Does temperature management improve outcome in patients resuscitated from a non-shockable rhythm?
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ABSTRACT:
SUBMITTER: Thomsen JH
PROVIDER: S-EPMC5506164 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:IntroductionRetrospective studies have shown conflicting benefit of utilizing targeted temperature management (TTM) in cardiac arrest (CA) patients with a non-shockable rhythm and presently there is only one randomized trial in this realm. We sought to determine trends and outcomes of TTM utilization in these patients from a large nationally representative United States population database.Methods and resultsData were derived from National Inpatient Sample (NIS) from January 2006 to December 2013. All patients were identified using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Patients with evidence of shockable rhythm (ventricular tachycardia, ventricular flutter and ventricular fibrillation) were excluded. Trends in TTM utilization and mortality were assessed over our study period. Various outcomes were measured in patients receiving TTM and no TTM in unmatched and propensity matched cohorts. Logistic regression analysis was done to determine predictors of mortality. A total of 1,185,479 CA patients were identified in whom cause of arrest was a non-shockable rhythm. Overall, there was a steady increase in TTM utilization over our study period. In propensity-matched groups, mortality was higher in patients in whom TTM was utilized compared to non-TTM group (72.9% vs 68.7%, P < .01). In adjusted analysis, TTM remains an independent predictor of increased mortality in our group. Mortality remained high with TTM utilization regardless of location of CA.ConclusionsTTM utilization was associated with increased mortality in CA patients with a non-shockable rhythm. These findings merit further confirmation in a large randomized trial before application into clinical practice.
| S-EPMC7457429 | biostudies-literature
Project description:BackgroundLittle is known about the effectiveness of surface cooling (SC) and endovascular cooling (EC) on the outcome of out-of-hospital cardiac arrest (OHCA) patients receiving target temperature management (TTM) according to their initial rhythm.MethodsWe retrospectively analysed data from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a multicentre, prospective nationwide database in Japan. For our analysis, OHCA patients aged ≥ 18 years who were treated with TTM between June 2014 and December 2017 were included. The primary outcome was 30-day survival with favourable neurological outcome defined as a Glasgow-Pittsburgh cerebral performance category score of 1 or 2. Cooling methods were divided into the following groups: SC (ice packs, fans, air blankets, and surface gel pads) and EC (endovascular catheters and any dialysis technique). We investigated the efficacy of the two categories of cooling methods in two different patient groups divided according to their initially documented rhythm at the scene (shockable or non-shockable) using multivariable logistic regression analysis and propensity score analysis with inverse probability weighting (IPW).ResultsIn the final analysis, 1082 patients were included. Of these, 513 (47.4%) had an initial shockable rhythm and 569 (52.6%) had an initial non-shockable rhythm. The proportion of patients with favourable neurological outcomes in SC and EC was 59.9% vs. 58.3% (264/441 vs. 42/72), and 11.8% (58/490) vs. 21.5% (17/79) in the initial shockable patients and the initial non-shockable patients, respectively. In the multivariable logistic regression analysis, differences between the two cooling methods were not observed among the initial shockable patients (adjusted odd ratio [AOR] 1.51, 95% CI 0.76-3.03), while EC was associated with better neurological outcome among the initial non-shockable patients (AOR 2.21, 95% CI 1.19-4.11). This association was constant in propensity score analysis with IPW (OR 1.40, 95% CI 0.83-2.36; OR 1.87, 95% CI 1.01-3.47 among the initial shockable and non-shockable patients, respectively).ConclusionWe suggested that the use of EC was associated with better neurological outcomes in OHCA patients with initial non-shockable rhythm, but not in those with initial shockable rhythm. A TTM implementation strategy based on initial rhythm may be important.
