End-tidal carbon dioxide after sodium bicarbonate infusion during mechanical ventilation or ongoing cardiopulmonary resuscitation.

PURPOSE: End-tidal CO2 is used to monitor the ventilation status or hemodynamic efficacy during mechanical ventilation or cardiopulmonary resuscitation (CPR), and it may be affected by various factors including sodium bicarbonate administration. This study investigated changes in end-tidal CO2 after sodium bicarbonate administration. MATERIALS AND METHODS: This single-center, prospective observational study included adult patients who received sodium bicarbonate during mechanical ventilation or CPR. End-tidal CO2 elevation was defined as an increase of ≥20% from the baseline end-tidal CO2 value. The time to initial increase (lag time, Tlag), time to peak (Tpeak), and duration of the end-tidal CO2 rise (Tduration) were compared between the patients with spontaneous circulation (SC group) and those with ongoing resuscitation (CPR group). RESULTS: Thirty-three patients, (SC group, n = 25; CPR group, n = 8), were included. Compared with the baseline value, the median values of peak end-tidal CO2 after sodium bicarbonate injection increased by 100% (from 21 to 41 mmHg) in all patients, 89.5% (from 21 to 39 mmHg) in the SC group, and 160.2% (from 15 to 41 mmHg) in the CPR group. The median Tlag was 17 s (IQR: 12-21) and the median Tpeak was 35 s (IQR: 27-52). The median Tduration was 420 s (IQR: 90-639). The median Tlag, Tpeak, and Tduration were not significantly different between the groups. Tduration was associated with the amount of sodium bicarbonate for SC group (correlation coefficient: 0.531, p = 0.006). CONCLUSION: The administration of sodium bicarbonate may lead to a substantial increase in end-tidal CO2 for several minutes in patients with spontaneous circulation and in patients with ongoing CPR. After intravenous administration of sodium bicarbonate, the use of end-tidal CO2 pressure as a physiological indicator may be limited.

Gastric Inflation in Prehospital Cardiopulmonary Resuscitation: Aspiration Pneumonia and Resuscitation Outcomes.

Background: Gastric inflation (GI) can induce gastric regurgitation and subsequent aspiration pneumonia, which can prolong intensive care unit stay. However, it has not been verified in patients with out-of-hospital cardiac arrest (OHCA). This study aimed to investigate the incidence of GI during prehospital resuscitation and its effect on aspiration pneumonia and resuscitation outcomes in patients with out-of-hospital cardiac arrest. Methods: This was a multicenter, retrospective, observational study. Patients with non-traumatic OHCA aged > 19 years who had been admitted to the emergency department were enrolled. Patients who received mouth-to-mouth ventilation during bystander cardiopulmonary resuscitation (CPR) were excluded from the evaluation owing to the possibility of GI following bystander CPR. Patients who experienced cardiac arrest during transportation to the hospital who were treated by the emergency medical service (EMS) personnel, and those with a nasogastric tube at the time of chest or abdominal radiography were also excluded. Radiologists independently reviewed plain chest or abdominal radiographs immediately after resuscitation to identify GI. Chest computed tomography performed within 24 h after return of spontaneous circulation was also reviewed to identify aspiration pneumonia. Results: Of 499 patients included in our analysis, GI occurred in approximately 57% during the prehospital resuscitation process, and its frequency was higher in a bag-valve mask ventilation group (n = 70, 69.3%) than in the chest compression-only cardiopulmonary resuscitation (n = 31, 55.4%), supraglottic airway (n = 180, 53.9%), and endotracheal intubation groups (n = 3, 37.5%) (p = 0.031). GI was inversely associated with initial shockable rhythm (adjusted odds ratio [OR] 0.53; 95% confidence interval [CI]: 0.30-0.94). Aspiration pneumonia was not associated with GI. Survival to hospital discharge and favorable neurologic outcomes were not associated with GI during prehospital resuscitation. Conclusions: GI in patients with OHCA was not associated with the use of different airway management techniques.

