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Multiple studies have investigated the association between hyperoxaemia following cardiac arrest (CA) and unfavourable outcomes; however, they have yielded inconsistent results. Most previous studies quantified oxygen exposure without considering its timing or duration. We investigated the relationship between unfavourable outcomes and supranormal arterial oxygen tension (PaOThis retrospective observational study included 838 adult non-traumatic patients with CA. The first 24 h following CA were divided into four 6-h time intervals, and the first 6-h period was further divided into three 2-h segments. Multivariable logistic regression analyses were conducted to assess associations of the highest PaOThe highest PaOSupranormal PaO

Background Various methods have been used to control body temperature in targeted temperature management (TTM), but few studies have compared specific subtypes of surface cooling systems. The aim of this study was to compare the efficiencies and neurological outcomes between hydrogels pad and water-circulating blanket cooling methods. Methods We conducted a multicentre, prospective, registry-based study of out-of-hospital cardiac arrest patients treated with TTM between 2015 and 2018. We compared the neurological outcomes, efficacies for cooling, and adverse events between patients who received TTM using a hydrogel pad and water-circulating blanket cooling. Patients were one-to-one matched using propensity scores to adjust for differences in the baseline characteristics of each cooling method. The primary outcome was a favourable neurological outcome at 6 months. Results We included 1,132 patients in the analysis, 870 of whom underwent hydrogel pad cooling, and the remaining 262 underwent water-circulating blanket cooling. In the unmatched cohort, a greater number of adverse events occurred in the water-circulating blanket group. The favourable neurologic outcome rates at 6 months were similar between the hydrogel pad group and the water circulating blanket group (30.2% vs. 29.8%, p = 0.939). In the propensity-matched cohort, which included 184 pairs, the rates of adverse events between the two groups were similar. The similarity of favourable neurologic outcome rates at 6 months between the two groups persisted (28.8% vs. 29.9%, p = 0.819). Conclusion Neurological outcomes and adverse events between the hydrogel pad cooling and water-circulating blanket cooling groups were similar.

OBJECTIVES We investigated awakening time and characteristics of awakening compared nonawakening and factors contributing to poor neurologic outcomes in out-of-hospital cardiac arrest survivors in no withdrawal of life-sustaining therapy settings. DESIGN Retrospective analysis of the Korean Hypothermia Network Pro registry. SETTING Multicenter ICU. PATIENTS Adult (≥ 18 yr) comatose out-of-hospital cardiac arrest survivors who underwent targeted temperature management at 33-36°C between October 2015 and December 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We measured the time from the end of rewarming to awakening, defined as a total Glasgow Coma Scale score greater than or equal to 9 or Glasgow Coma Scale motor score equals to 6. The primary outcome was awakening time. The secondary outcome was 6-month neurologic outcomes (poor outcome: Cerebral Performance Category 3-5). Among 1,145 out-of-hospital cardiac arrest survivors, 477 patients (41.7%) regained consciousness 30 hours (6-71 hr) later, and 116 patients (24.3%) awakened late (72 hr after the end of rewarming). Young age, witnessed arrest, shockable rhythm, cardiac etiology, shorter time to return of spontaneous circulation, lower serum lactate level, absence of seizures, and multisedative requirement were associated with awakening. Of the 477 who woke up, 74 (15.5%) had poor neurologic outcomes. Older age, liver cirrhosis, nonshockable rhythm, noncardiac etiology, a higher Sequential Organ Failure Assessment score, and higher serum lactate levels were associated with poor neurologic outcomes. Late awakeners were more common in the poor than in the good neurologic outcome group (38/74 [51.4%] vs 78/403 [19.4%]; p < 0.001). The awakening time (odds ratio, 1.005; 95% CIs, 1.003-1.008) and late awakening (odds ratio, 3.194; 95% CIs, 1.776-5.746) were independently associated with poor neurologic outcomes. CONCLUSIONS Late awakening after out-of-hospital cardiac arrest was common in no withdrawal of life-sustaining therapy settings and the probability of awakening decreased over time.

