bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 10: Transcriptional Profiling of the Neuroprotective Mechanisms of Inhaled Nitric Oxide in a Swine Model of Pediatric Cardiac Arrest
Authors: Hefti Marco , Senthil Kumaran , Mavroudis Constantine D , Karlsson Michael , Ehinger Johannes , Nadkarni Vinay M , Sutton Robert M , Berg Robert A , Morgan Ryan W , Kilbaugh Todd J
Published: July 2021

Introduction:
Neurologic morbidity is common after pediatric cardiac arrest and inhaled nitric oxide (iNO) may be protective. RNA sequencing may have a role in identifying differences in gene expression related to neurologic injury following cardiac arrest and the neuroprotective mechanism of iNO.

Hypothesis:
We hypothesized that genes related to energetically intensive functions such as synaptic vesicle trafficking would be downregulated after cardiac arrest and that this finding would be less prominent with iNO therapy.

Methods:
One-month old piglets underwent sham anesthesia or 7 minutes of asphyxia, induction of VF, and randomized and blinded therapy with AHA guideline-based CPR with iNO (iNO
+
) or without iNO (iNO
-
). Four hours post-ROSC, animals were euthanized and RNA was extracted from cerebral cortical tissue and sequenced on an Illumina HiSeq instrument. STAR was used to align reads to the SusScrofa11.1 reference followed by quantification with sub-reads. Normalization and differential expression analyses were performed using DESeq2 with RIN, RNA concentration, shocks delivered, epinephrine doses, post-ROSC epinephrine use, cerebral blood flow, ETCO
2
, and blood gas values as covariates. Benjamini-Hochberg-adjusted p values <0.05 were considered statistically significant.

Results:
Sham animals (n=5) and cardiac arrest animals with ROSC (iNO+ n=9; iNO- n=6) were included in analyses. 817 genes were differentially expressed between cardiac arrest and sham. 798 genes were differentially expressed between iNO
+
and iNO
-
. 24 genes were differentially expressed in opposite directions in the two comparisons, making them candidates for protective mechanisms of iNO. These included genes related to synaptic vesicle function (RAB27B, PACSIN1, DOC2A) and maintenance of synaptic structure (SH2D5, CA10). Cardiac arrest induced downregulation of synaptic vesicle genes including SNAP25 and synaptophysin, while iNO induced upregulation of others in the same ontology, including synapsins and synaptogamins.

Conclusions:
Piglets subjected to asphyxial cardiac arrest exhibited downregulation of genes related to synaptic vesicle trafficking. This was partially prevented by treatment with iNO.
Abstract 108: Pulselessness Despite Cardiopulmonary Resuscitation for Bradycardia in Hospitalized Children: Prevalence, Predictors of Survival, and Implications for Hospital Profiling
Authors: Khera Rohan , Tang Yuanyuan , Girotra Saket , Nadkarni Vinay M , Link Mark S , Raymond Tia , Guerguerian Anne-Marie , Berg Robert , Chan Paul S
Published: July 2021

Background:
Cardiopulmonary resuscitation (CPR) is initiated in hospitalized children with bradycardia and poor perfusion. However, it is unknown how often these children progress to pulseless in-hospital cardiac arrest (IHCA) despite CPR, and whether survival differs from primary pulseless IHCA.

Methods:
In Get With The Guidelines-Resuscitation (2000-2016), we identified all pediatric patients (age>30 days, <18 years) receiving CPR, and assessed the prevalence and predictors of survival among those progressing from bradycardia to pulselessness after initiation of CPR using multilevel Poisson regression that accounted for the pulseless rhythm.

Results:
Overall, 5592 pediatric patients were treated with CPR, of whom over half (2799) were for bradycardia with poor perfusion and the remaining 2793 were primary pulseless IHCAs. Among those with bradycardia, 869 (31%, or 16% of entire cohort) progressed to pulselessness after a median of 3 min of CPR (IQR 1- 9). Survival to discharge was 70% for bradycardia without pulselessness, 30% with bradycardia progressing to pulselessness, and 38% with primary pulseless IHCA (P<.001). Children who became pulseless while receiving CPR for bradycardia had a 19% lower likelihood (RR 0.81 [0.70 - 0.93]) of surviving to hospital discharge than those initially pulseless. Among children who progressed to pulselessness while receiving CPR for bradycardia, longer time to pulselessness was an independent predictor of lower survival (ref: <2 min, for 2-5 min: RR 0.54 [0.41 - 0.70]; for >5 min: RR 0.41 [0.32 - 0.53],
Figure
).

Conclusions:
Among non-neonatal pediatric patients in whom CPR is initiated, half have bradycardia with poor perfusion, and nearly one-third of these progress to IHCA despite CPR. Survival was lower for pediatric patients who subsequently became pulseless as compared to those who were initially pulseless. These findings have implications for care delivery and profiling hospital performance for pediatric IHCA.
Abstract 117: A Population Based Study in a Large Ethnically Diverse Metropolitan City Reveals Racial and Ethnic Disparities in Pediatric Cardiac Arrest
Authors: Miyake Christina Y , Srinivasan Saranya , Ostermayer Daniel , Wolf Dwayne , Kim Jeffrey J , delaUz Caridad M , Valdes Santiago O , Pedroza Claudia , Morris Shaine A , Lopez Keila N , Tran Vinh V , Lee Eric J , Milewicz Dianna , Sirbaugh Paul E
Published: July 2021

Background:
Data regarding racial and ethnic differences in incidence and survival in pediatric cardiac arrest are unknown. In large cities, universal tracking of cardiac arrest is limited by multiple response centers fielding calls. This study was performed in Houston, one of the largest and most ethnically diverse cities in the US. Every 911 call in the city is tracked by a single operations center, providing a unique opportunity to conduct a population based study.

