European Resuscitation Council Guidelines for Resuscitation 2015

Validation of CASPRI, GO-FAR, PIHCA scores in predicting favorable neurological outcomes after in-hospital cardiac arrest; A five-year three center retrospective study in IRAN

BACKGROUND

Predicting neurological outcomes following in-hospital cardiac arrest is crucial for guiding subsequent clinical treatments. This study seeks to validate the effectiveness of the CASPRI, GO-FAR, and PIHCA tools in predicting favorable neurological outcomes after in-hospital cardiac arrest.

METHOD

This retrospective study utilized a Utstein-style structured form to review the medical records of patients who experienced in-hospital cardiac arrest between March 2018 and March 2023. Predictors were examined using multivariable logistic regression, and the validity of the tools was assessed using ROC curves. Statistical analysis was conducted using SPSS version 25 software.

RESULTS

Out of the 1100 patients included in the study, 42 individuals (3.8%) achieved a favorable neurological outcome. multivariable regression analysis revealed that age, respiratory failure, resuscitation shift, duration of renal failure, and CPC score 24 h before cardiac arrest were significantly associated with favorable neurological outcomes. The predictive abilities of the CASPRI, GO-FAR, and PIHCA scores were calculated as 0.99 (95% CI, 0.98-1.00), 0.98 (95% CI, 0.97-0.99), and 0.96 (95% CI, 0.94-0.99) respectively. A statistically significant difference was observed in the predictive abilities of the CASPRI and PIHCA scores (P = 0.001), while the difference between CASPRI and GO-FAR did not reach significance (P = 0.057). Additionally, there was no significant difference between the predictive abilities of GO-FAR and PIHCA scores (P = 0.159).

CONCLUSION

The study concludes that CASPRI and GO-FAR scores show strong potential as objective measures for predicting favorable neurological outcomes post-cardiac arrest. Integrating these scores into clinical decision-making may enhance treatment and care strategies, in the Iranian healthcare context.

Intensive care unit cardiac arrest among very elderly critically ill patients - is cardiopulmonary resuscitation justified?

INTRODUCTION

The proportion of very elderly patients in the intensive care unit (ICU) is expected to rise. Furthermore, patients are likely more prone to suffer a cardiac arrest (CA) event within the ICU. The occurrence of intensive care unit cardiac arrest (ICU-CA) is associated with high mortality. To date, the incidence of ICU-CA and its clinical impact on outcome in the very old (≥ 90 years) patients treated is unknown.

METHODS

Retrospective analysis of all consecutive critically ill patients ≥ 90 years admitted to the ICU of a tertiary care university hospital in Hamburg (Germany). All patients suffering ICU-CA were included and CA characteristics and functional outcome was assessed. Clinical course and outcome were assessed and compared between the subgroups of patients with and without ICU-CA.

RESULTS

1,108 critically ill patients aged ≥ 90 years were admitted during the study period. The median age was 92.3 (91.0-94.2) years and 67% (n = 747) were female. 2% (n = 25) of this cohort suffered ICU-CA after a median duration 0.5 (0.2-3.2) days of ICU admission. The presumed cause of ICU-CA was cardiac in 64% (n = 16). The median resuscitation time was 10 (2-15) minutes and the initial rhythm was shockable in 20% (n = 5). Return of spontaneous circulation (ROSC) could be achieved in 68% (n = 17). The cause of ICU admission was primarily medical in the total cohort (ICU-CA: 48% vs. No ICU-CA: 34%, p = 0.13), surgical - planned (ICU-CA: 32% vs. No ICU-CA: 37%, p = 0.61) and surgical - unplanned/emergency (ICU-CA: 43% vs. No ICU-CA: 28%, p = 0.34). The median Charlson Comorbidity Index (CCI) was 2 (1-3) points for patients with ICU-CA and 1 (0-2) for patients without ICU-CA (p = 0.54). Patients with ICU-CA had a higher disease severity according to SAPS II (ICU-CA: 54 vs. No ICU-CA: 36 points, p < 0.001). Patients with ICU-CA had a higher rate of mechanically ventilation (ICU-CA: 64% vs. No ICU-CA: 34%, p < 0.01) and required vasopressor therapy more often (ICU-CA: 88% vs. No ICU-CA: 41%, p < 0.001). The ICU and in-hospital mortality was 88% (n = 22) and 100% (n = 25) in patients with ICU-CA compared to 17% (n = 179) and 28% (n = 306) in patients without ICU-CA. The mortality rate for patients with ICU-CA was observed to be 88% (n = 22) in the ICU and 100% (n = 25) in-hospital. In contrast, patients without ICU-CA had an in-ICU mortality rate of 17% (n = 179) and an in-hospital mortality rate of 28% (n = 306) (both p < 0.001).

CONCLUSION

The occurrence of ICU-CA in very elderly patients is rare but associated with high mortality. Providing CPR in this cohort did not lead to long-term survival at our centre. Very elderly patients admitted to the ICU likely benefit from supportive care only and should probably not be resuscitated due to poor chance of survival and ethical considerations. Providing personalized assurances that care will remain appropriate and in accordance with the patient's and family's wishes can optimise compassionate care while avoiding futile life-sustaining interventions.

Withdrawal/Withholding of Life-Sustaining Therapies: Limitation of Therapeutic Effort in the Intensive Care Unit

Background/Objectives: The change in critically ill patients makes limitation of therapeutic effort (LTE) a widespread practice when therapeutic goals cannot be achieved. We aimed to describe the application of LTE in a post-surgical Intensive Care Unit (ICU), analyze the measures used, the characteristics of the patients, and their evolution. Methods: Retrospective observational study, including all patients to whom LTE was applied in a postsurgical ICU between January 2021 and December 2022. The LTE defined were brain death, withdrawal of measures, and withholding. Withholding limitations included orders for no cardiopulmonary resuscitation, no orotracheal intubation, no reintubation, no tracheostomy, no renal replacement therapies, and no vasoactive support. Patient and ICU admission data were related to the applied LTE. Results: Of the 2056 admitted, LTE protocols were applied to 106 patients. The prevalence of LTE in the ICU was 5.1%. Data were analyzed in 80 patients. A total of 91.2% of patients had been admitted in an emergency situation, and 56.2% had been admitted after surgery. The most widespread limitation was treatment withholding (83.8%) compared to withdrawal (13.8%). No differences were found regarding who made the decision and the type of limitation employed. However, patients with the limitation of no intubation had a longer stay (p = 0.025). Additionally, the order of not starting or increasing vasopressor support resulted in a longer hospital stay (p = 0.007) and a significantly longer stay until death (p = 0.044). Conclusions: LTE is a frequent measure in critically ill patient management and is less common in the postoperative setting. The most widespread measure was withholding, with the do-not-resuscitate order being the most common. The decision was made mainly by the medical team and the family, respecting the wishes of the patients. A joint patient-centered approach should be made in these decisions to avoid futile treatment and ensure end-of-life comfort.

Family Presence During Resuscitation: Perspectives of Saudi Emergency Medicine Providers

Background Family presence during resuscitation (FPDR) has been a long-debated topic in medical circles in the last 40 years. Studies usually concentrate on the opinions and responses of the family members of the patients being resuscitated. Only a handful of studies have focussed on the medical practitioner's opinions and beliefs on the topic. Hence, this study aimed to investigate opinions and beliefs regarding FPDR among emergency medicine practitioners (EMPs) in the Kingdom of Saudi Arabia. Methodology This was a self-filled, questionnaire-based study conducted among 450 EMPs across the Kingdom of Saudi Arabia. Proportions and subgroup analyses were conducted with respect to gender, experience, and seniority. EMPs were asked about the number of family members they would allow to attend the resuscitation of a patient under their care in different clinical scenarios. Results A total of 392 (87.1%) EMPs participated in this study. Overall, 64% (n = 250) of EMPs reported that they would not allow FPDR in cases that involved trauma, or if the patient being revived was female. This percentage dropped to about 33% (n = 129) when the patient being resuscitated was a child or in out-of-hospital arrest. The majority of EMPs believed that the decision to allow FPDR was the physician's decision (n = 251, 64.8%) and not the right of the family (n = 133, 34.7%). Moreover, emergency medicine board-certified physicians were more likely to allow FPDR in different cases with 19 (18.5%) in adult arrest cases, 18 (18%) in pediatric cases, and 16 (15.1%) in trauma cases, than non-board-certified practitioners (p = 0.001, 0.007, and 0.031, respectively). Female EMPs were more likely to refuse FPDR than their male counterparts (p < 0.001). Conclusions Approximately, 60-70% of EMPs allowed a member of the family to attend the resuscitation of their loved one. However, this percentage dropped in cases where the patient was a female, or the case was a trauma case instead of a medical case. Most Saudi EMPs believed that FPDR hurts the resuscitating team and might hinder the resuscitation efforts.

Termination of Resuscitation Rules and Survival Among Patients With Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis

Importance

Termination of resuscitation (TOR) rules may help guide prehospital decisions to stop resuscitation, with potential effects on patient outcomes and health resource use. Rules with high sensitivity risk increasing inappropriate transport of nonsurvivors, while rules without excellent specificity risk missed survivors. Further examination of the performance of TOR rules in estimating survival of out-of-hospital cardiac arrest (OHCA) is needed.

Objective

To determine whether TOR rules can accurately identify patients who will not survive an OHCA.

Data Sources

For this systematic review and meta-analysis, the MEDLINE, Embase, CINAHL, Cochrane Library, and Web of Science databases were searched from database inception up to January 11, 2024. There were no restrictions on language, publication date, or time frame of the study.

Study Selection

Two reviewers independently screened records, first by title and abstract and then by full text. Randomized clinical trials, case-control studies, cohort studies, cross-sectional studies, retrospective analyses, and modeling studies were included. Systematic reviews and meta-analyses were reviewed to identify primary studies. Studies predicting outcomes other than death, in-hospital studies, animal studies, and non-peer-reviewed studies were excluded.

Data Extraction and Synthesis

Data were extracted by one reviewer and checked by a second. Two reviewers assessed risk of bias using the Revised Quality Assessment Tool for Diagnostic Accuracy Studies. Cochrane Screening and Diagnostic Tests Methods Group recommendations were followed when conducting a bivariate random-effects meta-analysis. This review followed the Preferred Reporting Items for a Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) statement and is registered with the International Prospective Register of Systematic Reviews (CRD42019131010).

