Improving Outcomes After Post-Cardiac Arrest Brain Injury: A Scientific Statement From the International Liaison Committee on Resuscitation.

This scientific statement presents a conceptual framework for the pathophysiology of post-cardiac arrest brain injury, explores reasons for previous failure to translate preclinical data to clinical practice, and outlines potential paths forward. Post-cardiac arrest brain injury is characterized by 4 distinct but overlapping phases: ischemic depolarization, reperfusion repolarization, dysregulation, and recovery and repair. Previous research has been challenging because of the limitations of laboratory models; heterogeneity in the patient populations enrolled; overoptimistic estimation of treatment effects leading to suboptimal sample sizes; timing and route of intervention delivery; limited or absent evidence that the intervention has engaged the mechanistic target; and heterogeneity in postresuscitation care, prognostication, and withdrawal of life-sustaining treatments. Future trials must tailor their interventions to the subset of patients most likely to benefit and deliver this intervention at the appropriate time, through the appropriate route, and at the appropriate dose. The complexity of post-cardiac arrest brain injury suggests that monotherapies are unlikely to be as successful as multimodal neuroprotective therapies. Biomarkers should be developed to identify patients with the targeted mechanism of injury, to quantify its severity, and to measure the response to therapy. Studies need to be adequately powered to detect effect sizes that are realistic and meaningful to patients, their families, and clinicians. Study designs should be optimized to accelerate the evaluation of the most promising interventions. Multidisciplinary and international collaboration will be essential to realize the goal of developing effective therapies for post-cardiac arrest brain injury.

Outcome prediction of cardiac arrest with automatically computed gray-white matter ratio on computed tomography images.

BACKGROUND: This study aimed to develop an automated method to measure the gray-white matter ratio (GWR) from brain computed tomography (CT) scans of patients with out-of-hospital cardiac arrest (OHCA) and assess its significance in predicting early-stage neurological outcomes. METHODS: Patients with OHCA who underwent brain CT imaging within 12 h of return of spontaneous circulation were enrolled in this retrospective study. The primary outcome endpoint measure was a favorable neurological outcome, defined as cerebral performance category 1 or 2 at hospital discharge. We proposed an automated method comprising image registration, K-means segmentation, segmentation refinement, and GWR calculation to measure the GWR for each CT scan. The K-means segmentation and segmentation refinement was employed to refine the segmentations within regions of interest (ROIs), consequently enhancing GWR calculation accuracy through more precise segmentations. RESULTS: Overall, 443 patients were divided into derivation N=265, 60% and validation N=178, 40% sets, based on age and sex. The ROI Hounsfield unit values derived from the automated method showed a strong correlation with those obtained from the manual method. Regarding outcome prediction, the automated method significantly outperformed the manual method in GWR calculation (AUC 0.79 vs. 0.70) across the entire dataset. The automated method also demonstrated superior performance across sensitivity, specificity, and positive and negative predictive values using the cutoff value determined from the derivation set. Moreover, GWR was an independent predictor of outcomes in logistic regression analysis. Incorporating the GWR with other clinical and resuscitation variables significantly enhanced the performance of prediction models compared to those without the GWR. CONCLUSIONS: Automated measurement of the GWR from non-contrast brain CT images offers valuable insights for predicting neurological outcomes during the early post-cardiac arrest period.

Application of Phosphorylated Tau for Predicting Outcomes Among Sudden Cardiac Arrest Survivors.

BACKGROUND: Phosphorylated Tau (p-Tau), an early biomarker of neuronal damage, has emerged as a promising candidate for predicting neurological outcomes in cardiac arrest (CA) survivors. Despite its potential, the correlation of p-Tau with other clinical indicators remains underexplored. This study assesses the predictive capability of p-Tau and its effectiveness when used in conjunction with other predictors. METHODS: In this single-center retrospective study, 230 CA survivors had plasma and brain computed tomography scans collected within 24 h after the return of spontaneous circulation (ROSC) from January 2016 to June 2023. The patients with prearrest Cerebral Performance Category scores ≥ 3 were excluded (n = 33). The neurological outcomes at discharge with Cerebral Performance Category scores 1-2 indicated favorable outcomes. Plasma p-Tau levels were measured using an enzyme-linked immunosorbent assay, diastolic blood pressure (DBP) was recorded after ROSC, and the gray-to-white matter ratio (GWR) was calculated from brain computed tomography scans within 24 h after ROSC. RESULTS: Of 197 patients enrolled in the study, 54 (27.4%) had favorable outcomes. Regression analysis showed that higher p-Tau levels correlated with unfavorable neurological outcomes. The levels of p-Tau were significantly correlated with DBP and GWR. For p-Tau to differentiate between neurological outcomes, an optimal cutoff of 456 pg/mL yielded an area under the receiver operating characteristic curve of 0.71. Combining p-Tau, GWR, and DBP improved predictive accuracy (area under the receiver operating characteristic curve = 0.80 vs. 0.71, p = 0.008). CONCLUSIONS: Plasma p-Tau levels measured within 24 h following ROSC, particularly when combined with GWR and DBP, may serve as a promising biomarker of neurological outcomes in CA survivors, with higher levels predicting unfavorable outcomes.