| S-EPMC8626556 | biostudies-literature
Project description:BackgroundTargeted temperature management (TTM) is recommended in adult patients following cardiac arrest (CA) with any rhythm. However, as to non-shockable (NSR) CA, high-quality evidence of TTM supporting its practices remains uncertain. Thus, we aimed to conduct a systematic review and meta-analysis with randomized controlled trials (RCTs) to explore the efficacy and safety of TTM in this population.MethodsWe searched PubMed, Embase, and Cochrane library databases for potential trials from inception through Aug 25, 2021. RCTs evaluating TTM for CA adults due to NSR were included, regardless of the timing of cooling initiation. Outcome measurements were mortality and good neurological function. We used the Cochrane bias tools to evaluate the quality of the included studies. Heterogeneity, subgroup analyses, and sensitivity analysis were investigated to test the robustness of the primary outcomes.ResultsA total of 14 RCTs with 4,009 adults were eligible for the final analysis. All trials had a low to moderate risk of bias. Of the included trials, six compared NSR patients with or without TTM, while eight compared pre-hospital to in-hospital TTM. Pooled data showed that TTM was not associated with improved mortality (Risk ratio [RR] 1.00; 95% CI, 0.944-1.05; P = 0.89, I 2 = 0%) and good neurological outcome (RR 1.18; 95% CI 0.90-1.55; P = 0.22, I 2 = 8%). Similarly, use of pre-hospital TTM resulted in neither an improved mortality (RR 0.99, 95% CI 0.97-1.03; I 2 = 0%, P = 0.32) nor favorable neurological outcome (RR 1.13, 95% CI 0.93-1.38; I 2 = 0%, P = 0.22). These results were further confirmed in the sensitivity analyses and subgroup analyses.ConclusionsOur results showed that using the TTM strategy did not significantly affect the mortality and neurologic outcomes in CA survival presenting initial NSR.
| S-EPMC9203727 | biostudies-literature
Project description:BackgroundPatients admitted after cardiac arrest with non-shockable rhythm frequently experience hemodynamic instability. This study assessed the hemodynamic consequences of TTM in this sub population.MethodsThis is a post hoc analysis of the HYPERION trial (NCT01994772), that randomized patients to either hypothermia or normothermia after non-shockable rhythm related cardiac arrest. Patients with no, moderate or severe circulatory failure were identified with cardiovascular Sequential Organ Failure Assessment at randomization. Primary outcome was the number of patients at day 7 with resolution of shock, accounting for the risk of death (competing risk analysis). Secondary endpoint included neurological outcome and death at day-90.Results584 patients were included in the analysis: 195 (34%), 46 (8%) and 340 (59%) had no, moderate and severe circulatory failure, respectively. Resolution of circulatory failure at day 7 was more frequently observed in the normothermia group than in the TTM group (60% [95 %CI 54-66] versus 53% [95 %CI 46-60], Gray-test: p = 0.016). The severity of circulatory failure at randomization was associated with its less frequent resolution at day 7 accounting for the risk of death (76 % [62-86] versus 54% [49-59] for patients with moderate versus severe circulatory failure, Gray test, p < 0.001, respectively). At day 90, the proportion of patients with Cerebral Performance Category score of 1 or 2 was lower in patients presenting severe circulatory failure (p = 0.038).ConclusionCirculatory failure is frequent after CA with non-shockable rhythm. Its severity at admission and TTM were associated with delayed resolution of circulatory failure.
| S-EPMC9289859 | biostudies-literature
Project description:BackgroundSingapore and Osaka in Japan have comparable population sizes and prehospital management; however, the frequency of ECPR differs greatly for out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythm. Given this disparity, we hypothesized that the outcomes among the OHCA patients with initial shockable rhythm in Singapore were different from those in Osaka. The aim of this study was to evaluate the outcomes of OHCA patients with initial shockable rhythm in Singapore compared to the expected outcomes derived from Osaka data using machine learning-based prediction models.MethodsThis was a secondary analysis of two OHCA databases: the Singapore PAROS database (SG-PAROS) and the Osaka-CRITICAL database from Osaka, Japan. This study included adult (18-74 years) OHCA patients with initial shockable rhythm. A machine learning-based prediction model was derived and validated using data from the Osaka-CRITICAL database (derivation data 2012-2017, validation data 2018-2019), and applied to the SG-PAROS database (2010-2016 data), to predict the risk-adjusted probability of favorable neurological outcomes. The observed and expected outcomes were compared using the observed-expected ratio (OE ratio) with 95% confidence intervals (CI).ResultsFrom the SG-PAROS database, 1,789 patients were included in the analysis. For OHCA patients who achieved return of spontaneous circulation (ROSC) on hospital arrival, the observed favorable neurological outcome was at the same level as expected (OE ratio: 0.905 [95%CI: 0.784-1.036]). On the other hand, for those who had continued cardiac arrest on hospital arrival, the outcomes were lower than expected (shockable rhythm on hospital arrival, OE ratio: 0.369 [95%CI: 0.258-0.499], and nonshockable rhythm, OE ratio: 0.137 [95%CI: 0.065-0.235]).ConclusionThis observational study found that the outcomes for patients with initial shockable rhythm but who did not obtain ROSC on hospital arrival in Singapore were lower than expected from Osaka. We hypothesize this is mainly due to differences in the use of ECPR.
