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Abstract Although patients who underwent night-time resuscitation for out-of-hospital cardiac arrest (OHCA) had worse clinical outcomes than those who underwent day-time resuscitation, the differences between the outcomes of patients with OHCA who underwent extracorporeal cardiopulmonary resuscitation (ECPR) in the day-time and night-time remain unclear. We analyzed data from the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan. Patients were categorized according to whether they received treatment during the day-time or night-time. The primary outcomes were survival to hospital discharge and favorable neurological outcome at discharge, and the secondary outcomes were estimated low-flow time, implementation time of ECPR, and complications due to ECPR. A multivariate logistic regression model adjusted for confounders was used for comparison. Among the 1644 patients, the night-time patients had a significantly longer ECMO implementation time and estimated low-flow time than the day-time patients, along with a significantly higher number of complications than the day-time patients. However, the survival and neurologically favorable survival rates did not differ significantly between the groups. Thus, although patients who underwent ECPR at night had an increased risk of longer implementation time and complications, their clinical outcomes did not differ from those who underwent day-time ECPR.

Abstract Background In out-of-hospital cardiac arrest (OHCA) patients with extracorporeal cardiopulmonary resuscitation (ECPR), the association between low-flow time and outcomes in accidental hypothermia (AH) patients compared to those of patients without AH has not been fully investigated. Methods This was a secondary analysis of the retrospective multicenter registry in Japan. We enrolled patients aged ≥ 18 years who had been admitted to the emergency department for OHCA and had undergone ECPR between January, 2013 and December, 2018. AH was defined as an arrival body temperature below 32 °C. The primary outcome was survival to discharge. Cubic spline analyses were performed to assess the non-linear associations between low-flow time and outcomes stratified by the presence of AH. We also analyzed the interaction between low-flow time and the presence of AH. Results Of 1252 eligible patients, 105 (8.4%) and 1147 (91.6%) were in the AH and non-AH groups, respectively. Median low-flow time was 60 (47–79) min in the AH group and 51 (42–62) min in the non-AH group. The survival discharge rates in the AH and non-AH groups were 44.8% and 25.4%, respectively. The cubic spline analyses showed that survival discharge rate remained constant regardless of low-flow time in the AH group. Conversely, a decreasing trend was identified in the survival discharge rate with longer low-flow time in the non-AH group. The interaction analysis revealed a significant interaction between low-flow time and AH in survival discharge rate (p for interaction = 0.048). Conclusions OHCA patients with arrival body temperature

Aim: Extracorporeal cardiopulmonary resuscitation (ECPR) is used to resuscitate patients with cardiac arrest; however, its effect in treating hypothermic cardiac arrest has not been well studied. Therefore, in this study, we aimed to examine the characteristics and outcomes of patients with hypothermic cardiac arrest who underwent ECPR, using a multicenter out-of-hospital cardiac arrest (OHCA) registry in Japan. Methods: Baseline characteristics of patients with hypothermic OHCA and body temperature below 32 °C were assessed. Logistic regression analysis was performed to identify factors associated with in-hospital mortality and neurological outcomes in these patients. Outcomes of hypothermic and cardiogenic OHCA cases were compared using propensity-score matching to investigate differences among subgroups. Results: We included 2,157 patients, with 102 and 1,646 in the hypothermic and cardiogenic groups, respectively. Higher age and longer low-flow time were independent risk factors for mortality, and higher age was an independent risk factor for unfavorable neurological outcomes in the hypothermic OHCA group.Eighty matched pairs were selected during propensity-score matching, and the mortality rate was lower in the hypothermic group than in the cardiogenic group (46.2% vs. 77.5%; p

Background: The influence of the Tokyo Summer Olympic/Paralympic Games on normal emergency medical system operations in Japan had not yet been fully elucidated. In this study, we examined whether out-of-hospital cardiac arrest (OHCA) patients treated during the Tokyo Olympic/Paralympic Games had differences in outcomes. Methods: Using the nationwide JAAM-OHCA Registry, we evaluated the outcomes of OHCA patients admitted to the hospital during the Tokyo Olympic/Paralympic Games (July 23 to Aug. 8 and Aug. 24 to Sept. 5) in 2021, compared to those during same the dates in 2020 (Term 1: July 23 to Aug. 8 and Aug. 24 to Sept. 5), those during the pre-Olympic/Paralympic term during the same weekdays in the weeks before the event (Term 2: June. 18 to July. 4 and July. 6 to July. 18), and those during the post-Olympic/Paralympic term during the same weekdays in the weeks after the event (Term 3: Sept. 10 to Sept. 26 and Sept. 28 to Oct. 10). The primary outcome was 30-day survival, and multivariable logistic analysis was performed, adjusted for age and sex. Results: A total of 3,111 OHCA patients were included in the study period (786 in the Olympic/Paralympic group, 774 in Term 1, 747 in Term 2, and 804 in Term 3). Crude 30-day survivals were 7.4% (58/786), 9.3% (72/774), 6.8% (51/747), and 8.2% (66/804), respectively. Using the Olympic/Paralympic group as a reference, multivariable logistic analysis revealed that 30-day survivals in Term 1 (OR 1.27 95% CI 0.88–1.83p = 0.20), Term 2 (OR 0.92 95% CI 0.62–1.36p = 0.67), and Term 3 (OR 1.10 95% CI 0.76–1.59p = 0.63) did not differ significantly. Conclusions: No significant differences in 30-day survival for OHCA patients admitted during the Tokyo Summer Olympic/Paralympic Games were identified.

