Pre-hospital airway management and survival outcomes after paediatric out-of-hospital cardiac arrests.

BACKGROUND: Paediatric out-of-hospital cardiac arrest (OHCA) results in high mortality and poor neurological outcomes. We conducted this study to describe and compare the effects of pre-hospital airway management on survival outcomes for paediatric OHCA in the Asia-pacific region. METHODS: We performed a retrospective analysis of the Pan Asian Resuscitation Outcomes Study (PAROS) data from January 2009 to June 2018. PAROS is a prospective, observational, multi-centre cohort study from eleven countries. The primary outcomes were one-month survival and survival with favourable neurological status, defined as Cerebral Performance Category1 or 2. We performed multivariate analyses of the unmatched and propensity matched cohort. RESULTS: We included 3131 patients less than 18 years in the study. 2679 (85.6%) children received bag-valve-mask (BVM) ventilations, 81 (2.6%) endotracheal intubations (ETI) and 371 (11.8%) supraglottic airways (SGA). 792 patients underwent propensity score matching. In the matched cohort, advanced airway management (AAM: SGA and ETI) when compared with BVM group was associated with decreased one-month survival [AAM: 28/396 (7.1%) versus BVM: 55/396 (13.9%); adjusted odds ratio (aOR), 0.46 (95% CI, 0.29 - 0.75); p = 0.002] and survival with favourable neurological status [AAM: 8/396 (2.0%) versus BVM: 31/396 (7.8%); aOR, 0.22 (95% CI, 0.10 - 0.50); p < 0.001]. For SGA group, we observed less 1-month survival [SGA: 24/337 (7.1%) versus BVM: 52/337 (15.4%); aOR, 0.41 (95 %CI, 0.25-0.69), p = 0.001] and survival with favourable neurological status. CONCLUSION: In children with OHCA in the Asia-Pacific region, pre-hospital AAM was associated with decreased one-month survival and less favourable neurological status.

International multi-center real world implementation trial to increase out-of-hospital cardiac arrest survival with a dispatcher-assisted cardio-pulmonary resuscitation package (Pan-Asian resuscitation outcomes study phase 2).

BACKGROUND: Dispatcher-assisted CPR (DA-CPR) has the potential to deliver early bystander CPR (BCPR) and improve out-of-hospital cardiac arrest (OHCA) survival. This study in the Asia-Pacific evaluated the impact of a DA-CPR program on BCPR rates and survival. METHODS: This was a three-arm, prospective, multi-national, population-based, community-level, implementation trial. Cases between January 2009 and June 2018 from the Pan-Asian Resuscitation Outcomes Study were included. Sites either implemented a comprehensive (with quality improvement tool) or a basic DA-CPR package, or served as controls. Primary outcome was survival-to-discharge/30th day post-arrest. Secondary outcomes were BCPR and favorable neurological outcome. A before-after comparison was made within each country; this before-after change was then compared across the three groups using logistic regression. RESULTS: 170,687 cases were analyzed. Before-after comparison showed that survival to discharge was higher in the 'implementation' period in all three groups: comprehensive odds ratio (OR) 1.09, 95% confidence interval (CI; [1.0-1.19]); basic OR 1.14, 95% CI (1.08-1.2); and control OR 1.25, 95% CI (1.02-1.53). Comparing between groups, the comprehensive group had significantly higher change in BCPR (comprehensive vs control ratio of OR 1.86, 95% CI [1.66-2.09]; basic vs control ratio of OR 0.94, 95% CI [0.85-1.05]; and comprehensive vs basic ratio of OR 1.97, 95% CI [1.87-2.08]) and survival with favorable neurological outcome (comprehensive vs basic ratio of OR 1.2, 95% CI [1.04-1.39]). CONCLUSION: We evaluated the impact of a DA-CPR program across heterogeneous EMS systems and demonstrated that a comprehensive DA-CPR program had the most impact on BCPR and favorable neurological outcome.

Outcomes and modifiable resuscitative characteristics amongst pan-Asian out-of-hospital cardiac arrest occurring at night.

