CPR is constantly evolving and is imperative for us to keep in track latest developments in the field. Below few important trials and updates in CPR.
AHA FOCUS Updates 2023
- Use of extracorporeal cardiopulmonary resuscitation (ECPR) for patients with cardiac arrest refractory to standard ACLS is reasonable in select patients when provided within an appropriately trained and equipped system of care. (Earlier insufficent evidence to suggest ECPR)
- Emergent coronary angiography is not recommended over a delayed or selective strategy in patients with return of spontaneous circulation after cardiac arrest unless they exhibit ST-segment elevation myocardial infarction, shock, electrical instability, signs of significant
- myocardial damage, or ongoing ischemia. (Earlier Emergency CAG was considered reasonable )
- AHA recommend selecting and maintaining a constant temperature between 32°C and 37.5°C during postarrest temperature control.(Earlier 32-36C)
- A therapeutic trial of a nonsedating antiseizure medication may be reasonable in adult survivors of cardiac arrest with electroencephalography patterns on the ictalinterictal continuum.
- Organ donation is an important outcome that should be considered in the development and evaluation of systems of care.(New)
ILCOR ACLS 2023 Updates
- Suggests to consider ECPR as a rescue therapy for selected patients with OHCA/IHCA when conventional CPR fails to restore spontaneous cicrculation.
- DSED Strategy or VC strategy may be considered for adults with cardiac arrest who remain in VF or pVT even after 3 consecutive shocks.
- Routine use of calcium is not recommended.
- Suggests using gradient recalled echo on brain MRI to predict good neurological outcome in patients who are comatose after cardiac arrest. They suggest againt using GWR, Aspect ratio, ADC on MRI.
- Suggest using normal NSE within 72 hours after ROSC in combination with other test for predicting favourable neurological outcome in adults who are comatose.
- Suggests using a continuous or nearly continuous normal voltage EEG background with periodic discharges or seizures within 72 hours from ROSC in combination with other indices to predict good outcome .
- Suggest using amplitude of N20 SSEP wave to predict good neurological outcome.
TAME Trial (NEJM.2023)
Study assessed whether mild hypercapnia (50-55 mmHg) compared with normocapnia improves the neurological outcome. Author believes that mild hypercapnia increases cerebral blood flow and may improve neurologic outcomes.Study found that favourable outcome at 6 months occured in 332 of 764 patients(43.5%) in mild hypercapnia group and in 350 of 784 (44.6%) in normocapnia patients. Study concluded that patients treated with mild hypercapnia for coma following OHCA didnot lead to better neurological outcome.
STEROCHA Trial :
A randomised control trials done to assess whether use of methyprednisolne reduce inflammation following OHCA reflected as reduction in IL6 and NSE levels. Study found that high dose of methylprednisolne could reduce IL6 levels but not NSE levels.
Box trial was done to assess the appropriate oxygentation target for mechanical ventilation in comatose survivors of OHCA. They assesed whether restrictive oxygen target(68 - 75mmHg)or liberal oxygen target (98-105 mmHg) can improve the outcome. Author believes that liberal oxygenation is associated with increased risk of ischemic encephalopathy in some studies and animal models have shown hyperoxia worsening brain damage. Study found that at 90 days death occured in 113 patients (28.7%) in restrictive group and 123 (31.1%) in liberal target group. Study concluded that both restrictive or liberal oxygenation strategy resulted in similar incidence of death or severe disability or coma.
Separately in the same trail they also assesed the blood pressure targets in comatose survivors of OHCA. They assesed whether MAP of 63mmHg with 77mmHg can improve the outcome. The authors believed that cardiac arrest patients have underlying cardiac disease and lowering the afterload may facilitate recovery and possibly outcome.Moreover use of vasopressors may be associated with adverse effects. Study found that primary outcome (Death at 90 days) has occured in 133 (34%) patients in the high target group compared to 127 (32%)patients in low target group. Study concluded that both high or low BP target resulted in similar incidence of death or severe disability or coma.
DOSE-VF (NEJM,2022)
A RCT study done to assess whether double sequential external defibrillation (rapid sequential shocks from 2 defibrillators) and vector change (changing to antero posterior position) improves outcome in patients with refractory VF compared to standard treatment. It is seen that almost 50% of patients remain in refractory VF despite multiple defibrillation attempts,there are case reports/case series that DSED and VC has been used for refractory VF. Study found that survival to hospital was common in DSED group than in standard group (30.4% v/s 13.3%) and more common in VC change group than in standard group (21.7%% v/s 13.3%) . Study also found that DSED is associated with good neurological outcome compared to standard group.
EXACT Trial (JAMA. 2022)
It is a multicentric RCT done to assess whether targeting lower oxygen saturation (90-94%)in the early phase of post resuscitation care of OHCA improves survival at discharge.Study found that 82 of 214 patients (38.3%) survived to hospital discharge in the intervention group v/s 101 of 211 patients(47.9%) in standard group.Study concluded that targeting lower saturation didnot improve survival to discharge.
EMERGE Trial (JAMA.2022)
A RCT done to assess whether Emergency CAG is beneficial in OHCA without ST segment elevation. Study found that 180 day survival rates among patients with CPC (Cerebral Performance Category) of 2 or < were 31% (47 of 141) and 30.7% (42 of 138) in the delayed CAG group. Study concluded that for OHCA patients without ST-segment elevation on ECG, a strategy of emergency CAG was not better than a strategy of delayed CAG with respect to 180-day survival rate and minimal neurologic sequela.
TTM2 Trial (NEJM,2021)
It is a open label, RCT done to asses whether TTM(33C) is associated with better outcome. Study found that 465 of 925 patients (50%) in hypothermia group died as compared with 446 of 925 patients (48%) in normothermia group.Study also found that 488of 881patients (55%) of patients assesed for functional outcome had moderately severe disability in hypothermia group died as compared with 479 of 866 patients (55%) in normothermia group.Study concluded that TTM didnot result in lower incidence of death by 6 months in patients with coma after OHCA.
TOM HAWK Trial (NEJM,2021)
Multicentric, RCT done to assess whether immediate CAG is beneficial in OHCA without ST segment elevation. Study found that 143 of 265 patients (54%) in the immediate group and 122 of 265 patients in the delayed angiography group had died. Study concluded that among patients with resuscitated out-of-hospital cardiac arrest without ST-segment elevation, a strategy of performing immediate angiography provided no benefit over a delayed or selective strategy with respect to the 30-day risk of death from any cause.
