mortality (29.9% vs. 42.9%, P = 0.042), lower cardiopulmonary resuscitation (CPR) (10.2% vs. 21.4%, P = 0.013), lower continuous renal replacement therapy (CRRT) (24.2% vs. 40.0%, P = 0.009), and more advanced care planning decisions before death (87.3% vs. 66.7%, P = 0.013) than the former patients. The better ICU mortality (hazard ratio, 1.641; P = 0.035), lower CPR (odds ratio [OR], 2.891; P = 0.009), lower CRRT (OR, 2.602; P = 0.005), and more advanced care planning decisions before death (OR, 4.978; P = 0.007) were also associated with intensivist direct management in the multivariate cox and logistic regression analysis.CONCLUSION: Intensivist direct management might be associated with better ICU outcomes than resident management under the supervision of an intensivist. Further large-scale prospective randomized trials are required to draw a definitive conclusion.]]>
Cardiopulmonary Resuscitation ; Critical Care ; Cross-Over Studies ; Humans ; Intensive Care Units ; Internal Medicine ; Internship and Residency ; Logistic Models ; Medical Staff ; Mortality ; Observational Study ; Organization and Administration ; Patients' Rooms ; Prospective Studies ; Renal Replacement Therapy ; Retrospective Studies ; Running ; Survival Rate

OBJECTIVE: The benefits of targeted temperature management (TTM) for resuscitated out of hospital cardiac arrest (OHCA) with an initial non-shockable rhythm are still unclear. This study examined whether TTM reduces the mortality and improves the neurological outcomes of OHCA with a non-shockable initial rhythm. METHODS: This study analyzed the clinical outcome of 401 resuscitated patients with an initial non-shockable rhythm among a total of 1,616 OHCA patients who were registered in Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance. The impact of TTM was investigated after accounting for the patients' propensity for TTM. The primary outcome was a 30-day in-hospital course with a neurologically favorable outcome defined by a cerebral performance categories scale ≤2. RESULTS: TTM was performed in 89 patients (22%) with an initial non-shockable rhythm. Patients who has received TTM had a tendency to be younger, more likely to be female, and more likely to undergo percutaneous coronary intervention. The clinical outcome of the patients in the initial non-shockable rhythm treated by TTM was superior to those without TTM (hazard ratio [HR], 0.36; 95% confidence interval [CI], 0.27–0.46). Further analysis after propensity score matching or inverse probability of treatment weighting (IPTW) showed consistent findings (propensity score matching: HR, 0.32; 95% CI, 0.22–0.45; IPTW: HR, 0.40; 95% CI, 0.31–0.52; P<0.001, all). CONCLUSION: In this nationwide OHCA registry, TTM was related to an approximately three-fold better 30-day neurologically favorable survival of resuscitated patients with TTM treatment than patients without TTM in the initial non-shockable rhythm.
Cardiopulmonary Resuscitation ; Epidemiological Monitoring ; Female ; Heart Arrest ; Humans ; Hypothermia, Induced ; Mortality ; Out-of-Hospital Cardiac Arrest ; Percutaneous Coronary Intervention ; Prognosis ; Propensity Score

BACKGROUND: Extracorporeal life support (ECLS) is used as a bridge to revascularization in high-risk patients with ischemic heart disease. We reviewed our experiences of coronary artery bypass grafting (CABG) after ECLS in patients with cardiac arrest or refractory cardiogenic shock. METHODS: We retrospectively reviewed 4,616 patients who underwent CABG at our institution between May 2006 and February 2017. We identified patients who underwent CABG following ECLS for cardiogenic shock or cardiac arrest. Twenty-three patients (0.5% of all CABG cases) were enrolled in the analysis. Their median age was 65 years (Q1–Q3, 58–77 years). Nine patients (39.1%) were diagnosed with ST-elevation myocardial infarction. Mechanical complications after acute myocardial infarction, including acute mitral regurgitation, left ventricular rupture, and ventricular septal defect, occurred in 9 patients (39.1%). RESULTS: The median time from cardiopulmonary resuscitation to ECLS initiation was 25 minutes (Q1–Q3, 18.5–28.5 minutes). Conventional CABG was performed in 10 patients (43.5%) who underwent concomitant intracardiac procedures. Postoperative ECLS was required in 16 patients (69.5%). The rate of successful ECLS weaning was 91.3% (n=21). There were 6 early mortalities (26.1%). CONCLUSION: CABG after ECLS was very rare in real-world circumstances. Although the early mortality rate was high, the risk of mortality may be acceptable under such devastating circumstances.
Cardiopulmonary Resuscitation ; Coronary Artery Bypass ; Coronary Vessels ; Extracorporeal Membrane Oxygenation ; Heart Arrest ; Heart Septal Defects, Ventricular ; Humans ; Mitral Valve Insufficiency ; Mortality ; Myocardial Infarction ; Myocardial Ischemia ; Retrospective Studies ; Rupture ; Shock, Cardiogenic ; Weaning

