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Qazi AH, Chan PS, Zhou Y, Vaughan-Sarrazin M, Girotra S. Trajectory of Risk-Standardized Survival Rates for In-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes 2020; 13:e006514. [PMID: 32907387 DOI: 10.1161/circoutcomes.120.006514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A hospital's risk-standardized survival rate (RSSR) for in-hospital cardiac arrest has emerged as an important metric to benchmark and incentivize hospital resuscitation quality. We examined whether hospital performance on the RSSR metric was stable or dynamic year-over-year and whether low-performing hospitals were able to improve survival outcomes over time. METHODS AND RESULTS We used data from 84 089 adult patients with an in-hospital cardiac arrest from 166 hospitals with continuous participation in Get With The Guidelines-Resuscitation from 2012 to 2017. A 2-level hierarchical regression model was used to compute RSSRs during a baseline (2012-2013) and two follow-up periods (2014-2015 and 2016-2017). At baseline, hospitals were classified as top-, middle-, and bottom-performing if they ranked in the top 25%, middle 50%, and bottom 25%, respectively, on their RSSR metric during 2012 to 2013. We compared hospital performance on RSSR during follow-up between top, middle, and bottom-performing hospitals' at baseline. During 2012 to 2013, 42 hospitals were identified as top-performing (median RSSR, 31.7%), 82 as middle-performing (median RSSR, 24.6%), and 42 as bottom-performing (median RSSR, 18.7%). During both follow-up periods, >70% of top-performing hospitals ranked in the top 50%, a substantial proportion remained in the top 25% of RSSR during 2014 to 2015 (54.6%) and 2016 to 2017 (40.4%) follow-up periods. Likewise, nearly 75% of bottom-performing hospitals remained in the bottom 50% during both follow-up periods, with 50.0% in the bottom 25% of RSSR during 2014 to 2015 and 40.5% in the bottom 25% during 2016 to 2017. While percentile rankings were generally consistent over time at ≈45% of study hospitals, ≈1 in 5 (21.4%) bottom-performing hospitals showed large improvement in percentile rankings over time and a similar proportion (23.7%) of top-performing hospitals showed large decline in percentile rankings compared with baseline. CONCLUSIONS Hospital performance on RSSR during baseline period was generally consistent over 4 years of follow-up. However, 1 in 5 bottom-performing hospitals had large improvement in survival over time. Identifying care and quality improvement innovations at these sites may provide opportunities to improve in-hospital cardiac arrest care at other hospitals.
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Affiliation(s)
- Abdul H Qazi
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (A.H.Q., M.V.-S., S.G.)
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (P.S.C.)
| | - Yunshu Zhou
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor (Y.Z.)
| | - Mary Vaughan-Sarrazin
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (A.H.Q., M.V.-S., S.G.).,Comprehensive Access and Delivery Research & Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City (M.V.-S., S.G.)
| | - Saket Girotra
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (A.H.Q., M.V.-S., S.G.).,Comprehensive Access and Delivery Research & Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City (M.V.-S., S.G.)
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Tripathi A, Girotra S, Toft LEB. Circadian variation of in-hospital cardiac arrest. Resuscitation 2020; 156:19-26. [PMID: 32853726 DOI: 10.1016/j.resuscitation.2020.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 07/24/2020] [Accepted: 08/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Out of hospital cardiac arrests, especially those due to ventricular tachyarrhythmias, have higher incidence in the morning. It is unknown whether in-hospital cardiac arrests follow a similar pattern. AIM OF THE STUDY The purpose of this study was to analyze the circadian variation of in-hospital cardiac arrest incidence. METHODS This retrospective review of data from the multicenter Get With The Guidelines-Resuscitation registry between 2000 and 2014 used multivariable hierarchical logistic regression analysis to examine circadian rhythm of in-hospital cardiac arrest over a 24-h cycle, stratified by initial shockable versus non-shockable rhythm. RESULTS Among 154,038 patients, initial rhythm was recorded as asystole or pulseless electrical activity (non-shockable) in 124,918 (81%), and ventricular fibrillation or ventricular tachycardia (shockable) in 29,120 (19%). Among non-shockable events, the highest relative proportion occurred during 0400-0759 (17.9%), followed by 0000-0359 (17.1%). For shockable rhythms the greatest relative proportion occurred between 2000-2359 (17.0%), followed by 1200-1559 (16.9%). Multivariable analysis showed that the relative risk of non-shockable compared to shockable arrest was slightly higher from midnight through 0359 (aOR 1.13; 95% CI 1.06-1.20, p < 0.001) and from 0400 through 0759 h (aOR 1.14; 95% CI 1.07-1.22, p < 0.001). Although statistically significant, the magnitude of difference in incidence by time of day was small in both groups. CONCLUSIONS Although small differences in the relative frequency of in-hospital cardiac arrest (both shockable and non-shockable rhythms) were noted during different time intervals, in-hospital cardiac arrest occurs with nearly equal frequency throughout the day. Our findings have important implications for hospital staffing models to ensure that quality of resuscitation care is consistent regardless of time.
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Affiliation(s)
- Avnish Tripathi
- University of Kentucky College of Medicine, 421 31 W Bypass, Bowling Green, KY 42101, United States.
| | - Saket Girotra
- University of Iowa Carver College of Medicine, 200 Hawkins Dr., 4427 JCP, Iowa City, IA 52242, United States.
| | - Lorrel E Brown Toft
- University of Nevada Reno School of Medicine, Department of Internal Medicine, 1664 N. Virginia St./0355, Reno, NV 89557, United States.
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Boller M, Fletcher DJ. Update on Cardiopulmonary Resuscitation in Small Animals. Vet Clin North Am Small Anim Pract 2020; 50:1183-1202. [PMID: 32798056 DOI: 10.1016/j.cvsm.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cardiopulmonary arrest (CPA), the acute cessation of ventilation and systemic perfusion, leads to discontinuation of tissue oxygen delivery and death if not quickly reversed. Reported resuscitation rates suggest that the heart can be restarted in 40% to 50% of dogs and cats treated with cardiopulmonary resuscitation (CPR). However, approximately 80% of these animals do not survive to hospital discharge. To minimize mortality due to CPA a broad strategy is required including preparedness and prevention measures, basic and advanced life support as well as post-cardiac arrest care. This article summarizes the current guidelines on the treatment of small animals with CPA..
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Affiliation(s)
- Manuel Boller
- Melbourne Veterinary School, The University of Melbourne, Melbourne, Victoria, Australia.
| | - Daniel J Fletcher
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, DCS Box 31, Ithaca, NY 14853, USA
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Provencio JJ, Hemphill JC, Claassen J, Edlow BL, Helbok R, Vespa PM, Diringer MN, Polizzotto L, Shutter L, Suarez JI, Stevens RD, Hanley DF, Akbari Y, Bleck TP, Boly M, Foreman B, Giacino JT, Hartings JA, Human T, Kondziella D, Ling GSF, Mayer SA, McNett M, Menon DK, Meyfroidt G, Monti MM, Park S, Pouratian N, Puybasset L, Rohaut B, Rosenthal ES, Schiff ND, Sharshar T, Wagner A, Whyte J, Olson DM. The Curing Coma Campaign: Framing Initial Scientific Challenges-Proceedings of the First Curing Coma Campaign Scientific Advisory Council Meeting. Neurocrit Care 2020; 33:1-12. [PMID: 32578124 PMCID: PMC7392933 DOI: 10.1007/s12028-020-01028-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Coma and disordered consciousness are common manifestations of acute neurological conditions and are among the most pervasive and challenging aspects of treatment in neurocritical care. Gaps exist in patient assessment, outcome prognostication, and treatment directed specifically at improving consciousness and cognitive recovery. In 2019, the Neurocritical Care Society (NCS) launched the Curing Coma Campaign in order to address the "grand challenge" of improving the management of patients with coma and decreased consciousness. One of the first steps was to bring together a Scientific Advisory Council including coma scientists, neurointensivists, neurorehabilitationists, and implementation experts in order to address the current scientific landscape and begin to develop a framework on how to move forward. This manuscript describes the proceedings of the first Curing Coma Campaign Scientific Advisory Council meeting which occurred in conjunction with the NCS Annual Meeting in October 2019 in Vancouver. Specifically, three major pillars were identified which should be considered: endotyping of coma and disorders of consciousness, biomarkers, and proof-of-concept clinical trials. Each is summarized with regard to current approach, benefits to the patient, family, and clinicians, and next steps. Integration of these three pillars will be essential to the success of the Curing Coma Campaign as will expanding the "curing coma community" to ensure broad participation of clinicians, scientists, and patient advocates with the goal of identifying and implementing treatments to fundamentally improve the outcome of patients.
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Affiliation(s)
- J Javier Provencio
- Department of Neurology and Neuroscience, University of Virginia, Charlottesville, VA, USA
| | - J Claude Hemphill
- Department of Neurology, Zuckerberg San Francisco General Hospital, University of California, San Francisco, Building 1, Room 101, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Brian L Edlow
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Raimund Helbok
- Department of Neurology, Neurocritical Care, Medical University of Innsbruck, Innsbruck, Austria
| | - Paul M Vespa
- Departments of Neurology and Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Michael N Diringer
- Department of Neurology, Washington University, Barnes-Jewish Hospital, St Louis, MO, USA
| | - Len Polizzotto
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Lori Shutter
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh/UPMC Health System, Pittsburgh, PA, USA
| | - Jose I Suarez
- Departments of Anesthesiology and Critical Care Medicine, Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert D Stevens
- Departments of Anesthesiology and Critical Care Medicine, Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Yama Akbari
- Departments of Neurology, Neurosurgery and the Beckman Laser Institute, University of California-Irvine, Irvine, CA, USA
| | - Thomas P Bleck
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Melanie Boly
- Department of Neurology, University of Wisconsin-Madison, Madison, WI, USA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
| | - Jed A Hartings
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Theresa Human
- Departments of Neurology and Neurosurgery, Washington University, Barnes-Jewish Hospital, St Louis, MO, USA
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Geoffrey S F Ling
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephan A Mayer
- Departments of Neurology and Neurosurgery, New York Medical College, Valhalla, NY, USA
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Martin M Monti
- Department of Psychology, University of California, Los Angeles, CA, USA
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Nader Pouratian
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Louis Puybasset
- Department of Anesthesiology and Critical Care, Sorbonne University, GRC 29, AP-HP, DMU DREAM, Pitié-Salpêtrière Hospital, 75013, Paris, France
| | - Benjamin Rohaut
- Department of Neurology, Neuro-ICU, Sorbonne University, Pitié-Salpêtrière Hospital, Paris, France
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicholas D Schiff
- Departments of Neurology, Neuroscience, and Medical Ethics, Weill Cornell Medicine, New York, NY, USA
| | - Tarek Sharshar
- Neuro-anesthesiology and Intensive Care Medicine, Sainte-Anne Hospital, Paris-Descartes University, Paris, France
- Experimental Neuropathology, Infection and Epidemiology Department, Institut Pasteur, Paris, France
| | - Amy Wagner
- Department of Physical Medicine and Rehabilitation, Department of Neuroscience, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
| | - DaiWai M Olson
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas, TX, USA
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105
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Crowley CP, Salciccioli JD, Kim EY. The association between ACLS guideline deviations and outcomes from in-hospital cardiac arrest. Resuscitation 2020; 153:65-70. [PMID: 32502576 PMCID: PMC7750980 DOI: 10.1016/j.resuscitation.2020.05.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/19/2020] [Accepted: 05/26/2020] [Indexed: 11/15/2022]
Abstract
AIM OF STUDY In hospital cardiac arrests occur at a rate of 1-5 per 1000 admissions and are associated with significant morbidity and mortality. We aimed to investigate the association between deviations from ACLS protocol and patient outcomes. METHODS This retrospective review was conducted at a single academic medical center. Data was collected on patients who suffered cardiac arrest from December 2015-November 2019. Our primary endpoint was return of spontaneous circulation. Secondary endpoints included survival to discharge and discharge with favorable neurological outcomes. RESULTS 108 patients were included, 74 obtained return of spontaneous circulation, and 23 survived to discharge. The median number of deviations from the ACLS protocol per event in ROSC group was 1 (IQR 0-3) compared to 6.5 (IQR 4-12) in non-ROSC group (p < .0001). The probability of obtaining ROSC was 96% with 0-2 deviations per event, 59% with 2-5 deviations per event, and 11% with greater than 6 deviations per event (p < .0001). The median deviation per event in patients who survived to discharge was 0 (IQR 0-1) vs. 3 (IQR 1-6, p < .0001) in those who did not. Lastly, survival to discharge with a favorable neurological outcome may be associated we less deviations per event (p < .006). CONCLUSION Our findings highlight the importance of adherence to the ACLS protocol. We found that deviations from the algorithm are associated with decreased rates of ROSC and survival to discharge. Additionally, higher rates of protocol deviations may be associated with higher rates of neurological impairments after cardiac arrest.
