A novel predictor of unsustained return of spontaneous circulation in cardiac arrest patients through a combination of capnography and pulse oximetry: a multicenter observational study

doi:10.5847/wjem.j.1920-8642.2023.186

Abstract

Abstract:

BACKGROUND: Unsustained return of spontaneous circulation (ROSC) is a critical barrier to survival in cardiac arrest patients. This study examined whether end-tidal carbon dioxide (ETCO₂) and pulse oximetry photoplethysmogram (POP) parameters can be used to identify unsustained ROSC.
METHODS: We conducted a multicenter observational prospective cohort study of consecutive patients with cardiac arrest from 2013 to 2014. Patients’ general information, ETCO₂, and POP parameters were collected and statistically analyzed.
RESULTS: The included 105 ROSC episodes (from 80 cardiac arrest patients) comprised 51 sustained ROSC episodes and 54 unsustained ROSC episodes. The 24-hour survival rate was significantly higher in the sustained ROSC group than in the unsustained ROSC group (29.2% vs. 9.4%, P<0.05). The logistic regression analysis showed that the difference between after and before ROSC in ETCO₂ (ΔETCO₂) and the difference between after and before ROCS in area under the curve of POP (ΔAUCp) were independently associated with sustained ROSC (odds ratio [OR]=0.931, 95% confidence interval [95% CI] 0.881-0.984, P=0.011 and OR=0.998, 95% CI 0.997-0.999, P<0.001). The area under the receiver operating characteristic curve of ΔETCO₂, ΔAUCp, and the combination of both to predict unsustained ROSC were 0.752 (95% CI 0.660-0.844), 0.883 (95% CI 0.818-0.948), and 0.902 (95% CI 0.842-0.962), respectively.
CONCLUSION: Patients with unsustained ROSC have a poor prognosis. The combination of ΔETCO₂ and ΔAUCp showed significant predictive value for unsustained ROSC.

Key words: Return of spontaneous circulation, Pulse oximetry photoplethysmogram, End-tidal carbon dioxide, Cardiac arrest, Cardiopulmonary resuscitation

Jing Yang, Hanqi Tang, Shihuan Shao, Feng Xu, Yangyang Fu, Shengyong Xu, Chen Li, Yan Li, Yang Liu, Joseph Harold Walline, Huadong Zhu, Yuguo Chen, Xuezhong Yu, Jun Xu. A novel predictor of unsustained return of spontaneous circulation in cardiac arrest patients through a combination of capnography and pulse oximetry: a multicenter observational study[J]. World Journal of Emergency Medicine, 2024, 15(1): 16-22.

Figures/Tables 3

Figure 1.

Table 1.

Figure 2.