Point-of-care testing for adult out-of-hospital cardiac arrest resuscitated at the ED to predict ROSC: Development and external validation of POC-ED-ROSC model.

BACKGROUND AND IMPORTANCE: Most prediction models, like return of spontaneous circulation (ROSC) after cardiac arrest (RACA) or Utstein-based (UB)-ROSC score, were developed for prehospital settings to predict the probability of ROSC in patients with out-of-hospital cardiac arrest (OHCA). A prediction model has been lacking for the probability of ROSC in patients with OHCA at emergency departments (EDs). OBJECTIVE: In the present study, a point-of-care (POC) testing-based model, POC-ED-ROSC, was developed and validated for predicting ROSC of OHCA at EDs. DESIGN, SETTINGS AND PARTICIPANTS: Prospectively collected data for adult OHCA patients between 2015 and 2020 were analysed. POC blood gas analysis obtained within 5 min of ED arrival was used. OUTCOMES MEASURE AND ANALYSIS: The primary outcome was ROSC. In the derivation cohort, multivariable logistic regression was used to develop the POC-ED-ROSC model. In the temporally split validation cohort, the discriminative performance of the POC-ED-ROSC model was assessed using the area under the receiver operating characteristic (ROC) curve (AUC) and compared with RACA or UB-ROSC score using DeLong test. MAIN RESULTS: The study included 606 and 270 patients in the derivation and validation cohorts, respectively. In the total cohort, 471 patients achieved ROSC. Age, initial cardiac rhythm at ED, pre-hospital resuscitation duration, and POC testing-measured blood levels of lactate, potassium and glucose were significant predictors included in the POC-ED-ROSC model. The model was validated with fair discriminative performance (AUC: 0.75, 95% confidence interval [CI]: 0.69-0.81) with no significant differences from RACA (AUC: 0.68, 95% CI: 0.62-0.74) or UB-ROSC score (AUC: 0.74, 95% CI: 0.68-0.79). CONCLUSION: Using only six easily accessible variables, the POC-ED-ROSC model can predict ROSC for OHCA resuscitated at ED with fair accuracy.

Comparison of outcomes between cardiogenic and non-cardiogenic cardiac arrest patients receiving targeted temperature management: The nationwide TIMECARD multicenter registry.

BACKGROUND AND PURPOSE: Targeted temperature management (TTM) has been recommended for post-resuscitation care of cardiac arrest (CA) patients who remain comatose. However, the differences between cardiogenic and non-cardiogenic causes need further investigation. Thus, this study aimed to investigate the difference in outcomes between cardiogenic and non-cardiogenic CA patients receiving TTM. METHODS: The TIMECARD registry established the study cohort and database for patients receiving TTM between January 2013 and September 2019. A total of 543 patients were enrolled, with 305 and 238 patients in the cardiogenic and non-cardiogenic groups, respectively. RESULTS: Compared with the non-cardiogenic group, the cardiogenic group had higher proportion of initial shockable rhythm, better survival (cardiogenic: 45.9%; non-cardiogenic: 30.7%, P = 0.0017), and better neurologic performance at discharge. In the cardiogenic group, witnessed collapse (OR = 0.31, 95% CI: 0.13-0.72), and coronary intervention (OR = 0.45, 95% CI: 0.24-0.84) were positive predictors for overall outcome. Mean arterial pressure <65 mmHg led to poor outcome regardless in the cardiogenic (OR = 3.31, 95% CI: 1.46-7.52) or non-cardiogenic group (OR = 2.39, 95% CI: 1.06-5.39). CONCLUSION: Patients with cardiogenic CA post TTM had better survival and neurologic performance at discharge than those without cardiogenic CA. Cardiogenic etiology was a potential predictor of better cardiac arrest survival, but it was not an independent risk factor for overall outcome after adjusting for potential covariates. In the cardiogenic group, better outcomes were reported in patients with witnessed collapse, bystander cardiopulmonary resuscitation, as well as those receiving coronary intervention.