Studies are divided on the effect of day-night temporal differences on clinical outcomes in out-of-hospital cardiac arrest (OHCA). This study aimed to elucidate any differences in OHCA survival between day and night occurrence, and the factors associated with differences in survival.This was a prospective, observational study of OHCA cases across multinational Pan-Asian sites. Cases were divided according to time call received by dispatch centers into day (0700H-1900H) and night (1900H-0659H). Primary outcome was 30-day survival. Secondary outcomes were prehospital and hospital modifiable resuscitative characteristics.About 22,501 out of 55,881 cases occurred at night. Night cases were less likely to be witnessed (40.2% vs. 43.1%, P < .001), more likely to occur at home (32.5% vs. 29%, P < .001), had non-shockable initial rhythms (90.8% vs. 89.4%, P < .001), lower bystander CPR rates (36.2 vs. 37.6%, P = .001), lower bystander AED application rate (0.3% vs. 0.7%, P < .001), lower rates of prehospital defibrillation (13% vs. 14.4%, P < .001), and were less likely to receive prehospital adrenaline (9.8% vs. 11%, P < .001). 30-day survival at night was lower with an adjusted odds ratio of 0.79 (95% CI 0.73-0.86, P < .001). On multivariate logistic regression, occurrence at night was associated with decreased provision of bystander CPR, bystander AED application, and prehospital adrenaline.30-day survival was worse in OHCA occurring at night. There were circadian patterns in incidence. Bystander CPR and bystander AED application were significantly lower at night in multivariate analysis. This would at least partially explain the decreased survival at night.

A Double-Blind, Randomized Control Trial of Rapidly Infused High Strong Ion Difference (SID) Fluid Versus Hartmann's Solution on Acid-Base Status in Sepsis Patients in the Emergency Department.

BACKGROUND: Balanced fluids are preferred in initial resuscitation of septic patients based on several recent studies. The Stewart's concept on acid-base balance predicts that high strong ion difference (SID) fluid thus will increase the pH level. To date, the impact of high SID fluid in septic patient with metabolic acidosis remains uncertain. We conducted single center, randomized, double-blind trial to compare the effect of high SID fluid vs. Hartmann's solution on acid-base status in selected sepsis patients in the Emergency Department. METHODS: Septic patient with hyperlactatemia and metabolic acidosis were randomized to receive either high SID fl uid or Hartmann's solution during initial fl uid resuscitation. The primary outcome measures the pH and bicarbonate levels difference pre- and post- resuscitation. RESULTS: One hundred and sixty-two patients underwent randomization, 81 were assigned each to receive high SID fluid or Hartmann's solution. Both groups had similar baseline characteristics. High SID group received 23.5 mL/kg and the Hartmann's group received 22.7 mL/kg (p = 0.360). High SID fluid increased the mean (± SD) pH by 0.107 (± 0.09) vs. Hartmann's solution by 0.014 (± 0.12), p ≤ 0.001. Mean bicarbonate level increased signifi cantly in high SID group compared to Hartmann's (4.30 ± 3.76 vs. 1.25 ± 3.33, p ≤ 0.001). High SID group had higher post resuscitation lactate clearance than Hartmann's group (25.4 ± 28.3% vs. 12.0 ± 34.1%, p = 0.009). Shorter hospital stay was observed in highSID group 8.04 ± 5.96 days vs. Hartmann's group 12.18 ± 12.41 days (p = 0.048). Both groups showed no difference in incidence of pulmonary oedema, acute kidney injury and mortality. CONCLUSIONS: Initial resuscitation using high SID fluid in selected septic patient improves pH and bicarbonate levels. The high SID group had better post resuscitation lactate clearance and shorter hospital stay.

Epidemiology and outcome of paediatric out-of-hospital cardiac arrests: A paediatric sub-study of the Pan-Asian resuscitation outcomes study (PAROS).

