Development of early prediction model of in-hospital cardiac arrest based on laboratory parameters.

BACKGROUND: In-hospital cardiac arrest (IHCA) is an acute disease with a high fatality rate that burdens individuals, society, and the economy. This study aimed to develop a machine learning (ML) model using routine laboratory parameters to predict the risk of IHCA in rescue-treated patients. METHODS: This retrospective cohort study examined all rescue-treated patients hospitalized at the First Medical Center of the PLA General Hospital in Beijing, China, from January 2016 to December 2020. Five machine learning algorithms, including support vector machine, random forest, extra trees classifier (ETC), decision tree, and logistic regression algorithms, were trained to develop models for predicting IHCA. We included blood counts, biochemical markers, and coagulation markers in the model development. We validated model performance using fivefold cross-validation and used the SHapley Additive exPlanation (SHAP) for model interpretation. RESULTS: A total of 11,308 participants were included in the study, of which 7779 patients remained. Among these patients, 1796 (23.09%) cases of IHCA occurred. Among five machine learning models for predicting IHCA, the ETC algorithm exhibited better performance, with an AUC of 0.920, compared with the other four machine learning models in the fivefold cross-validation. The SHAP showed that the top ten factors accounting for cardiac arrest in rescue-treated patients are prothrombin activity, platelets, hemoglobin, N-terminal pro-brain natriuretic peptide, neutrophils, prothrombin time, serum albumin, sodium, activated partial thromboplastin time, and potassium. CONCLUSIONS: We developed a reliable machine learning-derived model that integrates readily available laboratory parameters to predict IHCA in patients treated with rescue therapy.

Plasma neurofilament light is a predictor of neurological outcome 12 h after cardiac arrest.

BACKGROUND: Previous studies have reported high prognostic accuracy of circulating neurofilament light (NfL) at 24-72 h after out-of-hospital cardiac arrest (OHCA), but performance at earlier time points and after in-hospital cardiac arrest (IHCA) is less investigated. We aimed to assess plasma NfL during the first 48 h after OHCA and IHCA to predict long-term outcomes. METHODS: Observational multicentre cohort study in adults admitted to intensive care after cardiac arrest. NfL was retrospectively analysed in plasma collected on admission to intensive care, 12 and 48 h after cardiac arrest. The outcome was assessed at two to six months using the Cerebral Performance Category (CPC) scale, where CPC 1-2 was considered a good outcome and CPC 3-5 a poor outcome. Predictive performance was measured with the area under the receiver operating characteristic curve (AUROC). RESULTS: Of 428 patients, 328 (77%) suffered OHCA and 100 (23%) IHCA. Poor outcome was found in 68% of OHCA and 55% of IHCA patients. The overall prognostic performance of NfL was excellent at 12 and 48 h after OHCA, with AUROCs of 0.93 and 0.97, respectively. The predictive ability was lower after IHCA than OHCA at 12 and 48 h, with AUROCs of 0.81 and 0.86 (p ≤ 0.03). AUROCs on admission were 0.77 and 0.67 after OHCA and IHCA, respectively. At 12 and 48 h after OHCA, high NfL levels predicted poor outcome at 95% specificity with 70 and 89% sensitivity, while low NfL levels predicted good outcome at 95% sensitivity with 71 and 74% specificity and negative predictive values of 86 and 88%. CONCLUSIONS: The prognostic accuracy of NfL for predicting good and poor outcomes is excellent as early as 12 h after OHCA. NfL is less reliable for the prediction of outcome after IHCA.

Duration of resuscitation and long-term outcome after in-hospital cardiac arrest: A nationwide observational study.