TIMECARD score: An easily operated prediction model of unfavorable neurological outcomes in out-of-hospital cardiac arrest patients with targeted temperature management.

BACKGROUND: Targeted temperature management (TTM) is recommended for comatose out-of-hospital cardiac arrest (OHCA) survivors. Several prediction models have been proposed; however, most of these tools require data conversion and complex calculations. Early and easy predictive model of neurological prognosis in OHCA survivors with TTM warrant investigation. MATERIALS AND METHODS: This multicenter retrospective cohort study enrolled 408 non-traumatic adult OHCA survivors with TTM from the TaIwan network of targeted temperature ManagEment for CARDiac arrest (TIMECARD) registry during January 2014 to June 2019. The primary outcome was unfavorable neurological outcome at discharge. The clinical variables associated with unfavorable neurological outcomes were identified and a risk prediction score-TIMECARD score was developed. The model was validated with data from National Taiwan University Hospital. RESULTS: There were 319 (78.2%) patients presented unfavorable neurological outcomes at hospital discharge. Eight independent variables, including malignancy, no bystander cardiopulmonary resuscitation (CPR), non-shockable rhythm, call-to-start CPR duration >5 min, CPR duration >20 min, sodium bicarbonate use during resuscitation, Glasgow Coma Scale motor score of 1 at return of spontaneous circulation, and no emergent coronary angiography, revealed a significant correlation with unfavorable neurological prognosis in TTM-treated OHCA survivors. The TIMECARD score was established and demonstrated good discriminatory performance in the development cohort (area under the receiver operating characteristic curve [AUC] = 0.855) and validation cohorts (AUC = 0.918 and 0.877, respectively). CONCLUSION: In emergency settings, the TIMECARD score is a practical and simple-to-calculate tool for predicting neurological prognosis in OHCA survivors, and may help determine whether to initiate TTM in indicated patients.

Should We Prolong the Observation Period for Neurological Recovery After Cardiac Arrest?

OBJECTIVES: To evaluate whether the recommended observation period of 7 days for cardiac arrest survivors is sufficient for conscious recovery and to identify the variables associated with eventual neurologic recovery among patients with delayed awakening. DESIGN: A retrospective cohort study. SETTING: A single tertiary medical center. PATIENTS: Five-hundred twenty-nine nontraumatic adult cardiac arrest survivors with prearrest favorable neurologic function (Cerebral Performance Category 1-2) who survived to hospital discharge during 2011-2019. INTERVENTIONS: The enrolled patients were classified into favorable (Cerebral Performance Category 1-2) and poor (Cerebral Performance Category 3-4) neurologic recovery according to their neurologic function at hospital discharge. Among patients with favorable neurologic recovery, those who recovered within 7 days were assigned to the early recovery group or after 7 days as the late recovery group. MEASUREMENTS AND MAIN RESULTS: There were 395 patients exhibiting favorable neurologic recovery (n = 357 in the early group, n = 38 in late group) and 134 patients exhibiting poor neurologic recovery (poor recovery group). Among patients who remained unconscious on day 7, delayed awakening was associated with male sex (odds ratio [OR], 3.905; 95% CI, 1.153-13.221), prehospital return of spontaneous circulation (OR, 7.628; 95% CI, 2.084-27.922), therapeutic hypothermia (OR, 4.320; 95% CI, 1.624-11.488), and extracorporeal cardiopulmonary resuscitation (OR, 4.508; 95% CI, 1.414-14.371). Being transferred from another hospital, however, was less likely to be associated with delayed awakening (OR, 0.061; 95% CI, 0.009-0.431). The median duration for patients to regain clear consciousness in the late recovery group was 12.12 days. No patient who recovered consciousness had an unfavorable electroencephalography pattern, however, in patients with poor recovery, the 7-day electroencephalography showed 45 patients with generalized suppression (33.6%), two with burst suppression (1.5%), 14 with seizure/epileptic discharge (10.5%), and one with status epilepticus (0.7%). CONCLUSIONS: Up to 9.6% of cardiac arrest patients with favorable outcomes recover consciousness after the recommended 7 days of observation, indicating the observation time of 7 days seems justified but longer duration may be needed. The results of the culturally and clinically isolated population may limit the application to other population.

Factors affecting outcomes in patients with cardiac arrest who receive target temperature management: The multi-center TIMECARD registry.

