When to Expect Zero Survival in Arrest

January 27, 2017

Short Attention Span Summary

This is not going to go well…
Three criteria predicted zero survival to discharge after arrest with 100% specificity and 100% positive predictive value.  They were: out of hospital arrest not witnessed by EMS, non-shockable initial rhythm, and no ROSC before the third epinephrine dose.  If a patient meets all three of these criteria, you know the prognosis is grim.

Spoon Feed
No one survives to discharge if they have out-of-hospital arrest not witnessed by EMS, non-shockable initial rhythm, and no ROSC before the third epinephrine dose.  This can help us set expectations for the family and may help the ICU team identify potential donors earlier.

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Abstract

Ann Intern Med. 2016 Dec 6;165(11):770-778. doi: 10.7326/M16-0402. Epub 2016 Sep 13.

Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation.

Jabre P1, Bougouin W1, Dumas F1, Carli P1, Antoine C1, Jacob L1, Dahan B1, Beganton F1, Empana JP1, Marijon E1, Karam N1, Loupy A1, Lefaucheur C1, Jost D1, Cariou A1, Adnet F1, Rea TD1, Jouven X1.

Author information:

1From Paris Cardiovascular Research Center, Hôpital Necker-Enfants Malades, Hôpital Cochin, Université Paris Descartes-Sorbonne Paris Cité, Hôpital Saint-Louis, Université Paris Diderot – Paris VII, Hôpital Européen Georges Pompidou, and Paris Fire Brigade, Paris, France; Hôpital Avicenne, Université Paris 13, Bobigny, France; and Public Health-Seattle & King County and University of Washington, Seattle, Washington.

Abstract

Background:

In patients with out-of-hospital cardiac arrest (OHCA), care requirements can conflict with the need to promptly focus efforts on organ donation in patients who are pronounced dead.

Objective:

To evaluate objective criteria for identifying patients with OHCA with no chance of survival during the first minutes of cardiopulmonary resuscitation to enable prompt orientation toward organ donation.

Design:

Retrospective assessment using OHCA data from 2 registries and 1 trial.

Setting:

France (Paris Sudden Death Expertise Center [SDEC] prospective cohort [2011 to 2014] and PRESENCE multicenter cluster randomized trial [ClinicalTrials.gov: NCT01009606] [2009 to 2011]) and the United States (King County, Washington, prospective cohort [2006 to 2011]).

Patients:

1771 patients from the Paris SDEC 1-year cohort (2011 to 2012) and 5192 from the validation cohorts.

Measurements:

Evaluation of 3 objective criteria (OHCA not witnessed by emergency medical services personnel, nonshockable initial cardiac rhythm, and no return of spontaneous circulation before receipt of a third 1-mg dose of epinephrine), survival rate at hospital discharge among patients meeting these criteria, performance of the criteria, and number of patients eligible for organ donation.

Results:

In the Paris SDEC 1-year cohort, the survival rate among the 772 patients with OHCA who met the objective criteria was 0% (95% CI, 0.0% to 0.5%), with a specificity of 100% (CI, 97% to 100%) and a positive predictive value of 100% (CI, 99% to 100%). These results were verified in the validation cohorts. Ninety-five (12%) patients in the Paris SDEC 1-year cohort may have been eligible for organ donation.

Limitation:

Several patients had unknown outcomes.

Conclusion:

Three objective criteria enable the early identification of patients with OHCA with essentially no chance of survival and may help in decision making about the organ donation process.

Primary Funding Source:

French Ministry of Health.

PMID: 27618681 [PubMed – in process]