scholarly journals Implementation of Targeted Temperature Management After Out‐of‐Hospital Cardiac Arrest: Observations From the Los Angeles County Regional System

2020 ◽  
Vol 9 (24) ◽  
Author(s):  
Melody Hermel ◽  
Nichole Bosson ◽  
Andrea Fang ◽  
William J. French ◽  
James T. Niemann ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cardiac Arrest ◽  
Los Angeles ◽  
Los Angeles County ◽  
The United States ◽  
System Of Care ◽  
Temperature Management ◽  
Factors Associated ◽  
Regional System ◽  
Hospital Cardiac Arrest

Background Despite the benefits of targeted temperature management (TTM) for out‐of‐hospital cardiac arrest), implementation within the United States remains low. The objective of this study was to evaluate the prevalence and factors associated with TTM use in a large, urban‐suburban regional system of care. Methods and Results This was a retrospective analysis from the Los Angeles County regional cardiac system of care serving a population of >10 million residents. All adult patients aged ≥18 years with non‐traumatic out‐of‐hospital cardiac arrest transported to a cardiac arrest center from April 2011 to August 2017 were included. Patients awake and alert in the emergency department and patients who died in the emergency department before consideration for TTM were excluded. The primary outcome measure was prevalence of TTM use. The secondary analysis were annual trends in TTM use over the study period and factors associated with TTM use. The study population included 8072 patients; 4154 patients (51.5%) received TTM and 3767 patients (46.7%) did not receive TTM. Median age was 67 years, 4780 patients (59.2%) were men, 4645 patients (57.5%) were non‐White, and the most common arrest location was personal residence in 4841 patients (60.0%). In the adjusted analysis, younger age, male sex, an initial shockable rhythm, witnessed arrest, and receiving coronary angiography were associated with receiving TTM. Conclusions Within this regional system of care, use of TTM was higher than previously reported in the literature at just over 50%. Use of integrated systems of care may be a novel method to increase TTM use within the United States.

scholarly journals Hispanic/Latino‐Serving Hospitals Provide Less Targeted Temperature Management Following Out‐of‐Hospital Cardiac Arrest

2021 ◽  
Author(s):  
Nicholas A. Morris ◽  
Michael Mazzeffi ◽  
Patrick McArdle ◽  
Teresa L. May ◽  
Greer Waldrop ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Ethnic Disparities ◽  
The United States ◽  
Mixed Effects ◽  
Mixed Effects Model ◽  
Targeted Temperature Management ◽  
Community Level ◽  
Temperature Management ◽  
Hospital Cardiac Arrest ◽  
White Patients

Abstract Background Variation exists in outcomes following out‐of‐hospital cardiac arrest (OHCA), but whether racial and ethnic disparities exist in post‐arrest provision of targeted temperature management (TTM) is unknown. Methods and Results We performed a retrospective analysis of a prospectively collected cohort of patients who survived to admission following OHCA from the Cardiac Arrest Registry to Enhance Survival, whose catchment area represents ~50% of the United States from 2013‐2019. Our primary exposure was race/ethnicity and primary outcome was utilization of TTM. We built a mixed‐effects model with both state of arrest and admitting hospital modeled as random intercepts to account for clustering. Among 96,695 patients (24.6% Black, 8.0% Hispanic/Latino, 63.4% White), a smaller percentage of Hispanic/Latino patients received TTM than Black or White patients (37.5% vs. 45.0 % vs 43.3%, P < .001) following OHCA. In the mixed‐effects model, Black patients (Odds Ratio [OR] 1.153, 95% Confidence Interval [CI] 1.102‐1.207, P < .001) and Hispanic/Latino patients (OR 1.086, 95% CI 1.017‐1.159, P < .001) were slightly more likely to receive TTM compared to White patients, perhaps due to worse admission neurological status. We did find community level disparity as Hispanic/Latino‐serving hospitals (defined as the top decile of hospitals that cared for the highest proportion of Hispanic/Latino patients) provided less TTM (OR 0.587, 95% CI 0.474 to 0.742, P < .001). Conclusions Reassuringly, we did not find evidence of intrahospital or interpersonal racial or ethnic disparity in the provision of TTM. However, we did find inter‐hospital, community level disparity. Hispanic/Latino‐serving hospitals provided less guideline‐recommended TTM after OHCA.

scholarly journals Extracorporeal Cardiopulmonary Resuscitation for Out‐of‐Hospital Cardiac Arrest in Adult Patients

2020 ◽  
Vol 9 (7) ◽  
Author(s):  
Akihiko Inoue ◽  
Toru Hifumi ◽  
Tetsuya Sakamoto ◽  
Yasuhiro Kuroda
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
The United States ◽  
Adult Patients ◽  
Temperature Management ◽  
Secondary Brain Injury ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Hospital Cardiac Arrest

Abstract Extracorporeal cardiopulmonary resuscitation (ECPR) followed by targeted temperature management has been demonstrated to significantly improve the outcomes of out‐of‐hospital cardiac arrest (OHCA) in adult patients. Although recent narrative and systematic reviews on extracorporeal life support in the emergency department are available in the literature, they are focused on the efficacy of ECPR, and no comprehensively summarized review on ECPR for OHCA in adult patients is available. In this review, we aimed to clarify the prevalence, pathophysiology, predictors, management, and details of the complications of ECPR for OHCA, all of which have not been reviewed in previous literature, with the aim of facilitating understanding among acute care physicians. The leading countries in the field of ECPR are those in East Asia followed by those in Europe and the United States. ECPR may reduce the risks of reperfusion injury and deterioration to secondary brain injury. Unlike conventional cardiopulmonary resuscitation, however, no clear prognostic markers have been identified for ECPR for OHCA. Bleeding was identified as the most common complication of ECPR in patients with OHCA. Future studies should combine ECPR with intra‐aortic balloon pump, extracorporeal membrane oxygenation flow, target blood pressure, and seizure management in ECPR.

