and after balloon occlusion was 13.5 (IQR, 5.8-25.0) and 25.2 (IQR, 12.0-44.6) mmHg, respectively (P = 0.001). The median increase in the estimated CPP after balloon occlusion was 86.7%.The results of this study suggest that REBOA may increase the CPP during cardiopulmonary resuscitation in patients with non-traumatic OHCA. Additional studies are needed to investigate the effect on clinical outcomes.

This study investigated the changes in quality of life (QOL) after in-hospital cardiopulmonary arrest (IHCA) among survivors and examined the association between worsening QOL and 3-year all-cause mortality.This population-based cohort study used data from the National Health Insurance Service database in South Korea. Adult survivors who experienced IHCA between January 1, 2010, and December 31, 2018, and were alive for over 1 year after IHCA were included. Worsening QOL among IHCA survivors was determined using three criteria: decreased household income, unemployment, and acquired disability.A total of 22,611 IHCA survivors from 903 hospitals were included in the final analysis, and 7,796 (34.5%) experienced worsening QOL. Specifically, 5,595 (24.7%), 1,694 (7.5%), and 1,617 (7.2%) survivors experienced decreased household income, unemployment, and acquired disability, respectively. The proportion of brain lesion disability increased from 6.3% to 10.8% after IHCA. In multivariable Cox regression, worsening QOL was not associated with 3-year all-cause mortality (adjusted hazard ratio [aHR]: 1.03, 95% confidence interval [CI]: 0.96, 1.11; P = 0.372). However, among the QOL factors, acquired disability was associated with a 1.29-fold higher risk of 3-year all-cause mortality among IHCA survivors (aHR: 1.29, 95% CI: 1.15, 1.46; P 0.001).Approximately one-third of IHCA survivors experienced worsening QOL (decreased household income, unemployment, and acquired disability) at 1-year follow-up after IHCA in South Korea. Although overall worsening of QOL was not associated with 3-year all-cause mortality, acquired disability was associated with increased 3-year all-cause mortality among IHCA survivors.

We investigated the association between physician turnover and survival outcomes after in-hospital cardiopulmonary resuscitation (ICPR) in South Korea.This population-based cohort study used the South Korean national registration database as the data source. All adult patients admitted to the hospital and who underwent ICPR between 1 January 2010 and 31 December 2019, were included. Patients who underwent ICPR in March were included in the turnover group, while those who underwent ICPR in the other months were included in the non-turnover group. Propensity score (PS) matching was performed.Overall, 298,676 adult patients who underwent ICPR in 2,553 South Korean hospitals were included in the analysis. Among them, 26,342 (8.8%) and 272,334 (91.2%) were included in the turnover and non-turnover groups, respectively. In total, 7,009 (26.6%) and 6,903 (26.2%) of the 26,342 patients each in the turnover and non-turnover groups, respectively, were discharged alive after ICPR. Using logistic regression analysis in the PS-matched cohort, the two groups did not show any significant association in the live discharge rate after ICPR (odds ratio: 1.02, 95% confidence interval: 0.98, 1.06; P = 0.295). This non-significant association was also observed in patients who underwent ICPR in tertiary general hospitals that had cardiopulmonary resuscitation teams for ICPR (P = 0.136). Moreover, the median survival time in the turnover and non-turnover groups was 4.0 days (95% confidence interval: 3.8 days, 4.2 days; log-rank test, P = 0.796).Significant association between physician turnover and survival outcomes was not observed after ICPR in South Korea.

