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ObjectivesCerebral oximetry using near-infrared spectroscopy measures regional cerebral oxygen saturation (rSO2) non-invasively and may provide information regarding the quality of cerebral oxygen perfusion. We determined whether the level of rSO2obtained during cardiopulmonary resuscitation is associated with return of spontaneous circulation (ROSC) and survival in Emergency Department (ED) patients presenting with cardiac arrest.MethodsWe conducted a retrospective, observational study of adult ED patients presenting at an academic medical centre with cardiac arrest in whom continuous cerebral oximetry was performed. Demographic and clinical data including age, gender, presenting rhythm and mean rSO2readings were abstracted. Cerebral oxygenation was measured with a commercially available oximeter.ResultsA convenience study sample included 59 patients ages 18–102 years (mean age 68.7 ± 14.9 years); 50 (84.7%) were men. Presenting rhythms included pulseless electrical activity (21), asystole (20) and ventricular fibrillation/tachycardia (17). 24 patients (40.6%) had ROSC and only 1 (1.7%) survived to hospital discharge. Patients with and without ROSC were similar in age and presenting cardiac rhythms. The mean of mean rSO2levels was higher in patients with ROSC, 43.8 (95% CI 40.1 to 47.6) compared with those without ROSC, 34.2 (95% CI 30.6 to 37.8); p=0.001. 91.7% of patients with ROSC had a rSO2of 30% or greater compared with 62.9% in those without ROSC (p=0.01). The area under the curve for mean rSO2as a predictor of ROSC was 0.76 (95% CI 0.64 to 0.89).ConclusionsIn ED patients with cardiac arrest higher cerebral oxygen saturations are associated with higher rates of ROSC.

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Introduction:In-hospital cardiac arrest (IHCA) affects over 200 000 patients in the US annually. Approximately 20% will survive to hospital discharge, although outcomes vary between hospitals. Debriefing has been shown to improve resuscitation quality and teamwork and has been associated with improved IHCA outcomes. All IHCA at NYU Langone Health are attended by the ALERT team, a dedicated team of critical care nurses who perform active patient surveillance and respond to acute in-hospital emergencies. IHCA debriefs at NYU Langone Health have historically been performed on paper forms but were limited by low rates of compliance. As part of an ongoing quality improvement (QI) initiative, we designed and implemented an electronic debriefing tool for use after IHCA (eDebrief).Methods:The eDebrief tool was developed by the NYU Interdisciplinary Resuscitation Committee. The tool captures cardiopulmonary resuscitation (CPR) quality metrics, teamwork and leadership, use of resuscitation equipment (mechanical CPR, advanced airway adjuncts, and ultrasound), and outcomes. ALERT team nurses received an educational session and ad hocrefresher sessions if required. Data were collected at the conclusion of the event using an electronic device (iPhone, Apple, Cupertino CA). The tool is accessible using a QR code located on every code cart. Rates of IHCA debrief post-implementation (2/13/20-06/10/21) were compared to prior years (01/01/19 - 12/31/19 and 01/01/18-12/31/19).Results:The eDebrief tool was implemented on 2/13/20. During the post-implementation phase, there were 254 IHCA at NYU Langone Health. The eDebrief form was used in 175 events (69%). The debrief rate from previous calendar years were 38% and 42% for 2019 and 2018 respectively. Use of the eDebrief form has identified three targets for ongoing quality improvement and research projects: room overcrowding (identified in 64/175 IHCAs, 37%); ultrasound use (39/175 IHCAs, 22%); and optimization of mechanical CPR.Conclusions:Use of electronic debriefing is feasible at a large academic medical center and has been associated with increased uptake of IHCA debrief. Regular debriefs at our center have identified several targets for further quality improvement and research initiatives.

