Out-of-hospital cardiac arrest patients with an initial non-shockable rhythm could be candidates for extracorporeal cardiopulmonary resuscitation: a retrospective study.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) is a promising treatment for refractory out-of-hospital cardiac arrest (OHCA). Most studies evaluating the effectiveness of ECPR include patients with an initial shockable rhythm. However, the effectiveness of ECPR for patients with an initial non-shockable rhythm remains unknown. This retrospective single-center study aimed to evaluate the effectiveness of ECPR for patients with an initial non-shockable rhythm, with reference to the outcomes of OHCA patients with an initial shockable rhythm. METHODS: Adult OHCA patients treated with ECPR at our center during 2011-2018 were included in the study. Patients were classified into the initial shockable rhythm group and the non-shockable rhythm group. The primary outcome was the cerebral performance category (CPC) scale score at hospital discharge. A CPC score of 1 or 2 was defined as a good outcome. RESULTS: In total, 186 patients were eligible. Among them, 124 had an initial shockable rhythm and 62 had an initial non-shockable rhythm. Among all patients, 158 (85%) were male, with a median age of 59 (interquartile range [IQR], 48-65) years, and the median low flow time was 41 (IQR, 33-48) min. Collapse was witnessed in 169 (91%) patients, and 36 (19%) achieved return of spontaneous circulation (ROSC) transiently. Proportion of female patients, presence of bystander cardiopulmonary resuscitation, and collapse after the arrival of emergency medical service personnel were significantly higher in the non-shockable rhythm group. The rate of good outcomes at hospital discharge was not significantly different between the shockable and non-shockable groups (19% vs. 16%, p = 0.69). Initial shockable rhythm was not significantly associated with good outcome after controlling for potential confounders (adjusted odds ratio 1.58, 95% confidence interval: 0.66-3.81, p = 0.31). In the non-shockable group, patients with good outcomes had a higher rate of transient ROSC, and pulmonary embolism was the leading etiology. CONCLUSIONS: The outcomes of patients with an initial non-shockable rhythm are comparable with those having an initial shockable rhythm. OHCA patients with an initial non-shockable rhythm could be candidates for ECPR, if they are presumed to have reversible etiology and potential for good neurological recovery.

Dimethylthioarsenicals as arsenic metabolites and their chemical preparations.

Two unidentified arsenic metabolites were detected in the liver of rats on a gel filtration column by HPLC inductively coupled argon plasma mass spectrometry after an injection of dimethylarsinic (DMA(V)), dimethylarsinous (DMA(III)), monomethylarsonic (MMA(V)), or monomethylarsonous (MMA(III)) acid. The same arsenicals were also produced in vitro by incubation of DMA(III) in the liver supernatant but not by DMA(V). The two arsenic metabolites eluted at the same retention times as those of the two arsenicals prepared by reaction of DMA(V) with either thiosulfate plus disulfite or hydrogen sulfide or sodium sulfide plus sulfuric acid. The faster and slower eluting products on a gel filtration column were assigned as dimethyldithioarsinic acid (dimethylarsinodithioic acid) (DMTA(V)) and dimethylthioarsinous acid (DMTA(III)) from mass spectrometric data at m/z = 170 and 138 by electrospray ionization mass spectrometry with negative and positive ion modes, respectively. They were prepared selectively by reacting DMA(V) with hydrogen sulfide or sodium sulfide plus sulfuric acid under different reaction conditions. DMA(III) but not DMA(V) was transformed to DMTA(III) and DMTA(V) in the presence of sodium sulfide in vitro, suggesting that DMA(V) is reduced to DMA(III) with hydrogen sulfide, thiolated to DMTA(III), and then further thiolated oxidatively to DMTA(V). Metabolically, it is assumed that DMA(III) is transformed to DMTA(III) in the presence of sulfide ions, and then, DMTA(III) is oxidatively thiolated to DMTA(V). As the chemical species produced by reduction with the Reay and Asher method are DMTA(III) and DMTA(V), and different from DMA(III), the studies carried out with DMA(III) with the Reay and Asher method have to be reexamined.