Circulating Vitamin D Level and Risk of Sudden Cardiac Death and Cardiovascular Mortality: A Dose-Response Meta-Analysis of Prospective Studies.

BACKGROUND: We conducted a comprehensive meta-analysis of prospective cohort studies to analyze the effect of circulating vitamin D level on the risk of sudden cardiac death (SCD) and cardiovascular disease (CVD) mortality. METHODS: Prospective cohort studies evaluating the association between circulating vitamin D and risk of SCD and CVD mortality were systematically searched in the PubMed and Embase. Extracted data were analyzed using a random effects model and results were expressed in terms of hazard ratio (HR) and 95% confidence interval (CI). Restricted cubic spline analysis was used to estimate the dose-response relationships. RESULTS: Of the 1,321 records identified using the search strategy, a total of 19 cohort studies were included in the final meta-analysis. The pooled estimate of HR (95% CI) for low vs. high circulating vitamin D level was 1.75 (1.49-2.06) with I² value of 30.4%. In subgroup analysis, strong effects of circulating vitamin D were observed in healthy general population (pooled HR, 1.84; 95% CI, 1.43-2.38) and the clinical endpoint of SCD (pooled HRs, 2.68; 95% CI, 1.48-4.83). The dose-response analysis at the reference level of < 50 nmol/L showed a significant negative association between circulating vitamin D and risk of SCD and CVD mortality. CONCLUSION: Our meta-analysis of prospective cohort studies showed that lower circulating vitamin D level significantly increased the risk of SCD and CVD mortality.

Right-to-Left Shunts Occur During Cardiopulmonary Resuscitation: Echocardiographic Observations.

OBJECTIVES: A significant proportion of the population has a patent foramen ovale (PFO). The intracardiac pressure during cardiopulmonary resuscitation (CPR) may differ from that of normal circulation, which may result in a right-to-left shunt in the presence of a PFO. In this study, transesophageal echocardiography (TEE) was conducted to evaluate whether CPR carried out in patients after cardiac arrest causes right-to-left shunt. DESIGN: A retrospective observational study. SETTING: One academic medical center from January 2017 to April 2020. PATIENTS: Patients older than 20 years who suffered from nontraumatic out-of-hospital cardiac arrest (OHCA) and underwent intra-arrest TEE. MEASUREMENT AND MAIN RESULTS: Patients who had microbubbles resulting from fluid injection in the right atrium, as indicated on TEE imaging, were included in the analysis. The presence of right-to-left shunt was defined as the appearance of microbubbles in the systemic circulation, including the left atrium, left ventricle, or aorta. A total of 97 patients were included in the final analysis. A right-to-left shunt was observed in 21 patients (21.6%), and no shunt was found in 76 patients (78.4%). The degree of the right-to-left shunt, determined by the number of microbubbles, was mild in 11 patients (52.4%), moderate in eight (38.0%), and severe in two (9.6%). Multivariate analysis showed that no factors were associated with the presence of right-to-left shunt during CPR. CONCLUSIONS: Right-to-left shunts can be appreciated during CPR in patients who experience OHCA. Further studies are needed to verify its clinical significance.

Diagnosis of aortic dissection by transesophageal echocardiography during cardiopulmonary resuscitation.

OBJECTIVES: Early identification of the causes of cardiac arrest is helpful in determining the resuscitation measures during cardiopulmonary resuscitation (CPR). We aimed to evaluate the feasibility of transesophageal echocardiography (TEE) during CPR in diagnosing aortic dissection and the influence of aortic dissection on resuscitation outcome in adult patients with prolonged non-traumatic cardiac arrest. METHODS: Adult patients aged >20 years with non-traumatic cardiac arrest who underwent prolonged CPR (>10 min) and TEE examination during CPR were enrolled. The enrolled patients were grouped according to the presence of aortic dissection on TEE: the aortic dissection (AD) group and the non-AD group. Variables related to cardiac arrest event, CPR, and resuscitation outcome were compared between the two groups. RESULTS: Forty-five patients (median age, 71 years; 26 men) were enrolled. Ten (22.2%) and 35 (77.8%) patients were included in the AD and non-AD groups, respectively. No patients in the AD group survived. Aortic dissection on TEE was inversely related to the rate of return of spontaneous circulation on multivariate analysis (odds ratio, 0.019; 95% confidence interval, 0.001-0.750; p = .035). CONCLUSION: TEE is a useful tool for diagnosing aortic dissection as a cause of cardiac arrest during CPR. Aortic dissection is associated with poor resuscitation outcomes.

