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To the Editor: Corral Torres et al. [1] observed a significant relationship between severe alterations of venous blood gas variables and potassium at the start of cardiopulmonary resuscitation (CPR) of non-traumatic out-of-hospital cardiac arrest (OHCA) and low return of spontaneous circulation (ROSC) rate and neurological prognosis. The authors should be congratulated for their noteworthy study on this relevant question; nevertheless, we believe that the results interpretation requires words of caution because of some issues. Firstly, the authors do not report major confounders of venous blood analysis, especially pre-analytical conditions. For example, during CPR, it is often common to encounter intravenous line insertion difficulties [2], involving a longer low-flow period justifying intraosseous access [3]. Consequently, by itself, it may induce acidaemia and hyperkalaemia. Secondly, it is not reported if the result of blood gas venous analysis was taken into account in the caredelivered decision-making. For example, it is not reported how hyperkalaemia treatment was considered and/or treated and if the SAMUR (SAMUR: Servicio de Asistencia Municipal de Urgencia y Rescate, i.e. the specialized emergency system of Madrid, Spain) team physician decision was not influenced by the results’ analysis (e.g. care discontinuation because major blood gas analysis abnormalities). Thirdly, from a methodological point of view, the variables included in the multivariate analysis (age, sex, first monitored rhythm, witnessed cardiac arrest, previous manoeuvres) do not consider the in-hospital phase confounders for neurological outcome [4] and the no-flow duration [5]. Therefore, we believe that the egg and the chicken should not be confused: the longer no-flow duration, the greater metabolic consequences will be marked. Beyond this, the authors’ work is very interesting, but more information and conclusions could be drawn by, first, integrating the no-flow duration in the analysis and, second, using the metabolic trend changes occurring during CPR.

critical care

Prognostic value of venous blood analysis at the start of CPR in non-traumatic out-of-hospital cardiac arrest: association with ROSC and the neurological outcome: do not forget the no-flow influence!