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Lemée P, Chapalain X, Bailly P, Sparrow RL, Jean-Michel V, Prat G, Renault A, Tonnelier JM, Aubron C. PROACTIVE SCREENING ALGORITHM FOR EARLY-ONSET PNEUMONIA IN PATIENTS WITH OUT-OF-HOSPITAL CARDIAC ARREST: A BEFORE-AFTER IMPLEMENTATION STUDY. Shock 2024; 62:13-19. [PMID: 38661180 DOI: 10.1097/shk.0000000000002347] [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: 04/26/2024]
Abstract
ABSTRACT Introduction : Early-onset pneumonia (EOP) occurs in around 50% of critically ill patients with out-of-hospital cardiac arrest (OHCA) and is associated with increased morbidity. Prompt diagnosis of EOP in these patients is difficult because of targeted temperature management and the postcardiac arrest syndrome. We hypothesized that an algorithm for proactive screening of EOP would improve patient outcomes. Methods : We conducted a single-center observational study comparing the outcomes of mechanically ventilated adult patients with OHCA, before (study period 1) and after (study period 2) implementation of an algorithm for proactive diagnosis of EOP, including an early distal pulmonary specimen. An inverse probability treatment weighted multivariable regression was performed to identify independent parameters associated with duration of mechanical ventilation. A subgroup analysis was conducted in patients alive on day 5 after intensive care unit admission. Results : Over the 4-year study period, 190 patients (99 and 91 for study periods 1 and 2, respectively) were enrolled. The overall incidence of EOP was 57.4% and was similar between both study periods. Although there was no difference in the time interval to antibiotic initiation, study period 2 was independently associated with higher SpO 2 /FiO 2 ratios on days 3 and 4. We also observed a decrease in mechanical ventilation time in study period 2 (4.5 [1-11.3] vs. 3 [2-5.8] days; P = 0.07), and this reached statistical significance in the subgroup analysis of patients alive at day 5 (10 [5-17] vs. 5 [3-9] days, P = 0.01). Conclusion: In critically ill patients with OHCA, proactive diagnosis of EOP was not associated with a significant change in the time to antibiotic initiation. Further research is warranted to better define optimal diagnosis and management of EOP in this setting.
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Affiliation(s)
- Pauline Lemée
- Departement de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Xavier Chapalain
- Departement d'anesthésie-Réanimation, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Pierre Bailly
- Departement de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Rosemary L Sparrow
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Vanessa Jean-Michel
- Departement de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Gwenael Prat
- Departement de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Anne Renault
- Departement de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Jean-Marie Tonnelier
- Departement de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
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Dobroniak CC, Lehmann W, Cagirici R, Lesche V, Olgemoeller U, Spering C. [Treatment strategy for an unstable chest wall after cardiopulmonary resuscitation]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:197-203. [PMID: 38100032 DOI: 10.1007/s00113-023-01386-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 02/24/2024]
Abstract
Every year ca. 60,000 people in Germany undergo cardiopulmonary resuscitation (CPR). The two most frequent underlying causes are of cardiopulmonary and traumatic origin. According to the current CPR guidelines chest compressions should be performed in the middle of the sternum with a pressure frequency of 100-120/min and to a depth of 5-6 cm. In contrast to trauma patients where different injury patterns can arise depending on the accident mechanism, both the type of trauma and the injury pattern are similar in patients after CPR due to repetitive thorax compression. It is known that an early reconstruction of the thoracic wall and the restoration of the physiological breathing mechanics in trauma patients with unstable thoracic injuries reduce the rates of pneumonia and weaning failure and shorten the length of stay in the intensive care unit. As a result, it is increasingly being propagated that an unstable thoracic injury as a result of CPR should also be subjected to surgical treatment as soon as possible. In the hospital of the authors an algorithm was formulated based on clinical experience and the underlying evidence in a traumatological context and a surgical treatment strategy was designed, which is presented and discussed taking the available evidence into account.
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Affiliation(s)
- C C Dobroniak
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37077, Göttingen, Deutschland.