BACKGROUND: Target temperature management (TTM) is a recommended therapy for patients after cardiac arrest (PCA). The TaIwan Network of Targeted Temperature ManagEment for CARDiac Arrest (TIMECARD) registry was established for PCA who receive TTM therapy in Taiwan. We aim to determine the variables that may affect neurologic outcomes in PCA who undergo TTM. METHODS: We retrieved demographic variables, resuscitation variables, and cerebral performance category (CPC) scale score at hospital discharge from the TIMECARD registry. The primary outcome was a favorable neurologic outcome, defined as a CPC scale of 1 or 2 at discharge. A total of 540 PCA treated between January 2014 and September 2019 were identified from the registry. Univariate and multivariate analyses were performed to identify significant variables. RESULTS: The mortality rate was 58.1% (314/540). Favorable neurologic outcomes were noted in 117 patients (21.7%). The factors significantly influencing the neurologic outcome (p < 0.05) were the presence of an initial shockable rhythm or pulseless electric activity, a witnessed cardiac-arrest event, bystander cardiopulmonary resuscitation, a smaller total dose of epinephrine, the diastolic blood pressure value at return of spontaneous circulation, a pre-arrest CPC score of 1, coronary angiography, new-onset seizure, and new-onset serious infection. Older patients and those with premorbid diabetes mellitus, chronic kidney disease, malignancy, obstructive lung disease, or cerebrovascular accident were more likely to have an unfavorable neurologic outcome. CONCLUSION: In the TIMECARD registry, some PCA baseline characteristics, cardiac arrest events, cardiopulmonary resuscitation characteristics, and post-arrest management characteristics were significantly associated with neurologic outcomes.

Protocolized Post-Cardiac Arrest Care with Targeted Temperature Management.

Improvements in teamwork and resuscitation science have considerably increased the success rate of cardiopulmonary resuscitation. Cerebral injury, myocardial dysfunction, systemic ischemia and reperfusion response, and precipitating pathology after the return of spontaneous circulation (ROSC) constitute post-cardiac arrest syndrome. Because the entire body is involved in cardiac arrest and the early post-arrest period, protocolized post-arrest care consisting of cardiovascular optimization, ventilation and oxygenation adjustment, coronary revascularization, targeted temperature management (TTM), and control of seizures and blood sugar would benefit survival and neurological outcomes. Emergent coronary angiography is suggested for cardiac arrest survivors suspected of having ST-elevation myocardial infarction, however the superiority of culprit or complete revascularization in patients with multivessel coronary lesions remains undetermined. High-quality TTM should be considered for comatose patients who are successfully resuscitated from cardiac arrest, however the optimal target temperature may depend on the severity of their condition. The optimal timing for making prognostication should be no earlier than 72 h after rewarming in TTM patients, and 72 h following ROSC in non-TTM patients. To predict neurological recovery correctly may need the use of several prognostic tools together, including clinical neurological examinations, brain images, neurological studies and biomarkers.

Multivessel versus Culprit-Only Revascularization Strategies in Cardiac Arrest Survivors.

Background: Whether multivessel revascularization or culprit-only revascularization is more beneficial in cardiac arrest survivors with multivessel coronary artery disease remains unclear. We aimed to retrospectively evaluate whether multivessel or culprit-only revascularization following cardiac arrest was associated with a reduced incidence of in-hospital mortality. Methods: A total of 273 adult nontraumatic cardiac arrest survivors (aged ≥ 18 years) who underwent emergent coronary angiography (CAG) within 24 h following cardiac arrest were retrospectively recruited from three hospitals. Patients without definite coronary artery stenosis (n = 72), one-vessel stenosis (n = 74), or failed percutaneous coronary intervention (PCI; n = 37) were excluded. A total of 90 patients were enrolled for the final analysis and classified into multivessel (revascularization of more than one major vessel during the index CAG; n = 45) and culprit-only (revascularization of the infarct-related artery alone; n = 45) groups. Results: Twenty-five patients (55.6%) in the culprit-only group and 17 patients (37.8%) in the multivessel group failed to survive to discharge [adjusted hazard ratio (HR) = 0.47, 95% confidence interval (CI) = 0.24-0.95, p = 0.035]. The benefit of multivessel revascularization on survival was obvious among those with a prolonged cardiopulmonary resuscitation duration (> 10 min) (47.82% vs. 76.92%, adjusted HR = 0.27, 95% CI = 0.08-0.93, p = 0.03). No difference in neurological outcomes (favorable = cerebral performance category scores 1-2; poor = 3-5) between groups was observed (60.0% vs. 55.6%, adjusted OR = 1.22, 95% CI = 0.35-4.26, p = 0.753). Conclusions: Compared with culprit-only revascularization, multivessel revascularization was associated with lower in-hospital mortality among cardiac arrest survivors with multivessel lesions. Owing to the retrospective design and small sample size, the current study should be interpreted as observational and exploratory.

