Resuscitation最新文献

Objective: To summarise evidence on the clinical effectiveness of initial vascular attempts via the intraosseous route compared to the intravenous route in adult cardiac arrest.

Methods: We searched MEDLINE and Embase (OVID platform), the Cochrane library, and the International Clinical Trials Registry Platform from inception to September 4th 2024 for randomised clinical trials comparing the intraosseous route with the intravenous route in adult cardiac arrest. Our primary outcome was 30-day survival. Secondary outcomes included favourable neurological outcome at 30-days/hospital discharge and return of spontaneous circulation (both any ROSC and sustained ROSC). We performed meta-analyses using a fixed-effect model. We assessed risk of bias using the Cochrane Risk of Bias-2 tool and evidence certainty using the GRADE approach.

Results: We originally included three randomised clinical trials, but one trial was subsequently retracted. As such, two trials were included encompassing 7561 participants with out-of-hospital cardiac arrest. Initial attempts via the intraosseous, compared with intravenous, route did not increase the odds of 30-day survival (odds ratio 0.97, 95% confidence interval 0.80-1.18; 7540 participants; two trials; moderate-certainty evidence) or favourable neurological outcome at 30-days/hospital discharge (odds ratio 1.03, 95% confidence interval 0.81-1.31; 7454 participants; two trials; low-certainty evidence). The odds of achieving sustained return of spontaneous circulation were lower in the intraosseous group (odds ratio 0.89, 95% confidence interval 0.80-0.99; 7518 participants; two trials; moderate-certainty evidence).

Conclusion: Initial vascular access attempts via the intraosseous, compared with intravenous, route in adult cardiac arrest did not improve 30-day survival and may reduce the odds of a sustained return of spontaneous circulation.

Registration: PROSPERO CRD42024577647.

Background: Thiamine (vitamin B1) is an essential cofactor in mitochondrial oxidative metabolism. Recent trials evaluating thiamine as a metabolic resuscitator in post-cardiac arrest patients have shown variable results, possibly due to differences in baseline mitochondrial function. We hypothesized that baseline mitochondrial respiration predicts a greater response to thiamine supplementation.

Methods: This is a post hoc analysis of two randomized trials of thiamine administration in cardiac arrest patients (THICA, THACA). Mitochondrial function was assessed in peripheral blood mononuclear cells (PBMCs) using the Seahorse XF Analyzer to measure oxygen consumption rates (OCRs). Patients were stratified above or below the cohort median for each OCR variable. The primary outcome was change in lactate over 24 h.

Results: Seventy-four patients (40 thiamine vs. 34 placebo) had baseline OCR measurements and were included in the analysis. In the overall cohort, thiamine did not significantly reduce lactate compared to placebo (geometric mean ratio [GMR] = 0.83; 95% CI 0.64-1.09; p = 0.19). However, among patients with maximal or spare respiration above the median, thiamine treatment was associated with significantly lower lactate levels at 24 h (GMR = 0.61; 95% CI 0.44-0.83; p = 0.003 and GMR = 0.53; 95% CI 0.38-0.75; p < 0.001, respectively).

Conclusions: Thiamine supplementation was associated with reduced lactate in patients with preserved mitochondrial functional reserve. Baseline mitochondrial respiration may serve as a biomarker to identify critically ill patients most likely to benefit from metabolic resuscitation therapies.

Background: Brain death after hanging-induced cardiac arrest is a fatal complication about which few data are available. We aimed at identifying the early predictors of progression to brain death in patients with hanging-induced cardiac arrest.

Methods: Retrospective study including adults with return of spontaneous circulation from hanging-induced cardiac arrest admitted to 34 ICUs in France and Belgium between 2000 and 2024. Logistic multivariate regression was performed to identify factors associated with progression to brain death.

Results: Of the 554 patients with hanging-induced cardiac arrest, brain imaging was performed on admission in 443 (80.0%) patients. Overall, 169/554 (30.5%) and 142/443 (32.1%) patients progressed to brain death within a median time of 3 days, and up to 12 days, after the hanging-induced cardiac arrest. In 443 patients with brain imaging, five factors were independently associated with a higher risk of progression to brain death: female (OR, 1.76; 95% CI, 1.06-2.90; p = 0.03), asystole as first recorded rhythm (OR, 2.03; 95% CI, 1.27-3.29; p = 0.004), low-flow time > 30 min (OR, 1.84; 95% CI, 1.07-3.17; p = 0.03), total Logistic Organ Dysfunction System Score at day 1 (OR, 1.93/per point; 95% CI, 1.14-3.29; p = 0.02), and cerebral oedema and/or ischemic complication on brain CT scan at ICU admission (OR, 1.62; 95% CI, 1.01-2.61, p = 0.04). Conversely, age > 50 years (OR, 0.59; 95%CI, 0.35-0.98, p = 0.04) and status myoclonus ≤ day 2 (OR, 0.24; 95%CI, 0.09-0.54, p = 0.001) were associated with a lower risk of progression to brain death after hanging-induced cardiac arrest.

Conclusion: Our findings emphasise the very high rate of brain death after hanging-induced cardiac arrest. In our population, factors associated with brain death after hanging induced cardiac arrest predominantly reflect initial injury severity.

Background: Out-of-hospital cardiac arrest is associated with high mortality and substantial healthcare costs. The British Cardiovascular Interventional Society's conveyance algorithm prioritises direct transfer of patients with an initial shockable rhythm to specialist Cardiac Arrest Centres to support access to advanced cardiac intervention, neurocritical care, and structured rehabilitation. This study evaluated the cost-effectiveness of implementing the conveyance algorithm in a large regional population.

Methods: A hybrid decision-analytic model, combining a decision tree and Markov model was developed to assess the cost-effectiveness of the algorithm, compared with standard of care over a lifetime horizon. Model inputs were derived from a contemporary, observational pilot study. Health outcomes were expressed in quality-adjusted life years, and healthcare costs were discounted at an annual rate of 3.5%. Cost-effectiveness was assessed using the incremental cost-effectiveness ratio and net monetary benefit.

Results: The conveyance algorithm was cost-effective, with an incremental cost-effectiveness ratio of £2926 per quality-adjusted life year gained. Reductions in intensive care, hospital ward, post-assessment, and ambulance costs were partially offset by slightly higher costs related to admission, neuroprognostication, and longer-term care. Probabilistic analysis showed an 86.0% probability of cost-effectiveness at a willingness-to-pay threshold of £35,000 per quality-adjusted life year.

Conclusion: Selective rhythm-based transfer to specialist cardiac arrest centres improved resource efficiency with minimal additional cost. Although clinical outcome differences remain exploratory due to observational data, this economic evaluation supports further prospective, multi-centre evaluation to confirm broader clinical and health system benefits.