Cerebral regional oxygen saturation during cardiopulmonary resuscitation and return of spontaneous circulation: A systematic review and meta-analysis

AIM

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.

METHODS

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).

RESULTS

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.

CONCLUSIONS

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.

Echocardiography does not prolong peri-shock pause in cardiopulmonary resuscitation using the COACH-RED protocol with non-expert sonographers in simulated cardiac arrest

OBJECTIVE

Focused echocardiography during peri-shock pause (PSP) can prognosticate and detect reversible causes in cardiac arrest but minimising interruptions to chest compressions improves outcome. The COACH-RED protocol was adapted from the COACHED protocol to systematically incorporate echocardiography into rhythm check without prolonging PSP beyond the recommended 10 s. The primary objective of this study was to test the feasibility of emergency nurses learning to perform all roles in the COACH-RED protocol. PSP duration and change in participant confidence were secondary outcomes.

METHODS

After an initial two-hour workshop, five ALS-trained nurses were assessed for the correct use of COACH-RED protocol, without critical error, in three simulated cardiac arrest scenarios of four cycles each. Assessments were repeated on days 7 and 35. On day 35, three COACHED scenarios were also assessed for comparison. Participant roles per scenario and cardiac rhythm per cycle were randomised. Participants completed questionnaires on their confidence levels. Sessions were videotaped for accurate measurement of PSP duration and results tabulated for simple comparison. Statistical analysis was not performed due to small sample size.

RESULTS

There were no critical errors, two minor team-leading errors and two minor echosonography errors. Minor errors occurred in separate scenarios resulting in a 100% pass rate overall by predetermined criteria. Echocardiographic recordings were 100% adequate. Overall median PSP was 9.35 s for COACH-RED and 6.94 s for COACHED. Sub-group analysis of COACH-RED revealed median PSP 10.80 s in shockable rhythms and 8.74 s (∼2 s less) in non-shockable rhythms. Mean participant confidence in performing COACH-RED improved from 1.6 to 4.6, on a 5-point scale.

CONCLUSION

The COACH-RED protocol can be effectively performed by ALS-trained nurses, in all roles of this protocol, including echocardiography, in a simulated environment, after a single training session. Using this protocol, focused echocardiography does not prolong PSP beyond 10 s.

Do manual chest compressions provide substantial ventilation during prehospital cardiopulmonary resuscitation?

INTRODUCTION

Chest compressions have been suggested to provide passive ventilation during cardiopulmonary resuscitation. Measurements of this passive ventilatory mechanism have only been performed upon arrival of out-of-hospital cardiac arrest patients in the emergency department. Lung and thoracic characteristics rapidly change following cardiac arrest, possibly limiting the effectiveness of this mechanism after prolonged resuscitation efforts. Goal of this study was to quantify passive inspiratory tidal volumes generated by manual chest compression during prehospital cardiopulmonary resuscitation.

MATERIALS AND METHODS

A flowsensor was used during adult out-of-hospital cardiac arrest cases attended by a prehospital medical team. Adult, endotracheally intubated, non-traumatic cardiac arrest patients were eligible for inclusion. Immediately following intubation, the sensor was connected to the endotracheal tube. The passive inspiratory tidal volumes generated by the first thirty manual chest compressions performed following intubation (without simultaneous manual ventilation) were calculated.

RESULTS

10 patients (5 female) were included, median age was 64 years (IQR 56, 77 years). The median compression frequency was 111 compression per minute (IQR 107, 116 compressions per minute). The median compression depth was 5.6 cm (IQR 5.4 cm, 6.1 cm). The median inspiratory tidal volume generated by manual chest compressions was 20 mL (IQR 13, 28 mL).

CONCLUSION

Using a flowsensor, passive inspiratory tidal volumes generated by manual chest compressions during prehospital cardiopulmonary resuscitation, were quantified. Chest compressions alone appear unable to provide adequate alveolar ventilation during prehospital treatment of cardiac arrest.

Advanced cardiac life support certification for student pharmacists improves simulated patient survival

BACKGROUND AND PURPOSE

Basic life support (BLS) and advanced cardiac life support (ACLS) skills performance, as well as simulated patient survival, were compared for student pharmacist teams with and without at least one member with American Heart Association (AHA) ACLS certification.

