Application of cerebral oxygen saturation to prediction of the futility of resuscitation for out-of-hospital cardiopulmonary arrest patients: a single-center, prospective, observational study: Can cerebral regional oxygen saturation predict the futility of CPR?

doi:10.1016/j.ajem.2014.02.039

The American Journal of Emergency Medicine

Volume 32, Issue 7, July 2014, Pages 747-751

https://doi.org/10.1016/j.ajem.2014.02.039 Get rights and content

Abstract

Background

Cerebral regional oxygen saturation (rSO₂) can be measured immediately and noninvasively just after arrival at the hospital and may be useful for evaluating the futility of resuscitation for a patient with out-of-hospital cardiopulmonary arrest (OHCA). We examined the best practices involving cerebral rSO₂ as an indicator of the futility of resuscitation.

Methods

This study was a single-center, prospective, observational analysis of a cohort of consecutive adult OHCA patients who were transported to the University of Tokyo Hospital from October 1, 2012, to September 30, 2013, and whose cerebral rSO₂ values were measured.

Results

During the study period, 69 adult OHCA patients were enrolled. Of the 54 patients with initial lower cerebral rSO₂ values of 26% or less, 47 patients failed to achieve return of spontaneous circulation (ROSC) in the receiver operating characteristic curve analysis (optimal cutoff, 26%; sensitivity, 88.7%; specificity, 56.3%; positive predictive value, 87.0%; negative predictive value, 60.0%; area under the curve [AUC], 0.714; P = .0033). The AUC for the initial lower cerebral rSO₂ value was greater than that for blood pH (AUC, 0.620; P = .1687) or lactate values (AUC, 0.627; P = .1081) measured upon arrival at the hospital as well as that for initial higher (AUC, 0.650; P = .1788) or average (AUC, 0.677; P = .0235) cerebral rSO₂ values. The adjusted odds ratio of the initial lower cerebral rSO₂ values of 26% or less for ROSC was 0.11 (95% confidence interval, 0.01-0.63; P = .0129).

Conclusions

Initial lower cerebral rSO₂ just after arrival at the hospital, as a static indicator, is associated with non-ROSC. However, an initially lower cerebral rSO₂ alone does not yield a diagnosis performance sufficient for evaluating the futility of resuscitation.

Introduction

Out-of-hospital cardiopulmonary arrest (OHCA) has a very poor prognosis, with approximately 120 000, 280 000, and 380 000 victims annually in Japan, Europe, and the United States, respectively [1], [2], [3]. Of these victims, approximately 60% in Europe and 55% in the United States are transferred to hospitals, whereas almost all OHCA patients in Japan are transferred to hospitals [4], [5], [6], [7], [8]. In Japan, nonphysicians are legally prohibited from terminating resuscitation except in specific situations [4], [9], [10], [11], [12].

Although the rate of survival after OHCA has been increasing with advances in care throughout the “chain of survival,” it is still low [13], [14]. In our previous study, which was conducted using a nationwide administrative database in Japan, we found the following outcomes for OHCA patients transferred to hospitals: approximately 75% died within 24 hours after arrival at the hospital, approximately 17% survived more than 24 hours but died during hospitalization, and approximately 8% survived until discharge [4].

Although futile medical care should be avoided, it is very difficult to judge the futility of resuscitation in patients with OHCA. Even if a patient does not leave the hospital alive or develops neurological sequelae, it does not necessarily indicate that the medical care is futile. However, resuscitation efforts for patients who do not achieve sustained return of spontaneous circulation (ROSC) may be considered futile. In addition, in Japan, where resuscitation is attempted for almost all patients with OHCA, it is extremely important to be able to identify such patients. The earlier the futility of resuscitation in patients with OHCA can be established, the better it is. A definitive judgment just after hospital arrival is ideal in Japan.

Cerebral regional oxygen saturation (rSO₂) is measurable upon arrival at the hospital, and its measurement result can be obtained immediately. In addition, cerebral rSO₂ is noninvasive and may be available to judge the futility of resuscitation for patients with OHCA. Although the use of cerebral rSO₂ as a prognostic indicator of OHCA has been studied [15], [16], [17], [18], [19], the best practices for use of cerebral rSO₂ as a prognostic indicator of OHCA have not been established thus far.

