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Steinberg A. Emergent Management of Hypoxic-Ischemic Brain Injury. Continuum (Minneap Minn) 2024; 30:588-610. [PMID: 38830064 DOI: 10.1212/con.0000000000001426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article outlines interventions used to improve outcomes for patients with hypoxic-ischemic brain injury after cardiac arrest. LATEST DEVELOPMENTS Emergent management of patients after cardiac arrest requires prevention and treatment of primary and secondary brain injury. Primary brain injury is minimized by excellent initial resuscitative efforts. Secondary brain injury prevention requires the detection and correction of many pathophysiologic processes that may develop in the hours to days after the initial arrest. Key physiologic parameters important to secondary brain injury prevention include optimization of mean arterial pressure, cerebral perfusion, oxygenation and ventilation, intracranial pressure, temperature, and cortical hyperexcitability. This article outlines recent data regarding the treatment and prevention of secondary brain injury. Different patients likely benefit from different treatment strategies, so an individualized approach to treatment and prevention of secondary brain injury is advisable. Clinicians must use multimodal sources of data to prognosticate outcomes after cardiac arrest while recognizing that all prognostic tools have shortcomings. ESSENTIAL POINTS Neurologists should be involved in the postarrest care of patients with hypoxic-ischemic brain injury to improve their outcomes. Postarrest care requires nuanced and patient-centered approaches to the prevention and treatment of primary and secondary brain injury and neuroprognostication.
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May TL, Siladi S, Daley AL, Riker R, Zanichkowsky R, Burla M, Swan E, Talbot JA. Standardizing post-cardiac arrest care across rural-urban settings - qualitative findings on proposed post-cardiac arrest learning community intervention. BMC Health Serv Res 2023; 23:1258. [PMID: 37968683 PMCID: PMC10652430 DOI: 10.1186/s12913-023-10147-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 10/14/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Standardization of post-cardiac arrest care between emergency department arrival and intensive care unit admission can be challenging, particularly for rural centers, which can experience significant delays in interfacility transfer. One approach to addressing this issue is to form a post-cardiac arrest learning community (P-CALC) consisting of emergency department (ED) and intensive care unit (ICU) physicians and nurses who use data, shared resources, and collaboration to improve post-cardiac arrest care. MaineHealth, the largest regional health system in Maine, launched its P-CALC in 2022. OBJECTIVE To explore P-CALC participants' perspectives on current post-cardiac arrest care, attitudes toward implementing a P-CALC intervention, perceived barriers and facilitators to intervention implementation, and implementation strategies. METHODS We conducted semi-structured, individual, qualitative interviews with 16 staff from seven system EDs spanning the rural-urban spectrum. Directed content analysis was used to discern key themes in transcribed interviews. RESULTS Participants highlighted site- and system-level factors influencing current post-cardiac arrest care. They expressed both positive attitudes and concerns about the P-CALC intervention. Multiple facilitators and barriers were identified in regard to the intervention implementation. Five proposed implementation strategies emerged as important factors to move the intervention forward. CONCLUSIONS Implementation of a P-CALC intervention to effect system-wide improvements in post-cardiac arrest care is complex. Understanding providers' perspectives on current care practices, feasibility of quality improvement, and potential intervention impacts is essential for program development.
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Affiliation(s)
- Teresa L May
- Department of Critical Care, Maine Medical Center, Portland, ME, USA.
- Acute Care Center of Biomedical Research Excellence, Portland, ME, USA.
| | - Skye Siladi
- Muskie School of Public Service, University of Southern Maine, Portland, ME, USA
| | - Alison L Daley
- Acute Care Center of Biomedical Research Excellence, Portland, ME, USA
| | - Richard Riker
- Department of Critical Care, Maine Medical Center, Portland, ME, USA
- Acute Care Center of Biomedical Research Excellence, Portland, ME, USA
| | - Rita Zanichkowsky
- Acute Care Center of Biomedical Research Excellence, Portland, ME, USA
| | - Michael Burla
- Department of Emergency Medicine, Southern Maine Medical Center, Biddeford, ME, USA
| | - Erica Swan
- MaineHealth Corporate, Portland, ME, USA
| | - Jean A Talbot
- Muskie School of Public Service, University of Southern Maine, Portland, ME, USA
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Elmer J, Dougherty M, Guyette FX, Martin-Gill C, Drake CD, Callaway CW, Wallace DJ. Comparing strategies for prehospital transport to specialty care after cardiac arrest. Resuscitation 2023; 191:109943. [PMID: 37625579 PMCID: PMC10530609 DOI: 10.1016/j.resuscitation.2023.109943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/18/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023]
Abstract
Outcomes are better when patients resuscitated from out-of-hospital cardiac arrest (OHCA) are treated at specialty centers. The best strategy to transport patients from the scene of resuscitation to specialty care is unknown. METHODS We performed a retrospective cohort study. We identified patients treated at a single specialty center after OHCA from 2010 to 2021 and used OHCA geolocations to develop a catchment area using a convex hull. Within this area, we identified short term acute care hospitals, OHCA receiving centers, adult population by census block group, and helicopter landing zones. We determined population-level times to specialty care via: (1) direct ground transport; (2) transport to the nearest hospital followed by air interfacility transfer; and (3) ground transport to air ambulance. We used an instrumental variable (IV) adjusted probit regression to estimate the causal effect of transport strategy on functionally favorable survival to hospital discharge. RESULTS Direct transport to specialty care by ground to air ambulance had the shortest population-level times from OHCA to specialty care (median 56 [IQR 47-66] minutes). There were 1,861 patients included in IV regression of whom 395 (21%) had functionally favorable survival. Most (n = 1,221, 66%) were transported to the nearest hospital by ground EMS then to specialty care by air. Patient outcomes did not differ across transport strategies in our IV analysis. DISCUSSION We did not find strong evidence in favor of a particular strategy for transport to specialty care after OHCA. Population level time to specialty care was shortest with ground ambulance transport to the nearest helicopter landing zone.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Michelle Dougherty
- Department of Behavioral and Community Health Sciences, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Coleman D Drake
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David J Wallace
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
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Presciutti AM, Flickinger KL, Coppler PJ, Ratay C, Doshi AA, Perman SM, Vranceanu AM, Elmer J. Protective positive psychology factors and emotional distress after cardiac arrest. Resuscitation 2023:109846. [PMID: 37207872 DOI: 10.1016/j.resuscitation.2023.109846] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND There is a critical need to identify factors that can prevent emotional distress post-cardiac arrest (CA). CA survivors have previously described benefitting from utilizing positive psychology constructs (mindfulness, existential well-being, resilient coping, social support) to cope with distress. Here, we explored associations between positive psychology factors and emotional distress post-CA. METHODS We recruited CA survivors treated from 4/2021-9/2022 at a single academic medical center. We assessed positive psychology factors (mindfulness [Cognitive and Affective Mindfulness Scale-Revised], existential well-being [Meaning in Life Questionnaire Presence of Meaning subscale], resilient coping [Brief Resilient Coping Scale], perceived social support [ENRICHD Social Support Inventory]) and emotional distress (posttraumatic stress [Posttraumatic Stress Checklist-5], anxiety and depression symptoms [PROMIS Emotional Distress - Anxiety and Depression Short Forms 4a]) just before discharge from the index hospitalization. We selected covariates for inclusion in our multivariable models based on an association with any emotional distress factor (p < 0.10). For our final, multivariable regression models, we individually tested the independent association of each positive psychology factor and emotional distress factor. RESULTS We included 110 survivors (mean age 59 years, 64% male, 88% non-Hispanic White, 48% low income); 36.4% of survivors scored above the cut-off for at least one measure of emotional distress. In separate adjusted models, each positive psychology factor was independently associated with emotional distress (β: -0.20 to -0.42, all p < 0.05). CONCLUSIONS Higher levels of mindfulness, existential well-being, resilient coping, and perceived social support were each associated with less emotional distress. Future intervention development studies should consider these factors as potential treatment targets.