BACKGROUND: The Pan Asian Resuscitation Outcomes Study (PAROS) is a retrospective study of out- of-hospital cardiac arrest(OHCA), collaborating with EMS agencies and academic centers in Japan, South Korea, Malaysia, Singapore, Taiwan, Thailand and UAE-Dubai. The objectives of this study is to describe the characteristics and outcomes, and to find factors associated with survival after paediatric OHCA. METHODS: We studied all children less than 17 years of age with OHCA conveyed by EMS and non-EMS transports from January 2009 to December 2012. We did univariate and multivariate logistic regression analyses to assess the factors associated with survival-to-discharge outcomes. RESULTS: A total of 974 children with OHCA were included. Bystander cardiopulmonary resuscitation rates ranged from 53.5% (Korea), 35.6% (Singapore) to 11.8% (UAE). Overall, 8.6% (range 0%-9.7%) of the children survived to discharge from hospital. Adolescents (13-17 years) had the highest survival rate of 13.8%. 3.7% of the children survived with good neurological outcomes of CPC 1 or 2. The independent pre-hospital factors associated with survival to discharge were witnessed arrest and initial shockable rhythm. In the sub-group analysis, pre-hospital advanced airway [odds ratio (OR) = 3.35, 95% confidence interval (CI) = 1.23-9.13] was positively associated with survival-to-discharge outcomes in children less than 13 years-old. Among adolescents, bystander CPR (OR = 2.74, 95%CI = 1.03-7.3) and initial shockable rhythm (OR = 20.51, 95%CI = 2.15-195.7) were positive factors. CONCLUSION: The wide variation in the survival outcomes amongst the seven countries in our study may be due to the differences in the delivery of pre-hospital interventions and bystander CPR rates.

Effect of known history of heart disease on survival outcomes after out-of-hospital cardiac arrests.

OBJECTIVE: We aimed to investigate the effect of known heart disease on post-out-of-hospital cardiac arrest (OHCA) survival outcomes, and its association with factors influencing survival. METHODS: This was an observational, retrospective study involving an OHCA database from seven Asian countries in 2009-2012. Heart disease was defined as a documented diagnosis of coronary artery disease or congenital heart disease. Patients with non-traumatic arrests for whom resuscitation was attempted and with known medical histories were included. Differences in demographics, arrest characteristics and survival between patients with and without known heart disease were analysed. Multivariate logistic regression was performed to identify factors influencing survival to discharge. RESULTS: Of 19 044 eligible patients, 5687 had known heart disease. They were older (77 vs 72 years) and had more comorbidities like diabetes (40.9 vs 21.8%), hypertension (60.6 vs 36.0%) and previous stroke (15.2 vs 10.1%). However, they were not more likely to receive bystander cardiopulmonary resuscitation (P = 0.205) or automated external defibrillation (P = 0.980). On univariate analysis, known heart disease was associated with increased survival (unadjusted odds ratio 1.16, 95% confidence interval 1.03-1.30). However, on multivariate analysis, heart disease predicted poorer survival (adjusted odds ratio 0.76, 95% confidence interval 0.58-1.00). Other factors influencing survival corresponded with previous reports. CONCLUSIONS: Known heart disease independently predicted poorer post-OHCA survival. This study may provide information to guide future prospective studies specifically looking at family education for patients with heart disease and the effect on OHCA outcomes.

Association of the Emergency Medical Services-Related Time Interval with Survival Outcomes of Out-of-Hospital Cardiac Arrest Cases in Four Asian Metropolitan Cities Using the Scoop-and-Run Emergency Medical Services Model.

BACKGROUND: Response time interval (RTI) and scene time interval (STI) are key time variables in the out-of-hospital cardiac arrest (OHCA) cases treated and transported via emergency medical services (EMS). OBJECTIVE: We evaluated distribution and interactive association of RTI and STI with survival outcomes of OHCA in four Asian metropolitan cities. METHODS: An OHCA cohort from Pan-Asian Resuscitation Outcome Study (PAROS) conducted between January 2009 and December 2011 was analyzed. Adult EMS-treated cardiac arrests with presumed cardiac origin were included. A multivariable logistic regression model with an interaction term was used to evaluate the effect of STI according to different RTI categories on survival outcomes. Risk-adjusted predicted rates of survival outcomes were calculated and compared with observed rate. RESULTS: A total of 16,974 OHCA cases were analyzed after serial exclusion. Median RTI was 6.0 min (interquartile range [IQR] 5.0-8.0 min) and median STI was 12.0 min (IQR 8.0-16.1). The prolonged STI in the longest RTI group was associated with a lower rate of survival to discharge or of survival 30 days after arrest (adjusted odds ratio [aOR] 0.59; 95% confidence interval [CI] 0.42-0.81), as well as a poorer neurologic outcome (aOR 0.63; 95% CI 0.41-0.97) without an increasing chance of prehospital return of spontaneous circulation (aOR 1.12; 95% CI 0.88-1.45). CONCLUSIONS: Prolonged STI in OHCA with a delayed response time had a negative association with survival outcomes in four Asian metropolitan cities using the scoop-and-run EMS model. Establishing an optimal STI based on the response time could be considered.