Main Outcomes and Measures

Sensitivity and specificity tables with 95% CIs and bivariate summary receiver operating characteristic (SROC) curves were produced. Estimates of effects at different prevalence levels were calculated. These estimates were used to evaluate the practical implications of TOR rule use at different prevalence levels.

Results

This review included 43 nonrandomized studies published between 1993 and 2023, addressing 29 TOR rules and involving 1 125 587 cases. Fifteen studies reported the derivation of 20 TOR rules. Thirty-three studies reported external data validations of 17 TOR rules. Seven TOR rules had data to facilitate meta-analysis. One clinical study was identified. The universal termination of resuscitation rule had the best performance, with pooled sensitivity of 0.62 (95% CI, 0.54-0.71), pooled specificity of 0.88 (95% CI, 0.82-0.94), and a diagnostic odds ratio of 20.45 (95% CI, 13.15-31.83).

Conclusions and Relevance

In this review, there was insufficient robust evidence to support widespread implementation of TOR rules in clinical practice. These findings suggest that adoption of TOR rules may lead to missed survivors and increased resource utilization.

Ongoing CPR with an onboard physician

Introduction

Recent data are not available on ongoing CPR for emergency services with an onboard physician. The aim of the present study was to identify factors associated with the decision to transport patients to hospital with ongoing CPR and examine their survival to hospital discharge with good neurological status.

Methods

An observational study based on a registry of out-of-hospital cardiac arrests attended to by emergency services with an onboard physician. All OHCA cases occurring between the 1st of January and the 31st of December 2022 were included. Patients receiving ongoing CPR during transport to the hospital were compared with patients pronounced dead at the scene following arrival of the care team. The dependent variable was ongoing CPR during transport to the hospital. The main characteristics and the neurological status of patients surviving to discharge were described.

Results

A total of 9321 cases were included, of which 350 (3.7%) were transported to hospital with ongoing CPR. Such patients were young (59.9 ± 20.1 years vs 64.6 ± 16.9 years; p < 0.001; 95%CI: 0.98 [0.98; 0.99]) with arrest taking place outside of the home (151 [44.5%] vs 4045 [68.01%]; p < 0.001; 95%CI: 0.41 [0.31; 0.54]) and being witnessed by EMS (126 [36.0%] vs 667 [11.0%]; p < 0.001; 95%CI: 4.31 [3.19; 5.80]), whilst initial rhythm differed from asystole (164 [47.6%] vs 4325 [73.0%]; p < 0.01; 95%CI: 0.44 [0.33; 0.60]) and a mechanical device was more often employed during resuscitation and transport to hospital (199 [56.9%] vs 2050 [33.8%]; p < 0.001; 95%CI: 2.75 [2.10; 3.59]). Seven patients (2%) were discharged alive from hospital, five with ad integrum neurological recovery (CPC1) and two with minimally impaired neurological function (CPC2).

Conclusions

The strategy of ongoing CPR is uncommon in EMS with an onboard physician. Despite their limited efficacy, the availability of mechanical chest compression devices, together with the possibility of specific hospital treatments, mainly ICP and ECMO, opens up the possibility of this approach with determined patients.

The Current Discussion Regarding End-of-Life Care for Patients with Out-of-Hospital Cardiac Arrest with Initial Non-Shockable Rhythm: A Narrative Review

Despite recent advances in resuscitation science, outcomes in patients with out-of-hospital cardiac arrest (OHCA) with initial non-shockable rhythm remains poor. Those with initial non-shockable rhythm have some epidemiological features, including the proportion of patients with a witnessed arrest, bystander cardiopulmonary resuscitation (CPR), age, and presumed etiology of cardiac arrest have been reported, which differ from those with initial shockable rhythm. The discussion regarding better end-of-life care for patients with OHCA is a major concern among citizens. As one of the efforts to avoid unwanted resuscitation, advance directive is recognized as a key intervention, safeguarding patient autonomy. However, several difficulties remain in enhancing the effective use of advance directives for patients with OHCA, including local regulation of their use, insufficient utilization of advance directives by emergency medical services at the scene, and a lack of established tools for discussing futility of resuscitation in advance care planning. In addition, prehospital termination of resuscitation is a common practice in many emergency medical service systems to assist clinicians in deciding whether to discontinue resuscitation. However, there are also several unresolved problems, including the feasibility of implementing the rules for several regions and potential missed survivors among candidates for prehospital termination of resuscitation. Further investigation to address these difficulties is warranted for better end-of-life care of patients with OHCA.

Feasibility and performance of a combined extracorporeal assisted cardiac resuscitation and an organ donation program after uncontrolled cardiocirculatory death (Maastricht II)

INTRODUCTION

Approximately 500.000 people in Europe sustain cardiac arrest (CA) every year, being myocardial infarction the main etiology. Interest has been raised in a new approach to refractory cardiac arrest (rCA) using extra-corporeal oxygenation (ECMO). In settings where it can be rapidly implemented, ECMO assisted resuscitation (ECPR) may be considered. Additionally, donation after circulatory death, which seeks to obtain solid organs donation from patients suffering rCA, has increased its role effectively increasing the pool of donors. Combined programs with integration of ECPR and uncontrolled donation after circulatory determination of death (uDCDD) are worldwide limited and experience integrating these two techniques is lacking.

METHODS

We report a 24 months experience of ECPR and uDCDD kidney transplantation based on a management protocol in a university teaching hospital in the urban area of Lisbon.

RESULTS

Over a period of 24 months, 58 patients were admitted to our ICU with rCA, 6 (10%) in the ECPR program and 52 (90%) in the uDCDD. Seventy-eight percent of patients were male, with an average age of 49 year-old. CA was witnessed in 83% of cases and initial rhythm was ventricular fibrillation in 20 cases (35%). 13 (25%) patients were effective organ donors. Refusal for effective donation was mainly due to prior comorbidities.

DISCUSSION

The development of an integrated program for ECPR and uDCDD is feasible and requires a well-established and efficient activation program. In an era of significant organ shortage, it provides a viable option for increasing the organ donation pool, with promising results.

Outcome prediction in comatose cardiac arrest patients with initial shockable and non-shockable rhythms

BACKGROUND

Prognosis after out-of-hospital cardiac arrest (OHCA) is presumed poorer in patients with non-shockable than shockable rhythms, frequently leading to treatment withdrawal. Multimodal outcome prediction is recommended 72 h post-arrest in still comatose patients, not considering initial rhythms. We investigated accuracy of outcome predictors in all comatose OHCA survivors, with a particular focus on shockable vs. non-shockable rhythms.

METHODS

In this observational NORCAST sub-study, patients still comatose 72 h post-arrest were stratified by shockable vs. non-shockable rhythms for outcome prediction analyzes. Good outcome was defined as cerebral performance category 1-2 within 6 months. False positive rate (FPR) was used for poor and sensitivity for good outcome prediction accuracy.

RESULTS

Overall, 72/128 (56%) patients with shockable and 12/50 (24%) with non-shockable rhythms had good outcome (p < .001). For poor outcome prediction, absent pupillary light reflexes (PLR) and corneal reflexes (clinical predictors) 72 h after sedation withdrawal, PLR 96 h post-arrest, and somatosensory evoked potentials (SSEP), all had FPR <0.1% in both groups. Unreactive EEG and neuron-specific enolase (NSE) >60 μg/L 24-72 h post-arrest had better precision in shockable patients. For good outcome, the clinical predictors, SSEP and CT, had 86%-100% sensitivity in both groups. For NSE, sensitivity varied from 22% to 69% 24-72 h post-arrest. The outcome predictors indicated severe brain injury proportionally more often in patients with non-shockable than with shockable rhythms. For all patients, clinical predictors, CT, and SSEP, predicted poor and good outcome with high accuracy.

CONCLUSION

Outcome prediction accuracy was comparable for shockable and non-shockable rhythms. PLR and corneal reflexes had best precision 72 h after sedation withdrawal and 96 h post-arrest.

Family-witnessed resuscitation in the emergency department in a low-income country

Cardiac arrest is often a sudden and traumatic event. Family-witnessed resuscitation was first recommended by the American Heart Association over two decades ago. Since then several global professional bodies have identified a range of potential benefits for relatives; however, it remains contentious. For nurses working in emergency departments (EDs) in low-income countries, the evidence for, and experience of, family-witnessed resuscitation is limited. This article critically appraises the literature relating to the perceptions of medical professionals and critically ill patients and their families about communication, family presence and their involvement during resuscitation in the ED. Three themes relating to family-witnessed resuscitation in the ED were identified by a focused literature search. These were: leadership and communication, limitation of policies and guidelines and relatives' views. The recommendations from this review will be used to develop emergency and trauma nursing practice guidelines in Zambia, a low-income country in sub-Saharan Africa.

Uncontrolled Donation Potential After Circulatory Death in Slovenia Could Lead to More Organ Donations: Extrapolation of SiOHCA Study Data

Out-of-hospital cardiac arrest is one of the major health challenges faced by developed countries. Donation after circulatory death is a process of retrieving organs from individuals whose death has been confirmed by circulatory or respiratory criteria. In 2018, 136 625 people were listed on the waitlist covering over 16 countries. Out of these 136 625 individuals, 7383 died whilst waiting that year. The aim of this study is to assess the potential for the uncontrolled donation after circulatory death among out-of-hospital cardiac arrest patients in Slovenia. This non-interventional study was conducted using the Slovenian out-of-hospital cardiac arrest registry dataset. The database measured Out-of-hospital cardiac arrest in Slovenia between September and November 2022. From the database we chose patients who would be identified as donors by the uncontrolled donation after circulatory death guidelines for patient selection. Using the selection criteria we have narrowed the used data set from 294 unique patient records to 19. There were no organ donors in the cohort. With extrapolation we calculated that in 2022 there could be 111 donors in Slovenia that would fit the uncontrolled donation after circulatory death criteria. This equates to 52.4 pmp/y. We conclude that uncontrolled donation after circulatory death program in Slovenia would positively impact patients. Although our study is limited by a small sample of out-of-hospital cardiac arrest patients and short duration of the Slovenian out-of-hospital cardiac arrest registry inclusion, the results offer a good foundation to further explore uncontrolled organ donation in Slovenia and similar countries.