Abstract Recently, patients with out-of-hospital cardiac arrest (OHCA) refractory to conventional resuscitation have started undergoing extracorporeal cardiopulmonary resuscitation (ECPR). However, the mortality rate of these patients remains high. This study aimed to clarify whether a center ECPR volume was associated with the survival rates of adult patients with OHCA resuscitated using ECPR. This was a secondary analysis of a retrospective multicenter registry study, the SAVE-J II study, involving 36 participating institutions in Japan. Centers were divided into three groups according to the tertiles of the annual average number of patients undergoing ECPR: high-volume (≥ 21 sessions per year), medium-volume (11–20 sessions per year), or low-volume (

Abstract Background In some cases of patients with out-of-hospital cardiac arrest (OHCA) who underwent extracorporeal cardiopulmonary resuscitation (ECPR), negative pupillary light reflex (PLR) and mydriasis upon hospital arrival serve as common early indicator of poor prognosis. However, in certain patients with poor prognoses inferred by pupil findings upon hospital arrival, pupillary findings improve before and after the establishment of ECPR. The association between these changes in pupillary findings and prognosis remains unclear. This study aimed to clarify the association of pupillary examinations before and after the establishment of ECPR in patients with OHCA showing poor pupillary findings upon hospital arrival with their outcomes. To this end, we analysed retrospective multicentre registry data involving 36 institutions in Japan, including all adult patients with OHCA who underwent ECPR between January 2013 and December 2018. We selected patients with poor prognosis inferred by pupillary examinations, negative pupillary light reflex (PLR) and pupil mydriasis, upon hospital arrival. The primary outcome was favourable neurological outcome, defined as Cerebral Performance Category 1 or 2 at hospital discharge. Multivariable logistic regression analysis was performed to evaluate the association between favourable neurological outcome and pupillary examination after establishing ECPR. Results Out of the 2,157 patients enrolled in the SAVE-J II study, 723 were analysed. Among the patients analysed, 74 (10.2%) demonstrated favourable neurological outcome at hospital discharge. Multivariable analysis revealed that a positive PLR at ICU admission (odds ration [OR] = 11.3, 95% confidence intervals [CI] = 5.17–24.7) was significantly associated with favourable neurological outcome. However, normal pupil diameter at ICU admission (OR = 1.10, 95%CI = 0.52–2.32) was not significantly associated with favourable neurological outcome. Conclusion Among the patients with OHCA who underwent ECPR and showed poor pupillary examination findings upon hospital arrival, 10.2% had favourable neurological outcome at hospital discharge. A positive PLR after the establishment of ECPR was significantly associated with favourable neurological outcome.

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) can improve survival rates and neurological outcomes of patients with out-of-hospital cardiac arrest (OHCA). High levels of partial pressure of arterial oxygen (PaO2) negatively affect survival and neurological outcomes in patients with OHCA. However, research on associations of hyperoxemia with survival and neurological outcomes after ECPR remains limited, especially considering targeted temperature management (TTM) administration to patients. Additionally, few reports have examined the impact of hyperoxemia beyond 24 h. In this study, we aimed to examine the effect of prolonged hyperoxemia on survival and neurological outcomes after ECPR for OHCA in patients undergoing TTM. Methods: We performed a secondary observational analysis of data from the SAVE-J Ⅱ study, a retrospective, multicenter registry study of ECPR of patients with OHCA. Data on arterial PaO2 after ECPR for intensive care unit days 2–4 were collected and averaged. Patients were divided into two groups: hyperoxic (PaO2 ≥ 300 mmHg) and non-hyperoxic (PaO2

Background Extracorporeal cardiopulmonary resuscitation (ECPR) is an option for refractory cardiac arrest, and immediate initiation after indication is recommended. However, the practical goals of ECPR preparation (such as the door‐to‐needle time) remain unclear. This study aimed to elucidate the association between the door‐to‐needle time and neurological outcomes of out‐of‐hospital cardiac arrest. Methods and Results This is a post hoc analysis of a nationwide multicenter study on out‐of‐hospital cardiac arrest treated with ECPR at 36 institutions between 2013 and 2018 (SAVE‐J [Study of Advanced Cardiac Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan] II study). Adult patients without hypothermia (≥32 °C) in whom circulation was not returned at ECPR initiation were included. The probability of favorable neurological function at 30 days (defined as Cerebral Performance Category ≤2) was estimated using a generalized estimating equations model, in which institutional, patient, and treatment characteristics were adjusted. Estimated probabilities were then calculated according to the door‐to‐needle time with 3‐minute increments, and a clinical threshold was assumed. Among 1298 patients eligible for this study, 136 (10.6%) had favorable neurological function. The estimated probability of favorable outcomes was highest in patients with 1 to 3 minutes of door‐to‐needle time (12.9% [11.4%–14.3%]) and remained at 9% to 10% until 27 to 30 minutes. Then, the probability dropped gradually with each 3‐minute delay. A 30‐minute threshold was assumed, and shorter door‐to‐extracorporeal membrane oxygenation/low‐flow time and fewer adverse events related to cannulation were observed in patients with door‐to‐needle time

