Combined effects of targeted blood pressure, oxygenation, and duration of device-based fever prevention after out-of-hospital cardiac arrest on 1-year survival: post hoc analysis of a randomized controlled trial.

BACKGROUND: The "Blood Pressure and Oxygenation Targets in Post Resuscitation Care" (BOX) trial investigated whether a low versus high blood pressure target, a restrictive versus liberal oxygenation target, and a shorter versus longer duration of device-based fever prevention in comatose patients could improve outcomes. No differences in rates of discharge from hospital with severe disability or 90-day mortality were found. However, long-term effects and potential interaction of the interventions are unknown. Accordingly, the objective of this study is to investigate both individual and combined effects of the interventions on 1-year mortality rates. METHODS: The BOX trial was a randomized controlled two-center trial that assigned comatose resuscitated out-of-hospital cardiac arrest patients to the following three interventions at admission: A blood pressure target of either 63 mmHg or 77 mmHg; An arterial oxygenation target of 9-10 kPa or 13-14 kPa; Device-based fever prevention administered as an initial 24 h at 36 °C and then either 12 or 48 h at 37 °C; totaling 36 or 72 h of temperature control. Randomization occurred in parallel and simultaneously to all interventions. Patients were followed for the occurrence of death from all causes for 1 year. Analyzes were performed by Cox proportional models, and assessment of interactions was performed with the interventions stated as an interaction term. RESULTS: Analysis for all three interventions included 789 patients. For the intervention of low compared to high blood pressure targets, 1-year mortality rates were 35% (138 of 396) and 36% (143 of 393), respectively, hazard ratio (HR) 0.92 (0.73-1.16) p = 0.47. For the restrictive compared to liberal oxygenation targets, 1-year mortality rates were 34% (135 of 394) and 37% (146 of 395), respectively, HR 0.92 (0.73-1.16) p = 0.46. For device-based fever prevention for a total of 36 compared to 72 h, 1-year mortality rates were 35% (139 of 393) and 36% (142 of 396), respectively, HR 0.98 (0.78-1.24) p = 0.89. There was no sign of interaction between the interventions, and accordingly, no combination of randomizations indicated differentiated treatment effects. CONCLUSIONS: There was no difference in 1-year mortality rates for a low compared to high blood pressure target, a liberal compared to restrictive oxygenation target, or a longer compared to shorter duration of device-based fever prevention after cardiac arrest. No combination of the interventions affected these findings. Trial registration ClinicalTrials.gov NCT03141099, Registered 30 April 2017.

Benefits of cardiopulmonary resuscitation in cancer patients.

PURPOSE: According to meta-analytic data, the prognosis of a cancer patient post-cardiopulmonary resuscitation (CPR) is relatively similar to the general population. However, preselection of patients, the details of CPR, patient-specific characteristics, and post-CPR care are poorly described. The aim of this study is to identify prognostic factors in order to recognize cancer patient profiles more likely to benefit from CPR. METHODS: This is a retrospective study on a series of patients with solid or hematological malignancies who received CPR between January 2010 and December 2020 in a cancer institute. RESULTS: Sixty-eight patients were included. The ratio of solid to hematological malignancy was 44/24, of which 32 were metastatic solid tumors. Median age was 61 years. Hypoxemia (29%) was the primary factor for cardiac arrest, followed by septic shock (21%). ICU mortality and hospital mortality were 87% and 88% respectively. Younger age, the presence of hematological malignancy, or a metastatic solid tumor were poor predictors for in-hospital mortality. Similarly, cardiac arrest in the ICU, as the final consequence of a pathological process, and a resuscitation time of more than 10 min have a negative influence on prognosis. CONCLUSIONS: This study shows that CPR is a useful intervention in cancer patients, even in the elderly patient, especially in non-metastatic solid tumors where cardiac arrest is the consequence of an acute event and not a terminal process.

Norepinephrine versus epinephrine for hemodynamic support in post-cardiac arrest shock: A systematic review.