Seismocardiography measures the vibrations produced by the beating heart using an accelerometer sensor placed on the chest. We evaluated the ability of smartphone seismocardiography to distinguish between the presence and absence of spontaneous circulation.Seismocardiography signals were obtained using a smartphone placed on the sternum in a convenience sample of 60 adult patients (30 comatose patients with spontaneous circulation and 30 deceased patients). The maximum, minimum, and standard deviation (SD) of acceleration values for head-to-foot, right-to-left, and dorsoventral axes and the three axis-root mean square (RMS) of the acceleration signals were calculated. Blinded observers (n = 156) were each asked to determine the presence or absence of spontaneous circulation based on seismocardiography video clips for each of the 60 patients.The seismocardiography revealed periodic large positive peaks in the patients with spontaneous circulation, which were absent in the patients without spontaneous circulation. For each of the four output measurements (three independent axes plus the three-axis RMS), the acceleration maxima and SD were significantly higher and the minima significantly lower in the patients with spontaneous circulation than in those without spontaneous circulation (all P 0.001 except the minimum of three axis-RMS results [P = 0.009]). The observers accurately identified the seismocardiography signals from patients without spontaneous circulation, with a sensitivity of 97.6% (95% confidence interval, 97.0%-98.2%) and a specificity of 98.4% (95% confidence interval, 97.8%-99.0%).In conclusion, blinded observers accurately distinguished between seismocardiography signals from patients with and without spontaneous circulation.

We aimed to verify whether slow heart rate (HR) is associated with neurologic outcome and the factors that can contribute to the development of bradycardia in out-of-hospital cardiac arrest (OHCA) survivors who underwent targeted temperature management (TTM). We extracted the data of comatose adult OHCA survivors who underwent TTM between October 2015 and December 2018 from the prospective multicenter registry. Data on HR recorded every 6 hours within 72 hours after return of spontaneous circulation and calculated minimal, mean, and maximal HR and time to the lowest HR were obtained. HR50 bpm was defined as bradycardia. The primary outcome was a 6-month neurologic outcome based on Pittsburgh-Glasgow Cerebral Performance Category Scale. Of the 814 included patients, 508 (62.4%) had poor neurologic outcome and 197 (24.2%) had bradycardia. Bradycardia (odds ratio [OR], 0.574; 95% confidence interval [CI], 0.362-0.192), minimal HR (OR, 1.023; 95% CI, 1.008-1.037), and mean HR (OR, 1.016; 95% CI, 1.002-1.030) were independently associated with poor neurologic outcome, but not maximal HR and time to the lowest HR. Preexisting arrhythmia (OR, 2.067; 95% CI, 1.037-4.118), renal disease (OR, 2.028; 95% CI, 1.153-3.567), cardiac etiology (OR, 1.526; 95% CI, 1.045-2.228), downtime (OR, 0.985; 95% CI, 0.974-0.996), and serum lactate levels (OR, 0.936; 95% CI, 0.900-0.974) were independently associated with bradycardia. Bradycardia and decreased mean and minimal HR were independently associated with good neurologic outcomes. Bradycardia was associated with preexisting arrhythmia, renal disease, cardiac etiology, shorter downtime, and lower serum lactate level.

This study aimed to investigate the efficacy of the combination of neuron-specific enolase (NSE) measurement and initial neurological examination in predicting the neurological outcomes of patients with cardiac arrest (CA) by retrospectively analyzing data from the Korean Hypothermia Network prospective registry. NSE levels were recorded at 48 and 72 h after CA. The initial Full Outline of UnResponsiveness (FOUR) and Glasgow Coma Scale (GCS) scores were recorded. These variables were categorized using the scorecard method. The primary endpoint was poor neurological outcomes at 6 months. Of the 475 patients, 171 (36%) had good neurological outcomes at 6 months. The areas under the curve (AUCs) of the categorized NSE levels at 72 h, GCS score, and FOUR score were 0.889, 0.722, and 0.779, respectively. The AUCs of the combinations of categorized NSE levels at 72 h with categorized GCS scores and FOUR score were 0.910 and 0.912, respectively. Each combination was significantly higher than the AUC value of the categorized NSE level at 72 h alone (with GCS: p = 0.015; with FOUR: p = 0.026). Combining NSE measurement and initial neurological examination improved the prediction of neurological outcomes.