Neuroprognostic Accuracy of Quantitative Versus Standard Pupillary Light Reflex for Adult Postcardiac Arrest Patients: A Systematic Review and Meta-Analysis.

OBJECTIVES: An automated infrared pupillometer measures quantitative pupillary light reflex using a calibrated light stimulus. We examined whether the timing of performing quantitative pupillary light reflex or standard pupillary light reflex may impact its neuroprognostic performance in postcardiac arrest comatose patients and whether quantitative pupillary light reflex may outperform standard pupillary light reflex in early postresuscitation phase. DATA SOURCES: PubMed and Embase databases from their inception to July 2020. STUDY SELECTION: We selected studies providing sufficient data of prognostic values of standard pupillary light reflex or quantitative pupillary light reflex to predict neurologic outcomes in adult postcardiac arrest comatose patients. DATA EXTRACTION: Quantitative data required for building a 2 × 2 contingency table were extracted, and study quality was assessed using standard criteria. DATA SYNTHESIS: We used the bivariate random-effects model to estimate the pooled sensitivity and specificity of standard pupillary light reflex or quantitative pupillary light reflex in predicting poor neurologic outcome during early (< 72 hr), middle (between 72 and 144 hr), and late (≧ 145 hr) postresuscitation periods, respectively. We included 39 studies involving 17,179 patients. For quantitative pupillary light reflex, the cut off points used in included studies to define absent pupillary light reflex ranged from 0% to 13% (median: 7%) and from zero to 2 (median: 2) for pupillary light reflex amplitude and Neurologic Pupil index, respectively. Late standard pupillary light reflex had the highest area under the receiver operating characteristic curve (0.98, 95% CI [CI], 0.97-0.99). For early standard pupillary light reflex, the area under the receiver operating characteristic curve was 0.80 (95% CI, 0.76-0.83), with a specificity of 0.91 (95% CI, 0.85-0.95). For early quantitative pupillary light reflex, the area under the receiver operating characteristic curve was 0.83 (95% CI, 0.79-0.86), with a specificity of 0.99 (95% CI, 0.91-1.00). CONCLUSIONS: Timing of pupillary light reflex examination may impact neuroprognostic accuracy. The highest prognostic performance was achieved with late standard pupillary light reflex. Early quantitative pupillary light reflex had a similar specificity to late standard pupillary light reflex and had better specificity than early standard pupillary light reflex. For postresuscitation comatose patients, early quantitative pupillary light reflex may substitute for early standard pupillary light reflex in the neurologic prognostication algorithm.

Outcomes of Targeted Temperature Management for In-Hospital and Out-Of-Hospital Cardiac Arrest: A Matched Case-Control Study Using the National Database of Taiwan Network of Targeted Temperature Management for Cardiac Arrest (TIMECARD) Registry.

BACKGROUND This study aimed to compare outcomes of targeted temperature management (TTM) for patients with in-hospital and out-of-hospital cardiac arrest using the national database of TaIwan network of targeted temperature ManagEment for CARDiac arrest (TIMECARD) registry. MATERIAL AND METHODS A retrospective, matched, case-control study was conducted. Patients with in-hospital cardiac arrest (IHCA) treated with TTM after the return of spontaneous circulation (ROSC) were selected as the case group and controls were defined as the same number of patients with out-of-hospital cardiac arrest (OHCA), matched for sex, age, Charlson comorbidity index, and cerebral performance category. Neurological outcome and survival at hospital discharge were the primary outcome measures. RESULTS Data of 103 patients with IHCA and matched controls with OHCA were analyzed. Patients with IHCA were more likely to experience witnessed arrest and bystander cardiopulmonary resuscitation (CPR). The duration from collapse to the beginning of CPR, CPR time, and the duration from ROSC to initiation of TTM were shorter in the IHCA group but their initial arterial blood pressure after ROSC was lower. Overall, 88% of patients survived to completion of TTM and 43% survived to hospital discharge. Hospital survival (42.7% vs 42.7%, P=1.00) and favorable neurological outcome at discharge (19.4% vs 12.7%, P=0.25) did not differ between the 2 groups. CONCLUSIONS The findings from the national TIMECARD registry showed that clinical outcomes following TTM for patients with IHCA were not significantly different from OHCA when baseline factors were matched.

QRS duration predicts outcomes in cardiac arrest survivors undergoing therapeutic hypothermia.