Objective:
We aimed to examine race and ethnic differences in incidence and survival rates among pediatric cardiac arrests utilizing a non-sampled population in a large metropolitan area.

Methods:
We performed a retrospective review of all 911 emergency response records involving non-traumatic pediatric cardiac arrests <18 years between 2002-2017. Race and ethnicity data among patients with cardiac arrests were compared to Houston population census data.

Results:
There were 598 (57% males) pediatric cardiac arrests at median age of 10 mo (IQR 2 mo - 6 yrs). Infants <2 yrs accounted for 60% of cases, 2-5 yrs (14%), 6-10 yrs (15%) and 11-17 yrs (11%). Overall, non-Hispanic black children comprised a significantly larger proportion of those with cardiac arrest than would be expected given population distribution (Figure). When evaluating these differences by age, the largest discrepancy was among infants, where odds of arrest in non-Hispanic black or Hispanic was 2.3 (95%CI 1.2-4.4) and 2.9 (95% CI 1.4-5.8) compared to white children. Overall survival was poor (9%) and did not differ by race/ethnicity, sex, bystander CPR, or time from 911 call to emergency personnel arrival. The only variable associated with greater survival was witnessed arrest (OR 2.2, 95%CI 1.2-4.0).

Conclusions:
There are racial differences in cardiac arrest in Houston based on age. Identifying reasons for these differences may provide insights into environmental or genetic risk factors associated with pediatric cardiac arrests.
Abstract 122: The Role of Plasma Lysophosphatidylcholine in Patients With Out-of-Hospital Cardiac Arrest
Authors: Yagi Tsukasa , Yin Tai , Shinozaki Koichiro , Becker Lance B , Kim Junhwan
Published: July 2021

Background:
Phosphatidylcholine (PC) is the most abundant class of phospholipid found in plasma. Lysophosphatidylcholine (LPC), PC missing one acyl chain, is believed to be the main carrier of polyunsaturated fatty acids (PUFAs) to the brain. The continuous supply of PUFAs, such as eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and arachidonic acid (AA), are important to maintain proper function of the brain. Therefore, alterations in the plasma levels of LPC containing these fatty acids, LPC-EPA, LPC-DHA, and LPC-AA, indicate impaired delivery of fatty acids, which in turn may indicate abnormal brain function. Numerous animal studies have found altered LPC compositions in Alzheimer’s disease, cognitive impairment, brain ischemia, and aging. Moreover, administration of LPC has been shown to improve brain function in these pathological conditions. Since brain damage is the main cause of death in cardiac arrest, altered LPC profiles may be indicative of brain damage and also play a role in the recovery of brain function. The aim of this study was to measure the content of plasma LPC species in out-of-hospital cardiac arrest (OHCA) patients compared to healthy controls.

Methods:
Blood samples were obtained from 11 OHCA patients, who were admitted to Northshore University Hospital and achieved return of spontaneous circulation. Within 4 h of drawing, plasma was separated from the whole blood using centrifugation and stored at -80°C. Control samples were obtained from 19 healthy volunteers. The contents of LPC species were measured using LC-mass spectrometry.

Results:
We found the overall content of LPC is significantly lower in OHCA patients. The decrease is found in all species of LPC, including LPC-EPA (patients vs Controls = 0.17 vs 0.55 μmol/L, p=0.003), LPC-DHA (patients vs Controls = 0.47 vs 1.72 μmol/L, p=0.003), and LPC-AA (patients vs Controls = 1.98 vs 5.39 μmol/L, p<0.001). We also found decreased in LPC species containing saturated fatty acids, showing the decrease was not specific to PUFAs.

Conclusion:
We found OHCA patients have a significantly lower plasma LPC content. Understanding the detailed mechanism for this decrease and the role that LPC plays in the recovery of patients after OHCA requires more investigation.
Abstract 137: The Impact of Psychological Distress on Six-Month Recovery Perceptions in Survivors of Cardiac Arrest
Authors: Presciutti Alex , Sobczak Evie , Roh David J , Park Soojin , Claassen Jan , Kronish Ian , Sumner Jennifer , Agarwal Sachin
Published: July 2021

Introduction:
To determine the association of depressive and posttraumatic stress disorder symptoms with cardiac arrest (CA) survivors’ long-term recovery perceptions, after accounting for cognitive status, functional independence, and medical comorbidities.

Hypothesis:
We recently demonstrated that posttraumatic stress and depressive symptoms, not cognitive or functional impairment, were associated with cardiac arrest survivors’ negative recovery perceptions at hospital discharge. Current study aims to extend this work by examining the correlates of perceived recovery in these CA survivors at 6 months after their hospital discharge.

Methods:
Perceived recovery of 78 prospectively enrolled CA survivors at 6-months post-discharge was assessed through the question, “Do you feel that you have made a complete recovery from your arrest?” Psychological symptoms were measured using the Center for Epidemiological Studies-Depression scale (CES-D) and the PTSD Checklist-Specific (PCL-S). Logistic regression was utilized to assess the association between depression and PTSD symptoms with positive and negative recovery perceptions, adjusting for demographics, cognitive impairment (Repeatable Battery for Assessment of Neuropsychological Status or Telephone Interview for Cognitive Status), functional dependence (Modified Lawton Instrumental Activities of Daily Living), and medical comorbidities (Charlson Comorbidity Index).