EDUCATIONAL ACTIVITY AND SETTING

Doctor of pharmacy students in their third professional year completed a high-fidelity mannequin simulation. Within the previous year, 30 of 184 students (16%) completed ACLS certification. Rapid response teams (n = 31) of five to six members were formed through random student assignment. Two AHA instructors recorded and assessed performance using a checklist adapted from the AHA's standardized forms for BLS and ACLS assessment. Teams with and without ACLS certified members were compared for skills performance and simulated patient survival (i.e. correct performance of all BLS and ACLS skills).

FINDINGS

Teams with ACLS certified members (n = 21) were superior to teams without certified members (n = 10) for correct performance of all observed BLS and ACLS skills, including pulse assessment and medication selection for cardiovascular support. For teams who had ACLS certified members, simulated patient survival was 86% higher. The study groups did not differ in their ability to calculate a correct vasopressor infusion rate if warranted.

SUMMARY

BLS and ACLS skills performance were improved by AHA ACLS certification. Additionally, simulated patient survival was improved for teams with students who had at least one ACLS certified member.

Recommendations for Cardiopulmonary Resuscitation (CPR) of patients with suspected or confirmed COVID-19

The care for patients suffering from cardiopulmonary arrest in a context of a COVID-19 pandemic has particularities that should be highlighted. The following recommendations from the Brazilian Association of Emergency Medicine (ABRAMEDE), the Brazilian Society of Cardiology (SBC) and the Brazilian Association of Intensive Medicine (AMIB) and the Brazilian Society of Anesthesiology (SBA), associations and societies official representatives of specialties affiliated to the Brazilian Medical Association (AMB), aim to guide the various assistant teams, in a context of little solid evidence, maximizing the protection of teams and patients. It is essential to wear full Personal Protective Equipment (PPE) for aerosols during the care of Cardiopulmonary Resuscitation (CPR) and it is imperative to consider and treat the potential causes in these patients, especially hypoxia and arrhythmias caused by changes in the QT interval or myocarditis. The installation of an advanced invasive airway must be obtained early and the use of High Efficiency Particulate Arrestance (HEPA) filters at the interface with the valve bag is mandatory; situations of occurrence of CPR during mechanical ventilation and in a prone position demand peculiarities that are different from the conventional CPR pattern. Faced with the care of a patient diagnosed or suspected of COVID-19, the care follows the national and international protocols and guidelines 2015 ILCOR (International Alliance of Resuscitation Committees), AHA 2019 Guidelines (American Heart Association) and the Update of the Cardiopulmonary Resuscitation and Emergency Care Directive of the Brazilian Society of Cardiology 2019.

The association between ACLS guideline deviations and outcomes from in-hospital cardiac arrest

AIM OF STUDY

In hospital cardiac arrests occur at a rate of 1-5 per 1000 admissions and are associated with significant morbidity and mortality. We aimed to investigate the association between deviations from ACLS protocol and patient outcomes.

METHODS

This retrospective review was conducted at a single academic medical center. Data was collected on patients who suffered cardiac arrest from December 2015-November 2019. Our primary endpoint was return of spontaneous circulation. Secondary endpoints included survival to discharge and discharge with favorable neurological outcomes.

RESULTS

108 patients were included, 74 obtained return of spontaneous circulation, and 23 survived to discharge. The median number of deviations from the ACLS protocol per event in ROSC group was 1 (IQR 0-3) compared to 6.5 (IQR 4-12) in non-ROSC group (p < .0001). The probability of obtaining ROSC was 96% with 0-2 deviations per event, 59% with 2-5 deviations per event, and 11% with greater than 6 deviations per event (p < .0001). The median deviation per event in patients who survived to discharge was 0 (IQR 0-1) vs. 3 (IQR 1-6, p < .0001) in those who did not. Lastly, survival to discharge with a favorable neurological outcome may be associated we less deviations per event (p < .006).

CONCLUSION

Our findings highlight the importance of adherence to the ACLS protocol. We found that deviations from the algorithm are associated with decreased rates of ROSC and survival to discharge. Additionally, higher rates of protocol deviations may be associated with higher rates of neurological impairments after cardiac arrest.

Measuring health care students' attitudes toward interprofessional learning, perceptions of effectiveness as an interprofessional team member, and competence in managing adult cardiac arrest

BACKGROUND AND PURPOSE

Interprofessional education can be used to prepare healthcare graduates for teamwork. Simulations, when used with interprofessional education, create realistic clinical situations that promote teamwork. Faculty assessed changes in pharmacy and nursing students' competence in treating adult cardiac arrest and perceived readiness for interprofessional learning and teamwork.

