Big Survival Differences in Out-of-Hospital Cardiac Arrest Between EMS Agencies

MedicalResearch.com Interview with:

Masashi Okubo, MD. Clinical Instructor of Emergency Medicine Research Fellow Department of Emergency Medicine University of Pittsburgh

Dr. Okubo

Masashi OkuboMD.
Clinical Instructor of Emergency Medicine
Research Fellow
Department of Emergency Medicine
University of Pittsburgh

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: Out-of-hospital cardiac arrest (OHCA) is a major public health problem, annually affecting over 350,000 individuals in the US with low survival rate, 11.4% among those who were treated by emergency medical services (EMS). Prior studies showed a 5-fold difference (3.0% to 16.3%)  in survival to hospital discharge between 10 study sites in North America (US and Canada) and 6.5-fold difference (3.4% to 22.0%) between 132 US counties after OHCA.

However, it was unclear how much patient outcome after OHCA differ between EMS agencies which play a critical role in OHCA care. Among 43,656 adults treated for Out-of-hospital cardiac arrest by 112 EMS agencies in North America, we found that survival to hospital discharge differed from 0% to 28.9% between EMS agencies. There was a median difference of 56% in the odds of survival to hospital discharge for patients with similar characteristics between any 2 randomly selected EMS agencies, after adjusting for known measured sources of variability.

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Hypothermia for 48 or 24 Hours After Out-of-Hospital Cardiac Arrest?

MedicalResearch.com Interview with:

Hans Kirkegaard, MD, PhD, DMSci, DEAA, DLS Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine Aarhus University Hospital and Aarhus University Aarhus, Denmark 

Dr. Kirkegaard

Hans Kirkegaard, MD, PhD, DMSci, DEAA, DLS
Research Center for Emergency Medicine and
Department of Anesthesiology and Intensive Care Medicine
Aarhus University Hospital and Aarhus University
Aarhus, Denmark 

MedicalResearch.com: What is the background for this study?

Response: In 2002, two landmark studies demonstrated that mild therapeutic hypothermia (now known as targeted temperature management, TTM) for 12 or 24 hours improves neurological outcome in adult comatose patients suffering from out of hospital cardiac arrest. Accordingly, international guidelines now recommend TTM for at least 24 hours in this patient group.

However, there are no studies, only case reports that explore the effect of prolonged cooling. We therefore wanted to set up a trial that could fill out this knowledge gap, we hypothesized that doubling the hypothermia dose to 48 hour would improve neurological outcome without increasing the risk of adverse events considerably.

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Delayed Epinephrine Linked To Worse Survival From In-Patient Cardiac Arrest

MedicalResearch.com Interview with:
Rohan Khera, MD

Cardiology Fellow, T32 Clinical-Investigator Pathway
UT Southwestern Medical Center
Dallas, TX

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Nearly 200 thousand people have an in-hospital cardiac arrest in the US each year. Of these, the vast majority have a non-shockable initial rhythm – either pulseless electric activity (PEA) or asystole. The survival of this type of arrest remains poor at around 12-14%. Moreover, even after accounting for differences in case mix, there is a wide variation in survival across hospitals – and this serves as a potential avenue for targeting quality improvement strategies at poor performing hospitals.

Recent data suggest that a shorter time from the onset of cardiac arrest to the first dose of epinephrine is independently associated with higher survival. Against this background of wide hospital variation in cardiac arrest survival, and patient-level data suggesting an association between time to epinephrine and patient survival, we wanted to assess (A) if there were differences in time to epinephrine administration across hospitals, and (B) if a hospital’s rate of timely epinephrine use was associated with its cardiac arrest survival rate. Within Get With The Guidelines-Resuscitation, we identified nearly 104-thousand adult patients at 548 hospitals with an in-hospital cardiac arrest attributable to a non-shockable rhythms. delays to epinephrine,

We found that (a) proportion of cardiac arrests with delayed epinephrine markedly across hospitals, ranging from no arrests with delay (or 0%) to more than half of arrests at a hospital (54%).

There was an inverse correlation between a hospital’s rate of delayed epinephrine administration and its risk-standardized rate of survival to discharge and survival with functional recovery – compared to a low-performing hospitals, survival and recovery was 20% higher at hospitals that performed best on timely epinephrine use.

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Cardiac Arrest Survival Better At Tertiary Care Hospitals

Helle Søholm, MD, PhDDepartment of Cardiology Copenhagen University Hospital Rigshospitalet Denmark MedicalResearch.com Interview with:
Helle Søholm, MD, PhD
Department of Cardiology
Copenhagen University Hospital Rigshospitalet
Denmark
Medical Research: What is the background for this study?

Dr. Søholm: The background of the current study is that previous studies have found higher survival rates after out-of-hospital cardiac arrest and admission to tertiary heart centres for post-resuscitaton care compared with nontertiary hospitals, however the reasons for this difference has only been speculative. The aim of the study was to examine the level-of post-resuscitation care at tertiary heart centers compared with nontertiary hospitals and to associate this with outcome. Only patients without ST-segment elevation myocardial infarction was examined to avoid referral bias.