Changes in Diagnosis of Poisoning in Patients in the Emergency Room Using Systematic Toxicological Analysis with the National Forensic Service.

BACKGROUND: It is difficult to diagnose patients with poisoning and determine the causative agent in the emergency room. Usually, the diagnosis of such patients is based on their medical history and physical examination findings. We aimed to confirm clinical diagnoses using systematic toxicological analysis (STA) and investigate changes in the diagnosis of poisoning. METHODS: The Intoxication Analysis Service was launched in June 2017 at our hospital with the National Forensic Service to diagnose intoxication and identify toxic substances by conducting STA. Data were collected and compared between two time periods: before and after the initiation of the project, i.e., from June 2014 to May 2017 and from June 2017 to May 2020. RESULTS: A total of 492 and 588 patients were enrolled before and after the service, respectively. Among the 588 after-service patients, 446 underwent STA. Among the 492 before-service patients, 69.9% were diagnosed clinically, whereas the causative agent could not be identified in 35 patients. After starting the service, a diagnosis was confirmed in 84.4% of patients by performing a hospital-available toxicological analysis or STA. Among patients diagnosed with poisoning by toxins identified based on history taking, only 83.6% matched the STA results, whereas 8.4% did not report any toxin, including known substances. The substance that the emergency physician suspected after a physical examination was accurate in 49.3% of cases, and 12% of cases were not actually poisoned. In 13.4% of patients who visited the emergency room owing to poisoning of unknown cause, poisoning could be excluded after STA. Poisoning was determined to be the cause of altered mental status in 31.5% of patients for whom the cause could not be determined in the emergency room. CONCLUSION: A diagnosis may change depending on the STA results of intoxicated patients. Therefore, appropriate STA can increase the accuracy of diagnosis and help in making treatment decisions.

Delayed Splenic Rupture: A Rare Complication of Snakebites.

Bites by venomous snakes can cause fatal systemic and coagulation disorders. Rare complications, such as compartment syndrome and hemoperitoneum, may also require surgical intervention. Here, we describe our experience with an unusual case of snakebite-induced delayed splenic rupture. A 54-y-old male with no specific medical history visited a local hospital for a bite by an unidentified snake. He had been bitten on the left thumb and was administered antivenom. He was discharged from the local hospital after 3 d when his symptoms had improved. However, he revisited our emergency medical center 2 d later, reporting dizziness with diaphoresis. Focused abdominal ultrasonography and computed tomography revealed large amounts of intraperitoneal fluid collection and hemoperitoneum with splenic rupture, respectively. The patient underwent immediate blood transfusion and received antivenom treatment in our emergency department and, subsequently, emergency splenectomy. Histopathologic findings at the time of surgery revealed multifocal lacerations on the external surface of the spleen, with fresh hemorrhage. He recovered 7 d after surgery without any complication.

Recovery from acute kidney injury as a potent predictor of survival and good neurological outcome at discharge after out-of-hospital cardiac arrest.