EDUCATIONAL ACTIVITY AND SETTING

Eighty-three pharmacy students and 57 nursing students participated in a high fidelity simulation focused on adult cardiac arrest as an expectation of their respective courses. This study took place at a single campus College of Health Professions located at a public land grant institution.

FINDINGS

The Readiness for Health Care Students for Interprofessional Learning Scale (RIPLS) and Team Skills Scale (TSS) were used to develop a survey administered prepost simulation. A paired t-test indicated statistically significant increases of mean values prepost (p < 0.001) for: teamwork and collaboration, professional identity, team skills, and competence. An independent sample t-test found no differences by gender or degree.

DISCUSSION

This research supports using simulation in interprofessional education to increase competence and promote changes in attitudes toward interprofessional learning and teamwork.

SUMMARY

An interprofessional simulation increased student's perceived competence and positively increased perceptions of learning and working with other health profession students.

Two new chest compression methods might challenge the standard in a simulated infant model

Paediatric cardiorespiratory arrest is a rare event that requires a fast, quality intervention. High-quality chest compressions are an essential prognostic factor. The aim of this prospective, randomized and crossover study in infant manikin 2-min cardiorespiratory resuscitation scenario is to quantitatively compare the quality of the currently recommended method in infants (two-thumb-encircling hand techniques) with two new methods (the new two-thumb and the knocking-fingers techniques) using a 15:2 compression-to-ventilation ratio. Ten qualified health professionals were recruited. Variables analysed were mean rate and the ratio of compressions in the recommended rate range, mean depth and the ratio of compressions within the depth range recommendations, ratio of compressions with adequate chest release and ratio of compressions performed with the fingers in the correct position. Ratios of correct compressions for depth, rate, chest release and hand position were always above 70% regardless of the technique used. Reached mean depth and mean rate were similar to the 3 techniques. No statistically significant differences were found in any of the variables analysed.Conclusion: In an infant manikin, professionals are able to perform chest compressions with the new techniques with similar quality to that obtained with the standard method. What is Known: • Quality chest compressions are an essential prognostic factor in paediatric cardiorespiratory arrest. • It has been reported poor results when studied cardiorespiratory resuscitation quality in infants applying the recommended methods. What is New: • In a simulated scenario, quality of chest compressions performed with two new techniques (nTTT and KF) is similar to that obtained with the currently recommended method (TTHT).

[Successful prehospital emergency thoracotomy after blunt thoracic trauma : Case report and lessons learned]

BACKGROUND

The European Resuscitation Council guidelines for resuscitation in patients with traumatic cardiac arrest recommend the immediate treatment of all reversible causes, if necessary even prior to continuous chest compression. In the case of cardiac tamponade immediate emergency thoracotomy should also be considered.

OBJECTIVE

The authors report the case of a 23-year-old male patient with multiple injuries including blunt thoracic trauma, which caused a witnessed cardiac arrest. He successfully underwent prehospital emergency resuscitative thoracotomy. The lessons learned from this case on internal and external quality measures are discussed in detail.

RESULTS

After 60 min of technical rescue, extensive trauma life support including intubation, chest decompression and bleeding control was carried out. The cardiovascular insufficiency progressively deteriorated and under the suspicion of a cardiac tamponade a prehospital emergency thoracotomy was carried out. After successful resuscitative thoracotomy and return of spontaneous circulation (ROSC) the patient was airlifted to the next level 1 trauma center for damage control surgery (DCS). The patient could be discharged 59 days after the accident and now 2 years later is living a normal life without neurological or cardiopulmonary limitations. Airway management, chest decompression including resuscitative thoracotomy, fluid resuscitation and blood products were the key components to ensure that the patient achieved ROSC. Advanced Trauma Life Support® as well as structural prerequisites made these measures and good results for the patient possible.

Cost-utility of extracorporeal cardiopulmonary resuscitation in patients with cardiac arrest

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is a resource-intensive tool that provides haemodynamic and respiratory support in patients who have suffered cardiac arrest. In this study, we investigated the cost-utility of ECPR (cost/QALY) in cardiac arrest patients treated at our institution.

METHODS

We performed a retrospective review of patients who received ECPR following cardiac arrest between 2012 and 2018. All medical care-associated charges with ECPR and subsequent hospital admission were recorded. The quality-of-life of survivors was assessed with the Health Utilities Index Mark II. The cost-utility of ECPR was calculated with cost and quality-of-life data.