BACKGROUND: Prior studies have investigated the association between duration of resuscitation and short-term outcomes following in-hospital cardiac arrest (IHCA). However, it remains unknown whether there is an association between duration of resuscitation and long-term survival and functional outcomes. METHOD: We linked data from the Danish in-hospital cardiac arrest registry with nationwide registries and identified 8,727 patients between 2013 and 2019. Patients were stratified into four groups (A-D) according to quartiles of duration of resuscitation. Standardized average probability of outcomes was estimated using logistic regression. RESULTS: Of 8,727 patients, 53.1% (n = 4,604) achieved return of spontaneous circulation. Median age was 74 (1st-3rd quartile [Q1-Q3] 65-81 years) and 63.1% were men. Among all IHCA patients the standardized 30-day survival was 62.0% (95% CI 59.8-64.2%) for group A (<5 minutes), 32.7% (30.8-34.6%) for group B (5-11 minutes), 14.4% (12.9-15.9%) for group C (12-20 minutes) and 8.1% (7.0-9.1%) for group D (21 minutes or more). Similarly, 1-year survival was also highest for group A (50.4%; 48.2-52.6%) gradually decreasing to 6.6% (5.6-7.6%) in group D. Among 30-day survivors, survival without anoxic brain damage or nursing home admission within one-year post-arrest was highest for group A (80.4%; 78.2-82.6%), decreasing to 73.3% (70.0-76.6%) in group B, 67.2% (61.7-72.6%) in group C and 73.3% (66.9-79.7%) in group D. CONCLUSION: Shorter duration of resuscitation attempt during an IHCA is associated with higher 30-day and 1-year survival. Furthermore, we found that the majority of 30-day survivors were still alive 1-year post-arrest without anoxic brain damage or nursing home admission despite prolonged resuscitation.

Survival to hospital discharge and neurological outcomes with targeted temperature management after in-hospital cardiac arrest: a systematic review and meta-analysis.

BACKGROUND: Multiple randomized controlled trials have shown that targeted temperature management (TTM) has favorable effects in out-of-hospital cardiac arrest. However, the benefit of TTM in patients with in-hospital cardiac arrest (IHCA) remains to be verified. METHODS: The PubMed, Cochrane Library, and EMBASE databases were searched for clinical studies with the primary outcomes of survival to hospital discharge and neurological outcomes. Neurological outcomes were evaluated by the categorical scale of cerebral function (CPC); a score of 1-2 points was considered neurologically good, and a score of 3-5 points was considered a poor outcome. Revman 5.3 and Stata 14 software with the random effects model were used for analysis. P<0.05 was considered statistically significant. RESULTS: Six retrospective controlled studies with a total of 14,607 patients (TTM group: 1,845, control group: 12,762) were included and analyzed. There were no statistically significant differences between the two groups in survival to hospital discharge [odds ratio (OR) =1.02, 95% CI: 0.77-1.35, P=0.89, I2=47%] or favorable neurological outcomes (OR =1.06, 95% CI: 0.56-2.02, P=0.85, I2=79%). After excluding patients with non-shockable initial rhythms, TTM did not show any significant improvement in survival to hospital discharge. Subgroup analysis was performed according to the sample size. No significant improvement was observed between the two groups in terms of survival to hospital discharge or neurological outcome. DISCUSSION: In this meta-analysis, the effects of TTM on discharge survival and neurological prognosis were evaluated by studying the results of IHCA in 14,607 patients. We found that the TTM did not improve survival and neurological function in discharged patients. Our results showed that the sample size discrepancy had a large effect on the heterogeneity; to address this, subgroup analyses were performed according to the different sample sizes. However, TTM treatment in different sample size subgroups showed no significant effect on survival to hospital discharge. Moreover, in the large sample size subgroup, therapeutic hypothermia was associated with increased unfavorable neurological outcome compared with no hypothermia.

Impact of intraosseous versus intravenous resuscitation during in-hospital cardiac arrest: A retrospective study.