BACKGROUND: Acute kidney injury (AKI) after out-of-hospital cardiac arrest (OHCA) is a well-known predictor for mortality. However, the natural course of AKI including recovery rate after OHCA is uncertain. This study investigated the clinical course of AKI after OHCA and determined whether recovery from AKI impacted the outcomes of OHCA. METHODS: This retrospective multicentre cohort study included adult OHCA patients treated with targeted temperature management (TTM) between January 2016 and December 2017. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes criteria. The primary outcome was the recovery rate after AKI and its association with survival and good neurological outcome at discharge. RESULTS: A total of 3697 OHCA patients from six hospitals were screened and 275 were finally included. AKI developed in 175/275 (64%) patients and 69/175 (39%) patients recovered from AKI. In most cases, AKI developed within three days of return of spontaneous circulation [155/175 (89%), median time to AKI development 1 (1-2) day] and patients recovered within seven days of return of spontaneous circulation [59/69 (86%), median time to AKI recovery 3 (2-7) days]. Duration of AKI was significantly longer in the AKI non-recovery group than in the AKI recovery group [5 (2-9) vs. 1 (1-5) days; P < 0.001]. Most patients were diagnosed with AKI stage 1 initially [120/175 (69%)]. However, the number of stage 3 AKI patients increased from 30/175 (17%) to 77/175 (44%) after the initial diagnosis of AKI. The rate of survival discharge was significantly higher in the AKI recovery group than in the AKI non-recovery group [45/69 (65%) vs. 17/106 (16%); P < 0.001]. Recovery from AKI was a potent predictor of survival and good neurological outcome at discharge in the multivariate analysis (adjusted odds ratio, 8.308; 95% confidence interval, 3.120-22.123; P < 0.001 and adjusted odds ratio, 36.822; 95% confidence interval, 4.097-330.926; P = 0.001). CONCLUSIONS: In our cohort of adult OHCA patients treated with TTM (n = 275), the recovery rate from AKI after OHCA was 39%, and recovery from AKI was a potent predictor of survival and good neurological outcome at discharge.

The gradient between arterial and end-tidal carbon dioxide predicts in-hospital mortality in post-cardiac arrest patient.

PURPOSE: We investigated the predictive value of the gradient between arterial carbon dioxide (PaCO2) and end-tidal carbon dioxide (ETCO2) (Pa-ETCO2) in post-cardiac arrest patients for in-hospital mortality. METHODS: This retrospective observational study evaluated cardiac arrest patients admitted to the emergency department of a tertiary university hospital. The PaCO2 and ETCO2 values at 6, 12, and 24 h after return of spontaneous circulation (ROSC) were obtained from medical records and Pa-ETCO2 gap was calculated as the difference between PaCO2 and ETCO2 at each time point. Multivariate logistic regression analysis was performed to verify the relationship between Pa-ETCO2 gap and clinical variables. Receiver operating characteristic (ROC) curve analysis was performed to determine the cutoff value of Pa-ETCO2 for predicting in-hospital mortality. RESULTS: The final analysis included 58 patients. In univariate analysis, Pa-ETCO2 gaps were significantly lower in survivors than in non-survivors at 12 h [12.2 (6.5-14.8) vs. 13.9 (12.1-19.6) mmHg, p = 0.040] and 24 h [9.1 (6.3-10.5) vs. 17.1 (13.1-23.2) mmHg, p < 0.001)] after ROSC. In multivariate analysis, Pa-ETCO2 gap at 24 h after ROSC was related to in-hospital mortality [odds ratio (95% confidence interval): 1.30 (1.07-1.59), p = 0.0101]. In ROC curve analysis, the optimal cut-off value of Pa-ETCO2 gap at 24 h after ROSC was 10.6 mmHg (area under the curve, 0.843), with 77.8% sensitivity and 85.7% specificity. CONCLUSION: The Pa-ETCO2 gap at 24 h after ROSC was associated with in-hospital mortality in post-cardiac arrest patients.

Procalcitonin as a diagnostic marker for sepsis/septic shock in the emergency department; a study based on Sepsis-3 definition.