To determine the association between the induction rate and 6-month neurologic outcomes in out-of-hospital cardiac arrest (OHCA) survivors who underwent targeted temperature management (TTM). This retrospective observational study analyzed data prospectively collected from adult comatose OHCA survivors treated with TTM at the Chonnam National University Hospital in Gwangju, Korea, between October 2015 and December 2020. We measured the core body temperature (BT) through an esophageal probe and recorded it every 5 minutes throughout TTM. Induction time was defined as the elapsed time between the initiation of TTM and the achievement of target BT of 33°C. We calculated the induction rate as the change of BT divided by induction time. The primary outcome was a poor 6-month neurologic outcome, defined as cerebral performance category 3-5. Of the OHCA survivors, 218 patients were included, and 137 (62.8%) patients had a poor neurologic outcome. Patients with a poor neurologic outcome had lower BT at the initiation of TTM, shorter induction time, and higher induction rate than those with good neurologic outcomes. After adjusting for confounders, induction time (odds ratio [OR] 0.995; 95% confidence interval [CI], 0.992-0.999) and induction rate (OR 2.362; 95% CI, 1.178-4.734) were independently associated with poor neurologic outcome. BT at TTM initiation was not associated with a poor neurologic outcome. Induction rate was independently associated with a poor neurologic outcome in OHCA survivors who underwent TTM at 33°C.

Pralidoxime potentiated the pressor effect of adrenaline and facilitated restoration of spontaneous circulation (ROSC) after prolonged cardiac arrest. In this study, we hypothesised that pralidoxime would hasten ROSC in a model with a short duration of untreated ventricular fibrillation (VF). We also hypothesised that potentiation of the pressor effect of adrenaline by pralidoxime would not be accompanied by worsening of the adverse effects of adrenaline. After 5 min of VF, 20 pigs randomly received either pralidoxime (40 mg/kg) or saline, in combination with adrenaline, during cardiopulmonary resuscitation (CPR). Coronary perfusion pressure (CPP) during CPR, and ease of resuscitation were compared between the groups. Additionally, haemodynamic data, severity of ventricular arrhythmias, and cerebral microcirculation were measured during the 1-h post-resuscitation period. Cerebral microcirculatory blood flow and brain tissue oxygen tension (PbtO2) were measured on parietal cortices exposed through burr holes. All animals achieved ROSC. The pralidoxime group had higher CPP during CPR (P = 0.014) and required a shorter duration of CPR (P = 0.024) and smaller number of adrenaline doses (P = 0.024). During the post-resuscitation period, heart rate increased over time in the control group, and decreased steadily in the pralidoxime group. No inter-group differences were observed in the incidences of ventricular arrhythmias, cerebral microcirculatory blood flow, and PbtO2. Pralidoxime improved CPP and hastened ROSC in a model with a short duration of untreated VF. The potentiation of the pressor effect of adrenaline was not accompanied by the worsening of the adverse effects of adrenaline.

We evaluated the performance of cardiac arrest-specific prognostication scores developed for outcome prediction in the early hours after out-of-hospital cardiac arrest (OHCA) in predicting long-term outcomes using independent data. The following scores were calculated for 1,163 OHCA patients who were treated with targeted temperature management (TTM) at 21 hospitals in South Korea: OHCA, cardiac arrest hospital prognosis (CAHP), C-GRApH (named on the basis of its variables), TTM risk, 5-R, NULL-PLEASE (named on the basis of its variables), Serbian quality of life long-term (SR-QOLl), cardiac arrest survival, revised post-cardiac arrest syndrome for therapeutic hypothermia (rCAST), Polish hypothermia registry (PHR) risk, and PROgnostication using LOGistic regression model for Unselected adult cardiac arrest patients in the Early stages (PROLOGUE) scores and prediction score by Aschauer et al. Their accuracies in predicting poor outcome at 6 months after OHCA were determined using the area under the receiver operating characteristic curve (AUC) and calibration belt. In the complete-case analyses, the PROLOGUE score showed the highest AUC (0.923; 95% confidence interval [CI], 0.904-0.941), whereas the SR-QOLl score had the lowest AUC (0.749; 95% CI, 0.711-0.786). The discrimination performances were similar in the analyses after multiple imputation. The PROLOGUE, TTM risk, CAHP, NULL-PLEASE, 5-R, and cardiac arrest survival scores were well calibrated. The rCAST and PHR risk scores showed acceptable overall calibration, although they showed miscalibration under the 80% CI level at extreme prediction values. The OHCA score, C-GRApH score, prediction score by Aschauer et al., and SR-QOLl score showed significant miscalibration in both complete-case (P = 0.026, 0.013, 0.005, and0.001, respectively) and multiple-imputation analyses (P = 0.007, 0.018,0.001, and0.001, respectively). In conclusion, the discrimination performances of the prognostication scores were all acceptable, but some showed significant miscalibration.

