Tag Archives: Heart Arrest

Cerebral Oximetry During Cardiac Arrest: A Multicenter Study of Neurologic Outcomes and Survival. (Emrath)

Posted on by
Reply

Parnia S, et al. Cerebral Oximetry During Cardiac Arrest: A Multicenter Study of Neurologic Outcomes and Survival. Crit Care Med. 2016 Apr 11. [Epub ahead of print]

OBJECTIVES: 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.

DESIGN: Multicenter prospective study of in-hospital cardiac arrest.

SETTING: Five medical centers in the United States and the United Kingdom.

PATIENTS: 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.

INTERVENTIONS: Cerebral oximetry monitoring.

MEASUREMENTS AND MAIN RESULTS: 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.

CONCLUSIONS: 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.

Association of presence and timing of invasive airway placement with outcomes after pediatric in-hospital cardiac arrest. (Emrath)

Posted on by
Reply

Gupta P, Rettiganti M, Gossett JM, et al. Association of presence and timing of invasive airway placement with outcomes after pediatric in-hospital cardiac arrest. Resuscitation. 2015 Jul;92:53-8.

Full-text for Emory users.

BACKGROUND: Little data exist regarding the association of presence of an invasive airway before cardiac arrest or early placement of an invasive airway after cardiac arrest with outcomes in children who experience in-hospital cardiac arrest.

METHODS: We conducted a retrospective review of patients aged 1 day to 18 years who received cardiopulmonary resuscitation (CPR) for ≥ 1 min in any of the three intensive care units (ICUs) at a tertiary care, academic children’s hospital between 2002 and 2010. Specific outcomes evaluated included survival to hospital discharge, return of spontaneous circulation (ROSC), 24-h survival, and good neurological status at hospital discharge. We fitted multivariable logistic regression models to evaluate the association between the presence of an invasive airway prior to cardiac arrest and timing of placement of an invasive airway with these outcomes.

RESULTS: Three hundred and ninety-one patients were included. Of these, 197 (51%) patients were already tracheally intubated before the occurrence of cardiac arrest. Median time to intubation was 6 min [interquartile range (IQR): 2, 12] among the 194 patients tracheally intubated following cardiac arrest. We found lower survival to hospital discharge among patients intubated prior to cardiac arrest (intubated vs. non-intubated group, 43% vs. 61%, p < 0.001). After adjusting for patient and event characteristics, presence of an invasive airway prior to cardiac arrest was not associated with a significant improvement in survival to hospital discharge [odds ratio (OR): 0.70, 95% confidence interval (CI): 0.42-1.16, p = 0.17], or good neurological outcomes (OR: 0.60, 95% CI: 0.34-1.05, p = 0.07). Similarly, early placement of an invasive airway after cardiac arrest was also not associated with an improvement in survival to hospital discharge (OR: 1.05, 95% CI: 0.78-1.42, p = 0.73), or good neurological outcomes (OR: 1.08, 95% CI: 0.77-1.53, p = 0.65).

CONCLUSIONS: Our study demonstrates that presence of an invasive airway prior to cardiac arrest or early placement of an invasive airway after cardiac arrest is not associated with an improvement in survival to hospital discharge or good neurological outcomes. Further study of the relationship between invasive airway management and survival following cardiac arrest is warranted.

Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes. (Emrath)

Posted on by
Reply

Wolfe H, Zebuhr C, Topjian AA, et al. Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes*. Crit Care Med. 2014 Jul;42(7):1688-95.

Free full-text.

OBJECTIVE: In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events.

DESIGN, SETTING, AND PATIENTS: Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU.

INTERVENTIONS: Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers.

MEASUREMENTS AND MAIN RESULTS: Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for ≥ 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed “excellent cardiopulmonary resuscitation,” prospectively defined as a chest compression depth ≥ 38 mm, rate ≥ 100/min, ≤ 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91-6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01-7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9-10.6; p < 0.01).

CONCLUSION: Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.

Sodium bicarbonate use in shock and cardiac arrest: attitudes of pediatric acute care physicians. (Teppa)

Posted on by
Reply

Parker MJ, Parshuram CS. Sodium Bicarbonate Use in Shock and Cardiac Arrest: Attitudes of Pediatric Acute Care Physicians*. Crit Care Med. 2013 Sep;41(9):2188-2195.

OBJECTIVES: To evaluate the preferences and self-reported practices of pediatric acute care physicians with respect to sodium bicarbonate administration to infants and children in shock or cardiac arrest.

DESIGN: National survey study utilizing a self-administered questionnaire.

SETTING: Thirteen Canadian pediatric tertiary care centers.

SUBJECTS: Canadian pediatric critical care physicians, pediatric emergency physicians, and trainees in these subspecialties.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Survey items were evaluated based on Yes/No responses, frequency responses, and Likert scales. Overall response rate was 53% (151/284) with 49.0% (74/151) citing pediatric critical care as their primary practice. 82.0% of respondents (123/150) indicated they would administer sodium bicarbonate as part of ongoing resuscitation for septic shock, whereas 58.3% (88/151) would administer sodium bicarbonate in a cardiac arrest scenario (p = 0.004). 47.3% (71/150) selected a pH threshold at or below which they would administer sodium bicarbonate (mean, 6.94 ± 0.013; median, 7.00; range, 6.50-7.20; interquartile range, 6.90-7.00), whereas 20.5% (31/151) selected a base excess threshold (mean, -15.62 ± 0.78; median, -16; range, -20 to -4; interquartile range, -20 to -14). Both pH and duration of resuscitation were strongly associated with the decision to administer sodium bicarbonate (p < 0.0001). Respondents’ perceptions regarding a colleague’s likelihood of administering sodium bicarbonate to the same patient under the same circumstances reflect an acknowledgment of disparate practices with respect to sodium bicarbonate use. 53.0% (79/149) felt current American Heart Association guidelines help them in deciding whether to administer sodium bicarbonate to critically ill patients, and 84% would support a randomized trial.

CONCLUSION: Differences of opinion exist among pediatric acute care physicians with respect to the timing and appropriateness of sodium bicarbonate administration during resuscitation. Most indicated they would support moving forward with a clinical trial.

Full-text for Children’s and Emory users.