Background The recently developed deep learning (DL)-based early warning score (DEWS) has shown potential in predicting deteriorating patients. We aimed to validate DEWS in multiple centres and compare the prediction, alarming and timeliness performance with the modified early warning score (MEWS) to identify patients at risk for in-hospital cardiac arrest (IHCA). Method/research design This retrospective cohort study included adult patients admitted to the general wards of five hospitals during a 12-month period. The occurrence of IHCA within 24 h of vital sign observation was the outcome of interest. We assessed the discrimination using the area under the receiver operating characteristic curve (AUROC). Results The study population consists of 173,368 patients (224 IHCAs). The predictive performance of DEWS was superior to that of MEWS in both the internal (AUROC: 0.860 vs. 0.754, respectively) and external (AUROC: 0.905 vs. 0.785, respectively) validation cohorts. At the same specificity, DEWS had a higher sensitivity than MEWS, and at the same sensitivity, DEWS reduced the mean alarm count by nearly half of MEWS. Additionally, DEWS was able to predict more IHCA patients in the 24–0.5 h before the outcome, and DEWS was reasonably calibrated. Conclusion Our study showed that DEWS was superior to MEWS in three key aspects (IHCA predictive, alarming, and timeliness performance). This study demonstrates the potential of DEWS as an effective, efficient screening tool in rapid response systems (RRSs) to identify high-risk patients.

Introduction We developed a new neuroprognostication method for cardiac arrest (CA) using the relative volume of the most dominant cluster of low apparent diffusion coefficient (ADC) voxels and tested its performance in a multicenter setting. Methods Adult (>15 years) out-of-hospital CA patients from three different facilities who underwent an MRI 12h after resuscitation were retrospectively analyzed. Patients with unknown long-term prognosis or poor baseline neurologic function were excluded. Average ADCs (mean and median), LADCV (relative volume of low-ADC voxels) and DC-LADCV (relative volume of most dominant cluster of low-ADC voxels) were extracted using different thresholds between 400 and 800×10 −6 mm 2 s −1 at 10×10 −6 mm 2 s −1 intervals. Area under the receiver operating characteristic curve (AUROC) and sensitivity for poor outcome (6-month cerebral performance category score >2) while maintaining 100% specificity were measured. Results 110 patients were analyzed. Average ADCs showed fair performance with an AUROC of 0.822 (95% confidence interval [CI], 0.744–0.900) for the mean and 0.799 (95% CI, 0.716–0.882) for the median. LADCV showed better performance with a higher AUROC (maximum, 0.925) in an ADC threshold range of 400 to 690×10 −6 mm 2 s −1 . DC-LADCV showed the best performance with a higher AUROC (maximum, 0.955) compared with LADCV in an ADC threshold range of 600 to 680×10 −6 mm 2 s −1 . DC-LADCV had a high sensitivity for poor outcomes (>80%) in a wide threshold range from 400 to 580×10 −6 mm 2 s −1 with a maximum of 89.2%. Conclusions Quantitative analysis using DC-LADCV showed impressive performance in determining the prognosis of out-of-hospital CA patients in a multicenter setting.

Aim Although various quantitative methods have been developed for predicting neurological prognosis in patients with out-of-hospital cardiac arrest (OHCA), they are too complex for use in clinical practice. We aimed to develop a simple decision rule for predicting neurological outcomes following the return of spontaneous circulation (ROSC) in patients with OHCA using fast-and-frugal tree (FFT) analysis. Methods We performed a retrospective analysis of prospectively collected data archived in a multi-centre registry. Good neurological outcomes were defined as cerebral performance category (CPC) values of 1 or 2 at 28-day. Variables used for FFT analysis included age, sex, witnessed cardiac arrest, bystander cardiopulmonary resuscitation, initial shockable rhythm, prehospital defibrillation, prehospital ROSC, no flow time, low flow time, cause of arrest (cardiac or non-cardiac), pupillary light reflex, and Glasgow Coma Scale score after ROSC. Results Among the 456 patients enrolled, 86 (18.9%) experienced good neurological outcomes. Prehospital ROSC (true = good), prompt or sluggish light reflex response after ROSC (true = good), and presumed cardiac cause (true = good, false = poor) were selected as nodes for the decision tree. Sensitivity, specificity, positive predictive value, and negative predictive value of the decision tree for predicting good neurological outcomes were 100% (42/42), 64.0% (119/186), 38.5% (42/109), and 100% (119/119) in the training set and 95.5% (42/44), 57.6% (106/184), 35.0% (42/120), and 98.1% (106/108) in the test set, respectively. Conclusion A simple decision rule developed via FFT analysis can aid clinicians in predicting neurological outcomes following ROSC in patients with OHCA.