Purpose To assess the performance of the post-cardiac arrest (CA) prognostication strategy algorithm recommended by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) in 2020. Methods This was a retrospective analysis of the Korean Hypothermia Network Prospective Registry 1.0. Unconscious patients without confounders at day 4 (72–96 h) after return of spontaneous circulation (ROSC) were included. The association between the prognostic factors included in the prognostication strategy algorithm, except status myoclonus and the neurological outcome, was investigated, and finally, the prognostic performance of the prognostication strategy algorithm was evaluated. Poor outcome was defined as cerebral performance categories 3–5 at 6 months after ROSC. Results A total of 660 patients were included in the final analysis. Of those, 108 (16.4%) patients had a good neurological outcome at 6 months after CA. The 2020 ERC/ESICM prognostication strategy algorithm identified patients with poor neurological outcome with 60.2% sensitivity (95% CI 55.9–64.4) and 100% specificity (95% CI 93.9–100) among patients who were unconscious or had a GCS_M score ≤ 3 and with 58.2% sensitivity (95% CI 53.9–62.3) and 100% specificity (95% CI 96.6–100) among unconscious patients. When two prognostic factors were combined, any combination of prognostic factors had a false positive rate (FPR) of 0 (95% CI 0–5.6 for combination of no PR/CR and poor CT, 0–30.8 for combination of No SSEP N20 and NSE 60). Conclusion The 2020 ERC/ESICM prognostication strategy algorithm predicted poor outcome without an FPR and with sensitivities of 58.2–60.2%. Any combinations of two predictors recommended by ERC/ESICM showed 0% of FPR.

The effectiveness of extracorporeal membrane oxygenation (ECMO) for patients with refractory cardiogenic shock or cardiac arrest is being established, and serum lactate is well known as a biomarker of end-organ perfusion. We evaluated the efficacy of pre-ECMO lactate for predicting 6-month survival in patients with acute coronary syndrome (ACS) undergoing ECMO.We reviewed the medical records of 148 patients who underwent veno-arterial (VA) ECMO for ACS between January 2015 and June 2020. These patients were divided into survivors and non-survivors based on 6-month survival. All clinical data before and during ECMO were compared between the 2 groups.Patients' mean age was 66.0±10.5 years, and 116 (78.4%) were men. The total survival rate was 45.9% (n=68). Cox regression analysis showed that the pre-ECMO lactate level was an independent predictor of 6-month mortality (hazard ratio, 1.210; 95% confidence interval [CI], 1.064-1.376; p=0.004). The area under the receiver operating characteristic curve of pre-ECMO lactate was 0.64 (95% CI, 0.56-0.72; p=0.002; cut-off value=9.8 mmol/L). Kaplan-Meier survival analysis showed that the cumulative survival rate at 6 months was significantly higher among patients with a pre-ECMO lactate level of 9.8 mmol/L or less than among those with a level exceeding 9.8 mmol/L (57.3% vs. 31.8%, p=0.0008).A pre-ECMO lactate of 9.8 mmol/L or less may predict a favorable outcome at 6 months in ACS patients undergoing VA-ECMO. Further research aiming to improve the accuracy of predictions of reversibility in patients with high pre-ECMO lactate levels is essential.