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Affiliation(s)
- Conor P Crowley
- Critical Care Department, Mount Auburn Hospital, 330 Mount Auburn St., Cambridge MA 02138, USA.
| | - Justin D Salciccioli
- Critical Care Department, Mount Auburn Hospital, 330 Mount Auburn St., Cambridge MA 02138, USA
| | - Edy Y Kim
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
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106
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Pound G, Jones D, Eastwood GM, Paul E, Hodgson CL. Survival and functional outcome at hospital discharge following in-hospital cardiac arrest (IHCA): A prospective multicentre observational study. Resuscitation 2020; 155:48-54. [PMID: 32697963 DOI: 10.1016/j.resuscitation.2020.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 06/20/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
AIM To evaluate the functional outcome of patients after in-hospital cardiac arrest (IHCA) and to identify associations with good functional outcome at hospital discharge. METHOD Emergency calls were prospectively screened and data collected for IHCAs in seven Australian hospitals. Patients were included if aged > 18 years, admitted as an acute care hospital in-patient and experienced IHCA; defined by a period of unresponsiveness with no observed respiratory effort and commencement of external cardiac compressions. Data collected included patient demographics, clinical and cardiac arrest characteristics, survival and functional outcome at hospital discharge using the modified Rankin Scale (mRS) and Katz Index of Independence in ADLs (Katz-ADL). RESULTS 152 patients suffered 159 IHCAs (male 66.4%; mean age 70.2 (± 13.9) years). Sixty patients (39.5%) survived, of whom 43 (71.7%) had a good functional outcome (mRS ≤ 3) and 38 (63.3%) were independent with activities of daily living (ADLs) at hospital discharge (Katz-ADL = 6). Younger age (OR 0.95; 95% CI 0.91-0.98; p = 0.003), shorter duration of CPR (OR 0.84; 95% CI 0.77-0.91; p < 0.0001) and shorter duration of hospital admission prior to IHCA (OR 0.96; 95% CI 0.93-0.998; p = 0.04) were independently associated with a good functional outcome at hospital discharge. CONCLUSION The majority of survivors had a good functional outcome and were independent with their ADLs at hospital discharge. Factors associated with good functional outcome at hospital discharge were identified.
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Affiliation(s)
- G Pound
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Physiotherapy Department, St. Vincent's Hospital, Melbourne, Australia; Physiotherapy Department, The Alfred Hospital, Melbourne, Australia.
| | - D Jones
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Intensive Care Department, The Austin Hospital, Melbourne, Australia
| | - G M Eastwood
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Intensive Care Department, The Austin Hospital, Melbourne, Australia
| | - E Paul
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - C L Hodgson
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Physiotherapy Department, The Alfred Hospital, Melbourne, Australia
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107
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Hazwani TR, Alosaimi A, Almutairi M, Shaheen N, Al Hassan Z, Antar M. The Impact of Mock Code Simulation on the Resuscitation Practice and Patient Outcome for Children With Cardiopulmonary Arrest. Cureus 2020; 12:e9197. [PMID: 32789097 PMCID: PMC7417123 DOI: 10.7759/cureus.9197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Cardiopulmonary arrest is an uncommon event in pediatric patients. Additionally, physicians-in-training see far fewer cardiopulmonary arrest events. Therefore, they have limited confidence in their resuscitation skills. Mock code training with active participation and debriefing may be an effective tool to fill this gap in experience. The aims of the study were to assess the impact of a mock code simulation program on patient outcome for children with cardiopulmonary arrest in a tertiary pediatric academic center and provide evidence that code simulations can improve the quality of cardiopulmonary resuscitation (CPR). Methods This was a retrospective cohort study conducted in a tertiary academic center. This study had two phases: Phase 1 before the mock code simulation program began (pre-intervention) and Phase 2 after the mock code program began (post-intervention). The data were collected from pediatric patients with cardiopulmonary arrest during the study period who met the inclusion criteria, and variables included the survival rate at hospital discharge, CPR initiation time, time to the first dose of epinephrine, and the adherence rate to American Heart Association (AHA) guidelines. Results A total of 13 patients in the pre-intervention period and 19 patients in the post-intervention period were included. The results showed a significant improvement in team performance represented by a decrease in CPR initiation time post-intervention and improvement in AHA adherence; however, the results did not show a significant difference in the survival rate or mortality within 28 days of the cardiopulmonary arrest event between the pre- and post-intervention groups. Conclusions Mock code simulation was a helpful tool to enhance team performance and improve the quality of cardiac resuscitation and cardiac arrest recognition, while its impact on the survival rate was not significant in our study.
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Affiliation(s)
- Tarek R Hazwani
- Pediatric Intensive Care, King Abdulaziz Medical City, Ministry of National Guard - Health Affairs, Riyadh, SAU.,Pediatric Critical Care, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Arwa Alosaimi
- Pediatrics, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Manal Almutairi
- Family Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Naila Shaheen
- Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, SAU
| | - Zahra Al Hassan
- Nursing, Ministry of National Guard - Health Affairs, Riyadh, SAU
| | - Mohannad Antar
- Pediatrics, Ministry of National Guard - Health Affairs, Riyadh, SAU
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108
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Yen KC, Chan YH, Wu CT, Hsieh MJ, Wang CL, Wen MS, Chu PH. Resuscitation outcomes of a wireless ECG telemonitoring system for cardiovascular ward patients experiencing in-hospital cardiac arrest. J Formos Med Assoc 2020; 120:551-558. [PMID: 32653389 DOI: 10.1016/j.jfma.2020.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 06/01/2020] [Accepted: 07/01/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/PURPOSE In-hospital cardiac arrest is a serious issue for hospitalized patients. The documented initial rhythm and detected medical events have been reported to influence the survival of cardiopulmonary resuscitation. This study aimed to identify the effect of continuous real-time electrocardiogram (ECG) monitoring on the prognosis of resuscitated patients in a general cardiac ward. METHODS We conducted this retrospective study using medical records of hospitalized patients in a cardiovascular ward who experienced an in-hospital cardiac arrest and received cardiopulmonary resuscitation from February 2015 to December 2018. The patients who were considered to be at high risk of cardiac events such as ventricular arrhythmia would receive continuous ECG monitoring. A wireless ECG telemonitoring system was introduced to replace traditional bedside ECG monitors. The outcome measures were the initial success of resuscitation, 24-h survival after resuscitation, and survival to discharge. RESULTS We enrolled 115 patients with a cardiac arrest during hospitalization, of whom 73 (63%) patients received wireless ECG telemonitoring. Patients receiving continuous ECG monitoring were associated with higher opportunities of initial success of resuscitation and 24-h survival after resuscitation (67.1% vs. 40.5%, p = 0.005; and 49.3% vs. 26.2%, p = 0.015, respectively) when comparing to the non-monitoring group; but no significant difference in survival to discharge (21.9% vs. 16.7%, p = 0.498) was observed. With adjustment of the covariates, the monitoring group was associated with a higher likelihood to reach the initial success of resuscitation (odds ratios [ORs], 3.21; 95% confidence interval [CI], 1.03-9.98). However, the effect of monitoring on 24-h survival and survival to discharge was close to null after adjusting for covariates. CONCLUSION A wireless ECG telemonitoring system were beneficial to the initial success of resuscitation for patients at high risk of cardiovascular events suffering an in-hospital cardiac arrest; but had less impact on 24-h survival and survival to discharge.
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Affiliation(s)
- Kun-Chi Yen
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Chia-Tung Wu
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Ming-Jer Hsieh
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Chun-Li Wang
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Ming-Shien Wen
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.
| | - Po-Hsien Chu
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.
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109
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Girotra S, Tang Y, Chan PS, Nallamothu BK. Survival After In-Hospital Cardiac Arrest in Critically Ill Patients: Implications for COVID-19 Outbreak? Circ Cardiovasc Qual Outcomes 2020; 13:e006837. [PMID: 32438836 PMCID: PMC7393647 DOI: 10.1161/circoutcomes.120.006837] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Saket Girotra
- University of Iowa Carver College of Medicine and Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA
| | - Yuanyuan Tang
- Saint Luke’s Mid America Heart Institute, Kansas City, MO
| | - Paul S. Chan
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO
- Saint Luke’s Mid America Heart Institute, Kansas City, MO
| | - Brahmajee K. Nallamothu
- Department of Internal Medicine, University of Michigan Medical School and Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI
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Shimoda-Sakano TM, Schvartsman C, Reis AG. Epidemiology of pediatric cardiopulmonary resuscitation. J Pediatr (Rio J) 2020; 96:409-421. [PMID: 31580845 PMCID: PMC9432320 DOI: 10.1016/j.jped.2019.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/31/2019] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To analyze the main epidemiological aspects of prehospital and hospital pediatric cardiopulmonary resuscitation and the impact of scientific evidence on survival. SOURCE OF DATA This was a narrative review of the literature published at PubMed/MEDLINE until January 2019 including original and review articles, systematic reviews, meta-analyses, annals of congresses, and manual search of selected articles. SYNTHESIS OF DATA The prehospital and hospital settings have different characteristics and prognoses. Pediatric prehospital cardiopulmonary arrest has a three-fold lower survival rate than cardiopulmonary arrest in the hospital setting, occurring mostly at home and in children under 1year. Higher survival appears to be associated with age progression, shockable rhythm, emergency medical care, use of automatic external defibrillator, high-quality early life support, telephone dispatcher-assisted cardiopulmonary resuscitation, and is strongly associated with witnessed cardiopulmonary arrest. In the hospital setting, a higher incidence was observed in children under 1year of age, and mortality increased with age. Higher survival was observed with shorter cardiopulmonary resuscitation duration, occurrence on weekdays and during daytime, initial shockable rhythm, and previous monitoring. Despite the poor prognosis of pediatric cardiopulmonary resuscitation, an increase in survival has been observed in recent years, with good neurological prognosis in the hospital setting. CONCLUSIONS A great progress in the science of pediatric cardiopulmonary resuscitation has been observed, especially in developed countries. The recognition of the epidemiological aspects that influence cardiopulmonary resuscitation survival may direct efforts towards more effective actions; thus, studies in emerging and less favored countries remains a priority regarding the knowledge of local factors.
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Affiliation(s)
- Tania Miyuki Shimoda-Sakano
- Universidade de São Paulo (USP), Pediatria, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Pronto Socorro do Instituto da Criança, São Paulo, SP, Brazil; Sociedade de Pediatria de São Paulo (SPSP), Departamento de Emergência, Coordenação Ressuscitação Pediátrica, São Paulo, SP, Brazil; Sociedade de Cardiologia de São Paulo, Curso de PALS (Pediatric Advanced Life Support), São Paulo, SP, Brazil.
