Neurofilament light compared to neuron-specific enolase as a predictor of unfavourable outcome after out-of-hospital cardiac arrest.

AIM: We compared the prognostic abilities of neurofilament light (NfL) and neuron-specific enolase (NSE) in patients resuscitated from out-of-hospital cardiac arrest (OHCA) of various aetiologies. METHODS: We analysed frozen blood samples obtained at 24 and 48 hours from OHCA patients treated in 21 Finnish intensive care units in 2010 and 2011. We defined unfavourable outcome as Cerebral Performance Category (CPC) 3-5 at 12 months after OHCA. We evaluated the prognostic ability of the biomarkers by calculating the area under the receiver operating characteristic curves (AUROCs [95% confidence intervals]) and compared these with a bootstrap method. RESULTS: Out of 248 adult patients, 12-month outcome was unfavourable in 120 (48.4%). The median (interquartile range) NfL concentrations for patients with unfavourable and those with favourable outcome, respectively, were 689 (146-1804) pg/mL vs. 31 (17-61) pg/mL at 24 h and 1162 (147-4360) pg/mL vs. 36 (21-87) pg/mL at 48 h, p < 0.001 for both. The corresponding NSE concentrations were 13.3 (7.2-27.3) µg/L vs. 8.5 (5.8-13.2) µg/L at 24 h and 20.4 (8.1-56.6) µg/L vs. 8.2 (5.9-12.1) µg/L at 48 h, p < 0.001 for both. The AUROCs to predict an unfavourable outcome were 0.90 (0.86-0.94) for NfL vs. 0.65 (0.58-0.72) for NSE at 24 h, p < 0.001 and 0.88 (0.83-0.93) for NfL and 0.73 (0.66-0.81) for NSE at 48 h, p < 0.001. CONCLUSION: Compared to NSE, NfL demonstrated superior accuracy in predicting long-term unfavourable outcome after OHCA.

Airway management during in-hospital cardiac arrest: An international, multicentre, retrospective, observational cohort study.

AIM: To determine the type of airway devices used during in-hospital cardiac arrest (IHCA) resuscitation attempts. METHODS: International multicentre retrospective observational study of in-patients aged over 18 years who received chest compressions for cardiac arrest from April 2016 to September 2018. Patients were identified from resuscitation registries and rapid response system databases. Data were collected through review of resuscitation records and hospital notes. Airway devices used during cardiac arrest were recorded as basic (adjuncts or bag-mask), or advanced, including supraglottic airway devices, tracheal tubes or tracheostomies. Descriptive statistics and multivariable regression modelling were used for data analysis. RESULTS: The final analysis included 598 patients. No airway management occurred in 36 (6%), basic airway device use occurred at any time in 562 (94%), basic airway device use without an advanced airway device in 182 (30%), tracheal intubation in 301 (50%), supraglottic airway in 102 (17%), and tracheostomy in 1 (0.2%). There was significant variation in airway device use between centres. The intubation rate ranged between 21% and 90% while supraglottic airway use varied between 1% and 45%. The choice of tracheal intubation vs. supraglottic airway as the second advanced airway device was not associated with immediate survival from the resuscitation attempt (odds ratio 0.81; 95% confidence interval 0.35-1.8). CONCLUSION: There is wide variation in airway device use during resuscitation after IHCA. Only half of patients are intubated before return of spontaneous circulation and many are managed without an advanced airway. Further investigation is needed to determine optimal airway device management strategies during resuscitation following IHCA.

Correction to: Serum sodium and intracranial pressure changes after desmopressin therapy in severe traumatic brain injury patients: a multi-centre cohort study.

Following publication of the original article [1], we were notified that the collaborators' names part of the "The TBI Collaborative" group has not been indexed in Pubmed. Below the collaborators names full list.

Serum sodium and intracranial pressure changes after desmopressin therapy in severe traumatic brain injury patients: a multi-centre cohort study.