References 30

1	Fukuda T, Ohashi-Fukuda N, Sekiguchi H, Inokuchi R, Kukita I. Survival from pediatric out-of-hospital cardiac arrest during nights and weekends: an updated Japanese registry-based study. JACC Asia. 2022; 2(4):433-43. doi: 10.1016/j.jacasi.2022.01.005
2	Yan SJ, Chen M, Wen J, Fu WN, Song XY, Chen HJ, et al. Global research trends in cardiac arrest research: a visual analysis of the literature based on CiteSpace. World J Emerg Med. 2022; 13(4):290-6. doi: 10.5847/wjem.j.1920-8642.2022.071
3	Bartos JA, Yannopoulos D. Refractory cardiac arrest: where extracorporeal cardiopulmonary resuscitation fits. Curr Opin Crit Care. 2020; 26(6):596-602. doi: 10.1097/MCC.0000000000000769 pmid: 33027149
4	Salcido DD, Stephenson AM, Condle JP, Callaway CW, Menegazzi JJ. Incidence of rearrest after return of spontaneous circulation in out-of-hospital cardiac arrest. Prehosp Emerg Care. 2010; 14(4):413-8. doi: 10.3109/10903127.2010.497902 pmid: 20809686
5	Woo JH, Cho JS, Lee CA, Kim GW, Kim YJ, Moon HJ, et al. Survival and rearrest in out-of-hospital cardiac arrest patients with prehospital return of spontaneous circulation: a prospective multi-regional observational study. Prehosp Emerg Care. 2021; 25(1):59-66. doi: 10.1080/10903127.2020.1733716
6	Shinada K, Koami H, Matsuoka A, Sakamoto Y. Prediction of return of spontaneous circulation in out-of-hospital cardiac arrest with non-shockable initial rhythm using point-of-care testing: a retrospective observational study. World J Emerg Med. 2023; 14(2):89-95. doi: 10.5847/wjem.j.1920-8642.2023.031 pmid: 36911060
7	Salcido DD, Sundermann ML, Koller AC, Menegazzi JJ. Incidence and outcomes of rearrest following out-of-hospital cardiac arrest. Resuscitation. 2015; 86:19-24. doi: 10.1016/j.resuscitation.2014.10.011 pmid: 25447433
8	Lerner EB, O’Connell M, Pirrallo RG. Rearrest after prehospital resuscitation. Prehosp Emerg Care. 2011; 15(1):50-4.
9	Salcido DD, Schmicker RH, Kime N, Buick JE, Cheskes S, Grunau B, et al. Effects of intra-resuscitation antiarrhythmic administration on rearrest occurrence and intra-resuscitation ECG characteristics in the ROC ALPS trial. Resuscitation. 2018; 129:6-12. doi: S0300-9572(18)30239-9 pmid: 29803703
10	Lee DK, Jung E, Jo YH, Kim J, Lee JH, Park SM, et al. The association of extreme tachycardia and sustained return of spontaneous circulation after nontraumatic out-of-hospital cardiac arrest. Emerg Med Int. 2020; 2020:5285178.
11	Lewis LM, Stothert J, Standeven J, Chandel B, Kurtz M, Fortney J. Correlation of end-tidal CO₂ to cerebral perfusion during CPR. Ann Emerg Med. 1992; 21(9):1131-4. pmid: 1514728
12	Garnett AR, Ornato JP, Gonzalez ER, Johnson EB. End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. JAMA. 1987; 257(4):512-5.
13	Gomersall CD, Joynt GM, Morley AP. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med. 1997; 337(23):1694. doi: 10.1056/NEJM199712043372314
14	Kolar M, Krizmaric M, Klemen P, Grmec S. Partial pressure of end-tidal carbon dioxide successful predicts cardiopulmonary resuscitation in the field: a prospective observational study. Crit Care. 2008; 12(5):R115. doi: 10.1186/cc7009
15	Murphy RA, Bobrow BJ, Spaite DW, Hu C, McDannold R, Vadeboncoeur TF. Association between prehospital CPR quality and end-tidal carbon dioxide levels in out-of-hospital cardiac arrest. Prehosp Emerg Care. 2016; 20(3):369-77. doi: 10.3109/10903127.2015.1115929 pmid: 26830353
16	Paiva EF, Paxton JH, O'Neil BJ. The use of end-tidal carbon dioxide (ETCO₂) measurement to guide management of cardiac arrest: a systematic review. Resuscitation. 2018; 123:1-7. doi: 10.1016/j.resuscitation.2017.12.003
17	Xu J, Li C, Tang HQ, Tan DY, Fu YY, Zong L, et al. Pulse oximetry waveform: a non-invasive physiological predictor for the return of spontaneous circulation in cardiac arrest patients —A multicenter, prospective observational study. Resuscitation. 2021; 169:189-97. doi: 10.1016/j.resuscitation.2021.09.032