Because rSO₂ is affected by the ratio of composition of arteries and veins at the measurement site, even if a patient is measured again using the same timing, the value varies depending on the measurement site. Therefore, rSO₂ has been used as a dynamic indicator (relative change) rather than a static indicator (absolute value). One purpose of this study was to examine whether cerebral rSO₂ can be used as a static indicator. In addition, it is assumed that the values of cerebral rSO₂ measured at several sites may not be equal when cerebral rSO₂ is used as a static indicator. This study also aimed to examine whether the lowest, highest, or average value is the best for judging if resuscitation will be futile.

Section snippets

Study design and participants

This study was a single-center, prospective, observational analysis of a cohort of consecutive patients aged 18 years or older with OHCA who were transported to the University of Tokyo Hospital from October 1, 2012, to September 30, 2013, and whose cerebral rSO₂ values were measured. Approval for the study was obtained from the Institutional Review Board of the University of Tokyo. The requirement of prior informed patient consent was waived because of the emergency setting. Unless there were

Results

During the study period, 71 adult OHCA patients had cerebral rSO₂ measured. Of these patients, 2 were excluded because of lack of blood pH or lactate measurements. Of the remaining 69 patients, we obtained both initial lower and higher cerebral rSO₂ values for 63 patients (91.3%), and for 6 patients (8.7%), we obtained only 1 of 2 initial cerebral rSO₂ values (Fig.).

Table 1 shows the demographic characteristics of the cohort. Overall, the average patient age was 66.1 years. In addition, 48

Discussion

In this single-center prospective cohort study of OHCA patients whose cerebral rSO₂ values were measured, we found that initial lower cerebral rSO₂ as a static indicator may help predict the medical futility of resuscitation. The ROC analysis revealed that the initial lower cerebral rSO₂ more accurately identified patients with OHCA who could not achieve sustained ROSC than initial higher or average cerebral rSO₂. However, the AUC for initial lower cerebral rSO₂ regarding the prediction of

Conclusions

Cerebral rSO₂ can be measured immediately and noninvasively just after arrival at the hospital and might be used as a static indicator for the prediction of non-ROSC when the initial lower value is used. However, cerebral rSO₂ alone does not result in a diagnosis performance that is sufficient for judging the futility of resuscitation. Thus, cerebral rSO₂ should be used in combination with other indicators.

Acknowledgments

The authors thank all of the EMS personnel and participating physicians and nurses at The University of Tokyo Hospital.

References (30)

C. Atwood et al.
Incidence of EMS-treated out-of-hospital cardiac arrest in Europe
Resuscitation
(2005)
T. Fukuda et al.
Health care costs related to out-of-hospital cardiopulmonary arrest in Japan
Resuscitation
(2013)
J. Berdowski et al.
Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies
Resuscitation
(2010)
J.T. Grasner et al.
Quality management in resuscitation—towards a European Cardiac Arrest Registry (EuReCa)
Resuscitation
(2011)
K. Hasegawa et al.
Regional variability in survival outcomes of out-of-hospital cardiac arrest: the All-Japan Utstein Registry
Resuscitation
(2013)
K. Kajino et al.
Current termination of resuscitation (TOR) guidelines predict neurologically favorable outcome in Japan
Resuscitation
(2013)
T. Fukuda et al.
Applicability of the prehospital termination of resuscitation rule in an area dense with hospitals in Tokyo: a single-center, retrospective, observational study
Am J Emerg Med
(2014)
N. Ito et al.
Regional cerebral oxygen saturation on hospital arrival is a potential novel predictor of neurological outcomes at hospital discharge in patients with out-of-hospital cardiac arrest
Resuscitation
(2012)
K. Asim et al.
An assessment of the use of near infrared spectrophotometry (cerebral oximetry) in predicting the return of spontaneous circulation in out-of-hospital cardiac arrest
Am J Emerg Med
(2014)
A. Ahn et al.
A pilot study examining the role of regional cerebral oxygen saturation monitoring as a marker of return of spontaneous circulation in shockable (VF/VT) and non-shockable (PEA/Asystole) causes of cardiac arrest
Resuscitation
(2013)

S. Parnia et al.

A feasibility study evaluating the role of cerebral oxymetry in predicting return of spontaneous circulation in cardiac arrest

Resuscitation

(2012)

J.P. Nolan et al.