Voices of the Future: Junior Physicians' Experiences of Discussing Life-Sustaining Treatments With Hospitalized Patients

OBJECTIVES

Life-sustaining treatments (LST) aim to prolong life without reversing the underlying medical condition. Being associated with a high risk of developing unwanted adverse outcomes, decisions about LST are routinely discussed with patients at hospital admission, particularly when it comes to cardiopulmonary resuscitation. Physicians may encounter many challenges when enforcing shared decision-making in this domain. In this study, we map out how junior physicians in Southern Switzerland refer to their experiences when conducting LST discussions with hospitalized patients and their learning strategies related to this.

METHODS

In this qualitative exploratory study, we conducted semi-directive interviews with junior physicians working at the regional public hospital in Southern Switzerland and analyzed them with an inductive thematic analysis.

RESULTS

Nine physicians participated. We identified 3 themes: emotional burden, learning strategies and practices for conducting discussions. Participants reported feeling unprepared and often distressed when discussing LST with patients. Factors associated with emotional burden were related to the context and to how physicians developed and managed their emotions. Participants signaled having received insufficient education to prepare for discussing LST. They reported learning to discuss LST essentially through trial and error but particularly appreciated the possibility of mentoring and experiential training. Explanations that physicians gave about LST took into account patients' frequent misconceptions. Physicians reported feeling under pressure to ensure that decisions documented were medically indicated and being more at ease when patients decided by themselves to limit treatments. Communication was deemed as an important skill.

CONCLUSIONS

Junior physicians experienced conducting LST discussions as challenging and felt caught between advocating for medically relevant decisions and respecting patients' autonomy. Participants reported a substantive emotional burden and feeling unprepared for this task, essentially because of a lack of adequate training. Interventions aiming to ameliorate junior physicians' competency in discussing LST can positively affect their personal experiences and decisional outcomes.

The healthcare professionals' perspectives and experiences with family presence during resuscitation: A qualitative evidence synthesis

INTRODUCTION

Family presence during resuscitation (FPDR) is a growing hospital praxis despite lack of high-quality evidence. The aim of this qualitative evidence synthesis review was to synthesize current evidence regarding healthcare professionals (HCP) perspectives on barriers and facilitating factors of FPDR and the potential impact of FPDR on HCP performance.

METHODS

We conducted a systematic literature search May 17, 2023 including primary studies with qualitative study designs. We applied NVivo for data analysis. Data was coded with line-by-line coding and organized into themes and categories following the method for thematic synthesis described by Thomas and Harden to analyse data. The studies underwent quality appraisal by Critical Appraisal Skills Program. We used GRADE CERQual to assess the confidence in the evidence.

RESULTS

We identified 8241 articles suitable for screening, 141 articles were full text screened, and nine studies included from Australia, UK and USA. In total, 134 HCP participated, between 2005 and 2019. Most studies lacked sufficiently rigorous data analysis and findings were appraised to have moderate GRADE CERQual confidence. We identified three analytical themes ("Facilitating factors for FPDR", "Barriers for FPDR" and "How staff are affected by FPDR") with eight descriptive subthemes. One finding was of high GRADE CERQual confidence: a belief that FPDR is "the right thing to do" which was a "Facilitating factor of FPDR."

CONCLUSION

The evidence on HCP perspectives is of low to moderate confidence. The interviewed consent that FPDR is the "right thing to do", and an ethical principle of beneficence is dominant, especially regarding children.

How to predict the death risk after an in-hospital cardiac arrest (IHCA) in intensive care unit? A retrospective double-centre cohort study from a tertiary hospital in China

OBJECTIVES

Our objective is to develop a prediction tool to predict the death after in-hospital cardiac arrest (IHCA).

DESIGN

We conducted a retrospective double-centre observational study of IHCA patients from January 2015 to December 2021. Data including prearrest diagnosis, clinical features of the IHCA and laboratory results after admission were collected and analysed. Logistic regression analysis was used for multivariate analyses to identify the risk factors for death. A nomogram was formulated and internally evaluated by the boot validation and the area under the curve (AUC). Performance of the nomogram was further accessed by Kaplan-Meier survival curves for patients who survived the initial IHCA.

SETTING

Intensive care unit, Tongji Hospital, China.

PARTICIPANTS

Adult patients (≥18 years) with IHCA after admission. Pregnant women, patients with 'do not resuscitation' order and patients treated with extracorporeal membrane oxygenation were excluded.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the death after IHCA.

RESULTS

Patients (n=561) were divided into two groups: non-sustained return of spontaneous circulation (ROSC) group (n=241) and sustained ROSC group (n=320). Significant differences were found in sex (p=0.006), cardiopulmonary resuscitation (CPR) duration (p<0.001), total duration of CPR (p=0.014), rearrest (p<0.001) and length of stay (p=0.004) between two groups. Multivariate analysis identified that rearrest, duration of CPR and length of stay were independently associated with death. The nomogram including these three factors was well validated using boot calibration plot and exhibited excellent discriminative ability (AUC 0.88, 95% CI 0.83 to 0.93). The tertiles of patients in sustained ROSC group stratified by anticipated probability of death revealed significantly different survival rate (p<0.001).

CONCLUSIONS

Our proposed nomogram based on these three factors is a simple, robust prediction model to accurately predict the death after IHCA.

Ethical considerations in the prehospital treatment of out-of-hospital cardiac arrest: A multi-centre, qualitative study

BACKGROUND

Prehospital emergency physicians have to navigate complex decision-making in out-of-hospital cardiac arrest (OHCA) treatment that includes ethical considerations. This study explores Danish prehospital physicians' experiences of ethical issues influencing their decision-making during OHCA.

METHODS

We conducted a multisite ethnographic study. Through convenience sampling, we included 17 individual interviews with prehospital physicians and performed 22 structured observations on the actions of the prehospital personnel during OHCAs. We collected data during more than 800 observation hours in the Danish prehospital setting between December 2019 and April 2022. Data were analysed with thematic analysis.

RESULTS

All physicians experienced ethical considerations that influenced their decision-making in a complex interrelated process. We identified three overarching themes in the ethical considerations: Expectations towards patient prognosis and expectations from relatives, bystanders, and colleagues involved in the cardiac arrest; the values and beliefs of the physician and values and beliefs of others involved in the cardiac arrest treatment; and dilemmas encountered in decision-making such as conflicting values.

CONCLUSION

This extensive qualitative study provides an in-depth look at aspects of ethical considerations in decision-making in prehospital resuscitation and found aspects of ethical decision-making that could be harmful to both physicians and patients, such as difficulties in handling advance directives and potential unequal outcomes of the decision-making. The results call for multifaceted interventions on a wider societal level with a focus on advance care planning, education of patients and relatives, and interventions towards prehospital clinicians for a better understanding and awareness of ethical aspects of decision-making.

Outcomes of kidney transplantation from uncontrolled donors after circulatory death vs. expanded-criteria or standard-criteria donors after brain death at an Italian Academic Center: a prospective observational study

BACKGROUND

The use of kidneys from "expanded criteria" donors after brain death (ECD) and uncontrolled donors after circulatory death (uDCD) has been warranted to increase the pool of donors for kidney transplantation (KT). However, there is lack of evidence on the feasibility and safety of KT from such donors in the Italian setting.

METHODS

We queried our prospectively KT database to select patients undergoing KT from deceased donors (uDCDs, ECDs, and standard-criteria donors [SCD] after brain death) from January 2017 to December 2020, comparing the perioperative and mid-term functional outcomes.

RESULTS

Overall, 172 KTs were included. The donor's profile was different among the study groups, while recipients' characteristics were similar expect for median age. Grafts from uDCDs and ECDs had longer median cold ischemia times as compared to grafts from SCDs. The proportion of patients experiencing DGF, the median hospitalization, as well as the overall and major complications rate, were significantly higher among recipients from uDCDs. The proportion of patients needing dialysis at last follow-up was significantly higher among recipients from uDCDs (33.3% vs. 8.5% vs. 5.4%, P<0.001). However, the median eGFR at the last follow-up was lower for recipients from ECDs compared to those from uDCDs and SCDs, respectively (P<0.001).

CONCLUSIONS

While "marginal" donors represent a relevant source of organs, KTs from uDCDs carry higher risks of major surgical complications, DGF, and worse graft survival as compared to KT from both ECDs and SCDs. As such, the use of grafts from uDCDs should be carefully assessed balancing the potential benefits with the risk of primary no function and the subsequent immunological sensitization.

Family presence during resuscitation

BACKGROUND

Patients and their relatives often expect to be actively involved in decisions of treatment. Even during resuscitation and acute medical care, patients may want to have their relatives nearby, and relatives may want to be present if offered the possibility. The principle of family presence during resuscitation (FPDR) is a triangular relationship where the intervention of family presence affects the healthcare professionals, the relatives present, and the care of the patient involved. All needs and well-being must be balanced in the context of FPDR as the actions involving all three groups can impact the others.

OBJECTIVES

The primary aim of this review was to investigate how offering relatives the option to be present during resuscitation of patients affects the occurrence of post-traumatic stress disorder (PTSD)-related symptoms in the relatives. The secondary aim was to investigate how offering relatives the option to be present during resuscitation of patients affects the occurrence of other psychological outcomes in the relatives and what effect family presence compared to no family presence during resuscitation of patients has on patient morbidity and mortality. We also wanted to investigate the effect of FPDR on medical treatment and care during resuscitation. Furthermore, we wanted to investigate and report the personal stress seen in healthcare professionals and if possible describe their attitudes toward the FPDR initiative.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to 22 March 2022 without any language limits. We also checked references and citations of eligible studies using Scopus, and searched for relevant systematic reviews using Epistomonikos. Furthermore, we searched ClinicalTrials.gov, WHO ICTRP, and ISRCTN registry for ongoing trials; OpenGrey for grey literature; and Google Scholar for additional trials (all on 22 March 2022).