| | - Cláudio Schvartsman
- Universidade de São Paulo (USP), Pediatria, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Pronto Socorro do Instituto da Criança, São Paulo, SP, Brazil
| | - Amélia Gorete Reis
- Universidade de São Paulo (USP), Pediatria, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Pronto Socorro do Instituto da Criança, São Paulo, SP, Brazil; International Liaison Committee on Resuscitation (ILCOR), Brazil
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Shimoda‐Sakano TM, Schvartsman C, Reis AG. Epidemiology of pediatric cardiopulmonary resuscitation. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Hazwani TR, Harder N, Shaheen NA, Al Hassan Z, Antar M, Alshehri A, Alali H, Kazzaz YM. Effect of a Pediatric Mock Code Simulation Program on Resuscitation Skills and Team Performance. Clin Simul Nurs 2020. [DOI: 10.1016/j.ecns.2020.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Girotra S, Nallamothu BK, Tang Y, Chan PS. Association of Hospital-Level Acute Resuscitation and Postresuscitation Survival With Overall Risk-Standardized Survival to Discharge for In-Hospital Cardiac Arrest. JAMA Netw Open 2020; 3:e2010403. [PMID: 32648925 PMCID: PMC7352153 DOI: 10.1001/jamanetworkopen.2020.10403] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Survival after in-hospital cardiac arrest depends on 2 distinct phases: responsiveness and quality of the hospital code team (ie, acute resuscitation phase) and intensive and specialty care expertise (ie, postresuscitation phase). Understanding the association of these 2 phases with overall survival has implications for design of in-hospital cardiac arrest quality measures. OBJECTIVE To determine whether hospital-level rates of acute resuscitation survival and postresuscitation survival are associated with overall risk-standardized survival to discharge for in-hospital cardiac arrest. DESIGN, SETTINGS, AND PARTICIPANTS This observational cohort study included 86 426 patients with in-hospital cardiac arrest from January 1, 2015, through December 31, 2018, recruited from 290 hospitals participating in the Get With The Guidelines-Resuscitation registry. EXPOSURES Risk-adjusted rates of acute resuscitation survival, defined as return of spontaneous circulation for at least 20 minutes, and postresuscitation survival, defined as survival to discharge among patients achieving return of spontaneous circulation. MAIN OUTCOMES AND MEASURES The primary outcome was overall risk-standardized survival rate (RSSR) for in-hospital cardiac arrest calculated using a previously validated model. The correlation between a hospital's overall RSSR and risk-adjusted rates of acute resuscitation and postresuscitation survival were examined. RESULTS Of 86 426 patients with in-hospital cardiac arrest, the median age was 67.0 years (interquartile range [IQR], 56.0-76.0 years); 50 665 (58.6%) were men, and 71 811 (83.1%) had an initial nonshockable cardiac arrest rhythm. The median RSSR was 25.1% (IQR, 21.9%-27.7%). The median risk-adjusted acute resuscitation survival was 72.4% (IQR, 67.9%-76.9%), and risk-adjusted postresuscitation survival was 34.0% (IQR, 31.5%-37.7%). Although a hospital's RSSR was correlated with survival during both phases, the correlation with postresuscitation survival (ρ, 0.90; P < .001) was stronger compared with the correlation with acute resuscitation survival (ρ, 0.50; P < .001). Of note, there was no correlation between risk-adjusted acute resuscitation survival and postresuscitation survival (ρ, 0.09; P = .11). Compared with hospitals in the lowest RSSR quartile, hospitals in the highest RSSR quartile had higher rates of acute resuscitation survival (75.4% in quartile 4 vs 66.8% in quartile 1; P < .001) and postresuscitation survival (40.3% in quartile 4 vs 28.7% in quartile 1; P < .001), but the magnitude of difference was larger with postresuscitation survival. CONCLUSIONS AND RELEVANCE The findings suggest that hospitals that excel in overall in-hospital cardiac arrest survival, in general, excel in either acute resuscitation or postresuscitation care but not both; efforts to strengthen postresuscitation care may offer additional opportunities to improve in-hospital cardiac arrest survival.
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Affiliation(s)
- Saket Girotra
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
| | - Brahmajee K. Nallamothu
- Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Yuanyuan Tang
- Saint Luke’s Mid America Heart Institute and the University of Missouri, Kansas City
| | - Paul S. Chan
- Saint Luke’s Mid America Heart Institute and the University of Missouri, Kansas City
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Hadaya J, Dobaria V, Aguayo E, Kwon OJ, Sanaiha Y, Hyunh A, Sareh S, Benharash P. National trends in utilization and outcomes of extracorporeal support for in- and out-of-hospital cardiac arrest. Resuscitation 2020; 151:181-188. [DOI: 10.1016/j.resuscitation.2020.02.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/09/2020] [Accepted: 02/28/2020] [Indexed: 11/28/2022]
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Avant LC, Kezar CE, Swetz KM. Advances in Cardiopulmonary Life-Support Change the Meaning of What It Means to be Resuscitated. Palliat Med Rep 2020; 1:67-71. [PMID: 34223459 PMCID: PMC8241316 DOI: 10.1089/pmr.2020.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2020] [Indexed: 01/10/2023] Open
Abstract
As options for advanced cardiopulmonary support proliferate, the use of mechanical circulatory support, such as left ventricular assist device as destination therapy (LVAD-DT), is becoming increasingly commonplace. In the current case, a patient was hospitalized for complications related to his LVAD-DT requests "full code" status, despite a clinician's warning that performing chest compressions may damage the LVAD device or vascular structures leading to poor outcome. This discussion explores the ethical and legal considerations regarding a patient request for cardiopulmonary resuscitation when limited options for survival or further treatment are available.
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Affiliation(s)
- Leslie C. Avant
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Carolyn E. Kezar
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
| | - Keith M. Swetz
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
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[Internal hospital emergency management : Concepts for optimization of patient safety in hospitals]. Anaesthesist 2020; 69:702-711. [PMID: 32447431 DOI: 10.1007/s00101-020-00795-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Critical incidents in hospitals can often be predicted hours before the event and can mostly be detected earlier and presumably avoided. Quality management programs from US hospitals to reduce deaths following a severe postoperative complication (failure to rescue, FTR), have in this form not yet become established in Germany. A sensitive score-based early warning system for looming complications is decisive for successful in-hospital emergency management. In addition to measurement rounds where the frequency is adapted to the severity, this includes effective communication of the results to the ward physician, who in the best case scenario solves the problem alone. If the deployment of a medical rapid response emergency team (MET) is necessary, there must be clear chain of alarm pathways and the personnel on the ward must be able to take initial bridging action until the MET arrives. The MET provides 24/7 emergency and intensive medical expertise for peripheral wards and must be familiar with the location, well-equipped and trained. Communication skills are particularly required not only to be able to handle the immediate emergency situation but also to organize the downstream diagnostics and escalation of treatment; however, the MET is only one of the links in the in-hospital rescue chain, which can only improve the patient outcome when alerted in a timely manner. Feedback systems, such as participation in the German Resuscitation Registry, allow reflection of one's own performance in a national comparison. The chances offered by a MET will only be fully realized when it is integrated into an in-hospital emergency concept and this determines the added value for patient safety.
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Khera R, Tang Y, Link MS, Krumholz HM, Girotra S, Chan PS. Association Between Hospital Recognition for Resuscitation Guideline Adherence and Rates of Survival for In-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes 2020; 12:e005429. [PMID: 30871337 DOI: 10.1161/circoutcomes.118.005429] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Hospitals participating in the national Get With The Guidelines-Resuscitation registry receive an award for high rates of adherence to quality metrics for in-hospital cardiac arrest. We sought to evaluate whether awards based on these quality metrics can be considered a proxy for performance on cardiac arrest survival. Methods and Results Among 195 hospitals with continuous participation in Get With The Guidelines-Resuscitation between 2012 and 2015, we identified 78 that received an award (Gold or Silver) for ≥85% compliance for all 4 metrics for in-hospital cardiac arrest-time to chest compressions, ≤1 minute; time to defibrillation, ≤2 minutes; device confirmation of endotracheal tube placement; and a monitored/witnessed arrest-for at least 12 consecutive months during 2014 to 2015. Award hospitals had higher cardiac arrest volumes than nonaward hospitals but otherwise had similar site characteristics. During 2014 to 2015, award hospitals had higher rates of return of spontaneous circulation for in-hospital cardiac arrest than nonaward hospitals (median [interquartile range], 71% [64%-77%] versus 66% [59%-74%]; Spearman ρ, 0.19; P=0.009). However, rates of risk-standardized survival to discharge at award hospitals (median, 25% [interquartile range, 22%-30%]) were similar to nonaward hospitals (median, 24% [interquartile range, 12%-27%]; Spearman ρ, 0.13; P=0.06). Among hospitals in the best tertile for survival to discharge in 2014 to 2015, 55.4% (36/65) did not receive an award, with poor discrimination of high-performing hospitals by award status (C statistic, 0.53). Similarly, there was only a weak association between hospitals' award status in 2014 to 2015 and their rates of survival to discharge in the preceding 2-year period (Spearman ρ, 0.16; P=0.03). Conclusions The current recognition mechanism within a national registry for in-hospital cardiac arrest captures hospital performance on return of spontaneous circulation but is not well correlated with survival to discharge. This suggests that current awards for resuscitation quality may not adequately capture hospital performance on overall survival-the outcome of greatest interest to patients.
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Affiliation(s)
- Rohan Khera
- Division of Cardiology, UT Southwestern Medical Center, Dallas, TX (R.K., M.S.L.)
| | - Yuanyuan Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO (Y.T., P.S.C.)
| | - Mark S Link
- Division of Cardiology, UT Southwestern Medical Center, Dallas, TX (R.K., M.S.L.)
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (H.M.K.).,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.).,Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Saket Girotra
- Division of Cardiology, Department of Internal Medicine, University of Iowa (S.G.)
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute, Kansas City, MO (Y.T., P.S.C.).,Division of Cardiology, Department of Internal Medicine, University of Missouri-Kansas City (P.S.C.)
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Tonna JE, Selzman CH, Girotra S, Presson AP, Thiagarajan RR, Becker LB, Zhang C, Keenan HT. Patient and Institutional Characteristics Influence the Decision to Use Extracorporeal Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest. J Am Heart Assoc 2020; 9:e015522. [PMID: 32347147 PMCID: PMC7428578 DOI: 10.1161/jaha.119.015522] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Outcomes from extracorporeal cardiopulmonary resuscitation (ECPR) are felt to be influenced by selective use, but the characteristics of those receiving ECPR are undefined. We demonstrate the relationship between individual patient and hospital characteristics and the probability of ECPR use. METHODS AND RESULTS We performed an observational analysis of adult inpatient cardiac arrests in the United States from 2000 to 2018 reported to the American Heart Association's Get With The Guidelines—Resuscitation registry restricted to hospitals that provided ECPR. We calculated case mix adjusted relative risk (RR) of receiving ECPR for individual characteristics. From 2000 to 2018, 129 736 patients had a cardiac arrest (128 654 conventional cardiopulmonary resuscitation and 1082 ECPR) in 224 hospitals that offered ECPR. ECPR use was associated with younger age (RR, 1.5 for <40 vs. 40–59 years; 95% CI, 1.2–1.8), no pre‐existing comorbidities (RR, 1.4; 95% CI, 1.1–1.8) or cardiac‐specific comorbidities (congestive heart failure [RR, 1.3; 95% CI, 1.2–1.5], prior myocardial infarction [RR, 1.4; 95% CI, 1.2–1.6], or current myocardial infarction [RR, 1.5; 95% CI, 1.3–1.8]), and in locations of procedural areas at the times of cardiac arrest (RR, 12.0; 95% CI, 9.5–15.1). ECPR decreased after hours (3–11 pm [RR, 0.8; 95% CI, 0.7–1.0] and 11 pm–7 am [RR, 0.6; 95% CI, 0.5–0.7]) and on weekends (RR, 0.7; 95% CI, 0.6–0.9). CONCLUSIONS Less than 1% of in‐hospital cardiac arrest patients are treated with ECPR. ECPR use is influenced by patient age, comorbidities, and hospital system factors. Randomized controlled trials are needed to better define the patients in whom ECPR may provide a benefit.
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Affiliation(s)
- Joseph E Tonna
- Division of Cardiothoracic Surgery Department of Surgery University of Utah Health Salt Lake City UT.,Division of Emergency Medicine Department of Surgery University of Utah Health Salt Lake City UT
| | - Craig H Selzman
- Division of Cardiothoracic Surgery Department of Surgery University of Utah Health Salt Lake City UT
| | - Saket Girotra
- Division of Cardiovascular Medicine Department of Internal Medicine University of Iowa Carver College of Medicine Iowa City IA
| | - Angela P Presson
- Division of Epidemiology Department of Medicine University of Utah Health Salt Lake City UT
| | - Ravi R Thiagarajan
- Division of Cardiac Critical Care Boston Children's Hospital Harvard Medical School Boston MA
| | - Lance B Becker
- Department of Emergency Medicine North Shore University Hospital Northwell Health System Manhasset NY
| | - Chong Zhang
- Division of Epidemiology Department of Medicine University of Utah Health Salt Lake City UT
| | - Heather T Keenan
- Division of Critical Care Department of Pediatrics University of Utah Health Salt Lake City UT
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Girotra S, Tang Y, Chan P, Nallamothu BK. Survival After In-Hospital Cardiac Arrest In Critically Ill Patients: Implications For The Covid-19 Pandemic? MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.04.11.20060749. [PMID: 32511438 PMCID: PMC7217095 DOI: 10.1101/2020.04.11.20060749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The coronavirus disease 2019 (COVID-19) outbreak is placing a considerable strain on U.S. healthcare systems. Due to presumptions of poor outcomes in such critically ill patients, many hospitals have started considering a universal do-not-resuscitate order in patients with confirmed Covid-19 given a limited supply of intensive care unit (ICU) beds and the potential risk of transmission of infection to healthcare workers during resuscitation. However, empirical data on survival of cardiac arrest in Covid-19 patients are unavailable at this time. To inform this debate, we report survival outcomes following cardiopulmonary resuscitation in a cohort of similar critically ill patients with pneumonia or sepsis who were receiving mechanical ventilation in an ICU at the time of arrest. The probability of survival without severe neurological disability (CPC of 1 or 2) ranged from less than 3% to over 22% across key patient subgroups, For patients with an initial rhythm of asystole or PEA, who were also receiving vasopressors at the time of arrest, fewer than 10% were discharged without severe neurological disability (CPC of 1 or 2), and this number dropped to less than 3% in patients over 80 years old. In contrast, survival rates were much higher in younger patients, patients with an initial rhythm of VF or pulseless VT, and in patients receiving ventilatory support without vasopressors. Our findings suggest caution in universal resuscitation policies. Even in a cohort of critically ill patients on mechanical ventilation, survival outcomes following in-hospital resuscitation were not uniformly poor and varied markedly depending on age, co-morbidities and illness severity. We believe that these data can help inform discussions among patients, providers and hospital leaders regarding resuscitation policies and goals of care in the context of the COVID-19 pandemic.