Part 1: executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Resuscitation

(2010)

D.H. Newman et al.

Cerebral oximetry on out-of-hospital cardiac arrest: standard CPR rarely provides detectable hemoglobin-oxygen saturation to the frontal cortex

Resuscitation

(2004)

Fire and Disaster Management Agency, Ministry of Internal Affairs and Communications. [The current state of emergency...

V.L. Roger et al.

Heart disease and stroke statistics—2012 update: a report from the American Heart Association

Circulation

(2012)

Cited by (29)

Temporal changes in peripheral regional oxygen saturation associated with return of spontaneous circulation after out-of-hospital cardiac arrest: A prospective observational cohort study in Japan
2022, Resuscitation
Temporal changes in cerebral regional oxygen saturation (crSO₂) are useful for predicting return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) patients. However, little is known regarding the usefulness of peripheral regional oxygen saturation (prSO₂) associated with OHCA patient outcomes. This study evaluated the association between temporal changes in prSO₂ and ROSC in patients with OHCA.
This was a prospective study at two tertiary emergency centres in Japan. We evaluated the relationship between ROSC and temporal changes in crSO₂ and prSO₂. The rSO₂ sensor was attached to the patient’s forehead and upper arm, and rSO₂ was continuously measured until resuscitative efforts were terminated or until the patient with sustained ROSC (>20 min) arrived at the emergency department.
We included 145 patients with OHCA, of whom 35 achieved ROSC. Witness status (odds ratio [95% confidence interval]: 11.6 [3.13–58.1]) and ΔprSO₂ (1.13 [1.06–1.24]) were significantly associated with ROSC in multiple logistic analysis. In the ROSC group, ΔprSO₂ increased earlier than ΔcrSO₂ during cardiopulmonary resuscitation. In the non-ROSC group, there was no significant difference between ΔcrSO₂ and ΔprSO₂, and neither increased before termination of resuscitation (TOR).
We demonstrated for the first time that prSO₂ is associated with ROSC in OHCA patients and showed that temporal changes in prSO₂ could predict ROSC earlier than those in crSO₂. Our findings could provide time to prepare early interventions after ROSC and assist in determining the TOR for OHCA patients in Japan. Further studies are needed to validate these findings.
Cerebral regional oxygen saturation during cardiopulmonary resuscitation and return of spontaneous circulation: A systematic review and meta-analysis
2021, Resuscitation
Citation Excerpt :
Another study was a multicentre collaboration between USA and United Kingdom28. Regarding the primary outcomes, initial cerebral rSO2 values were reported by 11 studies (1 IHCA26, 9 OHCA22,29–33,35–37 and 1 mixed population8; 5 of these studies were conducted in Japan30,32,36–38, 3 in Europe22,33,35 and 3 in USA8,26,29); the values of overall cerebral rSO2 during CPR were provided by nine studies (5 IHCA12,25–28 and 4 OHCA22,23,29,34; one multicentre study across Europe and USA28, 3 single center studies conducted in Europe22,25,34 and 5 in USA12,23,26,27,29 – none in Japan). No studies clearly reported the exact time between the CA and the first detected cerebral rSO2 value.
Predicting the return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation in victims of cardiac arrest (CA) remains challenging. Cerebral regional oxygen saturation (rSO2) measured during resuscitation is feasible, and higher initial and overall values seem associated with ROSC. However, these observations were limited to the analysis of few small single-centre studies. There is a growing number of studies evaluating the role of cerebral rSO2 in the prediction of ROSC.
We conducted an updated meta-analysis aimed at investigating the association of initial and overall values of cerebral rSO2 with ROSC after CA. We performed subgroups analyses according to the location of CA and conducted a secondary analysis according to the country where the study was conducted (resuscitation practice varies greatly for out-of-hospital CA).
We included 17 studies. Higher initial rSO2 values (11 studies, n = 2870, 16.6% achieved ROSC) were associated with ROSC: Mean Difference (MD) -11.54 [95%Confidence Interval (CI)-20.96, -2.12]; p = 0.02 (I² = 97%). The secondary analysis confirmed this finding when pooling together European and USA studies, but did not for Japanese studies (p = 0.06). One multi-centre Japanese study was an outlier with large influence on 95%CI. Higher overall rSO2 values during resuscitation (9 studies, n = 894, 33.7% achieving ROSC) were associated with ROSC: MD-10.38; [-13.73, -7.03]; p < 0.00001 (I² = 77%). All studies were conducted in Europe/USA.
This updated meta-analysis confirmed the association between higher initial and overall values of cerebral rSO2 and ROSC after CA. However, we found geographical differences, since this association was not present when Japanese studies were analysed separately.
near infrared spectrometry; advanced cardiac life support; resuscitation order; cardiopulmonary resuscitation.
Usefulness of cerebral rSO<inf>2</inf> monitoring during CPR to predict the probability of return of spontaneous circulation
2019, Resuscitation
Cerebral oximetry (rSO₂) may be useful in assessing the probability of return of spontaneous circulation (ROSC). However, the potential of assessing the trend in the rSO₂ value has not been discussed when determining the probability of ROSC.
This was a retrospective study of out-of-hospital cardiac arrest (OHCA) patients with continuous rSO₂ values recorded during cardiopulmonary arrest. We used logistic regression analysis at each time point to investigate the best subsets of rSO₂-related variables for ROSC, which included rSO₂ (baseline), the baseline value of rSO₂; amount of maximum rise, the maximum difference of rSO₂ from rSO₂ (baseline) over t minutes; ΔrSO₂ (t):(amount of maximum rise)/rSO₂ (baseline) over t minutes after hospital arrival.