We investigated the association of extracorporeal circuit-based devices with temperature management and neurological outcome in out-of-hospital cardiac arrest survivors who underwent targeted temperature management. Patients with extracorporeal membrane oxygenation and/or continuous renal replacement therapy were classified as the extracorporeal group. We calculated the cooling rate during the induction period and time-weighted core temperatures (TWCT) during the maintenance period. We defined the sum of TWCT above or below 33 °C as positive and negative TWCT, respectively, and the sum of TWCT above 33.5 °C or below 32.5 °C as undercooling or overcooling, respectively. The primary outcome was the negative TWCT. The secondary outcomes were positive TWCT, cooling rate, undercooling, overcooling, and poor neurological outcomes, defined as Cerebral Performance Category 3–5. Among 235 patients, 150 (63.8%) had poor neurological outcomes and 52 (22.1%) were assigned to the extracorporeal group. The extracorporeal group (β, 0.307; p p = 0.005), lower positive TWCT (33.4 °C∙min [24.9–46.2] vs. 54.6 °C∙min [29.9–87.0]), and higher overcooling (5.01 °C min [0.00–10.08] vs. 0.33 °C min [0.00–3.78]). However, the neurological outcome was not associated with the use of extracorporeal devices (odds ratio, 1.675; 95% confidence interval, 0.685–4.094).

Rearrest occurs commonly after initial resuscitation following out-of-hospital cardiac arrest (OHCA). We determined (1) the predictors of rearrest during hospitalisation that can be identified in the hours immediately after OHCA, (2) the association between rearrest and favourable long-term outcomes, and (3) the predictors of favourable long-term outcomes in rearrest patients.Conditional multivariable logistic regression analyses were performed using the Korean Hypothermia Network prospective registry data, which included details of adult OHCA patients treated with targeted temperature management at 22 teaching hospitals in South Korea.Among the 1,233 patients, 260 (21.1%) experienced rearrest. Of the 192 patients resuscitated from first rearrest, 33 (17.2%) achieved 6-month favourable outcomes. Arrhythmia, heart failure, ST-segment elevation, lower initial Glasgow coma scale (GCS) motor score, higher initial lactate level, and antiarrhythmic drug use within 1 h were independently associated with rearrest. Higher lactate level and antiarrhythmic drug use were associated with shockable first rearrest, while arrhythmia, heart failure, ST-segment elevation, and lower GCS motor score were associated with non-shockable first rearrest. Rearrest was independently associated with a lower likelihood of 6-month favourable outcomes (P = 0.003). Initial shockable rhythm after OHCA, absence of diabetes, shorter cumulative time to restoration of spontaneous circulation, coronary angiography, and hypophosphataemia within 7 d were independently associated with 6-month favourable outcomes in the patients resuscitated from first rearrest.Rearrest during hospitalisation after OHCA was inversely associated with 6-month favourable outcomes. We identified several risk factors for rearrest and prognostic factors for patients resuscitated from first rearrest.

In electrical impedance tomography (EIT), multiple electrodes are attached around an imaging domain such as the human thorax to inject currents and measure induced boundary voltages. Using the meas...

Thrombocytopenia is common and associated with mortality in critically ill patients. However, the time course of platelet counts and its association with the neurologic outcome after out-of-hospital cardiac arrest (OHCA) are not well known. The purpose of this study is to describe the time course of platelet counts in relation to the neurologic outcome in patients undergoing targeted temperature management (TTM) after CA.Review of consecutive patients receiving TTM after out-of-hospital CA between 2009 and 2016. The blood sample was collected daily until 7 days. The primary outcome was poor neurologic outcome at 6 months after CA defined as Cerebral Performance Category of 3-5 and secondary outcome was mortality at 6 months.A total of 261 consecutive patients treated with TTM after OHCA between 2009 and 2016. One hundred seventy-five patients (67.0%) had poor neurologic outcomes 6 months after CA. The changes in the platelet counts over time between the good and poor outcome groups were statistically significant (p 0.001). The platelet counts declined during TTM in both groups. The platelet counts recovered to the normal range at the end of the first week in the good neurologic outcome group. However, the platelet counts remained low in the poor outcome group. Low platelet counts on the 7th day were associated with poor neurologic outcomes (aOR 0.975, 95% CI, 0.961-0.989) and mortality at 6 months (aOR 0.986, 95% CI, 0.975-0.997) after adjusting for covariates.The changes in platelet counts in OHCA patients have a biphasic pattern that is significantly different in patients with good neurologic outcomes and those with poor neurologic outcomes at 6 months. A low platelet count 7 days after CA was associated with a poor neurologic outcome and mortality at 6 months.