a b s t r a c t Objective: Advanced airway management is one of the fundamental skills of advanced cardiac life support (ACLS). A failed initial intubation attempt (FIIA) is common and has shown to be associated with adverse events. We analysed the association between FIIA and the overall effectiveness of ACLS. Methods: Using emergency department (ED) out-of-hospital cardiac arrest (OHCA) registry data from 2008 to 2012, non-traumatic ED-resuscitated adult OHCA patients on whom endotracheal intubation was initially tried were identified. Prehospital and demographic factors and patient outcomes were retrieved from the registry. The presence of a FIIA was determined by reviewing nurse-documented CPR records. The primary outcome was achieving a return of spontaneous circulation (ROSC). The secondary outcomes were time to ROSC and the ROSC rate during the first 30 min of ED resuscitation. Results: The study population (n = 512) was divided into two groups based on the presence of a FIIA (N = 77). Both groups were comparable without significant differences in demographic or prehospital factors. In the FIIA group, the unadjusted and adjusted odds ratios (ORs) for achieving a ROSC were 0.50 (95% confidence interval (CI), 0.31-0.81) and 0.40 (95% CI, 0.23-0.71), respectively. Multivariable median regression analysis revealed that FIIA was associated with an average delay of 3 min in the time to ROSC (3.08; 95% CI, 0.08-5.80). Competing risk regression analysis revealed a significantly slower ROSC rate during the first 15 min (adjusted subhazard ratio, 0.52; 95% CI, 0.35-0.79) in the FIIA group. Conclusion: FIIA is an independent risk factor for the decreased effectiveness of ACLS.

Valproic acid (VPA) has been known to reduce neuronal injury, has anti-inflammatory and anti-apoptotic effects as a histone deacetylase (HDAC) inhibitor. Thus, this study was performed to investigate the effects of VPA on survival and neurological outcomes in an asphyxial cardiac arrest model of rats.Male Sprague-Dawley rats were subjected to asphyxial cardiac arrest. For survival study, rats were subjected to 450s of asphyxial cardiac arrest. Cardiopulmonary resuscitation (CPR) was performed and then rats were blindly allocated to one of two groups (control group, n=10; VPA group, n=10). Valproic acid (300mgkg(-1)) or vehicle (normal saline) was administered via tail vein immediately after return of spontaneous circulation (ROSC) and observed for 72h. For neurological outcome study, rats (n=7 for each group) were subjected to same experimental procedures except duration of cardiac arrest of 360s. Neurological deficit scale (NDS) score was measured every 24h after ROSC for 72h and was ranged from 0 (brain dead) to 80 (normal). Brain tissues were harvested at 72h for evaluation of apoptotic injury and acetylation status of histone H3.In survival study, 2 rats in VPA group were excluded because cardiac arrest was not achieved in predetermined time. Thus, 10 rats were allocated to control group and 8 rats were allocated to VPA group. The survival rates at 72h after cardiac arrest were significantly higher in VPA group than in control group (6/8 in VPA group, 3/10 rats in control group; log rank test, p0.05). In neurological outcome study, all rats survived for 72h and NDS at 72h were significantly higher in VPA group than in control group (p0.05). In brain tissues, expressions of acetylated histone H3 were not significantly different. However, expressions of cleaved caspase-3 were significantly lower in VPA group than in control group (p0.05).VPA increased survival rates and improved neurologic outcome in asphyxial cardiac arrest model of rats while decreasing expressions of cleaved caspase-3.