PURPOSE: The preferred vasopressor in post-cardiac arrest shock has not been established with robust clinical outcomes data. Our goal was to perform a systematic review and meta-analysis comparing rates of in-hospital mortality, refractory shock, and hemodynamic parameters in post-cardiac arrest patients who received either norepinephrine or epinephrine as primary vasopressor support. METHODS: We conducted a search of PubMed, Cochrane Library, and CINAHL from 2000 to 2022. Included studies were prospective, retrospective, or published abstracts comparing norepinephrine and epinephrine in adults with post-cardiac arrest shock or with cardiogenic shock and extractable post-cardiac arrest data. The primary outcome of interest was in-hospital mortality. Other outcomes included incidence of arrhythmias or refractory shock. RESULTS: The database search returned 2646 studies. Two studies involving 853 participants were included in the systematic review. The proposed meta-analysis was deferred due to low yield. Crude incidence of in-hospital mortality was numerically higher in the epinephrine group compared with norepinephrine in both studies, but only statistically significant in one. Risk of bias was moderate to severe for in-hospital mortality. Additional outcomes were reported differently between studies, minimizing direct comparison. CONCLUSION: The vasopressor with the best mortality and hemodynamic outcomes in post-cardiac arrest shock remains unclear. Randomized studies are crucial to remedy this.

The association between initial post-resuscitation diastolic blood pressure and survival after pediatric cardiac arrest: a retrospective study.

BACKGROUND: Limited research has analyzed the association between diastolic blood pressure (DBP) and survival after pediatric cardiopulmonary resuscitation (CPR). This study aimed to explore the association between post-resuscitation diastolic blood pressure and survival in pediatric patients who underwent CPR. METHOD: This retrospective single-center study included pediatric patients admitted to the pediatric intensive care unit of Asan Medical Center between January 2016 to November 2022. Patients undergoing extracorporeal CPR and those with unavailable data were excluded. The primary endpoint was survival to ICU discharge. RESULTS: A total of 106 patients were included, with 67 (63.2%) achieving survival to ICU discharge. Multivariate logistic regression analysis identified DBP within 1 h after ROSC as the sole significant variable (p = 0.002, aOR, 1.043; 95% CI, 1.016-1.070). Additionally, DBP within 1 h demonstrated an area under the ROC curve of 0.7 (0.592-0.809) for survival to ICU discharge, along with mean blood pressure within the same timeframe. CONCLUSION: Our study highlights the importance of DBP within 1-hour post-ROSC as a significant prognostic factor for survival to ICU discharge. However, further validation through further prospective large-scale studies is warranted to confirm the appropriate post-resuscitation DBP of pediatric patients.

Critical care nurses' experiences of caring challenges during post-resuscitation period: a qualitative content analysis.

BACKGROUND: Patients in the post-resuscitation period experience critical conditions and require high-quality care. Identifying the challenges that critical care nurses encounter when caring for resuscitated patients is essential for improving the quality of their care. AIM: This study aimed to identify the challenges encountered by critical care nurses in providing care during the post-resuscitation period. METHODS: A qualitative study was conducted using semi-structured interviews. Sixteen nurses working in the intensive care units of three teaching hospitals were selected through purposive sampling. The Data collected were analyzed using qualitative content analysis. RESULTS: Participants experienced individual, interpersonal, and organizational challenges when providing post-resuscitation care. The most significant challenges include inadequate clinical knowledge and experience, poor management and communication skills, lack of support from nurse managers, role ambiguity, risk of violence, and inappropriate attitudes of physicians towards nurses' roles. Additionally, nurses expressed a negative attitude towards resuscitated patients. CONCLUSION: Critical care nurses face several challenges in providing care for resuscitated patients. To enhance the quality of post-resuscitation care, address the challenges effectively and improve long-time survival it is crucial to implement interventions such as In-service education, post-resuscitation briefing, promotion of interprofessional collaboration among healthcare teams, providing sufficient human resources, clarifying nurses' roles in the post-resuscitation period and increasing support from nursing managers.

Cumulative dose of epinephrine and mode of death after non-shockable out-of-hospital cardiac arrest: a registry-based study.