BACKGROUND: In traumatic brain injury (TBI) patients desmopressin administration may induce rapid decreases in serum sodium and increase intracranial pressure (ICP). AIM: In an international multi-centre study, we aimed to report changes in serum sodium and ICP after desmopressin administration in TBI patients. METHODS: We obtained data from 14 neurotrauma ICUs in Europe, Australia and UK for severe TBI patients (GCS ≤ 8) requiring ICP monitoring. We identified patients who received any desmopressin and recorded daily dose, 6-hourly serum sodium, and 6-hourly ICP. RESULTS: We studied 262 severe TBI patients. Of these, 39 patients (14.9%) received desmopressin. Median length of treatment with desmopressin was 1 [1-3] day and daily intravenous dose varied between centres from 0.125 to 10 mcg. The median hourly rate of decrease in serum sodium was low (- 0.1 [- 0.2 to 0.0] mmol/L/h) with a median period of decrease of 36 h. The proportion of 6-h periods in which the rate of natremia correction exceeded 0.5 mmol/L/h or 1 mmol/L/h was low, at 8% and 3%, respectively, and ICPs remained stable. After adjusting for IMPACT score and injury severity score, desmopressin administration was independently associated with increased 60-day mortality [HR of 1.83 (1.05-3.24) (p = 0.03)]. CONCLUSIONS: In severe TBI, desmopressin administration, potentially representing instances of diabetes insipidus is common and is independently associated with increased mortality. Desmopressin doses vary markedly among ICUs; however, the associated decrease in natremia rarely exceeds recommended rates and median ICP values remain unchanged. These findings support the notion that desmopressin therapy is safe.

Does care at a cardiac arrest centre improve outcome after out-of-hospital cardiac arrest? - A systematic review.

AIM: To perform a systematic review to answer 'In adults with attempted resuscitation after non-traumatic cardiac arrest does care at a specialised cardiac arrest centre (CAC) compared to care in a healthcare facility not designated as a specialised cardiac arrest centre improve patient outcomes?' METHODS: The PRISMA guidelines were followed. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 1st August 2018. Randomised controlled trials (RCTs) and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using ROBINS-I tool and GRADEpro respectively. Primary outcomes were survival to 30 days with favourable neurological outcomes and survival to hospital discharge with favourable neurological outcomes. Secondary outcomes were survival to 30 days, survival to hospital discharge and return of spontaneous circulation (ROSC) post-hospital arrival for patients with ongoing resuscitation. This systematic review was registered in PROSPERO (CRD 42018093369) RESULTS: We included data from 17 observational studies on out-of-hospital cardiac arrest (OHCA) patients in meta-analyses. Overall, the certainty of evidence was very low. Pooling data from only adjusted analyses, care at CAC was not associated with increased likelihood of survival to 30 days with favourable neurological outcome (OR 2.92, 95% CI 0.68-12.48) and survival to 30 days (OR 2.14, 95% CI 0.73-6.29) compared to care at other hospitals. Whereas patients cared for at CACs had improved survival to hospital discharge with favourable neurological outcomes (OR 2.22, 95% CI 1.74-2.84) and survival to hospital discharge (OR 1.85, 95% CI 1.46-2.34). CONCLUSIONS: Very low certainty of evidence suggests that post-cardiac arrest care at CACs is associated with improved outcomes at hospital discharge. There remains a need for high quality data to fully elucidate the impact of CACs.

Costs, outcome and cost-effectiveness of neurocritical care: a multi-center observational study.

BACKGROUND: Neurocritical illness is a growing healthcare problem with profound socioeconomic effects. We assessed differences in healthcare costs and long-term outcome for different forms of neurocritical illnesses treated in the intensive care unit (ICU). METHODS: We used the prospective Finnish Intensive Care Consortium database to identify all adult patients treated for traumatic brain injury (TBI), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) and acute ischemic stroke (AIS) at university hospital ICUs in Finland during 2003-2013. Outcome variables were one-year mortality and permanent disability. Total healthcare costs included the index university hospital costs, rehabilitation hospital costs and social security costs up to one year. All costs were converted to euros based on the 2013 currency rate. RESULTS: In total 7044 patients were included (44% with TBI, 13% with ICH, 27% with SAH, 16% with AIS). In comparison to TBI, ICH was associated with the highest risk of death and permanent disability (OR 2.6, 95% CI 2.1-3.2 and OR 1.7, 95% CI 1.4-2.1), followed by AIS (OR 1.9, 95% CI 1.5-2.3 and OR 1.5, 95% CI 1.3-1.8) and SAH (OR 1.8, 95% CI 1.5-2.1 and OR 0.8, 95% CI 0.6-0.9), after adjusting for severity of illness. SAH was associated with the highest mean total costs (€51,906) followed by ICH (€47,661), TBI (€43,916) and AIS (€39,222). Cost per independent survivor was lower for TBI (€58,497) and SAH (€96,369) compared to AIS (€104,374) and ICH (€178,071). CONCLUSION: Neurocritical illnesses are costly and resource-demanding diseases associated with poor outcomes. Intensive care of patients with TBI or SAH more commonly result in independent survivors and is associated with lower total treatments costs compared to ICH and AIS.

