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In a trial involving adults with out-of-hospital cardiac arrest, an intraosseous-first strategy for vascular access did not result in a higher incidence of 30-day survival than an intravenous-first strategy.

Prehospital advanced airway management with either initial endotracheal intubation (ETI) or initial supraglottic airway (SGA) insertion in patients with out-of-hospital cardiac arrest (OHCA) remains controversial. To compare the effectiveness of ETI and SGA in patients with nontraumatic OHCA. The Supraglottic Airway Device vs Endotracheal intubation (SAVE) trial was a multicenter cluster randomized clinical trial conducted in Taipei City, Taiwan. Individuals aged 20 years or older who experienced nontraumatic OHCA requiring advanced airway management and were treated by participating emergency medical service agencies were enrolled from November 11, 2016, to December 31, 2019. The final day of follow-up was February 19, 2020. Four advanced life support ambulance teams were divided into 2 randomization clusters, with each cluster assigned to either ETI or SGA in a biweekly period. The primary outcome of the SAVE trial was sustained return of spontaneous circulation (ROSC) (≥2 hours) after resuscitation. Secondary outcomes included prehospital ROSC, survival to hospital discharge, and favorable neurologic outcome, defined as a cerebral performance category score less than or equal to 2. Prespecified subgroups and the association between time to advanced airways were explored. Per protocol and intention-to-treat analysis were performed. A total of 936 patients (517 in the ETI group and 419 in the SGA group) were included in the primary analysis (median age, 77 [IQR, 62-85] years; 569 men [60.8%]). The first-attempt airway success rates were 77% with ETI (n = 413) and 83% with SGA (n = 360). Sustained ROSC was 26.9% (n = 139) in the ETI group vs 25.8% (n = 108) in the SGA group. The odds ratio of sustained ROSC was 1.02 (95% CI, 0.98-1.06) in the ETI group vs SGA group. The odds ratio of ETA vs SGA was 1.04 (95% CI, 1.02-1.07) for prehospital ROSC, 1.00 (95% CI, 0.94-1.06) for survival to hospital discharge, and 0.99 (95% CI, 0.94-1.03) for cerebral performance category scores less than or equal to 2. In this randomized clinical trial, among patients with OHCA, initial airway management with ETI did not result in a favorable outcome of sustained ROSC compared with SGA device insertion. ClinicalTrials.gov Identifier: NCT02967952.

Introduction Microcirculatory alterations are predictive of poor outcomes in patients with shock and after cardiac arrest in animal models. However, microcirculatory alterations during human cardiac arrest have not yet been studied. Methods We prospectively included adult patients receiving resuscitation after witnessed out-of-hospital cardiac arrest. Exclusion criteria were hypovolemia, hypo- or hyperthermia (< 34.0 °C, > 37.5 °C), peripheral arterial disease, Raynaud’s disease, and logistical issues (e.g., shortage of space). Capillary refill time was measured on the finger (CRT-F) and the earlobe (CRT-E) every other minute until return of spontaneous circulation (any ROSC) or termination of resuscitation. The primary endpoint was any ROSC, secondary endpoints were 30-day-mortality and good neurological outcome (defined as cerebral performance category 1–2). Based on the data structure, CRT-F and CRT-E values were grouped post-hoc into quartiles and tertiles. A cluster-robust standard error logistic regression was performed for the primary outcome. Trend analyses were made for each individual. Results After screening of 141 patients, 50 were included in the analysis (median age 75 years, 28% female, any ROSC 32%). The median CRT-F was > 10 [7–> 10] seconds; the median CRT-E was 3 [3–4] seconds. The any ROSC rate for patients in CRT-F quartile 1 (3–5 s) was 71.4%, 31.7% in quartile 2 (6–8 s), 23.1% in quartile 3 (9–10 s), and 10% in quartile 4 (> 10 s). The odds ratio of 0.39 (95% CI 0.20–0.73, p  = 0.004) indicated, that with an increase of CRT-F by a quartile, the chance of achieving any ROSC decreased by 61%. Patients with a decreasing CRT-F achieved any ROSC in 70%, whereas patients with constant or increasing CRT-F had any ROSC in only 21% ( p  = 0.008). In contrast, CRT-E showed no association with any ROSC (T1 [1–2 s.]: 16.7%, T2 [3 s.]: 27.5%, T3 [4—> 10 s.]: 22.4%, OR by tertiles: 1.18, 95% CI 0.58–2.44, p  = 0.646). Conclusion During out-of-hospital cardiac arrest, shorter CRT-F, but not CRT-E, is associated with a higher chance of any ROSC. Trial registration : This trial was pre-registered on clinicaltrials.gov with the number: NCT04791995 on March 2nd, 2021.