INTRODUCTION: The recent definition of sepsis was modified based on a scoring system focused on organ failure (Sepsis-3). It would be a time-consuming process to detect the sepsis patient using Sepsis-3. Procalcitonin (PCT) is a well-known biomarker for diagnosing sepsis/septic shock and monitoring the efficacy of treatment. We conducted a study to verify the predictability of PCT for diagnosing sepsis based on Sepsis-3 definition. MATERIALS & METHODS: This is a retrospective cohort study. The patients whose PCT was measured on the emergency department (ED) arrival and had final diagnosis related infection were enrolled. The patients were categorized by infection, sepsis, or septic shock followed by Sepsis-3 definition. "Pre-septic shock" was defined when a patient was initially diagnosed with sepsis, following which his/her mean arterial blood pressure decreased to under 65 mmHg refractory to fluid resuscitation and there was need for vasopressor use during ED admission. Receiver operating characteristics (ROC) curve and area under the curve (AUC) analysis were performed to verify sensitivity and specificity of PCT. RESULTS: 866 patients were enrolled in the final analysis. There are 287 cases of infection, 470 cases of sepsis, and 109 cases of septic shock. An optimal cutoff value for diagnosing sepsis was 0.41 ng/dL (sensitivity: 74.8% and specificity: 63.8%; AUC: 0745), septic shock was 4.7 ng/dL (sensitivity: 66.1% and specificity: 79.0%; AUC: 0.784), and "pre-septic shock" was 2.48 ng/dL (sensitivity: 72.8%, specificity: 72.8%, AUC: 0.781), respectively. CONCLUSION: PCT is a reliable biomarker to predict sepsis or septic shock according to the Sepsis-3 definitions.

Estimation of Arterial Blood Pressure Based on Artificial Intelligence Using Single Earlobe Photoplethysmography during Cardiopulmonary Resuscitation.

This study investigates the feasibility of estimation of blood pressure (BP) using a single earlobe photoplethysmography (Ear PPG) during cardiopulmonary resuscitation (CPR). We have designed a system that carries out Ear PPG for estimation of BP. In particular, the BP signals are estimated according to a long short-term memory (LSTM) model using an Ear PPG. To investigate the proposed method, two statistical analyses were conducted for comparison between BP measured by the micromanometer-based gold standard method (BPMEAS) and the Ear PPG-based proposed method (BPEST) for swine cardiac model. First, Pearson's correlation analysis showed high positive correlations (r = 0.92, p < 0.01) between BPMEAS and BPEST. Second, the paired-samples t-test on the BP parameters (systolic and diastolic blood pressure) of the two methods indicated no significant differences (p > 0.05). Therefore, the proposed method has the potential for estimation of BP for CPR biofeedback based on LSTM using a single Ear PPG.

Effect of Automated Simultaneous Sternothoracic Cardiopulmonary Resuscitation Device on Hemodynamics in Out-of-Hospital Cardiac Arrest Patients.

BACKGROUND: An automatic simultaneous sternothoracic cardiopulmonary resuscitation (SST-CPR) device is an apparatus that performs CPR by providing simultaneous cyclic compressions of the thorax with a thoracic strap and compression of the sternum with a piston. OBJECTIVE: This study was conducted to compare the hemodynamic effects of CPR with an automatic SST-CPR device to those with standard CPR (STD-CPR) in cardiac arrest patients. METHODS: A randomized trial was performed on victims of out-of-hospital cardiac arrest resistant to initial 20 min of CPR after emergency department (ED) arrival. Patients were instrumented with femoral arterial and internal jugular venous lines before enrollment. Informed consent was waived per protocol. Patients were randomized to SST-CPR or STD-CPR based on the day of the month. The primary outcome was a comparison of the mean estimated coronary perfusion pressure (CPP) between SST-CPR and STD-CPR. The secondary outcome was a comparison of compression arterial systolic pressure, compression arterial diastolic pressure, right atrial systolic pressure, right atrial diastolic pressure, return of spontaneous circulation rate, survival to hospital admission, survival at 30 days, favorable neurologic outcomes at 30 days, and adverse events between two groups. RESULTS: Of 62 patients with non-traumatic, adult, out-of-hospital cardiac arrest who presented to the ED, 24 received CPR with an automatic SST-CPR device (SST-CPR group), and 38 received standard CPR (STD-CPR group). Acquisition and analysis of hemodynamic data were completed in 11 (46%) patients in the SST-CPR group and 14 (37%) patients in the STD-CPR group. Compression arterial systolic pressure, right atrial systolic/diastolic pressures, and end-tidal carbon dioxide tension were not different between the two groups. Median compression arterial diastolic pressure (femoral arterial pressure during relaxation) was 20 mm Hg (mean 22 mm Hg; 95% confidence interval [CI] 5 to 38 mm Hg) and 0 mm Hg (mean -2 mm Hg; 95% CI -21 to 18 mm Hg) in the SST-CPR group and the STD-CPR group (p = 0.002), respectively. Median estimated CPP was 10 mm Hg (mean 16 mmHg; 95% CI 1 to 31 mm Hg) and 2 mm Hg (mean 4 mm Hg; 95% CI -4 to 12 mm Hg) in the SST-CPR group and the STD-CPR group (p = 0.017), respectively. CONCLUSIONS: CPR with an automatic SST-CPR device results in higher estimated CPP compared to standard CPR in patients with non-traumatic, out-of-hospital cardiac arrest.