PURPOSE: The use of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (r-AAA) is steadily increasing. We report early experiences of EVAR for r-AAA performed in two tertiary referral centers in Korea. METHODS: We retrospectively reviewed r-AAA patients treated by EVAR from May 2013 to December 2017. An EVAR-first strategy for r-AAA was adopted whenever feasible. The demographic information, anatomic characteristics, operative details, postoperative complications with special attention to abdominal compartment syndrome (ACS), and 30-day mortality were collected and analyzed. RESULTS: We identified 13 patients who underwent EVAR for r-AAA. Mean age was 74.2 years and mean AAA size was 74.2 mm. Two patients underwent cardiopulmonary resuscitation at initial presentation. Bifurcated stent grafts were used in 12 out of 13 cases and physician-modified endografts with fenestrated/chimney techniques were performed in 2 cases with short neck. Successful stent graft deployment was achieved in all cases. Three patients were suspected of having ACS and 2 of them underwent laparotomy for decompression. The 30-day mortality was 7.7% (1 of 13), the only mortality being a patient that refused decompressive laparotomy for suspected ACS. CONCLUSION: Despite the small numbers, the outcomes of EVAR for treatment of r-AAA were very promising, even in selected cases with unfavorable anatomy. These outcomes were achieved by a dedicated and well-trained team approach, and by use of high-end angiographic technology. Finally, ACS after EVAR is not uncommon, and requires a high index of suspicion as well as liberal use of decompressive surgery.
Aneurysm ; Aortic Aneurysm, Abdominal ; Blood Vessel Prosthesis ; Cardiopulmonary Resuscitation ; Decompression ; Endovascular Procedures ; Humans ; Intra-Abdominal Hypertension ; Korea ; Laparotomy ; Mortality ; Neck ; Postoperative Complications ; Retrospective Studies ; Rupture ; Tertiary Care Centers

BACKGROUND AND OBJECTIVES: This study aimed to confirm the effects of traditional holidays on the incidence and outcomes of out-of-hospital cardiac arrest (OHCA) in South Korea. METHODS: We studied 95,066 OHCAs of cardiac cause from a nationwide, prospective study from the Korea OHCA Registry from January 2012 to December 2016. We compared the incidence of OHCA, in-hospital mortality, and neurologic outcomes between traditional holidays, Seollal (Lunar New Year's Day) and Chuseok (Korean Thanksgiving Day), and other day types (weekday, weekend, and public holiday). RESULTS: OHCA occurred more frequently on traditional holidays than on the other days. The median OHCA incidence were 51.0 (interquartile range [IQR], 44.0–58.0), 53.0 (IQR, 46.0–60.5), 52.5 (IQR, 45.3–59.8), and 60.0 (IQR, 52.0–69.0) cases/day on weekday, weekend, public holiday, and traditional holiday, respectively (p<0.001). The OHCA occurred more often at home rather than in public place, lesser bystander cardiopulmonary resuscitation (CPR) was performed, and the rate of cessation of CPR within 20 minutes without recovery of spontaneous circulation was higher on traditional holiday. After multivariable adjustment, traditional holiday was associated with higher in-hospital mortality (adjusted hazard ratio [HR], 1.339; 95% confidence interval [CI], 1.058–1.704; p=0.016) but better neurologic outcomes (adjusted HR, 0.503; 95% CI, 0.281–0.894; p=0.020) than weekdays. CONCLUSIONS: The incidence of OHCAs was associated with day types in a year. It occurred more frequently on traditional holidays than on other day types. It was associated with higher in-hospital mortality and favorable neurologic outcomes than weekday.
Cardiopulmonary Resuscitation ; Epidemiology ; Heart Arrest ; Holidays ; Hospital Mortality ; Incidence ; Korea ; Mortality ; Out-of-Hospital Cardiac Arrest ; Prospective Studies