Results:
At 6 months, 53% of patients (n=41) had a negative recovery perception. 32.1% (n = 25) of patients screened for depression and 28.2% (n = 22) for PTSD. Patients with higher CES-D scores were significantly more likely to have a negative recovery perception in both unadjusted (Odds Ratio (OR): 1.10, 95% Confidence Interval (CI) [1.4, 1.16], p<0.001) and adjusted analyses (OR: 1.10, 95% CI [1.03, 1.16], p<0.01). PCL-S scores were significantly associated with negative recovery perception in an unadjusted model (OR: 1.05, 95% CI [1.01, 1.10], p < 0.01), but not after adjustment of covariates.

Conclusions:
In contrast with cognitive and functional measures, psychological symptoms were strongly associated with cardiac arrest survivors’ negative recovery perceptions at 6-months post-discharge.
Abstract 138: A Before and After Study of Active Compression Decompression Cardiopulmonary Resuscitation With the Impedance Threshold Device in a Large Urban Pre-Hospital System
Authors: Moore Johanna C , Grahl Michael , Marko Tracy , Blythe-Reske Ariel , Lage Amber , Hedge Erin , Bancroft-Howard Andrew , Klein Lauren , Scharber Sarah , Garthe Clayton , Ho Jeffrey
Published: July 2021

Introduction:
Active Compression Decompression cardiopulmonary resuscitation with an impedance threshold device (ACD+ITD CPR) is available for use in the United States. However, little is known regarding integration of this CPR system into a large urban prehospital system with short response times, routine use of mechanical CPR and ITD, and transport of patients to cardiac arrest centers. This is an ongoing before and after study of the implementation of ACD+ITD CPR in non-traumatic cardiac arrest cases 6 months pre and post protocol change.

Hypothesis:
Neurologically intact rates of survival, defined by Cerebral Performance Category (CPC) score of 1 or 2, would be higher post protocol.

Methods:
Basic life support first responders (n = 420) and paramedics (n = 207) underwent training including didactic and hands-on sessions to learn ACD+ITD CPR. The protocol included ACD+ITD CPR initially, with the option to transition to mechanical CPR at 15 minutes. Demographics, response time, CPR duration, initial rhythm, signs of perfusion during CPR, and return of spontaneous circulation (ROSC) were recorded prospectively by first responders. Chart review was performed to determine survival to hospital admission and CPC score at discharge.

Results:
Training occurred October 2016 to March 2017, with protocol change on May 1, 2017. Cases from November 2016-April 2017 (n = 136) and May 2017-November 2017 (n= 103) were reviewed. Complete data were available for 128 subjects pre-protocol change (94%) and 96 subjects (94%) post. Age, gender, response time, rhythm, total CPR time, and rates of bystander CPR and witnessed arrest were similar between groups. Post protocol change, 87% (89/102) received ACD+ITD CPR with median ACD+ITD CPR time of 15 minutes (range 2-300). Pre-protocol, 6/128 (4.7%) subjects survived with CPC score 1 or 2, versus 8/96 (13.5%) subjects post (difference 8.8%, 95% CI 1%-17%). ROSC rates were similar (pre: 54/127, 42.5% post: 44/93, 47%, difference 4.8%, 95% CI -8% - 18%)

Conclusions:
The change in protocol was straightforward with a high rate of adherence of the system for the recommended duration of therapy. Results are suggestive of a higher rate of neurological survival with the routine use of ACD+ITD CPR in a small cardiac arrest patient population.
Abstract 139: Impedance Threshold Device and Active Decompression Improve Hemodynamics in a Swine Model of Prolonged CPR
Authors: Lampe Joshua W , Tai Yin , Metzger Anja K , Kaufman Christopher L , Becker Lance B
Published: July 2021

Introduction:
Cardiopulmonary resuscitation with the impedance threshold device and active decompression (ITD-ACD CPR) has been shown to improve chest compression generated blood flow relative to standard chest compression. Using our high-fidelity swine model of cardiac arrest treated with prolonged mechanical chest compression (MCC) we studied the effect of different lift heights (amount of lift above the natural zero point of the sternum) during active decompression.

Methods:
CPR was performed on six domestic swine (~30 kg) using standard physiological monitoring. Flow was measured in the abdominal aorta, inferior vena cava (IVC), right common carotid and external jugular, and left femoral artery. Ventricular fibrillation (VF) was electrically induced. MCC were started after ten minutes of VF. Four MCC waveforms were used: Standard CPR (2”, 100 CPM), and ITD-ACD CPR (2”, 80 CPM) with 0.5”, 1.0”, and 1.5” lift past the zero point. MCC waveforms were changed every 2 min in a crossover design and delivered for 56 minutes. Data were analyzed in CPR cycles which included four epochs of CPR, one of each waveform, constituting 8 minutes of compressions.

Results:
Lift height had a significant (p<0.05) effect on carotid and jugular blood flow. Lift heights of 1.0 and 1.5” generated significantly more carotid blood flow in all 7 CPR cycles. A lift height of 1.5” generated significantly more jugular blood flow over all 7 CPR cycles. The interaction between duration of CPR and Jugular blood flow previously observed using this animal model was not observed. Carotid and jugular blood flow as a function of waveform and CPR cycle are shown in the figure.

Conclusions:
ITD-ACD CPR improved carotid and jugular blood flows, suggestive of improved cerebral perfusion. A lift height of 1.5” was required for significant improvement of jugular blood flows, while ITD-ACD CPR provided significantly better carotid blood flow than standard CPR at all lift heights.
Abstract 141: Resuscitation Time Bias in an Observational Study of Mechanical Chest Compression CPR
Authors: Levy Michael K , Kern Karl B , Yost Dana , Madsen Hardig Bjarne , Chapman Fred W
Published: July 2021

Recent observational studies have found associations between poorer outcomes and treatment that included mechanical CPR devices, contradicting findings from randomized trials. Resuscitation time bias is a systematic error occurring in observational studies of interventions applied to pulseless patients later in resuscitation attempts. Previous observational studies lack data on duration of resuscitation, a factor strongly related to outcome. We retrospectively analyzed cardiac arrest data to learn how resuscitation time and device use relate to clinical outcomes, and determine whether resuscitation time bias was present.