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Affiliation(s)
- Alexander M Presciutti
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital; Department of Psychiatry, Harvard Medical School.
| | | | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine
| | - Cecelia Ratay
- Department of Emergency Medicine, University of Pittsburgh School of Medicine
| | - Ankur A Doshi
- Department of Emergency Medicine, University of Pittsburgh School of Medicine
| | - Sarah M Perman
- Department of Emergency Medicine, University of Colorado School of Medicine
| | - Ana-Maria Vranceanu
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital; Department of Psychiatry, Harvard Medical School
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine; Department of Critical Care Medicine, University of Pittsburgh School of Medicine; Department of Neurology, University of Pittsburgh School of Medicine
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Alangaden KJ, Mosesso VN. Does Speed Kill? Post-ROSC Prehospital Scene Time and Outcomes. Resuscitation 2023; 188:109819. [PMID: 37150396 DOI: 10.1016/j.resuscitation.2023.109819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 04/26/2023] [Indexed: 05/09/2023]
Affiliation(s)
- Keith J Alangaden
- EMS Fellow, University of Pittsburgh School of Medicine Pittsburgh, PA, USA
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De-Arteaga M, Elmer J. Self-fulfilling prophecies and machine learning in resuscitation science. Resuscitation 2023; 183:109622. [PMID: 36306959 PMCID: PMC10687765 DOI: 10.1016/j.resuscitation.2022.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/22/2022] [Accepted: 10/17/2022] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Growth of machine learning (ML) in healthcare has increased potential for observational data to guide clinical practice systematically. This can create self-fulfilling prophecies (SFPs), which arise when prediction of an outcome increases the chance that the outcome occurs. METHODS We performed a scoping review, searching PubMed and ArXiv using terms related to machine learning, algorithmic fairness and bias. We reviewed results and selected manuscripts for inclusion based on expert opinion of well-designed or key studies and review articles. We summarized these articles to explore how use of ML can create, perpetuate or compound SFPs, and offer recommendations to mitigate these risks. RESULTS We identify-four key mechanisms through which SFPs may be reproduced or compounded by ML. First, imperfect human beliefs and behavior may be encoded as SFPs when treatment decisions are not accounted for. Since patient outcomes are influenced by a myriad of clinical actions, many of which are not collected in data, this is common. Second, human-machine interaction may compound SFPs through a cycle of mutual reinforcement. Third, ML may introduce new SFPs stemming from incorrect predictions. Finally, historically correct clinical choices may become SFPs in the face of medical progress. CONCLUSION There is a need for broad recognition of SFPs as ML is increasingly applied in resuscitation science and across medicine. Acknowledging this challenge is crucial to inform research and practice that can transform ML from a tool that risks obfuscating and compounding SFPs into one that sheds light on and mitigates SFPs.
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Affiliation(s)
- Maria De-Arteaga
- Information, Risk and Operations Management Department, McCombs School of Business, University of Texas at Austin, Austin, TX, USA
| | - Jonathan Elmer
- Departments of Emergency Medicine, Critical Care Medicine and Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Krampe N, Case N, Rittenberger JC, Condle JP, Doshi AA, Flickinger KL, Callaway CW, Wallace DJ, Elmer J. Evaluating novel methods of outcome assessment following cardiac arrest. Resuscitation 2022; 181:160-167. [PMID: 36410604 PMCID: PMC9771945 DOI: 10.1016/j.resuscitation.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION We compared novel methods of long-term follow-up after resuscitation from cardiac arrest to a query of the National Death Index (NDI). We hypothesized use of the electronic health record (EHR), and internet-based sources would have high sensitivity for identifying decedents identified by the NDI. METHODS We performed a retrospective study including patients treated after cardiac arrest at a single academic center from 2010 to 2018. We evaluated two novel methods to ascertain long-term survival and modified Rankin Scale (mRS): 1) a structured chart review of our health system's EHR; and 2) an internet-based search of: a) local newspapers, b) Ancestry.com, c) Facebook, d) Twitter, e) Instagram, and f) Google. If a patient was not reported deceased by any source, we considered them to be alive. We compared results of these novel methods to the NDI to calculate sensitivity. We queried the NDI for 200 in-hospital decedents to evaluate sensitivity against a true criterion standard. RESULTS We included 1,097 patients, 897 (82%) alive at discharge and 200 known decedents (18%). NDI identified 197/200 (99%) of known decedents. The EHR and local newspapers had highest sensitivity compared to the NDI (87% and 86% sensitivity, respectively). Online sources identified 10 likely decedents not identified by the NDI. Functional status estimated from EHR, and internet sources at follow up agreed in 38% of alive patients. CONCLUSIONS Novel methods of outcome assessment are an alternative to NDI for determining patients' vital status. These methods are less reliable for estimating functional status.
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Affiliation(s)
- Noah Krampe
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nicholas Case
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Emergency Medicine, Guthrie Robert Packer Hospital, Sayre, PA, USA; Department of Occupational Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, PA, USA
| | - Joseph P Condle
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ankur A Doshi
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Katharyn L Flickinger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David J Wallace
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Lanyi M, Elmer J, Guyette FX, Martin-Gill C, Venkat A, Traynor O, Walker H, Seaman K, Kochanek PM, Fink EL. Survival Rates After Pediatric Traumatic Out-of-Hospital Cardiac Arrest Suggest an Underappreciated Therapeutic Opportunity. Pediatr Emerg Care 2022; 38:417-422. [PMID: 35947060 PMCID: PMC9427720 DOI: 10.1097/pec.0000000000002806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Children with traumatic arrests represent almost one third of annual pediatric out-of-hospital cardiac arrests (OHCAs). However, traumatic arrests are often excluded from study populations because survival posttraumatic arrest is thought to be negligible. We hypothesized that children treated and transported by emergency medical services (EMS) personnel after traumatic OHCA would have lower survival compared with children treated after medical OHCA. METHODS We performed a secondary, observational study of children younger than 18 years treated and transported by 78 EMS agencies in southwestern Pennsylvania after OHCA from 2010 to 2014. Etiology was determined as trauma or medical by EMS services. We analyzed patient, cardiac arrest, and resuscitation characteristics and ascertained vital status using the National Death Index. We used multivariable logistic regression to test the association of etiology with mortality after covariate adjustment. RESULTS Forty eight of 209 children (23%) had traumatic OHCA. Children with trauma were older than those with medical OHCA (13.2 [3.8-15.9] vs 0.5 [0.2-2.4] years, P < 0.001). Prehospital return of spontaneous circulation frequency for trauma versus medical etiology was similar (90% vs 87%, P = 0.84). Patients with trauma had higher mortality (69% vs 45% P = 0.004). CONCLUSIONS More than 8 of 10 children with EMS treated and transported OHCA achieved return of spontaneous circulation. Despite lower survival rates than medical OHCA patients, almost one third of children with a traumatic etiology survived throughout the study period. Future research programs warrant inclusion of children with traumatic OHCA to improve outcomes.
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Affiliation(s)
- Maria Lanyi
- From the University of Pittsburgh Medical School
| | | | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh School of Medicine
| | | | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network
| | - Owen Traynor
- Department of Emergency Medicine, St Clair Hospital, Pittsburgh
| | - Heather Walker
- Department of Emergency Medicine, Excela Health, Greensburg
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Influence of the Level of Emergency Medical Facility on the Short-Term Treatment Results of Cardiac Arrest: Out-of-Hospital Cardiac Arrest and Interhospital Transfer. Emerg Med Int 2022; 2022:2662956. [PMID: 36065222 PMCID: PMC9440813 DOI: 10.1155/2022/2662956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/01/2022] [Indexed: 11/17/2022] Open
Abstract
Objective. This study aimed to elucidate whether direct transport of out-of-hospital cardiac arrest (OHCA) patients to higher-level emergency medical centres (EMCs) would result in better survival compared to resuscitation in smaller local emergency departments (EDs) and subsequent transfer. Methods. This study was a retrospective population-based analysis of cases registered in the national database of 2019. This study investigated the immediate results of cardiopulmonary resuscitation for OHCA compared between EMCs and EDs and the results of therapeutic temperature management (TTM) compared between the patients directly transported from the field and those transferred from other hospitals. In-hospital mortality was compared using multivariate logistic regression. Results. From the population dataset, 11,493 OHCA patients were extracted. (8,912 in the EMC group vs. 2,581 in the ED group). Multivariate logistic regression revealed that the odds for ED mortality were lower with treatment in EDs than with treatment in EMCs. (odds ratio 0.712 (95% confidence interval (CI): 0.638–0.796)). From the study dataset, 1,798 patients who received TTM were extracted. (1,164 in the direct visit group vs. 634 in the transferred group). Multivariate regression analysis showed that the odds ratio for overall mortality was 1.411 (95% CI: 0.809–2.446) in the transferred group. (
). Conclusion. The immediate outcome of OHCA patients who were transported to EDs was not inferior to that of EMCs. Therefore, it would be acceptable to transport OHCA patients to the nearest emergency facilities rather than to the specialized centres in distant areas.