AIM: To compare outcomes between Intraosseous (IO) and peripheral intravenous (PIV) injection during in-hospital cardiac arrest (IHCA) and examine its utility in individuals with obesity. METHODS: We performed a retrospective cohort analysis of adult, atraumatic IHCA at a single tertiary care center. Subjects were classified as either IO or PIV resuscitation. The primary outcome of interest was survival to hospital discharge. The secondary outcomes of interest were survival with favourable neurologic status, rates-of-ROSC (ROR) and time-to-ROSC (TTR). Subgroup analysis among patients with BMI ≥ 30 kg/m2 was performed. RESULTS: Complete data were available for 1852 subjects, 1039 of whom met eligibility criteria. A total of 832 were resuscitated via PIV route and 207 via IO route. Use of IO compared to PIV was associated with lower overall survival to hospital discharge (20.8% vs 28.4% p = 0.03), lower rates of survival with favourable neurologic status (18.4% vs 25.2% p = 0.04), lower ROR (72.2% vs 80.7%) and longer TTR (12:38 min vs 9:01 min). After multivariate adjustment there was no significant differences between IO and PIV in rates of survival to discharge (OR 0.71, 95% CI 0.47-1.06, p = 0.09) or rates of survival with favourable neurologic status (OR 0.74, 95% CI 0.49-1.13, p = 0.16). The ROR and TTR remained significantly worse in the IO group. Subgroup analysis of patients with BMI ≥ 30 kg/m2 identified no benefit or harm with use of IO compared to PIV. CONCLUSION: Intraosseous medication delivery is associated with inferior rates-of-ROSC and longer times-to-ROSC compared to PIV, but no differences in overall survival to hospital discharge or survival with favourable neurologic status during IHCA.

Resuscitation outcomes of a wireless ECG telemonitoring system for cardiovascular ward patients experiencing in-hospital cardiac arrest.

BACKGROUND/PURPOSE: In-hospital cardiac arrest is a serious issue for hospitalized patients. The documented initial rhythm and detected medical events have been reported to influence the survival of cardiopulmonary resuscitation. This study aimed to identify the effect of continuous real-time electrocardiogram (ECG) monitoring on the prognosis of resuscitated patients in a general cardiac ward. METHODS: We conducted this retrospective study using medical records of hospitalized patients in a cardiovascular ward who experienced an in-hospital cardiac arrest and received cardiopulmonary resuscitation from February 2015 to December 2018. The patients who were considered to be at high risk of cardiac events such as ventricular arrhythmia would receive continuous ECG monitoring. A wireless ECG telemonitoring system was introduced to replace traditional bedside ECG monitors. The outcome measures were the initial success of resuscitation, 24-h survival after resuscitation, and survival to discharge. RESULTS: We enrolled 115 patients with a cardiac arrest during hospitalization, of whom 73 (63%) patients received wireless ECG telemonitoring. Patients receiving continuous ECG monitoring were associated with higher opportunities of initial success of resuscitation and 24-h survival after resuscitation (67.1% vs. 40.5%, p = 0.005; and 49.3% vs. 26.2%, p = 0.015, respectively) when comparing to the non-monitoring group; but no significant difference in survival to discharge (21.9% vs. 16.7%, p = 0.498) was observed. With adjustment of the covariates, the monitoring group was associated with a higher likelihood to reach the initial success of resuscitation (odds ratios [ORs], 3.21; 95% confidence interval [CI], 1.03-9.98). However, the effect of monitoring on 24-h survival and survival to discharge was close to null after adjusting for covariates. CONCLUSION: A wireless ECG telemonitoring system were beneficial to the initial success of resuscitation for patients at high risk of cardiovascular events suffering an in-hospital cardiac arrest; but had less impact on 24-h survival and survival to discharge.

Regional trends in In-hospital Cardiac Arrest following sepsis-related admissions and subsequent mortality.