Among the 90 included patients, 35 achieved ROSC. Area under the curve (AUC) analysis revealed that ΔrSO₂ over a 16-min measurement period was significantly higher than ΔrSO₂ measured over 4-, 8-, 12-, and 20-min periods. During this 16-min period, the subset showing the best AUC value was interaction of the amount of maximum rise and rSO₂ (baseline) rather than the amount of maximum rise or ΔrSO₂ alone (AUC = 0.91).
The combination of rSO₂ (baseline) with the amount of maximum rise in rSO₂ value over time might be a new index for the prediction of ROSC that could be useful in guiding cardiopulmonary resuscitation. Further studies are needed to validate these findings.
A feasibility study for the continuous measurement of pupillary response using the pupillography during CPR in out-of-hospital cardiac arrest patients
2019, Resuscitation
We investigated the change in pupil size and pupil light reflex (PLR) using a pupillography capable of continuous measurement both during CPR and immediately following the return-of-spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) comatose patients in an emergency department.
Pupil size and PLR were continuously measured both during CPR and immediately following ROSC until intensive care unit (ICU) admission. The changes in pupil sizes during CPR were categorized into three groups (no change – N, decreased – D, and increased – I groups).
Pupillography was applied for 118 and 60 patients during CPR and immediately following ROSC, respectively. Only two patients had a PLR during CPR. The number of patients included each group were 58 (N-group), 21 (D-group) and 39 (I-group). In the D-group, the proportion of witnessed arrest was higher than in the N-group and I-group (81% vs. 55% and 49%, respectively; p = 0.049). There were statistically significant shorter prehospital time in the D-group than the N-group and I-group (13 vs. 23 and 24 min, respectively; p = 0.012). PLR was observed immediately following ROSC in 14 patients. PLR was maintained in seven of these patients until admission to intensive care unit. Six of the seven patients who remained with PLR until ICU admission had survival to hospital discharge, and three of them had good neurological recovery.
Our study demonstrated that measurement of the continuous pupillary response can be feasible. Patients with the presence of PLR following ROSC had better outcomes.
Regional cerebral oxygen saturation during cardiopulmonary resuscitation as a predictor of return of spontaneous circulation and favourable neurological outcome – A review of the current literature
2018, Resuscitation
Regional cerebral oxygen saturation (rSO2) can be measured non-invasively even at no- or low-flow states. It thus allows assessment of brain oxygenation during CPR. Certain rSO2 values had been associated with return of spontaneous circulation (ROSC) and neurological outcome in the past. Clear-cut thresholds for the prediction of beneficial outcome, however, are still lacking.
We conducted a database search to extract all available investigations on rSO2 measurement during CPR. Mean, median, and ΔrSO2 values were either taken from the studies or calculated. Thresholds for the outcome “ROSC” and “neurological outcome” were sought.
We retrieved 26 publications for the final review. The averaged mean rSO2 for patients achieving ROSC was 41 ± 12% vs. 30 ± 12% for non-ROSC (p = .009). ROSC was not observed when mean rSO2 remained <26%. In ROSC patients, ΔrSO2 was 22 ± 16% vs. 7 ± 10% in non-ROSC patients (p = .009). A rSO2 threshold of 36% predicted ROSC with a sensitivity of 67% and specificity of 69% while ΔrSO2 of 7% showed a sensitivity of 100% and a specificity of 86% (AUC = 0.733 and 0.893, respectively). Mean rSO2 of 47 ± 11% was associated with favourable and 38 ± 12% with poor neurological outcome. There was, however, a great overlap between groups due to scarce data.
Higher rSO2 consistently correlated with increased rates of ROSC. The discriminatory power of rSO2 to prognosticate favourable neurological outcome remains unclear. Measuring rSO2 during CPR could potentially facilitate clinical decision-making.
Cerebral oximetry versus end tidal CO<inf>2</inf> in predicting ROSC after cardiac arrest
2018, American Journal of Emergency Medicine
Both end tidal CO₂ (ETCO₂) and cerebral oxygen saturations (rSO₂) have been studied to determine their ability to monitor the effectiveness of CPR and predict return of spontaneous circulation (ROSC). We compared the accuracy of ETCO₂ and rSO₂ at predicting ROSC in ED patients with out-of-hospital cardiac arrest (OHCA).
We performed a prospective, observational study of adult ED patients presenting in cardiac arrest. We collected demographic and clinical data including age, gender, presenting rhythm, rSO₂, and ETCO₂. We used receiver operating characteristic curves to compare how well rSO₂ and ETCO₂ predicted ROSC.
225 patients presented to the ED with cardiac arrest between 10/11 and 10/14 of which 100 had both rSO₂ and ETCO₂ measurements. Thirty three patients (33%) had sustained ROSC, only 2 survived to discharge. The AUCs for rSO₂ and ETCO₂ were similar (0.69 [95% CI, 0.59–0.80] and 0.77 [95% CI, 0.68–0.86], respectively), however, rSO₂ and ETCO₂ were poorly correlated (0.12, 95% CI, − 0.08–0.31). The optimal cutoffs for rSO₂ and ETCO₂ were 50% and 20 mm Hg respectively. At these cutoffs, ETCO₂ was more sensitive (100%, 95% CI 87–100 vs. 48%, 31–66) but rSO₂ was more specific (85%, 95% CI, 74–92 vs. 45%, 33–57).
While poorly correlated, rSO₂ and ETCO₂ have similar diagnostic characteristics. ETCO₂ is more sensitive and rSO₂ is more specific at predicting ROSC in OHCA.