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Kim GW, Moon HJ, Lim H, Kim YJ, Lee CA, Park YJ, Lee KM, Woo JH, Cho JS, Jeong WJ, Choi HJ, Kim CS, Choi HJ, Choi IK, Heo NH, Park JS, Lee YH, Park SM, Jeong DK. Effects of Smart Advanced Life Support protocol implementation including CPR coaching during out-of-hospital cardiac arrest. Am J Emerg Med 2022; 56:211-217. [DOI: 10.1016/j.ajem.2022.03.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 03/21/2022] [Accepted: 03/27/2022] [Indexed: 01/23/2023] Open
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Eiding H, Kongsgaard UE, Olasveengen TM, Heyerdahl F. Interhospital transport of critically ill patients: A prospective observational study of patient and transport characteristics. Acta Anaesthesiol Scand 2022; 66:248-255. [PMID: 34811736 DOI: 10.1111/aas.14005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 09/20/2021] [Accepted: 10/15/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The cohort of critically ill patients transported between Intensive Care Units (ICUs) in Norway has not been studied previously. The aim of this study was to describe the characteristics of patients and transports for different types of interhospital transfers and explore whether there were differences in morbidity and mortality between the different transfer categories and the general Norwegian ICU population. METHODS All transports of critically ill adult patients transferred between two geographically different Intensive Care Units during a one-year period were registered. Patient and transport data were obtained from The Norwegian Intensive Care Registry, The Norwegian Cause of Death Registry, the hospital Electronic Patient Journal, the Air Ambulance Journal System, and the Emergency Medical Communication Centre database. RESULTS 821 transports of 788 surgical and medical patients were enrolled. Simplified Acute Physiology Scores (SAPSII) were 43, 36 and 38 for urgent secondary transport, non-urgent secondary transport and return transfers, respectively. These were comparable to nationwide SAPSII scores that were 40 for university hospitals and 34 for local hospitals during the same time period. The return transfers had a median SOFA-score of 4.7 and 53% were mechanically ventilated. Only 33% of return transfers were performed by established teams. CONCLUSION Intensive care patients transferred between ICUs are as critically ill as the rest of the ICU population, with a similar morbidity and mortality. The return transfers of ICU-patients appear under-triaged compared to secondary transports in terms of allocated resources.
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Affiliation(s)
- Helge Eiding
- Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
- Department of Research and Development Norwegian Air Ambulance Foundation Oslo Norway
| | - Ulf E. Kongsgaard
- Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine Medical Faculty University of Oslo Oslo Norway
| | - Theresa M. Olasveengen
- Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine Medical Faculty University of Oslo Oslo Norway
| | - Fridtjof Heyerdahl
- Department of Research and Development Norwegian Air Ambulance Foundation Oslo Norway
- Institute of Clinical Medicine Medical Faculty University of Oslo Oslo Norway
- Division of Prehospital Services Oslo University Hospital Oslo Norway
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Xiao A, Callaway CW, Coppler PJ. Long-term Outcomes of Post-Cardiac Arrest Patients with Severe Neurological and Functional Impairments at Hospital Discharge. Resuscitation 2022; 174:93-101. [PMID: 35189302 PMCID: PMC10404449 DOI: 10.1016/j.resuscitation.2022.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/10/2022] [Accepted: 02/12/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients resuscitated from cardiac arrest who have severe neurological or functional disability at discharge require high-intensity long-term support. However, few data describe the long-term survival and health-care utilization for these patients. METHODS We identified a cohort of cardiac arrest survivors ≥ 18 years of age, treated at a single center in Western Pennsylvania from January 2010 to December 2019, with a modified Rankin scale (mRS) of 5 at hospital discharge. We recorded demographics, cardiac arrest characteristics, and neurological exam at hospital discharge. We characterized long term survival and mortality through December 31, 2020 through National Death Index query. We described survival time overall and in subgroups using Kaplan-Meier curves and compared using log-rank tests.We linked cases with administrative data to determine 30, 90 day, and one-year hospital readmission rate. For subjects unable to follow commands at discharge, we reviewed records from index hospitalization to the present to describe improvement in neurological status and return home. RESULTS We screened 2,687 patients of which 975 survived to discharge. We identified 190 subjects with mRS of 5 at hospital discharge who were sent to non-hospice settings. Of these, 43 (23%) did not follow commands at discharge. One-year mortality was 38% (n = 71) with a median survival time of 4.2 years (IQR 0.3-10.9). Duration of survival was shorter in older subjects but did not differ based on, sex, or ability to follow commands at hospital discharge. Within the first year of discharge, 58% (n = 111) of subjects had at least one hospitalization with a median length of stay of 8 days [IQR 3-19]. Of subjects who did not follow commands at hospital discharge, 5/43 (11%) followed commands and 9 (21%) were reportedly living at home on subsequent encounters. CONCLUSIONS Of survivors treated over a decade at our institution, 20% (n = 190) were discharged from the hospital with severe functional disability. One-year mortality was 38%, and hospital readmissions were frequent. Few patients discharged unable to follow commands regained the ability over the period of observation, but many did return to living at home. These data can help inform decision maker expectations for patient trajectory and life expectancy.
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13
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Steinberg A, Grayek E, Arnold RM, Callaway C, Fischhoff B, Krishnamurti T, Mohan D, White DB, Elmer J. Physicians' cognitive approach to prognostication after cardiac arrest. Resuscitation 2022; 173:112-121. [PMID: 35017011 PMCID: PMC8983442 DOI: 10.1016/j.resuscitation.2022.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 12/02/2021] [Accepted: 01/03/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Elucidate how physicians formulate a neurological prognosis after cardiac arrest and compare differences between experts and general providers. METHODS We performed semi-structured interviews with experts in post-arrest care and general physicians. We created an initial model and interview guide based on professional society guidelines. Two authors independently coded interviews based on this initial model, then identified new topics not included in it. To describe individual physicians' cognitive approach to prognostication, we created a graphical representation. We summarized these individual "mental models" into a single overall model, as well as two models stratified by expertise. RESULTS We performed 36 interviews (17 experts and 19 generalists), most of whom practice in Europe (23) or North America (12). Participants described their approach to prognosis formulation as complex and iterative, with sequential and repeated data acquisition, interpretation, and prognosis formulation. Eventually, this cycle results in a final prognosis and treatment recommendation. Commonly mentioned factors were diagnostic test performance, time from arrest, patient characteristics. Participants also discussed factors rarely discussed in prognostication research including physician and hospital characteristics. We found no substantial differences between experts and general physicians. CONCLUSION Physicians' cognitive approach to neurologic prognostication is complex and influenced by many factors, including some rarely considered in current research. Understanding these processes better could inform interventions designed to aid physicians in prognostication.
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Affiliation(s)
- Alexis Steinberg
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Emily Grayek
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Clifton Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA, USA; Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Tamar Krishnamurti
- Department of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Douglas B White
- Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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14
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Flickinger KL, Jaramillo S, Repine MJ, Koller AC, Holm M, Skidmore E, Callaway C, Rittenberger JC. One-year outcomes in individual domains of the cerebral performance category extended. Resusc Plus 2021; 8:100184. [PMID: 34934994 DOI: 10.1016/j.resplu.2021.100184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/05/2021] [Accepted: 11/13/2021] [Indexed: 01/14/2023] Open
Abstract
Background Physical and cognitive impairments are common after cardiac arrest, and recovery varies. This study assessed recovery of individual domains of the Cerebral Performance Category- Extended (CPC-E) 1-year after cardiac arrest. We hypothesized patients would have recovery in all CPC-E domains 1-year after the index cardiac arrest. Methods Prospective cohort study of cardiac arrest survivors evaluating outcome measures mRS, CPC, and CPC-E. Outcomes were assessed at discharge, 3-months, 6-months, and 1-year. We defined recovery of a CPC-E domain when >90% of patients had scores of 1-2 in that domain. Results Of 156 patients discharged, 57 completed the CPC-E at discharge, and were included in the analysis. 37 patients had follow-up at 3-months, and 23 patients had follow-up at 6 and 12 months. Only 16 patients had assessments at all four timepoints. Domains of alertness (N = 56, 98%) logical thinking (N = 56; 98%), and attention (N = 55; 96%) recovered by hospital discharge. BADL (N = 34; 92%) and motor skills (N = 36; 97%) recovered by 3-months. Most patients (N = 20; 87%) experienced slight-to-no disability or symptoms (mRS 0-2/CPC 1-2) at 1-year follow up. CPC-E domains of short term memory (78%), mood (87%), fatigue (22%), complex ADL (78%), and return to work (65%) did not recover by 1-year. Conclusions CPC-E domains of alertness, logical thinking, and attention recover rapidly, while domains of short term memory, mood, fatigue, complex ADL and return to work remain chronically impaired 1-year after cardiac arrest. These deficits are not detected by mRS and CPC. Interventions to improve recovery in these domains are needed.