RESULTS

ECPR was used in 32 patients (15/32 in-hospital, 47%) with a median age of 55.0 years (IQR 46.3-63.3 years), 59% male and 66% African American. The median duration of ECPR support was 2.1 days (IQR 0.9-3.8 days). Survival to hospital discharge was 16%. The median score of the Health Utilities Index Mark II at discharge for the survivors was 0.44 (IQR 0.32-0.52). The median operating cost for patients undergoing ECMO was $125,683 per patient (IQR $49,751-$206,341 per patient). The calculated cost-utility for ECPR was $56,156/QALY gained.

CONCLUSIONS

The calculated cost-utility is within the threshold considered cost-effective in the United States (<$150,000/QALY gained). These results are comparable to the cost-effectiveness of heart transplantation for end-stage heart failure. Larger studies are needed to assess the cost-utility of ECPR and to identify whether other factors, such as patient characteristics, affect the cost-utility benefit.

Guideline removal of atropine and survival after adult in-hospital cardiac arrest with a non-shockable rhythm

AIM

To determine whether the removal of atropine from the 2010 ACLS guidelines for non-shockable cardiac arrests was associated with a change in survival.

METHODS

Using the Get With The Guidelines^®-Resuscitation registry, we included adults with an index in-hospital cardiac arrest between 2006 and 2015. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and favorable functional outcome. An interrupted time-series analysis was used to compare survival before (pre-guidelines) and after (post-guidelines) introduction of the 2010 guidelines. A difference-in-difference approach was used to compare the interrupted time-series results between the non-shockable and shockable cohorts to account for guideline changes unrelated to atropine.

RESULTS

We included 20,499 non-shockable and 3968 shockable cardiac arrests. Patient characteristics were similar between the pre-guidelines and post-guidelines period. Atropine was used for 8653 (87%) non-shockable and 680 (35%) shockable cardiac arrests in the pre-guidelines period and 3643 (35%) non-shockable and 320 (16%) shockable cardiac arrests in the post-guidelines period. The change over time in survival from the pre-guidelines to the post-guidelines period was not significantly different for the non-shockable compared to the shockable cohort (risk difference: 2.0% [95%CI: -0.8, 4.8] per year, p = 0.17). The immediate change in survival after introducing the guidelines was also not different between the cohorts (risk difference: 3.5% [95%CI: -2.6, 9.7], p = 0.26). Results were similar for the secondary outcomes and in multiple sensitivity analyses.

CONCLUSIONS

The removal of atropine from the 2010 guidelines was not associated with a significant change in survival.

Transcutaneous cardiac pacing competency among junior residents undergoing an ACLS course: impact of a modified high fidelity manikin

BACKGROUND

Transcutaneous cardiac pacing (TCP) is recommended to treat unstable bradycardia. Simulation might improve familiarity with this low-frequency procedure. Current mannequins fail to reproduce key features of TCP, limiting their usefulness. The objective of this study was to measure the impact of a modified high-fidelity mannequin on the ability of junior residents to achieve six critical tasks for successful TCP.

METHODS

First-year residents from various postgraduate programs taking an advanced cardiovascular life support (ACLS) course were enrolled two consecutive years (2015 and 2016). Both cohorts received the same standardized course content. An ALS simulator® mannequin was used to demonstrate and practice TCP during the bradycardia workshop of the first cohort (control cohort, 2015) and a modified high-fidelity mannequin that reproduces key features of TCP was used for the second cohort (intervention cohort, 2016). Participants were tested after training with a simulation scenario requiring TCP. Performances were graded based on six critical tasks. The primary outcome was the successful use of TCP, defined as having completed all tasks.

RESULTS

Eighteen participants in the intervention cohort completed all tasks during the simulation scenario compared to none in the control cohort (36 vs 0%, p < 0.001). Participants in the intervention cohort were more likely to recognize when pacing was inefficient (86 vs 12%), obtain ventricular capture (48 vs 2%), and check for a pulse rate to confirm capture (48 vs 0%).

CONCLUSIONS

TCP is a difficult skill to master for junior residents. Training using a modified high-fidelity mannequin significantly improved their ability to establish TCP during a simulation scenario.

Drugs in Out-of-Hospital Cardiac Arrest

Managing out-of-hospital cardiac arrest involves unique challenges, including delays in the initiation of advanced interventions and a limited number of trained personnel on scene. Recent out-of-hospital randomized controlled trials, systematic reviews, and metaanalyses provide key insights into what interventions are best proven to positively impact patient outcomes from out-of-hospital cardiac arrest. We review the literature on medications used in out-of-hospital cardiac arrest and summarize evidence-based guidelines from the American Heart Association that form the basis for most emergency medical services cardiac arrest protocols across the United States.