BACKGROUND: Epinephrine increases the chances of return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA), especially when the initial rhythm is non-shockable. However, this drug could also worsen the post-resuscitation syndrome (PRS). We assessed the association between epinephrine use during cardiopulmonary resuscitation (CPR) and subsequent intensive care unit (ICU) mortality in patients with ROSC after non-shockable OHCA. METHODS: We used data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (capturing OHCA data located in the Greater Paris area, France) between May 2011 and December 2021. All adults with ROSC after medical, cardiac and non-cardiac causes, non-shockable OHCA admitted to an ICU were included. The mode of death in the ICU was categorized as cardiocirculatory, neurological, or other. RESULTS: Of the 2,792 patients analyzed, there were 242 (8.7%) survivors at hospital discharge, 1,004 (35.9%) deaths from cardiocirculatory causes, 1,233 (44.2%) deaths from neurological causes, and 313 (11.2%) deaths from other etiologies. The cardiocirculatory death group received more epinephrine (4.6 ± 3.8 mg versus 1.7 ± 2.8 mg, 3.2 ± 2.6 mg, and 3.5 ± 3.6 mg for survivors, neurological deaths, and other deaths, respectively; p < 0.001). The proportion of cardiocirculatory death increased linearly (R2 = 0.92, p < 0.001) with cumulative epinephrine doses during CPR (17.7% in subjects who did not receive epinephrine and 62.5% in those who received > 10 mg). In multivariable analysis, a cumulative dose of epinephrine was strongly associated with cardiocirculatory death (adjusted odds ratio of 3.45, 95% CI [2.01-5.92] for 1 mg of epinephrine; 12.28, 95% CI [7.52-20.06] for 2-5 mg; and 23.71, 95% CI [11.02-50.97] for > 5 mg; reference 0 mg; population reference: alive at hospital discharge), even after adjustment on duration of resuscitation. The other modes of death (neurological and other causes) were also associated with epinephrine use, but to a lesser extent. CONCLUSIONS: In non-shockable OHCA with ROSC, the dose of epinephrine used during CPR is strongly associated with early cardiocirculatory death. Further clinical studies aimed at limiting the dose of epinephrine during CPR seem warranted. Moreover, strategies for the prevention and management of PRS should take this dose of epinephrine into consideration for future trials.

The Selective NLRP3-inflammasome inhibitor MCC950 Mitigates Post-resuscitation Myocardial Dysfunction and Improves Survival in a Rat Model of Cardiac Arrest and Resuscitation.

PURPOSE: To investigate the effects of the selective NLRP3 inflammasome inhibitor MCC950 on post-resuscitation myocardial function and survival in a rat model of cardiopulmonary resuscitation (CPR). METHODS: Thirty-six Sprague Dawley rats were randomized into three groups: (1) MCC950, (2) control, and (3) sham. Each group consisted of a 6 h non-survival subgroup (n = 6) and a 48 h survival subgroup (n = 6). Ventricular fibrillation (VF) was induced and untreated for 6 min. CPR was initiated and continued for 8 min. Resuscitation was attempted with a 4 J defibrillation. MCC950 (10 mg/kg) or vehicle was administered via intraperitoneal injection immediately after the return of spontaneous circulation (ROSC). Myocardial function and sublingual microcirculation were measured after ROSC in the non-survival subgroups. Plasma levels of interleukin Iß (IL-1ß) and cardiac troponin I (cTnI) were measured at baseline and 6 h in the non-survival subgroups. Heart tissue was harvested to measure the NLRP3 inflammasome constituents, including NLRP3, apoptosis-associated speck-like protein (ASC), Caspase-1, and IL-1ß. Survival duration and neurologic deficit score (NDS) were recorded and evaluated among survival groups. RESULTS: Post-resuscitation myocardial function and sublingual microcirculation were improved in MCC950 compared with control (p < 0.05). IL-1ß and cTnI were decreased in MCC950 compared to control (p < 0.01). The MCC950 treated groups showed significantly reduced ASC, caspase-1, and IL-1ß compared with the control group (p < 0.05). Survival at 48 h after ROSC was greater in MCC950 (p < 0.05) with improved NDS (p < 0.05). CONCLUSION: Administration of MCC950 following ROSC mitigates post-resuscitation myocardial dysfunction and improves survival.