Parenchymal lung injuries related to standard cardiopulmonary resuscitation.

OBJECTIVES: We analyzed chest computed tomographic scan to evaluate parenchymal lung injury and its clinical significance in patients who received standard cardiopulmonary resuscitation and were resuscitated from cardiac arrest. METHODS: We enrolled nontraumatic out-of-hospital cardiac arrest patients older than 19 years who had been admitted to the emergency department in cardiac arrest and successfully resuscitated after cardiopulmonary resuscitation. Chest computed tomography was obtained immediately after return of spontaneous circulation (ROSC). To allocate the area of lung contusion, we divided both hemithoraces into 3 regions longitudinally, and each part was subdivided into 4 segments except the lower part of the left lung. To stratify the severity of lung contusion, each segment was scored depending on the area of lung contusion. Oxygen index (OI) was measured at the time of ROSC, 24, 48, and 72 hours and 1 week after cardiac arrest. RESULTS: Lung contusion was developed in 37 (41%) patients and median lung contusion score (LCS) was 17 (12-26). Lung contusion was not associated with hospital mortality (P = .924) or length of intensive care unit stay (P = .446). The OI at the time of ROSC was lower in patients with LCS greater than 23 than that in patients with LCS less than or equal to 23 (126 [93-224] vs 278 [202-367]; P = .008); however, the OI at the other timelines was not different between patients with LCS greater than 23 and patients with LCS less than or equal to 23. CONCLUSION: Extensive lung contusion is associated with a lower oxygenation index at the time of ROSC, but did not affect the resuscitation outcome.

Reduced Mortality in Severely Injured Patients Using Hospital-based Helicopter Emergency Medical Services in Interhospital Transport.

Recent evidence has demonstrated the survival benefits of helicopter transport for trauma patients. The purpose of this study was to evaluate the effectiveness of hospital-based helicopter emergency medical services (H-HEMS) in comparison with ground ambulance transport in improving mortality outcomes in patients with major trauma. Study participants were divided into 2 groups according to type of transport to the trauma center; that is, either via ground emergency medical services (GEMS) or via H-HEMS. The study was conducted from October 2013 to July 2015. Mortality outcomes in the H-HEMS group were compared with those in the GEMS group by using the Trauma and Injury Severity Score (TRISS) analysis. The number of participants finally included in the study was 312. Among these patients, 63 were adult major trauma patients transported via H-HEMS, and 47.6% were involved in traffic accidents. For interhospital transport, the Z and W statistics revealed significantly higher scores in the H-HEMS group than in the GEMS group (Z statistic, 2.02 vs. 1.16; P = 0.043 vs. 0.246; W statistic, 8.87 vs. 2.85), and 6.02 more patients could be saved per 100 patients when H-HEMS was used for transportation. TRISS analysis revealed that the use of H-HEMS for transporting adult major trauma patients was associated with significantly improved survival compared to the use of GEMS.

Prognostic value of gray matter to white matter ratio in hypoxic and non-hypoxic cardiac arrest with non-cardiac etiology.