A pilot study of hyperoxemia on neurological injury, inflammation and oxidative stress.

BACKGROUND: Normobaric hyperoxia is used to alleviate secondary brain ischaemia in patients with traumatic brain injury (TBI), but clinical evidence is limited and hyperoxia may cause adverse events. METHODS: An open label, randomised controlled pilot study comparing blood concentrations of reactive oxygen species (ROS), interleukin 6 (IL-6) and neuron-specific enolase (NSE) between two different fractions of inspired oxygen in severe TBI patients on mechanical ventilation. RESULTS: We enrolled 27 patients in the Fi O2 0.40 group and 38 in the Fi O2 0.70 group; 19 and 23 patients, respectively, completed biochemical analyses. In baseline, there were no differences between Fi O2 0.40 and Fi O2 0.70 groups, respectively, in ROS (64.8 nM [22.6-102.1] vs. 64.9 nM [26.8-96.3], P = 0.80), IL-6 (group 92.4 pg/ml [52.9-171.6] vs. 94.3 pg/ml [54.8-133.1], P = 0.52) or NSE (21.04 ug/l [14.0-30.7] vs. 17.8 ug/l [14.1-23.9], P = 0.35). ROS levels did not differ at Day 1 (24.2 nM [20.6-33.5] vs. 29.2 nM [22.7-69.2], P = 0.10) or at Day 2 (25.4 nM [21.7-37.4] vs. 47.3 nM [34.4-126.1], P = 0.95). IL-6 concentrations did not differ at Day 1 (112.7 pg/ml [65.9-168.9) vs. 83.9 pg/ml [51.8-144.3], P = 0.41) or at Day 3 (55.0 pg/ml [34.2-115.6] vs. 49.3 pg/ml [34.4-126.1], P = 0.95). NSE levels did not differ at Day 1 (15.9 ug/l [9.0-24.3] vs. 15.3 ug/l [12.2-26.3], P = 0.62). There were no differences between groups in the incidence of pulmonary complications. CONCLUSION: Higher fraction of inspired oxygen did not increase blood concentrations of markers of oxidative stress, inflammation or neurological injury or the incidence of pulmonary complications in severe TBI patients on mechanical ventilation.

The effects of intravenous lipid emulsion on hemodynamic recovery and myocardial cell mitochondrial function after bupivacaine toxicity in anesthetized pigs.

Local anesthetic toxicity is thought to be mediated partly by inhibition of cardiac mitochondrial function. Intravenous (i.v.) lipid emulsion may overcome this energy depletion, but doses larger than currently recommended may be needed for rescue effect. In this randomized study with anesthetized pigs, we compared the effect of a large dose, 4 mL/kg, of i.v. 20% Intralipid® ( n = 7) with Ringer's acetate ( n = 6) on cardiovascular recovery after a cardiotoxic dose of bupivacaine. We also examined mitochondrial respiratory function in myocardial cell homogenates analyzed promptly after needle biopsies from the animals. Bupivacaine plasma concentrations were quantified from plasma samples. Arterial blood pressure recovered faster and systemic vascular resistance rose more rapidly after Intralipid than Ringer's acetate administration ( p < 0.0001), but Intralipid did not increase cardiac index or left ventricular ejection fraction. The lipid-based mitochondrial respiration was stimulated by approximately 30% after Intralipid ( p < 0.05) but unaffected by Ringer's acetate. The mean (standard deviation) area under the concentration-time curve (AUC) of total bupivacaine was greater after Intralipid (105.2 (13.6) mg·min/L) than after Ringer's acetate (88.1 (7.1) mg·min/L) ( p = 0.019). After Intralipid, the AUC of the lipid-un-entrapped bupivacaine portion (97.0 (14.5) mg·min/L) was 8% lower than that of total bupivacaine ( p < 0.0001). To conclude, 4 mL/kg of Intralipid expedited cardiovascular recovery from bupivacaine cardiotoxicity mainly by increasing systemic vascular resistance. The increased myocardial mitochondrial respiration and bupivacaine entrapment after Intralipid did not improve cardiac function.