SELECTION CRITERIA

We included randomized controlled trials of adults who have witnessed a resuscitation attempt of a patient (who was their relative) at the emergency department or in the pre-hospital emergency medical service.  The participants of this review included relatives, patients, and healthcare professionals during resuscitation.  We included relatives aged 18 years or older who have witnessed a resuscitation attempt of a patient (who is their relative) in the emergency department or pre-hospital. We defined relatives as siblings, parents, spouses, children, or close friends of the patient, or any other descriptions used by the study authors. There were no limitations on adult age or gender. We defined patient as a patient with cardiac arrest in need of cardiopulmonary resuscitation (CPR), a patient with a critical medical or traumatic life-threatening condition, an unconscious patient, or a patient in any other way at risk of sudden death. We included all types of healthcare professionals as described in the included studies. There were no limitations on age or gender.

DATA COLLECTION AND ANALYSIS

We checked titles and abstracts of studies identified by the search, and obtained the full reports of those studies deemed potentially relevant. Two review authors independently extracted data. As it was not possible to conduct meta-analyses, we synthesized data narratively.

MAIN RESULTS

The electronic searches yielded a total of 7292 records after deduplication. We included 2 trials (3 papers) involving a total of 595 participants: a cluster-randomized trial from 2013 involving pre-hospital emergency medical services units in France, comparing systematic offer for a relative to witness CPR with the traditional practice, and its 1-year assessment; and a small pilot study from 1998 of FPDR in an emergency department in the UK. Participants were 19 to 78 years old, and between 56% and 64% were women. PTSD was measured with the Impact of Event Scale, and the median score ranged from 0 to 21 (range 0 to 75; higher scores correspond to more severe disease). In the trial that accounted for most of the included participants (570/595), the frequency of PTSD-related symptoms was significantly higher in the control group after 3 and 12 months, and in the per-protocol analyses a significant statistical difference was found in favor of FPDR when looking at PTSD, anxiety and depression, and complicated grief after 1 year.  One of the included studies also measured duration of patient resuscitation and personal stress in healthcare professionals during FPDR and found no difference between groups. Both studies had high risk of bias, and the evidence for all outcomes except one was assessed as very low certainty.

AUTHORS' CONCLUSIONS

There was insufficient evidence to draw any firm conclusions on the effects of FPDR on relatives' psychological outcomes.   Sufficiently powered and well-designed randomized controlled trials may change the conclusions of the review in future.

Unexpected carboxyhemoglobin half-life during cardiopulmonary resuscitation: a case report

BACKGROUND

Cardiac arrest (CA) following CO poisoning (CO-induced CA) exposes patients to an extremely high risk of mortality and remains challenging to treat effectively. Terminal carboxyhemoglobin elimination half-life (COHbt_1/2) is critically affected by ventilation, oxygen therapy, and cardiac output, which are severely affected conditions in cases of CA.

CASE PRESENTATION

Asystole occurred in an 18-year-old woman after unintentional exposure to CO in her bathroom. Cardiopulmonary resuscitation (CPR) was started immediately, including mechanical ventilation with a fraction of inspired oxygen (FiO₂) of 1.0 and external chest compressions with a LUCAS® device. CPR was stopped after 101 min, as it was unsuccessful. During this period, we calculated a COHbt_1/2 of 40.3 min using a single compartmental model.

CONCLUSIONS

This result suggests that prolongation of CPR time needed to back COHb at 10%, a level more compatible with successful return of spontaneous circulation (ROSC), could be compatible with a realistic CPR time. Calculating COHbt_1/2 during CPR may help with decision-making regarding the optimal duration of resuscitation efforts and further with HBO₂ or ECLS. Further evidence-based data are needed to confirm this result.

Update on Mechanical Circulatory Support

Mechanical circulatory support (MCS) devices provide temporary or intermediate- to long-term support for acute cardiopulmonary support. In the last 20 to 30 years, tremendous growth in MCS device usage has been seen. These devices offer support for isolated respiratory failure, isolated cardiac failure, or both. Initiation of MCS devices requires the input from multidisciplinary teams using patient factors and institutional resources to guide decision making, along with a planned "exit strategy" for bridge to decision, bridge to transplant, bridge to recovery, or as destination therapy. Important considerations for MCS use include patient selection, cannulation/insertion strategies, and complications of each device.

Clinical characteristics and outcomes after extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients with an initial asystole rhythm

AIM

This study aimed to describe the characteristics of cases of out-of-hospital cardiac arrest (OHCA) with an initial asystole rhythm in which extracorporeal cardiopulmonary resuscitation (ECPR) was introduced and discuss the clinical indications for ECPR in such patients.

METHODS

This was a secondary analysis of the SAVE-J II study, a retrospective, multicentre, registry study involving 36 participating institutions in Japan. Patients with an initial asystole rhythm were selected. Favourable neurological outcomes (cerebral performance categories 1-2) constituted the primary outcome.

RESULTS

In total, 202 patients met the inclusion criteria, with favourable neurological outcomes at hospital discharge in 12 patients (5.9%). Causes of cardiac arrest with favourable neurological outcomes were hypothermia (7 cases), acute coronary syndrome (2 cases), arrhythmia (2 cases), and pulmonary embolism (1 case). Among patients with non-hypothermia (temperature ≥32 °C) on hospital arrival with the cardiac rhythm of asystole or pulseless electrical activity (PEA) on arrival, all 107 patients (66 asystole, 41 PEA) who lacked one or more of the requirements (witness; bystander CPR; signs of life or pupil < 5 mm) had unfavourable neurological outcomes. All 5 cases with favourable neurological outcomes, except for 1 case with a short duration of no-flow time that was highly suspected based on the patient's history, met all the requirements on hospital arrival.

CONCLUSIONS

A total of 202 ECPR cases with an initial asystole rhythm, including 12 patients with favourable neurological outcomes, were described. Even if the initial cardiac rhythm is asystole, ECPR could be considered if certain conditions are met.

Factors Influencing the Initiative Behavior of Intensive Care Unit Nurses toward End-of-Life Decision Making: A Cross-Sectional Study

Background: Although the importance of intensive care unit (ICU) nurse initiative in end-of-life (EOL) decision making has been confirmed, there are few studies on the nurses' initiative in EOL situations. Objectives: To explore the role and mechanism of facilitators/barriers and perceived stress on the behavior of ICU nurses that initiate EOL decision making (i.e., initiative behavior). Design: This research adopted a cross-sectional descriptive design. Setting/Participants: A questionnaire composed of demographics, facilitators/barriers scale, perceived stress scale, and initiative behavior for EOL decision-making scale was used for registered ICU nurses in five tertiary general hospitals in Zhejiang Province, China. Results: The average score of the EOL decision initiative behavior was 5.54 on a range of 2-10. The results of correlation analysis indicated that the facilitators promote the initiative behavior, whereas the barriers interfere with initiative behavior. Facilitators/barriers in the EOL decision-making process significantly predicted the initiative behavior of ICU nurses in decision making (β = 0.698, p < 0.001). Facilitators/barriers had a significant indirect effect on the initiative behavior of ICU nurses through perceived stress. The 95% confidence interval was (-0.327 to -0.031), and the mediating effect of perceived stress accounted for 6.31% of the total effect. Conclusion: In the EOL context, the decision initiative of ICU nurses was at a medium level. Medical managers should implement intervention strategies based on the path that affects the initiative behavior of ICU nurses to reduce barriers and stress level in the decision-making process. That is, they should improve inter-team collaboration, nurse-patient communication, clarity of role responsibilities, and emotional support in dying situations to increase initiative and participation of ICU nurses in decision making.

Successful rescue of renal transplantation with cardiac arrest after electrical storm: A case report

RATIONALE

Most patients with end-stage chronic kidney disease are associated with complications such as renal hypertension, renal anemia, hyperkalemia, water-sodium retention, and disorders of acid-base balance after long-term renal replacement therapy, which can lead to increased cardiac burden, some degree of myocardial damage, and finally progress to arrhythmia and heart failure. These are the main reasons why patients with chronic kidney disease are prone to cardiovascular events after renal transplantation.

PATIENT CONCERNS

We report a case of sudden onset of ventricular fibrillation on the postoperative second day, with repeated electrical storm accompanied by cardiac arrest during resuscitation, a very long cardiopulmonary resuscitation (CPR) process of 5 hours and 14 minutes, and >20 cycles of cardiac defibrillation.

DIAGNOSES

According to the patient history and resuscitation process, a diagnosis of ES with cardiac arrest after renal transplantation was formulated.

INTERVENTION

According to the American Heart Association guidelines for CPR and cardiovascular emergencies, resuscitation measures such as CPR, tracheal intubation, electric defibrillation, symptomatic medication, etc. were performed on the patient.

OUTCOMES

Finally, the patient was successfully resuscitated, after which the patient had stable respiratory circulation and no neurological complications. To our knowledge, this is the only reported case in which a patient survived with good neurologic outcomes after a resuscitation that lasted as long as 5 hours and 14 minutes.

LESSONS

This case of adequate resuscitation can provide experience and a basis for CPR of patients with in-hospital complications of cardiovascular events for a long time.

Time point for transport initiation in out-of-hospital cardiac arrest cases with ongoing cardiopulmonary resuscitation: a nationwide cohort study in Japan

Aim

This study aimed to investigate the time point of the decision to initiate transport with ongoing cardiopulmonary resuscitation (CPR) in Japan.

Methods

We analyzed adult out-of-hospital cardiac arrest (OHCA) cases that achieved return of spontaneous circulation (ROSC) before hospital arrival from the All-Japan Utstein Registry during 2015-2017. We constructed receiver operating characteristics (ROC) curves to illustrate the ability of achieving ROSC as a predictor of neurologically favorable outcomes as a function of increasing time points of resuscitation before ROSC. Furthermore, a multivariable logistic regression analysis was carried out to identify factors associated with outcomes.