PURPOSE: This study evaluated the prognostic performance of the gray to white matter ratio (GWR) on brain computed tomography (CT) in out-of-hospital cardiac arrest (OHCA) survivors with a noncardiac etiology and compared the prognostic performance of GWR between hypoxic and nonhypoxic etiologies. METHODS: Using a multicenter retrospective registry of adult OHCA patients treated with targeted temperature management, we identified those with a noncardiac etiology who underwent brain CT within 24 hours after restoration of spontaneous circulation. Attenuation of the gray matter and white matter (at the level of the basal ganglia, centrum semiovale, and high convexity) were measured and GWRs were calculated. The primary outcome was neurologic outcome. RESULTS: Of 164 patients, 145 (88.4%) were discharged with a poor neurologic outcome. Lower GWR was associated with a poor neurologic outcome. The sensitivities of this marker were markedly low (9.7%-43.5%) at cutoff values, with 100% sensitivity. The cutoff values of the GWR for hypoxic arrest showed higher sensitivities than those for nonhypoxic arrest. The area under the curve (AUC) values of the GWR for the caudate nucleus/posterior limb of the internal capsule, putamen/corpus callosum, and basal ganglia were significant in the hypoxic group, whereas the AUC of the putamen/corpus callosum was the only significant GWR in the nonhypoxic group. CONCLUSION: A low GWR is associated with poor neurologic outcome in noncardiac etiology OHCA patients treated with targeted temperature management. Gray to white matter ratio can help to predict the neurologic outcome in a cardiac arrest with hypoxic etiology rather than a nonhypoxic etiology.

The utility of noninvasive nasal positive pressure ventilators for optimizing oxygenation during rapid sequence intubation.

OBJECTIVES: The objective of the study is to investigate the feasibility of noninvasive nasal positive pressure ventilation (NINPPV) for optimizing oxygenation during the rapid sequence intubation in critically ill patients. METHODS: A prospective, observational study was performed in an emergency department. Noninvasive nasal positive pressure ventilation was applied in the preoxygenation step and maintained until successful intubation. A pulse oximetry (Spo2) was continuously monitored throughout the procedure and recorded 5 times. The degree of interfering was surveyed with 10-point Likert scale. RESULTS: Thirty patients were enrolled. The most of enrolled patients were diagnosed as pneumonia, acute heart failure, and traumatic brain injury. The Spo2 was increased to 100% (98%-100%) at the time of starting endotracheal intubation with NINPPV and maintained as 97% (95%-100%) until successful intubation (P< .001). Total apnea duration was 195 seconds (190-196). The degree of interfering intubation was 1 (0-1). CONCLUSIONS: Noninvasive nasal positive pressure ventilation would be useful for optimizing oxygenation during rapid sequence intubation.

A Randomized Controlled Trial of Compression Rates during Cardiopulmonary Resuscitation.

UNLABELLED: The objective of this study was to compare the efficacy of cardiopulmonary resuscitation (CPR) with 120 compressions per minute (CPM) to CPR with 100 CPM in patients with non-traumatic out-of-hospital cardiac arrest. We randomly assigned patients with non-traumatic out-of-hospital cardiac arrest into two groups upon arrival to the emergency department (ED). The patients received manual CPR either with 100 CPM (CPR-100 group) or 120 CPM (CPR-120 group). The primary outcome measure was sustained restoration of spontaneous circulation (ROSC). The secondary outcome measures were survival discharge from the hospital, one-month survival, and one-month survival with good functional status. Of 470 patients with cardiac arrest, 136 patients in the CPR-100 group and 156 patients in the CPR-120 group were included in the final analysis. A total of 69 patients (50.7%) in the CPR-100 group and 67 patients (42.9%) in the CPR-120 group had ROSC (absolute difference, 7.8% points; 95% confidence interval [CI], -3.7 to 19.2%; P = 0.183). The rates of survival discharge from the hospital, one-month survival, and one-month survival with good functional status were not different between the two groups (16.9% vs. 12.8%, P = 0.325; 12.5% vs. 6.4%, P = 0.073; 5.9% vs. 2.6%, P = 0.154, respectively). We did not find differences in the resuscitation outcomes between those who received CPR with 100 CPM and those with 120 CPM. However, a large trial is warranted, with adequate power to confirm a statistically non-significant trend toward superiority of CPR with 100 CPM. ( CLINICAL TRIAL REGISTRATION INFORMATION: www.cris.nih.go.kr, cris.nih.go.kr number, KCT0000231).