Several studies reported that disturbances in cellular ion homeostasis occur following ischaemia, the magnitude of which was proportional to illness severity. The changes in serum electrolyte levels following ischaemia were minor compared with the changes in ion concentrations in the extracellular fluid. To amplify the serum electrolyte changes, we devised a new index (ion shift index), which could be calculated using commonly measured serum electrolyte levels, and explored its prognostic value in adult cardiac arrest patients.This retrospective observational study included adult cardiac arrest survivors treated at a tertiary university hospital between January 2014 and December 2017. Using the first available serum electrolyte levels, the ion shift index was calculated as follows: ion shift index = (potassium + phosphate + magnesium) / calcium. The primary outcome was poor outcome at hospital discharge (cerebral performance categories 3-5).The area under the receiver operating characteristic curve (AUC) of ion shift index for predicting poor outcome was 0.878 (95% confidence interval [CI], 0.849-0.907). The AUC of ion shift index was greater than those of individual electrolytes (all p 0.001). In multivariate analysis, higher ion shift index levels were independently associated with poor outcome (odds ratio, 2.916; 95% CI, 1.798-4.730; p 0.001). The AUC of multivariate model including ion shift index was greater than that of multivariate model after excluding ion shift index (p = 0.007).Our results suggest that the ion shift index can be helpful in the early prognostication of adult cardiac arrest patients.

We examined the association between variability in body temperature (BT) and water temperature (WT) during the maintenance period of targeted temperature management (TTM) and neurologic outcomes in out-of-hospital cardiac arrest (OHCA) survivors. Adult (≥18 years), comatose OHCA survivors who underwent TTM at 33°C between October 2015 and December 2019 were included. We collected data on BT and WT recorded every minute during the TTM maintenance period. Temperature variability was measured as the standard deviation of BT and WT during the 33°C maintenance period. The primary outcome was a poor neurologic outcome, defined as a cerebral performance category scale 3-5 at 6 months. Of the 154 included patients, 96 (62.3%) had poor outcomes. The BT variability in the poor outcome group was lower than that in the good outcome group (0.16°C [0.13-0.27°C] vs. 0.13°C [0.11-0.18°C]). In addition, the WT variability during the maintenance period in the poor outcome group was lower than that in the good outcome group (2.24°C [1.80-3.96°C] vs. 1.77°C [1.26-2.32°C]). In the multivariate analysis, WT variability (odds ratio 0.508; 95% confidence interval, 0.295-0.874

Severe neurological impairment was more prevalent in cardiac arrest survivors who were administered epinephrine than in those administered placebo in a randomized clinical trial, short-term reduction of brain tissue O2 tension (PbtO2) after epinephrine administration in swine following a short duration of untreated cardiac arrest has also been reported. We investigated the effects of epinephrine administered during cardiopulmonary resuscitation (CPR) on cerebral oxygenation after restoration of spontaneous circulation (ROSC) in a swine model with a clinically relevant duration of untreated cardiac arrest. After 7 min of ventricular fibrillation, 24 pigs randomly received either epinephrine or saline placebo during CPR. Parietal cortex measurements during 60-min post-resuscitation period showed that the area under the curve (AUC) for PbtO2 was smaller in the epinephrine group than in the placebo group during the initial 10-min period and subsequent 50-min period (both p &lt, 0.05). The AUC for number of perfused cerebral capillaries was smaller in the epinephrine group during the initial 10-min period (p = 0.005), but not during the subsequent 50-min period. In conclusion, epinephrine administered during CPR reduced PbtO2 for longer than 10 min following ROSC in a swine model with a clinically relevant duration of untreated cardiac arrest.