Abstract Background Bleeding is the most common complication in out-of-hospital cardiac arrest (OHCA) patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). No studies comprehensively described the incidence rate, timing of onset, risk factors, and treatment of bleeding complications in OHCA patients receiving ECPR in a multicenter setting with a large database. This study aimed to analyze the risk factors of bleeding during the first day of admission and to comprehensively describe details of bleeding during hospitalization in patients with OHCA receiving ECPR in the SAVE-J II study database. Methods This study was a secondary analysis of the SAVE-J II study, which is a multicenter retrospective registry study from 36 participating institutions in Japan in 2013–2018. Adult OHCA patients who received ECPR were included. The primary outcome was the risk factor of bleeding complications during the first day of admission. The secondary outcomes were the details of bleeding complications and clinical outcomes. Results A total of 1,632 patients were included. Among these, 361 patients (22.1%) had bleeding complications during hospital stay, which most commonly occurred in cannulation sites (14.3%), followed by bleeding in the retroperitoneum (2.8%), gastrointestinal tract (2.2%), upper airway (1.2%), and mediastinum (1.1%). These bleeding complications developed within two days of admission, and 21.9% of patients required interventional radiology (IVR) or/and surgical interventions for hemostasis. The survival rate at discharge of the bleeding group was 27.4%, and the rate of favorable neurological outcome at discharge was 14.1%. Multivariable logistic regression analysis showed that the platelet count ( 10 × 104/μL) was significantly associated with bleeding complications during the first day of admission (adjusted odds ratio [OR]: 1.865 [1.252–2.777], p = 0.002). Conclusions In a large ECPR registry database in Japan, up to 22.1% of patients experienced bleeding complications requiring blood transfusion, IVR, or surgical intervention for hemostasis. The initial platelet count was a significant risk factor of early bleeding complications. It is necessary to lower the occurrence of bleeding complications from ECPR, and this study provided an additional standard value for future studies to improve its safety.

Aim: To investigate the factors associated with favourable neurological outcomes in adult patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). Methods: This retrospective observational study used secondary analysis of the SAVE-J II multicentre registry data from 36 institutions in Japan. Between 2013 and 2018, 2157 patients with OHCA who underwent ECPR were enrolled in SAVE-J II. A total of 1823 patients met the study inclusion criteria. Adult patients (aged ≥ 18 years) with OHCA, who underwent ECPR before admission to the intensive care unit, were included in our secondary analysis. The primary outcome was a favourable neurological outcome at hospital discharge, defined as a Cerebral Performance Category score of 1 or 2. We used a multivariate logistic regression model to examine the association between factors measured at the incident scene or upon hospital arrival and favourable neurological outcomes. Results: Multivariable analysis revealed that shockable rhythm at the scene [odds ratio (OR); 2.11; 95% confidence interval (CI), 1.16–3.95] and upon hospital arrival (OR 2.59; 95% CI 1.60–4.30), bystander CPR (OR 1.63; 95% CI 1.03–1.88), body movement during resuscitation (OR 7.10; 95% CI 1.79–32.90), gasping (OR 4.33; 95% CI 2.57–7.28), pupillary reflex on arrival (OR 2.93; 95% CI 1.73–4.95), and male sex (OR 0.43; 95% CI 0.24–0.75) significantly correlated with neurological outcomes. Conclusions: Shockable rhythm, bystander CPR, body movement during resuscitation, gasping, pupillary reflex, and sex were associated with favourable neurological outcomes in patients with OHCA treated with ECPR.

Aim: Out-of-hospital cardiac arrest (OHCA) is a life-threatening emergency with high mortality. The “chain of survival” is critical to improving patient outcomes. To develop and enhance this chain of survival, measuring and monitoring the resuscitation processes and outcomes are essential for quality assurance. In Japan, several OHCA registries have successfully been implemented at both local and national levels. We aimed to review and summarise the conception, strengths, and challenges of OHCA registries in Japan. Method and results: The following representing registries in Japan were reviewed: the All-Japan Utstein registry, the Utstein Osaka Project/the Osaka-CRITICAL study, the SOS-KANTO study, the JAAM-OHCA study, and the SAVE-J II study. The All-Japan Utstein registry, operated by the Fire and Disaster Management Agency of Japan and one of the largest nationwide population-based registries in the world, collects data concerning all patients with OHCA in Japan, excluding in-hospital data. Other research- and hospital-based registries collect detailed out-of-hospital and in-hospital data. The Osaka-CRITICAL study and the SOS-KANTO study are organized at regional levels, and hospitals in the Osaka prefecture and in the Kanto area participate in these registries. The JAAM-OHCA study is managed by the Japanese Association of Acute Medicine and includes 107 hospitals throughout Japan. The Save-J II study focuses on patients with OHCA treated with extracorporeal cardiopulmonary resuscitation. Conclusion: Each OHCA registry has its own philosophy, strengths, perspectives, and challenges; however, all have been successful in contributing to the improvement of emergency medical service (EMS) systems through the quality improvement process. These registries are expected to be further utilized to enhance EMS systems and improve outcomes for patients with OHCA, while also contributing to the field of resuscitation science.

Aim: Out-of-hospital cardiac arrest (OHCA) is a life-threatening emergency that requires rapid and efficient intervention. Recently, several novel approaches have emerged and have been incorporated into resuscitation systems in some local areas of Japan. This review describes innovative resuscitation systems and highlights their strengths. Main text: First, we discuss the deployment of a physician-staffed ambulance, in which emergency physicians offer advanced resuscitation to patients with OHCA on site. In addition, we describe the experimental practice of extracorporeal membrane oxygenation (ECPR) in a prehospital setting. Second, we describe a physician-staffed helicopter, wherein a medical team provides advanced resuscitation at the scene. We also explain their initiative to provide early ECPR, even in remote areas. Finally, we provide an overview of the “hybrid ER” system which is a “one-fits-all” resuscitation bay equipped with computed tomography and fluoroscopy equipment. This system is expected to help swiftly identify and rule out irreversible causes of cardiac arrest, such as massive subarachnoid hemorrhage, and implement ECPR without delay. Conclusion: Although these revolutionary approaches may improve the outcomes of patients with OHCA, evidence of their effectiveness remains limited. In addition, it is crucial to ensure cost-effectiveness and sustainability. We will continue to work diligently to assess the effectiveness of these systems and focus on the development of cost-effective and sustainable systems.