Adverse events associated with poor neurological outcome during targeted temperature management and advanced critical care after out-of-hospital cardiac arrest.

INTRODUCTION: The aim of this study was to investigate the association of adverse events (AEs) during targeted temperature management (TTM) and other AEs and concomitant treatments during the advanced critical care period with poor neurological outcome at hospital discharge in adult out-of-hospital cardiac arrest (OHCA) patients. METHODS: This was a retrospective study using Korean Hypothermia Network registry data of adult OHCA patients treated with TTM in 24 teaching hospitals throughout South Korea from 2007 to 2012. Demographic characteristics, resuscitation and post-resuscitation variables, AEs, and concomitant treatments during TTM and the advanced critical care were collected. The primary outcome was poor neurological outcome, defined as a cerebral performance category (CPC) score of 3-5 at hospital discharge. The AEs and concomitant treatments were individually entered into the best multivariable predictive model of poor neurological outcome to evaluate the associations between each variable and outcome. RESULTS: A total of 930 patients, including 704 for whom a complete dataset of AEs and covariates was available for multivariable modeling, were included in the analysis; 476 of these patients exhibited poor neurological outcome [CPC 3 = 50 (7.1%), CPC 4 = 214 (30.4%), and CPC 5 = 212 (30.1%)]. Common AEs included hyperglycemia (45.6%), hypokalemia (31.3%), arrhythmia (21.3%) and hypotension (29%) during cooling, and hypotension (21.6%) during rewarming. Bleeding (5%) during TTM was a rare AE. Common AEs during the advanced critical care included pneumonia (39.6%), myoclonus (21.9%), seizures (21.7%) and hypoglycemia within 72 hours (23%). After adjusting for independent predictors of outcome, cooling- and rewarming-related AEs were not significantly associated with poor neurological outcome. However, sepsis, myoclonus, seizure, hypoglycemia within 72 hours and anticonvulsant use during the advanced critical care were associated with poor neurological outcome [adjusted odds ratios (95% confidence intervals) of 3.12 (1.40-6.97), 3.72 (1.93-7.16), 4.02 (2.04-7.91), 2.03 (1.09-3.78), and 1.69 (1.03-2.77), respectively]. Alternatively, neuromuscular blocker use was inversely associated with poor neurological outcome (0.48 [0.28-0.84]). CONCLUSIONS: Cooling- and rewarming-related AEs were not associated with poor neurological outcome at hospital discharge. Sepsis, myoclonus, seizure, hypoglycemia within 72 hours and anticonvulsant use during the advanced critical care period were associated with poor neurological outcome at hospital discharge in our study.

Shock duration after resuscitation is associated with occurrence of post-cardiac arrest acute kidney injury.

This retrospective observational study investigated the clinical course and predisposing factors of acute kidney injury (AKI) developed after cardiac arrest and resuscitation. Eighty-two patients aged over 18 yr who survived more than 24 hr after cardiac arrest were divided into AKI and non-AKI groups according to the diagnostic criteria of the Kidney Disease/Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for AKI. Among 82 patients resuscitated from cardiac arrest, AKI was developed in 66 (80.5%) patients (AKI group) leaving 16 (19.5%) patients in the non-AKI group. Nineteen (28.8%) patients of the AKI group had stage 3 AKI and 7 (10.6%) patients received renal replacement therapy during admission. The duration of shock developed within 24 hr after resuscitation was shorter in the non-AKI group than in the AKI group (OR 1.02, 95% CI 1.01-1.04, P < 0.05). On Multiple logistic regression analysis, the only predisposing factor of post-cardiac arrest AKI was the duration of shock. In conclusion, occurrence and severity of post-cardiac arrest AKI is associated with the duration of shock after resuscitation. Renal replacement therapy is required for patients with severe degree (stage 3) post-cardiac arrest AKI.