| | - W Lehmann
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37077, Göttingen, Deutschland
| | - R Cagirici
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37077, Göttingen, Deutschland
| | - V Lesche
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37077, Göttingen, Deutschland
| | - U Olgemoeller
- Klinik für Kardiologie und Pneumologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - C Spering
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37077, Göttingen, Deutschland
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Van Wijck SFM, Prins JTH, Verhofstad MHJ, Wijffels MME, Van Lieshout EMM. Rib fractures and other injuries after cardiopulmonary resuscitation for non-traumatic cardiac arrest: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2024:10.1007/s00068-023-02421-7. [PMID: 38206442 DOI: 10.1007/s00068-023-02421-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/04/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE This study aims to ascertain the prevalence of rib fractures and other injuries resulting from CPR and to compare manual with mechanically assisted CPR. An additional aim was to summarize the literature on surgical treatment for rib fractures following CPR. DESIGN Systematic review and meta-analysis. DATA SOURCES Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar. REVIEW METHODS The databases were searched to identify studies reporting on CPR-related injuries in patients who underwent chest compressions for a non-traumatic cardiopulmonary arrest. Subgroup analysis was conducted to compare the prevalence of CPR-related injuries in manual versus mechanically assisted chest compressions. Studies reporting on surgery for CPR-related rib fractures were also reviewed and summarized. RESULTS Seventy-four studies reporting CPR-related injuries were included encompassing a total of 16,629 patients. Any CPR-related injury was documented in 60% (95% confidence interval [95% CI] 49-71) patients. Rib fractures emerged as the most common injury, with a pooled prevalence of 55% (95% CI 48-62). Mechanically assisted CPR, when compared to manual CPR, was associated with a higher risk ratio for CPR-related injuries of 1.36 (95% CI 1.17-1.59). Eight studies provided information on surgical stabilization of CPR-related rib fractures. The primary indication for surgery was the inability to wean from mechanical ventilation in the presence of multiple rib fractures. CONCLUSION Rib fractures and other injuries frequently occur in patients who undergo CPR after a non-traumatic cardiopulmonary arrest, especially when mechanical CPR is administered. Surgical stabilization of CPR-related rib fractures remains relatively uncommon. LEVEL OF EVIDENCE Level III, systematic review and meta-analysis.
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Affiliation(s)
- Suzanne F M Van Wijck
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Jonne T H Prins
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Mathieu M E Wijffels
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Leivaditis V, Hofmann A, Haaf B, Wiegand A, Papatriantafyllou A, Grapatsas K, Koletsis E, Charokopos N, Verras GI, Tasios K, Skevis K, Panagiotopoulos I, Antzoulas A, Mulita F, Dahm M. Extensive chest wall stabilization after cardiopulmonary resuscitation and urgent cardiac surgery. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2023; 20:205-209. [PMID: 37937167 PMCID: PMC10626408 DOI: 10.5114/kitp.2023.131937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/22/2023] [Indexed: 11/09/2023]
Affiliation(s)
- Vasileios Leivaditis
- Department of Cardiothoracic and Vascular Surgery, Westpfalz Klinikum, Kaiserslautern, Germany
| | - Alexander Hofmann
- Department of Orthopedics and Traumatology, Westpfalz Klinikum, Kaiserslautern, Germany
| | - Bernd Haaf
- Department of Cardiothoracic and Vascular Surgery, Westpfalz Klinikum, Kaiserslautern, Germany
| | - Anke Wiegand
- Department of Radiology, Westpfalz Klinikum, Kaiserslautern, Germany
| | | | - Konstantinos Grapatsas
- Department of Thoracic Surgery and Thoracic Endoscopy, University Medicine Essen – Ruhrlandklinik, Essen, Germany
| | - Efstratios Koletsis
- Department of Cardiothoracic Surgery, Patras University Hospital, Patras, Greece
| | - Nikolaos Charokopos
- Department of Cardiothoracic Surgery, Patras University Hospital, Patras, Greece
| | | | | | | | | | - Andreas Antzoulas
- Department of General Surgery, Patras University Hospital, Patras, Greece
| | - Francesk Mulita
- Department of General Surgery, Patras University Hospital, Patras, Greece
| | - Manfred Dahm
- Department of Cardiothoracic and Vascular Surgery, Westpfalz Klinikum, Kaiserslautern, Germany
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Tam J, Soufleris C, Ratay C, Frisch A, Elmer J, Case N, Flickinger KL, Callaway CW, Coppler PJ. Diagnostic yield of computed tomography after non-traumatic out-of-hospital cardiac arrest. Resuscitation 2023; 189:109898. [PMID: 37422167 DOI: 10.1016/j.resuscitation.2023.109898] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/20/2023] [Accepted: 06/29/2023] [Indexed: 07/10/2023]
Abstract
AIM Determine the frequency with which computed tomography (CT) after out-of-hospital cardiac arrest (OHCA) identifies clinically important findings. METHODS We included non-traumatic OHCA patients treated at a single center from February 2019 to February 2021. Clinical practice was to obtain CT head in comatose patients. Additionally, CT of the cervical spine, chest, abdomen, and pelvis were obtained if clinically indicated. We identified CT imaging obtained within 24 hours of emergency department (ED) arrival and summarized radiology findings. We used descriptive statistics to summarize population characteristics and imaging results, report their frequencies and, post hoc, compared time from ED arrival to catheterization between patients who did and did not undergo CT. RESULTS We included 597 subjects, of which 491 (82.2%) had a CT obtained. Time to CT was 4.1 hours [2.8-5.7]. Most (n = 480, 80.4%) underwent CT head, of which 36 (7.5%) had intracranial hemorrhage and 161 (33.5%) had cerebral edema. Fewer subjects (230, 38.5%) underwent a cervical spine CT, and 4 (1.7%) had acute vertebral fractures. Most subjects (410, 68.7%) underwent a chest CT, and abdomen and pelvis CT (363, 60.8%). Chest CT abnormalities included rib or sternal fractures (227, 55.4%), pneumothorax (27, 6.6%), aspiration or pneumonia (309, 75.4%), mediastinal hematoma (18, 4.4%) and pulmonary embolism (6, 3.7%). Significant abdomen and pelvis findings were bowel ischemia (24, 6.6%) and solid organ laceration (7, 1.9%). Most subjects that had CT imaging deferred were awake and had shorter time to catheterization. CONCLUSIONS CT identifies clinically important pathology after OHCA.