Methods and Results:
We analyzed data from all 49 patients with ventricular fibrillation, out-of-hospital cardiac arrest treated by our emergency medical service in one year. We compared 19 patients who received only standard manual CPR (the sCPR group) to 30 patients who received manual followed by mechanical CPR (the mCPR group). Response to CPR differed between groups even before device application. All sCPR patients achieved return of spontaneous circulation (ROSC), and did so after a median (IQR) of 3.3 (2.2-5.1) minutes of manual CPR. Patients in the mCPR group failed to get ROSC through 6.9 (5.3-11.0) min of manual CPR; mCPR patients that did get ROSC did so after 11.2 (5.7-23.8) additional minutes of CPR, delivered by a mechanical device. mCPR patients also received significantly more defibrillations and ALS drugs. ROSC and survival to hospital discharge were higher in the sCPR than the mCPR group (100% vs. 70%, P = 0.008; 74% vs. 43%, P = 0.045).

Conclusion:
Only patients remaining pulseless after early resuscitation efforts received mechanical CPR. Consequently, mechanical CPR devices assisted by facilitating prolonged treatment of patients who already had lower chances of survival before device application. Resuscitation time bias was present, and must be considered when interpreting registry reports comparing sCPR and mCPR.
Abstract 142: Evaluation of Clinical Efficacy and Safety of a Newly Developed Automated Cardiopulmonary Resuscitation Device; A Porcine Cardiac Arrest Model
Authors: Kim Ki Hong , Shin Sang Do , Kim Tae Han , Hong Ki Jeong , Choi Seong Wook , Kang Seong Min , Song Gyeong Jun , Song Sung Wook , Lee Eui Jung , Lee Seon Yeong , Lee Yu Seong , Park Jin Hyung
Published: July 2021

Background:
Various automated compression device (ACD) have been adopted by emergency medical services (EMS) worldwide to ensure cardiopulmonary resuscitation (CPR) quality. We developed a new ACD with a manual adjustment function according to compression depth and rate. This study aimed to compare the CPR quality and chest injury caused between the new ACD and a conventional device (LUCAS, Physio-Control, Sweden).

Methods:
A randomized experimental trial using each eight pigs for ACD and Lucas group were performed to compare the CPR quality, outcomes, and safety. After 1-minute of untreated electrical-induced ventricular fibrillation, followed by 8-minutes of basic life support, and 20-minutes of advanced cardiac life support including epinephrine infusion were provided under mechanical ventilation. Hemodynamic parameters were obtained and observed end-tidal CO2 (ETCO2) were continuously measured from endotracheal tube as study outcome. Mixed model analysis and repeated measure ANOVA were used to compare the difference of hemodynamic parameters and observed ETCO2. We examined the all pigs for gross pathologic findings (number of lung contusion, laceration, bone fracture, and hematoma in the thoracic cavity) after CPR procedures through open thoracotomy.

Results:
There was no significant difference for hemodynamic parameters such as mean arterial pressure, 29.4 mmHg in ACD group versus 35.3 mmHg in Lucas group (p-value= 0.39). Observed ETCO2 between ACD and Lucas group were 18.0 and 26.8 mmHg (p-value=0.24). Repeated measure ANOVA for observed ETCO2 did not show significant difference (17.6 versus 26.0, p-value= 0.29). The gross pathologic findings through open thoracotomy examination after CPR showed insignificant difference of injury number in chest cavity and wall (7.63 versus 9.38, p-value= 0.49).

Conclusions:
Hemodynamic parameters and observed ETCO2 were slightly better in Lucas group than new ACD group. However, the statistical significances were not found in the porcine experimental mechanical models.
Abstract 144: Differing Pattern of ECG Changes During Resuscitation From Pulseless Electrical Activity Depending on Etiology
Authors: Skjeflo Gunnar W , Nordseth Trond , Loennechen Jan Pål , Bergum Daniel , Skogvoll Eirik
Published: July 2021

Introduction:
Pulseless electrical activity (PEA) is a frequent initial rhythm in in-hospital cardiac arrest. ECG changes during cardiopulmonary resuscitation (CPR) have been linked to prognosis; QRS complex narrowing and increase in QRS-rate/heart rate was observed before return of spontaneous circulation (ROSC). Our hypothesis was that ECG changes during CPR of patients with cardiac arrest with initial PEA could also be different depending on etiology of arrest.

Methods:
Patients with cardiac arrest with initial PEA at St. Olav University Hospital (Trondheim, Norway) between January 2009 and January 2012 were prospectively included. QRS duration and heart rate were measured at all pauses in chest compressions. Etiologies were categorized as ‘Cardiac’ or ‘Other’. Trends in the material were inspected using additive mixed effects models for the last 18 minutes before ROSC or end of CPR and development of QRS width was analyzed using linear mixed effects models based on these trends.

Results:
A total of 63 patients for whom a reliable cause of arrest could be identified retrospectively were included. 1844 combined measurements of QRS width and heart rate were made. According to the additive mixed effects model the development in heart rate was similar in both etiology groups. The change in QRS width differed in patients who obtained ROSC, with the Cardiac group narrowing more than the other group, and both groups ending at essentially the same QRS widths at ROSC (figure). By the linear mixed effects model this difference in change was statistically significant (p=0.04). In patients who did not have ROSC, the cardiac group had significantly (p=0.001, linear mixed effects model) wider QRS complexes, but the change towards ROSC was the same in both groups.