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Affiliation(s)
- Katharyn L Flickinger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Stephany Jaramillo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Melissa J Repine
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Allison C Koller
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Margo Holm
- Department of Occupational Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, PA, USA
| | - Elizabeth Skidmore
- Department of Occupational Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, PA, USA
| | - Clif Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Occupational Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, PA, USA.,Department of Emergency Medicine, Guthrie Robert Packer Hospital, Sayre, PA, USA
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15
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Yeo JW, Ng ZHC, Goh AXC, Gao JF, Liu N, Lam SWS, Chia YW, Perkins GD, Ong MEH, Ho AFW. Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 11:e023806. [PMID: 34927456 PMCID: PMC9075197 DOI: 10.1161/jaha.121.023806] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background The role of cardiac arrest centers (CACs) in out‐of‐hospital cardiac arrest care systems is continuously evolving. Interpretation of existing literature is limited by heterogeneity in CAC characteristics and types of patients transported to CACs. This study assesses the impact of CACs on survival in out‐of‐hospital cardiac arrest according to varying definitions of CAC and prespecified subgroups. Methods and Results Electronic databases were searched from inception to March 9, 2021 for relevant studies. Centers were considered CACs if self‐declared by study authors and capable of relevant interventions. Main outcomes were survival and neurologically favorable survival at hospital discharge or 30 days. Meta‐analyses were performed for adjusted odds ratio (aOR) and crude odds ratios. Thirty‐six studies were analyzed. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR, 1.85 [95% CI, 1.52–2.26]), even when including high‐volume centers (aOR, 1.50 [95% CI, 1.18–1.91]) or including improved‐care centers (aOR, 2.13 [95% CI, 1.75–2.59]) as CACs. Survival significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59–2.32]), even when including high‐volume centers (aOR, 1.74 [95% CI, 1.38–2.18]) or when including improved‐care centers (aOR, 1.97 [95% CI, 1.71–2.26]) as CACs. The treatment effect was more pronounced among patients with shockable rhythm (P=0.006) and without prehospital return of spontaneous circulation (P=0.005). Conclusions were robust to sensitivity analyses, with no publication bias detected. Conclusions Care at CACs was associated with improved survival and neurological outcomes for patients with nontraumatic out‐of‐hospital cardiac arrest regardless of varying CAC definitions. Patients with shockable rhythms and those without prehospital return of spontaneous circulation benefited more from CACs. Evidence for bypassing hospitals or interhospital transfer remains inconclusive.
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Affiliation(s)
- Jun Wei Yeo
- Yong Loo Lin School of Medicine National University of Singapore Singapore
| | - Zi Hui Celeste Ng
- Yong Loo Lin School of Medicine National University of Singapore Singapore
| | | | | | - Nan Liu
- Centre for Quantitative Medicine Duke-NUS Medical SchoolNational University of Singapore Singapore
| | - Shao Wei Sean Lam
- Health Services Research Centre SingHealth Duke-NUS Academic Medical Centre Singapore
| | - Yew Woon Chia
- Department of Cardiology Tan Tock Seng Hospital Singapore
| | - Gavin D Perkins
- Warwick Medical School University of Warwick Coventry United Kingdom
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine Singapore General Hospital Singapore.,Health Services & Systems Research Duke-NUS Medical School Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine Singapore General Hospital Singapore.,Pre-Hospital and Emergency Research Centre Health Services and Systems Research Duke-NUS Medical School Singapore
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16
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Zadorozny EV, Guyette FX, Flickinger KL, Martin-Gill C, Amoah K, Artist O, Mohammed A, Condle JP, Callaway CW, Elmer J, Coppler PJ. Time to specialty care and mortality after cardiac arrest. Am J Emerg Med 2021; 50:618-624. [PMID: 34879476 DOI: 10.1016/j.ajem.2021.09.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/03/2021] [Accepted: 09/10/2021] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Out of hospital cardiac arrest (OHCA) patients are often transported to the closest emergency department (ED) or cardiac center for initial stabilization and may be transferred for further care. We investigated the effects of delay to transfer on in hospital mortality at a receiving facility. METHODS We included OHCA patients transported from the ED by a single critical care transport service to a quaternary care facility between 2010 and 2018. We calculated dwell time as time from arrest to critical care transport team contact. We abstracted demographics, arrest characteristics, and interventions started prior to transport arrival. For the primary analysis, we used logistic regression to determine the association of dwell time and in-hospital mortality. As secondary outcomes we investigated for associations of dwell time and mortality within 24 h of arrival, proximate cause of death among decedents, arterial pH and lactate on arrival, sum of worst SOFA subscales within 24 h of arrival, and rearrest during interfacility transport. RESULTS We included 572 OHCA patients transported from an outside ED to our facility. Median dwell time was 113 (IQR = 85-159) minutes. Measured in 30 min epochs, increasing dwell time was not associated with in-hospital mortality, 24-h mortality, cause of death and initial pH, but was associated with lower 24-h SOFA score (p = 0.01) and lower initial lactate (p = 0.03). Rearrest during transport was rare (n = 29, 5%). Dwell time was associated with lower probability of rearrest during transport (OR = 0.847, (95% CI 0.68-1.01), p = 0.07). CONCLUSIONS Dwell time was not associated with in-hospital mortality. Rapid transport may be associated with risk of rearrest. Prospective data are needed to clarify optimal patient stabilization and transport strategies.
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Affiliation(s)
- Eva V Zadorozny
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Francis X Guyette
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Katharyn L Flickinger
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Christian Martin-Gill
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Kaia Amoah
- Howard University College of Medicine, Washington, DC, USA
| | - Onaje Artist
- Howard University College of Medicine, Washington, DC, USA
| | | | - Joseph P Condle
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Clifton W Callaway
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Jonathan Elmer
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA; University of Pittsburgh School of Medicine, Department of Critical Care Medicine, Pittsburgh, Pennsylvania, USA; University of Pittsburgh School of Medicine, Department of Neurology, Pittsburgh, Pennsylvania, USA
| | - Patrick J Coppler
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA.
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17
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Park JH, Choi J, Lee S, Shin SD, Song KJ. Use of Time-to-Event Analysis to Develop On-Scene Return of Spontaneous Circulation Prediction for Out-of-Hospital Cardiac Arrest Patients. Ann Emerg Med 2021; 79:132-144. [PMID: 34417073 DOI: 10.1016/j.annemergmed.2021.07.121] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/05/2021] [Accepted: 07/14/2021] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVE We aimed to train and validate the time to on-scene return of spontaneous circulation prediction models using time-to-event analysis among out-of-hospital cardiac arrest patients. METHODS Using a Korean population-based out-of-hospital cardiac arrest registry, we selected a total of 105,215 adults with presumed cardiac etiologies between 2013 and 2018. Patients from 2013 to 2017 and from 2018 were analyzed for training and test, respectively. We developed 4 time-to-event analyzing models (Cox proportional hazard [Cox], random survival forest, extreme gradient boosting survival, and DeepHit) and 4 classification models (logistic regression, random forest, extreme gradient boosting, and feedforward neural network). Patient characteristics and Utstein elements collected at the scene were used as predictors. Discrimination and calibration were evaluated by Harrell's C-index and integrated Brier score. RESULTS Among the 105,215 patients (mean age 70 years and 64% men), 86,314 and 18,901 patients belonged to the training and test sets, respectively. On-scene return of spontaneous circulation was achieved in 5,240 (6.1%) patients in the former set and 1,709 (9.0%) patients in the latter. The proportion of emergency medical services (EMS) management was higher and scene time interval longer in the latter. Median time from EMS scene arrival to on-scene return of spontaneous circulation was 8 minutes for both datasets. Classification models showed similar discrimination and poor calibration power compared to survival models; Cox showed high discrimination with the best calibration (C-index [95% confidence interval]: 0.873 [0.865 to 0.882]; integrated Brier score at 30 minutes: 0.060). CONCLUSION Incorporating time-to-event analysis could lead to improved performance in prediction models and contribute to personalized field EMS resuscitation decisions.