Results

Of 373,993 OHCA patients with attempted resuscitation during 2015-2017, 22,067 patients with prehospital ROSC were included in our study. Patients were divided into the shockable initial rhythm (n = 5,580) and nonshockable initial rhythm (n = 16,487) cohorts. The ROC curves showed 10 min was the best test performance time point for a neurologically favorable outcome for shockable initial rhythm patients (sensitivity, 0.78; specificity, 0.53; area under the ROC curve [AUC], 0.70) and 8 min for nonshockable initial rhythm patients (sensitivity, 0.74; specificity, 0.77; AUC, 0.83). Multivariable logistic regression analyses revealed that CPR durations using the cut-off value were independently associated with better outcomes for both shockable initial rhythm patients (odds ratio, 2.09; 95% confidence interval, 1.81-2.42) and nonshockable initial rhythm patients (odds ratio, 3.34; 95% confidence interval, 2.92-3.82).

Conclusion

When Japanese emergency medical service (EMS) providers attend OHCA cases, the decision to initiate transport with ongoing CPR should be made at approximately 10 min after EMS providers initiate CPR for shockable initial rhythm patients and at approximately 8 min for nonshockable initial rhythm patients.

Duration of Resuscitation and Long-Term Outcome After In-Hospital Cardiac Arrest: A Nationwide Observational Study

BACKGROUND

Prior studies have investigated the association between duration of resuscitation and short-term outcomes following in-hospital cardiac arrest (IHCA). However, it remains unknown whether there is an association between duration of resuscitation and long-term survival and functional outcomes.

METHOD

We linked data from the Danish in-hospital cardiac arrest registry with nationwide registries and identified 8,727 patients between 2013 and 2019. Patients were stratified into four groups (A-D) according to quartiles of duration of resuscitation. Standardized average probability of outcomes was estimated using logistic regression.

RESULTS

Of 8,727 patients, 53.1% (n=4,604) achieved return of spontaneous circulation. Median age was 74 (1^st-3^rd quartile [Q1-Q3] 65-81 years) and 63.1% were men. Among all IHCA patients the standardized 30-day survival was 62.0% (95% CI 59.8%-64.2%) for group A (< 5 minutes), 32.7% (30.8%-34.6%) for group B (5-11 minutes), 14.4% (12.9%-15.9%) for group C (12-20 minutes) and 8.1% (7.0%-9.1%) for group D (21 minutes or more). Similarly, 1-year survival was also highest for group A (50.4%; 48.2%-52.6%) gradually decreasing to 6.6% (5.6%-7.6%) in group D. Among 30-day survivors, survival without anoxic brain damage or nursing home admission within one-year post-arrest was highest for group A (80.4%; 78.2%-82.6%), decreasing to 73.3% (70.0%-76.6%) in group B, 67.2% (61.7%-72.6%) in group C and 73.3% (66.9%-79.7%) in group D.

CONCLUSION

Shorter duration of resuscitation attempt during an IHCA is associated with higher 30-day and 1-year survival. Furthermore, we found that the majority of 30-day survivors were still alive 1-year post-arrest without anoxic brain damage or nursing home admission despite prolonged resuscitation.

Inhibition of Γδ T Cells Alleviates Brain Ischemic Injury in Cardiopulmonary-Cerebral Resuscitation Mice

BACKGROUND

A half-million people in the United States suffer from cardiac arrest (CA) requiring cardiopulmonary resuscitation (CPR). An inflammatory mechanism is associated with neuronal injury in the presence of cerebral ischemia. T lymphocytes are identified as crucial regulators of inflammation. Therefore, we investigated the relationship between CA/CPR-induced ischemia injury and T lymphocytes.

METHODS

C57BL/6 mice were subjected to CA through injection of KCl (30 μL of 0.5 mol/L) and cessation of mechanical ventilation followed by CPR. The survival rate and neurologic deficit scores were assessed. Terminal deoxynucleotidyl transferase dUTP nick end labeling staining was carried out to detect neuronal death. Histologic changes were observed by hematoxylin-eosin staining. The levels of Trgv4, Trgv5 and Trgv7 were quantified by RT-qPCR. Inflammatory responses were identified by measurement of IL-1β, IL-6 and IL-17.

RESULTS

Downregulated γδ T cells improved survival and neurologic outcomes and inhibits neuronal apoptosis. γδ T inhibition protected brains from CA/CPR-mediated tissue damage. UC7-13D5 treatment inhibited the levels of γδ T markers. Knockdown of γδ T cells ameliorated neuroinflammation.

CONCLUSIONS

Inhibition of γδ T cells ameliorates ischemic injury in mice with CA/CPR by attenuating inflammation and neuronal apoptosis.

Evolution of European Resuscitation and End-of-Life Practices from 2015 to 2019: A Survey-Based Comparative Evaluation

BACKGROUND

In concordance with the results of large, observational studies, a 2015 European survey suggested variation in resuscitation/end-of-life practices and emergency care organization across 31 countries. The current survey-based study aimed to comparatively assess the evolution of practices from 2015 to 2019, especially in countries with "low" (i.e., average or lower) 2015 questionnaire domain scores.

METHODS

The 2015 questionnaire with additional consensus-based questions was used. The 2019 questionnaire covered practices/decisions related to end-of-life care (domain A); determinants of access to resuscitation/post-resuscitation care (domain B); diagnosis of death/organ donation (domain C); and emergency care organization (domain D). Responses from 25 countries were analyzed. Positive or negative responses were graded by 1 or 0, respectively. Domain scores were calculated by summation of practice-specific response grades.

RESULTS

Domain A and B scores for 2015 and 2019 were similar. Domain C score decreased by 1 point [95% confidence interval (CI): 1-3; p = 0.02]. Domain D score increased by 2.6 points (95% CI: 0.2-5.0; p = 0.035); this improvement was driven by countries with "low" 2015 domain D scores. In countries with "low" 2015 domain A scores, domain A score increased by 5.5 points (95% CI: 0.4-10.6; p = 0.047).

CONCLUSIONS

In 2019, improvements in emergency care organization and an increasing frequency of end-of-life practices were observed primarily in countries with previously "low" scores in the corresponding domains of the 2015 questionnaire.

Factors influencing prehospital physicians' decisions to initiate advanced resuscitation for asystolic out-of-hospital cardiac arrest patients

BACKGROUND

The decision to initiate or continue advanced life support (ALS) in out-of-hospital cardiac arrest (OHCA) could be difficult due to the lack of information and contextual elements, especially in non-shockable rhythms. This study aims to explore factors associated with clinicians' decision to initiate or continue ALS and the conditions associated with higher variability in asystolic patients.

METHODS

This retrospective observational study enrolled 2653 asystolic patients on whom either ALS was attempted or not by the emergency medical services (EMS) physician. A multivariable logistic regression analysis was performed to find the factors associated with the decision to access ALS. A subgroup analysis was performed on patients with a predicted probability of ALS between 35% and 65%. The single physicians' behaviour was compared to that predicted by the model taking into account the entire agency.

RESULTS

Age, location of event, bystander CPR and EMS-witnessed event were independent factors influencing physicians' choices about ALS. Non-medical OHCA, younger patients, less experienced physicians, presence of breath activity at the emergency call and a longer time for ALS arrival were more frequent among cases with an expected higher variability in behaviours with ALS. Significant variability was detected between physicians.

CONCLUSIONS

Significant inter-physician variability in access to ALS could be present within the same EMS, especially among less experienced physicians, non-medical OHCA and in presence of signs of life during emergency call. This arbitrariness has been observed and should be properly addressed by EMS team members as it raises ethical issues regarding the disparity in treatment.

External validation and insights about the calibration of the return of spontaneous circulation after cardiac arrest (RACA) score

Background

The return of spontaneous circulation (ROSC) after cardiac arrest (RACA) score was developed as a tool to predict ROSC probability (pROSC) based on easily available information and it could be useful to compare the performances of different EMS agencies or the effects of eventual interventions.

We performed an external validation of the RACA score in a cohort of out of hospital cardiac arrest (OHCA) patients managed by the EMS of the metropolitan city of Bologna, Italy.

Methods

We analyzed data from 2,310 OHCA events prospectively collected between January 2009 and June 2021. Discrimination was assessed with the area under the ROC curve (AUROC), while the calibration belts were used for the comparison of observed versus expected ROSC rates. The AUROCs from our cohort and other validation cohorts were compared using a studentized range test.

Results

The AUROC for the study population was 0.691, comparable to that described by previous validation studies. Despite an acceptable overall calibration, we found a poor calibration for asystole and low pROSC ranges in PEA and shockable rhythms. The model showed a good calibration for patients aged over 80, while no differences in performance were found when evaluating events before and after the implementation of 2015 ERC guidelines.

Conclusions

Despite AUROC values being similar in different validation studies for RACA score, we suggest separating the different rhythms when assessing ROSC probability with the RACA score, especially for asystole.

Patient and public involvement and engagement with cardiac arrest survivors

Background

Patient and public involvement and engagement (PPIE) with cardiac arrest survivors is an essential component of research to strengthen development, design, delivery and dissemination to ensure research priorities are in the public interest and patient friendly. Cardiac arrest survivors and their relatives were engaged in PPIE to help develop the methods of a research study that aims to reduce individual and care process variation during paramedic-led resuscitation.

Methods

This research methodology paper represents the views of seven PPIE representatives and the authors. PPIE representatives included five cardiac arrest survivors and two relatives. Content for the paper was generated by discussion using audio or video call. Notes were taken by the author which included direct quotations generated by the PPIE process.

Results

The PPIE representatives considered research surrounding the decisions made by paramedics to be important. From their first-hand experiences, survivors and their relatives felt that a future research study should focus on patient survival. The decision-making of paramedics was identified as most important to explore. Quality of life before the cardiac arrest was considered important as this may help to inform best-interest decisions. The neurologic recovery of patients was important; however, rehabilitation may be extensive and therefore unachievable within the study timeframe. Relatives highlighted that while incorporating their views during resuscitation was important, gaining consent for research participation was not appropriate.

Conclusion

PPIE added value and helped to develop a future study to reduce variation in the resuscitation decisions made by paramedics. The group identified what is important to survivors and their relatives and the factors they would like paramedics to consider when making a resuscitation decision. By identifying these factors, the PPIE process has helped to drive the research methods where both quantitative and qualitative designs would be appropriate. Issues in gaining research consent during resuscitation were highlighted.