Increased need for interventions predicts mortality in the critically ill.

INTRODUCTION: The aim of this study was to determine the association of early treatment intensity with hospital mortality of intensive care unit (ICU) patients. METHODS: We performed an observational study based on a national ICU registry. We included adult patients treated in Finnish ICUs between 2003 and 2013 with the length of ICU stay of more than 3 days. We measured treatment intensity with the Therapeutic Intervention Scoring System (TISS-76). We assessed mean and daily TISS scores. To define the change in treatment intensity during the first days in the ICU, we calculated the difference between the TISS score on day 3 and the score on day 1 (ΔTISS). We used multivariate logistic regression to adjust for baseline differences and continuous net reclassification improvement (NRI) to determine the impact of adding TISS data to the baseline prediction model on its prognostic performance. RESULTS: We identified 42,493 patients eligible for the study. For 71% of the patients, ΔTISS was ≤ 0 and crude hospital mortality was 18%. ΔTISS > 0 was observed for 29% of the patients, with a hospital mortality of 23%. When compared to the group ΔTISS ≤ 0, the category ΔTISS > 0 was independently associated with substantially increased mortality. Adding TISS data to the prediction model resulted in the improvement of prognostic performance particularly in the patients with the lowest initial baseline risk. CONCLUSIONS: Early increase in TISS scores was associated with increased risk of death, especially in patients with a lower initial severity of illness.

Intravenous lipid emulsion for levobupivacaine intoxication in acidotic and hypoxaemic pigs.

Intravenous lipid emulsion is, in some countries, the recommended treatment for local anaesthetic toxicity. Systemic local anaesthetic toxicity results in hypoxaemia and acidosis, and whether this influences the effects of lipid therapy on drug concentrations and cardiovascular recovery is currently unknown. Twenty anaesthetised pigs were given a 3-mg/kg bolus of levobupivacaine followed by a five minute phase of hypoventilation and 1 mmol/kg of lactic acid in one minute. After lactic acid infusion, pigs were treated, in randomised order, with either 20% lipid emulsion or Ringer's acetate for 30 min: a 1.5-ml/kg bolus followed by a 0.25-ml/kg/minute infusion. Haemodynamic parameters were recorded and blood samples were collected for pharmacokinetic analysis. There was no difference between the groups in the area under the plasma levobupivacaine concentration-time curve (AUC) or between that and AUC of unentrapped levobupivacaine in the Lipid group, or in the plasma half-lives. The cardiovascular outcome and normalisation of the electrocardiogram were similar in both groups. Five pigs developed marked hypotension: one in both groups died, while two in the Lipid group and one in the Ringer group needed adrenaline. Administration of lipid emulsion did not improve cardiovascular recovery from levobupivacaine toxicity exacerbated by acidosis and hypoxaemia. Lipid emulsion did not entrap levobupivacaine or affect levobupivacaine pharmacokinetics.

Unconscious trauma patients: outcome differences between southern Finland and Germany-lesson learned from trauma-registry comparisons.