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Affiliation(s)
- Jeong Ho Park
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea; Department of Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Jinwook Choi
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea; Institute of Medical and Biological Engineering, Medical Research Center, Seoul National University, Seoul, Korea.
| | - SangMyeong Lee
- School of Electrical Engineering, Undergraduate School of Korea University, Seoul, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Kyoung Jun Song
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea; Department of Emergency Medicine, Seoul National University College of Medicine and Seoul National University Boramae Medical Center, Seoul, Korea
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18
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Between-hospital variability in organ donation after resuscitation from out-of-hospital cardiac arrest. Resuscitation 2021; 167:372-379. [PMID: 34363855 DOI: 10.1016/j.resuscitation.2021.07.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 07/15/2021] [Accepted: 07/22/2021] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Survival and recovery after out-of-hospital cardiac arrest (OHCA) varies between hospitals, with better outcomes associated with high-volume and specialty care. We evaluated if there is a similar relationship with organ donation after OHCA. METHODS We studied a cohort of adults resuscitated from OHCA from 2010 to 2018, treated at one of 112 hospitals served by a regional organ procurement organization (OPO). We obtained hospital-level characteristics from Centers for Medicare and Medicaid Services and Health Resources and Services Administration and obtained patients' clinical information from the OPO health record. We excluded patients with no potential to donate on initial referral. Our primary exposure was treatment at a high-volume hospital (defined >500 eligible cases during the study period) and our primary outcomes were suitability to donate after full medical evaluation, successful organ procurement and organ transplantation. We used mixed effects models to quantify between-hospital variability in the primary outcomes RESULTS: Overall, 9,792 patients were included and 796 (8%) were organ donors. We identified significant between-hospital variation in odds of donation (median odds ratio 1.64 [95% CI 1.42 - 2.02]). Hospital volume explained the greatest proportion of variability. High volume centers had a higher proportion of referrals with potential to donate (16.9 vs 12.2%), actual donation (10.3 vs 6.2%), and successful transplantation (9.4 vs 5.7%). Overall, 2032/7763 (26%) of recovered transplantable organs in this region were procured from OHCA patients. CONCLUSION High volume centers are more likely to refer and procure transplantable organs from patients with non-survivable OHCA.
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19
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Awakening from post anoxic coma with burst suppression with identical bursts. Resusc Plus 2021; 7:100151. [PMID: 34386780 PMCID: PMC8342773 DOI: 10.1016/j.resplu.2021.100151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/14/2021] [Accepted: 07/02/2021] [Indexed: 11/20/2022] Open
Abstract
Background Electroencephalography (EEG) is commonly used after cardiac arrest. Burst suppression with identical bursts (BSIB) has been reported as a perfectly specific predictor of poor outcome but published case series are small. We describe two patients with BSIB who awakened from coma after cardiac arrest. Methods We identified two out-of-hospital cardiac arrest (OHCA) patients with coma and BSIB. We determined the etiology of arrest, presenting neurological examination, potential confounders to neurological assessment, neurodiagnostics and time to awakening. We reviewed and interpreted EEGs using 2021 American Clinical Neurophysiology Society guidelines. We quantified identicality of bursts by calculating pairwise correlation coefficients between the first 500 ms of each aligned burst. Results In case one we present a 62-year-old man with OHCA secondary to septic shock. EEG showed burst suppression pattern, with bursts consisted of high amplitude generalized spike waves in lock-step with myoclonus (inter-burst correlation = 0.86). He followed commands 3 days after arrest, when repeat EEG showed a continuous, variable and reactive background without epileptiform activity. Case two was a 49-year-old woman with OHCA secondary to polysubstance overdose. Initial EEG revealed burst suppression with high amplitude generalized polyspike-wave bursts with associated myoclonus. She followed commands on post-arrest day 4, when repeat EEG showed a continuous, variable and reactive background with frequent runs of bifrontal predominant sharply contoured rhythmic delta activity. Conclusion These cases highlight the perils of prognosticating with a single modality in comatose cardiac arrest patients.
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20
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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22
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Hwang SO, Cha KC, Jung WJ, Roh YI, Kim TY, Chung SP, Kim YM, Park JD, Kim HS, Lee MJ, Na SH, Cho GC, Kim ARE. 2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 2. Environment for cardiac arrest survival and the chain of survival. Clin Exp Emerg Med 2021; 8:S8-S14. [PMID: 34034446 PMCID: PMC8171179 DOI: 10.15441/ceem.21.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 04/02/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Woo Jin Jung
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young-Il Roh
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Tae Youn Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Min Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Jin Lee
- Department of Emergency Medicine, Kyungpook National University College of Medicine, Daegu, Korea
| | - Sang-Hoon Na
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Gyu Chong Cho
- Department of Emergency Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Ai-Rhan Ellen Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Seoul, Korea
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23
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Kim YM, Jeung KW, Kim WY, Park YS, Oh JS, You YH, Lee DH, Chae MK, Jeong YJ, Kim MC, Ha EJ, Hwang KJ, Kim WS, Lee JM, Cha KC, Chung SP, Park JD, Kim HS, Lee MJ, Na SH, Kim ARE, Hwang SO. 2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 5. Post-cardiac arrest care. Clin Exp Emerg Med 2021; 8:S41-S64. [PMID: 34034449 PMCID: PMC8171174 DOI: 10.15441/ceem.21.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 03/07/2021] [Accepted: 03/19/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- Young-Min Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joo Suk Oh
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yeon Ho You
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Minjung Kathy Chae
- Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Yoo Jin Jeong
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Min Chul Kim
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Eun Jin Ha
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Jin Hwang
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Won-Seok Kim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Myung Lee
- Department of General Surgery, Korea University College of Medicine, Seoul, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Jin Lee
- Department of Emergency Medicine, Kyoungbook University College of Medicine, Daegu, Korea
| | - Sang-Hoon Na
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ai-Rhan Ellen Kim
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - on behalf of the Steering Committee of 2020 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of General Surgery, Korea University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Kyoungbook University College of Medicine, Daegu, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 417] [Impact Index Per Article: 139.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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Abstract
The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.
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26
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 338] [Impact Index Per Article: 112.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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Coppler PJ, Callaway CW, Guyette FX, Baldwin M, Elmer J. Early risk stratification after resuscitation from cardiac arrest. J Am Coll Emerg Physicians Open 2020; 1:922-931. [PMID: 33145541 PMCID: PMC7593432 DOI: 10.1002/emp2.12043] [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: 12/31/2019] [Revised: 02/12/2020] [Accepted: 02/18/2020] [Indexed: 01/08/2023] Open
Abstract
Emergency clinicians often resuscitate cardiac arrest patients, and after acute resuscitation, clinicians face multiple decisions regarding disposition. Recent evidence suggests that out-of-hospital cardiac arrest patients with return of spontaneous circulation have higher odds of survival to hospital discharge, long-term survival, and improved functional outcomes when treated at centers that can provide advanced multidisciplinary care. For community clinicians, a high volume cardiac arrest center may be hours away. While current guidelines recommend against neurological prognostication in the first hours or days after return of spontaneous circulation, there are early findings suggestive of irrecoverable brain injury in which the patient would receive no benefit from transfer. In this Concepts article, we describe a simplified approach to quickly evaluate neurological status in cardiac arrest patients and identify findings concerning for irrecoverable brain injury. Characteristics of the arrest and resuscitation, initial neurological assessment, and brain computed tomography together can identify patients with high likelihood of irrecoverable anoxic injury. Patients who may benefit from centers with access to continuous electroencephalography are discussed. This approach can be used to identify patients who may benefit from rapid transfer to cardiac arrest centers versus those who may benefit from care close to home. Risk stratification also can provide realistic expectations for recovery to families.
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Affiliation(s)
- Patrick J. Coppler
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Clifton W. Callaway
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Francis X. Guyette
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Maria Baldwin
- Department of NeurologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Jonathan Elmer
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
- Department of NeurologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
- Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
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Abstract
Patients resuscitated from cardiac arrest require complex management. An organized approach to early postarrest care can improve patient outcomes. Priorities include completing a focused diagnostic work-up to identify and reverse the inciting cause of arrest, stabilizing cardiorespiratory instability to prevent rearrest, minimizing secondary brain injury, evaluating the risk and benefits of transfer to a specialty care center, and avoiding early neurologic prognostication.
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Kalra R, Bartos JA, Kosmopoulos M, Carlson C, John R, Shaffer A, Martin C, Raveendran G, Yannopoulos D. Echocardiographic evaluation of cardiac recovery after refractory out-of-hospital cardiac arrest. Resuscitation 2020; 154:38-46. [PMID: 32673734 DOI: 10.1016/j.resuscitation.2020.06.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 06/17/2020] [Accepted: 06/23/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The mechanisms and degree of myocardial recovery during treatment with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are unclear. We performed a descriptive study to evaluate myocardial recovery and changes in parameters of myocardial loading using echocardiography. METHODS We retrospectively evaluated patients with refractory ventricular tachycardia/ventricular fibrillation out-of-hospital cardiac arrest who were treated with the Minnesota Resuscitation Consortium protocol. Left ventricular ejection fraction (LVEF), end-diastolic diameter (LVEDD), end-systolic diameter (LVESD), and fractional shortening were assessed using serial echocardiography. One-way analysis of variance (ANOVA) was used to compare parameters over six hospitalization stages. Two-way ANOVA was used to compare these parameters between patients that survived the index hospitalization and those that died. RESULTS 77 patients had >1 echocardiographic turndown evaluations. Thirty-eight patients survived to discharge and 39 patients died. Of 39 in-hospital deaths, 17 patients died before VA-ECMO decannulation and 22 patients died after VA-ECMO decannulation. Among all patients, LVEF improved from 9.7 ± 10.1% from the first echocardiogram after rewarming to 43.1 ± 13.1% after decannulation (p < 0.001) and fractional shortening ratio improved from 0.14 ± 0.12 to 0.31 ± 0.14 (p < 0.001). The LVEDD and LVESD remained stable (p = 0.36 and p = 0.12, respectively). Patients that died had a lower LVEF by an average of 6.93% (95% confidence interval: -10.0 to -3.83, p < 0.001), but other parameters were similar. CONCLUSION Refractory cardiac arrest patients treated with VA-ECMO experience significant recovery of ventricular function during treatment. We postulate that this primarily occurs via reduction of LV preload.