Conclusion:
During the last 18 minutes before ROSC ECG characteristics differed depending on etiology, with cardiac etiologies having wider QRS complexes in the no-ROSC groups and narrowing more towards ROSC in the ROSC groups.
Abstract 150: Impact of Epinephrine on ECG Changes During Resuscitation From Out-of-Hospital Cardiac Arrest With Initial Pulseless Electrical Activity
Authors: Skjeflo Gunnar W , Skogvoll Eirik , Loennechen Jan Pål , Olasveengen Theresa M , Wik Lars , Nordseth Trond
Published: July 2021

Introduction:
Presence of electrocardiographic rhythm, documented by the electrocardiogram (ECG), in the absence of palpable pulses defines pulseless electrical activity (PEA). Our aims were to examine the development of ECG characteristics during advanced life support (ALS) from Out-of-Hospital-Cardiac-Arrest (OHCA) with initial PEA, and to explore the effects of epinephrine on these characteristics.

Methods:
Patients with OHCA and initial PEA in a randomized controlled trial of ALS with or without intravenous access and medications were included. QRS widths and heart-rates were measured in recorded ECG signals during pauses in compressions. Statistical analysis was carried out by multivariate regression (MANOVA).

Results:
Defibrillator recordings from 170 episodes of cardiac arrest were analyzed, 4840 combined measurements of QRS complex width and heart rate were made. By the multivariate regression model both whether epinephrine was administered and whether return of spontaneous circulation (ROSC) was obtained were significantly associated with changes in QRS width and heart rate. For both control and epinephrine groups, ROSC was preceded by decreasing QRS width and increasing rate, but in the epinephrine group an increase in rate without a decrease in QRS width was associated with poor outcome (fig).

Conclusion:
The QRS complex characteristics are affected by epinephrine administration during ALS, but still yields valuable prognostic information.
Abstract 153: Does the Revision of Resuscitation Guidelines Improve the Outcome of In-Hospital Cardiac Arrest?
Authors: Miyake Akihiro , Nonogi Hiroshi , Fujimoto Yoshihisa , Fujiwara Shinsuke , Naito Takaki , Morooka Takaya , Hatasako Nobuyuki , Tosaka Naoki , Yokoyama Hiroyuki , Fujitani Shigeki
Published: July 2021

Background:
Resuscitation guidelines have been improved every five years using ILCOR international consensus and outcomes for out-of-hospital cardiac arrest improved. However, it remained unknown whether the outcome of in-hospital cardiac arrest has improved. The purpose of this research is to compare the outcomes of multicenter registrations in Japan and to consider the role of rapid response system (RRS).

Methods:
We compared the two multicenter prospective registrations for adult in-hospital cardiac arrest conducted in Japan. We compared the outcome of Japanese Registry of CPR (J-RCPR,12 hospitals) conducted in the "Guideline 2005" era and Japanese Registry for Survey Of in-hospital Resuscitation Trial (J-RESORT,8 hospitals) conducted in the "Guidelines 2010" era. We searched the number of hospitals participating in the rapid response system multicenter collaborative research (RRS) conducted in Japan.

Results:
J-RCPR had 491 cases, mean age 71 ± 15 years old, male 63%(311/491), J-RESORT 284 cases, mean age 72 ± 17 years old, male 68%(193/284). ROSC rate was 64.7% (318/491), 77.5% (220/284), respectively (p<0.05). The survival rate after 24 hours was 49.8% (245/491), 50.7% (144/284) (NS), the survival rate after 30 days was 27.8% (137/491), 33.1% (94/284) (NS), and the favorable neurological outcome rate (CPC 1 or CPC 2) was 21.4% (105/491), 22.9% (65/284) (NS), respectively. The proportion of witnessed cardiac arrest was 77.2% (379/491), 81.7% (232/284) (NS), the location of incidence in general wards was 54.0% (265/491), 46.1% (131/284) (NS), and the shockable rhythm was 28.1% (138/491), 22.5% (64/284) (NS), respectively. In both registries, the median interval from the occurrence of cardiac arrest to the initiation of resuscitation was 0 min. The proportion of participating hospitals to RRS was only 6 facilities in 2013 and increased to 41 facilities in 2016, but still less than 1% of the total number of hospitals in Japan.

Conclusion:
This study showed no improvement in the outcome of in-hospital cardiac arrest and very few hospitals using RRS during the past 10 years. To improve the outcome of the in-hospital cardiac arrest, it is necessary to investigate the nation-wide status of in-hospital cardiac arrest and the effectiveness of RRS.
Abstract 154: Guideline Removal of Atropine and Survival After Adult In-Hospital Cardiac Arrest With Non-Shockable Rhythms
Authors: Holmberg Mathias J , Moskowitz Ari , Wiberg Sebastian , Witten Lise , Grossestreuer Anne V , Yankama Tuyen , Perman Sarah , Donnino Michael W , Andersen Lars W
Published: July 2021

Introduction:
Atropine was removed from the 2010 American Heart Association’s Advanced Cardiac Life Support guidelines as routine management of non-shockable cardiac arrest, although the evidence to support or refute the use of atropine is lacking. In a previous study, atropine usage was shown to subsequently decline markedly. Whether removing atropine from the guidelines has affected survival remains unknown.

Methods:
Using the Get With The Guidelines®-Resuscitation registry, we included adult patients with an index in-hospital cardiac arrest between 2006-2015. Non-shockable and shockable cardiac arrest patients with high vs. low propensity score to receive atropine were separated into two cohorts. An interrupted time-series analysis was used to compare survival before (pre-exposure) and after (post-exposure) introduction of the 2010 guidelines. A difference-in-difference approach was used to compare the interrupted time-series results between the non-shockable and shockable cohorts to account for guideline changes unrelated to atropine.

