Development and validation of a nomogram to predict in-hospital cardiac arrest among patients admitted with acute coronary syndrome.

AIM: This study aimed to develop and validate a nomogram to recognize in-hospital cardiac arrest (CA) in patients with acute coronary syndrome (ACS). METHODS: This multicenter case-control study reviewed 164 ACS patients who had in-hospital CA and randomly selected 521 ACS patients with no CA experience. We randomly assigned 80% of the participants to a development cohort, 20% of those to an independent validation cohort. The least absolute shrinkage and selection operator (LASSO) regression model was used for data dimension reduction, and multivariable logistic regression analysis was used to develop the CA prediction nomogram. Nomogram performance was assessed with respect to discrimination, calibration, and clinical usefulness. RESULTS: Seven parameters, including chest pain, Killip class, potassium, BNP, arrhythmia, platelet count, and NEWS, were used to create individualized CA prediction nomograms. The CA prediction nomogram showed good discrimination (C-index of 0.896, 95%CI, 0.865-0.927) and calibration. Application of the CA prediction nomogram in assessments of the validation cohort improved discrimination (C-index of 0.914, 95%CI, 0.873-0.967) and calibration. The results of decision curve analysis demonstrated that the CA prediction nomogram was clinically useful. CONCLUSION: Our study generated a friendly risk score to recognize in-hospital CA with good discrimination and calibration. Further studies need to establish a pathway to guide the application of the risk score in clinical practice.

SSEP retains its value as predictor of poor outcome following cardiac arrest in the era of therapeutic hypothermia.

OBJECTIVES: To re-evaluate the role of median nerve somatosensory evoked potentials (SSEPs) and bilateral loss of the N20 cortical wave as a predictor of unfavorable outcome in comatose patients following cardiac arrest (CA) in the therapeutic hypothermia (TH) era. METHODS: Review the results and conclusions drawn from isolated case reports and small series of comatose patients following CA in which the bilateral absence of N20 response has been associated with recovery, and evaluate the proposal that SSEP can no longer be considered a reliable and accurate predictor of unfavorable neurologic outcome. RESULTS: There are many methodological limitations in those patients reported in the literature with severe post anoxic encephalopathy who recover despite having lost their N20 cortical potential. These limitations include lack of sufficient clinical and neurologic data, severe core body hypothermia, specifics of electrophysiologic testing, technical issues such as background noise artifacts, flawed interpretations sometimes related to interobserver inconsistency, and the extreme variability in interpretation and quality of SSEP analysis among different clinicians and hospitals. CONCLUSIONS: The absence of the SSEP N20 cortical wave remains one of the most reliable early prognostic tools for identifying unfavorable neurologic outcome in the evaluation of patients with severe anoxic-ischemic encephalopathy whether or not they have been treated with TH. When confounding factors are eliminated the false positive rate (FPR) approaches zero.

Subphenotypes of Cardiac Arrest Patients Admitted to Intensive Care Unit: a latent profile analysis of a large critical care database.

Cardiac arrest (CA) may occur due to a variety of causes with heterogeneity in their clinical presentation and outcomes. This study aimed to identify clinical patterns or subphenotypes of CA patients admitted to the intensive care unit (ICU). The clinical and laboratory data of CA patients in a large electronic healthcare database were analyzed by latent profile analysis (LPA) to identify whether subphenotypes existed. Multivariable Logistic regression was used to assess whether mortality outcome was different between subphenotypes. A total of 1,352 CA patients fulfilled the eligibility criteria were included. The LPA identified three distinct subphenotypes: Profile 1 (13%) was characterized by evidence of significant neurological injury (low GCS). Profile 2 (15%) was characterized by multiple organ dysfunction with evidence of coagulopathy (prolonged aPTT and INR, decreased platelet count), hepatic injury (high bilirubin), circulatory shock (low mean blood pressure and elevated serum lactate); Profile 3 was the largest proportion (72%) of all CA patients without substantial derangement in major organ function. Profile 2 was associated with a significantly higher risk of death (OR: 2.09; 95% CI: 1.30 to 3.38) whilst the mortality rates of Profiles 3 was not significantly different from Profile 1 in multivariable model. LPA using routinely collected clinical data could identify three distinct subphenotypes of CA; those with multiple organ failure were associated with a significantly higher risk of mortality than other subphenotypes. LPA profiling may help researchers to identify the most appropriate subphenotypes of CA patients for testing effectiveness of a new intervention in a clinical trial.

Pulseless electrical activity following traumatic cardiac arrest: Sign of life or death?