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Leung KHB, Sun CLF, Yang M, Allan KS, Wong N, Chan TCY. Optimal in-hospital defibrillator placement. Resuscitation 2020; 151:91-98. [PMID: 32268160 DOI: 10.1016/j.resuscitation.2020.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/27/2020] [Accepted: 03/24/2020] [Indexed: 11/29/2022]
Abstract
AIMS To determine if mathematical optimization of in-hospital defibrillator placements can reduce in-hospital cardiac arrest-to-defibrillator distance compared to existing defibrillators in a single hospital. METHODS We identified treated IHCAs and defibrillator placements in St. Michael's Hospital in Toronto, Canada from Jan. 2013 to Jun. 2017 and mapped them to a 3-D computer model of the hospital. An optimization model identified an equal number of optimal defibrillator locations that minimized the average distance between IHCAs and the closest defibrillator using a 10-fold cross-validation approach. The optimized and existing defibrillator locations were compared in terms of average distance to the out-of-sample IHCAs. We repeated the analysis excluding intensive care units (ICUs), operating theatres (OTs), and the emergency department (ED). We also re-solved the model using fewer defibrillators to determine when the average distance matched the performance of existing defibrillators. RESULTS We identified 433 treated IHCAs and 53 defibrillators. Of these, 167 IHCAs and 31 defibrillators were outside of ICUs, OTs, and the ED. Optimal defibrillator placements reduced the average IHCA-to-defibrillator distance from 16.1 m to 2.7 m (relative decrease of 83.0%; P = 0.002) compared to existing defibrillator placements. For non-ICU/OT/ED IHCAs, the average distance was reduced from 24.4 m to 11.9 m (relative decrease of 51.3%; P = 0.002. 8-9 optimized defibrillator locations were sufficient to match the average IHCA-to-defibrillator distance of existing defibrillator placements. CONCLUSIONS Optimization-guided placement of in-hospital defibrillators can reduce the distance from an IHCA to the closest defibrillator. Equivalently, optimization can match existing defibrillator performance using far fewer defibrillators.
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Affiliation(s)
- K H Benjamin Leung
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, ON, Canada
| | - Christopher L F Sun
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, United States; Department of Perioperative Services, Massachusetts General Hospital, Boston, MA, United States
| | - Matthew Yang
- Department of Critical Care, St. Michael's Hospital, Toronto, ON, Canada
| | - Katherine S Allan
- Department of Cardiology, St. Michael's Hospital, Toronto, ON, Canada
| | - Natalie Wong
- Department of Critical Care, St. Michael's Hospital, Toronto, ON, Canada
| | - Timothy C Y Chan
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
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Wiberg S, Holmberg MJ, Donnino MW, Kjaergaard J, Hassager C, Witten L, Berg KM, Moskowitz A, Andersen LW. Age-dependent trends in survival after adult in-hospital cardiac arrest. Resuscitation 2020; 151:189-196. [PMID: 32246986 DOI: 10.1016/j.resuscitation.2020.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/14/2020] [Accepted: 03/05/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND While survival after in-hospital cardiac arrest (IHCA) has improved in recent years, it remains unknown whether this trend primarily applies to younger IHCA victims. The aim of this study was to assess trends in survival to hospital discharge after adult IHCA across age groups from 2000 to 2016. METHODS This is an observational study of IHCA patients included in the Get With The Guidelines®-Resuscitation registry between 2000 and 2016. The primary outcome was survival to hospital discharge. Patients were stratified into five age groups: <50 years, 50-59 years, 60-69 years, 70-79 years, and ≥80 years. Generalized linear regression was used to obtain absolute survival rates over time. RESULTS A total of 234,767 IHCA patients were included. The absolute increase in survival per calendar year was 0.8% (95% CI 0.7-1.0%, p < 0.001) for patients younger than 50 years, 0.6% (95% CI 0.4-0.7%, p < 0.001) for patients between 50 and 59 years, 0.5% (95% CI 0.4-0.6%, p < 0.001) for patients between 60 and 69 years, 0.5% (95% CI 0.4-0.6%, p < 0.001) for patients between 70 and 79 years, and 0.5% (95% CI 0.4-0.6%, p < 0.001) for patients older than 80 years. We observed a significant interaction between calendar year and age group (p < 0.001), indicating that the rate of improvement in survival over time was significantly different between age groups. CONCLUSIONS For patients with IHCA, rates of survival to discharge have improved significantly from 2000 to 2016 across all age groups.
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Affiliation(s)
- Sebastian Wiberg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
| | - Mathias J Holmberg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Michael W Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jesper Kjaergaard
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lise Witten
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Katherine M Berg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ari Moskowitz
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Lars W Andersen
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
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Holmberg MJ, Ross CE, Atkins DL, Valdes SO, Donnino MW, Andersen LW. Lidocaine versus amiodarone for pediatric in-hospital cardiac arrest: An observational study. Resuscitation 2020; 149:191-201. [PMID: 31954741 PMCID: PMC10416093 DOI: 10.1016/j.resuscitation.2019.12.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/25/2019] [Accepted: 12/02/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lidocaine and amiodarone are both included in the pediatric cardiac arrest guidelines as treatments of shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, although there is limited evidence to support this recommendation. METHODS In this cohort study from the Get With The Guidelines - Resuscitation registry, we included pediatric patients (≤18 years) with an in-hospital cardiac arrest between 2000 and 2018, who presented with an initial or subsequent shockable rhythm (ventricular fibrillation and pulseless ventricular tachycardia). Patients receiving amiodarone were matched to patients receiving lidocaine based on a propensity score, calculated from multiple patient, event, and hospital characteristics. RESULTS A total of 365 patients were available for the analysis, of which 180 (49%) patients were matched on the propensity score. The median age in the raw cohort was 6 (quartiles, 0.5-14) years, 164 (45%) patients were female, and 238 (65%) patients received an antiarrhythmic for an initial shockable rhythm. In the matched cohort, there were no statistically significant differences between patients receiving lidocaine compared to amiodarone in return of spontaneous circulation (RR, 0.99 [95%CI, 0.82-1.19]; p = 0.88), survival to 24 h (RR, 1.02 [95%CI, 0.76-1.38]; p = 0.88), survival to hospital discharge (RR, 1.01 [95%CI, 0.63-1.63]; p = 0.96), and favorable neurological outcome (RR, 0.65 [95%CI, 0.35-1.21]; p = 0.17). The results remained consistent in multiple sensitivity analyses. CONCLUSIONS In children with cardiac arrest receiving antiarrhythmics for a shockable rhythm, there was no significant difference in clinical outcomes between those receiving lidocaine compared to amiodarone.
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Affiliation(s)
- Mathias J Holmberg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.
| | - Catherine E Ross
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Dianne L Atkins
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
| | - Santiago O Valdes
- Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Michael W Donnino
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Lars W Andersen
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Intensive Care Medicine, Randers Regional Hospital, Randers, Denmark.
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Delays in Cardiopulmonary Resuscitation, Defibrillation, and Epinephrine Administration All Decrease Survival in In-hospital Cardiac Arrest. Anesthesiology 2020; 130:414-422. [PMID: 30707123 DOI: 10.1097/aln.0000000000002563] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC Rapid response to witnessed, pulseless cardiac arrest is associated with increased survival. WHAT THIS ARTICLE TELLS US THAT IS NEW Assessment of witnessed, pulseless cardiac arrests occurring at 538 hospitals during a 9-yr period indicates that CPR did not occur immediately at 0 min in 5.7% of patients despite guidelines for instantaneous initiation. Delay in initiation of CPR was associated with significantly decreased survival.Time to initiation of CPR and subsequent time to initiation of administration of defibrillation shock (for shockable arrhythmias) and epinephrine were both associated with reduced patient survival. BACKGROUND Because the extent to which delays in initiating cardiopulmonary resuscitation (CPR) versus the time from CPR to defibrillation or epinephrine treatment affects survival remains unknown, it was hypothesized that all three independently decrease survival in in-hospital cardiac arrest. METHODS Witnessed, index cases of cardiac arrest from the Get With The Guidelines-Resuscitation Database occurring between 2000 and 2008 in 538 hospitals were included in this analysis. Multivariable risk-adjusted logistic regression examined the association of time to initiation of CPR and time from CPR to either epinephrine treatment or defibrillation with survival to discharge. RESULTS In the overall cohort of 57,312 patients, there were 9,802 survivors (17.1%). Times to initiation of CPR greater than 2 min were associated with a survival of 14.7% (91 of 618) as compared with 17.1% (9,711 of 56,694) if CPR was begun in 2 min or less (adjusted odds ratio [95% CI], 0.68 [0.54 to 0.87]; P < 0.002). Times from CPR to either defibrillation or epinephrine treatment of 2 min or less were associated with a survival of 18.0% (7,654 of 42,475), as compared with 15.0% (1,680 of 11,227) for 3 to 5 min (reference, 0 to 2 min; adjusted odds ratios [95% CI], 0.83 [0.78 to 0.88]; P < 0.001), 12.8% (382 of 2,983) for 6 to 8 min (0.67 [0.60 to 0.76], P < 0.001), and 13.7% (86 of 627) for 9 to 11 min (0.54 [0.42 to 0.69], P < 0.001). CONCLUSIONS Delays in the initiation of CPR and from CPR to defibrillation or epinephrine treatment were each associated with lower survival.
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Chan PS, Tang Y. Risk-Standardizing Rates of Return of Spontaneous Circulation for In-Hospital Cardiac Arrest to Facilitate Hospital Comparisons. J Am Heart Assoc 2020; 9:e014837. [PMID: 32200716 PMCID: PMC7428602 DOI: 10.1161/jaha.119.014837] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Sustained return of spontaneous circulation (ROSC) is the most proximal and direct assessment of acute resuscitation quality in hospitals. However, validated tools to benchmark hospital rates for ROSC after in‐hospital cardiac arrest currently do not exist. Methods and Results Within the national Get With The Guidelines‐Resuscitation registry, we identified 83 206 patients admitted from 335 hospitals from 2014 to 2017 with in‐hospital cardiac arrest. Using hierarchical logistic regression, we derived and validated a model for ROSC, defined as spontaneous and sustained ROSC for ≥20 consecutive minutes, from 24 pre‐arrest variables and calculated rates of risk‐standardized ROSC for in‐hospital cardiac arrest for each hospital. Overall, rates of ROSC were 72.0% and 72.7% for the derivation and validation cohorts, respectively. The model in the derivation cohort had moderate discrimination (C‐statistic 0.643) and excellent calibration (R2 of 0.996). Seventeen variables were associated with ROSC, and a parsimonious model retained 10 variables. Before risk‐adjustment, the median hospital ROSC rate was 70.5% (interquartile range: 64.7–76.9%; range: 33.3–89.6%). After adjustment, the distribution of risk‐standardized ROSC rates was narrower: median of 71.9% (interquartile range: 68.2–76.4%; range: 42.2–84.6%). Overall, 56 (16.7%) of 335 hospitals had at least a 10% absolute change in percentile rank after risk standardization: 27 (8.0%) with a ≥10% negative percentile change and 29 (8.7%) with a ≥10% positive percentile change. Conclusions We have derived and validated a model to risk‐standardize hospital rates of ROSC for in‐hospital cardiac arrest. Use of this model can support efforts to compare acute resuscitation survival across hospitals to facilitate quality improvement.