Abstract Background Extracorporeal cardiopulmonary resuscitation (ECPR) is rapidly becoming a common treatment strategy for patients with refractory cardiac arrest. Despite its benefits, ECPR raises a variety of ethical concerns when the treatment is discontinued. There is little information about the decision to withhold/withdraw life-sustaining therapy (WLST) for out-of-hospital cardiac arrest (OHCA) patients after ECPR. Methods We conducted a secondary analysis of data from the SAVE-J II study, a retrospective, multicenter study of ECPR in Japan. Adult patients who underwent ECPR for OHCA with medical causes were included. The prevalence, reasons, and timing of WLST decisions were recorded. Outcomes of patients with or without WLST decisions were compared. Further, factors associated with WLST decisions were examined. Results We included 1660 patients in the analysis; 510 (30.7%) had WLST decisions. The number of WLST decisions was the highest on the first day and WSLT decisions were made a median of two days after ICU admission. Reasons for WLST were perceived unfavorable neurological prognosis (300/510 [58.8%]), perceived unfavorable cardiac/pulmonary prognosis (105/510 [20.5%]), inability to maintain extracorporeal cardiopulmonary support (71/510 [13.9%]), complications (10/510 [1.9%]), exacerbation of comorbidity before cardiac arrest (7/510 [1.3%]), and others. Patients with WLST had lower 30-day survival (WLST vs. no-WLST: 36/506 [7.1%] vs. 386/1140 [33.8%], p

Background Risk stratification is important in patients with post–cardiac arrest syndrome. The Post‐Cardiac Arrest Syndrome for Therapeutic Hypothermia (CAST) and revised CAST (rCAST) scores have been well validated for predicting neurological outcomes, particularly for conventionally resuscitated patients with post–cardiac arrest syndrome. However, no studies have evaluated patients undergoing extracorporeal cardiopulmonary resuscitation. Methods and Results Adult patients with out‐of‐hospital cardiac arrest who underwent extracorporeal cardiopulmonary resuscitation were analyzed in this retrospective observational multicenter cohort study. We validated the accuracy of the CAST/rCAST scores for predicting neurological outcomes at 30 days. Moreover, we compared the predictive performance of these scores with the TiPS65 risk score derived from patients with out‐of‐hospital cardiac arrest who were resuscitated using extracorporeal cardiopulmonary resuscitation. A total of 1135 patients were analyzed. The proportion of patients with favorable neurological outcomes was 16.6%. In the external validation, the area under the receiver operating characteristic curve of the CAST score was significantly higher than that of the rCAST score (area under the receiver operating characteristic curve 0.677 versus 0.603; P

Background: We examined the association between body mass index (BMI) and outcomes in patients with out-of-hospital cardiac arrest (OHCA) undergoing extracorporeal cardiopulmonary resuscitation (ECPR). Methods: We retrospectively analyzed the database of an observational multicenter cohort in Japan. Adult patients with OHCA of cardiac etiology who received ECPR between 2013 and 2018 were categorized as follows: underweight, BMI

Background: Neuromuscular blocking agents are used to control shivering in cardiac arrest patients treated with target temperature management. However, their effect on outcomes in patients treated with extracorporeal cardiopulmonary resuscitation is unclear. Methods: This study was a secondary analysis of the SAVE-J II study, a retrospective multicenter study of 2175 out-of-hospital cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation in Japan. We classified patients into those who received neuromuscular blocking agents and those who did not and compared in-hospital mortality and incidence rates of favorable neurological outcome and in-hospital pneumonia between the groups using multivariable regression models and stabilized inverse probability weighting with propensity scores. Results: Six hundred sixty patients from the SAVE-J II registry were analyzed. Neuromuscular blocking agents were used in 451 patients (68.3%). After adjusting for potential confounders, neuromuscular blocking agents use was not significantly associated with in-hospital mortality (aHR 0.88; 95% CI, 0.67–1.14), favorable neurological outcome (aOR 0.85; 95% CI, 0.60–1.11), or pneumonia (aOR 1.52; 95% CI, 0.85–2.71). The results for in-hospital mortality (aHR 0.89; 95% CI, 0.64–1.25), favorable neurological outcome (aOR 0.94; 95% CI, 0.59–1.48) and pneumonia (aOR 1.59; 95% CI, 0.74–3.41) were similar after weighting was performed. Conclusions: Although data on the rationale for using neuromuscular blocking agents were unavailable, their use was not significantly associated with outcomes in out-of-hospital cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation and targeted temperature management. Neuromuscular blocking agents should be used based on individual clinical indications.

Aim: This study aimed to describe the frequency, clinical characteristics, and outcomes of pneumonia in OHCA patients treated with ECPR in a multicenter setting. Methods: This is a secondary analysis of the SAVE-J II study, which was a multicenter, retrospective cohort of OHCA patients treated with ECPR. Age, sex, comorbidities, presence of witnessed CA, presence of bystander CPR, initial rhythm, cause of CA, low-flow time, initiation of targeted temperature management, details of sputum culture, pneumonia, and prophylactic antibiotic use were recorded. Pneumonia was diagnosed when the patients met all the clinical, radiologic, and microbiologic criteria acquired after hospitalization. Results: In total, 1,986 patients were included in the analysis, and 947 (48%) died during the first 2 days of admission. A prophylactic antibiotic was used in 712 (35.9%) patients. Overall, the hazard of death was high on days 1 and 2 of admission, exceeding 20% on both days; 251 (12.6%) patients developed pneumonia during hospitalization, and the hazard of pneumonia development remained high (>2%) in the first 7 days of admission.Staphylococcus aureus and Klebsiella species were commonly identified in the sputum culture. Among patients who survived the first 7 days, the odds ratio (OR) of those with pneumonia and unfavorable neurological outcomes defined by cerebral performance category 3–5 was approximately 1. In those who survived the first 10 days, the OR was greater than 1 with a wide confidence interval. Conclusions: This is the first study describing details of pneumonia in OHCA patients treated with ECPR using a large dataset.