BACKGROUND AND OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) support is increasingly used in primary percutaneous coronary intervention (PCI) during cardiopulmonary resuscitation (CPR) to treat acute myocardial infarction (AMI) patients who experienced cardiogenic shock. However, to date, there have been no studies on the relationship between clinical outcomes and CPR time in such patients with AMI treated by ECMO-assisted primary PCI. METHODS: From July 2008 to March 2016, we analyzed data from 42 AMI with cardiogenic shock patients who underwent CPR and were treated by ECMO-assisted primary PCI. The primary outcome was 30-day in-hospital mortality after primary PCI. The predictors of mortality were determined using a Cox proportional hazards model. RESULTS: Thirty-day in-hospital mortality was observed for 33 patients (78.6%). The mean CPR time was 37.0±37.3 minutes. The best cut-off CPR time value associated with clinical outcome was calculated to be 12.5 minutes using receiver operating characteristic curve analysis. Multivariate analysis revealed that CPR time of > 12.5 minutes was an independent predictor of 30-day mortality (adjusted hazard ratio, 4.71; 95% confidence interval, 1.30–17.406; p=0.018). CONCLUSIONS: Despite ECMO support, the clinical outcomes of AMI patients with a complication of cardiogenic shock remain poor. Prolonged CPR time is associated with a poor prognosis in patients with AMI treated by ECMO-assisted primary PCI.
Cardiopulmonary Resuscitation ; Extracorporeal Membrane Oxygenation ; Hospital Mortality ; Humans ; Membranes ; Mortality ; Multivariate Analysis ; Myocardial Infarction ; Percutaneous Coronary Intervention ; Prognosis ; Proportional Hazards Models ; ROC Curve ; Shock, Cardiogenic

OBJECTIVE: To evaluate the prognostic value of the difference between peripheral venous and arterial partial pressure of carbon dioxide in patients with septic shock following early resuscitation. METHODS: This prospective study was conducted among the patients with septic shock treated in our department during the period from May, 2017 to May, 2018. Peripheral venous, peripheral arterial and central venous blood samples were collected simultaneously and analyzed immediately at bedside after 6-h bundle treatment. Arterial blood lactate concentration (Lac) and the arterial (PaCO), peripheral venous (PpvCO) and central venous partial pressure of carbon dioxide (PcvCO) were recorded. The differences between PpvCO and PaCO (Ppv-aCO) and between PcvCO and PaCO (Pcv-aCO) were calculated. Pearson correlation analysis was used to test the agreement between Pcv-aCO and Ppv-aCO. Multivariable logistic regression analysis was performed to analyze the possible risk factors for 28-day mortality, and the receiver-operating characteristic curve (ROC) was plotted to assess the prognostic values of these factors for 28-day mortality. RESULTS: A total of 62 patients were enrolled in this study, among who 35 survived and 27 died during the 28-day period. Compared with the survivor group, the patients died within 28 days showed significantly higher Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) score (24.2±6.0 20.5±4.9, =0.011), sequential organ failure assessment (SOFA) score (14.9±4.7 12.2±4.5, =0.027), PcvaCO (5.5±1.6 7.1±1.7, < 0.001), PpvaCO (7.1±1.8 10.0±2.7, < 0.001), and arterial lactate level (3.3±1.2 4.2±1.3, =0.003) after 6-h bundle treatment. Pearson correlation analysis showed that Ppv-aCO was significantly correlated with Pcv-aCO (=0.897, R= 0.805, < 0.001). Multiple logistic regression analysis identified Ppv-aCO (β=0.625, =0.001, OR=1.869, 95% CI: 1.311-2.664) and lactate level (β=0.584, =0.041, OR=1.794, 95%CI: 1.024-3.415) as the independent risk factors for 28-day mortality. The maximum area under the ROC (AUC) of Ppv-aCO was 0.814 (95%CI: 0.696- 0.931, < 0.001), and at the best cut- off value of 9.05 mmHg, Ppv-aCO had a sensitivity of 70.4% and a specificity of 88.6% for predicting 28-day mortality. The AUC of lactate level was 0.732 (95%CI: 0.607-0.858, =0.002), and its sensitivity for predicting 28-day mortality was 70.4% and the specificity was 74.3% at the best cut-off value of 3.45 mmol/L; The AUC of Pcv-aCO was 0.766 (95%CI: 0.642-0.891, < 0.001), and its sensitivity was 66.7% and the specificity was 80.0% at the best cut-off value of 7.05 mmHg. CONCLUSIONS A high Ppv-aCO after early resuscitation of septic shock is associated with poor outcomes. Ppv-aCO is well correlated with Pcv-aCO and can be used as an independent indicator for predicting 28-day mortality in patients with septic shock.
APACHE ; Carbon Dioxide ; Cardiopulmonary Resuscitation ; Humans ; Lactic Acid ; blood ; Organ Dysfunction Scores ; Partial Pressure ; Pilot Projects ; Prognosis ; Prospective Studies ; ROC Curve ; Regression Analysis ; Shock, Septic ; blood ; mortality