Mechanical versus manual chest compressions in the treatment of in-hospital cardiac arrest patients in a non-shockable rhythm: a randomised controlled feasibility trial (COMPRESS-RCT)

BACKGROUND

Mechanical chest compression devices consistently deliver high-quality chest compressions. Small very low-quality studies suggest mechanical devices may be effective as an alternative to manual chest compressions in the treatment of adult in-hospital cardiac arrest patients. The aim of this feasibility trial is to assess the feasibility of conducting an effectiveness trial in this patient population.

METHODS

COMPRESS-RCT is a multi-centre parallel group feasibility randomised controlled trial, designed to assess the feasibility of undertaking an effectiveness to compare the effect of mechanical chest compressions with manual chest compressions on 30-day survival following in-hospital cardiac arrest. Over approximately two years, 330 adult patients who sustain an in-hospital cardiac arrest and are in a non-shockable rhythm will be randomised in a 3:1 ratio to receive ongoing treatment with a mechanical chest compression device (LUCAS 2/3, Jolife AB/Stryker, Lund, Sweden) or continued manual chest compressions. It is intended that recruitment will occur on a 24/7 basis by the clinical cardiac arrest team. The primary study outcome is the proportion of eligible participants randomised in the study during site operational recruitment hours. Participants will be enrolled using a model of deferred consent, with consent for follow-up sought from patients or their consultee in those that survive the cardiac arrest event. The trial will have an embedded qualitative study, in which we will conduct semi-structured interviews with hospital staff to explore facilitators and barriers to study recruitment.

DISCUSSION

The findings of COMPRESS-RCT will provide important information about the deliverability of an effectiveness trial to evaluate the effect on 30-day mortality of routine use of mechanical chest compression devices in adult in-hospital cardiac arrest patients.

TRIAL REGISTRATION

ISRCTN38139840 , date of registration 9th January 2017.

Capnography during cardiac arrest

Successful resuscitation from cardiac arrest depends on provision of adequate blood flow to vital organs generated by cardiopulmonary resuscitation (CPR). Measurement of end-tidal expiratory pressure of carbon dioxide (ETCO₂) using capnography provides a noninvasive estimate of cardiac output and organ perfusion during cardiac arrest and can therefore be used to monitor the quality of CPR and predict return of spontaneous circulation (ROSC). In clinical observational studies, mean ETCO₂ levels in patients with ROSC are higher than those in patients with no ROSC. In prolonged out of hospital cardiac arrest, ETCO₂ levels <10 mmHg are consistently associated with a poor outcome, while levels above this threshold have been suggested as a criterion for considering patients for rescue extracorporeal resuscitation. An abrupt rise of ETCO₂ during CPR suggests that ROSC has occurred. Finally, detection of CO₂ in exhaled air following intubation is the most specific criterion for confirming endotracheal tube placement during CPR. The aetiology of cardiac arrest, variations in ventilation patterns during CPR, and the effects of drugs such as adrenaline or sodium bicarbonate administered as a bolus may significantly affect ETCO₂ levels and its clinical significance. While identifying ETCO₂ as a useful monitoring tool during resuscitation, current guidelines for advanced life support recommend against using ETCO₂ values in isolation for decision making in cardiac arrestmanagement.

Implementation of a real-time qualitative app to evaluate resuscitation performance in an Advanced Cardiac Life Support course

Objective:

In addition to high-quality chest compression, parameters of resuscitation efficiency such as early chest compression, early defibrillation, and decreased hands-off time are also vital in the Advanced Cardiac Life Support (ACLS) protocol. However, because of limited time and equipment in ACLS courses, efficiency of performance is difficult to evaluate.

Materials and Methods:

A free, easy-to-use iOS and Android app (CodeTracer^®) was developed for real-time recording of cardiopulmonary resuscitation (CPR) performance. Interventions performed during resuscitation were set up as buttons. When the simulated scenario in the ACLS course began, instructors recorded every intervention and the team performed by pushing the appropriate buttons. When the scenario ended, the CodeTracer^® automatically computed parameters, including the percentage of no-flow time, time to initiating CPR, and time to initiating defibrillation and also generated a graphic log for later discussion.

Results:

A total of 76 resuscitation episodes were recorded, 27 in the practice scenarios and 49 in the final Megacode simulations. After the course, the average percentage of no-flow time decreased 5.79%, time to initiating CPR decreased 3.05 s, and time to initiating defibrillation decreased up to 20.27 s. Of note, physicians as leaders seem to have better performance after the ACLS course than before, but the results were insignificant except for the percentage of no-flow time.