| S-EPMC10496207 | biostudies-literature
Project description:In 2013 the Minnesota Resuscitation Consortium developed an organized approach for the management of patients resuscitated from shockable rhythms to gain early access to the cardiac catheterization laboratory (CCL) in the metro area of Minneapolis-St. Paul. Eleven hospitals with 24/7 percutaneous coronary intervention capabilities agreed to provide early (within 6 hours of arrival at the Emergency Department) access to the CCL with the intention to perform coronary revascularization for outpatients who were successfully resuscitated from ventricular fibrillation/ventricular tachycardia arrest. Other inclusion criteria were age >18 and <76 and presumed cardiac etiology. Patients with other rhythms, known do not resuscitate/do not intubate, noncardiac etiology, significant bleeding, and terminal disease were excluded. The primary outcome was survival to hospital discharge with favorable neurological outcome. Patients (315 out of 331) who were resuscitated from VT/VF and transferred alive to the Emergency Department had complete medical records. Of those, 231 (73.3%) were taken to the CCL per the Minnesota Resuscitation Consortium protocol while 84 (26.6%) were not taken to the CCL (protocol deviations). Overall, 197 (63%) patients survived to hospital discharge with good neurological outcome (cerebral performance category of 1 or 2). Of the patients who followed the Minnesota Resuscitation Consortium protocol, 121 (52%) underwent percutaneous coronary intervention, and 15 (7%) underwent coronary artery bypass graft. In this group, 151 (65%) survived with good neurological outcome, whereas in the group that did not follow the Minnesota Resuscitation Consortium protocol, 46 (55%) survived with good neurological outcome (adjusted odds ratio: 1.99; [1.07-3.72], P=0.03). Early access to the CCL after cardiac arrest due to a shockable rhythm in a selected group of patients is feasible in a large metropolitan area in the United States and is associated with a 65% survival rate to hospital discharge with a good neurological outcome.
| S-EPMC4859384 | biostudies-literature
Project description:AimWe aimed to identify subphenotypes among patients with out-of-hospital cardiac arrest (OHCA) with initial non-shockable rhythm by applying machine learning latent class analysis and examining the associations between subphenotypes and neurological outcomes.MethodsThis study was a retrospective analysis within a multi-institutional prospective observational cohort study of OHCA patients in Osaka, Japan (the CRITICAL study). The data of adult OHCA patients with medical causes and initial non-shockable rhythm presenting with OHCA between 2012 and 2016 were included in machine learning latent class analysis models, which identified subphenotypes, and patients who presented in 2017 were included in a dataset validating the subphenotypes. We investigated associations between subphenotypes and 30-day neurological outcomes.ResultsAmong the 12,594 patients in the CRITICAL study database, 4,849 were included in the dataset used to classify subphenotypes (median age: 75 years, 60.2% male), and 1,465 were included in the validation dataset (median age: 76 years, 59.0% male). Latent class analysis identified four subphenotypes. Odds ratios and 95% confidence intervals for a favorable 30-day neurological outcome among patients with these subphenotypes, using group 4 for comparison, were as follows; group 1, 0.01 (0.001-0.046); group 2, 0.097 (0.051-0.171); and group 3, 0.175 (0.073-0.358). Associations between subphenotypes and 30-day neurological outcomes were validated using the validation dataset.ConclusionWe identified four subphenotypes of OHCA patients with initial non-shockable rhythm. These patient subgroups presented with different characteristics associated with 30-day survival and neurological outcomes.
| S-EPMC9136939 | biostudies-literature
Project description:BackgroundPatients with shockable sudden cardiac arrest (SCA; ventricular fibrillation/tachycardia) have significantly better resuscitation outcomes than do those with nonshockable rhythm (pulseless electrical activity/asystole). Heart failure (HF) increases the risk of SCA, but presenting rhythms have not been previously evaluated.ObjectiveWe hypothesized that based on unique characteristics, HFpEF (HF with preserved ejection fraction; left ventricular ejection fraction [LVEF] ≥50%), bHFpEF (HF with borderline preserved ejection fraction; LVEF >40% and <50%), and HFrEF (HF with reduced ejection fraction; LVEF ≤40%) manifest differences in presenting rhythm during SCA.MethodsConsecutive cases of SCA with HF (age ≥18 years) were ascertained in the Oregon Sudden Unexpected Death Study (2002-2019). LVEF was obtained from echocardiograms performed before and unrelated to the SCA event. Presenting rhythms were identified from first responder reports. Logistic regression was used to evaluate the independent association of presenting rhythm with HF subtype.ResultsOf 648 subjects with HF and SCA (median age 72 years; interquartile range 62-81 years), 274 had HFrEF (23.4% female), 92 had bHFpEF (35.9% female), and 282 had HFpEF (42.5% female). The rates of shockable rhythms were 44.5% (n = 122), 48.9% (n = 45), and 27.0% (n = 76) for HFrEF, bHFpEF, and HFpEF, respectively (P < .001). Compared with HFpEF, the adjusted odds ratios for shockable rhythm were 1.86 (95% confidence interval 1.27-2.74; P = .002) in HFrEF and 2.26 (95% CI 1.35-3.77; P = .002) in bHFpEF. The rates of survival to hospital discharge were 10.6% (n = 29) in HFrEF, 22.8% (n = 21) in bHFpEF, and 9.9% (n = 28) in HFpEF (P = .003).ConclusionThe rates of shockable rhythm during SCA depend on the HF clinical subtype. Patients with bHFpEF had the highest likelihood of shockable rhythm, correlating with the highest rates of survival.