PURPOSE: International trauma registry comparisons are scarce and lack standardised methodology. Recently, we performed a 6-year comparison between southern Finland and Germany. Because an outcome difference emerged in the subgroup of unconscious trauma patients, we aimed to identify factors associated with such difference and to further explore the role of trauma registries for evaluating trauma-care quality. METHODS: Unconscious patients [Glasgow Coma Scale (GCS) 3-8] with severe blunt trauma [Injury Severity Score (ISS) ≥16] from Helsinki University Hospital's trauma registry (TR-THEL) and the German Trauma Registry (TR-DGU) were compared from 2006 to 2011. The primary outcome measure was 30-day in-hospital mortality. Expected mortality was calculated by Revised Injury Severity Classification (RISC) score. Patients were separated into clinically relevant subgroups, for which the standardised mortality ratios (SMR) were calculated and compared between the two trauma registries in order to identify patient groups explaining outcome differences. RESULTS: Of the 5243 patients from the TR-DGU and 398 from the TR-THEL included, nine subgroups were identified and analyzed separately. Poorer outcome appeared in the Finnish patients with penetrating head injury, and in Finnish patients under 60 years with isolated head injury [TR-DGU SMR = 1.06 (95 % CI = 0.94-1.18) vs. TR-THEL SMR = 2.35 (95 % CI = 1.20-3.50), p = 0.001 and TR-DGU SMR = 1.01 (95 % CI = 0.87-1.16) vs. TR-THEL SMR = 1.40 (95 % CI = 0.99-1.81), p = 0.030]. A closer analysis of these subgroups in the TR-THEL revealed early treatment limitations due to their very poor prognosis, which was not accounted for by the RISC. CONCLUSION: Trauma registry comparison has several pitfalls needing acknowledgement: the explanation for outcome differences between trauma systems can be a coincidence, a weakness in the scoring system, true variation in the standard of care, or hospitals' reluctance to include patients with hopeless prognosis in registry. We believe, however, that such comparisons are a feasible method for quality control.

External validation of the Norwegian survival prediction model in trauma after major trauma in Southern Finland.

BACKGROUND: The Norwegian Survival Prediction Model in Trauma (NORMIT) is a newly developed outcome prediction model for patients with trauma. We aimed to compare the novel NORMIT to the more commonly used Trauma and Injury Severity Score (TRISS) in Finnish trauma patients. METHODS: We performed a retrospective open-cohort study, using the trauma registry of Helsinki university hospital's trauma unit, including severely injured patients (new injury severity score > 15) admitted from 2007 to 2011. We used 30-day in-hospital mortality as the primary outcome, and discharge functional outcome as a secondary outcome of interest. Model performance was evaluated by comparing discrimination (by area under the receiver operating characteristic curve [AUC]), using a re-sample bootstrap technique, and by assessing calibration (GiViTI belt). RESULTS: We identified 1111 patients fulfilling the study inclusion criteria. Overall mortality was 13% (n = 147). NORMIT showed slightly better discrimination for mortality prediction (AUC = 0.83, 95% confidence interval [CI] = 0.80-0.86 vs. AUC = 0.79, 95% CI = 0.75-0.83, P = 0.004) and functional outcome prediction (AUC = 0.78, 95% CI = 0.76-0.82 vs. AUC = 0.75, 95% CI = 0.72-0.78, P < 0.001) than TRISS. Calibration testing revealed poor calibration for both NORMIT and TRISS (P < 0.001), by giving too pessimistic predictions (predicted survival significantly lower than actual survival). CONCLUSION: NORMIT and TRISS showed good discrimination, but poor calibration, in this mixed cohort of severely injured trauma patients from Southern Finland. We found NORMIT to be a feasible alternative to TRISS for trauma patient outcome prediction, but trauma prediction models with improved calibration are needed.

Temporal trends in cardiac arrest incidence and outcome in Finnish intensive care units from 2003 to 2013.

PURPOSE: To estimate temporal trends in incidence and hospital mortality after cardiac arrest in Finnish intensive care units. METHODS: Using a large nationwide intensive care unit (ICU) database we identified patients suffering from cardiac arrest following ICU admission (ICU-CA) during the study period (2003-2013). ICU-CA was defined as need for cardiopulmonary resuscitation and/or defibrillation (non-arrest cardioversions were excluded) according to the Therapeutic Intervention Scoring System-76. Patients admitted with an admission diagnosis of cardiac arrest were excluded. We determined crude incidence and risk-adjusted hospital mortality (based on a customized severity of illness model) for all ICU-CA patients, and for predefined admission diagnosis subgroups. Temporal trends for the observed period were calculated for crude incidence and risk-adjusted hospital mortality. RESULTS: Crude incidence for all ICU-CA patients was 29/1,000 ICU admissions, with the highest incidence 118/1,000 in the non-operative cardiovascular subgroup. Overall hospital mortality for ICU-CA patients was 55.5% [95% confidence interval (CI) 54-57%]. Hospital mortality was 53.1% (95% CI 50.4-55.8%) for non-operative cardiovascular ICU-CA patients, 32.9% (95% CI 26.9-38.9%) for post cardiac surgery ICU-CA patients, and 56.3% (95% CI 51.2-61.3%) for neurological/neurosurgical ICU-CA patients. There was a significant reduction in the overall ICU-CA incidence and in the risk-adjusted hospital mortality of ICU-CA and non-cardiac arrest cases (non-CA) over the observed study period (p < 0.001). CONCLUSION: Our data suggest that the incidence of ICU-CA has decreased in Finnish ICUs between 2003 and 2013. Similar reduction in hospital mortality over time was observed for both ICU-CA and non-CA populations.

