Risultati per: Circulation

Circulation, Volume 150, Issue Suppl_1, Page ASu204-ASu204, November 12, 2024. Introduction:International guidelines support use of end-tidal carbon dioxide (ETCO2) for monitoring resuscitation in out-of-hospital cardiac arrest (OHCA). Specific ETCO2cutoffs have been proposed for termination of resuscitation, though data on rates of ROSC based on changes in ETCO2is limited. We aimed to evaluate the relationship between change in ETCO2in OHCA and its relationship to return of spontaneous circulation (ROSC) using a US national database.Methods:This retrospective analysis of National Emergency Medical Services Information System (NEMSIS) datasets from 2020 to 2022 evaluated all adult patients who underwent resuscitation for OHCA and had multiple ETCO2measurements. We excluded cases with missing data. The highest difference between two sequential ETCO2measurements (MΔETCO2) and total difference between minimum and maximum ETCO2measurements [TΔETCO2] were calculated for each case. ΔETCO2groups were stratified into 10-unit increments and we compared rates of ROSC between groups. We then used multivariable logistic regression to evaluate the association between each 5 unit increase in ΔETCO2and ROSC. We adjusted for age, sex, location, witness status, initial shockable rhythm, and CPR or AED prior to EMS arrival.Results:We included 274,516 total patients with 1,686,390 ETCO2measurements. The median number of ETCO2measurements was 5 (IQR 3-8). Median age was 65, 62.8% were male, 60.1% had witnessed arrests, and 78.3% received CPR and 32.3% received AED placement prior to EMS arrival. ROSC rates based on MΔETCO2were 0-10 mmHg [33.3%], 10-20 mmHg [42.3%], 20-30 mmHg [49.7%], 30-40 mmHg [53.2%], and >40 mmHg [56.6%]. ROSC rates for TΔETCO2were 0-10 mmHg [29.6%], 10-20 mmHg [36.7%], 20-30 mmHg [43.5%], 30-40 mmHg [48.9%], and >40 mmHg [54.6%]. Adjusted odds of ROSC per 10 mmHg increase in MΔETCO2was 1.21 [1.21-1.22] and TΔETCO2was 1.19 [1.19-1.19].Conclusions:Increasing max and overall ΔETCO2was associated with increased rates and odds of ROSC for OHCA.

Circulation, Volume 150, Issue Suppl_1, Page ASa1001-ASa1001, November 12, 2024. Introduction:Epinephrine is the mainstay of drug treatment during cardiac arrest and it is firmly established that it promotes Return of Spontaneous Circulation (ROSC). In this study we aimed to describe the effect and occurrence of ROSC after administering epinephrine to hospitalized patients with primary pulseless electrical activity (PEA), i.e., administered during PEA as the first recorded arrest rhythm.Method:We investigated 78 episodes of primary PEA registered between Aug. 2018 and Oct. 2022 at St. Olav University Hospital (Trondheim, Norway). In 36 episodes, the first dose of epinephrine was administered during primary PEA and registered with minute precision. We created different time dependent covariate profiles for the effect of epinephrine, starting at 0 (time of administration), rising linearly to 1 (presumed maximum effect) and decreasing to 0 immediately thereafter. Time to presumed maximum effect started at 5 seconds (s) after administration and increased in steps of 5s until 300s. We entered each of these different covariate profiles into separate Cox regression models using time to ROSC as outcome obtaining in total 60 Hazard ratios (HR) from all the models.Results:Median time to epinephrine administration was 185s (range 80 to 310) after start of resuscitation. In total, 23 patients obtained ROSC after the administration of epinephrine and 15 patients obtained ROSC without epinephrine. The different hazard ratios (y-axis) were plotted against the location of the maximum point of the covariate profile (x-axis) in Fig. 1. HR peaked twice, at 70 and 155s, 11.4(p< 0.001) and 4.1(p= 0.013), respectively.Discussion:This study indicates a strong effect of epinephrine during primary PEA 1-2 min after administration. This information may provide the treating team with useful insight on what to expect after administering epinephrine. In addition, the actual effect may be even larger, as the sickest patients (expected to respond less well to epinephrine) are more often monitored and thus recieve epinephrine earlier.