Post-cardiac arrest intensive care in Sweden: A survey of current clinical practice.

BACKGROUND: European guidelines recommend targeted temperature management (TTM) in post-cardiac arrest care. A large multicentre clinical trial, however, showed no difference in mortality and neurological outcome when comparing hypothermia to normothermia with early treatment of fever. The study results were valid given a strict protocol for the assessment of prognosis using defined neurological examinations. With the current range of recommended TTM temperatures, and applicable neurological examinations, procedures may differ between hospitals and the variation of clinical practice in Sweden is not known. AIM: The aim of this study was to investigate current practice in post-resuscitation care after cardiac arrest as to temperature targets and assessment of neurological prognosis in Swedish intensive care units (ICUs). METHODS: A structured survey was conducted by telephone or e-mail in all Levels 2 and 3 (= 53) Swedish ICUs during the spring of 2022 with a secondary survey in April 2023. RESULTS: Five units were not providing post-cardiac arrest care and were excluded. The response rate was 43/48 (90%) of the eligible units. Among the responding ICUs, normothermia (36-37.7°C) was applied in all centres (2023). There was a detailed routine for the assessment of neurological prognosis in 38/43 (88%) ICUs. Neurological assessment was applied 72-96 h after return of spontaneous circulation in 32/38 (84%) units. Electroencephalogram and computed tomography and/or magnetic resonance imaging were the most common technical methods available. CONCLUSION: Swedish ICUs use normothermia including early treatment of fever in post-resuscitation care after cardiac arrest and almost all apply a detailed routine for the assessment of neurological prognosis. However, available methods for prognostic evaluation varies between hospitals.

Veno-arterial CO2 difference and lactate for prediction of early mortality after cardiac arrest.

Patients admitted to intensive care after cardiac arrest are at risk of circulatory shock and early mortality due to cardiovascular failure. The aim of this study was to evaluate the ability of the veno-arterial pCO2 difference (∆pCO2 ; central venous CO2 - arterial CO2 ) and lactate to predict early mortality in postcardiac arrest patients. This was a pre-planned prospective observational sub-study of the target temperature management 2 trial. The sub-study patients were included at five Swedish sites. Repeated measurements of ∆pCO2 and lactate were conducted at 4, 8, 12, 16, 24, 48, and 72 h after randomization. We assessed the association between each marker and 96-h mortality and their prognostic value for 96-h mortality. One hundred sixty-three patients were included in the analysis. Mortality at 96 h was 17%. During the initial 24 h, there was no difference in ∆pCO2 levels between 96-h survivors and non-survivors. ∆pCO2 measured at 4 h was associated with an increased risk of death within 96 h (adjusted odds ratio: 1.15; 95% confidence interval [CI]: 1.02-1.29; p = .018). Lactate levels were associated with poor outcome over multiple measurements. The area under the receiving operating curve to predict death within 96 h was 0.59 (95% CI: 0.48-0.74) and 0.82 (95% CI: 0.72-0.92) for ∆pCO2 and lactate, respectively. Our results do not support the use of ∆pCO2 to identify patients with early mortality in the postresuscitation phase. In contrast, non-survivors demonstrated higher lactate levels in the initial phase and lactate identified patients with early mortality with moderate accuracy.

Nurses' Perceptions Towards Resuscitated Patients: A Qualitative Study.

Nurses' perceptions of resuscitated patients may affect their care, and this has not been investigated in previous literature. The aim of this study was to explore nurses' perceptions towards resuscitated patients. In this descriptive-qualitative study seventeen clinical nurses participated using purposive sampling. In-depth, semi-structured interviews were conducted and data were analyzed by conventional content analysis. Four main categories emerged: Injured, undervalued, problematic, and destroyer of resources. Participants considered resuscitated patients to have multiple physical injuries, which are an important source of legal problems and workplace violence, and they believed that these patients will eventually die. Resuscitated patients are considered forgotten and educational cases. Iranian nurses have a strong negative perception towards resuscitated patients. Improving the quality of cardiopulmonary resuscitation, improving the knowledge and skills of personnel in performing resuscitation, and supporting managers and doctors to nurses in the post-resuscitation period can change the attitude of nurses and improve post-resuscitation care.