Conclusions:

CodeTracer^® can record and calculate objective parameters for resuscitation performance in ACLS courses and can assist instructors in disseminating important concepts to participants. It can be a useful tool in ACLS courses.

Prehospital advanced cardiac life support by EMT with a smartphone-based direct medical control for nursing home cardiac arrest

OBJECTIVE

To compare the survival to discharge between nursing home (NH) cardiac arrest patients receiving smartphone-based advanced cardiac life support (SALS) and basic life support (BLS).

METHODS

The SALS registry includes data on cardiac arrest from 7 urban and suburban areas in Korea between July 2015 and December 2016. We include adult patients (>18) with out-of-hospital cardiac arrest (OHCA) of medical causes and EMS attended and dispatched in. SALS is an advanced field resuscitation including drug administration by paramedics with video communication-based direct medical direction. Prehospital resuscitation method was key exposure (SALS, BLS). The primary outcome was survival to discharge.

RESULTS

A total of 616 consecutive out-of-hospital cardiopulmonary resuscitation cases in NHs were recorded, and 199 (32.3%) underwent SALS. Among the NH arrest patients, the survival discharge rate was a little higher in the SALS group than the BLS group (4.0% vs 1.7%), but the difference was not significant (P = 0.078). Survival discharge with good neurologic outcome rates was 0.5% in the SALS group and 1.0% in the BLS group (P = 0.119). On the other hand, in the non-NH group, all outcome measures significantly improved when SALS was performed compared to BLS alone (survival discharge rate: 10.0% vs 7.3%, P = 0.001; good neurologic outcome: 6.8% vs 3.3%, P < 0.001).

CONCLUSIONS

As a result of providing prehospital ACLS with direct medical intervention through remote video calls to paramedics, the survival to discharge rate and that with good neurologic outcome (CPC 1, 2) of non-NH patients significantly improved, however those of NH patients were not significantly increased.

Adherence to advanced cardiovascular life support (ACLS) guidelines during in-hospital cardiac arrest is associated with improved outcomes

AIM OF THE STUDY

Identifying modifiable factors associated with survival following in-hospital cardiac arrest is crucial. The purpose of this study was to determine the extent to which adherence to the 2010 American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) guidelines in their entirety affects patient outcomes. In addition, we explored the role of code leader training level on patient outcomes.

METHODS

We conducted a retrospective review of records for cardiac arrests that occurred on hospital wards and were run by the hospital code team, at three tertiary care centres over 2 to 4 years. Deviations from the ACLS guidelines were quantified using a standardized checklist. Primary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge.

RESULTS

Of 160 resuscitation events, ROSC was achieved in 75 events (46.9%) and survival to hospital discharge in 20 patients (13.1%). On average, there were 2.3 deviations from ACLS guidelines during events that led to ROSC and 3.9 deviations during events that did not lead to ROSC (p < 0.0001). There were fewer deviations during events that led to survival to hospital discharge (2.1) compared to those where the patient did not survive to hospital discharge (3.1; p = 0.016). Code leader training level was not associated with patient outcomes. Multivariable logistic regression analysis confirmed an association between deviations from ACLS guidelines and ROSC, but not for survival to hospital discharge. The latter finding may reflect a very low survival rate.

CONCLUSION

We found that higher numbers of deviations from ACLS guidelines were associated with a lower likelihood of ROSC and survival to hospital discharge. These findings emphasize the importance of adherence to ACLS guidelines and the need for training healthcare personnel in resuscitation guidelines in order to improve outcomes for victims of in-hospital cardiac arrest.

Data supporting the use of end-tidal carbon dioxide (ETCO2) measurement to guide management of cardiac arrest: A systematic review

The data presented in this article are related to the research article, "The Use of End-Tidal Carbon Dioxide (ETCO2) Measurement to Guide Management of Cardiac Arrest: A Systematic Review" [1]. This article is a systematic review and meta-analysis of existing data on the subject of whether any level of end-tidal carbon dioxide (ETCO2) measured during cardiopulmonary resuscitation (CPR) correlates with return of spontaneous circulation (ROSC) or survival in adult patients experiencing cardiac arrest in any setting. These data are made publicly available to enable critical or extended analyses.

Association of the time to first epinephrine administration and outcomes in out-of-hospital cardiac arrest: SOS-KANTO 2012 study

OBJECTIVE

This study assessed the association between the timing of first epinephrine administration (EA) and the neurological outcomes following out-of-hospital cardiac arrests (OHCAs) with both initial shockable and non-shockable rhythms.