Introduction This study aimed to investigate the ion shift index (ISI) as a prognostic factor of severe trauma. We hypothesized that the initial ISI measured in the emergency department (ED) is associated with discharge survival in severe non-isolated head injury (IHI) patients. Materials and methods This retrospective observational study included severe trauma patients with available medical records from January 2017 to December 2018 but excluded those with IHI. Logistic regression analysis was conducted to identify the risk factors for mortality in non-IHI patients, and adjustments were performed for relevant covariates. An area under the receiver operating characteristics curve (AUROC) analysis was performed to examine the primary outcome of our study, which was mortality at hospital discharge in severe non-IHI trauma patients. Results Of the 483 severe non-IHI trauma patients included in the study, 86 patients (17.8 %) died. The multiple logistic regression analysis demonstrated ISI (odds ratio [OR], 2.300; 95% CI, 1.183–4.470) was significantly associated with mortality in the non-IHI group. Additionally, trauma and injury severity score (TRISS; OR, 0.538; 95% CI, 0.447–0.649), lactate (OR, 1.410; 95% CI, 1.252–1.588), creatinine (OR, 1.554; 95% CI, 1.221–1.979), and activated partial thromboplastin time (aPTT; OR, 1.050; 95% CI, 1.021–1.080) were independently associated with mortality at hospital discharge. The AUROC values for TRISS, lactate, aPTT, creatinine, and ISI were as follows: 0.892 (95% CI, 0.861–0.918), 0.838 (95% CI, 0.803–0.870), 0.754 (95% CI, 0.712–0.792), 0.650 (95% CI, 0.606–0.693), and 0.848 (95% CI, 0.813–0.879), respectively. The AUROC for the multiple logistic regression model with ISI was 0.942 (95% CI, 0.917–0.962). In a model in which TRISS was omitted, the addition of ISI to other predictors significantly improved the AUROC to 0.900 (95% CI, 0.869-0.925) (p=0.039). Conclusion The initial ISI in the ED after trauma was associated with mortality in severe non-IHI trauma patients. In conjunction with other prognostic indicators, it could be used as an early prognostic marker, particularly if TRISS is unavailable.

Author's summary Few studies have focused on acute myocardial infarction (AMI) with cardiogenic shock after resuscitated out-of-hospital cardiac arrest (OHCA). Only a small number of studies have reported the timing of extracorporeal membrane oxygenation (ECMO) in patients with AMI with cardiogenic shock. The current study, which used the large nationwide OHCA registry, shows that ECMO treatment before revascularization can decrease 30-day mortality, compared to ECMO after revascularization, in patients with AMI complicated by profound cardiogenic shock after resuscitated cardiac arrest. The current study emphasized the importance of early ECMO therapy before revascularization in circumstance which is difficult to determine optimal revascularization timing., Background and Objectives The study sought to investigate the impact of early extracorporeal membrane oxygenation (ECMO) support before revascularization in patients with acute myocardial infarction (AMI) complicated by profound cardiogenic shock after resuscitated cardiac arrest. It is difficult to determine optimal timing of ECMO in patients with AMI complicated by profound cardiogenic shock after resuscitated cardiac arrest. Methods Among 116,374 patients experiencing out-of-hospital cardiac arrest in South Korea, a total of 184 resuscitated patients with AMI complicated by profound cardiogenic shock, and who were treated successfully with percutaneous coronary intervention (PCI) and ECMO, were enrolled. Patients were divided into 2 groups according to the timing of ECMO: pre-PCI ECMO (n=117) and post-PCI ECMO (n=67). We compared 30-day mortality between the 2 groups. Results In-hospital mortality was 78.8% in the entire study population and significantly lower in the pre-PCI ECMO group (73.5% vs. 88.1%, p=0.020). Thirty-day mortality was also lower in the pre-PCI ECMO group compared to the post-PCI ECMO group (74.4% vs. 91.0%; adjusted hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.47–0.93; p=0.017). Shockable rhythm at the emergency room (HR, 0.57; 95% CI, 0.36–0.91; p=0.019) and successful therapeutic hypothermia (HR, 0.40; 95% CI, 0.23–0.69; p=0.001) were also associated with improved 30-day survival. Conclusions ECMO support before revascularization was associated with an improved short-term survival rate compared to ECMO after revascularization in patients with AMI complicated by profound cardiogenic shock after resuscitated cardiac arrest.