Targeted temperature management evolving over time-A local process analysis.

BACKGROUND: Post-resuscitation care of comatose survivors from cardiac arrest includes target temperature management (TTM) to mitigate cerebral reperfusion injury. High-quality TTM requires protocols enhancing good precision. This study explored how the quality of TTM may have evolved with increasing experience from clinical trial protocols and standard operating procedures. We hypothesized that there would be a positive effect over time, detectable between trial periods and between trial periods and later everyday practice. METHODS: Three TTM quality parameters were defined: time to target, temperature variability, and fever incidence. Data from 181 patients treated during three different time periods in a tertiary center were analyzed; 45 from Period 1 (local trial cohort 2011-2013) targeting 33°C or 36°C; 76 from Period 2 (local trial cohort 2018-2020) targeting 33 or <37.5°C; 60 from Period 3 (current standard operating procedure 2020-2021) targeting 36°C. Groups of similar target temperatures from different time periods were compared using ordinary group statistics. RESULTS: TTM quality in all three parameters increased between trial periods. There were no differences in TTM quality as to temperature variability or fever incidence between the <37.5°C Period 2 and the 36°C Period 3 groups. A 33°C target temperature was associated with lower fever incidence than 36°C and <37.5°C target regimes. CONCLUSION: The observed increase in TTM quality in this single-center study may be a result of increased competence through learning and training in different strict TTM protocols. If so, the results of this study further support the protocolization of post-cardiac arrest intensive care.

[ERC guidelines 2021 on cardiopulmonary resuscitation]. / ERC-Leitlinien 2021 zur kardiopulmonalen Reanimation.

The current European guidelines on cardiopulmonary resuscitation were published in 2021. The guidelines, which are structured in 12 chapters, were supplemented with the chapters on epidemiology and life-saving systems. In the following article, the recommendations on basic life support, advanced measures for resuscitation in adults and postresuscitation treatment are discussed.

[Guidelines of the European Resuscitation Council (ERC) on cardiopulmonary resuscitation 2021: update and comments]. / Leitlinien des European Resuscitation Council (ERC) zur kardiopulmonalen Reanimation 2021: Update und Kommentar.

The European guidelines on cardiopulmonary resuscitation, which are divided into 12 chapters, have recently been published. In addition to the already known chapters, the topics "epidemiology" and "life-saving systems" have been integrated for the first time. For each chapter five practical key statements were formulated. In the present article the revised recommendations on basic measures and advanced resuscitation measures in adults as well as on postresuscitation treatment are summarized and commented on.

Neonatal stabilization in Canada: Updates to acute care of at-risk newborns (ACoRN) practices and programming.

Disparities in preterm birth and neonatal mortality rates persist in Canada, in part as the result of insufficient training in newborn resuscitation and stabilization care, and inconsistent adherence to best practices. The Neonatal Resuscitation Program (NRP) has been the standard of care in all facilities providing perinatal care in Canada since the 1990s, but perinatal care providers and educators have continued to recognize gaps in knowledge and skill when stabilizing newborns post-resuscitation, especially in settings where this care is encountered infrequently. The Acute Care of at-Risk Newborns (ACoRN) program was developed to bridge such gaps. In ACoRN, an initial Primary Survey and systems-based care pathways (Sequences) prioritize and guide the assessment, essential care, and management of at-risk or unwell newborns in the first hours and days of life. This practice point highlights changes to practice and recommendations since 2012, when the ACoRN text and program were last revised. Like NRP, ACoRN is administered in Canada by the Canadian Paediatric Society (CPS). A newly revised and updated textbook and teaching program, both launched in 2021, will standardize care, increase competence and confidence among perinatal care providers, and improve neonatal outcomes in Canada and elsewhere in years to come.

Rationale of Blood Purification in the Post-Resuscitation Syndrome following Out-of-Hospital Cardiac Arrest: A Narrative Review.