Results:
We included 21,822 non-shockable and 4,268 shockable cardiac arrests. Patient characteristics were similar between the pre-exposure and post-exposure period. Atropine was used for 9,170 (86%) non-shockable and 733 (34%) shockable cardiac arrests in the pre-exposure period and 3,903 (35%) non-shockable and 339 (16%) shockable cardiac arrests in the post-exposure period. The change over time in survival from the pre-exposure to the post-exposure period was not significantly different for the non-shockable compared to the shockable cohort (mean difference: 2.0% [95%CI: -0.7, 4.6] per year, p = 0.15, Figure). The immediate change in survival after introducing the guidelines was also not different between the cohorts (mean difference: 3.9% [95%CI: -2.2, 10], p = 0.21, Figure).

Conclusions:
The removal of atropine from the 2010 guidelines was not associated with a change in survival in our analysis.
Abstract 158: Pediatric In-Hospital Cardiac Arrest Associated With Pulmonary Hypertension: A Common Pathophysiology
Authors: Morgan Ryan W , Topjian Alexis A , Wang Yan , Atkin Natalie J , Kilbaugh Todd J , McGowan Francis X , Berg Robert A , Mercer-Rosa Laura , Sutton Robert M , Himebauch Adam S
Published: July 2021

Introduction:
In laboratory studies, pulmonary hypertension (PH) during CPR worsens outcomes but can be ameliorated with inhaled nitric oxide (iNO). The prevalence of pre-arrest PH among children with IHCA and its impact on outcomes are not well described.

Hypothesis:
We hypothesized that among children with IHCA, pre-arrest PH would be common and associated with worse survival to discharge.

Methods:
Retrospective single-center cohort study of consecutive pediatric ICU patients (1/1/2006 - 12/31/2017) with an echocardiogram in the 48 hours preceding IHCA, excluding those with cyanotic congenital heart disease. Echocardiograms were analyzed by a cardiologist blinded to other patient data. PH was defined as abnormal septal position and/or peak tricuspid regurgitant velocity > 2.8 m/sec. Patient and arrest characteristics and treatments were compared between subjects with and without PH using non-parametric tests. Logistic regression evaluated the association between PH and outcome, adjusting
a priori
for age and initial arrest rhythm, as well as for candidate variables associated with survival (p<0.10).

Results:
Of 284 IHCA subjects, 57 (20%) had an evaluable echocardiogram. PH was present in 20/57 (35%); 9/20 (45%) had no prior clinical history of PH. Children with PH had worse RV systolic function as measured by median fractional area change (32% vs. 45%; p=0.005), RV global longitudinal strain (-15% vs. -21.1%; p=0.046), and tricuspid annular plane systolic excursion z-score (-4.50 vs. -3.53; p=0.17). Children with PH had more RV dilation (median RV:LV end-diastolic area ratio 0.90 vs. 0.52; p=0.005) and similar rates of qualitative LV dysfunction (45% vs. 59%, p=0.40). Children with PH were more likely to receive iNO [16/20 (80%) vs. 12/37 (32%); p<0.001] and isoproterenol [9/20 (45%) vs. 1/37 (3%); p<0.001] during CPR. There were no differences in other IHCA characteristics. On multivariable analysis, PH was not associated with ROSC [14/20 (70%) vs. 24/37 (65%); adjOR 1.30 (0.25 - 6.69); p=0.77] or survival to hospital discharge [8/20 (40%) vs. 10/37 (27%); adjOR 1.17 (0.22 - 6.44); p=0.85].

Conclusions:
PH was present in 35% of children with IHCA. In a cohort with a high frequency of treatment with iNO during CPR, PH was not associated with survival.
Abstract 166: Insertion or Replacement of an Advanced Airway is Not Associated With Adverse Outcome in Neonatal Intensive Care Unit Cardiopulmonary Resuscitation
Authors: Ahmad Kaashif A , Stine Christina N , LeVan Jaclyn M , Kohlleppel Katy L , Velasquez Steven G , Henderson Cody L , Bhalala Utpal S
Published: July 2021

Introduction:
There is a paucity of data regarding variables that impact the outcome in patients who require cardiopulmonary resuscitation (CPR) in the neonatal intensive care unit (NICU). The impact of initial need or replacement of an existing advanced airway (AA) has not been described in this population. The 2016 Neonatal Resuscitation Program (NRP) places emphasis on AA placement prior to initiating compressions in the delivery room setting. We hypothesized that providers would similarly emphasize airway placement for NICU CPR.

Methods:
We conducted a retrospective review of patients requiring CPR with chest compressions from 2012 to 2017 across 10 NICUs in San Antonio, Texas. We identified cases by clinician selection of a CPR code and by a review of all patients who died prior to NICU discharge.

Results:
We review a total of 211 NICU CPR events, 210 of which had complete data regarding the AA. An AA was present at the onset of CPR for 179 (85.2%) of CPR events and an existing airway replaced during CPR for 31 (14.7%) CPR events. All patients without an AA present at onset of CPR had an airway immediately placed. The median time to insertion of AA was 1 minute (IQR 1, 5 minutes). In comparing patients who had an AA present at CPR onset versus absent AA, there was no significant difference in rate of return of spontaneous circulation (ROSC, 63.7% vs 64.5%, p=0.92) or time to ROSC (10.2 vs 12.7 min, p=.66). The median time for replacement of an AA during CPR was 1 minute (IQR 1, 4 minutes). Those with a time to replace the AA of >= 5 minutes had a similar ROSC rate compared to those who had AA replacement in < 5 minutes (75% vs 73.7%, p=.96). The decision to replace an AA during CPR was associated with a non-significant increase in rate of ROSC (74.2% vs 62%, p=0.19) and no significant difference in time to ROSC (11.5 min vs. 10.4 min, p=0.65).