Circulation, Volume 150, Issue Suppl_1, Page ASu304-ASu304, November 12, 2024. Objective:The optimal timing for defibrillation attempts in out-of-hospital cardiac arrest (OHCA) patients with recurrent shockable rhythms [ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT)] is uncertain. This study examined the association between “time to DC shock” and the return of spontaneous circulation (ROSC) in OHCA patients with recurrent shockable rhythms.Methods:This was a retrospective analysis of data from the Salt Lake City Fire Department (SLCFD) from 2012 to 2023. Rhythm-filtering technology, used since 2012, enabled real-time and accurate interpretation of cardiac rhythms during CPR, with local protocols allowing early defibrillation for recurrent VF/ pulseless VT cases. Patients who experienced four or five episodes of shockable rhythms and received defibrillation were included. Generalized estimating equation (GEE) analysis was used to evaluate the association between time to shock preceding recurrent defibrillation and ROSC.Results:A total of 142 patients were included, with a mean age of 59.7 ± 15 years; 105 (73.9%) were male, 63 (44.4%) arrested in public locations, and 101 (71.1%) had witnessed arrests. Adjusted GEE analysis revealed that longer time to shock was associated with lower odds of achieving ROSC (OR: 0.81, 95% CI: 0.72–0.93, p = 0.005). Every one-minute delay in defibrillation is predicted to decrease the likelihood of achieving ROSC by 19%.Conclusion:In patients with recurrent shockable rhythms, every one-minute delay in delivering a shock was associated with a statistically significant 19% reduction in the chance of achieving ROSC. This finding highlights the importance of reducing the time to defibrillation in managing recurrent shockable rhythms and suggests reevaluating the current recommendation of two-minute intervals for rhythm check and shock delivery.

Circulation, Volume 150, Issue Suppl_1, Page A4142224-A4142224, November 12, 2024. Introduction:Right heart failure under the support of a left ventricular assist device (LVAD) presents a life-threatening condition characterized by organ edema and limited LVAD support. Implementing an inferior vena cava-pulmonary artery (IVC-PA) bypass graft may mitigate these complications by reducing central venous pressure (CVP) and improving LVAD support efficiency. This study aimed to elucidate an adequate graft diameter for an IVC-PA bypass in terms of CVP reduction during LVAD-assisted circulation using an in vitro biventricular pulsatile circulatory system.Methods:We developed a biventricular pulsatile circulation system capable of providing circulatory assistance via an LVAD (centrifugal pump) connected to the apex of a left ventricular model （Fig）. A representative condition of cardiogenic shock was produced by adjusting LV systolic pressure, aortic pressure, and CVP to 80 mmHg, 80/40 mmHg, and 7.5 mmHg, respectively. A right heart failure model was produced by adjusting LV systolic pressure, aortic pressure, and CVP to 45 mmHg, 70 mmHg, and 16 mmHg, respectively, under LVAD support at 1700 rpm. Then, an adequate IVC-PA bypass diameter was investigated in terms of reducing CVP and increasing bypass flow support among 4mm and 18 mm with 2mm interval. The diameters of PA and IVC, and systolic PA pressure were set to 19 mm, 19 mm, and 18 mmHg, respectively. Elastic LV and RV models were driven by pneumatic positive and negative pressures.Results:We found a linearly increasing trend of bypass flow and a decreasing trend of CVP with increasing bypass diameters from 4 to 12 mm. When applying the bypass graft over 12mm diameter, bypass flow and CVP plateaued at 3.4 L/min and 7.5 mmHg, respectively (Fig).Conclusion:Our sophisticated in vitro biventricular circulation study suggests that in scenarios of right heart failure under LVAD support, implementing a bypass graft from the IVC to the PA is effective for decreasing CVP and reducing right ventricular preload. This study indicates that the optimal bypass diameter for reducing CVP is 12 mm when the diameters of the IVC and PA are 19 mm. These findings encouraged us to evaluate the efficacy in in vivo clinical settings.

