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The relationship between no-flow interval and survival with favourable neurological outcome in out-of-hospital cardiac arrest: Implications for outcomes and ECPR eligibility

  • Author Footnotes
    1 Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.
    Andrew Guy
    Correspondence
    Corresponding author.
    Footnotes
    1 Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.
    Affiliations
    Royal Columbian Hospital Emergency Department, 330 E Columbia St., New Westminster, BC V3L 3W7, Canada
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  • Author Footnotes
    2 University of Fukui Hospital, Fukui Prefecture, Japan.
    Takahisa Kawano
    Footnotes
    2 University of Fukui Hospital, Fukui Prefecture, Japan.
    Affiliations
    23-3 Shimoaigetsu, Eiheiji Town, Yoshida County, Fukui Prefecture, Japan
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  • Author Footnotes
    1 Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.
    ,
    Author Footnotes
    3 British Columbia Emergency Health Services, Canada.
    Floyd Besserer
    Footnotes
    1 Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.
    3 British Columbia Emergency Health Services, Canada.
    Affiliations
    University Hospital of Northern British Columbia Emergency Department, 1475 Edmonton St., Prince George, BC V2M 1S2, Canada
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  • Author Footnotes
    1 Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.
    ,
    Author Footnotes
    4 Centre for Health Evaluation & Outcome Sciences, Vancouver, BC. Canada.
    Frank Scheuermeyer
    Footnotes
    1 Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.
    4 Centre for Health Evaluation & Outcome Sciences, Vancouver, BC. Canada.
    Affiliations
    St. Paul's Hospital Emergency Department, 1081 Burrard St., Vancouver, BC V6Z 1Y6, Canada
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  • Author Footnotes
    5 Division of Critical Care, University of British Columbia, Vancouver, Canada.
    Hussein D. Kanji
    Footnotes
    5 Division of Critical Care, University of British Columbia, Vancouver, Canada.
    Affiliations
    Intensive Care Unit, Vancouver General Hospital, 899 West 12th St., Vancouver, BC V5Z 1M9, Canada
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  • Author Footnotes
    1 Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.
    ,
    Author Footnotes
    4 Centre for Health Evaluation & Outcome Sciences, Vancouver, BC. Canada.
    Jim Christenson
    Footnotes
    1 Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.
    4 Centre for Health Evaluation & Outcome Sciences, Vancouver, BC. Canada.
    Affiliations
    Department of Emergency Medicine, Diamond Health Care Center 11th Floor, 2775 Laurel St., Vancouver, BC V5Z 1M9, Canada
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  • Author Footnotes
    1 Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.
    ,
    Author Footnotes
    3 British Columbia Emergency Health Services, Canada.
    ,
    Author Footnotes
    4 Centre for Health Evaluation & Outcome Sciences, Vancouver, BC. Canada.
    Brian Grunau
    Footnotes
    1 Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.
    3 British Columbia Emergency Health Services, Canada.
    4 Centre for Health Evaluation & Outcome Sciences, Vancouver, BC. Canada.
    Affiliations
    St. Paul's Hospital Emergency Department, 1081 Burrard St., Vancouver, BC V6Z 1Y6, Canada
    Search for articles by this author
  • Author Footnotes
    1 Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.
    2 University of Fukui Hospital, Fukui Prefecture, Japan.
    3 British Columbia Emergency Health Services, Canada.
    4 Centre for Health Evaluation & Outcome Sciences, Vancouver, BC. Canada.
    5 Division of Critical Care, University of British Columbia, Vancouver, Canada.

      Abstract

      Background

      The “no flow” interval is the time from out-of-hospital cardiac arrest (OHCA) to cardiopulmonary resuscitation (CPR). Its prognostic value is important to define for prehospital resuscitation decisions, post-resuscitation care and prognostication, and extracorporeal cardiopulmonary resuscitation (ECPR) candidacy assessment.

      Methods

      We examined bystander-witnessed OHCAs without bystander CPR from two Resuscitation Outcomes Consortium datasets. We used modified Poisson regression to model the relationship between the no-flow interval (9-1-1 call to professional resuscitation) and favourable neurological outcome (Modified Rankin Score ≤ 3) at hospital discharge. Furthermore, we identified the no-flow interval beyond which no patients had a favourable outcome. We analysed a subgroup to simulate ECPR-treated patients (witnessed arrest, age < 65, non-asystole initial rhythm, and >30 min until return of circulation).

      Results

      Of 43,593 cases, we included 7299; 616 (8.4%) had favourable neurological outcomes. Increasing no-flow interval was inversely associated with favourable neurological outcomes (adjusted relative risk 0.87, 95% CI 0.85–0.90); the adjusted probability of a favourable neurological outcome decreased by 13% (95% CI 10–15%) per minute. No patients (0/7299, 0%; 1-sided 97.5% CI 0–0.051%) had both a no-flow interval >20 min and a favourable neurological outcome. In the hypothetical ECPR group, 0/152 (0%; 1-sided 97.5% CI 0–2.4%) had both a no-flow interval >10 min and a favourable neurological outcome.

      Conclusions

      The probability of a favourable neurological outcome in OHCA decreases by 13% for every additional minute of no-flow time until high-quality CPR, with the possibility of favourable outcomes up to 20 min.

      Keywords

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