BACKGROUND: Generally considered a sign of life, PEA is the most common arrhythmia encountered following pre-hospital traumatic cardiac arrest. Some recommend cardiac ultrasound (CUS) to determine cardiac wall motion (CWM) prior to terminating resuscitation efforts. This purpose of this study was to evaluate the outcomes of patients with traumatic cardiac arrest presenting with PEA, with and without CWM. METHODS: Trauma patients who underwent pre-hospital CPR were identified from the registries of two level-1 trauma centers. Pre-hospital management by emergency medical transport services was guided by advanced life support protocols. The on-duty trauma surgeon directed the resuscitations and performed or supervised CUS and determined CWM. RESULTS: Among 277 patients who underwent pre-hospital CPR, 110 patients had PEA on arrival to ED. 69 (62.7%) were injured by blunt mechanisms. Median CPR duration was 20.0 and 8.0 min for pre-hospital and ED, respectively. Sixty-three patients (22.7%) underwent resuscitative thoracotomy. One hundred seventy-two patients (62.1%) received CUS and of these 32 (18.6%) had CWM. CWM was significantly associated with survival to hospital admission (21.9% vs. 1.4%; P < 0.001); however, no patient with CUS survived to hospital discharge. Overall, only one patient with PEA on arrival survived to discharge. CONCLUSION: Following pre-hospital traumatic cardiac arrest, PEA on arrival portends death. Although CWM is associated with survival to admission, it is not associated with meaningful survival. Heroic resuscitative measures may be unwarranted for PEA following pre-hospital traumatic arrest, regardless of CWM.

Combination of S100B and procalcitonin improves prognostic performance compared to either alone in patients with cardiac arrest: A prospective observational study.

This study aimed to determine whether the combination of procalcitonin (PCT) and S100B improves prognostic performance compared to either alone in cardiac arrest (CA) patients treated with targeted temperature management (TTM).We performed a prospective cohort study of CA patients treated with TTM. PCT and S100B levels were obtained at 0, 24, 48, and 72 hours after return of spontaneous circulation. The prognostic performance was analyzed using each marker and the combination of the 2 markers for predicting poor neurological outcome at 3 months and mortality at 14 days and 3 months.A total of 97 patients were enrolled, of which 67 (69.1%) had poor neurological outcome. S100B showed a better prognostic performance (area under the curve [AUC], 0.934; sensitivity, 77.6%; and specificity, 100%) than PCT (AUC, 0.861; sensitivity, 70.2%; and specificity, 83.3%) with the highest prognostic value at 24 hours. The combination of 24-hour PCT and S100B values (S100B ≥0.2 µg/L or PCT ≥6.6 ng/mL) improved sensitivity (85.07%) compared with S100B alone. In multivariate analysis, PCT was associated with mortality at 14 days (odds ratio [OR]: 1.064, 95% confidence interval [CI]: 1.014-1.118), whereas S100B was associated with neurological outcomes at 3 months (OR: 9.849, 95% CI: 2.089-46.431).The combination of PCT and S100B improved prognostic performance compared to the use of either biomarker alone in CA patient treated with TTM. Further studies that will identify the optimal cutoff values for these biomarkers must be conducted.

La donación de órganos en asistolia controlada tipo iii de Maastricht: implicaciones éticas y cuidados al final de la vida / Organ donation after controlled cardiac death under Maastricht category iii: Ethical implications and end of life care

El descenso en la potencialidad de donación en muerte encefálica ha determinado la necesidad de valorar fuentes alternativas y la donación en asistolia representa una buena opción. Los objetivos del presente artículo han sido describir las características de la donación de órganos controlada tipo iii de Maastricht y determinar los cuidados al final de la vida y el papel de las enfermeras en el proceso de donación. En este tipo de donación, la parada cardiocirculatoria es previsible tras la limitación de tratamientos de soporte vital. Se trata de pacientes para los que no existen opciones de terapia efectivas y, en el contexto de una práctica organizada y planificada en la que participan cada uno de los profesionales implicados en el cuidado del paciente, se toma la decisión, de acuerdo con la familia, de retirar medidas de soporte vital. Esta limitación de tratamientos de soporte vital nunca se lleva a cabo con el objetivo de realizar una donación Maastricht iii, sino con el de evitar la prolongación del proceso de morir mediante intervenciones inútiles y posiblemente degradantes. La obligación del equipo de salud es proporcionar una muerte digna y ello no solo incluye la ausencia de dolor, sino que se debe garantizar al paciente y su entorno familiar una sensación de placidez y serenidad. Una vez tomada la decisión de no instauración o retirada de medidas, la enfermera tiene un papel importante en la implementación de un plan de cuidados paliativos en el que deben participar médicos, enfermeros y paciente/familiares, y cuyo foco debe ser la dignidad y el bienestar del paciente, considerando sus necesidades físicas, psicológicas y espirituales