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Affiliation(s)
- Paul S Chan
- Saint Luke's Mid America Heart Institute Kansas City.,University of Missouri Kansas City
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Crabb DB, Hurwitz JE, Reed AC, Smith ZJ, Martin ET, Tyndall JA, Taasan MV, Plourde MA, Beattie LK. Innovation in resuscitation: A novel clinical decision display system for advanced cardiac life support. Am J Emerg Med 2020; 43:217-223. [PMID: 32291164 DOI: 10.1016/j.ajem.2020.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 02/12/2020] [Accepted: 03/06/2020] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION The Advanced Cardiac Life Support (ACLS) Clinical Decision Display System (CDDS) is a novel application designed to optimize team organization and facilitate decision-making during ACLS resuscitations. We hypothesized that resuscitation teams would more consistently adhere to ACLS guideline time intervals in simulated resuscitation scenarios with the CDDS compared to without. METHODS We conducted a simulation-based, non-blinded, randomized, crossover-design study with resuscitation teams comprised of Emergency Medicine physicians, registered nurses, critical care technicians, and paramedics. Each team performed 4 ACLS scenarios in randomized sequences, half with the CDDS and half without. We analyzed the resuscitations and recorded the times of interventions that have defined intervals by ACLS: rhythm checks, epinephrine administration, and shock delivery. In addition, we surveyed each resuscitation team regarding their experience using the CDDS. RESULTS On average, teams performed rhythm checks 4.9 s closer to ACLS guidelines with the CDDS (p = 0.0358). Teams were also more consistent; on average, teams reduced the variation of time between consecutive doses of epinephrine by 45% (p = 0.0001) and defibrillation by 47% (p < 0.0001). Ninety-eight percent of participants indicated they would use the CDDS if available in real cardiac arrests. CONCLUSIONS This study demonstrates that the CDDS improves the accuracy and precision of timed ACLS interventions in a simulated setting. Resuscitation teams were strongly in favor of utilizing the CDDS in clinical practice. Further investigations of the introduction of the platform into real time clinical environments will be needed to assess true efficacy and patient outcomes.
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Affiliation(s)
- David B Crabb
- Dept. of Emergency Medicine, University of Florida College of Medicine (UF COM), Gainesville, FL, United States of America.
| | - Joshua E Hurwitz
- Dept. of Emergency Medicine, UF COM, Gainesville, FL, Present: Roper Saint Francis, Charleston, SC, United States of America.
| | - Austin C Reed
- Dept. of Emergency Medicine, UF COM, Gainesville, FL, United States of America.
| | - Zachary J Smith
- UF Health Shands Hospital, Gainesville, FL, United States of America.
| | - Emmett T Martin
- Dept. of Emergency Medicine, UF COM, Gainesville, FL, United States of America.
| | - J Adrian Tyndall
- Dept. of Emergency Medicine, UF COM, Gainesville, FL, United States of America.
| | - Michael V Taasan
- Dept. of Emergency Medicine, UF COM, Gainesville, FL, United States of America.
| | - Michelle A Plourde
- Previous: Dept. of Emergency Medicine, UF COM, Gainesville, FL, Present: North Florida Regional Medical Center, Gainesville, FL, United States of America
| | - Lars K Beattie
- Dept. of Emergency Medicine, UF COM, Gainesville, FL, United States of America.
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Albert M, Herlitz J, Rawshani A, Ringh M, Claesson A, Djärv T, Nordberg P. Cardiac arrest after pulmonary aspiration in hospitalised patients: a national observational study. BMJ Open 2020; 10:e032264. [PMID: 32198299 PMCID: PMC7103825 DOI: 10.1136/bmjopen-2019-032264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To study characteristics and outcomes among patients with in-hospital cardiac arrest (IHCA) due to pulmonary aspiration. DESIGN A retrospective observational study based on data from the Swedish Registry of Cardiopulmonary Resuscitation (SRCR). SETTING The SRCR is a nationwide quality registry that covers 96% of all Swedish hospitals. Participating hospitals vary in size from secondary hospitals to university hospitals. PARTICIPANTS The study included patients registered in the SRCR in the period 2008 to 2017. We compared patients with IHCA caused by pulmonary aspiration (n=127), to those with IHCA caused by respiratory failure of other causes (n=2197). PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome was 30-day survival. Secondary outcome was sustained return of spontaneous circulation (ROSC) defined as ROSC at the scene and admitted alive to the intensive care unit. RESULTS In the aspiration group 80% of IHCA occurred on general wards, as compared with 63.6% in the respiratory failure group (p<0.001). Patients in the aspiration group were less likely to be monitored at the time of the arrest (18.5% vs 38%, p<0.001) and had a significantly lower rate of sustained ROSC (36.5% vs 51.6%, p=0.001). The unadjusted 30-day survival rate compared with the respiratory failure group was 7.9% versus 18.0%, p=0.024. In a propensity score analysis (including variables; year, age, gender, location of arrest, initial heart rhythm, ECG monitoring, witnessed collapse and a previous medical history of; cancer, myocardial infarction or heart failure) the OR for 30-day survival was 0.46 (95% CI 0.19 to 0.94). CONCLUSIONS In-hospital cardiac arrest preceded by pulmonary aspiration occurred more often on general wards among unmonitored patients. These patients had a lower 30-day survival rate compared with IHCA caused by respiratory failure of other causes.
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Affiliation(s)
- Malin Albert
- Department of Clinical Science and Education, Sodersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Johan Herlitz
- Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Araz Rawshani
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska academy, Gothenburg, Sweden
| | - Mattias Ringh
- Department of Medicine, Center for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Claesson
- Department of Medicine, Center for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Therese Djärv
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Per Nordberg
- Department of Medicine, Center for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
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Kim J, Park YR, Lee JH, Lee JH, Kim YH, Huh JW. Development of a Real-Time Risk Prediction Model for In-Hospital Cardiac Arrest in Critically Ill Patients Using Deep Learning: Retrospective Study. JMIR Med Inform 2020; 8:e16349. [PMID: 32186517 PMCID: PMC7113801 DOI: 10.2196/16349] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/29/2019] [Accepted: 12/21/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Cardiac arrest is the most serious death-related event in intensive care units (ICUs), but it is not easily predicted because of the complex and time-dependent data characteristics of intensive care patients. Given the complexity and time dependence of ICU data, deep learning-based methods are expected to provide a good foundation for developing risk prediction models based on large clinical records. OBJECTIVE This study aimed to implement a deep learning model that estimates the distribution of cardiac arrest risk probability over time based on clinical data and assesses its potential. METHODS A retrospective study of 759 ICU patients was conducted between January 2013 and July 2015. A character-level gated recurrent unit with a Weibull distribution algorithm was used to develop a real-time prediction model. Fivefold cross-validation testing (training set: 80% and validation set: 20%) determined the consistency of model accuracy. The time-dependent area under the curve (TAUC) was analyzed based on the aggregation of 5 validation sets. RESULTS The TAUCs of the implemented model were 0.963, 0.942, 0.917, 0.875, 0.850, 0.842, and 0.761 before cardiac arrest at 1, 8, 16, 24, 32, 40, and 48 hours, respectively. The sensitivity was between 0.846 and 0.909, and specificity was between 0.923 and 0.946. The distribution of risk between the cardiac arrest group and the non-cardiac arrest group was generally different, and the difference rapidly increased as the time left until cardiac arrest reduced. CONCLUSIONS A deep learning model for forecasting cardiac arrest was implemented and tested by considering the cumulative and fluctuating effects of time-dependent clinical data gathered from a large medical center. This real-time prediction model is expected to improve patient's care by allowing early intervention in patients at high risk of unexpected cardiac arrests.
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Affiliation(s)
- Junetae Kim
- Graduate School of Cancer Science and Policy, National Cancer Center, Goyang-si, Republic of Korea.,Cancer Data Center, National Cancer Control Institute, National Cancer Center, Goyang-si, Republic of Korea.,Healthcare AI Team, Healthcare Platform Center, National Cancer Center, Goyang-si, Republic of Korea
| | - Yu Rang Park
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Lee
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Ho Lee
- Department of Biomedical Informatics, Asan Medical Center, Seoul, Republic of Korea.,Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Hak Kim
- Department of Biomedical Informatics, Asan Medical Center, Seoul, Republic of Korea.,Health Innovation Big Data Center, Asan Institute for Life Science, Asan Medical Center, Seoul, Republic of Korea.,Medical Information Office, Asan Medical Center, Seoul, Republic of Korea.,Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
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Abstract
PURPOSE OF REVIEW The present review aims to describe the clinical impact and assessment tools capable of identifying delirium in cardiac arrest survivors and providing strategies aimed at preventing and treating delirium. RECENT FINDINGS Patient factors leading to a cardiac arrest, initial resuscitation efforts, and postresuscitation management all influence the potential for recovery and the risk for development of delirium. Data suggest that delirium in cardiac arrest survivors is an independent risk factor for morbidity and mortality. Recognizing delirium in postcardiac arrest patients can be challenging; however, detection is not only achievable, but important as it may aid in predicting adverse outcomes. Serial neurologic examinations and delirium assessments, targeting light sedation when possible, limiting psychoactive medications, and initiating patient care bundles are important care aspects for not only allowing early identification of primary and secondary brain injury, but in improving patient morbidity and mortality. SUMMARY Developing delirium after cardiac arrest is associated with increased morbidity and mortality. The importance of addressing modifiable risk factors, recognizing symptoms early, and initiating coordinated treatment strategies can help to improve outcomes within this high risk population.
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129
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Unexpected cardiac arrests occurring inside the ICU: outcomes of a French prospective multicenter study. Intensive Care Med 2020; 46:1005-1015. [DOI: 10.1007/s00134-020-05992-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 02/26/2020] [Indexed: 11/30/2022]
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130
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Rasul K, Awadallah D, Mathieu W, Bhandary S. Pro: Adult Cardiac Surgery Should Proceed in the Event of Cardiac Arrest After Induction of Anesthesia. J Cardiothorac Vasc Anesth 2020; 34:1663-1665. [PMID: 32122733 DOI: 10.1053/j.jvca.2020.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 02/01/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Kareem Rasul
- School of Medicine, The University of Cincinnati, University of Cincinnati Medical Center, Cincinnati, OH
| | - Doaa Awadallah
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Cincinnati, OH
| | - Wana Mathieu
- School of Medicine, The Ohio State University, Wexner Medical Center, Cincinnati, OH
| | - Sujatha Bhandary
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, The Ohio State University, Wexner Medical Center, Cincinnati, OH.
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Ko RE, Ryu JA, Cho YH, Sung K, Jeon K, Suh GY, Park TK, Lee JM, Song YB, Hahn JY, Choi JH, Choi SH, Gwon HC, Carriere KC, Ahn J, Yang JH. The differential neurologic prognosis of low-flow time according to the initial rhythm in patients who undergo extracorporeal cardiopulmonary resuscitation. Resuscitation 2020; 148:121-127. [DOI: 10.1016/j.resuscitation.2020.01.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/25/2019] [Accepted: 01/10/2020] [Indexed: 01/12/2023]
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132
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Kim H, Cho YH. Role of extracorporeal cardiopulmonary resuscitation in adults. Acute Crit Care 2020; 35:1-9. [PMID: 32131575 PMCID: PMC7056953 DOI: 10.4266/acc.2020.00080] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 12/04/2022] Open
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) has been performed with increasing frequency worldwide to improve the low survival rate of conventional cardiopulmonary resuscitation (CCPR). Several studies have shown that among patients who experience in-hospital cardiac arrest, better survival outcomes and neurological outcomes can be expected after ECPR than after CCPR. However, studies have not clearly shown a short-term survival benefit of ECPR for patients who experience out-of-hospital cardiac arrest. Favorable outcomes are associated with a shorter low-flow time, an initial shockable rhythm, lower serum lactate levels, higher blood pH, and a lower Sequential Organ Failure Assessment score. Indications for ECPR include young age, witnessed arrest with bystander cardiopulmonary resuscitation, an initial shockable rhythm, correctable causes such as a cardiac etiology, and no return of spontaneous circulation within 10–20 minutes of CCPR. ECPR is a complex intervention that requires a highly trained team, specialized equipment, and multidisciplinary support within a healthcare system, and it has the risk of several life-threatening complications. Therefore, physicians should carefully select patients for ECPR who can gain the most benefit, instead of applying ECPR indiscriminately.