BACKGROUND: Whether the electrocardiography (ECG) serial changes predict outcomes in cardiac arrest survivors undergoing therapeutic hypothermia remains unclear. METHODS AND RESULTS: This retrospective observational study enrolled 366 adult nontraumatic cardiac arrest survivors who underwent therapeutic hypothermia in a tertiary transfer center during 2006-2018. The ECG at return of spontaneous circulation (ROSC), during hypothermia and after rewarming were analyzed. 295 cardiac arrest survivors were included. Compared with the survivors, the non-survivors had longer QRS durations at the ROSC (118.33 ± 32.47 ms vs 106.88 ± 29.78 ms, p < 0.001) and after rewarming (99.26 ± 25.07 ms vs 93.03 ± 19.09 ms, p = 0.008). The enrolled patients were classified into 4 groups based on QRS duration at the ROSC and after rewarming, namely (1) narrow-narrow (narrow QRS at ROSC and narrow QRS after rewarming, n = 156), (2) narrow-wide (n = 29), (3) wide-narrow (n = 87), and (4) wide-wide (n = 23) group. The wide-wide group had the worst survival rates [odds ratio (OR) = 0.141, p = 0.001], followed by the narrow-wide group (OR 0.223, p = 0.003) and the wide-narrow group (OR 0.389, p = 0.003). CONCLUSIONS: In cardiac arrest survivors given therapeutic hypothermia, QRS durations at the ROSC, after rewarming and their changes may predict survival to hospital discharge.

Associations of thoracic cage size and configuration with outcomes of adult in-hospital cardiac arrest: A retrospective cohort study.

BACKGROUND: To analyse the association of thoracic cage size and configuration with outcomes following in-hospital cardiac arrest (IHCA). METHODS: A single-centred retrospective study was conducted. Adult patients experiencing IHCA during 2006-2015 were screened. By analysing computed tomography images, we measured thoracic anterior-posterior and transverse diameters, circumference, and both anterior and posterior subcutaneous adipose tissue (SAT) depths at the level of the internipple line (INL). We also recorded the anatomical structure located immediately posterior to the sternum at the INL. RESULTS: A total of 649 patients were included. The median thoracic circumference was 88.6 cm. The median anterior and posterior thoracic SAT depths were 0.9 and 1.5 cm, respectively. The ascending aorta was found to be the most common retrosternal structure (57.6%) at the INL. Multivariate logistic regression analyses indicated that anterior thoracic SAT depth of 0.8-1.6 cm (odds ratio [OR]: 2.98, 95% confidence interval [CI]: 1.40-6.35; p-value = 0.005) and thoracic circumference of 83.9-95.0 cm (OR: 2.48, 95% CI: 1.16-5.29; p-value = 0.02) were positively associated with a favourable neurological outcome while left ventricular outflow track or aortic root beneath sternum at the level of INL was inversely associated with a favourable neurological outcome (OR: 0.37, 95% CI: 0.15-0.91; p-value = 0.03). CONCLUSION: Thoracic circumference and anatomic configuration might be associated with IHCA outcomes. This proof-of-concept study suggested that a one-size-fits-all resuscitation technique might not be suitable. Further investigation is needed to investigate the method of providing personalized resuscitation tailored to patient needs.

Post-cardiac arrest care and targeted temperature management: A consensus of scientific statement from the Taiwan Society of Emergency & Critical Care Medicine, Taiwan Society of Critical Care Medicine and Taiwan Society of Emergency Medicine.

BACKGROUND: Post-cardiac arrest care is critically important in bringing cardiac arrest patients to functional recovery after the detrimental event. More high quality studies are published and evidence is accumulated for the post-cardiac arrest care in the recent years. It is still a challenge for the clinicians to integrate these scientific data into the real clinical practice for such a complicated intensive care involving many different disciplines. METHODS: With the cooperation of the experienced experts from all disciplines relevant to post-cardiac arrest care, the consensus of the scientific statement was generated and supported by three major scientific groups for emergency and critical care in post-cardiac arrest care. RESULTS: High quality post-cardiac arrest care, including targeted temperature management, early evaluation of possible acute coronary event and intensive care for hemodynamic and respiratory care are inevitably needed to get full recovery for cardiac arrest. Management of these critical issues were reviewed and proposed in the consensus CONCLUSION: The goal of the statement is to provide help for the clinical physician to achieve better quality and evidence-based care in post-cardiac arrest period.

Comparing Effectiveness of Initial Airway Interventions for Out-of-Hospital Cardiac Arrest: A Systematic Review and Network Meta-analysis of Clinical Controlled Trials.