Aim: We examined the association between the location of cardiac arrest and outcomes of patients with out-of-hospital cardiac arrest (OHCA) who underwent extracorporeal cardiopulmonary resuscitation (ECPR). Methods: This was a secondary analysis of SAVE-J II, a multicentre retrospective registry with 36 participating institutions across Japan, which enrolled adult patients with OHCA who underwent ECPR. The outcomes of interest were favourable neurologic outcome at discharge. We compared the outcome between OHCA cases that occurred at residential and public locations, using a multilevel logistic regression model allowing for the random effect of each hospital. Results: Among 1,744 enrolled OHCAs, 809 and 935 occurred at residential (house: 603; apartment: 206) and public (street: 260; workplace: 210; others: 465) locations, respectively. The proportion of favourable neurologic outcomes was lower in OHCAs at residential locations than those at public locations (88/781 (11.3%) vs.131/891 (14.7%); adjusted odds ratio, 0.72 [95% confidence interval, 0.53–0.99]). However, subgroup analyses for patients with EMS aged

Therapeutic hypothermia for severe traumatic brain injury (TBI) has been repeatedly studied, but no past studies have assessed the detailed head computed tomography (CT) findings. We sought to investigate individual CT findings of severe TBI patients treated with targeted temperature management utilizing the head CT database obtained from the Brain Hypothermia study. Enrolled patients underwent either mild therapeutic hypothermia (32.0?C?34.0?C) or fever control (35.5?C?37.0?C). We assessed individual head CT images on arrival and after rewarming and investigated the correlations with outcomes. The initial CT data were available for 125 patients (hypothermia group?=?80, fever control group?=?45). Baseline characteristics and CT findings, such as hematoma thickness and midline shift, were similar in all aspects between the two groups. The favorable outcomes in the hypothermia and fever control groups were 38 (47.5%) and 24 (53.3%; p?=?0.53) for all 125 patients, respectively; 21 (46.7%) vs. 10 (38.5%; p?=?0.50) for 71 patients with acute subdural hematoma (SDH), respectively; and 12 (75.0%) vs. 4 (36.4%; p?=?0.045) in 27 young adults (?50 years) with acute SDH, respectively. There was a trend toward favorable outcomes for earlier time to reach 35.5?C (190 vs. 377?min, p?=?0.052) and surgery (155 vs. 180?min, p?=?0.096) in young patients with acute SDH. The second CT image revealed progression of the brain injury. This study demonstrated the potential benefits of early hypothermia in young patients with acute SDH, despite no difference in CT findings between the two groups. However, the small number of cases involved hindered the drawing of definitive conclusions. Future studies are warranted to validate the results.

Abstract The aim of this single-center retrospective study was to investigate the association between the time in range (TIR) of relative normoglycemia (RN) and in-hospital mortality. We defined RN as measured blood glucose in the range of 70–140% of A1C-derived average glucose and absolute normoglycemia (AN) as 70–140 mg/dL. We conducted multivariate logistic regression analyses to examine the association between TIR of RN > 80% or TIR of AN > 80% up to 72 h after ICU admission and in-hospital mortality (Model 1 and Model 2, respectively). The discrimination of the models was assessed using the area under the receiver operating characteristic curve (AUROC). Among 328 patients, 35 died in hospital (11%). Model 1 showed that TIR of RN > 80% was associated with reduced in-hospital mortality (adjusted OR 0.16; 95% CI 0.06–0.43; P 80% was not. The AUROC of Model 1 was significantly higher than that of Model 2 (0.84 [95% CI 0.77–0.90] vs. 0.79 [0.70–0.87], P = 0.008).Our findings provide a foundation for further studies exploring individualized glycemic management in ICUs.

Abstract Study Objective Early deployment of extracorporeal cardiopulmonary resuscitation (ECPR) is critical in treating refractory out‐of‐hospital cardiac arrest (OHCA) patients who are potential candidates for ECPR. The effect of prehospital advanced life support (ALS), including epinephrine administration or advanced airway, compared with no ALS in this setting remains unclear. This study's objective was to determine the association between any prehospital ALS care and outcomes of patients who received ECPR with emergency medical services‐treated OHCA. Methods This was a secondary analysis of data from the Study of Advanced Cardiac Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan (SAVE‐J) II study. Patients were separated into 2 groups—those who received prehospital ALS (ALS group) and those did not receive prehospital ALS (no ALS group). Multiple logistic regression analysis was used to investigate the association between prehospital ALS and favorable neurological outcomes (defined as Cerebral Performance Category scores 1–2) at hospital discharge. Results A total of 1289 patients were included, with 644 patients in the ALS group and 645 patients in the no ALS group. There were fewer favorable neurological outcomes at hospital discharge in the ALS group compared with the no ALS group (10.4 vs 19.8%, p