Purpose The probability of the return of spontaneous circulation (ROSC) and subsequent favourable outcomes changes dynamically during advanced cardiac life support (ACLS). We sought to model these changes using time-to-event analysis in out-of-hospital cardiac arrest (OHCA) patients. Methods Adult (≥18 years old), non-traumatic OHCA patients without prehospital ROSC were included. Utstein variables and initial arterial blood gas measurements were used as predictors. The incidence rate of ROSC during the first 30min of ACLS in the emergency department (ED) was modelled using spline-based parametric survival analysis. Conditional probabilities of subsequent outcomes after ROSC (1-week and 1-month survival and 6-month neurologic recovery) were modelled using multivariable logistic regression. The ROSC and conditional probability models were then combined to estimate the likelihood of achieving ROSC and subsequent outcomes by providing k additional minutes of effort. Results A total of 727 patients were analyzed. The incidence rate of ROSC increased rapidly until the 10th minute of ED ACLS, and it subsequently decreased. The conditional probabilities of subsequent outcomes after ROSC were also dependent on the duration of resuscitation with odds ratios for 1-week and 1-month survival and neurologic recovery of 0.93 (95% CI: 0.90–0.96, p p =0.001) and 0.93 (0.87–0.99, p =0.031) per 1-min increase, respectively. Calibration testing of the combined models showed good correlation between mean predicted probability and actual prevalence. Conclusions The probability of ROSC and favourable subsequent outcomes changed according to a multiphasic pattern over the first 30min of ACLS, and modelling of the dynamic changes was feasible.

Paraquat intoxication induces acute lung injury and numerous fatalities have been reported. The mechanism of toxic effect of paraquat is oxidative injury and inflammation. Therapeutic hypothermia has been known to have antioxidant and anti-inflammatory effects. This study was designed to evaluate the effect of therapeutic hypothermia on paraquat intoxication.Male Sprague-Dawley rats were given 50 mg/kg of paraquat intraperitoneally and divided into the normothermia (36-38°C) group and the hypothermia (30-32°C) group after 1h of paraquat administration. The hypothermia group underwent 2 h of hypothermia followed by 2 h of rewarming. In the survival study, mortality was observed for 24 h after paraquat administration. An in the second experiment, lung tissues and plasma were harvested at 6 h after paraquat administration.The 12 h survival rate was significantly higher in the hypothermia group than in the normothermia group (100% vs. 50%, p0.05), but survival rates for 24 h were not different. Acute lung injury score was lower in the hypothermia group than in the normothermia group (p0.05). Thmalondialdehyde contents of lung tissues, plasma interleukin-6 and nitrite/nitrate concentrations were significantly decreased in the HT group compared to the NT group (p0.05).Therapeutic hypothermia delayed early mortality and attenuated acute lung injury in paraquat intoxication.

Objective Recent studies suggested quantitative analysis of diffusion-weighted magnetic resonance imaging as a promising tool for early prognostication of cardiac arrest patients. However, most of their methods involve significant manual image handling often subjective and difficult to reproduce. Therefore developing a computerized analysis method using easy-to-define characteristics would be useful. Methods Comatose out-of-hospital cardiac arrest (OHCA) patients who underwent brain MRI between January 2008 and July 2012 were identified from an OHCA registry. Apparent diffusion coefficient (ADC) axial images were analyzed using a program to detect and characterize clusters of low ADC pixels from six brain regions including frontal, occipital, parietal, rolandic and temporal and basal ganglia region. Identified clusters were ranked according to size, mean ADC and minimum ADC to assess the regional maximum cluster size (MCS), lowest mean ADC (LMEAN) and lowest minimum ADC (LMIN). Their power to predict poor outcome, defined as 6-month CPC 3 or higher, was assessed by contingency table analyses. Results 51 OHCA patients were eligible during the study period. The sensitivities of MCS, LMEAN and LMIN to detect poor outcome varied according to brain region from 62.5 to 90.0%, 50.0 to 72.5% and 42.5 to 82.5% with their specificities set to 100%, respectively. The MCS of occipital region showed most favorable test profile (sensitivity 90%, specificity 100%; AUROC 0.940, 95% confidence interval 0.874–1.000). Conclusion The cluster-based computerized image analysis might be a simple but useful method for prediction of poor neurologic outcome. Future studies validating its prognostic performance are required.