Introduction:Current consensus holds that CPR must balance chest compressions and ventilation rate (VR), with a low VR being essential for venous return and cardiac output. AHA guidelines recommend a VR of 10 ventilations per minute (vpm) after advanced airway placement. We sought to examine VR adherence and its impact on end-tidal CO2(ETCO2) and ROSC >20 minutes.Methods:This is a retrospective analysis of data from AWARE II, a multicenter prospective observational study of adult in-hospital cardiac arrest (IHCA) outcomes at 14 US and UK sites. Inclusion criteria were: 1) adult patient in CA, 2) advanced airway already in place or placed during the CA, and 3) at least one minute of VR and ETCO2data available after removal of the last minute of CPR in subjects achieving ROSC (due to the rise of ETCO2just prior to ROSC).Results:A total of 563 subjects were enrolled in the parent study. Of these, 225 had ETCO2and VR tracings available, and 201 had sufficient data for inclusion. Mean age was 69.3 (range 18-100), patients were 63.7% male, and 16.4% had a shockable initial rhythm. A total of 116 subjects (57.7%) achieved ROSC, which was sustained in 76 (37.8%), leading to survival to hospital discharge with favorable neurological outcomes in 9 (4.5%). Mean VR was 16.3 vpm, with 171 (85.1%) subjects being ventilated in excess of guidelines; only 16 (8.0%) subjects received 8-10 vpm. Higher VR had a weak but significant association with increased mean ETCO2(linear R2= 0.11, p < 1x10-6) and sustained ROSC (OR 1.05; 95% CI: 1.01-1.11; p = 0.02). Patients with sustained ROSC had a significantly higher VR at 17.7 vpm than those without sustained ROSC at 15.6 vpm (p = 0.007). Patients receiving a VR close to AHA guidelines (6-12 vpm) had a significantly lower rate of sustained ROSC (26.1%, n = 46) than patients receiving >12 vpm (42.0%, n = 148) (OR 2.30; 95% CI: 1.08-4.89; p = 0.031 using a multivariate model including patient age, shockable initial rhythm, known cardiac disease, witnessed IHCA, and use of mechanical compressions).Conclusions:VR within AHA guidelines is rare during IHCA. However, ventilation in excess of current guidelines may increase rates of sustained ROSC, an essential predicate to survival. AHA guidelines on VR in CPR with an advanced airway may not yet be optimized.

Background:Cardiac arrest (CA) has an annual US incidence of >500,000 with survival rates ~10%. Although most studies focus on survival and neurological outcomes, understanding long-term psychological consequences is of equal importance. Some have reported negative psychological outcomes such as anxiety, depression, and PTSD; however, since survivors of other adverse life-threatening disorders, including cancer, report positive psychological growth, we sought to test the hypothesis that CA survival may also be associated with growth of positive psychological traits.Method:Invitations were sent to CA survivors through their local hospitals or national registries to participate in an online pilot cross sectional study. Overall, 47 agreed and were given a series of standardized questionnaires to assess the following positive personality traits: empathy, compassion, forgiveness, altruism, optimism, gratitude, positivity, spirituality, consideration for others’ needs, and happiness. Using a 5-point Likert scale, they then estimated the relative change in these traits since their CA event, where 1=significant decrease, 2=moderate decrease, 3=no change, 4 =moderate increase, and 5=significant increase.Results:Overall 42 of 47 (89%) reported a return to their daily functional activities. Personality trait ratings were analyzed using a sign test relative to a population median score of 3 (i.e. no change) for statistical analysis. Participants showed statistically significant differences in all the assessed personality traits: gratitude (median=4, p<0.0001), compassion (median=4, p= p<0.0001), altruism (median=4, p<0.0001), empathy (median=4, p<0.0001), spirituality(median=4, p<0.0001), consideration for others’ needs (median=4, p<0.0001), forgiveness(median=4, p<0.0005), optimism (median=4, p<0.001), positivity (median=4, p<0.005), and happiness(median=4, p<0.05).Conclusions:Long-term psychological sequelae of CA survivorship remains ill understood. However, some CA survivors may develop greater positive psychological traits following CA. Further studies are required to assess the relationship between CA and long-term positive changes and quality of life, as well as possible therapeutic interventions.

Background Severe hypoxic respiratory failure from COVID-19 pneumonia carries a high mortality risk. There is uncertainty surrounding which patients benefit from corticosteroids in combination with tocilizumab and the dosage and timing of these agents. The balance of controlling inflammation without increasing the risk of secondary infection is difficult. At present, dexamethasone 6 mg is the standard of care in COVID-19 hypoxia; whether this is the ideal choice of steroid or dosage remains to be proven.Objectives The primary objective was to assess the impact on mortality of tocilizumab only, corticosteroids only, and combination therapy in patients with COVID-19 respiratory failure.Methods A multihospital, retrospective study of adult patients with severe respiratory failure from COVID-19 who received supportive therapy, corticosteroids, tocilizumab, or combination therapy were assessed for 28-day mortality, biomarker improvement, and relative risk of infection. Propensity-matched analysis was performed between corticosteroid alone and combination therapies to further assess mortality benefit.Results The steroid-only, tocilizumab-only, and combination groups showed hazard reduction in mortality at 28 days when compared with supportive therapy. In a propensity-matched analysis, the combination group (daily equivalent dexamethasone 10 mg and tocilizumab 400 mg) had an improved 28-day mortality compared with the steroid-only group (daily equivalent dexamethasone 10 mg; hazard ratio (95% CI) = 0.56 (0.38-0.84), P= 0.005] without increasing the risk of infection.Conclusion and Relevance Combination of tocilizumab and corticosteroids was associated with improved 28-day survival when compared with corticosteroids alone. Modification of steroid dosing strategy as well as steroid type may further optimize therapeutic effect of the COVID-19 treatment.