Conclusions:
The achievement of ROSC or time to ROSC are not impacted by the need to place an initial AA at the onset of CPR or the need to replace the AA during CPR in the NICU. This may be due to the rapid initial placement and replacement of the AA observed in NICU CPR events. These data indicate that NICU CPR providers emphasize rapid AA placement similar to NRP guidelines.
Abstract 172: Initial Rhythm and Rhythm at Moment of Transport Related to Survival in Potential ECPR Patients in the Netherlands
Authors: de Graaf Corina , Beesems Stefanie G , Koster Rudolph W
Published: July 2021

Purpose:
Extracorporeal cardiopulmonary resuscitation (ECPR) shows promising results in patients found in ventricular fibrillation (VF) without return of spontanous circulation (ROSC) on scene. Insight in rhythm at moment of transport and survival of potential ECPR patients could help to identify which patients should be transported for ECPR.

Methods:
Data of potential ECPR patients (shockable first rhythm, witnessed arrest, bystander CPR and age 18-70 year) transported without ROSC between 2012 and 2016 in the Amsterdam Resuscitation Study (ARREST) database were analyzed. Initial rhythm and rhythm at moment of transport was related to 30-day survival.

Results:
Of 5872 OHCA patients with attempted resuscitation, 649 (11%) were transported with ongoing CPR. Of these, 162 (25%) were considered potential ECPR patients and 153 cases with complete data were analysed. Thirteen of these 153 patients (9%) were alive at 30 days. At start of transport, 68 patients (44%) had VF/VT, 58 (38%) PEA and 27 (18%) asystole. Of these, 10, 2 and 1 patients survived, respectively (figure). 30-day survival of patients with a shockable rhythm at start of transport was significantly higher compared to non-shockable rhythms (15% vs 3%, p=0.014). During transport 10 of 153 patients (7%) achieved ROSC, and 3 patients (30%) survived. VF/VT at start of transport identified 10/13 (77%) of all survivors. In patients without ROSC at hospital arrival, VF/VT also resulted in the highest survival (13%).

Conclusion:
In ECPR candidate patients, a shockable rhythm at the moment of transport (44%) identified 77% of patients surviving 30 days.
Abstract 177: Resuscitation Team Challenges During In-Hospital Cardiac Arrest: A Prospective Multicenter Study
Authors: Lauridsen Kasper G , Schmidt Anders S , Nadkarni Vinay M , Berg Robert A , Bach Leif , Møller Dorthe S , Qvortrup Mette , Sørensen Betina Ø , Dodt Karen K , Krarup Niels H , Kirkegaard Hans , Højbjerg Rikke , Nielsen Rasmus P , Løfgren Bo
Published: July 2021

Introduction:
Measured quality of CPR is often substandard compared to guideline recommendations during adult in-hospital cardiac arrest.

Aim:
To investigate the self-perceived CPR quality, teamwork and communication and to identify the most frequently reported challenges experienced during in-hospital cardiac arrest.

Methods:
Prospective multicenter study including self-reported data from resuscitation attempts treated by cardiac arrest teams in 5 Danish hospitals (1 university hospital, 4 regional hospitals). Data from October 2016 to May 2018 was included. Following each resuscitation attempt, all cardiac arrest team members were questioned by an online questionnaire, specifically on perceived CPR quality, teamwork and communication on a Likert scale. In addition, challenges experienced during the resuscitation attempt were inquired.

Results:
Of 491 cardiac arrests, the cardiac arrest team was actively involved in 387 cases (79%). Of 2,271 questionnaires there were 1,639 responses (response rate: 72%). Overall, 87% agreed or partially agreed that the CPR quality was optimal, 89% agreed or partially agreed that the teamwork was optimal, and 88% agreed or partially agreed that the communication was optimal. The most frequently reported challenges experienced were: too many health care providers present in the room (26%), healthcare providers poorly placed relative to each other in the room during resuscitation (16%), lacking space for resuscitation equipment (16%), problems finding resuscitation equipment (14%), problems finding the location of cardiac arrest (5%), and other challenges (10%). Challenges with too many healthcare providers in the room were associated with the total amount of persons in the room (p<0.001), amount of non-team members present (P<0.001) but not the number of members on the cardiac arrest team (p=0.70).

Conclusions:
During in-hospital resuscitation, most cardiac arrest team members perceive that CPR quality, teamwork, and communication are optimal. However, Challenges during resuscitation are not uncommon and include overcrowding, lack of space and problems locating resuscitation equipment.
Abstract 181: An Analysis of Worldwide Public Access Defibrillator Usage Since October 2012. Does CPR Prior to Defibrillation Improve Survival Outcomes?
Authors: Torney Hannah , Harvey Adam , McAlister Olibhear , Kernaghan Amy , Davis Laura , McEneaney David , Adgey Jennifer
Published: July 2021

Introduction:
As outlined by the Chain of Survival, effective cardiopulmonary resuscitation (CPR) and rapid defibrillation are vital to improve survival from sudden cardiac arrest (SCA). Placement of public access defibrillators (PADs) is becoming more common in public spaces, and they are more frequently used by untrained lay-users. The objective of this analysis was to assess the effect of CPR prior to defibrillation, and the success of PAD usage in terms of first shock success and survival to hospital admission.