The decrease in potential donation after brain death has resulted in a need to evaluate alternative sources. Donation after cardiac death is a good option. The objectives of this article are to describe the Maastricht type iii controlled organ donation characteristics and to determine end-of-life care and the role of nurses in the donation process. In this type of donation, cardiocirculatory arrest is predictable after the limitation of life sustaining treatments. These are patients for whom there are no effective therapy options and, in the context of an organised and planned practice involving all the professionals involved in the care of the patient, the decision is made, in consultation with the family, to withdraw life support measures. This limitation of life sustaining treatments is never carried out with the aim of making a Maastricht iii donation, but to avoid prolonging the dying process through useless and possibly degrading interventions. The obligation of the health team is to provide a dignified death and this not only includes the absence of pain, but the patient and their family must be guaranteed a feeling of calmness and serenity. Once the decision has been taken to withhold or withdraw measures, the nurse has an important role in the implementation of a palliative care plan in where physicians, nurses and patients/families should be involved and whose focus should be on patients' dignity and comfort, considering their physical, psychological and spiritual needs

Organ donation after controlled cardiac death under Maastricht category iii: Ethical implications and end of life care. / La donación de órganos en asistolia controlada tipo iii de Maastricht: implicaciones éticas y cuidados al final de la vida.

The decrease in potential donation after brain death has resulted in a need to evaluate alternative sources. Donation after cardiac death is a good option. The objectives of this article are to describe the Maastricht type iii controlled organ donation characteristics and to determine end-of-life care and the role of nurses in the donation process. In this type of donation, cardiocirculatory arrest is predictable after the limitation of life sustaining treatments. These are patients for whom there are no effective therapy options and, in the context of an organised and planned practice involving all the professionals involved in the care of the patient, the decision is made, in consultation with the family, to withdraw life support measures. This limitation of life sustaining treatments is never carried out with the aim of making a Maastricht iii donation, but to avoid prolonging the dying process through useless and possibly degrading interventions. The obligation of the health team is to provide a dignified death and this not only includes the absence of pain, but the patient and their family must be guaranteed a feeling of calmness and serenity. Once the decision has been taken to withhold or withdraw measures, the nurse has an important role in the implementation of a palliative care plan in where physicians, nurses and patients/families should be involved and whose focus should be on patients' dignity and comfort, considering their physical, psychological and spiritual needs.

A Conceptual Framework to Reduce Inpatient Preventable Deaths.

BACKGROUND: Efforts to reduce preventable deaths in the in-hospital setting should target both cardiopulmonary arrest (CPA) prevention and optimal resuscitation. This requires consideration of a broad range of clinical issues and processes. A comprehensive, integrated system of care (SOC) that links data collection with a modular education program to reduce preventable deaths has not been defined. METHODS: This study was conducted in two urban university hospitals from 2005 to 2009. The Advanced Resuscitation Training (ART) program was implemented in 2007, incorporating hands-on resuscitative skills and in-hospital-specific training with an institutional resuscitation database. Linkage between the database and training modules occurs via the ART Matrix, which classifies all CPA events into the following etiologies: sepsis, hemorrhage, pulmonary embolus, heart failure, tachyarrhythmias, bradyarrhythmias, acute respiratory distress syndrome, non-intubated pulmonary disease, obstructive apnea, traumatic brain injury, ischemic brain injury, and intracranial mass lesions. This taxonomy was validated using descriptive statistics, before-and-after analysis evaluating CPA incidence, and multivariate logistic regression to predict CPA survival. RESULTS: A total of 336 inpatients suffered a cardiopulmonary arrest during the study period-187 in the pre-ART period and 149 in the post-ART period. The vast majority of CPA events were categorized using the ART Matrix with high inter-observer reliability. As anticipated, changes in CPA incidence and survival were observed for some Matrix categories but not others following ART implementation. In addition, multivariate logistic regression revealed strong independent associations between taxonomy classifications and outcome. CONCLUSION: A novel SOC using a unique taxonomy for arrest classification appears to be effective at reducing inpatient CPA incidence and outcome.

Neurostimulant use is associated with improved survival in comatose patients after cardiac arrest regardless of electroencephalographic substrate.