Circulation, Volume 150, Issue Suppl_1, Page ASa902-ASa902, November 12, 2024. Introduction:Patients who regain return of spontaneous circulation (ROSC) after in-hospital cardiac arrest are often critically ill and at risk of re-arrest. However, re-arrest is insufficiently studied. Pre-hospital data indicate a re-arrest rate ranging from 3% to 39%. Our study aims to assess the immediate hazard of re-arrest after ROSC, depending on whether the patient’s last observed rhythm before ROSC was shockable or not.Methods:We analyzed defibrillator recordings and clinical data from 763 cardiac arrest episodes at four different hospitals. ROSC was defined as an organized ECG rhythm compatible with a pulse, accompanied by the absence of chest compressions for at least one minute. An organized rhythm with a QRS frequency ≥ 12 was categorized as pulseless electrical activity (PEA). Conversely, a QRS frequency < 12 or a flat line represented asystole. Ventricular fibrillation or tachycardia (VF/VT) was identified based on its distinct morphology. We further stratified ROSC based on whether the preceding rhythm was shockable or not. After comparing four different parametric time-to-event models, we chose the most useful one and estimated the immediate hazard of re-arrest along the timeline of resuscitation.Results:After the initial event of cardiac arrest, we observed 316 re-arrests. Among these, 68% relapsed to PEA, 25% relapsed to VF/VT, and 7% relapsed to asystole. Summarized in the figure, the initial hazard of re-arrest from ROSC after PEA or asystole to a non-shockable rhythm was 0.02 per minute. By the 9th minute, this hazard decreased to 0.01 per minute. Meanwhile, the hazard for re-arrest to a shockable rhythm remained constant at 0.01 per minute. For re-arrest from ROSC after VF/VT back to VF/VT, the hazard was 0.05 per minute initially, decreasing to 0.03 per minute by the 12th minute. The corresponding hazard for re-arrest to PEA or asystole remained at 0.01 per minute.Conclusion:The hazard of re-arrest after return of spontaneous circulation (ROSC) to either pulseless electrical activity (PEA), asystole, or ventricular fibrillation/tachycardia (VF/VT) varies by the last observed state before ROSC. Notably, re-arrest to VF/VT following ROSC after previous VF/VT poses the highest risk. This understanding can assist healthcare professionals in anticipating events during the critical minutes following successful resuscitation and adjusting treatment accordingly.

Circulation, Volume 150, Issue Suppl_1, Page A4141869-A4141869, November 12, 2024. Introduction:Over 290,000 in-hospital cardiac arrests occur annually in the United States. Survival is about 25% with significant variation across the country. Evidence supports high-quality chest compressions as a vital factor to achieving return of spontaneous circulation (ROSC) and improving outcomes after cardiac arrest. Research illustrates a propensity for healthcare professionals to provide chest compressions at a rate outside the American Heart Association guideline of 100-120 compressions/minute.Goal/Hypothesis:The team hypothesized greater compliance with chest compression rate guidelines would increase ROSC. The goal of this initiative was to increase CC rate compliance from a facility baseline of 15-64% toward the published benchmark of 80%, and to positively impact ROSC.Method:An interdisciplinary team focused on optimizing CC rate compliance. The Plan, Do, Study, Act methodology provided structure and a systematic approach to data informed improvements. Rate data was collected, then shared on a Power BI dashboard and in a facility specific report. The impact of the awareness campaign was assessed at the end of each quarterly cycle for 9 facilities.Results/Outcomes:Data for 2023 included 487 code events and 6,315 minutes of CPR. At year end, improvements were found at 5 facilities (12, 12, 14, 17,&7%) over baseline, and 2 facilities achieved the benchmark. Statistical analysis was conducted to evaluate CC rate compliance in correlation with ROSC. Cases were sorted into 2 groups: Group 1 (compliance 80% or greater) or Group 2 (compliance less than 31.6% – calculated first quartile). Three hundred two cases met inclusion criteria. Cochran’s formula was used (95% CI) to calculate sample size (Group 1:111 cases; Group 2:107cases). A Chi-squared test showed a significant difference in achieving ROSC between the groups (p=0.0223). Group 1 achieved ROSC 20% more frequently than Group 2.Conclusions:Chest compression rate compliance was positively associated with improved rate of ROSC in this project. Project findings prompted the system resuscitation committee to require facilities to set a goal for CC rate compliance improvement. Improvement can be achieved without financial or educational burden. Other performance-based quality metrics to improve clinical outcomes should be included in future research with consideration of co-morbidities.

Stroke, Ahead of Print.

Circulation, Volume 150, Issue 18, Page 1469-1474, October 29, 2024.

Circulation, Volume 150, Issue 17, Page 1307-1307, October 22, 2024.

Circulation, Volume 150, Issue 12, Page 966-970, September 17, 2024.

Circulation, Volume 150, Issue 8, Page 651-656, August 20, 2024.

Circulation, Volume 150, Issue 4, Page 336-339, July 23, 2024.

Circulation, Volume 150, Issue 1, Page 1-3, July 2, 2024.

Circulation, Volume 149, Issue 24, Page 1921-1926, June 11, 2024.

Circulation, Volume 149, Issue 18, Page 1461-1465, April 30, 2024.