Methods:
This dataset was composed of voluntarily submitted demographic information and electronic PAD files collected from October 2012 - June 2018. Summary statistics were calculated, and proportions were determined with 95% confidence intervals (CI) where appropriate. The association between CPR prior to defibrillation and survival was investigated by fitting a logistical model with survival as the dependent variable and CPR as covariate.

Results:
A total of 2812 PAD events were analyzed. Mean (SD) patient age was 61 (19) years and males comprised 72.5% (1922 of 2650 events where gender was known) of the events reported. The most common locations of SCA were the home (1039, 36.9%), public (719, 25.6%) and medical facility (328, 11.7%). Median (IQR) time to PAD delivery was 5 (3, 11) minutes. Ventricular fibrillation or tachycardia was present in 1010 (35.9%) patients, and 979 received a shock, with 87.2% (95%CI [85.0%, 89.3%]) achieving first shock success. Of the 849 shockable patients for whom survival was known, 565 (66.5%, (95%CI [63.3%, 69.7%]) survived to hospital admission. Survival outcome was known for 2150 patients, and 681 (31.7%, 95%CI [29.7%, 33.69%]) survived to hospital admission. A total of 1649 (58.6%) SCAs were witnessed and 1293 (78.4%) patients received bystander CPR prior to defibrillation. Bystander CPR prior to defibrillation was significantly associated with survival to hospital admission (OR = 2.17, 95%CI [1.69, 2.81], p<0.001).

Conclusion:
These results suggest that CPR application prior to application of a PAD significantly increases a patient’s chances of surviving to hospital admission. This study did not assess CPR quality, but it is intuitive that good quality CPR would align with higher survival outcomes.
Abstract 184: AED Application in Non-Shockable Out-of-Hospital Cardiac Arrest Does Not Reduce Survival
Authors: Pollack Ross A , Brown Siobhan P , Rea Thomas , Kudenchuk Peter J , Weisfeldt Myron L
Published: July 2021

Introduction:
It is well established that AEDs improve outcome in shockable out-of-hospital cardiac arrest (OHCA). An increasing proportion (now the majority) of OHCAs present with non-shockable rhythms. Survival from non-shockable OHCA depends on high-quality CPR in transit to definitive care. Studies of AED use in non-shockable in-hospital arrest (as opposed to OHCA) have shown reduced survival with AED application possibly due to CPR interruptions to apply pads and perform rhythm analysis. We sought to determine whether AED application in non-shockable public, witnessed OHCA has a significant association with survival to discharge.

Methods:
This is a retrospective analysis of OHCA from 2010-2015 at 10 Resuscitation Outcomes Consortium centers. All adult, public, witnessed non-shockable OHCAs were included. Non-shockable arrest was defined as no shock delivered by the AED or by review of defibrillator tracings (10%). The initial rhythm on EMS arrival was used to confirm the rhythm. The primary outcome was survival to hospital discharge with favorable neurological status (modified rankin score <3). The OR was adjusted for the Utstein variables.

Results:
During the study period there were 1,597 non-shockable public, witnessed OHCA, 9.8% of which had an AED applied. The initial rhythm on EMS arrival was PEA or asystole in 86% of cases. Significantly more OHCA in the AED applied group had CPR performed. 6.5% of those without an AED applied survived with favorable neurologic status compared to 9% with an AED. After adjustment for the Utstein variables including bystander CPR, the aOR for survival with favorable neurologic outcome was 1.38 (95% CI:0.72-2.65).

Conclusion:
After adjusting for patient characteristics and bystander CPR, the application of an AED in non-shockable public witnessed OHCA had no significant association with survival or neurological outcome supporting the relative safety and potential benefit of AED application in non-shockable OHCA.
Abstract 19: Progressive Metabolic Derangement During Prolonged Resuscitation for Refractory VT/VF Cardiac Arrest and the Relationship to Neurologically Intact Survival With Extracorporeal Cardiopulmonary Resuscitation
Authors: Bartos Jason A , Carlson Claire , Raveendran Ganesh , John Ranjit , Aufderheide Tom P , Yannopoulos Demetris
Published: July 2021

Background:
Multiple studies have shown declining likelihood of neurologically intact survival with prolonged resuscitation with standard CPR. With standard CPR, survival after VT/VF arrest declines from 35-45% at initiation of CPR to 10-20% survival at 30 min.

Objective:
The aim of this study was to examine the effects of resuscitation duration on neurologically intact survival in the Minnesota Resuscitation Consortium ECPR protocol. Further, the progressive metabolic derangement of prolonged resuscitation was observed for the first time in this population.

Methods:
Between December 1, 2015 and May 1, 2018, 115 consecutive adult patients with refractory out-of-hospital VT/VF cardiac arrest requiring ongoing CPR were transported to the cardiac catheterization laboratory where ECLS was initiated and coronary angiography and PCI were performed as needed. Patients achieving an organized cardiac rhythm were admitted for further treatment.

Results:
Overall, 41% of patients receiving full resuscitative efforts were discharged neurologically intact. Neurologically intact survival declined with increasing duration of CPR with 100% survival in patients placed on ECLS within 30 min. Survival declined to 50% within 50 min and 20% within 70 min. Lactic acid and paCO2 increased over time peaking at 15 mmol/L and 72 mmHg, respectively. pH declined accordingly reaching 6.92 at its nadir. paO2 was stable over time but variable between patients.

Conclusions:
Likelihood of neurologically intact survival declined with increasing duration of CPR for patients going on to receive ECLS. The metabolic profile worsened during prolonged CPR with increasing lactic acidemia and hypercapnia but survival could be achieved with the hemodynamic support provided by ECLS. Together these findings support the need for rapid transport of patients to teams prepared to place ECLS. Substantial decline in survival begins at 30 min of CPR.