We sought to investigate the prognostic implication of early coagulopathy represented by initial DIC score in out-of-hospital cardiac arrest (OHCA).OHCA registry was analyzed to identify patients with ROSC without recent use of anticoagulant between 2008 and 2011. Patients were assessed for prehosptial factors, initial laboratory results and therapeutic hypothermia. Outcome variables were survival discharge, 6-month CPC and survival duration within the first week after ROSC. Logistic regression and Cox proportional hazards models were used for both univariable and multivariable analysis.Among 273 eligible patients, initial DIC score was available in 252 (92.3%). Higher DIC score was associated with increased inhospital death (odds ratio [OR], 1.89 per unit; 95% confidence interval [CI], 1.48-2.41) and unfavorable long-term outcome (6-month CPC 3-5; OR, 2.21 per unit; 95% CI, 1.60-3.05). The adjusted ORs for both outcomes were 1.61 (95% CI, 1.17-2.22) and 1.84 (95% CI, 1.26-2.67), respectively. We categorized DIC score in five groups as3, 3, 4, 5 and5 and analyzed differential mortality risk using Cox proportional hazards model. Compared with reference group (DIC score3), the adjusted HR for early mortality in each remaining group was 1.96 (95% CI, 1.13-3.40), 2.26 (95% CI, 1.27-4.02), 2.77 (95% CI, 1.58-4.85) and 4.29 (95% CI, 2.22-8.30), respectively (p-trend0.001). The area under the receiver operating characteristic of DIC score for prediction of unfavorable long-term outcome was 0.79 (95% CI, 0.69-0.88).Increased initial DIC score in OHCA was an independent predictor for poor outcomes and early mortality risk.

Post-resuscitation period is characterized by high early mortality due to post-cardiac arrest syndrome. Recent studies found that elevated red cell distribution width (RDW) is a strong predictor of mortality in critically ill patients. We investigated the prognostic significance of RDW in out-of-hospital cardiac arrest (OHCA) victims.Analysis of emergency department OHCA registry extending from January 2007 to December 2010 was conducted. Patients with ROSC were assessed for Utstein predictors including sex, age, arrest location, presence of witness, bystander cardiopulmonary resuscitation, response time, initial rhythm and cause of arrest. RDW, hematocrit, white blood cell and platelet counts, blood urea nitrogen (BUN), creatinine and albumin were also obtained. Outcome variable was survival duration within 30 days. RDW was categorized in quartiles as13.2%, 13.2% to 14.0%, 14.1% to 15.4% and15.4%. Hazard ratios (HRs) were estimated using Cox-proportional hazard models in both univariate and multivariate analysis. All prognostic variables with their p value0.1 in univariate analysis were used in multivariate analysis for adjustment.Among 409 OHCA patients, 219 patients had ROSC. Highest RDW quartile (RDW15.4%), female sex, older age, non-shockable initial rhythm, increased BUN and creatinine and decreased albumin, hematocrit and platelet count were associated with increased mortality in univariate analysis. In multivariate analysis, the highest RDW quartile was independently associated with all-cause mortality (HR=1.95; 95% CI 1.05-3.60; p=0.034) during 30-day post-resuscitation period. Other significant variables were age, initial rhythm and serum albumin.Initial RDW is an independent predictor of all-cause mortality in post-resuscitation patients.