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Affiliation(s)
- Rajat Kalra
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Jason A Bartos
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Marinos Kosmopoulos
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Claire Carlson
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ranjit John
- Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Andrew Shaffer
- Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Cindy Martin
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, United States
| | - Ganesh Raveendran
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Demetris Yannopoulos
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN, USA.
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Callaway CW, Coppler PJ, Faro J, Puyana JS, Solanki P, Dezfulian C, Doshi AA, Elmer J, Frisch A, Guyette FX, Okubo M, Rittenberger JC, Weissman A. Association of Initial Illness Severity and Outcomes After Cardiac Arrest With Targeted Temperature Management at 36 °C or 33 °C. JAMA Netw Open 2020; 3:e208215. [PMID: 32701158 PMCID: PMC7378753 DOI: 10.1001/jamanetworkopen.2020.8215] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE It is uncertain what the optimal target temperature is for targeted temperature management (TTM) in patients who are comatose following cardiac arrest. OBJECTIVE To examine whether illness severity is associated with changes in the association between target temperature and patient outcome. DESIGN, SETTING, AND PARTICIPANTS This cohort study compared outcomes for 1319 patients who were comatose after cardiac arrest at a single center in Pittsburgh, Pennsylvania, from January 2010 to December 2018. Initial illness severity was based on coma and organ failure scores, presence of severe cerebral edema, and presence of highly malignant electroencephalogram (EEG) after resuscitation. EXPOSURE TTM at 36 °C or 33 °C. MAIN OUTCOMES AND MEASURES Primary outcome was survival to hospital discharge, and secondary outcomes were modified Rankin Scale and cerebral performance category. RESULTS Among 1319 patients, 728 (55.2%) had TTM at 33 °C (451 [62.0%] men; median [interquartile range] age, 61 [50-72] years) and 591 (44.8%) had TTM at 36 °C (353 [59.7%] men; median [interquartile range] age, 59 [48-69] years). Overall, 184 of 187 patients (98.4%) with severe cerebral edema died and 234 of 243 patients (96.3%) with highly malignant EEG died regardless of TTM strategy. Comparing TTM at 33 °C with TTM at 36 °C in 911 patients (69.1%) with neither severe cerebral edema nor highly malignant EEG, survival was lower in patients with mild to moderate coma and no shock (risk difference, -13.8%; 95% CI, -24.4% to -3.2%) but higher in patients with mild to moderate coma and cardiopulmonary failure (risk difference, 21.8%; 95% CI, 5.4% to 38.2%) or with severe coma (risk difference, 9.7%; 95% CI, 4.0% to 15.3%). Interactions were similar for functional outcomes. Most deaths (633 of 968 [65.4%]) resulted after withdrawal of life-sustaining therapies. CONCLUSIONS AND RELEVANCE In this study, TTM at 33 °C was associated with better survival than TTM at 36 °C among patients with the most severe post-cardiac arrest illness but without severe cerebral edema or malignant EEG. However, TTM at 36 °C was associated with better survival among patients with mild- to moderate-severity illness.
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Affiliation(s)
- Clifton W. Callaway
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick J. Coppler
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John Faro
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob S. Puyana
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pawan Solanki
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cameron Dezfulian
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ankur A. Doshi
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan Elmer
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Adam Frisch
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Francis X. Guyette
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Masashi Okubo
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jon C. Rittenberger
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alexandra Weissman
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Cardiac arrest survivors lost to follow-up after 3-Months, 6-Months and 1-Year. Resuscitation 2020; 150:8-16. [DOI: 10.1016/j.resuscitation.2020.02.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/30/2020] [Accepted: 02/17/2020] [Indexed: 11/15/2022]
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Sonnier M, Rittenberger JC. State-of-the-art considerations in post-arrest care. J Am Coll Emerg Physicians Open 2020; 1:107-116. [PMID: 33000021 PMCID: PMC7493544 DOI: 10.1002/emp2.12022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 11/10/2022] Open
Abstract
Cardiac arrest has a high rate of morbidity and mortality. Several advances in post-cardiac arrest management can improve outcome, but are time-dependent, placing the emergency physician in a critical role to both recognize the need for and initiate therapy. We present a novel perspective of both the workup and therapeutic interventions geared toward the emergency physician during the first few hours of care. We describe how the immediate care of a post-cardiac arrest patient is resource intensive and requires simultaneous evaluation for the underlying cause and intensive management to prevent further end organ damage, particularly of the central nervous system. The goal of the initial focused assessment is to rapidly determine if any reversible causes of cardiac arrest are present and to intervene when possible. Interventions performed in this acute period are aimed at preventing additional brain injury through optimizing hemodynamics, providing ventilatory support, and by using therapeutic hypothermia when indicated. After the initial phase of care, disposition is guided by available resources and the clinician's judgment. Transfer to a specialized cardiac arrest center is prudent in centers that do not have significant support or experience in the care of these patients.
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Affiliation(s)
| | - Jon C. Rittenberger
- Guthrie Robert Packer HospitalSayrePennsylvania
- Geisinger Commonwealth Medical CollegeScrantonPennsylvania
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Mohr NM, Wu C, Ward MJ, McNaughton CD, Richardson K, Kaboli PJ. Potentially avoidable inter-facility transfer from Veterans Health Administration emergency departments: A cohort study. BMC Health Serv Res 2020; 20:110. [PMID: 32050947 PMCID: PMC7014752 DOI: 10.1186/s12913-020-4956-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 02/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inter-facility transfer is an important strategy for improving access to specialized health services, but transfers are complicated by over-triage, under-triage, travel burdens, and costs. The purpose of this study is to describe ED-based inter-facility transfer practices within the Veterans Health Administration (VHA) and to estimate the proportion of potentially avoidable transfers. METHODS This observational cohort study included all patients treated in VHA EDs between 2012 and 2014 who were transferred to another VHA hospital. Potentially avoidable transfers were defined as patients who were either discharged from the receiving ED or admitted to the receiving hospital for ≤1 day without having an invasive procedure performed. We conducted facility- and diagnosis-level analyses to identify subgroups of patients for whom potentially avoidable transfers had increased prevalence. RESULTS Of 6,173,189 ED visits during the 3-year study period, 18,852 (0.3%) were transferred from one VHA ED to another VHA facility. Rural residents were transferred three times as often as urban residents (0.6% vs. 0.2%, p < 0.001), and 22.8% of all VHA-to-VHA transfers were potentially avoidable transfers. The 3 disease categories most commonly associated with inter-facility transfer were mental health (34%), cardiac (12%), and digestive diagnoses (9%). CONCLUSIONS VHA inter-facility transfer is commonly performed for mental health and cardiac evaluation, particularly for patients in rural settings. The proportion that are potentially avoidable is small. Future work should focus on improving capabilities to provide specialty evaluation locally for these conditions, possibly using telehealth solutions.
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Affiliation(s)
- Nicholas M. Mohr
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA USA
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, USA
- Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242 USA
| | - Chaorong Wu
- Institute for Clinical and Translational Sciences, University of Iowa, Iowa City, Iowa USA
| | - Michael J. Ward
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Candace D. McNaughton
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Kelly Richardson
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA USA
| | - Peter J. Kaboli
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa USA
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Gul SS, Cohen SA, Avery KL, Balakrishnan MP, Balu R, Chowdhury MAB, Crabb D, Huesgen KW, Hwang CW, Maciel CB, Murphy TW, Han F, Becker TK. Cardiac arrest: An interdisciplinary review of the literature from 2018. Resuscitation 2020; 148:66-82. [PMID: 31945428 DOI: 10.1016/j.resuscitation.2019.12.030] [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: 08/22/2019] [Revised: 11/23/2019] [Accepted: 12/15/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The Interdisciplinary Cardiac Arrest Research Review (ICARE) group was formed in 2018 to conduct a systematic annual search of peer-reviewed literature relevant to cardiac arrest (CA). The goals of the review are to illustrate best practices and help reduce knowledge silos by disseminating clinically relevant advances in the field of CA across disciplines. METHODS An electronic search of PubMed using keywords related to CA was conducted. Title and abstracts retrieved by these searches were screened for relevancy, separated by article type (original research or review), and sorted into 7 categories. Screened manuscripts underwent standardized scoring of overall methodological quality and importance. Articles scoring higher than 99 percentiles by category-type were selected for full critique. Systematic differences between editors and reviewer scores were assessed using Wilcoxon signed-rank test. RESULTS A total of 9119 articles were identified on initial search; of these, 1214 were scored after screening for relevance and deduplication, and 80 underwent full critique. Prognostication & Outcomes category comprised 25% and Epidemiology & Public Health 17.5% of fully reviewed articles. There were no differences between editor and reviewer scoring. CONCLUSIONS The total number of articles demonstrates the need for an accessible source summarizing high-quality research findings to serve as a high-yield reference for clinicians and scientists seeking to absorb the ever-growing body of CA-related literature. This may promote further development of the unique and interdisciplinary field of CA medicine.