Survival and outcome prediction using the Apache III and the out-of-hospital cardiac arrest (OHCA) score in patients treated in the intensive care unit (ICU) following out-of-hospital, in-hospital or ICU cardiac arrest.

BACKGROUND: There are few data comparing outcome and the utility of severity of illness scoring systems following intensive care after out-of-hospital (OHCA), in-hospital (IHCA) and intensive care unit (ICUCA) cardiac arrest. We investigated survival, factors associated with survival and the correlation and accuracy of general and specific scoring systems, including the Apache III score and the OHCA score in OHCA, IHCA and ICUCA patients. MATERIAL AND METHODS: Prospective analysis of data on all cardiac arrest patients treated in a tertiary hospital between August 1st 2008 and July 30th 2010. Collected data included resuscitation and post-resuscitation care data as defined by the Utstein Guidelines, Apache III on admission and the OHCA score on admission in OHCA and IHCA patients and after the arrest in ICUCA patients. Statistical methods were used to identify factors associated with outcome and the predictive ability and correlation of the aforementioned scores. RESULTS: Of a total of 3931 patients treated in the ICU, 51 were admitted following OHCA, 50 following IHCA and 22 suffered an ICUCA and had sustained return of spontaneous circulation (ROSC). Survival at 30 days was highest among ICUCAs (67%) followed by IHCAs (38%) and OHCAs (29%). Using multivariate analysis delay ROSC was the only independent predictor of survival. The OHCA score performed with moderate accuracy for predicting 30-day mortality (area under the curve 0.77 [0.69-0.86] and was slightly better than the Apache III score 0.71 (0.61-0.80). Using multiple logistic regression the Apache III and the OHCA score were both independent predictors of hospital survival and correlation between these two scores was weak (correlation coefficient of 0.244). CONCLUSIONS: Latency to ROSC seems to be the most important determinant of survival in patients following ICU care after a cardiac arrest in this single center trial. The OHCA score and the Apache III score offer moderate predictive accuracy in ICU cardiac arrest patients but correlated weakly with each other. Illness severity adjustment for cardiac arrest patients in ICU should include features of both these scoring systems.

Comparison of Helsinki and European Resuscitation Council "do not attempt to resuscitate" guidelines, and a termination of resuscitation clinical prediction rule for out-of-hospital cardiac arrest patients found in asystole or pulseless electrical activity.

BACKGROUND: The outcome of out-of-hospital cardiac arrest (OHCA) with a non-shockable rhythm is poor. For patients found in asystole or pulseless electrical activity (PEA), recent guidelines or rules that may be used include "do not attempt to resuscitate" (DNAR) guidelines from Helsinki, discontinuing resuscitation in the guidelines of the European Resuscitation Council and a clinical prediction rule from Canada. We compared these guidelines and the rule using a large Scandinavian dataset. MATERIALS AND METHODS: The Swedish Cardiac Arrest Registry includes prospectively collected data on 44121 OHCA patients. We identified patients with asystole or PEA as the initial rhythm and excluded cases caused by trauma or drowning. The specificities and positive predictive values (PPVs) were calculated for the guidelines, and the clinical prediction rule for comparison. RESULTS: A total of 20484 patients with non-shockable rhythms were identified; 85% had asystole and 15% PEA. The overall survival to hospital admission was 9% (n=1.861) and 1% (n=231) were alive at 1 month from the arrest. The specificity of the Helsinki guidelines in identifying non-survivors was 71% (95% confidence interval (CI): 65-77%) and the PPV was 99.4% (95% CI: 99.3-99.5), while the corresponding values for the European Resuscitation Council (ERC) was 95% (95% CI: 91.3-97.5) and 99.9% (95% CI: 99.9-99.9) and, for the prediction rule, 99.1% (95% CI: 96.7-99.9) and 99.9% (95% CI: 99.9-100.00), respectively. CONCLUSION: In this comparison study, the Helsinki DNAR guidelines did not perform well enough in a general OHCA material to be widely adopted. The main reason for this was the unpredicted survival of patients with unwitnessed asystole. The clinical prediction rule and the recommendations of the ERC Guidelines worked well.