METHODS

This was a post-hoc analysis of a multicenter prospective cohort study (SOS-KANTO 2012), which registered OHCA patients in the Kanto region of Japan from January 2012 to March 2013. We included consecutive adult OHCA patients who received epinephrine. The primary result included 1-month favorable neurological outcomes defined as cerebral performance category (CPC) 1 or 2. Secondary results included 1-month survival and return of spontaneous circulation (ROSC) after arrival at the hospital. Multivariable logistic regression analysis determined the association between delay per minute of the time from call to first EA in both pre- or in-hospital settings and outcomes.

RESULTS

Of the 16,452 patients, 9344 were eligible for our analyses. In univariable analysis, the delay in EA was associated with decreased favorable neurological outcomes only when the initial rhythm was a non-shockable rhythm. In multivariable analyses, delay in EA was associated with decreased ROSC (adjusted odds ratio [OR] for one minute delay, 0.97; 95% confidence interval [CI], 0.96-0.98) and 1-month survival (adjusted OR, 0.95; 95% CI, 0.92-0.97) when the initial rhythm was a non-shockable rhythm, whereas during a shockable rhythm, delay in EA was not associated with decreased ROSC and 1-month survival.

CONCLUSIONS

While assessing the effectiveness of epinephrine for OHCA, we should consider the time-limited effects of epinephrine. Additionally, consideration of early EA based on the pathophysiology is needed.

[Organ assist devices in the future : Limits and perspectives]

In the last decade, extracorporeal organ assist devices (extracorporeal membrane oxygenation [ECMO]) have been increasingly applied to treat the most severe forms of respiratory failure and cardiogenic shock, although the underlying scientific evidence is still limited and the methods carry a high risk of complications despite all technical improvements. The selection of those patients who most benefit from these devices is still a great challenge for intensivists and all other involved disciplines. Besides the severity of the acute organ failure, it is important to thoroughly evaluate etiology and treatment options of the underlying disease, comorbidities, and the functional status of the patients in an interdisciplinary team. This also includes ethical challenges. Because of the complexity of the treatment and the high organizational demands it is reasonable to concentrate ECMO treatments in specifically qualified centers and to promote a comprehensive scientific analysis of the treatment data.

Standardized model of porcine resuscitation using a custom-made resuscitation board results in optimal hemodynamic management

AIM

Standardized modeling of cardiac arrest and cardiopulmonary resuscitation (CPR) is crucial to evaluate new treatment options. Experimental porcine models are ideal, closely mimicking human-like physiology. However, anteroposterior chest diameter differs significantly, being larger in pigs and thus poses a challenge to achieve adequate perfusion pressures and consequently hemodynamics during CPR, which are commonly achieved during human resuscitation. The aim was to prove that standardized resuscitation is feasible and renders adequate hemodynamics and perfusion in pigs, using a specifically designed resuscitation board for a pneumatic chest compression device.

METHODS AND RESULTS

A "porcine-fit" resuscitation board was designed for our experiments to optimally use a pneumatic compression device (LUCAS® II, Physio-Control Inc.), which is widely employed in emergency medicine and ideal in an experimental setting due to its high standardization. Asphyxial cardiac arrest was induced in 10 German hybrid landrace pigs and cardiopulmonary resuscitation was performed according to ERC/AHA 2015 guidelines with mechanical chest compressions. Hemodynamics were measured in the carotid and pulmonary artery. Furthermore, arterial blood gas was drawn to assess oxygenation and tissue perfusion. The custom-designed resuscitation board in combination with the LUCAS® device demonstrated highly sufficient performance regarding hemodynamics during CPR (mean arterial blood pressure, MAP 46 ± 1 mmHg and mean pulmonary artery pressure, mPAP of 36 ± 1 mmHg over the course of CPR). MAP returned to baseline values at 2 h after ROSC (80 ± 4 mmHg), requiring moderate doses of vasopressors. Furthermore, stroke volume and contractility were analyzed using pulse contour analysis (106 ± 3 ml and 1097 ± 22 mmHg/s during CPR). Blood gas analysis revealed CPR-typical changes, normalizing in the due course. Thermodilution parameters did not show persistent intravascular volume shift.

CONCLUSION

Standardized cardiopulmonary resuscitation is feasible in a porcine model, achieving adequate hemodynamics and consecutive tissue perfusion of consistent quality.