Aim of the study N-acetylcysteine (NAC) has been investigated to attenuate organ injury in various experimental and clinical studies. However, results in hemorrhagic shock (HS) were controversial. We determined the effects of continuous administration of NAC on acute lung injury (ALI) and acute kidney injury (AKI) in HS model. Methods Twenty male Sprague-Dawley rats were used. Pressure controlled HS model defined by mean arterial pressure (MAP) 40±2mmHg for 90min followed by resuscitation and observation was used. Rats ( n =10 per group) were randomized into 2 groups with NAC or dextrose. Intravenous NAC was given continuously from 15min after induction of HS to the end of observation period (2h). We measured serum IL-6, nitrite/nitrate concentration. NF-κB p65 DNA binding activity, expressions of cytoplasmic phosphorylated IκB-α (p-IκB-α) and IκB-α, malondialdehyde (MDA) and histopathological injury scores in lung and kidney were also evaluated. Results MAP did not show any difference during the study period. NAC decreased histopathologic scores in both lung and kidney. Lung and kidney MDA levels were significantly lower in the NAC group compared to control group. Serum nitrite/nitrate and IL-6 were also significantly lower in the NAC group. The levels of lung cytoplasmic p-IκB-α expression was mitigated by NAC, and NF-κB p65 DNA binding activity was also significantly decreased in the NAC group. Conclusions Continuous infusion of NAC attenuated inflammatory response and acute lung and kidney injury after hemorrhagic shock in rats.

Aim of the study Acute lung injury (ALI) develops in various clinical situations and is associated with high morbidity and mortality and therapeutic hypothermia (HT) has been studied to attenuate the ALI. However, the optimal method of rewarming has not been determined. We determined the effect of speed of rewarming and the administration of anti-inflammatory or anti-oxidant agents on ALI in an intestinal ischemia and reperfusion (I/R) model treated with HT. Materials and methods A Sprague–Dawley rat model of intestine ischemia and reperfusion was used. Two parallel animal experiments were conducted. In the survival study, rats ( n = 5 per group) underwent normothermic intestinal ischemia (60 min, 36–38 °C) and then randomized into 7 groups with reperfusion: normothermia (NT), HT without rewarming (30–32 °C, HT), 2 h HT + rewarming for 1 h (RW1), 2 h HT + rewarming for 2 h (RW2), RW1 + N-acetyl cysteine (RW-NAC), RW1 + ethylpyruvate (RW-EP), and RW1 + dexamethasone (RW + Dexa). In the second experiment, we investigated the histological and biochemical effects on the lung 4 h after reperfusion ( n = 8 per group). Results The survival rate was lowest after NT. The HT, RW2, and RW-Dexa groups survived longer than the RW1, RW-NAC, and RW-EP groups. ALI scores were lower in the HT, RW2, and RW-Dexa groups than RW1. Lung malondialdehyde content was also lower in these groups. Interleukin (IL)-6 was significantly higher in the RW1 group. Inducible NO synthase gene expression in lung was lower in the HT, RW2, and RW-Dexa than RW1, and serum NO was lower in the RW2 and RW-Dexa than RW1. Conclusion Gradual rewarming and administration of dexamethasone improved survival and attenuated ALI after intestinal I/R injury treated with HT in rats.

Background: Acute pulmonary edema (APE) in cardiac arrest is a frequently observed phenomenon. Although possible mechanismshadbeen suggestedbasedon several case reports, its etiology and clinical significances are largely unknown. We investigated its risk factors and prognostic association. Methods: We identified non-traumatic witnessed out-ofhospital cardiac arrest patients who had achieved sustained ROSC from an EDOHCA registry extending from 2008 to 2012. The severity of APEwas assessed fromfirst chest radiograph taken after ROSC and graded to three. (1) Normal image or interstitial-type APE, (2) alveolar-type APE, (3) lobar-type APE.We assessed prehospital and inhospital resuscitation duration, cardiothoracic ratio, DIC score and pCO2, base deficit, lactic acid and C-reactive protein level as surrogate markers of mechanical injury duration, underlying heart function, coagulopathy, ventilation adequacy, overall ischemicburden and underlying inflammation, respectively, as well as other possible influencing factors from the registry and patient medical records. The independent associations between the APE severity and the possible etiologic factors were assessed with partial proportional odds model. Results: 227 patients were identified and included for analysis. Factorswith theirp value