Even today, little is known about the pathophysiology of the post-resuscitation syndrome. Our narrative review is one of the first summarizing all the knowledge about this phenomenon. We have focused our review upon the potential role of blood purification in attenuating the consequences of the post-resuscitation syndrome. Blood purification can decrease the cytokine storm particularly when using a CytoSorb absorber. Acrylonitrile 69-based oXiris membranes can remove endotoxin and high-mobility group box 1 protein. Blood purification techniques can quickly induce hypothermia. Blood purification can be used with veno-arterial extracorporeal membrane oxygenation to remove excess water. Further trials are needed to provide more concrete data about the use of blood purification in the post-resuscitation syndrome.

[Quality indicators and structural requirements for Cardiac Arrest Centers-Update 2021]. / Qualitätskriterien und strukturelle Voraussetzungen für Cardiac Arrest Zentren ­ Update 2021: Deutscher Rat für Wiederbelebung/German Resuscitation Council (GRC).

An update of the first description of quality indicators and structural requirements for Cardiac Arrest Centers from 2017 based on first experiences and certifications is presented. Criteria were adjusted, substantiated and in some parts redefined for feasibility in everyday clinical use.

Sex differences in survival after out-of-hospital cardiac arrest: a meta-analysis.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a leading cause of sudden cardiac death worldwide. Researchers have found significant pathophysiological differences between females and males and clinically significant sex differences related to medical services. However, conflicting results exist and there is no uniform agreement regarding sex differences in survival and prognosis after OHCA. Therefore, we investigated the relationship between the prognosis of OHCA and sex factors. METHODS: We comprehensively searched the PubMed, Embase, and Cochrane databases and obtained a total of 1042 articles, from which 33 studies were selected for inclusion. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a random-effects model. RESULTS: The meta-analysis included 1,268,664 patients. Compared with males, females were older (69.7 years vs. 65.4 years, p < 0.05) and more frequently suffered OHCA without witnesses (58.39% vs 62.70%, p < 0.05). Females were less likely to receive in-hospital interventions than males. There was no significant difference between females and males in the survival from OHCA to hospital admission (OR 0.99, 95% CI 0.89-1.1). However, females had lower chances for survival from hospital admission to discharge (OR 0.59, 95% CI 0.48-0.73), overall survival to hospital discharge (OR 0.73, 95% CI 0.62-0.86), and favorable neurological outcomes (OR 0.62, 95% CI 0.47-0.83) compared with males. CONCLUSIONS: Our results indicate that the overall discharge survival rate of females is lower than that of males, and females face a poor prognosis of the nervous system. This is likely related to the pathophysiological characteristics of females, more conservative treatment measures compared with males, and different post-resuscitation care. However, these findings should be interpreted with caution due to the presence of several confounding factors.

Association Between Post-Resuscitation Coronary Angiography With and Without Intervention and Neurological Outcomes After Out-of-Hospital Cardiac Arrest.

Objective: This study aimed to investigate the association between coronary angiography (CAG) with and without percutaneous coronary intervention (PCI) after out-of-hospital cardiac arrest (OHCA) and neurological recovery and to determine the influence of primary electrocardiogram or patient age on the effects of CAG. Methods: Adult patients with OHCA with cardiac etiology who were admitted to PCI-capable hospitals from 2016 to 2017 were enrolled in this study from the nationwide OHCA registry of Korea. Coronary intervention was categorized into three groups: No CAG, CAG without PCI, and CAG with PCI. The endpoint was good neurological recovery. Multivariable logistic regression and interaction analyses (intervention × electrocardiogram and intervention × age) were conducted by calculating adjusted odds ratios (aORs) and 95% confidence intervals (CI). Results: Of a total of 6,802 eligible OHCA patients, 1,218 (17.9%) underwent CAG without PCI and 1,136 (16.7%) underwent CAG with PCI. The CAG without PCI and CAG with PCI groups were more likely to have good neurological recovery than the No CAG group (57.4% vs. 61.6% vs. 16.3%; 3.39 [2.83-4.06] for CAG without PCI and 3.32 [2.74-4.01] for CAG with PCI). Interaction analysis showed that although the effect size differed according to patient characteristics, both CAG groups were associated with an increased likelihood of good neurological recovery, regardless of primary electrocardiogram and age group. In younger patients, CAG with PCI had greater outcome benefits than CAG without PCI (8.54 [4.31-16.95] vs. 4.10 [2.69-6.24]), whereas CAG without PCI had a larger effect size than CAG with PCI in elderly patients (4.46 [2.59-7.68] vs. 2.92 [1.80-4.73]) (p value for interaction 0.02). Conclusions: Post-resuscitation CAG with and without PCI are associated with better neurological recovery in patients with OHCA, regardless of primary electrocardiogram and patient age.