Abstract Background Whether extracorporeal cardiopulmonary resuscitation (ECPR) is indicated for patients with pulseless electrical activity (PEA) remains unclear. Pulmonary embolism with PEA is a good candidate for ECPR; however, PEA can sometimes include an aortic disease and intracranial haemorrhage, with extremely poor neurological outcomes, and can thus not be used as a suitable candidate. We began employing an ECPR strategy that utilised a hybrid emergency room (ER) to perform computed tomography (CT) before extracorporeal membrane oxygenation (ECMO) induction from January 2020. Therefore, the present study aimed to evaluate the effectiveness of this ECPR strategy. Methods Medical records of patients who transferred to our hybrid ER and required ECPR for PEA between January 2020 and November 2021 were reviewed. Results Twelve consecutive patients (median age, 67 [range, 57–73] years) with PEA requiring ECPR were identified in our hybrid ER. Among these patients, nine were diagnosed using an initial CT scan (intracranial haemorrhage (3); cardiac tamponade due to aortic dissection (3); aortic rupture (2); and cardiac rupture (1)), and unnecessary ECMO was avoided. The remaining three patients underwent ECPR, and two of them survived with favourable neurological outcomes. Patients not indicated for ECPR were excluded before ECMO induction. Conclusion Our ECPR strategy that involved the utilisation of a hybrid ER may be useful for the exclusion of patients with PEA not indicated for ECPR and decision making.

Abstract Background The prevalence of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA) has been increasing rapidly worldwide. However, guidelines or clinical studies do not provide sufficient data on ECPR practice. The aim of this study was to provide real-world data on ECPR for patients with OHCA, including details of complications. Methods We did a retrospective database analysis of observational multicenter cohort study in Japan. Adult patients with OHCA of presumed cardiac etiology who received ECPR between 2013 and 2018 were included. The primary outcome was favorable neurological outcome at hospital discharge, defined as a cerebral performance category of 1 or 2. Results A total of 1644 patients with OHCA were included in this study. The patient age was 18–93 years (median: 60 years). Shockable rhythm in the initial cardiac rhythm at the scene was 69.4%. The median estimated low flow time was 55 min (interquartile range: 45–66 min). Favorable neurological outcome at hospital discharge was observed in 14.1% of patients, and the rate of survival to hospital discharge was 27.2%. The proportions of favorable neurological outcome at hospital discharge in terms of shockable rhythm, pulseless electrical activity, and asystole were 16.7%, 9.2%, and 3.9%, respectively. Complications were observed during ECPR in 32.7% of patients, and the most common complication was bleeding, with the rates of cannulation site bleeding and other types of hemorrhage at 16.4% and 8.5%, respectively. Conclusions In this large cohort, data on the ECPR of 1644 patients with OHCA show that the proportion of favorable neurological outcomes at hospital discharge was 14.1%, survival rate at hospital discharge was 27.2%, and complications were observed during ECPR in 32.7%.

Aim: This study aimed to investigate the relationship between transient return of spontaneous circulation (ROSC) before extracorporeal membrane oxygenation (ECMO) initiation and outcomes in out-of-hospital cardiac arrest (OHCA) patients, who were resuscitated with extracorporeal cardiopulmonary resuscitation (ECPR). Methods: This study was a secondary analysis of the SAVE-J II study, which was a retrospective multicentre registry study involving 36 participating institutions in Japan. We classified patients into two groups according to the presence or absence of transient ROSC before ECMO initiation. Transient ROSC was defined as any palpable pulse of ≥1 min before ECMO initiation. The primary outcome was favourable neurological outcomes (cerebral performance categories 1–2). Results: Of 2,157 patients registered in the SAVE-J II study, 1,501 met the study inclusion criteria; 328 (22%) experienced transient ROSC before ECMO initiation. Patients with transient ROSC had better outcomes than those without ROSC (favourable neurological outcome, 26% vs 12%, P

The Hybrid Emergency Room System (HERS) allows clinicians to perform life-saving procedures without having to transfer patients. Several studies have reported the effectiveness of the HERS in the treatment of blunt trauma patients. However, the use of a hybrid emergency room (ER) for the treatment of penetrating cardiac injuries, including impalement injuries, has not been reported. We present the case of a patient with cardiac impalement injury that was diagnosed via computed tomography (CT) and was managed via extracorporeal membrane oxygenation (ECMO) in the hybrid ER and via surgery in the operating room. A 55-year-old man was transferred to our hybrid ER due to a penetrating wood injury through the right thoracic region. The patient had unstable vital signs. A CT scan revealed a pericardial effusion, right lung contusion, and bilateral pneumothoraxes. There were no signs of hemothorax or aortic injury. Veno-arterial-ECMO was performed in preparation for surgery. The patient was then transferred to the operating room. Pericardiotomy and cardiac repair were performed, and the ECMO was discontinued postoperatively. The patient was discharged on postoperative day 10 without complications. The hybrid ER allows rapid CT examination without relocation. Thus, it facilitates the formation of a timely and effective treatment plan. This report documents the successful management of a cardiac impalement injury in the HERS.

Abstract Background Physical restraint has been commonly indicated to patients with brain dysfunction in neurocritical care. The effect of physical restraints on outcomes of critically ill adults remains controversial as no randomized controlled trials have compared its safety and efficacy, and the association between physical restraint requirement and neurological outcome in patients with subarachnoid hemorrhage (SAH) has not been fully examined. The aim of this study was to examine the association between physical restraint requirement and neurological outcomes in patients with SAH. Methods A single-center, retrospective study was conducted on patients with acute phase SAH treated for > 72 h in the intensive care unit from 2014 to 2020. Patients were divided into three groups based on the amount of time required for physical restraint during the first 24–72 h after admission: no, intermittent, and continuous use of physical restraint. Unfavorable neurologic outcome, assessed using the modified Rankin scale upon hospital discharge, has been considered as primary end point. Results Overall, 101 patients were included in the study, with 52 patients (51.5%) having unfavorable neurological outcomes. Among them, 46 patients (45.5%) did not use physical restraint, and 55 (54.5%) patients used physical restraint during the first 24–72 h after admission: 26 (25.7%) intermittent and 29 (28.7%) continuous. Multivariable logistic regression analysis showed that continuous use of physical restraint during the first 24–72 h after admission was significantly associated with unfavorable neurological outcomes in patients with SAH (odds ratio, 3.54; 95% confidence interval, 1.05–13.06; p = 0.042) compared with no physical restraint. Conclusions Continuous use of physical restraint during the first 24–72 h after admission was more significantly associated with unfavorable neurological outcomes than no physical restraint among patients with SAH during the acute phase.