Study of the impact of training of registered nurses in cardiopulmonary resuscitation in a tertiary care centre on patient mortality

Background and Aims:

Nurses should have cardiopulmonary resuscitation (CPR) knowledge and skills to be able to implement effective interventions during in-hospital cardiac arrest. The aim of this descriptive study was to assess mortality impact after nurses' CPR training with pre-CPR training data at our institute.

Methods:

Training regarding CPR was given to nurses, and CPR mortality 1-year before basic life support (BLS) and advanced cardiac life support (ACLS) training were collected and compared with post-training 1-year CPR mortality.

Results:

A total of 632 adult patients suffering in-hospital cardiac arrest over the study period. CPR was attempted in 294 patients during the pre-BLS/ACLS training period and in 338 patients in the post-BLS/ACLS training period. In the pre-BLS/ACLS training period, 58 patients (19.7%) had return of spontaneous circulation (ROSC), while during the post-BLS/ACLS training period, 102 patients (30.1%) had ROSC (P = 0.003). Sixteen of the 58 patients (27.5%) who achieved ROSC during the pre-BLS/ACLS training period survived to hospital discharge, compared 54 out of 102 patients (52.9%) in the post-BLS/ACLS training period (P < 0.0001). There was no significant association between either the age or sex with the outcomes in the study.

Conclusion:

Training nurses in cardiopulmonary resuscitation resulted in a significant improvement in survival to hospital discharge after in-hospital cardiac arrest.

Hospital resuscitation teams: a review of the risks to the healthcare worker

Background

“Code blue” events and related resuscitation efforts involve multidisciplinary bedside teams that implement specialized interventions aimed at patient revival. Activities include performing effective chest compressions, assessing and restoring a perfusing cardiac rhythm, stabilizing the airway, and treating the underlying cause of the arrest. While the existing critical care literature has appropriately focused on the patient, there has been a dearth of information discussing the various stresses to the healthcare team. This review summarizes the available literature regarding occupational risks to medical emergency teams, characterizes these risks, offers preventive strategies to healthcare workers, and highlights further research needs.

Methods

We performed a literature search of PubMed for English articles of all types (randomized controlled trials, case-control and cohort studies, case reports and series, editorials and commentaries) through September 22, 2016, discussing potential occupational hazards during resuscitation scenarios. Of the 6266 articles reviewed, 73 relevant articles were included.

Results

The literature search identified six potential occupational risk categories to members of the resuscitation team—infectious, electrical, musculoskeletal, chemical, irradiative, and psychological. Retrieved articles were reviewed in detail by the authors.

Conclusion

Overall, we found there is limited evidence detailing the risks to healthcare workers performing resuscitation. We identify these risks and offer potential solutions. There are clearly numerous opportunities for further study in this field.

Cardiopulmonary Resuscitation: Evaluation of Knowledge, Efficacy, and Retention in Young Doctors Joining Postgraduation Program

Background:

High-quality cardiopulmonary resuscitation (CPR) and rapid defibrillation the cornerstone for resuscitation from cardiac arrest and increase the incidence of return of spontaneous circulation. Regular CPR training imparted to health-care personnel increases knowledge and helps in skill enhancing.

Aims:

The aim of this study is to evaluate background knowledge, percentage improvement in the skills, and residual knowledge after a period of 6 months of postgraduate (PG) students as well as the efficacy of the designed teaching program for CPR.

Design:

The study type was interventional, nonrandomized with end point classification as efficacy study. Study Interventional model was single group assignment.

Methods:

A questionnaire-based study was conducted on 41 first year PG students. Their educational qualification was Bachelor of Medicine and Bachelor of Surgery. The study was conducted; 3 months after, these PG students joined hospital for their PG studies. The questionnaire designed by the Department of Anesthesiology and Critical Care was given as the pretest (before the CPR training program was initiated), posttest (immediately after the CPR training program was concluded), and residual knowledge test (conducted after 6 months of the CPR training program). After collection of data, a descriptive analysis was performed to evaluate results.

Statistical Analysis:

Statistical analysis was conducted for determining the test of significance using two-tailed, paired t-test.

Results:

The average overall score was 25.58 (±5.605) marks out of a maximum of 40 marks in the pretest, i.e., 63.97%. It improved to 33.88 (±3.38) marks in posttest, i.e., 84.74%. After 6 months in the residual knowledge test, the score declined to 26.96 (±6.09) marks, i.e., 67.4%.

Conclusion:

The CPR training program being conducted was adequately efficacious, but a refresher course after 6 months could help taking the knowledge and skills acquired by our PG students a long way.