In situ simulation training for parental presence during critical situations in PICU: an observational study

Family presence during invasive procedures or cardiopulmonary resuscitation (CPR) is a part of the family-centered approach in pediatric intensive care units (PICUs). We established a simulation program aiming at providing communication tools to healthcare professionals. The goal of this study was to evaluate the impact of this program on the stress of PICU professionals and its acceptance. An observational study of a simulation program, with questionnaire, was used to measure pre- and post-simulation stress and the degree of satisfaction of the participants. PICU of Geneva Children's Hospital, Switzerland. Forty simulations with four different simulation scenarios and various types of parental behavior, as imitated by professional actors, were completed during a 1-year period. Primary outcomes were the difference in perceived stress level before and after the simulation and the degree of satisfaction of healthcare professionals (nursing assistants, nurses, physicians). The impact of previous experience with family members during critical situations or CPR was evaluated by variation in perceived stress level. Overall, 201 questionnaires were analyzed. Perceived stress associated with parental presence decreased from a pre-simulation value of 6 (IQR, 4-7) to 4 (IQR, 2-5) post-simulation on a scale of 1-10. However, in 25.7% of cases, the individually perceived post-simulation stress level was higher than the pre-simulation one. Satisfaction of the participants was high with a median of 10 (IQR, 9-10) out of 10.

CONCLUSIONS

A simulation program helps reduce PICU team emotional stress associated with the presence of family members during critical situations or CPR, and is welcomed by PICU team members.

WHAT IS KNOWN

• Family presence during cardiopulmonary resuscitation (CPR) or critical situations is a part of the family-centered approach in pediatric intensive care. • The benefits for the family have been already demonstrated. However, this policy is still controversy among healthcare professionals.

WHAT IS NEW

• A simulation program seeking to provide skills focused on family presence management in the PICU is useful to reduce stress and was well accepted by participants. • It might become an indispensable training intervention for the implementation of a PICU policy to allow family presence during CPR or other critical situations.

Impact of family presence during cardiopulmonary resuscitation on team performance and perceived task load: a prospective randomised simulator-based trial

OBJECTIVES

Guidelines recommend family presence to be offered during cardiopulmonary resuscitation (CPR). Data on the effects of family presence on the quality of CPR and rescuers' workload and stress levels are sparse and conflicting. This randomised trial investigated the effects of family presence on quality of CPR, and rescuers' perceived stress.

DESIGN

Prospective randomised single-blind trial.

SETTING

Voluntary workshops of educational courses.

PARTICIPANTS

1085 physicians (565 men) randomised to 325 teams entered the trial. 318 teams completed the trial without protocol violation.

INTERVENTIONS

Teams were randomised to a family presence group (n=160) or a control group (n=158) and to three versions of leadership: (a) designated at random, (b) designated by the team or (c) left open. Thereafter, teams were confronted with a simulated cardiac arrest which was video-recorded. Trained actors played a family member according a scripted role.

MAIN OUTCOME MEASURES

The primary endpoint was hands-on time. Secondary outcomes included interaction time, rescuers' perceived task load and adherence to CPR algorithms.

RESULTS

Teams interacted with the family member during 24 (17-36) % of the time spent for resuscitation. Family presence had no effect on hands-on time (88% (84%-91%) vs 89% (85%-91%); p=0.18). Family presence increased frustration (60 (30-75) vs 45 (30-70); p<0.001) and perceived temporal (75 (55-85) vs 70 (50-80); p=0.001) and mental demands (75 (60-85) vs 70 (55-80); p=0.009), but had no relevant effect on CPR performance markers. Leadership condition had no effects.

CONCLUSIONS

Interacting with a family member occupied about a quarter of the time spent for CPR. While this additional task was associated with an increase in frustration and perceived temporal and mental demands, family presence had no relevant negative effect on the quality of CPR.

TRIAL REGISTRATION NUMBER

DRKS00024759.

Extracorporeal Life Support in Accidental Hypothermia with Cardiac Arrest-A Narrative Review

Severely hypothermic patients, especially suffering cardiac arrest, require highly specialized treatment. The most common problems affecting the recognition and treatment seem to be awareness, logistics, and proper planning. In severe hypothermia, pathophysiologic changes occur in the cardiovascular system leading to dysrhythmias, decreased cardiac output, decreased central nervous system electrical activity, cold diuresis, and noncardiogenic pulmonary edema. Cardiac arrest, multiple organ dysfunction, and refractory vasoplegia are indicative of profound hypothermia. The aim of these narrative reviews is to describe the peculiar pathophysiology of patients suffering cardiac arrest from accidental hypothermia. We describe the good chances of neurologic recovery in certain circumstances, even in patients presenting with unwitnessed cardiac arrest, asystole, and the absence of bystander cardiopulmonary resuscitation. Guidance on patient selection, prognostication, and treatment, including extracorporeal life support, is given.

The do-not-resuscitate-like (DNRL) order, a medical directive for limiting life-sustaining treatment in the end-of-life care of children with cancer: experience of major cancer center in Brazil

PURPOSE

In the last few decades, interest in palliative care and advance care planning has grown in Brazil and worldwide. Empirical studies are needed to reduce therapeutic obstinacy and medical futility in the end-of-life care of children with incurable cancer. The aim of this study was to investigate the effects of do-not-resuscitate-like (DNRL) orders on the quality of end-of-life care of children with incurable solid tumors at a cancer center in Brazil.

METHODS

A retrospective observational cohort study of 181 pediatric patients with solid tumors followed at the Pediatric Oncology Department of the Brazilian National Cancer Institute, Rio de Janeiro, Brazil, who died due to disease progression from 2009 to 2013. Medical records were reviewed for indicators of quality of end-of-life care, including overtreatment, care planning, and care at death, in addition to documentation of the diagnosis of life-limiting illness and the presence of a DNRL order. Data were summarized using descriptive statistics. Univariate and multivariate logistic regression analyses were used to examine associations between demographics, disease, treatment, and indicators of end-of-life care with a DNRL order.

RESULTS

A documented DNRL order was associated with lower odds of dying in the intensive care unit or emergency room (80%), dying within 30 days of endotracheal tube placement (80%), or cardiopulmonary resuscitation (CPR) administration at the time of death (96%).

CONCLUSION

Placement of DNRL orders early in the disease process is critical in reducing futile treatment in pediatric patients with incurable cancer.

Extracorporeal cardiopulmonary resuscitation for refractory in-hospital cardiac arrest: A retrospective cohort study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is a rescue therapy for refractory cardiac arrest, but its high mortality has raised questions about patient selection. No selection criteria have been proposed for patients experiencing in-hospital cardiac arrest. We aimed to identify selection criteria available at the time ECPR was considered for patients with in-hospital cardiac arrest. We analyzed data of in-hospital cardiac arrest patients undergoing ECPR in our extracorporeal membrane oxygenation (ECMO) center (March 2007 to March 2019). Intensive care unit (ICU) and 1-year survival post-hospital discharge were assessed. Factors associated with ICU survival before ECPR were investigated. An external validation cohort from a previous multicenter study was used to validate our results.

RESULTS

Among the 137 patients (67.9% men; median [IQR] age, 54 [43-62] years; low-flow duration, 45 [30-70] min) requiring ECPR, 32.1% were weaned-off ECMO. Their respective ICU- and 1-year survival rates were 21.9% and 19%. Most 1-year survivors had favorable neurological outcomes (cerebral performance category score 1 or 2). ICU survivors compared to nonsurvivors, respectively, were more likely to have a shockable initial rhythm (53.3% versus 24.3%; P < 0.01), a shorter median (IQR) low-flow time (30 (25-53) versus 50 (35-80) min, P < 0.01) and they more frequently underwent a subsequent intervention (63.3% versus 26.2%, P < 0.01). The algorithm obtained by combining age, initial rhythm and low-flow duration discriminated between patient groups with very different survival probabilities in the derivation and validation cohorts.

CONCLUSION

Survival of ECPR-managed in-hospital cardiac arrest patients in this cohort was poor but hospital survivors' 1-year neurological outcomes were favorable. When deciding whether or not to use ECPR, the combination of age, initial rhythm and low-flow duration can improve patient selection.

How senior paramedics decide to cease resuscitation in pulseless electrical activity out of hospital cardiac arrest: a mixed methods study

BACKGROUND

Evidenced-based guidelines on when to cease resuscitation for pulseless electrical activity are limited and support for paramedics typically defaults to the senior clinician. Senior clinicians include paramedics employed to work beyond the scope of clinical guidelines as there may be a point at which it is reasonable to cease resuscitation. To support these decisions, one ambulance service has applied a locally derived cessation of resuscitation checklist. This study aimed to describe the patient, clinical and system factors and examine senior clinician experiences when ceasing resuscitation for pulseless electrical activity.

DESIGN AND METHODS

An explanatory sequential mixed method study was conducted in one ambulance service in the South West of England. A consecutive sample of checklist data for adult pulseless electrical activity were retrieved from 1st December 2015 to 31st December 2018. Unexpected results which required exploration were identified and developed into semi-structured interview questions. A purposive sample of senior clinicians who ceased resuscitation and applied the checklist were interviewed. Content framework analysis was applied to the qualitative findings.

RESULTS

Senior clinicians ceased resuscitation for 50 patients in the presence of factors known to optimise survival: Witnessed cardiac arrest (n = 37, 74%), bystander resuscitation (n = 30, 60%), defibrillation (n = 22, 44%), return of spontaneous circulation (n = 8, 16%). Significant association was found between witnessed cardiac arrest and bystander resuscitation (p = .00). Six senior clinicians were interviewed, and analysis resulted in four themes: defining resuscitation futility, the impact of ceasing resuscitation, conflicting views and clinical decision tools. In the local context, senior clinicians applied their clinical judgement to balance survivability. Multiple factors were considered as the decision to cease resuscitation was not always clear. Senior clinicians deviated from the checklist when the patient was perceived as non-survivable.

CONCLUSION

Senior clinicians applied clinical judgement to assess patients as non-survivable or when continued resuscitation was considered harmful with no patient benefit. Senior clinicians perceived pre-existing factors with duration of resuscitation and clinical factors known to optimise patient survival. Future practice could look beyond a set criteria in which to cease resuscitation, however, it would be helpful to investigate the value or threshold of factors associated with patient outcome.