| S-EPMC7541513 | biostudies-literature
Project description:BACKGROUND:Dyscarbia is common in out-of-hospital cardiac arrest (OHCA) patients and its association to neurological outcome is undetermined. METHODS:This is an exploratory post-hoc substudy of the Target Temperature Management (TTM) trial, including resuscitated OHCA patients, investigating the association between serial measurements of arterial partial carbon dioxide pressure (PaCO2) and neurological outcome at 6 months, defined by the Cerebral Performance Category (CPC) scale, dichotomized to good outcome (CPC 1 and 2) and poor outcome (CPC 3-5). The effects of hypercapnia and hypocapnia, and the time-weighted mean PaCO2 and absolute PaCO2 difference were analyzed. Additionally, the association between mild hypercapnia (6.0-7.30 kPa) and neurological outcome, its interaction with target temperature (33 °C and 36 °C), and the association between PaCO2 and peak serum-Tau were evaluated. RESULTS:Of the 939 patients in the TTM trial, 869 were eligible for analysis. Ninety-six percent of patients were exposed to hypocapnia or hypercapnia. None of the analyses indicated a statistical significant association between PaCO2 and neurological outcome (P?=?0.13-0.96). Mild hypercapnia was not associated with neurological outcome (P?=?0.78) and there was no statistically significant interaction with target temperature (Pinteraction?=?0.95). There was no association between PaCO2 and peak serum-Tau levels 48 or 72 h after return of spontaneous circulation (ROSC). CONCLUSIONS:Dyscarbia is common after ROSC. No statistically significant association between PaCO2 in the post-cardiac arrest phase and neurological outcome at 6 months after cardiac arrest was detected. There was no significant interaction between mild hypercapnia and temperature in relation to neurological outcome.
| S-EPMC6098627 | biostudies-literature
Project description:BackgroundThe TiPS65 score is a validated scoring system used to predict neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients with shockable rhythm treated with extracorporeal cardiopulmonary resuscitation (ECPR). This study aimed to assess the predictive performance of the TiPS65 score in OHCA patients with initial non-shockable rhythm treated with ECPR.MethodsThis was a secondary analysis using the JAAM-OHCA registry, a multicenter prospective cohort study. The study included adult OHCA patients with initial non-shockable rhythm who underwent ECPR. The TiPS65 score assigned one point to each of four variables: time to hospital ≤25 minutes, pH value ≥7.0 on initial blood gas assessment, shockable on hospital arrival, and age younger than 65 years. Based on the sum score, the predictive performance for 1-month survival and favorable neurological outcomes, defined as the Cerebral Performance Category 1 or 2, was evaluated.ResultsAmong 57,754 patients in the registry, 370 were included in the analysis. The overall one-month survival and favorable neurological outcome were 11.1% (41/370) and 4.2% (15/370), respectively. The 1-month survival rates based on the TiPS65 score were as follows: 11.2% (12/107) for 0 points, 9.3% (14/150) for 1 point, 10.0% (9/90) for 2 points, and 26.1% (6/23) for ≥3 points. Similarly, the 1-month favorable neurological outcomes were: 5.6% (6/107) for 0 points, 2.7% (4/150) for 1 point, 4.4% (4/90) for 2 points, and 4.3% (1/23) for ≥3 points. The area under the curve was 0.535 (95% CI: 0.437-0.630) for 1-month survival and 0.530 (95% CI: 0.372-0.683) for 1-month neurological outcome.ConclusionThis study demonstrates that the TiPS65 score has limited prognostic performance among OHCA patients with initial non-shockable rhythm treated with ECPR. Further research is warranted to develop a predictive tool specifically focused on OHCA with initial non-shockable rhythm to aid in determining candidates for ECPR.
| S-EPMC10477678 | biostudies-literature