STUDY OBJECTIVE: We compare effectiveness of different airway interventions during cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest. METHODS: We systematically searched the PubMed and EMBASE databases from their inception through August 2018 and selected randomized controlled trials or quasi randomized controlled trials comparing intubation, supraglottic airways, or bag-valve-mask ventilation for treating adult out-of-hospital cardiac arrest patients. We performed a network meta-analysis along with sensitivity analyses to investigate the influence of high intubation success rate on meta-analytic results. RESULTS: A total of 8 randomized controlled trials and 3 quasi randomized controlled trials were included in the network meta-analysis: 7,361 patients received intubation, 7,475 received supraglottic airway, and 1,201 received bag-valve-mask ventilation. The network meta-analysis indicated no differences among these interventions for survival or neurologic outcomes at hospital discharge. Rather, network meta-analysis suggested that supraglottic airway improved the rate of return of spontaneous circulation compared with intubation (odds ratio 1.11; 95% confidence interval 1.03 to 1.20) or bag-valve-mask ventilation (odds ratio 1.35; 95% confidence interval 1.11 to 1.63). Furthermore, intubation improved the rate of return of spontaneous circulation compared with bag-valve-mask ventilation (odds ratio 1.21; 95% confidence interval 1.01 to 1.44). The sensitivity analyses revealed that the meta-analytic results were sensitive to the intubation success rates across different out-of-hospital care systems. CONCLUSION: Although there were no differences in long-term survival or neurologic outcome among these airway interventions, these system-based comparisons demonstrated that supraglottic airway was better than intubation or bag-valve-mask ventilation and intubation was better than bag-valve-mask ventilation in improving return of spontaneous circulation. The intubation success rate greatly influenced the meta-analytic results, and therefore these comparison results should be interpreted with these system differences in mind.

Targeted temperature management and emergent coronary angiography are associated with improved outcomes in patients with prehospital return of spontaneous circulation.

BACKGROUND/PURPOSE: Whether targeted temperature management (TTM) and emergent coronary angiography (CAG) remain associated with better outcomes in patients with prehospital return of spontaneous circulation (ROSC) was unknown. METHODS: This retrospective cohort study enrolled 81 adult, nontraumatic out-of-hospital cardiac arrest patients who had good pre-arrest neurological function and achieved prehospital ROSC during 2012 to August 2017. The outcomes were survival-to-discharge and neurological recovery at discharge. RESULTS: Fifty-five patients (67.9%) survived to hospital discharge (the survivor group) and twenty-six (32.1%) failed (the non-survivor group). A total of 47 patients (58.0%) presented favorable neurological outcomes [Cerebral Performance Category (CPC) score = 1-2, the favorable group], and 34 patients (42.0%) presented unfavorable neurological outcomes (CPC score = 3-5, the poor group). The survivor group had more patients with TTM (45.5% vs. 19.2%, p = 0.023) and emergent CAG (76.4% vs. 19.2%, p < 0.001) than the non-survivor group, and similar findings were noted in the neurological outcomes (TTM: 44.7% vs. 26.5%, p = 0.094; CAG: 80.9% vs. 26.5%, p < 0.001). TTM remained associated with increased survival-to-discharge [odds ratio (OR) = 14.635, 95% confidence interval (CI) = 1.296-165.305, p = 0.030] and a trend toward good neurological recovery (OR = 4.551, 95%CI = 0.963-21.517, p = 0.056). After excluding patients with rapid neurological recovery after ROSC (n = 70), TTM was associated with good neurological outcomes (OR = 4.534, 95% CI = 1.075-19.127, p = 0.040). Emergent CAG had the trend associated with survival-to-discharge (OR = 9.599, 95%CI = 0.764-120.634, p = 0.080) and was significantly associated with good neurological outcomes (OR = 21.785, 95%CI = 2.004-236.836, p = 0.011). CONCLUSION: In patients with prehospital ROSC, both TTM and emergent CAG were associated to improved survival and neurological outcomes.

Associations between early intra-arrest blood acidaemia and outcomes of adult in-hospital cardiac arrest: A retrospective cohort study.

