A 4-year implementation strategy of aggressive post-resuscitation care and temperature management after cardiac arrest

The Role of Extracorporeal Membrane Oxygenation ECMO in Accidental Hypothermia and Rewarming in Out-of-Hospital Cardiac Arrest Patients-A Literature Review

Accidental hypothermia, defined as an unintentional drop of the body core temperature below 35 °C, is one of the causes of cardiocirculatory instability and reversible cardiac arrest. Currently, extracorporeal life support (ECLS) rewarming is recommended as a first-line treatment for hypothermic cardiac arrest patients. The aim of the ECLS rewarming is not only rapid normalization of core temperature but also maintenance of adequate organ perfusion. Veno-arterial extracorporeal membrane oxygenation (ECMO) is a preferred technique due to its lower anticoagulation requirements and potential to prolong circulatory support. Although highly efficient, ECMO is acknowledged as an invasive treatment option, requiring experienced medical personnel and is associated with the risk of serious complications. In this review, we aimed to discuss the clinical aspects of ECMO management in severely hypothermic cardiac arrest patients.

Targeted Temperature Management after Cardiac Arrest: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

Target temperature management (TTM) in cardiac arrest (CA) survivors is recommended after hospital admission for its possible beneficial effects on survival and neurological outcome. Whether a lower target temperature (i.e., 32–34 °C) improves outcomes is unclear. We conducted a systematic review and meta-analysis on Pubmed and EMBASE to evaluate the effects on mortality and neurologic outcome of TTM at 32–34 °C as compared to controls (patients cared with “actively controlled” or “uncontrolled” normothermia). Results were analyzed via risk ratios (RR) and 95% confidence intervals (CI). Eight randomized controlled trials (RCTs) were included. TTM at 32–34 °C was compared to “actively controlled” normothermia in three RCTs and to “uncontrolled” normothermia in five RCTs. TTM at 32–34 °C does not improve survival as compared to normothermia (RR:1.06 (95%CI 0.94, 1.20), p = 0.36; I² = 39%). In the subgroup analyses, TTM at 32–34 °C is associated with better survival when compared to “uncontrolled” normothermia (RR: 1.31 (95%CI 1.07, 1.59), p = 0.008) but shows no beneficial effects when compared to “actively controlled” normothermia (RR: 0.97 (95%CI 0.90, 1.04), p = 0.41). TTM at 32–34 °C does not improve neurological outcome as compared to normothermia (RR: 1.17 (95%CI 0.97, 1.41), p = 0.10; I² = 60%). TTM at 32–34 °C increases the risk of arrhythmias (RR: 1.35 (95%CI 1.16, 1.57), p = 0.0001, I² = 0%). TTM at 32–34 °C does not improve survival nor neurological outcome after CA and increases the risk of arrhythmias.

Audit and Feedback in emergency: a systematic review and an Italian project to investigate and improve quality of care

The Audit and Feedback process (AandF) is commonly accepted as a good way to improve quality in health care, also in Emergency Departments (ED), where health aspects and pathologies are very different, usually acute and highly complex. Within an Italian Ministry of Health research project called EASY-NET, we conducted a systematic review of literature on AandF in EDs from 2014 to December 2019 to evaluate the impact of this approach in a particular setting where time-dependent indicators are fundamental. We selected 24 articles: 9 about infective pathologies (i.e. antibiotic stewardship), 6 about cardiovascular acute emergencies (i.e. cardiac arrest), 2 about stroke, 3 about laboratory tests, and 4 about other fields (i.e. diabetic ketoacidosis or use of prothrombin complex). Most of articles proposed a multimodal approach: only 7 concerned AandF alone. Despite the wide range on interventions modality and the poor comparability of the considered studies, the results are encouraging and confirm the importance to implement AandF both in emergency and in other clinical settings.

Implementation of a nurse-led protocol for early extubation after cardiac surgery: A pilot study

BACKGROUND

Protocols for nurse-led extubation are as safe as a physician-guided weaning in general intensive care unit (ICU). Early extubation is a cornerstone of fast-track cardiac surgery, and it has been mainly implemented in post-anaesthesia care units. Introducing a nurse-led extubation protocol may lead to reduced extubation time.

AIM

To investigate results of the implementation of a nurse-led protocol for early extubation after elective cardiac surgery, aiming at higher extubation rates by the third postoperative hour.

METHODS

A single centre prospective study in an 18-bed, consultant-led Cardiothoracic ICU, with a 1:1 nurse-to-patient ratio. During a 3-wk period, the protocol was implemented with: (1) Structured teaching sessions at nurse handover and at bed-space (all staff received teaching, over 90% were exposed at least twice; (2) Email; and (3) Laminated sheets at bed-space. We compared “standard practice” and “intervention” periods before and after the protocol implementation, measuring extubation rates at several time-points from the third until the 24^th postoperative hour.

RESULTS

Of 122 cardiac surgery patients admitted to ICU, 13 were excluded as early weaning was considered unsafe. Therefore, 109 patients were included, 54 in the standard and 55 in the intervention period. Types of surgical interventions and baseline left ventricular function were similar between groups. From the third to the 12^th post-operative hour, the intervention group displayed a higher proportion of patients extubated compared to the standard group. However, results were significant only at the sixth hour (58% vs 37%, P = 0.04), and not different at the third hour (13% vs 6%, P = 0.33). From the 12^th post-operative hour time-point onward, extubation rates became almost identical between groups (83% in standard vs 83% in intervention period).

CONCLUSION

The implementation of a nurse-led protocol for early extubation after cardiac surgery in ICU may gradually lead to higher rates of early extubation.

Effectiveness of antiarrhythmic drugs for shockable cardiac arrest: A systematic review

PURPOSE

The purpose of this systematic review is to provide up-to-date evidence on effectiveness of antiarrhythmic drugs for shockable cardiac arrest to help inform the 2018 International Liaison Committee on Resuscitation Consensus on Science with Treatment Recommendations.

METHODS

A search was conducted in electronic databases Medline, Embase, and Cochrane Library from inception to August 15, 2017.

RESULTS

Of the 9371 citations reviewed, a total of 14 RCTs and 17 observational studies met our inclusion criteria for adult population and only 1 observational study for pediatric population. Based on RCT level evidence for adult population, none of the anti-arrhythmic drugs showed any difference in effect compared with placebo, or with other anti-arrhythmic drugs for the critical outcomes of survival to hospital discharge and discharge with good neurological function. For the outcome of return of spontaneous circulation, the results showed a significant increase for lidocaine compared with placebo (RR = 1.16; 95% CI, 1.03-1.29, p = 0.01).

CONCLUSION

The high level evidence supporting the use of antiarrhythmic drugs during CPR for shockable cardiac arrest is limited and showed no benefit for critical outcomes of survival at hospital discharge, survival with favorable neurological function and long-term survival. Future high quality research is needed to confirm these findings and also to evaluate the role of administering antiarrhythmic drugs in children with shockable cardiac arrest, and in adults immediately after ROSC.