Associations between gender and cardiac arrest outcomes in Pan-Asian out-of-hospital cardiac arrest patients.

BACKGROUND: The incidence of out-of-hospital cardiac arrest (OHCA) in women is thought to be lower than that of men, with better outcomes in some Western studies. OBJECTIVES: This study aimed to investigate the effect of gender on OHCA outcomes in the Pan-Asian population. METHODOLOGY: This was a retrospective, secondary analysis of the Pan Asian Resuscitation Outcomes Study (PAROS) data between 2009 and 2012. We included OHCA cases which were presumed cardiac etiology, aged 18 years and above and resuscitation attempted by emergency medical services (EMS) systems. We used multi-level mixed-effects logistic regression models to account for the clustering effect of individuals within the country. Primary outcome was survival to hospital discharge. RESULTS: We included a total of 40,159 OHCA cases, 40% of which were women. We found that women were more likely to be older and have an initial non-shockable arrest rhythm; they were more likely to receive bystander cardio-pulmonary resuscitation (CPR). The univariate analysis showed that women were significantly less likely to have return of spontaneous circulation (ROSC) at scene or in the emergency department (ED), and had lower rates of survival-to-admission and discharge, and poorer overall and cerebral performance outcomes. There was however, no significant gender difference on outcomes after adjustment of other confounders. Women in the reproductive age group (age 18-44 years) were significantly more likely to have ROSC at scene or in the ED, higher rates of survival-to-admission and discharge, and have better overall and cerebral performance outcomes after adjustment for differences in baseline and pre-hospital factors. Menopausal women (age 55 years and above) were less likely to survive to admission after adjusting for other pre-hospital characteristics but not after age adjustment. CONCLUSION: Differences in survival outcomes between reproductive and menopausal women highlight a need for further investigations into the plausible social, pathologic or hormonal basis.

Rationale, Methodology, and Implementation of a Dispatcher-assisted Cardiopulmonary Resuscitation Trial in the Asia-Pacific (Pan-Asian Resuscitation Outcomes Study Phase 2).

Abstract Background. Survival outcomes from out-of-hospital cardiac arrest (OHCA) in Asia are poor (2-11%). Bystander cardiopulmonary resuscitation (CPR) rates are relatively low in Asia. Dispatcher-assisted CPR (DA-CPR) has recently emerged as a potentially cost-effective intervention to increase bystander CPR and survival from OHCA. The Pan-Asian Resuscitation Outcomes Study (PAROS), an Asia-Pacific cardiac arrest registry, was set up in 2009, with the aim of understanding OHCA as a disease in Asia and improving OHCA survival. The network has adopted DA-CPR as part of its strategy to improve OHCA survival. Objective. This article aims to describe the conceptualization, study design, potential benefits, and difficulties for implementation of DA-CPR trial in the Asia-Pacific. Methods. Two levels of intervention, basic and comprehensive, will be offered to PAROS participating sites. The basic level consists of implementation of a DA-CPR protocol and training program, while the comprehensive level consists of implementation of the basic level, with the addition of a dispatch quality measurement tool, quality improvement program, and community education program. Sites that are not able to implement the package will contribute control data. The primary outcome of the study is survival to hospital discharge or survival to 30 days post cardiac arrest. DA-CPR and bystander CPR are secondary outcomes. Conclusion. Implementation of DA-CPR requires concerted efforts by EMS leaders and supervisors, dispatchers, hospital stakeholders, policy makers, and the general public. The DA-CPR trial implemented by the PAROS sites, if successful, can serve as a model for other countries considering such an intervention in their EMS systems.