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Affiliation(s)
- Hongsun Kim
- Department of Thoracic and Cardiovascular surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Nguyen D, Kritek PA, Greco SA, Prutkin JM. Bradycardia at the onset of pulseless electrical activity arrests in hospitalized patients is associated with improved survival to discharge. Heliyon 2020; 6:e03491. [PMID: 32140601 PMCID: PMC7049649 DOI: 10.1016/j.heliyon.2020.e03491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/13/2020] [Accepted: 02/21/2020] [Indexed: 11/29/2022] Open
Abstract
Background Recent studies have suggested that the incidence of in-hospital pulseless electrical activity (PEA) arrests is increasing. Bradycardia in patients with in-hospital PEA is common but it is unknown if it is associated with respiratory arrest or patient outcomes. Objective To determine risk factors and outcomes associated with bradycardic-PEA arrests, and relationship between bradycardia and respiratory arrest. Methods This was a retrospective cohort study of all inpatient cardiac arrests at an academic medical center over a four-year period. Patient demographics, comorbidities, vital signs, arrest event data, and outcomes were abstracted from the medical record. PEA arrest was defined as a non-shockable rhythm with loss of pulse requiring cardiopulmonary resuscitation and having organized electrocardiographic activity. Bradycardia was classified as a HR < 60 bpm at the time of pulse loss. The primary outcomes were survival of arrest and survival to hospital discharge. Results Between July 2013 and August 2017, there were 176 in-hospital patients with PEA arrests. While 105 (59.7%) survived the arrest, only 38 (21.6%) survived to discharge. A total of 66 (37.5%) were bradycardic-PEA arrests. Patients with bradycardic PEA arrests were no more likely to have their arrest precipitated by respiratory failure than non-bradycardic PEA patients (36.4% vs 27.3%, P = 0.24), but patients with non-bradycardic PEA arrests were more likely to have a CIED than non-bradycardic PEA patients (14.5% vs 3.0%, P = 0.02). On multivariate analysis, bradycardic PEA was associated with improved survival to hospital discharge (OR = 3.31, 95% CI: 1.41–7.79, p = 0.006), but not survival of arrest (OR 1.45, 95% CI: 0.68–3.09, p = 0.34). Respiratory arrest was an independent predictor of survival of code (OR 2.62, 95% CI: 1.36–5.47, P = 0.01) and to hospital discharge (OR 3.47, 95% CI: 1.35–8.91, P = 0.01). Other predictors of survival to discharge include history of coronary artery disease, and non-use of epinephrine, atropine, and sodium bicarbonate. Conclusion In a retrospective study of hospitalized patients in the intensive care unit and non-intensive care, bradycardia at the time of PEA cardiac arrest was associated with improved survival to hospital discharge but not survival of arrest. Respiratory arrest was an independent predictor of survival, but there was no association between respiratory arrest and bradycardic PEA arrest.
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Affiliation(s)
- Dan Nguyen
- University of Washington, Internal Medicine Residency, USA
| | - Patricia A Kritek
- University of Washington, Division of Pulmonary, Critical Care and Sleep Medicine, USA
| | - Sheryl A Greco
- University of Washington, Divisions of Critical Care and Cardiology, Patient Care Services, USA
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Loftus TJ, Tighe PJ, Filiberto AC, Balch J, Upchurch GR, Rashidi P, Bihorac A. Opportunities for machine learning to improve surgical ward safety. Am J Surg 2020; 220:905-913. [PMID: 32127174 DOI: 10.1016/j.amjsurg.2020.02.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/09/2020] [Accepted: 02/14/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Delayed recognition of decompensation and failure-to-rescue on surgical wards are major sources of preventable harm. This review assimilates and critically evaluates available evidence and identifies opportunities to improve surgical ward safety. DATA SOURCES Fifty-eight articles from Cochrane Library, EMBASE, and PubMed databases were included. CONCLUSIONS Only 15-20% of patients suffering ward arrest survive. In most cases, subtle signs of instability often occur prior to critical illness and arrest, and underlying pathology is reversible. Coarse risk assessments lead to under-triage of high-risk patients to wards, where surveillance for complications depends on time-consuming manual review of health records, infrequent patient assessments, prediction models that lack accuracy and autonomy, and biased, error-prone decision-making. Streaming electronic heath record data, wearable continuous monitors, and recent advances in deep learning and reinforcement learning can promote efficient and accurate risk assessments, earlier recognition of instability, and better decisions regarding diagnosis and treatment of reversible underlying pathology.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Patrick J Tighe
- Departments of Anesthesiology, Orthopedics, and Information Systems/Operations Management, University of Florida Health, Gainesville, FL, USA
| | - Amanda C Filiberto
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Jeremy Balch
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Gilbert R Upchurch
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Parisa Rashidi
- Departments of Biomedical Engineering, Computer and Information Science and Engineering, and Electrical and Computer Engineering, University of Florida, Gainesville, FL, USA; Precision and Intelligence in Medicine, Department of Medicine, University of Florida Health, Gainesville, FL, USA
| | - Azra Bihorac
- Precision and Intelligence in Medicine, Department of Medicine, University of Florida Health, Gainesville, FL, USA; Department of Medicine, University of Florida Health, Gainesville, FL, USA.
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Shirah BH, Al Nozha FA, Zafar SH, Kalumian HM. Mass Gathering Medicine (Hajj Pilgrimage in Saudi Arabia): The Outcome of Cardiopulmonary Resuscitation during Hajj. J Epidemiol Glob Health 2020; 9:71-75. [PMID: 30932393 PMCID: PMC7310767 DOI: 10.2991/jegh.k.190218.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 04/05/2018] [Indexed: 11/26/2022] Open
Abstract
The annual Hajj (pilgrimage) to the Islamic holy shrines at the city of Makkah in the Kingdom of Saudi Arabia is one of the largest yearly recurring mass gatherings worldwide. We aim to evaluate the outcome of outside and inside the hospital cardiopulmonary resuscitation to resuscitate cardiopulmonary arrest among pilgrims. In a prospective cohort study of cardiac arrest patients during Hajj period (January 2004–December 2007 and January 2010–December 2011), 426 patients were resuscitated. The mean age was 64.0 ± 12.0 years. A total of 252 (52.2%) patients had an outside the hospital cardiac arrest, whereas 174 (40.8%) patients had an inside the hospital cardiac arrest. The survival rate of outside the hospital was 5%, whereas inside the hospital was 30%. The overall survival rate was 15.5%. During Hajj, cardiopulmonary resuscitation inside the hospital was associated with better clinical outcomes than outside the hospital. Patients with cardiac arrest outside of the hospital are much less likely to survive due to the lack of immediately trained help and the delay of arrival of aid due to overcrowding. Sudden cardiac arrest leading to death could be minimized if cardiopulmonary resuscitation and defibrillation are delivered before the arrival of emergency medical services.
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Affiliation(s)
- Bader Hamza Shirah
- King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | | | - Syed Husham Zafar
- Department of Medicine, Al Ansar General Hospital, Al Madina Al Munawarrah, Saudi Arabia
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Perman SM, Beaty BL, Daugherty SL, Havranek EP, Haukoos JS, Juarez-Colunga E, Bradley SM, Fendler TJ, Chan PS. Do Sex Differences Exist in the Establishment of "Do Not Attempt Resuscitation" Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest? J Am Heart Assoc 2020; 9:e014200. [PMID: 32063126 PMCID: PMC7070220 DOI: 10.1161/jaha.119.014200] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Women have higher utilization of “do not attempt resuscitation” (DNAR) orders during treatment for critical illness. Occurrence of sex differences in the establishment of DNAR orders after resuscitation from in‐hospital cardiac arrest is unknown. Whether differences in DNAR use by sex lead to disparities in survival remains unclear. Methods and Results We identified 71 820 patients with return of spontaneous circulation (ROSC) after in‐hospital cardiac arrest from the Get With The Guidelines–Resuscitation registry. Multivariable models evaluated the association between de novo DNAR (anytime after ROSC, within 12 hours of ROSC, or within 72 hours of ROSC) by sex and the association between sex and survival to discharge accounting for DNAR. All models accounted for clustering of patients within hospital and adjusted for demographic and cardiac arrest characteristics. The cohort included 30 454 (42.4%) women, who were slightly more likely than male participants to establish DNAR orders anytime after ROSC (45.0% versus 43.5%; adjusted relative risk: 1.15 [95% CI, 1.10–1.20]; P<0.0001). Of those with DNAR orders, women were more likely to be DNAR status within the first 12 hours (51.8% versus 46.5%; adjusted relative risk: 1.40 [95% CI, 1.30–1.52]; P<0.0001) and within 72 hours after ROSC (75.9% versus 70.9%; adjusted relative risk: 1.35 [95% CI, 1.26–1.45]; P<0.0001). However, no difference in survival to hospital discharge between women and men (34.5% versus 36.7%; adjusted relative risk: 1.00 [95% CI, 0.99–1.02]; P=0.74) was appreciated. Conclusions In patients successfully resuscitated from in‐hospital cardiac arrest, there was no survival difference between men and women while accounting for DNAR. However, women had a higher rate of DNAR status early after resuscitation (<12 and <72 hours) in comparison to men.
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Affiliation(s)
- Sarah M Perman
- Department of Emergency Medicine University of Colorado, School of Medicine Aurora CO
| | - Brenda L Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science University of Colorado, School of Medicine Aurora CO
| | - Stacie L Daugherty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science University of Colorado, School of Medicine Aurora CO.,Division of Cardiology University of Colorado School of Medicine Aurora CO
| | | | - Jason S Haukoos
- Department of Emergency Medicine University of Colorado, School of Medicine Aurora CO.,Department of Emergency Medicine Denver Health Medical Center Denver CO.,Department of Epidemiology Colorado School of Public Health Aurora CO
| | - Elizabeth Juarez-Colunga
- Adult and Child Consortium for Health Outcomes Research and Delivery Science University of Colorado, School of Medicine Aurora CO
| | - Steven M Bradley
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation Minneapolis MN
| | | | - Paul S Chan
- Department of Cardiology Mid America Heart Institute Kansas City MO
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Harari DY, Macauley RC. Betting on CPR: a modern version of Pascal's Wager. JOURNAL OF MEDICAL ETHICS 2020; 46:110-113. [PMID: 31527140 DOI: 10.1136/medethics-2019-105558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/28/2019] [Accepted: 09/01/2019] [Indexed: 06/10/2023]
Abstract
Many patients believe that cardiopulmonary resuscitation (CPR) is more likely to be successful than it really is in clinical practice. Even when working with accurate information, some nevertheless remain resolute in demanding maximal treatment. They maintain that even if survival after cardiac arrest with CPR is extremely low, the fact remains that it is still greater than the probability of survival after cardiac arrest without CPR (ie, zero). Without realising it, this line of reasoning is strikingly similar to Pascal's Wager, a Renaissance-era argument for accepting the proposition for God's existence. But while the original argument is quite logical-if not universally compelling-the modern variant makes several erroneous assumptions. The authors here present a case of a patient who unwittingly appeals to Pascal's Wager to explain his request for maximal treatment, in order to highlight the crucial divergences from the original Wager. In understanding the faulty assumptions inherent in the application of Pascal's Wager to code status decisions-and identifying the underlying motivations which the Wager serves to confirm-providers can better ensure that the true values and preferences of patients are upheld.
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Affiliation(s)
- David Y Harari
- Dept. of Psychiatry, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Robert C Macauley
- Dept. of Pediatrics, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
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Initiation and Assessment of Timekeeping Roles During In-Hospital Cardiac Arrests to Track Rhythm Checks and Epinephrine Dosing. Crit Care Explor 2020; 2:e0069. [PMID: 32166289 PMCID: PMC7063905 DOI: 10.1097/cce.0000000000000069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objectives: Compliance to advanced cardiac life support algorithm is low and associated with worse outcomes from in-hospital cardiac arrests. This study aims to improve algorithm compliance by delegation of two separate code team members for timing rhythm check and epinephrine administration in accordance to the advanced cardiac life support algorithm. Design: Prospective intervention with historical controls. Setting: Single academic medical center. Patients: Patients who suffered in-hospital cardiac arrest during study period were considered for inclusion. Patients in which the advanced cardiac life support algorithm or new timekeeper roles were not used were excluded. Interventions: Two existing code team members were delegated to time epinephrine and rhythm checks. Measurements and Main Results: Primary endpoint was deviations from the 2-minute rhythm check or 3- to 5-minute epinephrine administration. Each deviation outside allotted time intervals was counted as one deviation. However, instances in which multiple intervals passed were counted as multiple deviations. Algorithm adherence was analyzed before and after intervention. Secondary endpoints included return of spontaneous circulation rate, time until first dose of epinephrine, and anonymous survey data. Thirteen pre intervention in-hospital cardiac arrests were compared with 13 in-hospital cardiac arrests post. Prior to intervention, the median deviation per in-hospital cardiac arrest was 5 (interquartile range, 3–7) versus 1 post (interquartile range 0–1; p = 0.0003). The median time until first dose of epinephrine was administered pre intervention was 5 minutes (interquartile range, 0–4) versus post intervention median of 0 (interquartile range, 0–0; p = 0.02). Pre-intervention return of spontaneous circulation rate was 46.1% versus 69.2% post. Surveys demonstrated advanced cardiac life support providers felt time keeping roles made it easier to track epinephrine administration and rhythm checks and improved team communication. Conclusions: Two separate timekeeper roles during in-hospital cardiac arrests improved algorithm compliance, code team function, and was favored by code team members. Timekeeper roles may be associated with improved rates of return of spontaneous circulation and less time until the first dose of epinephrine was administered. This study is limited by small sample size and single-center design.