Medical Research: What are the main findings?

Dr. Søholm: The main findings of the study of 1.078 patients was that the survival in patients admitted to tertiary heart centers was significantly higher compared with survival in patients admitted to nontertiary hospitals even after adjustment for known risk markers including pre-arrest co-morbidity. We found that the adjusted odds of predefined markers of level-of-care differed in both the acute phase after admission, during the intensive care admission and in the workup prior to hospital discharge. The odds of admission to an intensive care unit was 1.8 for patients admitted to a tertiary heart centre. During the intensive care admission the odds of a temporay pacemaker was 6.4, use of vasoactive agents 1.5, acute and late coronary angiography was 10 and 3.8 respectively, neurophysiological examination 1.8, brain computed tomography 1.9, whereas no difference in the odds of therapeutic hypothermia was found. Prior to hospital discharge the odds of a consultation by a cardiologist was 8.6, having an echocardiography was 2.9, and survivors more often had an implantable cardioverter defibrillator implanted (odds 2.1) as compared with patients admitted to nontertiary hospitals.

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Neuron-Specific Biomarker May Help Predict Outcome After Out-of-Hospital Cardiac Arrest

dr-pascal-stammetMedicalResearch.com Interview with:
Dr Pascal Stammet

Dépt. Anesthésie-Réanimation
Centre Hospitalier de Luxembourg
Luxembourg

MedicalResearch: What is the background for this study? What are the main findings?

Dr Stammet: Patients hospitalized after an out-of-hospital cardiac arrest (OHCA) survive in about fifty percent and nine out of ten survivors have a good functional level six months after the arrest. However, in the early days after the cardiac arrest it is difficult to distinguish those who will survive from those who have very severe brain damage, not compatible with life. Biomarkers, like neuron specific enolase (NSE) have shown a prognostic value for outcome prediction. As a consequence of the widespread use of induced hypothermia, to improve survival and neurological function, for patients resuscitated form cardiac arrest, concerns have arisen about the impact of body temperature on previously published cut-off values for poor outcome. NSE has thus been questioned as a useful clinical tool. Recently, the Target Temperature Management trial (TTM-trial) published in November 2013 in the NEJM has shown no benefit of a target body temperature of 33°C over 36°C in patients with out-of-hospital cardiac arrest admitted to the ICU. In the present sub-study, we have analyzed the value of NSE to predict outcome in a cohort of 686 patients of the TTM-trial. Importantly, serial measurements of NSE at 24, 48 and 72 hours allowed accurate outcome prediction, with better performance than clinical and peri-arrest data alone. NSE did not significantly differ between temperature groups meaning that clinicians can use NSE as an adjunct prognostic tool regardless of the chosen temperature management strategy. Continue reading

Out-of-Hospital Cardiac Arrest: Continuous vs Interrupted Chest Compressions?

MedicalResearch.com Interview with:
Siobhan Brown, Ph.D.
Biostatistician, ROC Clinical Trials Center
University of Washington

Medical Research: What is the background for this study? What are the main findings?

Dr. Brown: There are several observational studies suggesting that patients with out-of-hospital cardiac arrest may be more likely to survive to hospital discharge when emergency medical service provides do not pause for ventilations while performing CPR (i.e., give continuous compressions); however, the American Heart Association recommends that rescuers pause after each 30 compression to give two ventilations (interrupted compressions). We designed and are conducting a randomized clinical trial comparing the two approaches to see which results in better survival.

The trial is still ongoing, so watch for results in late 2015!

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High Estrogen, Low Testosterone Linked To Sudden Cardiac Arrest

Sumeet S. Chugh MD Pauline and Harold Price Endowed Professor Associate Director, the Heart Institute Section Chief, Clinical Cardiac Electrophysiology Cedars-Sinai Medical Center, Los Angeles, CAMedicalResearch.com Interview with:
Sumeet S. Chugh MD
Pauline and Harold Price Endowed Professor
Associate Director, the Heart Institute
Section Chief, Clinical Cardiac Electrophysiology
Cedars-Sinai Medical Center, Los Angeles, CA

Medical Research: What are the main findings of the study?

Dr. Chugh: Our study, conducted in the community, showed that there are unique alterations in sex hormone levels identified among patients who have sudden cardiac arrest. Male victims have lower testosterone and both males and females have higher estrogren levels.

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Initiatives to Improve Cardiac Arrest Management

Mads Wissenberg, MD Department of Cardiology Gentofte Hospital, University of Copenhagen Niels Andersens Vej 65 2900 Hellerup, Denmark Post 635MedicalResearch.com Interview with:
Mads Wissenberg, MD
Department of Cardiology
Gentofte Hospital, University of Copenhagen
Niels Andersens Vej 65
2900 Hellerup, Denmark Post 635

MedicalResearch.com: What are the main findings of the study?