Patients with return of spontaneous circulation (ROSC) following cardiac arrest are a critically important population requiring close monitoring and targeted interventions in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the management of this condition. This paper provides evidence-based updates concerning the management of the post-ROSC patient. The patient with ROSC following cardiac arrest is critically ill, including a post-cardiac arrest syndrome which may include hypoxic brain injury, myocardial dysfunction, systemic ischemia and reperfusion injury, and persistent precipitating pathophysiology. Initial priorities in the ED setting in the post-ROSC patient include supporting cardiopulmonary function, addressing and managing the underlying cause of arrest, minimizing secondary cerebral injury, and correcting physiologic derangements. Testing including laboratory assessment, electrocardiogram (ECG), and imaging are necessary, aiming to evaluate for the precipitating cause and assess end-organ injury. Computed tomography head-to-pelvis may be helpful in the post-ROSC patient, particularly when the etiology of arrest is unclear. There are several important components of management, including targeting a mean arterial pressure of at least 65 mmHg, preferably >80 mmHg, to improve end-organ and cerebral perfusion pressure. An oxygenation target of 92–98 % is recommended using ARDSnet protocol, along with carbon dioxide partial pressure values of 35–55 mmHg. Antibiotics should be reserved for those with evidence of infection but may be considered if the patient is comatose, intubated, and undergoing hypothermic targeted temperature management (TTM). Corticosteroids should not be routinely administered. While the majority of cardiac arrests in adults are associated with cardiovascular disease, not all post-ROSC patients require emergent coronary angiography. However, if the patient has ST-segment elevation on ECG following ROSC, emergent angiography and catheterization is recommended. This should also be considered if the patient had an initial history concerning for acute coronary syndrome or a presenting arrhythmia of ventricular fibrillation or pulseless ventricular tachycardia. TTM at 32-34° C does not appear to demonstrate improved outcomes compared with targeted normothermia, but fever should be avoided. An understanding of literature updates can improve the ED care of patients post-ROSC.

Although three established models for predicting the return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) exist, combinational external validation of these models remains limited. This study aimed to externally validate and compare the performance of three predictive models—RACA, P-ROSC, and UB-ROSC–and provide evidence to guide the selection and application of predictive models for prehospital ROSC in diverse settings. A retrospective validation was conducted using the National Taiwan University Hospital Hsinchu and Yunlin Branch Out-of-Hospital Cardiac Arrest Research Databases. Patients with EMS-treated OHCAs admitted to the hospital between January 2016 and July 2023 were recruited. The primary outcome was prehospital ROSC. Model performance was evaluated using discrimination, calibration, sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic odds ratio. Calibration and density distribution plots were generated. All three models demonstrated moderate-to-high discrimination with AUROCs of 0.758 (RACA), 0.755 (P-ROSC), and 0.747 (UB-ROSC). The RACA score exhibited better calibration across the risk deciles, whereas the P-ROSC and UB-ROSC scores tended to overestimate the probabilities at higher predicted risk levels. The P-ROSC score required fewer variables and showed the best separation between prehospital and non-prehospital ROSC cases. Optimal cut-off values for the RACA, P-ROSC, and UB-ROSC scores were 0.45, 41, and − 13, respectively, with corresponding sensitivities of 62 %, 56 %, and 71 % and specificities of 78 %, 82 %, and 69 %. All models achieved high NPVs (>96 %), but PPVs remained low (16–21 %). The P-ROSC, which requires fewer variables, has emerged as the most practical model for Taiwanese populations. However, the choice of the model should be guided by the availability of variables, regional EMS characteristics, and trends in prehospital ROSC rates. [Display omitted]