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Affiliation(s)
- Jonathan Tam
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Christopher Soufleris
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Cecelia Ratay
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Adam Frisch
- Department of Emergency 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 Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nicholas Case
- 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
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Dąbrowski S, Lange S, Basiński A. Analgesic Use in Patients during Cardio-Pulmonary Resuscitation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3654. [PMID: 36834346 PMCID: PMC9961124 DOI: 10.3390/ijerph20043654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/12/2023] [Accepted: 02/15/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Cardiopulmonary resuscitation-induced consciousness is a newly recognized phenomenon with an increasing incidence. A return of consciousness during cardiopulmonary resuscitation affects up to 0.9% of cases. Patients may also experience physical pain associated with chest compressions, as most victims of cardiac arrest who are subjected to resuscitative efforts sustain ribs or sternum fractures. METHODS A rapid review was carried out from August 2021 to December 2022. RESULTS Thirty-two articles were included in the rapid review. Of these, eleven studies focused on the return of consciousness during CPR, and twenty-one on CPR-induced chest injuries. CONCLUSION A small number of studies that have dealt with the return of consciousness associated with cardiopulmonary resuscitation made it hard to clearly determine how often this occurs. There were more studies that dealt with chest trauma during resuscitation, but no study considered the use of analgesics. Of note, there was no standardized therapeutic approach as far as the use of analgesics and/or sedatives was considered. This is probably due to the lack of guidelines for analgesic management during cardiopulmonary resuscitation and peri-resuscitative period.
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Affiliation(s)
- Sebastian Dąbrowski
- Department of Medical Rescue, Faculty of Health Sciences with the Institute of Maritime and Tropical Medicine, Medical University of Gdańsk, Dębinki 7, 80-211 Gdańsk, Poland
| | - Sandra Lange
- Department of Internal and Pediatric Nursing, Medical University of Gdańsk, Dębinki 7, 80-211 Gdańsk, Poland
| | - Andrzej Basiński
- Department of Medical Rescue, Faculty of Health Sciences with the Institute of Maritime and Tropical Medicine, Medical University of Gdańsk, Dębinki 7, 80-211 Gdańsk, Poland
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van Veelen NM, Buenter L, Kremo V, Peek J, Leiser A, Kestenholz P, Babst R, Paulus Beeres FJ, Minervini F. Outcomes after fixation of rib fractures sustained during cardiopulmonary resuscitation: A retrospective single center analysis. Front Surg 2023; 10:1120399. [PMID: 36755767 PMCID: PMC9899886 DOI: 10.3389/fsurg.2023.1120399] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/04/2023] [Indexed: 01/24/2023] Open
Abstract
Background Historically rib fractures have been typically treated non-operatively. Recent studies showed promising results after osteosynthesis of rib fractures in trauma patients with flail segments or multiple rib fractures. However, there is a paucity of data on rib fixation after cardiopulmonary resuscitation (CPR). This study evaluated the outcomes of patients who received rib fixation after CPR. Methods Adult patients who received surgical fixation of rib fractures sustained during CPR between 2010 and 2020 were eligible for inclusion in this retrospective study. Outcome measures included complications, quality of life (EQ 5D 5L) and level of dyspnea. Results Nineteen patients were included with a mean age of 66.8 years. The mean number of fractured ribs was ten, seven patients additionally had a sternum fracture. Pneumonia occurred in 15 patients (74%), of which 13 were diagnosed preoperatively and 2 post-operatively. Six patients developed a postoperative pneumothorax, none of which required revision surgery. One patient showed persistent flail chest after rib fixation and required additional fixation of a concomitant sternum fracture. One infection of the surgical site of sternal plate occurred, while no further surgery related complications were reported. Mean EQ-5D-5L was 0.908 and the average EQ VAS was 80. One patient reported persisting dyspnea. Conclusion To date, this is the largest reported cohort of patients who received rib fixation for fractures sustained during CPR. No complications associated with rib fixation were reported whereas one infection after sternal fixation did occur. Current follow-up demonstrated a good long-term quality of life after fixation, warranting further studies on this topic. Deeper knowledge on this subject would be beneficial for a wide spectrum of physicians.
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Affiliation(s)
- Nicole Maria van Veelen
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Lea Buenter
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Valérie Kremo
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jesse Peek
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Alfred Leiser
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Peter Kestenholz
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland,Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | | | - Fabrizio Minervini
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland,Correspondence: Fabrizio Minervini
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