Answer: Our main findings from this nationwide study are that during a 10-year period where several national initiatives were taken to increase bystander CPR and improve advanced care, bystander CPR increased more than a two-fold from 21 % in 2001 to 45% in 2010. In the same period survival on arrival at the hospital increased more than a two-fold from 8% in 2001 to 22% in 2010, and 30-day survival more than a three-fold from 3.5% in 2001 to 11% in 2010.
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Predictors of Survival from Perioperative Cardiopulmonary Arrests: A Retrospective Analysis of 2,524 Events from the Get With The Guidelines-Resuscitation Registry

Satya Krishna Ramachandran MD FRCA Director, Quality Assurance Department of Anesthesiology University of MichiganMedicalResearch.com eInterview with
Satya Krishna Ramachandran MD FRCA
Director, Quality Assurance
Department of Anesthesiology
University of Michigan

MedicalResearch.com: What are the main findings of the study?

Answer:

  • Background: A cardiac arrest is a life-threatening condition where the heart has stopped beating. This remains one of the biggest fears of patients undergoing anesthesia and surgery. This is a rare complication around anesthesia, with only seven arrests per 10,000 patients undergoing surgeries unrelated to the heart. Although this is a rare complication nowadays, previous research has provided limited understanding of risk factors and outcomes.  Cardiac arrests that happen during or soon after anesthesia and surgery may present themselves in different ways and have differences in survival or further complications. By studying these arrests in a large national database of cardiac arrests called the “Get With The Guidelines – Resuscitation” registry, we were able to identify over 2,500 instances of cardiac arrest occurring during or soon after anesthesia. This database is supported by the American Heart Association and has specific information on patient conditions, life-saving treatments and recovery from the arrests.
  • Findings: Cardiac arrests that happen during or immediately after anesthesia are rare events. But we have found that recovery from these events is much better than previous reports of arrests from other hospital locations. We have also found that life-saving treatment is given extremely rapidly in the operating room and the post-anesthesia care unit. These are two locations that anesthesiologists and peri-anesthesia nurses closely monitor patients for complications. We believe that the better recovery seen in these places is because of the immediate availability of these trained caregivers.

MedicalResearch.com: Were any of the findings unexpected?

Answer:

  • Specifically, recovery from asystole (a type of cardiac arrest where the electrical activity of the heart completely stops) in the operating room is at least three times better than previous reports from other hospital locations. We also found that life-saving treatment was given much faster in these locations. We think this improved survival is mainly because of the presence of trained anesthesiologists and nurse providers who directly monitor and respond quickly to any cardiac arrest situation.
  • Patients developing arrests during or immediately after anesthesia (in the post-anesthesia care unit) were more likely to survive with good brain function than other hospital locations.  We believe that the presence of trained anesthesiologists in both locations improve chances of good recovery due to careful monitoring and immediate responses to these uncommon events.

MedicalResearch.com: What should clinicians and patients take away from your report?

Answer:

  • We found that one out of every three patients who develop a perioperative cardiac arrest survives to hospital discharge. We also found that two out of every three patients who survived had no signs of brain damage after the arrest.
  • We also identified several risk-conditions during hospital admission that reduce the chance of successful recovery from a perioperative cardiac arrest. These include major trauma, heart failure, low blood pressure, electrolyte disturbances, kidney failure, late stage cancer, major infection of the blood, and breathing difficulties. Patients with older age and longer arrest times had reduced chance of successful recovery.
  • The following conditions improved chances of successful recovery from arrests: presence of a heart rhythm abnormality, ventricular fibrillation arrest, and difficulty in keeping open the breathing passage. We showed that patients recover better from cardiac arrests that happen during or immediately after anesthesia, compared to other hospital locations. However, we also found that arrests that happen during weekends and at night have worse outcomes.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Answer:

  • Research into the role of monitoring in preventing postoperative complications including cardiac arrests is essential. There are concerns about inadequate monitoring of postoperative patients in US hospitals. On the other hand, there are concerns that increasing the level of monitoring also increases nursing fatigue to alarms, similar to a “cry-wolf” situation. As most monitoring strategies are potentially associated with immense healthcare benefits, costs and risks, good quality research into the value and effectiveness of monitoring postoperative patients is essential.
  • We also found that patients who had signs of brain damage at the time of hospital admission had the lowest chance of surviving the arrest and recovering their brain function. In these patients, the chance of good recovery was low, even if they did not have any other major risk-conditions listed above. On the other hand, patients who had good brain function at the time of hospital admission had a good chance of recovery even if they had many risk-conditions listed above.  Future research into do-not-resuscitate orders needs to incorporate this finding.

Citation:

Predictors of Survival from Perioperative Cardiopulmonary Arrests: A Retrospective Analysis of 2,524 Events from the Get With The Guidelines-Resuscitation Registry

Ramachandran, Satya Krishna; Mhyre, Jill; Kheterpal, Sachin; Christensen, Robert E.; Tallman, Kristen; Morris, Michelle; Chan, Paul S.; for the American Heart Association’s Get With The Guidelines-Resuscitation Investigators

Anesthesiology., POST AUTHOR CORRECTIONS, 30 April 2013
doi: 10.1097/ALN.0b013e318289bafe