Relationship Between Institutional Volume of Out-of-Hospital Cardiac Arrest Cases and 1-Month Neurologic Outcomes: A Post Hoc Analysis of a Prospective Observational Study.

BACKGROUND: The influence of institutional volume of out-of-hospital cardiac arrest (OHCA) cases on outcomes remains unclear. OBJECTIVES: This study evaluated the relationship between institutional volume of adult, nontraumatic OHCA cases and 1-month favorable neurologic outcomes. METHODS: This study retrospectively analyzed data between January 2012 and March 2013 from a prospective observational study in the Kanto area of Japan. We analyzed adult patients with nontraumatic OHCA who underwent cardiopulmonary resuscitation by emergency medical service personnel and in whom spontaneous circulation was restored. Based on the institutional volume of OHCA cases, we divided institutions into low-, middle-, or high-volume groups. The primary and secondary outcomes were 1-month favorable neurologic outcomes and 1-month survival, respectively. A multivariate logistic regression analysis adjusted for propensity score and in-hospital variables was performed. RESULTS: Of 2699 eligible patients, 889, 898, and 912 patients were transported to low-volume (40 institutions), middle-volume (14 institutions), and high-volume (9 institutions) centers, respectively. Using low-volume centers as the reference, transport to a middle- or high-volume center was not significantly associated with a favorable 1-month neurologic outcome (adjusted odds ratio [OR] 1.21 [95% confidence interval {CI} 0.84-1.75] and adjusted OR 0.77 [95% CI 0.53-1.12], respectively) or 1-month survival (adjusted OR 1.10 [95% CI 0.82-1.47] and adjusted OR 0.76 [95% CI 0.56-1.02], respectively). CONCLUSIONS: Institutional volume was not significantly associated with favorable 1-month neurologic outcomes or 1-month survival in OHCA. Further investigation is needed to determine the association between hospital characteristics and outcomes in patients with OHCA.

Venoarterial Extracorporeal Membrane Oxygenation Increased Immune Function of Spleen and Decreased Reactive Oxygen Species During Post-Resuscitation.

We aimed to investigate the effect of venoarterial extracorporeal membrane oxygenation (VA-ECMO) on immune function of the spleen and reactive oxygen species (ROS) during post-resuscitation in a porcine model. After 8 min of untreated ventricular fibrillation and 6 min of basic life support, pigs were randomized into two groups: Group 1 received VA-ECMO and Group 2 received conventional cardiopulmonary resuscitation. After successful return of spontaneous circulation, the hemodynamic status was determined and blood samples were collected at 0, 1, 2, 4, and 6 h. Surviving pigs were euthanized 6 h after return of spontaneous circulation, their spleens were harvested and the T-cells were separated. Then, we investigated immune function parameters of the spleen and ROS levels. VA-ECMO increased the return of spontaneous circulation and 6 h survival rate after return of spontaneous circulation. Compared with the conventional cardiopulmonary resuscitation group, the VA-ECMO group showed increased superoxide dismutase and decreased malondialdehyde and ROS levels. Furthermore, VA-ECMO was associated with a high rate of CD4+ and CD4+/CD8+, high levels of interleukin 2, interferon γ, and interferon γ/interleukin 4, as well as high proliferation of lymphocytes. The apoptotic rate of T-cells was lower in the VA-ECMO group than it was in the conventional cardiopulmonary resuscitation group. VA-ECMO increased immune function of spleen and decreased ROS levels during post-resuscitation. Further research is expected to illustrate whether the differences in immune responses are due to ROS or some other perfusion related effect on spleen.