BACKGROUND: Resuscitation guidelines list acidaemia as a potentially reversible cause of cardiac arrest without specifying the threshold defining acidaemia. We examined the association between early intra-arrest arterial blood gas (ABG) data and outcomes of in-hospital cardiac arrest (IHCA). METHODS: This single-centred retrospective study reviewed patients with IHCA between 2006 and 2015. Early intra-arrest ABG data were measured within 10 min of initiating cardiopulmonary resuscitation. The ABG analysis included measurements of blood pH, PaCO2, and HCO3-. RESULTS: Among the 1065 included patients, 60 (5.6%) achieved neurologically intact survival. Mean blood pH was 7.2. Mean PaCO2 and HCO3- levels were 59.7 mmHg and 22.1 mmol/L, respectively. A blood pH of 7.2 was identified by a generalised additive models plot to define severe acidaemia. The PaCO2 level was higher in patients with severe acidaemia (mean: 74.5 vs. 44.1 mmHg) than in those without. Multivariable logistic regression analyses indicated that blood pH > 7.2 was associated with a favourable neurological recovery (odds ratio [OR]: 2.79, 95% confidence interval [CI]: 1.43-5.46; p-value = 0.003) and blood pH was positively associated with survival at hospital discharge (OR: 5.80, 95% CI: 1.62-20.69; p-value = 0.007). CONCLUSION: Early intra-arrest blood pH was associated with IHCA outcomes, while levels of PaCO2 and HCO3- were not. A blood pH of 7.2 could be used as the threshold defining severe acidaemia during arrest and help profile patients with IHCA. Innovative interventions should be developed to improve the outcomes of patients with severe acidaemia, such as novel ventilation methods.

Obesity is associated with poor prognosis in cardiogenic arrest survivors receiving coronary angiography.

BACKGROUND: The role of body mass index (BMI) in clinical outcomes in patients resuscitated from cardiac arrest (CA) has recently drawn attention. We evaluated the effect of BMI on the prognosis of patients successfully resuscitated from cardiogenic arrest. METHODS: This retrospective cohort study included 273 non-traumatic adult cardiogenic arrest survivors receiving coronary angiography after return of spontaneous circulation in three hospitals from January 2011 to September 2017. These patients were classified as underweight, normal-weight, overweight, and obese, based on BMI (<18.5; 18.5-24.9; 25.0-29.9; and ≥30 kg/m2, respectively). In-hospital mortality and poor neurological outcomes were compared among groups. RESULTS: The obese group had significantly higher rates of in-hospital mortality and poor neurological outcomes (cerebral performance scale = 3-5) than did the other groups (for underweight, normal-weight, overweight, and obese groups, in-hospital mortality rates were 38.5%, 29.8%, 39.0%, and 64.1%, respectively, p = 0.002; poor neurological outcomes were 53.9%, 43.8%, 47.0%, and 71.8%, respectively, p = 0.02). The obese group exhibited higher risks of in-hospital mortality and poor neurological outcomes than did the normal-weight group (in-hospital mortality: adjusted hazard ratio (aHR) = 5.21, 95% confidence interval (CI) 2.16-10.32, p < 0.001; poor neurological outcomes: aHR = 3.77, 95% CI 1.69-8.36, p = 0.002). CONCLUSION: Obesity was associated with higher risks of in-hospital mortality and poor neurological recovery.

Outcomes associated with amiodarone and lidocaine for the treatment of adult in-hospital cardiac arrest with shock-refractory pulseless ventricular tachyarrhythmia.

BACKGROUND: To determine the association between amiodarone or lidocaine and outcomes in adult in-hospital cardiac arrest (IHCA) with shock-refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT). METHODS: A retrospective study in a single medical centre was conducted. Patients experiencing an IHCA between 2006 and 2015 were screened. Shock-refractory ventricular tachyarrhythmias were defined as VF/pVT requiring more than one defibrillation attempt. A multivariate logistic regression analysis was used to study the associations between the independent variables and outcomes. RESULTS: A total of 130 patients were included. Among these, 113 patients (86.9%) were administered amiodarone as the first antiarrhythmic agent (amiodarone first) following VF/pVT, and the other patients were administered lidocaine (lidocaine first). The median time to the first defibrillation and first antiarrhythmic drug administration were 2 and 9 min, respectively. The analysis demonstrated that the amiodarone-first group experienced a higher likelihood of terminating the VF/pVT within three shocks (odds ratio: 11.61, 95% confidence interval: 1.34-100.84; p-value = 0.03), as compared with the lidocaine-first group. However, there were no significant differences between the amiodarone- and lidocaine-first groups in sustained return of spontaneous circulation, survival for 24 h, survival, or favourable neurological outcomes at hospital discharge. CONCLUSION: For patients with IHCA and shock-refractory VF/pVT, the adoption of an amiodarone-first strategy seemed to be associated with the termination of VF/pVT using fewer shocks. Nonetheless, because of the small sample size, additional large-scale studies should be conducted to investigate whether this advantage could be translated into a long-term benefit in survival or neurological outcomes.