Do patient characteristics or factors at resuscitation influence long-term outcome in patients surviving to be discharged following in-hospital cardiac arrest?

INTRODUCTION: Few studies have focused on factors influencing long-term outcome following in-hospital cardiac arrest. The present study assesses whether long-term outcome is influenced by difference in patient factors or factors at resuscitation. METHODS: An analysis of cardiac arrest data collected from one Swedish tertiary hospital and from five Finnish secondary hospitals supplemented with data on 1 year survival. Multiple logistic regression analysis was used to identify factors associated with survival at 12 months. RESULTS: A total of 441 patients survived to hospital discharge following in-hospital cardiac arrest and 359 (80%) were alive at 12 months. Factors independently associated with survival [odds ratio (OR) >1 indicates increased survival and <1 decreased survival] at 12 months were; age [OR 0.95, 95% confidence interval (CI) 0.93-0.98], renal disease (OR 0.3, CI 0.1-0.9), good functional status at discharge (OR 4.9, CI 1.3-18.9), arrest occurring at (compared with arrests on general wards) emergency wards (OR 4.7, CI 1.4-15.3), cardiac care unit (OR 2.8, CI 1.2-6.4), intensive care unit (OR 2.4, CI 1.1-5.7), ward for thoracic surgery (OR 10.2, CI 2.6-40.1) and unit for interventional radiology (OR 13.3, CI 3.4-52.0). There was no difference in initial rhythm, delay to defibrillation or delay to return of spontaneous circulation between survivors and nonsurvivors. CONCLUSION: Several patient factors, mainly age, functional status and co-morbid disease, influence long-term survival following cardiac arrest in hospital. The location where the arrest occurred also influences survival, but initial rhythm, delay to defibrillation and to return of spontaneous circulation do not.

Variability in survival after in-hospital cardiac arrest depending on the hospital level of care.

BACKGROUND: Survival after in-hospital cardiac arrest (IHCA) differs considerably between hospitals. This study tries to determine whether this difference is due to patient selection because of the hospital level of care or to effective resuscitation management. METHODS: Prospectively collected data on management of in-hospital cardiac arrests from Sahlgrenska Hospital, a tertiary hospital in Gothenburg, Sweden (cohort one) and from five Finnish secondary hospitals (cohort two). A multiple logistic regression model was created for predicting survival to hospital discharge. RESULTS: A total of 954 cases from Sahlgrenska Hospital and 624 patients from the hospitals in Finland were included. The delay to defibrillation was longer at Sahlgrenska than at the five Finnish secondary hospitals (p=0.045). Significant predictors of survival were: (1) age below median (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.5-2.8); (2) no diabetes (OR 1.9, CI 1.2-2.9); (3) arrests occurring during office hours (OR 1.5, CI 1.1-2.2); (4) witnessed cardiac arrest (OR 6.3, CI 2.6-15.3); (5) ventricular fibrillation or ventricular tachycardia as the initial rhythm (OR 4.9, CI 3.5-6.7); (6) location of the arrest (compared to arrests in general wards, GW): thoracic surgery and heart transplantation ward (OR 2.9, CI 1.5-5.9), interventional radiology (OR 4.8, CI 1.9-12.0) and other in-hospital locations (3.0, CI 1.6-5.7) and (7) hospital (compared to arrests at Sahlgrenska Hospital); arrests at Etelä-Karjala Central Hospital [CH] (OR 0.3, CI 0.1-0.7), Päijät-Hame CH (OR 0.3, CI 0.1-0.8) and Seinäjoki CH (OR 0.4, CI 0.3-0.7). CONCLUSION: The comparison of survival following IHCA between different hospitals is difficult, there seems to be undefined factors greatly associated with outcome. A great variability in survival within different hospital areas probably because of differences in patient selection, patient surveillance and resuscitation management was also noted. A locally implemented strong in-hospital chain of survival is probably the only way to improve outcome following IHCA.