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Affiliation(s)
- Sarah S Gul
- Department of Surgery, Yale University, New Haven, CT, United States
| | - Scott A Cohen
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States
| | - K Leslie Avery
- Division of Pediatric Critical Care, Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | | | - Ramani Balu
- Division of Neurocritical Care, Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | | | - David Crabb
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States
| | - Karl W Huesgen
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States
| | - Charles W Hwang
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States
| | - Carolina B Maciel
- Division of Neurocritical Care, Department of Neurology, University of Florida, Gainesville, FL, United States; Department of Neurology, Yale University, New Haven, CT, United States
| | - Travis W Murphy
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States
| | - Francis Han
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States
| | - Torben K Becker
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States.
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Chonde M, Escajeda J, Elmer J, Callaway CW, Guyette FX, Boujoukos A, Sappington PL, Smith AJ, Schmidhofer M, Sciortino C, Kormos RL. Challenges in the development and implementation of a healthcare system based extracorporeal cardiopulmonary resuscitation (ECPR) program for the treatment of out of hospital cardiac arrest. Resuscitation 2019; 148:259-265. [PMID: 31887368 DOI: 10.1016/j.resuscitation.2019.12.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 12/12/2019] [Accepted: 12/17/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapies. Many institutions are interested in developing their own ECPR program. However, there may be challenges in logistics and implementation. AIMS The aim of our protocol was to demonstrate that an ECPR team was feasible within our healthcare system and that the identification of UPMC Presbyterian as a receiving center allowed for successful treatment within 30 min from EMS dispatch. METHODS We developed out of hospital cardiac arrest (OHCA) ECPR protocols for Emergency Medical Services (EMS), EMS communications, and our in-hospital ECPR team. Inclusion criteria indentified patients with a potentially reversible arrest etiology and high probability of recoverable brain injury using a simple checklist: witnessed collapse, layperson CPR, initial shockable rhythm, and age 18-60 years. We trained local EMS crews to screen patients and reviewed the criteria with a Medic Command Physician prior to transport to our hospital. RESULTS From October 2015 to March 31st 2018, EMS treated 1165 EMS OHCA cases, transported 664 (57%) to a local hospital, and transported 120 (10%) to our institution. Of these, five (4.1%) patients underwent ECPR. Among excluded cases, 64 (53%) had nonshockable rhythms, 48 (40%) were unwitnessed arrests, 50 (42%) were over age 60 and the remaining 20 (17%) had no documented reasons for exclusion. For ECPR cases, median pre-hospital CPR duration was 26 [IQR 25-40] min. Four patients (80%) received mechanical CPR. Interval from arrest to arrival on scene was 5 [IQR 4-6] min and interval from radio call to activation of ECPR was 13 [IQR 7-21] min. Interval from EMS dispatch to departure from scene was 20 [IQR 19-21] min. Time from EMS dispatch to initiation of ECPR was 63 [IQR 59-69] min. CONCLUSIONS ECPR is an infrequent occurrence in EMS practice. Most apparently eligible patients did not get ECPR, highlighting the need for ongoing programmatic development, provider education, and qualitative work exploring barriers to implementation.
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Affiliation(s)
- Meshe Chonde
- University of Pittsburgh, Department of Medicine, Divison of Cardiology, United States.
| | - Jeremiah Escajeda
- University of Pittsburgh, Department of Emergency Medicine, United States
| | - Jonathan Elmer
- University of Pittsburgh, Department of Emergency Medicine, United States; University of Pittsburgh, Department of Critical Care Medicine, United States
| | - Clifton W Callaway
- University of Pittsburgh, Department of Emergency Medicine, United States
| | - Frank X Guyette
- University of Pittsburgh, Department of Emergency Medicine, United States
| | - Arthur Boujoukos
- University of Pittsburgh, Department of Critical Care Medicine, United States
| | - Penny L Sappington
- University of Pittsburgh, Department of Critical Care Medicine, United States
| | - Anson J Smith
- University of Pittsburgh, Department of Medicine, Divison of Cardiology, United States
| | - Mark Schmidhofer
- University of Pittsburgh, Department of Medicine, Divison of Cardiology, United States
| | | | - Robert L Kormos
- University of Pittsburgh, Department of Cardiothoracic Surgery, United States
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Soar J, Maconochie I, Wyckoff MH, Olasveengen TM, Singletary EM, Greif R, Aickin R, Bhanji F, Donnino MW, Mancini ME, Wyllie JP, Zideman D, Andersen LW, Atkins DL, Aziz K, Bendall J, Berg KM, Berry DC, Bigham BL, Bingham R, Couto TB, Böttiger BW, Borra V, Bray JE, Breckwoldt J, Brooks SC, Buick J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Cheng A, Chung SP, Considine J, Couper K, Dainty KN, Dawson JA, de Almeida MF, de Caen AR, Deakin CD, Drennan IR, Duff JP, Epstein JL, Escalante R, Gazmuri RJ, Gilfoyle E, Granfeldt A, Guerguerian AM, Guinsburg R, Hatanaka T, Holmberg MJ, Hood N, Hosono S, Hsieh MJ, Isayama T, Iwami T, Jensen JL, Kapadia V, Kim HS, Kleinman ME, Kudenchuk PJ, Lang E, Lavonas E, Liley H, Lim SH, Lockey A, Lofgren B, Ma MHM, Markenson D, Meaney PA, Meyran D, Mildenhall L, Monsieurs KG, Montgomery W, Morley PT, Morrison LJ, Nadkarni VM, Nation K, Neumar RW, Ng KC, Nicholson T, Nikolaou N, Nishiyama C, Nuthall G, Ohshimo S, Okamoto D, O’Neil B, Yong-Kwang Ong G, Paiva EF, Parr M, Pellegrino JL, Perkins GD, Perlman J, Rabi Y, Reis A, Reynolds JC, Ristagno G, Roehr CC, Sakamoto T, Sandroni C, Schexnayder SM, Scholefield BR, Shimizu N, Skrifvars MB, Smyth MA, Stanton D, Swain J, Szyld E, Tijssen J, Travers A, Trevisanuto D, Vaillancourt C, Van de Voorde P, Velaphi S, Wang TL, Weiner G, Welsford M, Woodin JA, Yeung J, Nolan JP, Fran Hazinski M. 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation 2019; 140:e826-e880. [DOI: 10.1161/cir.0000000000000734] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.
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2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2019; 145:95-150. [DOI: 10.1016/j.resuscitation.2019.10.016] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Organ donation after resuscitation from cardiac arrest. Resuscitation 2019; 145:63-69. [PMID: 31654724 DOI: 10.1016/j.resuscitation.2019.10.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/27/2019] [Accepted: 10/14/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND We compared the characteristics and outcomes of post-arrest donors to those of other donors, described the proportion of post-arrest decedents who donated, and compared their characteristics to post-arrest decedents who did not donate. METHODS We performed a retrospective cohort study including patients who died at a single academic medical center from January 1, 2010 to February 28, 2019. We linked our registry of consecutive post-arrest patients to donation-related data from the Center for Organ Procurement and Recovery (CORE). We used data from CORE to identify donor eligibility, first person designation, family approaches to seek consent for donation, and approach outcomes. We determined number of organs procured and number transplanted, stratified by donor type (brain death donors (BDD) vs donors after circulatory determination of death (DCD)). RESULTS There were 12,130 decedents; 1525 (13%) were resuscitated from cardiac arrest. CORE staff approached families of 836 (260 (31%) post-arrest, 576 (69%) not post-arrest) to request donation. Post-arrest patients and families were more likely to authorize donation (172/260 (66%) vs 331/576 (57%), P = 0.02), and more likely to be DCDs (50/146 (34%) vs 55/289 (19%), P < 0.001). Overall, 4.1 ± 1.5 organs were procured and 2.9 ± 1.9 transplanted per BDD, which did not differ by post-arrest status, 3.2 ± 1.2 organs were procured and 1.8 ± 1.1 transplanted per DCD. Number of organs transplanted per DCD did not differ by post-arrest status. Unfavorable arrest characteristics were more common among post-arrest organ donors compared to non-donors. CONCLUSION Patients resuscitated from cardiac arrest with irrecoverable brain injury have excellent potential to become organ donors.