We investigated the association between post-rewarming fever (PRF) and 6-month neurologic outcomes in cardiac arrest survivors. This was a multicenter study based on a registry of comatose adult (&ge, 18 years) out-of-hospital cardiac arrest (OHCA) survivors who underwent targeted temperature management between October 2015 to December 2018. PRF was defined as peak temperature &ge, 38.0 &deg, C within 72 h after completion of rewarming, and PRF timing was categorized as within 24, 24&ndash, 48, and 48&ndash, 72 h epochs. The primary outcome was neurologic outcomes at six months after cardiac arrest. Unfavorable neurologic outcome was defined as cerebral performance categories three to five. A total of 1031 patients were included, and 642 (62.3%) had unfavorable neurologic outcomes. PRF developed in 389 (37.7%) patients in 72 h after rewarming: within 24 h in 150 (38.6%), in 24&ndash, 48 h in 155 (39.8%), and in 48&ndash, 72 h in 84 (21.6%). PRF was associated with improved neurologic outcomes (odds ratio (OR), 0.633, 95% confidence interval (CI), 0.416&ndash, 0.963). PRF within 24 h (OR, 0.355, 95% CI, 0.191&ndash, 0.659), but not in 24&ndash, 48 h or 48&ndash, 72 h, was associated with unfavorable neurologic outcomes. Early PRF within 24 h after rewarming was associated with favorable neurologic outcomes.

Although experimental extracorporeal membrane oxygenation (ECMO) animal models have been reported, there are few studies on the immune response to ECMO. We developed the venoarterial (VA) and venovenous (VV) model in rats and serially investigated the changes in the distribution of immune cells. Forty rats underwent both VA and VV modes of ECMO, and blood samples were collected at 1 day before ECMO (D-1), at the end of ECMO run (D+0), and 3 days after the ECMO (D+3). Flow cytometry was used to characterize surface marker expression (CD3, CD4, CD8, CD43, CD45, CD45R, CD161, and His48) on immune cells. Granulocytes were initially activated in both ECMO types and were further reduced but not normalized until 3 days of decannulation. Monocyte and natural killer cells were decreased initially in VA mode. B lymphocytes, helper T lymphocytes, and cytotoxic T lymphocytes also significantly decreased in VA modes after ECMO, but this phenomenon was not prominent in the VV modes. Overall immune cells proportion changed after ECMO run in both modes, and the immunologic balance altered significantly in the VA than in VV mode. Our ECMO model is feasible for the hemodynamic and immunologic research, and further long-term evaluation is needed.

Several studies have suggested that sympathetic overstimulation causes deleterious effects in septic shock. A previous study suggested that pralidoxime exerted a pressor effect through a mechanism unrelated to the sympathetic nervous system; this effect was buffered by the vasodepressor action of pralidoxime mediated through sympathoinhibition. In this study, we explored the effects of pralidoxime on hemodynamics and survival in rats with peritonitis-induced sepsis. This study consisted of two sub-studies: survival and hemodynamic studies. In the survival study, 66 rats, which survived for 10 hours after cecal ligation and puncture (CLP), randomly received saline placebo, pralidoxime, or norepinephrine treatment and were monitored for up to 24 hours. In the hemodynamic study, 44 rats were randomly assigned to sham, CLP-saline placebo, CLP-pralidoxime, or CLP-norepinephrine groups, and hemodynamic measurements were performed using a conductance catheter placed in the left ventricle. In the survival study, 6 (27.2%), 15 (68.1%), and 5 (22.7%) animals survived the entire 24-hour monitoring period in the saline, pralidoxime, and norepinephrine groups, respectively (log-rank test P = 0.006). In the hemodynamic study, pralidoxime but not norepinephrine increased end-diastolic volume (P