scholarly journals Mechanical circulatory support for refractory out-of-hospital cardiac arrest: a Danish nationwide multicenter study

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Sivagowry Rasalingam Mørk ◽  
Carsten Stengaard ◽  
Louise Linde ◽  
Jacob Eifer Møller ◽  
Lisette Okkels Jensen ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Cardiac Arrest ◽  
Survival Rate ◽  
Neurological Outcome ◽  
Mechanical Circulatory Support ◽  
Circulatory Support ◽  
Good Neurological Outcome ◽  
Factors Associated ◽  
National Consensus ◽  
Hospital Cardiac Arrest

Abstract Background Mechanical circulatory support (MCS) with either extracorporeal membrane oxygenation or Impella has shown potential as a salvage therapy for patients with refractory out-of-hospital cardiac arrest (OHCA). The objective of this study was to describe the gradual implementation, survival and adherence to the national consensus with respect to use of MCS for OHCA in Denmark, and to identify factors associated with outcome. Methods This retrospective, observational cohort study included patients receiving MCS for OHCA at all tertiary cardiac arrest centers (n = 4) in Denmark between July 2011 and December 2020. Logistic regression and Kaplan–Meier survival analysis were used to determine association with outcome. Outcome was presented as survival to hospital discharge with good neurological outcome, 30-day survival and predictors of 30-day mortality. Results A total of 259 patients were included in the study. Thirty-day survival was 26%. Sixty-five (25%) survived to hospital discharge and a good neurological outcome (Glasgow–Pittsburgh Cerebral Performance Categories 1–2) was observed in 94% of these patients. Strict adherence to the national consensus showed a 30-day survival rate of 30% compared with 22% in patients violating one or more criteria. Adding criteria to the national consensus such as signs of life during cardiopulmonary resuscitation (CPR), pre-hospital low-flow < 100 min, pH > 6.8 and lactate < 15 mmol/L increased the survival rate to 48%, but would exclude 58% of the survivors from the current cohort. Logistic regression identified asystole (RR 1.36, 95% CI 1.18–1.57), pulseless electrical activity (RR 1.20, 95% CI 1.03–1.41), initial pH < 6.8 (RR 1.28, 95% CI 1.12–1.46) and lactate levels > 15 mmol/L (RR 1.16, 95% CI 1.16–1.53) as factors associated with increased risk of 30-day mortality. Patients presenting signs of life during CPR had reduced risk of 30-day mortality (RR 0.63, 95% CI 0.52–0.76). Conclusions A high survival rate with a good neurological outcome was observed in this Danish population of patients treated with MCS for OHCA. Stringent patient selection for MCS may produce higher survival rates but potentially withholds life-saving treatment in a significant proportion of survivors.

scholarly journals Echocardiographic parameters during prolonged targeted temperature Management in out-of-hospital Cardiac Arrest Survivors to predict neurological outcome – a post-hoc analysis of the TTH48 trial

2021 ◽  
Vol 29 (1) ◽  
Author(s):  
Thomas Hvid Jensen ◽  
Peter Juhl-Olsen ◽  
Bent Roni Ranghøj Nielsen ◽  
Johan Heiberg ◽  
Christophe Henri Valdemar Duez ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Neurological Outcome ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
Targeted Temperature Management ◽  
Temperature Management ◽  
Left Ventricular Ejection ◽  
Secondary Outcome ◽  
Ventricular Ejection Fraction ◽  
Hospital Cardiac Arrest

Abstract Background Transthoracic echocardiographic (TTE) indices of myocardial function among survivors of out-of-hospital cardiac arrest (OHCA) have been related to neurological outcome; however, results are inconsistent. We hypothesized that changes in average peak systolic mitral annular velocity (s’) from 24 h (h) to 72 h following start of targeted temperature management (TTM) predict six-month neurological outcome in comatose OHCA survivors. Methods We investigated the association between peak systolic velocity of the mitral plane (s’) and six-month neurological outcome in a population of 99 patients from a randomised controlled trial comparing TTM at 33 ± 1 °C for 24 h (h) (n = 47) vs. 48 h (n = 52) following OHCA (TTH48-trial). TTE was conducted at 24 h, 48 h, and 72 h after reaching target temperature. The primary outcome was 180 days neurological outcome assessed by Cerebral Performance Category score (CPC180) and the primary TTE outcome measure was s’. Secondary outcome measures were left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), e’, E/e’ and tricuspid annular plane systolic excursion (TAPSE). Results Across all three scan time points s’ was not associated with neurological outcome (ORs: 24 h: 1.0 (95%CI: 0.7–1.4, p = 0.98), 48 h: 1.13 (95%CI: 0.9–1.4, p = 0.34), 72 h: 1.04 (95%CI: 0.8–1.4, p = 0.76)). LVEF, GLS, E/e’, and TAPSE recorded on serial TTEs following OHCA were neither associated with nor did they predict CPC180. Estimated median e’ at 48 h following TTM was 5.74 cm/s (95%CI: 5.27–6.22) in patients with good outcome (CPC180 1–2) vs. 4.95 cm/s (95%CI: 4.37–5.54) in patients with poor outcome (CPC180 3–5) (p = 0.04). Conclusions s’ assessed on serial TTEs in comatose survivors of OHCA treated with TTM was not associated with CPC180. Our findings suggest that serial TTEs in the early post-resuscitation phase during TTM do not aid the prognostication of neurological outcome following OHCA. Trial registration NCT02066753. Registered 14 February 2014 – Retrospectively registered,

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