查看更多>>摘要：? 2022 Elsevier B.V.Background: The decision to initiate or continue advanced life support (ALS) in out-of-hospital cardiac arrest (OHCA) could be difficult due to the lack of information and contextual elements, especially in non-shockable rhythms. This study aims to explore factors associated with clinicians’ decision to initiate or continue ALS and the conditions associated with higher variability in asystolic patients. Methods: This retrospective observational study enrolled 2653 asystolic patients on whom either ALS was attempted or not by the emergency medical services (EMS) physician. A multivariable logistic regression analysis was performed to find the factors associated with the decision to access ALS. A subgroup analysis was performed on patients with a predicted probability of ALS between 35% and 65%. The single physician's behaviour was compared to that predicted by the model taking into account the entire agency. Results: Age, location of event, bystander cardiopulmonary resuscitation and EMS-witnessed event were independent factors influencing physicians’ choices about ALS. Non-medical OHCA, younger patients, less experienced physicians, presence of breath activity at the emergency call and a longer time for ALS arrival were more frequent among cases with an expected higher variability in behaviours with ALS. Significant variability was detected between physicians. Conclusions: Significant inter-physician variability in access to ALS could be present within the same EMS, especially among less experienced physicians, non-medical OHCA and in presence of signs of life during emergency call. This arbitrariness has been observed and should be properly addressed by EMS team members as it raises ethical issues regarding the disparity in treatment.
查看更多>>摘要：? 2022 Elsevier B.V.Background: We aimed to identify distinct trajectories of end-tidal carbon dioxide (EtCO2) during cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest (OHCA) and to investigate the association between EtCO2 trajectories and OHCA outcomes. Methods: This was a secondary analysis of a prospectively collected database on adult patients with OHCA who had been resuscitated in the emergency department of a tertiary medical center between 2015 and 2020. The primary outcome was the return of spontaneous circulation (ROSC). Group-based trajectory modelling was used to identify the EtCO2 trajectories. Multivariable logistic regression analysis was performed to evaluate the association between EtCO2 trajectories and ROSC. The predictive performance of the EtCO2 trajectories was assessed using the area under the receiver operating characteristic curve (AUC). Results: The study comprised 655 patients with OHCA. In the primary analysis, three distinct EtCO2 trajectories, including 10-mmHg, 30-mmHg, and 50-mmHg trajectories, were identified. Compared with the 10-mmHg trajectory, both 30-mmHg (odds ratio [OR]: 4.66, 95% confidence interval [CI]: 3.15–6.90) and 50-mmHg (OR: 7.58, 95% CI: 4.30–13.35) trajectories were associated with a higher likelihood of ROSC. In a sensitivity analysis of excluding EtCO2 measured before tracheal intubation or after sodium bicarbonate administration, the predictive ability of the identified EtCO2 trajectories remained. As a single predictor of ROSC, EtCO2 trajectories had an acceptable discriminative performance (AUC: 0.69, 95% CI: 0.66–0.73). Conclusion: Three distinct EtCO2 trajectories during cardiopulmonary resuscitation were identified and significantly associated with outcomes. Early identification of these EtCO2 trajectories could potentially guide the ongoing resuscitation efforts.
查看更多>>摘要：? 2022 Elsevier B.V.Aim: To investigate whether intentional cooling, achieved temperature and hypothermia duration were associated with in-hospital death in patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest. Methods: This is a retrospective analysis of the Extracorporeal Life Support Organization Registry. Patients 18–79 years of age who received ECPR between 2010 and 2019 were included. We compared outcomes for intentional cooling versus no intentional cooling. Then, among those who completed intentional cooling, we compared the outcomes between i) achieved temperature ≤ 34 °C, 34–36 °C, and > 36 °C, and ii) duration ≤ 36 °C for < 12 h, 12–48 h, and ≥ 48 h. The primary outcome was in-hospital mortality within 90 days. Cox proportional hazard models were generated with adjustment for covariates. Results: Among 4,214 ECPR patients, 1,511 patients were included in the final analysis. After multivariable adjustment, there was no significant difference in in-hospital mortality between patients with intentional cooling and no intentional cooling (hazard ratio [HR], 1.06 [95% CI 0.93–1.21]; p = 0.394). In the 609 patients who completed intentional cooling, temperature at 34–36 °C had a significantly lower adjusted HR for in-hospital mortality compared with > 36 °C (HR, 0.73 [0.55–0.96]; p = 0.025). Moreover, temperature ≤ 36 °C for 12–48 h had a significantly lower adjusted HR for in-hospital mortality compared with ≤ 36 °C for < 12 h (HR, 0.69 [0.53–0.90]; p = 0.005). Conclusion: Intentional cooling was not associated with lower in-hospital mortality in ECPR patients. However, among patients with intentional cooling, achieving temperature of 34–36 °C for 12–48 h was associated with lower in-hospital mortality.
NSTL
Elsevier