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139
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Outcomes After Extracorporeal Cardiopulmonary Resuscitation of Pediatric In-Hospital Cardiac Arrest: A Report From the Get With the Guidelines-Resuscitation and the Extracorporeal Life Support Organization Registries. Crit Care Med 2020; 47:e278-e285. [PMID: 30747771 DOI: 10.1097/ccm.0000000000003622] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to determine cardiac arrest- and extracorporeal membrane oxygenation-related risk factors associated with unfavorable outcomes after extracorporeal cardiopulmonary resuscitation. DESIGN We performed an analysis of merged data from the Extracorporeal Life Support Organization and the American Heart Association Get With the Guidelines-Resuscitation registries. SETTING A total of 32 hospitals reporting to both registries between 2000 and 2014. PATIENTS Children younger than 18 years old who suffered in-hospital cardiac arrest and underwent extracorporeal cardiopulmonary resuscitation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 593 children included in the final cohort, 240 (40.5%) died prior to decannulation from extracorporeal membrane oxygenation and 352 (59.4%) died prior to hospital discharge. A noncardiac diagnosis and preexisting renal insufficiency were associated with increased odds of death (adjusted odds ratio, 1.85 [95% CI, 1.19-2.89] and 4.74 [95% CI, 2.06-10.9], respectively). The median time from onset of the cardiopulmonary resuscitation event to extracorporeal membrane oxygenation initiation was 48 minutes (interquartile range, 28-70 min). Longer time from onset of the cardiopulmonary resuscitation event to extracorporeal membrane oxygenation initiation was associated with higher odds of death prior to hospital discharge (adjusted odds ratio for each 5 additional minutes of cardiopulmonary resuscitation prior to extracorporeal membrane oxygenation initiation, 1.04 [95% CI, 1.01-1.07]). Each individual adverse event documented during the extracorporeal membrane oxygenation course, including neurologic, pulmonary, renal, metabolic, cardiovascular and hemorrhagic, was associated with higher odds of death, with higher odds as the cumulative number of documented adverse events during the extracorporeal membrane oxygenation course increased. CONCLUSIONS Outcomes after extracorporeal cardiopulmonary resuscitation reported by linking two national registries are encouraging. Noncardiac diagnoses, preexisting renal insufficiency, longer time from onset of the cardiopulmonary resuscitation event to extracorporeal membrane oxygenation initiation, and adverse events during the extracorporeal membrane oxygenation course are associated with worse outcomes.
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Holmberg MJ, Ross CE, Yankama T, Roberts JS, Andersen LW. Epinephrine in children receiving cardiopulmonary resuscitation for bradycardia with poor perfusion. Resuscitation 2020; 149:180-190. [PMID: 31926260 DOI: 10.1016/j.resuscitation.2019.12.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/08/2019] [Accepted: 12/30/2019] [Indexed: 10/25/2022]
Abstract
AIM To determine whether the use of epinephrine in pediatric patients receiving cardiopulmonary resuscitation for bradycardia and poor perfusion was associated with improved clinical outcomes. METHODS Using the Get With The Guidelines-Resuscitation registry, we included pediatric patients (≤18 years) who received in-hospital cardiopulmonary resuscitation for bradycardia with poor perfusion (non-pulseless event) between January 2000 and December 2018. Time-dependent propensity score matching was used to match patients receiving epinephrine within the first 10 min of resuscitation to patients at risk of receiving epinephrine within the same minute. RESULTS In the full cohort, 55% of patients were male and 39% were neonates. A higher number of patients receiving epinephrine required vasopressors and mechanical ventilation prior to the event compared to those not receiving epinephrine. A total of 3528 patients who received epinephrine were matched to 3528 patients at risk of receiving epinephrine based on the propensity score. Epinephrine was associated with decreased survival to hospital discharge (RR, 0.79 [95% CI, 0.74-0.85]; p < 0.001), return of spontaneous circulation (RR, 0.94 [95% CI, 0,91-0.96]; p < 0.001), 24-h survival (RR, 0.85 [95% CI, 0.81-0.90]; p < 0.001), and favorable neurological outcome (RR, 0.76 [95% CI, 0.68-0.84]; p < 0.001). Epinephrine was also associated with an increased risk of progression to pulselessness (RR, 1.17 [95% CI, 1.06-1.28]; p < 0.001). CONCLUSION In children receiving cardiopulmonary resuscitation for bradycardia with poor perfusion, epinephrine was associated with worse outcomes, although the study does not eliminate the potential for confounding.
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Affiliation(s)
- Mathias J Holmberg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.
| | - Catherine E Ross
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Medical Critical Care and Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tuyen Yankama
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Joan S Roberts
- Division of Pediatric Critical Care, University of Washington, Seattle, WA, USA
| | - Lars W Andersen
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Intensive Care Medicine, Randers Regional Hospital, Randers, Denmark
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Starks MA, Wu J, Peterson ED, Stafford JA, Matsouaka RA, Boulware LE, Svetkey LP, Chan PS, Pun PH. In-Hospital Cardiac Arrest Resuscitation Practices and Outcomes in Maintenance Dialysis Patients. Clin J Am Soc Nephrol 2020; 15:219-227. [PMID: 31911423 PMCID: PMC7015080 DOI: 10.2215/cjn.05070419] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 11/14/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Patients on maintenance dialysis with in-hospital cardiac arrest have been reported to have worse outcomes relative to those not on dialysis; however, it is unknown if poor outcomes are related to the quality of resuscitation. Using the Get With The Guidelines-Resuscitation (GWTG-R) registry, we examined processes of care and outcomes of in-hospital cardiac arrest for patients on maintenance dialysis compared with nondialysis patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used GWTG-R data linked to Centers for Medicare and Medicaid data to identify patients with ESKD receiving maintenance dialysis from 2000 to 2012. We then case-matched adult patients on maintenance dialysis to nondialysis patients in a 1:3 ratio on the basis of age, sex, race, hospital, and year of arrest. Logistic regression models with generalized estimating equations were used to assess the association of in-hospital cardiac arrest and outcomes by dialysis status. RESULTS After matching, there were a total of 31,144 GWTG-R patients from 372 sites, of which 8498 (27%) were on maintenance dialysis. Patients on maintenance dialysis were less likely to have a shockable initial rhythm (20% versus 21%) and less likely to be within the intensive care unit at the time of arrest (46% versus 47%) compared with nondialysis patients; they also had lower composite scores for resuscitation quality (89% versus 90%) and were less likely to have defibrillation within 2 minutes (54% versus 58%). After adjustment, patients on maintenance dialysis had similar adjusted odds of survival to discharge (odds ratio [OR], 1.05; 95% confidence interval [95% CI], 0.97 to 1.13), better acute survival (OR, 1.33; 95% CI, 1.26 to 1.40), and were more likely to have favorable neurologic status (OR, 1.12; 95% CI, 1.04 to 1.22) compared with nondialysis patients. CONCLUSIONS Although there appears to be opportunities to improve the quality of in-hospital cardiac arrest care for among those on maintenance dialysis, survival to discharge was similar for these patients compared with nondialysis patients.
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Affiliation(s)
| | | | | | | | - Roland A Matsouaka
- Duke Clinical Research Institute.,Department of Biostatistics and Bioinformatics
| | | | - Laura P Svetkey
- Division of Nephrology, Duke University Medical Center, Durham, North Carolina; and
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Patrick H Pun
- Duke Clinical Research Institute, .,Division of Nephrology, Duke University Medical Center, Durham, North Carolina; and
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Aljethaily A, Al-Mutairi T, Al-Harbi K, Al-Khonezan S, Aljethaily A, Al-Homaidhi HS. Pediatricians' Perceptions Toward Do Not Resuscitate: A Survey in Saudi Arabia and Literature Review. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2020; 11:1-8. [PMID: 32021536 PMCID: PMC6954090 DOI: 10.2147/amep.s228399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/04/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To explore the pediatricians' attitudes and perceptions toward do-not-resuscitate (DNR) orders in a specific region of the world not fully explored before. METHODS A cross-sectional study was conducted between March 4 and May 30, 2018. Pediatricians from three public hospitals in the city of Riyadh were asked to respond to a questionnaire consisting of 22 questions designed to meet the objectives of our study. RESULTS A total of 203 pediatricians (51.2% female) completed the questionnaire, both junior pediatricians (JPs) and senior pediatricians (SPs). A majority (58.9% of JPs and 61.4% of SPs) thought patients have the right to demand intensive care, despite their terminal illness. Half the participants in both groups thought that DNR is a physician's decision. Only 9.3% of JPs and 12.5% of SPs felt comfortable discussing DNR with patients/families. Medical school was also a source of knowledge on DNR issues, mainly for JPs (40.2% of JPs vs 20.8% of SPs, P=0.005). Half the participants felt that DNR is consistent with Islamic beliefs, while 57.9% of JPs vs 41.7% of SPs felt they are legally protected. Hospital policy was clear to 48.6% of JPs vs 66.7% of SPs, while procedure was clear to 35.5% of JPs vs 49% of SPs. CONCLUSION Several factors are present that may hinder DNR implementation, such as doubts concerning being legally protected, doubts concerning consistency with Islamic sharia, unclear policies and procedures, and lack of training and orientation on DNR issues. Policies may need to include patients as decision-makers.
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Affiliation(s)
| | | | - Khalid Al-Harbi
- College of Medicine, Al-Imam University, Riyadh, Saudi Arabia
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Detection of Deteriorating Patients on Surgical Wards Outside the ICU by an Automated MEWS-Based Early Warning System With Paging Functionality. Ann Surg 2020; 271:100-105. [DOI: 10.1097/sla.0000000000002830] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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144
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Tanaka T, Nomura Y, Hirama C, Takamatsu Y, Wakatake H, Suzuki T, Kawarazaki H, Sakurada T, Fujitani S, Taira Y. Cardiac arrest during hemodialysis: a survey of five Japanese hospitals. Acute Med Surg 2020; 7:e476. [PMID: 31988788 PMCID: PMC6971461 DOI: 10.1002/ams2.476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/31/2019] [Accepted: 11/18/2019] [Indexed: 11/07/2022] Open
Abstract
AIM Intraprocedural cardiac arrest is a serious complication among patients receiving hemodialysis. However, the frequency and reaction to these events remain unclear. This study aimed to explore the clinical picture of cardiac arrest during hemodialysis. METHODS Ten cardiac arrests that had occurred during 217,984 hemodialysis treatments in five Japanese hospitals, between 2008 and 2017, were reviewed. We investigated the underlying disease, vital signs, emergency responses, and outcomes using patient medical records. RESULTS The cardiac arrest rate ranged from 1.1 to 7.5 per 100,000 hemodialysis sessions. All included cases of cardiac arrest occurred in a hemodialysis unit and had been witnessed and reported by supervising clinicians. The initial rhythm was ventricular fibrillation/ventricular tachycardia in six patients (60%) and pulseless electrical activity/asystole in four patients (40%). Seven (70%) patients showed a return of spontaneous circulation (ROSC), and two (20%) patients were discharged with a cerebral performance category score of 1. There was a statistically significant difference in the ROSC rate (P = 0.048) only in the event of an emergency call. The SpO2 and respiratory rates had not been recorded in six patients. There was no significant difference in ROSC between initial rhythms of ventricular fibrillation/ventricular tachycardia and pulseless electrical activity/asystole. CONCLUSION We evaluated the frequency of cardiac arrest during hemodialysis. Overall assessment including respiratory status is needed at initiation of hemodialysis. In case of a sudden change in a patient's status, high-quality resuscitation treatment that includes an emergency call can improve prognosis.