We present the first documented case of emergent pericardial drainage and return (PD-R) under extracorporeal membrane oxygenation (ECMO) for the management of aortic rupture into the pericardial sac caused by acute type A aortic dissection (AADA). An 83-year-old woman collapsed during an elective coronary intervention. ECMO was eventually required. Acute accumulation of pericardial effusion with aortic dissection was revealed by echocardiography. Percutaneous pericardial drainage was performed using a drainage line connected to the venous line of the ECMO system to maintain blood flow and blood pressure. After stabilization of the patient’s hemodynamics, immediate aortic repair was successfully performed and the patient was discharged with no neurological deficit. In cases of massive amounts of pericardial drainage and persistent hemorrhagic shock due to aortic rupture with AADA, PD-R connected to ECMO is useful while waiting for aortic repair.

Abstract We report a case of vascular injury caused by a multi‐lumen catheter for CRRT inserted through left jugular vein. Diagnosis was delayed because CRRT could be continued. Clinicians should be aware of potential vascular complications associated with the wrong placement of multi‐lumen catheters even if blood flow continues without difficulty.

Objectives: Several studies have examined the association between advanced airway management (AAM) and survival for arrest that is non-shockable, noncardiac in origin, or due to suffocation; however, the efficacy of prehospital AAM compared with no AAM following foreign body removal by emergency medical services (EMS) has not been examined. We aimed to compare neurological outcomes in patients after out-of-hospital cardiac arrest (OHCA) due to foreign body airway obstruction (FBAO) managed with and without AAM after foreign body removal. Methods: This retrospective observational cohort study used all emergency transportation data of Japan and the All-Japan Utstein Registry. We included patients with OHCA aged ≥18 years undergoing resuscitation and removal of airway foreign bodies by EMS from January 2015 to December 2017. The exposure of interest was prehospital AAM by EMS after foreign body removal, and the primary outcome was a favorable neurological outcome at hospital discharge (i.e., a cerebral performance category of 1–2). Results: Overall, 329,098 adults had OHCAs and 23,060 had foreign bodies removed from their airways; 3681 adult patients met our eligibility criteria and were divided as: AAM (2045) and non-AAM (1636) groups. Propensity score matching resulted in 1210 matched pairs with balanced baseline characteristics between the groups. The rate of favorable neurological outcome was significantly lower in the AAM group than in the non-AAM group (OR 0.34, 95% CI 0.19–0.62). However, survival was not significantly different between the two groups (OR 1.08, 95% CI 0.84–1.37). Conclusions: We have not demonstrated the benefit of AAM for patients with OHCA due to FBAO. Further study will be required to confirm the efficacy of AAM for those patients.

Abstract Background The association between isolated admission heart rate (HR) and prognosis has been discussed, but not that between gross HR change and neurological outcome in patients with severe traumatic brain injury (TBI). In the acute phase of severe TBI, HR is influenced by several factors (e.g., pain, sympathetic activation, hypovolemia, fever, body temperature). Therefore, admission HR and gross HR change should be examined in patients with TBI treated with a well-designed protocol, such as was done in the Brain Hypothermia (B-HYPO) Study. Methods This was a post hoc analysis of the B-HYPO Study, which was conducted as a prospective, multicenter, randomized controlled trial in patients with severe TBI receiving mild therapeutic hypothermia (MTH; 32.0 °C–34.0 °C) or fever control (35.5 °C–37.0 °C) in Japan. Patients with MTH were examined, and HR change (%HR) in the early MTH phase was calculated as follows: [admission HR – HR at day 1]/admission HR × 100. Patients were divided into six groups, using admission HR (

Background Studies describing the effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for peripartum cardiopulmonary arrest are lacking. Case Presentation A 39‐year‐old woman underwent elective cesarean section. Right after surgery, she fell into a cardiac arrest and was promptly transferred to our institute by ambulance. On arrival, we immediately initiated ECPR, within 63 min of the cardiac arrest. Return of spontaneous circulation was achieved 80 min after induction of extracorporeal membrane oxygenation. As the hemodynamics of the patient stabilized, extracorporeal membrane oxygenation was discontinued on day 3 of hospitalization. The patient’s cerebral performance category score was 3 at discharge, which improved to 2 after 3 months. Conclusion This case suggests that prompt interhospital transfer and ECPR might be effective for peripartum cardiac arrest due to nonhemorrhagic events.