There is a significant correlation between mean arterial pressure (MAP) levels after the return of spontaneous circulation (ROSC) and the outcomes of out-of-hospital cardiac arrest (OHCA) patients. This study investigates the impact of MAP regulation within 12 h post-ROSC on OHCA outcomes. This retrospective, single-center cohort study included non-traumatic OHCA patients who achieved ROSC at a medical center in Taiwan between January 1, 2017, and December 31, 2022. The primary outcomes were 30-day mortality and neurological status assessed by the Cerebral Performance Category (CPC) score. A total of 231 OHCA survivors were included in the analysis. Patients were stratified into three tertiles based on MAP distribution, with each group consisting of 77 patients, as follows: MAP < 80 mmHg, 80 ≤ MAP <95 mmHg, and MAP ≥ 95 mmHg, based on measurements taken within the first 12 h post-ROSC. No significant differences were observed in mortality or CPC scores between the 80 ≤ MAP < 95 mmHg and ≥ 95 mmHg groups. However, MAP levels below 80 mmHg were correlated with significantly higher 30-day mortality (hazard ratio [HR] = 1.760, 95% confidence interval [CI] = 1.130–2.760, P = 0.013) and worse neurological outcomes (HR = 1.560, 95% CI = 1.060–2.300, P = 0.023). MAP <80 mmHg within the first 12 h post-ROSC is a strong predictor of poor clinical outcomes in OHCA patients, while a higher MAP target (≥ 95 mmHg) is not associated with additional benefit in the early post-arrest period. •Maintaining MAP ≥80 mmHg post-ROSC is associated with improved survival in OHCA.•MAP ≥80 mmHg is correlated with more favorable neurological outcomes.•Pursuing higher MAP target (≥ 95 mmHg) shows no extra benefit in early post-arrest care.

To explore the impact of mild hypercapnia or normocapnia on the prognosis of patients after the return of spontaneous circulation (ROSC) following cardiac arrest (CA). This systematic review and meta-analysis followed the guidelines in the PROSPERO report. Information was retrieved in PubMed, Cochrane Library, Embase, and Web of Science to collect all publications in English from January 1, 2000, to March 1, 2024, involving post-CA with mild hypercapnia. Study selection and data extraction were performed by two authors using Review Manager 5.4 software. The primary/secondary outcomes, including overall or ICU mortality, were evaluated. 6 studies, including 4 observational studies, were ultimately enrolled in this study. A total of 19,025 patients were included in the studies, with 6899 receiving therapeutic mild hypercapnia and 12,126 maintaining normocapnia. Three studies focused on out-of-hospital patients, one study on in-hospital patients, one study on both in-hospital and out-of-hospital patients, and one study not specifying the type of CA. Compared to normocapnia, there was no significant difference in overall mortality among patients with mild hypercapnia (P = 0.51, OR = 1.13, 95 % CI: 0.93–1.38) and the proportion of patients with favorable neurological prognosis was not altered (OR:0.95, 95 % CI:0.80–1.14, P = 0.52). The overall ICU mortality rate was not significantly different between mild hypercapnia and normocapnia (OR:1.08,95 % CI:0.89–1.32, P = 0.42), and subgroup analysis showed that the results of randomized controlled trials and observational studies were consistent. The presented meta-analysis suggests that mild hypercapnia is not associated with improvements in overall survival, ICU survival, or neurological prognosis compared to normocapnia in patients with CA. This is the first meta-analysis specifically to compare the clinical outcome of CA with mild hypercapnia or normocapnia and find that mild hypercapnia may not be detrimental to the prognosis of patients after CA. It is unnecessary to control the mild hypercapnia intensively to normal range of PaCO2 in clinics.

Background The effect of steroid use on outcomes in patients with cardiac arrest (CA) remains controversial. We systematically reviewed the literature to investigate whether steroid use after CA increased the return of spontaneous circulation (ROSC) rate and survival to discharge in patients with CA. Methods PubMed, Embase, CNKI, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials (RCTs) and observational studies on the effect of steroid use on outcomes in adults with CA. The outcomes were ROSC and survival to discharge. Results Seven studies (four RCTs and three observational studies) were included. Pooled analysis suggested that steroid use was associated with increased ROSC in patients with CA. Steroid use was significantly associated with survival to discharge, which was a consistent finding in RCTs and observational studies. Subgroup analysis based on the time of drug administration (during cardiopulmonary resuscitation [CPR] vs. after CA) showed that steroid use during CPR and after CA were significantly associated with an increased rate of ROSC and survival to discharge. Conclusion Current evidence indicates that steroid use after CA could increase ROSC and survival to discharge in patients with CA. However, high-quality and adequately powered RCTs are warranted.