Background:While 50% of cardiac arrest (CA) survivors report negative psychological outcomes including post-traumatic stress disorder (PTSD), depression, and anxiety, 10% report a positive transformational outcome associated with recall of cognitive activity and 2-3% report external awareness during CPR. Though, often referred to using the poorly defined term of near-death experiences (NDE), this aspect of CA survivorship remains ill understood.Methods:In an ongoing prospective study (AWARE-II) we piloted methods to administer audiovisual stimuli to test implicit and explicit memories using a tablet computer with images and sounds delivered during on-going CPR.Results:Among 465 in-hospital CA lasting >5 min, 44 (9%) survived and 21 were interviewed. Of these, 4 (19%) reported explicit memories, including (internal) cognitive processes such as feeling peace, joy, and a perception of seeing relatives, while other memories were suggestive of (external) awareness e.g. hearing people talking, drugs given. One of 19 correctly recalled the audio stimuli given during CPR, but none identified the visual test. In this limited sample, there were no signs of implicit learning. We then compared these to 22 self-reported memories from a registry of CA survivors, Additional themes emerged as follows: 1) a sense of joy and peace (95%), perception of a light (86%), a tunnel (59%), a review and judgment of major life events including a person?s own actions and intentions (54%), and an overall feeling of positive transformation after the event (95%).Conclusion:External awareness and internal cognitive activity may occur during CA. However, it is unclear whether explicit recall sufficiently describes the entirety of cognitive processes during CA, or whether implicit memories may also form. In some survivors, memories lead to greater life-meaning and a positive transformation, which contrasts with negative psychological outcomes such as PTSD. In this context, in place of NDE a more appropriate term might be transformative experience of death (TED). Further studies, are needed to delineate the role of implicit and explicit learning and how cognitive activity during CPR may relate to brain resuscitation quality and overall psychological outcomes.

Background:There is a need to monitor brain resuscitation during CPR. Furthermore, 10% of CA survivors report cognitive activity and 2-3% report consciousness during CPR.Methods:Using data from a prospective study (AWARE-II) with bimodal brain monitoring during CPR (EEG, [Massimo] and regional cerebral oxygenation [rSO2 normal 60-80%]) using cerebral oximetry [Nonin]), we sought to identify EEG rhythms, their progression over time, and underlying rSO2 thresholds. Inclusion criteria: In hospital CA, ? 18 years. Raw EEG data were captured as images (1/second) during CPR pauses, while rSO2 was captured continuously.Results:38 patients were recruited; mean age 69?16 with duration of CPR (10-60 mins). We captured 362 EEG images. 91 (25%) were artifacts. Among the 271 interpretable images, there were 13 EEG rhythms placed into 6 groups based on their association with normal/near normal, seizures, coma, absence of cortical activity as follows: Group 1 (Non-epileptogenic): Theta, Delta, Alpha, Group 2 (Epileptogenic/Spike and Wave): Generalized Rhythmic Delta Activity (GRDA) + Spike (S), Delta + S, Theta + S, Burst Suppression with GRDA + S, Group 3 (Flat-line): Marked Voltage Attenuation (MVA), Group 4 (Coma State): Burst Suppression (w/ GRDA, Delta, and/or Theta), Group 5: GRDA, Group 6: Generalized Periodic Discharges (GPD). MVA/absence of activity was observed throughout CPR time and across all rSO2 ranges. Normal/near normal (non-epileptogenic) including alpha rhythms (which to our knowledge is described for the first time), and epileptogenic rhythms were observed with rSO2>30%Conclusions:While unclear whether non-epileptogenic rhythms are associated with transient periods of ROSC, however real-time bimodal brain monitoring provides insights regarding brain resuscitation and its dynamic interaction with patient factors. While ischemia may cause epileptogenic activity, there are periods of normal/near-normal cortical activity despite prolonged CPR >45-60 mins. A minimal threshold of brain oxygen delivery (rSO2>30%) may be required for cortical activity. These data raise questions regarding assumptions of irreversible brain damage with prolonged CPR, as well as the possibility of consciousness and cognitive activity during CPR.