Aim A lack of known guidelines for the provision of extracorporeal cardiopulmonary resuscitation (ECPR) to patients with out‐of‐hospital cardiac arrest (OHCA) has led to variability in practice between hospitals even in the same country. Because variability in ECPR practice has not been completely examined, we aimed to describe the variability in ECPR practice in patients with OHCA from the emergency department (ED) to the intensive care units (ICU). Methods An anonymous online questionnaire to examine variability in ECPR practice was completed in January 2020 by 36 medical institutions who participated in the SAVE‐J II study. Institutional demographics, inclusion and exclusion criteria, initial resuscitation management, extracorporeal membrane oxygenation (ECMO) initiation, initial ECMO management, intra‐aortic balloon pumping/endotracheal intubation/management during coronary angiography, and computed tomography criteria were recorded. Results We received responses from all 36 institutions. Four institutions (11.1%) had a hybrid emergency room. Cardiovascular surgery was always involved throughout the entire ECMO process in only 14.7% of institutions; 60% of institutions had formal inclusion criteria and 50% had formal exclusion criteria. In two‐thirds of institutions, emergency physicians carried out cannulation. Catheterization room was the leading location of cannulation (48.6%) followed by ED (31.4%). The presence of formal exclusion criteria significantly increased with increasing ECPR volume (P for trend

Background: The focused assessment with sonography for trauma (FAST) examination is helpful for the identification of pericardial effusion in trauma. However, in a cardiac rupture with a pericardial perforation, pericardial effusion is not always detected by FAST. We experienced the case that FAST and enhanced CT failed to detect pericardial effusion. Case presentation: A 51-year old woman injured after falling from a height of 3 m was brought to our institute. Focused assessment with sonography for trauma and enhanced computed tomography did not reveal any pericardial effusion; however, a massive hemothorax was revealed. Because the patient's hemodynamic state had become unstable, we performed an urgent left anterolateral thoracotomy. A left pericardial perforation was detected. By performing a clamshell thoracotomy, we found a rupture of 1 cm in diameter at the left atrial appendage. The hemodynamic state was stabilized by suturing the injury site. The postoperative course was uneventful, and the patient was transferred to another hospital after 31 days of admission. Conclusions: Cardiac injury in the left atrial appendage is rare and sometimes difficult to diagnose and to repair. In the case of a blunt chest trauma with a massive hemothorax, although focused assessment with sonography for trauma gives negative results for pericardial effusion, a cardiac rupture with pericardial perforation should be considered.

Abstract Extracorporeal cardiopulmonary resuscitation (ECPR) followed by targeted temperature management has been demonstrated to significantly improve the outcomes of out‐of‐hospital cardiac arrest (OHCA) in adult patients. Although recent narrative and systematic reviews on extracorporeal life support in the emergency department are available in the literature, they are focused on the efficacy of ECPR, and no comprehensively summarized review on ECPR for OHCA in adult patients is available. In this review, we aimed to clarify the prevalence, pathophysiology, predictors, management, and details of the complications of ECPR for OHCA, all of which have not been reviewed in previous literature, with the aim of facilitating understanding among acute care physicians. The leading countries in the field of ECPR are those in East Asia followed by those in Europe and the United States. ECPR may reduce the risks of reperfusion injury and deterioration to secondary brain injury. Unlike conventional cardiopulmonary resuscitation, however, no clear prognostic markers have been identified for ECPR for OHCA. Bleeding was identified as the most common complication of ECPR in patients with OHCA. Future studies should combine ECPR with intra‐aortic balloon pump, extracorporeal membrane oxygenation flow, target blood pressure, and seizure management in ECPR.

BACKGROUND:Studies in the non-emergency department (ED) settings have reported the relationships of post-intubation hypertension with poor patient outcomes. While ED-based studies have examined post-intubation hypotension and its sequelae, little is known about, post-intubation hypertension and its risk factors in the ED settings. In this context, we aimed to identify the incidence of post-intubation hypertension in the ED, and to test the hypothesis that repeated intubation attempts are associated with an increased risk of post-intubation hypertension. METHODS:This study is a secondary analysis of the data from a multicenter prospective observational study of emergency intubations in 15 EDs from 2012 through 2016. The analytic cohort comprised all adult non-cardiac-arrest patients undergoing orotracheal intubation without pre-intubation hypotension. The primary exposure was the repeated intubation attempts, defined as ≥2 laryngoscopic attempts. The outcome was post-intubation hypertension defined as an increase in systolic blood pressure (sBP) of >20% along with a post-intubation sBP of >160 mmHg. To investigate the association of repeated intubation attempts with the risk of post-intubation hypertension, we fit multivariable logistic regression models adjusting for ten potential confounders and patient clustering within the EDs. RESULTS:Of 3,097 patients, the median age was 69 years, 1,977 (64.0%) were men, and 991 (32.0%) underwent repeated intubation attempts. Post-intubation hypertension was observed in 276 (8.9%). In the unadjusted model, the incidence of post-intubation hypertension did not differ between the patients with single intubation attempt and those with repeated attempts (8.5% versus 9.8%, unadjusted P = 0.24). By contrast, after adjusting for potential confounders and patient clustering in the random-effects model, the patients who underwent repeated intubation attempts had a significantly higher risk of post-intubation hypertension (OR, 1.56; 95% CI, 1.11-2.18; adjusted P = 0.01). CONCLUSIONS:We found that 8.9% of patients developed post-intubation hypertension, and that repeated intubation attempts were significantly associated with a significantly higher risk of post-intubation hypertension in the ED.

This was the case of a male patient in his 60s, who suddenly collapsed. When the ambulance team arrived, the initial waveform was pulseless electrical activity; accordingly, a supraglottic airway device was inserted, and the patient was immediately transported to a referring hospital. On arrival, the patient resumed spontaneous circulation, the patient was diagnosed with Stanford type B acute aortic dissection and was referred to the author’s hospital, where diffuse swelling of the anterior cervical region was revealed. CT performed by the previous hospital revealed compression of the trachea. The cause of cardiac arrest was considered to be severe airway stenosis secondary to a retropharyngeal haematoma associated with Stanford type B acute aortic dissection. Stanford type B acute aortic dissection can be complicated by retropharyngeal haematomas, which can lead to airway obstruction and even cardiac arrest. This condition also requires careful airway examination. [ABSTRACT FROM AUTHOR]