BACKGROUND: Previous studies have reported regional variation in either the incidence or outcomes of sepsis or In-hospital Cardiac Arrest (IHCA) discretely; however, regional variations in the incidence and outcomes of sepsis-associated IHCA (SA-IHCA) have never been studied. METHODS: From the National Inpatient Sample (NIS), discharges with sepsis and sepsis-associated IHCA were identified in 4 geographic regions (Northeast, Midwest, South, West) from 2007 to 2014 using applicable ICD-9-CM codes. We assessed the regional incidence and trends in SA-IHCA and subsequent inpatient outcomes. RESULTS: Out of 8,058,091 sepsis-related admissions, 187,163 (2.3%) were associated with IHCA with a rising trend in the incidence from 2007- to 2014 (2.0% to 2.6%, ptrend < 0.001). The overall incidence of SA-IHCA was highest in South (2.6%) with the highest mortality in West (74.4%) (p < 0.001). The incidence of SA-IHCA increased in the South (2.4%-3.0%) and Midwest (1.6%-2.4%) from 2007 to 2014. Mortality has not significantly increased or decreased across all regions. Compared with the West, survivors in the Northeast, Midwest, and the South were less likely to be discharged home and were more likely to be transferred to other facilities. In the SA-IHCA cohort, the mean length of stay for SA-IHCA was highest in Northeast (˜10.9 days) and lowest in Midwest (˜8.6 days) (p < 0.001). Hospital charges were highest in the West ($234,278) and lowest in the Midwest ($125,725) (p < 0.001). CONCLUSION: This nationwide analysis demonstrates that the highest incidence of SA-IHCA is in the Southern region of the US whereas the associated in-hospital mortality was highest in the West. The incidence of SA-IHCA is rising in the Midwest and South from 2007 to 2014. Despite significant advances in the treatment of sepsis and IHCA, there has been no significant improvement in the incidence of SA-IHCA and subsequent survival in any US geographic region from 2007 to 2014.

Description of hot debriefings after in-hospital cardiac arrests in an international pediatric quality improvement collaborative.

BACKGROUND: The American Heart Association recommends debriefing after attempted resuscitation from in-hospital cardiac arrest (IHCA) to improve resuscitation quality and outcomes. This is the first published study detailing the utilization, process and content of hot debriefings after pediatric IHCA. METHODS: Using prospective data from the Pediatric Resuscitation Quality Collaborative (pediRES-Q), we analyzed data from 227 arrests occurring between February 1, 2016, and August 31, 2017. Hot debriefings, defined as occurring within minutes to hours of IHCA, were evaluated using a modified Team Emergency Assessment Measure framework for qualitative content analysis of debriefing comments. RESULTS: Hot debriefings were performed following 108 of 227 IHCAs (47%). The median interval to debriefing was 130 min (Interquartile range [IQR] 45, 270). Median debriefing duration was 15 min (IQR 10, 20). Physicians facilitated 95% of debriefings, with a median of 9 participants (IQR 7, 11). After multivariate analysis, accounting for hospital site, debriefing frequency was not associated with patient age, gender, race, illness category or unit type. The most frequent positive (plus) comments involved cooperation/coordination (60%), communication (47%) and clinical standards (41%). The most frequent negative (delta) comments involved equipment (46%), cooperation/coordination (45%), and clinical standards (36%). CONCLUSION: Approximately half of pediatric IHCAs were followed by hot debriefings. Hot debriefings were multi-disciplinary, timely, and often addressed issues of team cooperation/coordination, communication, clinical standards, and equipment. Additional studies are warranted to identify barriers to hot debriefings and to evaluate the impact of these debriefings on patient outcomes.

Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO).

PURPOSE: To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department. METHODS: We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel. RESULTS: Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. Nearly 93% of programs are based at academic/teaching hospitals. 65% of programs are less than 5 years old, and 60% of programs perform ≤3 cases per year. Most programs (90%) had inpatient eCPR or salvage ECMO programs prior to starting ED ECMO programs. The majority of programs do not have formal inclusion and exclusion criteria. Most programs preferentially obtain vascular access via the percutaneous route (70%) and many (40%) use mechanical CPR during cannulation. The most commonly used console is the Maquet Rotaflow(®). Cannulation is most often performed by cardiothoracic (CT) surgery, and nearly all programs (>85%) involve CT surgeons, perfusionists, and pharmacists. CONCLUSIONS: Over a third of centers that submitted adult eCPR cases to ELSO have performed ED ECMO. These programs are largely based at academic hospitals, new, and have low volumes. They do not have many formal inclusion or exclusion criteria, and devices and techniques are variable.