View all citing articles on Scopus

^☆: Contributors: T Fukuda, as the principal investigator, made substantial contributions to idea formation, study design and completion, data collection, management, and analysis, interpretation of results, and drafting and revising the manuscript. N Ohashi, M Nishida, M Gunshin, K Doi, T Matsubara, S Nakajima, and N Yahagi participated in idea formation, data collection and management, and reviewing the manuscript critically for important intellectual content. T Fukuda performed the statistical analysis. All authors approved the final version for publication.

^☆☆: Funding sources: This study was supported in part by a grant from the University of Tokyo Hospital.

^★: Conflict of interest statement: We declare that we have no conflicts of interest.

View full text

Original ContributionApplication of cerebral oxygen saturation to prediction of the futility of resuscitation for out-of-hospital cardiopulmonary arrest patients: a single-center, prospective, observational study: Can cerebral regional oxygen saturation predict the futility of CPR?☆,☆☆,★

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Study design and participants

Results

Discussion

Conclusions

Acknowledgments

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Am J Emerg Med

Resuscitation

Am J Emerg Med

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Heart disease and stroke statistics—2012 update: a report from the American Heart Association

Circulation

Original Contribution
Application of cerebral oxygen saturation to prediction of the futility of resuscitation for out-of-hospital cardiopulmonary arrest patients: a single-center, prospective, observational study: Can cerebral regional oxygen saturation predict the futility of CPR?☆,☆☆,★