AIM: Identify EEG patterns that predict or preclude favorable response in comatose post-arrest patients receiving neurostimulants. METHODS: We examined a retrospective cohort of consecutive electroencephalography (EEG)-monitored comatose post-arrest patients. We classified the last day of EEG recording before neurostimulant administration based on continuity (continuous/discontinuous), reactivity (yes/no) and malignant patterns (periodic discharges, suppression burst, myoclonic status epilepticus or seizures; yes/no). In subjects who did not receive neurostimulants, we examined the last 24h of available recording. For our primary analysis, we used logistic regression to identify EEG predictors of favorable response to treatment (awakening). RESULTS: In 585 subjects, mean (SD) age was 57 (17) years and 227 (39%) were female. Forty-seven patients (8%) received a neurostimulant. Neurostimulant administration independently predicted improved survival to hospital discharge in the overall cohort (adjusted odds ratio (aOR) 4.00, 95% CI 1.68-9.52) although functionally favorable survival did not differ. No EEG characteristic predicted favorable response to neurostimulants. In each subgroup of unfavorable EEG characteristics, neurostimulants were associated with increased survival to hospital discharge (discontinuous background: 44% vs 7%, P=0.004; non-reactive background: 56% vs 6%, P<0.001; malignant patterns: 63% vs 5%, P<0.001). CONCLUSION: EEG patterns described as ominous after cardiac arrest did not preclude survival or awakening after neurostimulant administration. These data are limited by their observational nature and potential for selection bias, but suggest that EEG patterns alone should not affect consideration of neurostimulant use.

Categorization of survival and death after cardiac arrest.

BACKGROUND: Most cardiac arrest (CA) patients remain comatose post-resuscitation, prompting goals-of-care (GOC) conversations. The impact of these conversations on patient outcomes has not been well described. METHODS: Patients (n=385) treated for CA in Columbia University ICUs between 2008-2015 were retrospectively categorized into various modes of survival and death based on documented GOC discussions. Patients were deemed "medically unstable" if there was evidence of hemodynamic instability at the time of discussion. Cerebral performance category (CPC) greater than 2 was defined as poor outcome at discharge and one-year post-arrest. RESULTS: The survival rate was 31% (n=118); most commonly after early recovery without any discussions (57%, n=67), followed by survival due to family wishes despite physicians predicting poor neurological prognosis (20%, n=24), and then survival after physician/family agreement of favorable prognosis (17%, n=20). The survivors due to family wishes had significantly worse outcomes compared to the early recovery group (discharge: p=0.01; one-year: p=0.06) and agreement group (p<0.001; p<0.001), though 2 patients did achieve favorable recovery. Among nonsurvivors (n=267), withdrawal of life-sustaining therapy (WLST) while medically unstable was most common (31%; n=83), followed by death after care was capped (24%, n=65), then WLST while medically stable (17%, n=45). Death despite full support, brain death and WLST due to advanced directives were less common causes. CONCLUSIONS: Most survivors due to family wishes despite poor neurological prognosis die or have poor outcomes at one-year. However, a small number achieve favorable recovery, demonstrating limitations with current prognostication methods. Among nonsurvivors, most WLST occurs while medically unstable, suggesting an overestimation of WLST due to unfavorable neurological prognosis.

Characterization of in-hospital cardiac arrest in adult patients at a tertiary hospital in Kenya

Background: In-hospital cardiac arrest (IHCA) is defined as a cardiac arrest that occurs in a hospital and for which resuscitation is attempted. Despite the increased morbidity and mortality, IHCA incidence and outcomes remain largely unknown especially in sub-Saharan Africa. This study describes the baseline characteristics, prearrest physiological parameters and the rate of survival to hospital discharge of adult patients with an IHCA at a tertiary hospital in Kenya. Methods: This was a retrospective chart review. Data on patient characteristics, pre-arrest physiological parameters and discharge condition were collected on all patients 18 years of age or older with an IHCA at the Aga Khan University Hospital, Nairobi, from January 2013 to December 2013. Results: The main study population comprised 108 patients. The mean age was 59.3 ± 18.4 years and 63 (58.3%) patients were men. The initial rhythm post cardiac arrest was pulseless electrical activity (41.7%) or asystole (35.2%) in the majority of cases. Hypertension (43.5%), septicaemia (40.7%), renal insufficiency (30.6%), diabetes mellitus (25.9%) and pneumonia (15.7%) were the leading pre-existing conditions in the patients. A Modified Early Warning Score (MEWS) of 5 or more was reached in 56 (67.5%, n= 83) patients before the cardiac arrest. The rate of survival to hospital discharge was 11.1%. All the patients who survived to hospital discharge had a good neurological outcome. Conclusions: Early identification of warning signs that precede many in-hospital arrests may enable institution of treatment to prevent patient deterioration. Local hospitals should be encouraged to provide patients with resuscitation services and equipment in line with evidence-based programmes