18	Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, et al. Cardiopulmonary resuscitation quality: [corrected]improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013; 128(4):417-35. doi: 10.1161/CIR.0b013e31829d8654 pmid: 23801105
19	Stankovic N, Holmberg MJ, Høybye M, Granfeldt A, Andersen LW. Age and sex differences in outcomes after in-hospital cardiac arrest. Resuscitation. 2021; 165:58-65. doi: 10.1016/j.resuscitation.2021.05.017 pmid: 34098034
20	Jacobs I, Nadkarni V, Bahr J, Berg RA, Billi JE, Bossaert L, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, Inter American Heart Foundation, Resuscitation Councils of Southern Africa). Circulation. 2004; 110(21):3385-97. doi: 10.1161/01.CIR.0000147236.85306.15 pmid: 15557386
21	Guay J, Lortie L. An evaluation of pediatric in-hospital advanced life support interventions using the pediatric Utstein guidelines: a review of 203 cardiorespiratory arrests. Can J Anaesth. 2004; 51(4):373-8. doi: 10.1007/BF03018242
22	Benhamed A, Canon V, Mercier E, Heidet M, Gossiome A, Savary D, et al. Prehospital predictors for return of spontaneous circulation in traumatic cardiac arrest. J Trauma Acute Care Surg. 2021; 92(3):553-60. doi: 10.1097/TA.0000000000003474 pmid: 34797815
23	Lin YR, Wu HP, Huang CY, Chang YJ, Lin CY, Chou CC. Significant factors in predicting sustained ROSC in paediatric patients with traumatic out-of-hospital cardiac arrest admitted to the emergency department. Resuscitation. 2007; 74(1):83-9. doi: 10.1016/j.resuscitation.2006.11.022
24	Bhardwaj A, Ikeda DJ, Grossestreuer AV, Sheak KR, Delfin G, Layden T, et al. Factors associated with re-arrest following initial resuscitation from cardiac arrest. Resuscitation. 2017; 111:90-5. doi: S0300-9572(16)30584-6 pmid: 27992736
25	Jung YH, Jeung KW, Lee HY, Lee BK, Lee DH, Shin J, et al. Rearrest during hospitalisation in adult comatose out-of-hospital cardiac arrest patients: risk factors and prognostic impact, and predictors of favourable long-term outcomes. Resuscitation. 2022; 170:150-9. doi: 10.1016/j.resuscitation.2021.11.037
26	Pokorná M, Necas E, Kratochvíl J, Skripský R, Andrlík M, Franek O. A sudden increase in partial pressure end-tidal carbon dioxide (P(ET)CO(2)) at the moment of return of spontaneous circulation. J Emerg Med. 2010; 38(5):614-21. doi: 10.1016/j.jemermed.2009.04.064 pmid: 19570645
27	Gudipati CV, Weil MH, Bisera J, Deshmukh HG, Rackow EC. Expired carbon dioxide: a noninvasive monitor of cardiopulmonary resuscitation. Circulation. 1988; 77(1):234-9. pmid: 3121209
28	Awad AA, Stout RG, Ghobashy MAM, Rezkanna HA, Silverman DG, Shelley KH. Analysis of the ear pulse oximeter waveform. J Clin Monit Comput. 2006; 20(3):175-84. doi: 10.1007/s10877-006-9018-z pmid: 16612551
29	Reisner A, Shaltis PA, McCombie D, Asada HH. Utility of the photoplethysmogram in circulatory monitoring. Anesthesiology. 2008; 108(5):950-8. doi: 10.1097/ALN.0b013e31816c89e1 pmid: 18431132
30	McGrath SP, Ryan KL, Wendelken SM, Rickards CA, Convertino VA. Pulse oximeter plethysmographic waveform changes in awake, spontaneously breathing, hypovolemic volunteers. Anesth Analg. 2011; 112(2):368-74. doi: 10.1213/ANE.0b013e3181cb3f4a pmid: 20103539

Parameters	Unsustained ROSC patients (n=32)	Sustained ROSC patients (n=48)	P-value
Sex, female, n (%)	7 (21.9)	17 (35.4)	0.195
Age, years, median (IQR)	63.0 (45.5, 77.0)	63.5 (50.3, 73.5)	0.848
Location of cardiac arrest, n (%)
Out of hospital	6 (18.8)	11 (22.9)	0.655
In hospital	26 (81.2)	37 (77.1)	0.655
Cause of cardiac arrest, n (%)
Cardiogenic	12 (37.5)	17 (35.4)	0.849
Hypoxemic	9 (28.1)	18 (37.5)	0.385
Shock	6 (18.8)	6 (12.5)	0.655
Stroke	2 (6.3)	3 (6.3)	1.000
Trauma	3 (9.4)	4 (8.3)	1.000
Survival rate, n (%)
24-hour survival	3 (9.4)	14 (29.2)	0.034^*
28-day survival	0 (0)	4 (8.3)	0.249

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