A decline in OHCA performance metrics during the pandemic has been reported in the literature but the cause is still not known. The Montgomery County Fire and Rescue Service (MCFRS) observed a decline in both the rate of return of spontaneous circulation (ROSC) and the proportion of resuscitations that resulted in cerebral performance category (CPC) 1 or 2 discharge of the patient beginning in March of 2020. This study examines whether the decline in these performance metrics persists when known COVID positive patients are excluded from the analysis. Two samples of OHCA patients for similar time periods (one year apart) before and after the start of the COVID pandemic were developed. A database of known COVID positive patients among EMS encounters was used to identify and exclude COVID positive patients. OHCA outcomes in these two groups were then compared using a Chi-square test and Fisher's exact test for difference in proportions and Analysis of Variance (ANOVA) for difference in means. A two-stage multivariable logistic regression model was used to develop odds ratios for achieving ROSC and CPC 1 or 2 discharge in each period. After excluding known COVID patients, 32.5% of the patients in the pre-COVID period achieved ROSC compared to 25.1% in the COVID period (p = 0.007). 6% of patients in the pre-COVID period were discharged with CPC 1 or 2 compared to 3.2% from the COVID era (p = 0.026). Controlling for all available patient characteristics, patients undergoing OHCA resuscitation prior to be beginning of the pandemic were 1.2 times more likely to achieve ROSC and 1.6 times more likely to be discharged with CPC 1 or 2 than non-COVID patients in the pandemic era sample. When known COVID patients are excluded, pre-pandemic OHCA resuscitation patients were more likely to achieve ROSC and CPC 1 or 2 discharge. The prevalence of known COVID positive patients among all OHCA resuscitations during the pandemic was not sufficient to fully account for the marked decrease in both ROSC and CPC 1 or 2 discharges. Other causative factors must be sought.

Some evidence suggests that both hypothermia and anesthesia can exert similar effects on metabolism and ventilation. This study examined the synergistic effects of anesthesia and hypothermia on ventilation in spontaneously breathing adult mice under three different conditions, that is, (1) pentobarbital group (n = 7) in which mice were anesthetized with intraperitoneal pentobarbital of 80 mg/kg, (2) sevoflurane‐continued group (n = 7) in which mice were anesthetized with 1 MAC sevoflurane, and (3) sevoflurane‐discontinued group (n = 7) in which sevoflurane was discontinued at a body temperature below 22˚C. We cooled mice in each group until breathing ceased and followed this with artificial rewarming while measuring changes in respiratory variables and heart rate. We found that the body temperature at which respiration arrested is much lower in the sevoflurane‐discontinued group (13.8 ± 2.0˚C) than that in the sevoflurane‐continued group (16.7 ± 1.2˚C) and the pentobarbital group (17.0 ± 1.4˚C). Upon rewarming, all animals in all three groups spontaneously recovered from respiratory arrest. There was a considerable difference in breathing patterns between sevoflurane‐anesthetized mice and pentobarbital‐anesthetized mice during progressive hypothermia in terms of changes in tidal volume and respiratory frequency. The changes in the respiratory pattern during rewarming are nearly mirrored images of the changes observed during cooling in all three groups. These observations indicate that adult mice are capable of autoresuscitation from hypothermic respiratory arrest and that anesthesia and hypothermia exert synergistic effects on the occurrence of respiratory arrest while the type of anesthetic affects the breathing pattern that occurs during progressive hypothermia leading to respiratory arrest. Adult mice are capable of autoresuscitation from respiratory arrest, regardless of the presence or type of anesthetics. Anesthesia increases the body temperature at which respiratory arrest occurs. The type of anesthetic affects the breathing pattern that occurs during progressive hypothermia leading to respiratory arrest.