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Affiliation(s)
- Taku Tanaka
- Medical Emergency and Disaster CenterKawasaki Municipal Tama HospitalKawasakiJapan
| | - Yu Nomura
- Medical Emergency and Disaster CenterKawasaki Municipal Tama HospitalKawasakiJapan
| | - Chie Hirama
- Medical Emergency and Disaster CenterKawasaki Municipal Tama HospitalKawasakiJapan
| | - Yuka Takamatsu
- Medical Emergency and Disaster CenterKawasaki Municipal Tama HospitalKawasakiJapan
| | - Haruaki Wakatake
- Emergency Medical CenterYokohama City Seibu HospitalSt. Marianna University School of MedicineYokohamaJapan
| | - Toshihiko Suzuki
- Department of Nephrology, Endocrinology, and Diabetes MedicineTokyo Bay Urayasu Ichikawa Medical CenterUrayasuJapan
| | | | - Tsutomu Sakurada
- Department of Nephrology and HypertensionSt. Marianna University School of MedicineKawasakiJapan
| | - Shigeki Fujitani
- Department of Emergency and Critical Care MedicineSt. Marianna University School of MedicineKawasakiJapan
| | - Yasuhiko Taira
- Department of Emergency and Critical Care MedicineSt. Marianna University School of MedicineKawasakiJapan
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Response to commentary on “Therapeutic hypothermia attenuates paraplegia and neuronal damage in the lumbar spinal cord in a rat model of asphyxial cardiac arrest” by Lee et al.,. J Therm Biol 83 (2019) 1–7.". J Therm Biol 2020; 87:102455. [DOI: 10.1016/j.jtherbio.2019.102455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/09/2019] [Indexed: 11/18/2022]
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Hoehne SN, Hopper K, Epstein SE. Prospective Evaluation of Cardiopulmonary Resuscitation Performed in Dogs and Cats According to the RECOVER Guidelines. Part 2: Patient Outcomes and CPR Practice Since Guideline Implementation. Front Vet Sci 2019; 6:439. [PMID: 31921901 PMCID: PMC6914737 DOI: 10.3389/fvets.2019.00439] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/25/2019] [Indexed: 11/22/2022] Open
Abstract
Cardiopulmonary resuscitation (CPR) outcomes have not been prospectively described since implementation of the Reassessment Campaign on Veterinary Resuscitation (RECOVER) guidelines. This study aimed to prospectively describe CPR outcomes and document arrest variables in dogs and cats at a U.S. veterinary teaching hospital since implementation of the RECOVER guidelines using the 2016 veterinary Utstein-style CPR reporting guidelines. One-hundred and seventy-two dogs and 47 cats that experienced cardiopulmonary arrest (CPA) underwent CPR following implementation of the RECOVER guidelines and were prospectively included. Supervising clinicians completed a data form for CPR events immediately following completion of CPR from December 2013 to June 2018. Seventy-five (44%) dogs and 26 (55%) cats attained return of spontaneous circulation (ROSC), 45 dogs (26%) and 16 cats (34%) had ROSC ≥ 20 min, 13 dogs (8%) and 10 cats (21%) were alive 24 h after CPR, and 12 dogs (7%) and 9 cats (19%) survived to hospital discharge. The most common cause of death in animals with ROSC ≥ 20 min was euthanasia. Patient outcomes were not significantly different since publication of the RECOVER guidelines except for a higher feline survival to hospital discharge rate. Dogs (p = 0.02) but not cats with initial shockable rhythms had increased rates of ROSC while the development of a shockable rhythm during CPR efforts was not associated with ROSC (p = 0.30). In closed chest CPR an end-tidal carbon dioxide (EtCO2) value of >16.5 mmHg was associated with a 75% sensitivity and 64% specificity for achieving ROSC. Since publication of the RECOVER guidelines, CPR practice did not clinically significantly change at our institution and no improvement of already high ROSC rates was noted. The percentage of cats surviving to hospital discharge was higher than previously reported and the reason for this improvement is not evident with these results. Euthanasia remains a major confounding factor in assessing intermediate and long-term CPR outcomes in dogs and cats.
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Affiliation(s)
- Sabrina N Hoehne
- William R. Pritchard Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Steven E Epstein
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
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Predicting the probability of survival with mild or moderate neurological dysfunction after in-hospital cardiopulmonary arrest: The GO-FAR 2 score. Resuscitation 2019; 146:162-169. [PMID: 31821836 DOI: 10.1016/j.resuscitation.2019.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/18/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND The Good Outcome Following Attempted Resuscitation (GO-FAR) Score uses pre-arrest factors to predict survival after In-Hospital Cardiac Arrest (IHCA) with minimal neurological dysfunction, (cerebral performance category (CPC) ≤1). Moderate neurological dysfunction (CPC ≤2) may be a more acceptable outcome. OBJECTIVE To predict survival after IHCA with mild or moderate neurological dysfunction based on pre-arrest factors. METHODS 52,468 patients with IHCA from 2012-2017. Data was divided into training (44%), testing (22%), and validation (34%) sets. Univariate analysis was used to identify variables with >3% difference in survival with CPC ≤2. These variables carried forward to the multivariate logistic regression model. The most parsimonious model that best classified patients as having a very poor (≤5%), below average (≤10%), average (11%-30%), or above average (>30%) likelihood of survival with CPC ≤2 was chosen. RESULTS Age >85, admission CPC <2, and non-surgical admission were strongly association with poor survival (-12.1%, -14.4%, and -18%, respectively). Nine variables were included in the logistic regression analysis. The final updated model, GO FAR 2, categorized 6.2% of patients with a very poor predicted survival, 24.8% of patients with a below average predicted survival, and 11.3% with above average predicted survival. The observed survival among those with very poor predicted survival was 4.5%. CONCLUSION The GO FAR 2 score provides clinicians with a prognostic estimate of the likelihood of a good outcome after IHCA based on pre-arrest patient factors. Future research is required to validate the GO-FAR 2 score.
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Vorster ID, Beningfield S. Evaluation of self-reported confidence amongst radiology staff in initiating basic life support across hospitals in the Cape Town Metropole West region. SA J Radiol 2019; 23:1720. [PMID: 31824739 PMCID: PMC6890570 DOI: 10.4102/sajr.v23i1.1720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 08/05/2019] [Indexed: 11/01/2022] Open
Abstract
Background The immediate response to cardiac arrest is regarded as the most time-critical intervention. First responders for cardiac arrests in imaging departments are often radiology staff. The study aim was to determine radiology staff members' confidence in initiating basic life support. Objectives The objectives of this study included determining the general confidence levels regarding identifying cardiac arrest and initiation of basic life support (BLS) amongst Radiology staff within the studied sites, as well as to identify potential areas of uncertainty. Another objective included identifying what would contribute to increasing levels of confidence and competence in identifying cardiac arrest and initiating BLS. Method A multi-centre cross-sectional survey was conducted using peer-validated, anonymous questionnaires. Questionnaires were distributed to radiology staff working in public sector hospitals within the Cape Town Metropole West. Due to the limited subject pool, a convenience sample was collected. Data were therefore statistically analysed using only summary statistics (mean, standard deviation, proportions, and so on), and detailed comparisons were not made. Results We disseminated 200 questionnaires, and 74 were completed (37%). There were no incomplete questionnaires or exclusions from the final sample. Using a 10-point Likert scale, the mean ability to recognise cardiac arrest was 6.45 (SD ± 2.7), securing an airway 4.86 (SD ± 2.9), and providing rescue breaths and initiating cardiac compressions 6.14 (SD ± 2.9). Only two (2.7%) of the participants had completed a basic life support course in the past year; 11 (14.8%) had never completed any basic life support course and 28 (37.8%) had never completed any life support or critical care course. Radiologists, radiology trainees and nurses had the greatest confidence in providing rescue breaths and initiating cardiac compressions from all the groups. Conclusion The study demonstrated a substantial lack of confidence in providing basic life support in the participating hospital imaging departments' staff. The participants indicated that regular training and improved support systems would increase confidence levels and improve skills.
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Affiliation(s)
- Isak D Vorster
- Department of Diagnostic Radiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Steve Beningfield
- Division of Radiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Hoehne SN, Epstein SE, Hopper K. Prospective Evaluation of Cardiopulmonary Resuscitation Performed in Dogs and Cats According to the RECOVER Guidelines. Part 1: Prognostic Factors According to Utstein-Style Reporting. Front Vet Sci 2019; 6:384. [PMID: 31788482 PMCID: PMC6854014 DOI: 10.3389/fvets.2019.00384] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 10/21/2019] [Indexed: 11/13/2022] Open
Abstract
Factors associated with positive cardiopulmonary resuscitation (CPR) outcomes defined according to the veterinary Utstein-style CPR reporting guidelines have not been described since implementation of the Reassessment Campaign on Veterinary Resuscitation (RECOVER) CPR clinical guidelines in 2012. The aims of this study were to assess factors associated with positive CPR outcomes at a U.S. veterinary teaching hospital, to re-evaluate these factors since implementation of the RECOVER guidelines compared to reported factors prior to their publication, and to identify potential additional factors since guideline publication. One-hundred and seventy-two dogs and 47 cats that experienced cardiopulmonary arrest (CPA) and had CPR performed were prospectively included in this observational study. Supervising clinicians were asked to complete a data form on CPR events immediately following completion of CPR efforts. Multivariable logistic regression was used to evaluate the effect of twenty hospital, animal, and arrest variables on the three patient outcomes “any return of spontaneous circulation (ROSC),” “sustained ROSC,” and survival to hospital discharge. Cats had significantly higher odds to achieve any ROSC [OR (95%CI) 2.72 (1.12–6.61), p = 0.028] and survive to hospital discharge than dogs [OR (95%CI) 4.87 (1.52–15.58), p = 0.008]. Patients had significantly lower odds of achieving any ROSC if CPA occurred during nighttime hours [OR (95%CI) nighttime = 0.52 (0.27–0.98), p = 0.043], and higher odds if CPA was witnessed [OR (95%CI) 3.45 (1.57–7.55), p = 0.002], if less people were involved in CPR efforts [OR (95%CI) 0.8 (0.66–0.96), p = 0.016], if pulses were palpable during CPR [OR (95%CI) 9.27 (4.16–20.63), p < 0.0005], and if an IV catheter was already in place at the time of CPA [OR (95%CI) 5.07 (2.12–12.07), p = 0.0003]. Odds for survival to hospital discharge were significantly higher if less people were involved in CPR efforts [OR (95%CI) 0.65 (0.46–0.91), p = 0.013] and for patients of the anesthesia service [OR (95%CI) 14.82 (3.91–56.17), p = 0.00007]. Overall, factors associated with improved CPR outcomes have remained similar since incorporation of RECOVER guidelines into daily practice. Witnessed CPA events and high-quality CPR interventions were associated with positive patient outcomes, emphasizing the importance of timely recognition and initiation of CPR efforts. An optimal CPR team size has yet to be determined.
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Affiliation(s)
- Sabrina N Hoehne
- William R. Pritchard Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Steven E Epstein
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
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Grønbek KS, Mørch SS, Pedersen NE, Petersen TS, Meyhoff CS. Myocardial injury and mortality in patients with excessive oxygen administration before cardiac arrest. Acta Anaesthesiol Scand 2019; 63:1330-1336. [PMID: 31286469 DOI: 10.1111/aas.13446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 06/21/2019] [Accepted: 06/25/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Hyperoxia after cardiac arrest may be associated with higher mortality, and trials have found that excess oxygen administration in patients with myocardial infarction is associated with increased infarct size. The effect of hyperoxia before cardiac arrest is sparsely investigated. Our aim was to assess the association between excessive oxygen administration before cardiac arrest and the extent of subsequent myocardial injury. METHODS We performed a retrospective study including patients who had in-hospital cardiac arrest during 2014 in the Capital Region of Denmark. We excluded patients without peripheral oxygen saturation measurements within 48 hours before cardiac arrest. Patients were divided in three groups of pre-arrest oxygen exposure, based on average peripheral oxygen saturation and supplemental oxygen. Primary outcome was peak troponin concentration within 30 days. Secondary outcomes included 30-day mortality. Data were analyzed using multiple logistic regression and Wilcoxon rank sum test. RESULTS Of 163 patients with cardiac arrest, 28 had excessive oxygen administration (17%), 105 had normal oxygen administration (64%) and 30 had insufficient oxygen administration (18%) before cardiac arrest. Peak troponin was median 224 ng/L in the excessive oxygen administration group vs 365 ng/L in the normal oxygen administration group (P = .54); 20 of 28 (71%) in the excessive oxygen administration group died within 30 days compared to 54 of 105 (51%) in the normal oxygen administration group. (OR 1.87, 95% CI 0.56-6.19) CONCLUSIONS: Excessive oxygen administration within 48 hours before in-hospital cardiac arrest was not statistically associated with significantly higher peak troponin or mortality.
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Affiliation(s)
- K. S. Grønbek
- Department of Anaesthesia and Intensive Care Bispebjerg and Frederiksberg Hospital, University of Copenhagen Copenhagen Denmark
| | - S. S. Mørch
- Department of Anaesthesia and Intensive Care Bispebjerg and Frederiksberg Hospital, University of Copenhagen Copenhagen Denmark
| | - N. E. Pedersen
- Copenhagen Academy for Medical Education and Simulation Herlev Hospital, University of Copenhagen Copenhagen Denmark
| | - T. S. Petersen
- Department of Clinical Pharmacology Bispebjerg and Frederiksberg Hospital, University of Copenhagen Copenhagen Denmark
| | - C. S. Meyhoff
- Department of Anaesthesia and Intensive Care Bispebjerg and Frederiksberg Hospital, University of Copenhagen Copenhagen Denmark
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