The Effect of Family Presence During Resuscitation and Invasive Procedures on Patients and Families: An Umbrella Review

INTRODUCTION

The concept of family presence during resuscitation and invasive procedures is a controversial issue and has not been universally adopted by health care providers. Owing to the sheer number of studies in this field, we conducted this umbrella study to provide an overview of this concept with the aim of investigating the impact of family presence on patients, families, and resuscitation and invasive procedures.

METHODS

In this review, using the Joanna Briggs Institute levels of evidence umbrella methodology guidelines, the authors searched PubMed, Google Scholar, Embase, MEDLINE, Web of Science, Scopus, and the Cochrane database for systematic review and meta-analysis studies that evaluated the presence of family during resuscitation and invasive procedures without time limit until July 2020. The following key words were used for the search: family presence; family witness; parent presence; parent witness; and resuscitation.

RESULTS

A total of 254 articles published between January 1967 and July 2020 were screened. Five articles (1 meta-analysis and 4 systematic reviews) met the inclusion criteria. The review showed that family presence during resuscitation or invasive procedures does not have negative effects on family members, patients, or the resuscitation or invasive intervention process. Family members focus on the patients, not the ongoing treatment. The presence of family members is beneficial for both family members and health care staff. None of the reviewed studies reported a negative effect on family members.

DISCUSSION

The presence of parents and other immediate family members during resuscitation and invasive procedures has positive impacts on patients, families, and health care staff.

Factors Influencing Physician Decision Making to Attempt Advanced Resuscitation in Asystolic Out-of-Hospital Cardiac Arrest

The objective of this study was to identify the key elements used by prehospital emergency physicians (EP) to decide whether or not to attempt advanced life support (ALS) in asystolic out-of-hospital cardiac arrest (OHCA). From 1 January 2009 to 1 January 2017, all adult victims of asystolic OHCA in Geneva, Switzerland, were retrospectively included. Patients with signs of “obvious death” or with a Do-Not-Attempt-Resuscitation order were excluded. Patients were categorized as having received ALS if this was mentioned in the medical record, or, failing that, if at least one dose of adrenaline had been administered during cardiopulmonary resuscitation (CPR). Prognostic factors known at the time of EP’s decision were included in a multivariable logistic regression model. Included were 784 patients. Factors favourably influencing the decision to provide ALS were witnessed OHCA (OR = 2.14, 95% CI: 1.43–3.20) and bystander CPR (OR = 4.10, 95% CI: 2.28–7.39). Traumatic aetiology (OR = 0.04, 95% CI: 0.02–0.08), age > 80 years (OR = 0.14, 95% CI: 0.09–0.24) and a Charlson comorbidity index greater than 5 (OR = 0.12, 95% CI: 0.06–0.27) were the factors most strongly associated with the decision not to attempt ALS. Factors influencing the EP’s decision to attempt ALS in asystolic OHCA are the relatively young age of the patients, few comorbidities, presumed medical aetiology, witnessed OHCA and bystander CPR.

The do not resuscitate order (DNR) from the perspective of oncology nurses: A study in Saudi Arabia

PURPOSE

Issues related to life and death are largely influenced by the culture and religious beliefs of a society. This research aimed to survey a sample of oncology nurses in Saudi Arabia about their attitude towards the do not resuscitate order (DNR).

METHOD

A cross-sectional design was employed. A survey was sent to 190 nurses in the Comprehensive Cancer Center (CCC) in King Fahad Medical City (KFMC). A total of 157 nurses with a diploma or higher degree agreed to participate in the study.

RESULTS

Many nurses showed a neutral attitude regarding DNR to cancer patients and/or their families 2.4 ± 0.4. Moreover, the results of the multiple logistic regression tests revealed that all the listed factors are not associated with the attitude towards DNR orders (P > .05).

CONCLUSION

It is generally believed that nurses the faith and background of nurses from Muslim countries has a profound influence on their attitude towards DNR. However, this was not the picture that was revealed by the results of this study. In this study, all the nurses made it clear that they wanted to know about the autonomy of patients in respect of DNR orders.

IMPLICATION TO CLINICAL PRACTICE

It is necessary to develop programmes that address the DNR order and respect patient autonomy and rights. Moreover, hospital policies that address the issues of DNR order are required for all end-of-life care.

Evaluation of Autonomous Actions on Bystander-Initiated Cardiopulmonary Resuscitation and Public Access Defibrillation in Tokyo

The frequencies of autonomous bystander-initiated cardiopulmonary resuscitation (CPR) and public access defibrillation have not yet been clarified. We aimed to evaluate the frequency of autonomous actions by citizens not having a duty to act.This retrospective observational study included patients who suffered an out-of-hospital cardiac arrest (OHCA) in Tokyo between January 1, 2013 and December 31, 2017. The Delphi method with a panel of 11 experts classified the locations of OHCA resuscitations into 3 categories as follows; autonomous, non autonomous, and undetermined. The locations determined as autonomous were further divided into 2 groups; home and other locations. Bystander-initiated CPR and application of an automated external defibrillator (AED) pad were evaluated in 43,460 patients with OHCA.Group A (non autonomous), group B (autonomous, not home), and group C (home), consisted of 7,352, 3,193, and 32,915 patients, respectively. Compared with group A, group B and group C had significantly lower rates of bystander-initiated CPR (group A, B, C; 68.3% versus 38.6% versus 23.9%) and AED pad application (groups A, B, C; 26.8% versus 15.1% versus 0.6%). In addition, multivariate analysis demonstrated that an autonomous location of resuscitation was independently associated with the frequencies of bystander-initiated CPR and AED pad application, even after adjusting for age, sex, and witness status.Autonomous actions by citizens were unacceptably infrequent. Therefore, the education and training of citizens is necessary to further enhance autonomous CPR.

Comparison of attitude of nurses and nursing students toward euthanasia

BACKGROUND

Euthanasia is a controversial issue in many countries. However, there is little evidence about attitudes of nurses and nursing students toward euthanasia.

RESEARCH AIMS

The present study aimed to compare nurses and nursing students' attitudes toward euthanasia.

RESEARCH DESIGN

This is a descriptive cross-sectional study.

PARTICIPANTS AND RESEARCH CONTEXT

Using census sampling, 390 nurses and 125 nursing students were enrolled in this study.

METHODS

Data were collected using a socio-demographic questionnaire and Euthanasia Attitude Scale that included 20 items that sought to record participants' level of agreement with euthanasia based on a Likert-type scale.

ETHICAL CONSIDERATIONS

Objectives of the study were stated for all samples, and emphasized the confidentiality of their specifics and responses, and informed written consent was obtained from all participants.

FINDINGS

The mean score of nurses and nursing students' attitudes about euthanasia was 3.14 ± 0.26 and 3.22 ± 0.24 out of 5, respectively. The majority of nurses (n = 250, 65.78%) and nursing students (n = 97, 80.83%) had a positive attitude toward euthanasia. There was a significant statistical difference between the attitudes of nurses and nursing students to euthanasia (p = .005).

DISCUSSION

The results indicated that the majority of students and nurses had a positive attitude regarding euthanasia.

CONCLUSION

It was recommended to conduct more studies on euthanasia in Iran.

Documentation of ethically relevant information in out-of-hospital resuscitation is rare: a Danish nationwide observational study of 16,495 out-of-hospital cardiac arrests

Background

Decision-making in out-of-hospital cardiac arrest should ideally include clinical and ethical factors. Little is known about the extent of ethical considerations and their influence on prehospital resuscitation. We aimed to determine the transparency in medical records regarding decision-making in prehospital resuscitation with a specific focus on ethically relevant information and consideration in resuscitation providers’ documentation.

Methods

This was a Danish nationwide retrospective observational study of out-of-hospital cardiac arrests from 2016 through 2018. After an initial screening using broadly defined inclusion criteria, two experienced philosophers performed a qualitative content analysis of the included medical records according to a preliminary codebook. We identified ethically relevant content in free-text fields and categorised the information according to Beauchamp and Childress’ four basic bioethical principles: autonomy, non-maleficence, beneficence, and justice.

Results

Of 16,495 medical records, we identified 759 (4.6%) with potentially relevant information; 710 records (4.3%) contained ethically relevant information, whereas 49 did not. In general, the documentation was vague and unclear. We identified four kinds of ethically relevant information: patients’ wishes and perspectives on life; relatives’ wishes and perspectives on patients’ life; healthcare professionals’ opinions and perspectives on resuscitation; and do-not-resuscitate orders. We identified some “best practice” examples that included all perspectives of decision-making.

Conclusions

There is sparse and unclear evidence on ethically relevant information in the medical records documenting resuscitation after out-of-hospital cardiac arrests. However, the “best practice” examples show that providing sufficient documentation of decision-making is, in fact, feasible. To ensure transparency surrounding prehospital decisions in cardiac arrests, we believe that it is necessary to ensure more systematic documentation of decision-making in prehospital resuscitation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00654-y.

The cardiac arrest centre for the treatment of sudden cardiac arrest due to presumed cardiac cause - aims, function and structure: Position paper of the Association for Acute CardioVascular Care of the European Society of Cardiology (AVCV), European Association of Percutaneous Coronary Interventions (EAPCI), European Heart Rhythm Association (EHRA), European Resuscitation Council (ERC), European Society for Emergency Medicine (EUSEM) and European Society of Intensive Care Medicine (ESICM)

Approximately 10% of patients resuscitated from out-of-hospital cardiac arrest survive to hospital discharge. Improved management to improve outcomes is required, and it is proposed that such patients should be preferentially treated in cardiac arrest centres. The minimum requirements of therapy modalities for the cardiac arrest centre are 24/7 availability of an on-site coronary angiography laboratory, an emergency department, an intensive care unit, imaging facilities such as echocardiography, computed tomography and magnetic resonance imaging, and a protocol outlining transfer of selected patients to cardiac arrest centres with additional resources (out-of-hospital cardiac arrest hub hospitals). These hub hospitals are regularly treating a high volume of patients and offer further treatment modalities. This consensus document describes the aims, the minimal requirements for therapeutic modalities and expertise, and the structure, of a cardiac arrest centre. It represents a consensus among the major European medical associations and societies involved in the treatment of out-of-hospital cardiac arrest patients.