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Teran F, McGovern SK, Dainty KN, Sawyer KN, Blewer AL, Kurz MC, Reynolds JC, Rittenberger JC, Del Rios Rivera M, Leary M. The Latest in Resuscitation Science Research: Highlights From the 2018 American Heart Association's Resuscitation Science Symposium. J Am Heart Assoc 2019; 8:e012256. [PMID: 31057034 PMCID: PMC6512088 DOI: 10.1161/jaha.119.012256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Felipe Teran
- 1 Department of Emergency Medicine Center for Resuscitation Science University of Pennsylvania Philadelphia PA
| | - Shaun K McGovern
- 1 Department of Emergency Medicine Center for Resuscitation Science University of Pennsylvania Philadelphia PA
| | - Katie N Dainty
- 2 Office of Research & Innovation North York General Hospital Toronto Canada.,3 Institute of Health Policy, Management and Evaluation University of Toronto Canada
| | - Kelly N Sawyer
- 4 Department of Emergency Medicine University of Pittsburgh PA
| | - Audrey L Blewer
- 5 Department of Family Medicine and Community Health Duke University Durham NC
| | - Michael C Kurz
- 6 Department of Emergency Medicine Alabama Resuscitation Center University of Alabama Medicine Hoover AL
| | - Joshua C Reynolds
- 7 Department of Emergency Medicine Michigan State University College of Human Medicine Grand Rapids MI
| | | | - Marina Del Rios Rivera
- 8 Department of Emergency Medicine University of Illinois College of Medicine Chicago IL
| | - Marion Leary
- 1 Department of Emergency Medicine Center for Resuscitation Science University of Pennsylvania Philadelphia PA.,9 School of Nursing University of Pennsylvania Philadelphia PA
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May TL, Lary CW, Riker RR, Friberg H, Patel N, Søreide E, McPherson JA, Undén J, Hand R, Sunde K, Stammet P, Rubertsson S, Belohlvaek J, Dupont A, Hirsch KG, Valsson F, Kern K, Sadaka F, Israelsson J, Dankiewicz J, Nielsen N, Seder DB, Agarwal S. Variability in functional outcome and treatment practices by treatment center after out-of-hospital cardiac arrest: analysis of International Cardiac Arrest Registry. Intensive Care Med 2019; 45:637-646. [PMID: 30848327 PMCID: PMC6486427 DOI: 10.1007/s00134-019-05580-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/22/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE Functional outcomes vary between centers after out-of-hospital cardiac arrest (OHCA) and are partially explained by pre-existing health status and arrest characteristics, while the effects of in-hospital treatments on functional outcome are less understood. We examined variation in functional outcomes by center after adjusting for patient- and arrest-specific characteristics and evaluated how in-hospital management differs between high- and low-performing centers. METHODS Analysis of observational registry data within the International Cardiac Arrest Registry was used to perform a hierarchical model of center-specific risk standardized rates for good outcome, adjusted for demographics, pre-existing functional status, and arrest-related factors with treatment center as a random effect variable. We described the variability in treatments and diagnostic tests that may influence outcome at centers with adjusted rates significantly above and below registry average. RESULTS A total of 3855 patients were admitted to an ICU following cardiac arrest with return of spontaneous circulation. The overall prevalence of good outcome was 11-63% among centers. After adjustment, center-specific risk standardized rates for good functional outcome ranged from 0.47 (0.37-0.58) to 0.20 (0.12-0.26). High-performing centers had faster time to goal temperature, were more likely to have goal temperature of 33 °C, more likely to perform unconscious cardiac catheterization and percutaneous coronary intervention, and had differing prognostication practices than low-performing centers. CONCLUSIONS Center-specific differences in outcomes after OHCA after adjusting for patient-specific factors exist. This variation could partially be explained by in-hospital management differences. Future research should address the contribution of these factors to the differences in outcomes after resuscitation.
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Affiliation(s)
- Teresa L May
- Department of Critical Care Services, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA. .,Clinical and Translational Science Institute, Tufts University, Boston, ME, 02111, USA.
| | - Christine W Lary
- Center for Outcomes Research, Maine Medical Center, Portland, ME, USA
| | - Richard R Riker
- Department of Critical Care Services, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Hans Friberg
- Department of Anesthesia and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden
| | - Nainesh Patel
- Division of Cardiovascular Medicine, Lehigh Valley Hospital and Health Network, Allentown, PA, USA
| | - Eldar Søreide
- Critical Care and Anesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway.,Department Clinical Medicine, University of Bergen, Bergen, Norway
| | - John A McPherson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Johan Undén
- Department of Clinical Sciences, Lund University, Getingevägen, 22185, Lund, Sweden.,Department of Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | - Robert Hand
- Department of Critical Care, Eastern Maine Medical Center, Bangor, ME, USA
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Pascal Stammet
- Medical Department National Rescue Services, Luxembourg, 14, rue Stümper, 2557, Luxembourg, Luxembourg
| | - Stein Rubertsson
- Department of Surgical Sciences/Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Jan Belohlvaek
- Department of Internal Medicine II, Cardiovascular Medicine, General Teaching Hospital and 1st Medical School, Charles University in Prague, Prague, Czech Republic
| | - Allison Dupont
- Department of Cardiology, Northeast Georgia Medical Center, Gainesville, Georgia, USA
| | - Karen G Hirsch
- Stanford Neurocritical Care Program, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Felix Valsson
- Department of Anesthesia and Intensive Care, Landspitali University Hospital, Reykyavik, Iceland
| | - Karl Kern
- Division of Cardiology, Sarver Heart Center, University of Arizona, Tucson, USA
| | - Farid Sadaka
- Mercy Hospital St Louis, St Louis University, St. Louis, MO, USA
| | - Johan Israelsson
- Department of Internal Medicine, Division of Cardiology, Kalmar County Hospital, Kalmar, Sweden
| | - Josef Dankiewicz
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences, Anesthesia and Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - David B Seder
- Department of Critical Care Services, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia-Presbyterian Medical Center, New York, NY, USA
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Yeung J, Matsuyama T, Bray J, Reynolds J, Skrifvars MB. Does care at a cardiac arrest centre improve outcome after out-of-hospital cardiac arrest? - A systematic review. Resuscitation 2019; 137:102-115. [PMID: 30779976 DOI: 10.1016/j.resuscitation.2019.02.006] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/08/2019] [Accepted: 02/11/2019] [Indexed: 02/07/2023]
Abstract
AIM To perform a systematic review to answer 'In adults with attempted resuscitation after non-traumatic cardiac arrest does care at a specialised cardiac arrest centre (CAC) compared to care in a healthcare facility not designated as a specialised cardiac arrest centre improve patient outcomes?' METHODS The PRISMA guidelines were followed. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 1st August 2018. Randomised controlled trials (RCTs) and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using ROBINS-I tool and GRADEpro respectively. Primary outcomes were survival to 30 days with favourable neurological outcomes and survival to hospital discharge with favourable neurological outcomes. Secondary outcomes were survival to 30 days, survival to hospital discharge and return of spontaneous circulation (ROSC) post-hospital arrival for patients with ongoing resuscitation. This systematic review was registered in PROSPERO (CRD 42018093369) RESULTS: We included data from 17 observational studies on out-of-hospital cardiac arrest (OHCA) patients in meta-analyses. Overall, the certainty of evidence was very low. Pooling data from only adjusted analyses, care at CAC was not associated with increased likelihood of survival to 30 days with favourable neurological outcome (OR 2.92, 95% CI 0.68-12.48) and survival to 30 days (OR 2.14, 95% CI 0.73-6.29) compared to care at other hospitals. Whereas patients cared for at CACs had improved survival to hospital discharge with favourable neurological outcomes (OR 2.22, 95% CI 1.74-2.84) and survival to hospital discharge (OR 1.85, 95% CI 1.46-2.34). CONCLUSIONS Very low certainty of evidence suggests that post-cardiac arrest care at CACs is associated with improved outcomes at hospital discharge. There remains a need for high quality data to fully elucidate the impact of CACs.
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Affiliation(s)
- J Yeung
- Warwick Medical School, University of Warwick, United Kingdom.
| | - T Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - J Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne Australia
| | - J Reynolds
- Department of Emergency Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - M B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
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