Intraoperative pulmonary thromboembolism is a high mortality situation. Early mortality in patients with pulmonary thromboembolism varies from 2% in normotensive patients to 30% in patients with cardiogenic shock. The use of extracorporeal cardiopulmonary resuscitation can improve survival and neurologic outcomes of cardiac arrest. We report a case of intraoperative massive pulmonary thromboembolism with circulatory collapse and cardiac arrest during anesthesia for pelvic bone fracture surgery, which were rescued by extracorporeal membrane oxygenation.
Anesthesia ; Cardiopulmonary Resuscitation ; Extracorporeal Membrane Oxygenation ; Heart Arrest ; Humans ; Mortality ; Pelvic Bones ; Pulmonary Embolism ; Shock ; Shock, Cardiogenic

Diffuse alveolar hemorrhage (DAH) is a rare manifestation of trauma or long bone fracture. A relationship between fat embolism and DAH has been reported. A 73-year-old female developed sudden cardiac arrest during a femur fracture operation. Cardiopulmonary resuscitation (CPR) was repeated for about 130 minutes. During CPR, blood was detected in the endotracheal tube. Diffuse patch ground glass opacity appearance and increased pulmonary artery with bulging of interventricular septum toward the left ventricle were detected on a chest computed tomography scan. After full supportive care including ventilator therapy, the patient's condition became stabilized and she was extubated after 7 days. We report a case of DAH in the course of a suspected fat embolism during femur fracture operation. Although DAH is a rare manifestation of fat embolism, early diagnosis and aggressive treatment likely can decrease morbidity and mortality.
Aged ; Cardiopulmonary Resuscitation ; Death, Sudden, Cardiac ; Early Diagnosis ; Embolism ; Embolism, Fat ; Female ; Femur ; Fractures, Bone ; Glass ; Heart Ventricles ; Hemorrhage ; Humans ; Mortality ; Pulmonary Artery ; Thorax ; Ventilators, Mechanical

PURPOSE: Accidental out-of-hospital deliveries are generally associated with high rates of perinatal morbidity and mortality. To determine the status of accidental out-of-hospital deliveries transferred by emergency medical services (EMS), we analyzed the records of EMS runsheets in two South Korean provinces, Gyeonggi and Gangwon. METHODS: The EMS runsheets of patients who were more than 20 weeks pregnant and had delivery-related symptoms between January 2012 and December 2013 in Gyeonggi and Gangwon province were reviewed retrospectively. We analyzed the characteristics of accidental out-of-hospital deliveries by comparing these with those non out-of-hospital deliveries. RESULTS: There were 1,426 urgent dispatches during the study period. In 137 (9.6%) out-of-hospital deliveries, which took place prior to arriving at the hospital, and 48 of these were attended by EMS providers. The accidental out-of-hospital deliveries were more frequent during night time and more common among multiparous and younger age women; however, these observation was without any significance with respect to premature birth. The rate of the accidental out-of-hospital deliveries was not significantly different between rural and urban areas. Twenty cases of complication, including 10 arrests of neonates and EMS providers managed them by the following intervention: reduction of nuchal cord, umbilical cord clamping and cut, warming-up of and stimulating the neonates warms, using oropharyngeal suction, O₂ supplication, and neonatal cardiopulmonary resuscitation. CONCLUSION: As the rate of accidental out-of-hospital deliveries in patients who were transferred by EMS is higher than the rate of out-of-hospital deliveries in general, EMS providers should be fully trained. Moreover, there is the need for more completive records and continuous education.
Cardiopulmonary Resuscitation ; Constriction ; Education ; Emergencies* ; Emergency Medical Services* ; Female ; Gangwon-do ; Gyeonggi-do ; Humans ; Infant, Newborn ; Mortality ; Nuchal Cord ; Obstetric Labor Complications ; Pregnancy ; Premature Birth ; Retrospective Studies ; Suction ; Umbilical Cord