Background Early administration of convalescent plasma obtained from blood donors who have recovered from coronavirus disease 2019 (Covid-19) may prevent disease progression in acutely ill, high-risk patients with Covid-19. Methods In this randomized, multicenter, single-blind trial, we assigned patients who were being treated in an emergency department for Covid-19 symptoms to receive either one unit of convalescent plasma with a high titer of antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or placebo. All the patients were either 50 years of age or older or had one or more risk factors for disease progression. In addition, all the patients presented to the emergency department within 7 days after symptom onset and were in stable condition for outpatient management. The primary outcome was disease progression within 15 days after randomization, which was a composite of hospital admission for any reason, seeking emergency or urgent care, or death without hospitalization. Secondary outcomes included the worst severity of illness on an 8-category ordinal scale, hospital-free days within 30 days after randomization, and death from any cause. Results A total of 511 patients were enrolled in the trial (257 in the convalescent-plasma group and 254 in the placebo group). The median age of the patients was 54 years; the median symptom duration was 4 days. In the donor plasma samples, the median titer of SARS-CoV-2 neutralizing antibodies was 1:641. Disease progression occurred in 77 patients (30.0%) in the convalescent-plasma group and in 81 patients (31.9%) in the placebo group (risk difference, 1.9 percentage points; 95% credible interval, −6.0 to 9.8; posterior probability of superiority of convalescent plasma, 0.68). Five patients in the plasma group and 1 patient in the placebo group died. Outcomes regarding worst illness severity and hospital-free days were similar in the two groups. Conclusions The administration of Covid-19 convalescent plasma to high-risk outpatients within 1 week after the onset of symptoms of Covid-19 did not prevent disease progression. (SIREN-C3PO ClinicalTrials.gov number, NCT04355767 .)

Background Functionally favorable survival remains low after out-of-hospital cardiac arrest (OHCA). When initial interventions fail to achieve return of spontaneous circulation (ROSC), they are repeated with little incremental benefit. Patients without rapid ROSC do not typically survive with good functional outcome. Novel approaches to OHCA have yielded functionally favorable survival in patients who failed traditional measures, but the optimal transition point from traditional measures to novel therapies is ill defined. Our objective was to estimate the dynamic probability of survival and functional recovery as a function of resuscitation effort duration, in order to identify this transition point. Methods and Results Retrospective cohort study of a cardiac arrest database at a single site. We included 1,014 adult (≥18 years) patients suffering non-traumatic OHCA between 2005–2011, defined as receiving CPR or defibrillation from a professional provider. We stratified by functional outcome at hospital discharge (modified Rankin scale–mRS). Survival to hospital discharge was 11%, but only 6% had mRS 0–3. Within 16.1 minutes of CPR, 89.7% (95%CI: 80.3%, 95.8%) of patients with good functional outcome had achieved ROSC, and the probability of good functional recovery fell to 1%. Adjusting for prehospital and inpatient covariates, CPR duration (minutes) is independently associated with favorable functional status at hospital discharge (OR 0.84; 95%CI 0.72, 0.98;p=0.02). Conclusions Probability of survival to hospital discharge with mRS 0–3 declines rapidly with each minute of CPR. Novel strategies should be tested early after cardiac arrest rather than after complete failure of traditional measures.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

Background Little evidence guides the appropriate duration of resuscitation in out-of-hospital cardiac arrest (OHCA), and case features justifying longer or shorter durations are ill-defined. We estimated the impact of resuscitation duration on the probability of favorable functional outcome in OHCA using a large, multi-center cohort. Methods Secondary analysis of a North American, single blind, multi-center, cluster-randomized clinical trial (ROC-PRIMED) of consecutive adults with non-traumatic, EMS-treated, OHCA. Primary exposure was duration of resuscitation in minutes (onset of professional resuscitation to return of spontaneous circulation [ROSC] or termination of resuscitation). Primary outcome was survival to hospital discharge with favorable outcome (modified Rankin scale [mRS] 0-3). Subjects were additionally classified as survival with unfavorable outcome (mRS 4-5), ROSC without survival (mRS 6), or without ROSC. Subject accrual was plotted as a function of resuscitation duration, and the dynamic probability of favorable outcome at discharge was estimated for the whole cohort and subgroups. Adjusted logistic regression models tested the association between resuscitation duration and survival with favorable outcome. Results The primary cohort included 11,368 subjects (median age 69 years [IQR: 56-81 years]; 7,121 men [62.6%]). Of these, 4,023 (35.4%) achieved ROSC, 1,232 (10.8%) survived to hospital discharge, and 905 (8.0%) had mRS 0-3 at discharge. Distribution of CPR duration differed by outcome (p<0.00001). For CPR duration up to 37.0 minutes (95%CI 34.9-40.9 minutes), 99% with eventual mRS 0-3 at discharge achieved ROSC. Dynamic probability of mRS 0-3 at discharge declined over elapsed resuscitation duration, but subjects with initial shockable cardiac rhythm, witnessed cardiac arrest, and bystander CPR were more likely to survive with favorable outcome after prolonged efforts (30-40 minutes). Adjusting for prehospital (OR 0.93; 95%CI 0.92-0.95) and inpatient (OR 0.97; 95%CI 0.95-0.99) covariates, resuscitation duration was associated with survival to discharge with mRS 0-3. Conclusions Shorter resuscitation duration was associated with likelihood of favorable outcome at hospital discharge. Subjects with favorable case features were more likely to survive prolonged resuscitation up to 47 minutes.