In-hospital family-witnessed resuscitation with a focus on the prevalence, processes, and outcomes of resuscitation: A retrospective observational cohort study

AIM

International and national guidelines support in-hospital, family-witnessed resuscitation, provided that patients are not negatively affected. Empirical evidence regarding whether family presence interferes with resuscitation procedures is still scarce. The aim was to describe the prevalence and processes of family-witnessed resuscitation in hospitalised adult patients, and to investigate associations between family-witnessed resuscitation and the outcomes of resuscitation.

METHODS

Nationwide observational cohort study based on data from the Swedish Registry of Cardiopulmonary Resuscitation.

RESULTS

In all, 3257 patients with sudden, in-hospital cardiac arrests were included. Of those, 395 had family on site (12%), of whom 186 (6%) remained at the scene. It was more common to offer family the option to stay during resuscitation if the cardiac arrest occurred in emergency departments, intensive-care units or cardiac-care units, compared to hospital wards (44% vs. 26%, p < 0.001). It was also more common for a staff member to be assigned to take care of family in acute settings (68% vs. 56%, p = 0.017). Mean time from cardiac arrest to termination of resuscitation was longer in the presence of family (20.67 min vs. 17.49 min, p = 0.020), also when controlling for different patient and contextual covariates in a regression model (Stand(β) 0.039, p = 0.027). No differences were found between family-witnessed and non-family-witnessed resuscitation in survival immediately after resuscitation (57% vs. 53%, p = 0.291) or after 30 days (35% vs. 29%, p = 0.086).

CONCLUSIONS

In-hospital, family-witnessed resuscitation is uncommon, but the processes and outcomes do not seem to be negatively affected, suggesting that staff should routinely invite family to witness resuscitation.

[Ethics of resuscitation and end of life decisions]

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

'It's not magic': A qualitative analysis of geriatric physicians' explanations of cardio-pulmonary resuscitation in hospital admissions

BACKGROUND

Discussing patient preferences for cardio-pulmonary resuscitation (CPR) is routine in hospital admission for older people. The way the conversation is conducted plays an important role for patient comprehension and the ethics of decision making.

OBJECTIVE

The objective was to examine how CPR is explained in geriatric rehabilitation hospital admission interviews, focussing on circumstances in which physicians explain CPR and the content of these explanations.

METHOD

We recorded forty-three physician-patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR was discussed. Data were analysed in French with thematic and conversation analysis, and the extracts used for publication were translated into English.

RESULTS

Mean patient age was 83.7 years; 53.5% were admitted for rehabilitation after surgery or traumatism. CPR was explained in 53.8% of the conversations. Most explanations were brief and concerned the technical procedures, mentioning only rarely potential outcome. With one exception, medical indication and prognosis of CPR did not feature in these explanations. Explanations occurred either before the patient's answer (as part of the question about CPR preferences) or after the patient's answer, generated by patients' indecision, misunderstanding and by the need to clarify answers.

DISCUSSION AND CONCLUSIONS

The scarcity and simplicity of CPR explanations highlight a reluctance to have in-depth discussions and reflect the assumption that CPR does not need explaining. Providing patients with accurate information about the outcomes and risks of CPR is incremental for reaching informed decisions and patient-centred care.

PATIENT CONTRIBUTION

Patients were involved in the data collection stage of the study.

Impact of Total Epinephrine Dose on Long Term Neurological Outcome for Cardiac Arrest Patients: A Cohort Study

Introduction: Although epinephrine is universally acknowledged to increase return of spontaneous circulation (ROSC) after cardiac arrest, its balanced effects on later outcomes remain uncertain, causing potential harm during post-resuscitation phase. Recent studies have questioned the efficacy and potential deleterious effects of epinephrine on long-term survival and neurological outcomes, despite that the adverse relationship between epinephrine dose and outcome can be partially biased by longer CPR duration and underlying comorbidities. This study explored the long-term effect of epinephrine when used in a cohort of patients that underwent cardiac arrest during cardiopulmonary resuscitation.

Methods: The data were originally collected from a retrospective institutional database from January 2007 to December 2015 and are now available on Dryad (via: https://doi.org/10.5061/dryad.qv6fp83). Use of epinephrine was coded by dose (<2 mg, 2 mg, 3–4 mg, ≥5 mg). A favorable neurological outcome was defined using a Cerebral Performance Category (CPC) 1 or 2. The association between epinephrine dosing and 3-months neurological outcome was analyzed by univariate analysis and multivariate logistic regression.

Results: Univariate and multivariate analysis demonstrated a negative association between total epinephrine dose and neurological outcome. Of the 373 eligible patients, 92 received less than 2 mg of epinephrine, 60 received 2 mg, 97 received 3–4 mg and 124 received more than 5 mg. Compared to patients who received less than 2 mg of epinephrine, the adjusted odds ratio (OR) of a favorable neurological outcome was 0.8 (95% confidence interval [CI]: 0.38–1.68) for 2 mg of epinephrine, 0.43 (95% confidence interval [CI]: 0.21–0.89) for 3–4 mg of epinephrine and 0.40 (95% confidence interval [CI]: 0.17–0.96) for more than 5 mg of epinephrine.

Conclusion: In this cohort of patients who achieved ROSC, total epinephrine dosing during resuscitation was associated with a worse neurological outcome three months after cardiac arrest, after adjusting other confounding factors. Further researches are needed to investigate the long-term effect of epinephrine on cardiac arrest patients.

To transport or to terminate resuscitation on-site. What factors influence EMS decisions in patients without ROSC? A mixed-methods study

BACKGROUND

If a patient in out-of-hospital cardiac arrest (OHCA) does not achieve return of spontaneous circulation (ROSC) despite advanced life support, emergency medical services can decide to either transport the patient with ongoing CPR or terminate resuscitation on scene.

PURPOSE

To determine differences between patients without ROSC to be transported vs. terminated on scene and explore medical and nonmedical factors that contribute to the decision-making of paramedics on scene.

METHODS

Mixed-methods approach combining quantitative and qualitative data. Quantitative data on all-cause OHCA patients without ROSC on scene, between January 1, 2012, and December 31, 2016, in the Amsterdam Resuscitation Study database, were analyzed to find factors associated with decision to transport. Qualitative data was collected by performing 16 semi-structured interviews with paramedics from the study region, transcribed and coded to identify themes regarding OHCA decision-making on the scene.

RESULTS

In the quantitative Utstein dataset, of 5870 OHCA patients, 3190 (54%) patients did not achieve ROSC on scene. In a multivariable model, age (OR 0.98), public location (OR 2.70), bystander witnessed (OR 1.65), EMS witnessed (OR 9.03), and first rhythm VF/VT (OR 11.22) or PEA (OR 2.34), were independently associated with transport with ongoing CPR. The proportion of variance explained by the model was only 0.36. With the qualitative method, four main themes were identified: patient-related factors, local circumstances, paramedic-related factors, and the structure of the organization.

CONCLUSION

In patients without ROSC on scene, besides known resuscitation characteristics, the decision to transport a patient is largely determined by non-protocollized factors.

Transportation during and after cardiac arrest: who, when, how and where?

PURPOSE OF REVIEW

Out-of-hospital cardiac arrest (OHCA) is the most devastating and time-critical medical emergency. Survival after OHCA requires an integrated system of care, of which transport by emergency medical services is an integral component. The transport system serves to commence and ensure uninterrupted high-quality resuscitation in suitable patients who would benefit, terminate resuscitation in those that do not, provide critical interventions, as well as convey patients to the next appropriate venue of care. We review recent evidence surrounding contemporary issues in the transport of OHCA, relating to who, where, when and how to transport these patients.

RECENT FINDINGS

We examine the clinical and systems-related evidence behind issues including: contemporary approaches to field termination of resuscitation in patients in whom continued resuscitation and transport to hospital would be medically futile, OHCA patients and organ donation, on-scene versus intra-transport resuscitation, significance of response time, intra-transport interventions (mechanical chest compression, targeted temperature management, ECMO-facilitated cardiopulmonary resuscitation), OHCA in high-rise locations and cardiac arrest centers. We highlight gaps in current knowledge and areas of active research.

SUMMARY

There remains limited evidence to guide some decisions in transporting the OHCA patient. Evidence is urgently needed to elucidate the roles of cardiac arrest centers and ECPR in OHCA.

Measuring Core Body Temperature Using a Non-invasive, Disposable Double-Sensor During Targeted Temperature Management in Post-cardiac Arrest Patients

Background: Precisely measuring the core body temperature during targeted temperature management after return of spontaneous circulation is mandatory, as deviations from the recommended temperature might result in side effects such as electrolyte imbalances or infections. However, previous methods are invasive and lack easy handling. A disposable, non-invasive temperature sensor using the heat flux approach (Double Sensor), was tested against the standard method: an esophagus thermometer.

Methods: The sensor was placed on the forehead of adult patients (n = 25, M/F, median age 61 years) with return of spontaneous circulation after cardiac arrest undergoing targeted temperature management. The recorded temperatures were compared to the established measurement method of an esophageal thermometer. A paired t-test was performed to examine differences between methods. A Bland-Altman-Plot and the intraclass correlation coefficient were used to assess agreement and reliability. To rule out possible influence on measurements, the patients' medication was recorded as well.

Results: Over the span of 1 year and 3 months, data from 25 patients were recorded. The t-test showed no significant difference between the two measuring methods (t = 1.47, p = 0.14, n = 1,319). Bland-Altman results showed a mean bias of 0.02°C (95% confidence interval 0.00–0.04) and 95% limits of agreement of −1.023°C and 1.066°C. The intraclass correlation coefficient was 0.94. No skin irritation or allergic reaction was observed where the sensor was placed. In six patients the bias differed noticeably from the rest of the participants, but no sex-based or ethnicity-based differences could be identified. Influences on the measurements of the Double Sensor by drugs administered could also be ruled out.

Conclusions: This study could demonstrate that measuring the core body temperature with the non-invasive, disposable sensor shows excellent reliability during targeted temperature management after survived cardiac arrest. Nonetheless, clinical research concerning the implementation of the sensor in other fields of application should be supported, as well as verifying our results by a larger patient cohort to possibly improve the limits of agreement.