Resuscitation highlights in 2014

Transoesophageal echocardiography in cardiac arrest: From the emergency department to the intensive care unit

Cardiac arrest is a hyper-acute condition with a high mortality that requires rapid diagnostics and treatment. As such, point-of-care ultrasound (POCUS) has become a valuable tool in the assessment of these patients. While transthoracic echocardiography (TTE) is the more conventional modality used to find reversible causes of cardiac arrest, transoesophageal echocardiography (TOE) has been increasingly utilised due to its superior image quality, continuous imaging, and ability to be operated away from the patient's chest. TOE also has a number of applications in the aftermath of cardiac arrest, such as during the initiation of extracorporeal cardiopulmonary resuscitation (ECPR) and the subsequent monitoring of extracorporeal membranous oxygenation (ECMO). As TOE has evolved, multiple variations have been developed with different utilities. In this article, we will review the evidence supporting the use of TOE in cardiac arrest and where the different forms of TOE can be applied to evaluate the cardiac arrest patient in a timely and accurate manner.

Comparison of the Quality of Echocardiography Imaging Between the Left Lateral Decubitus and Supine Positions

Introduction It is commonly taught that positioning the patient in the left lateral decubitus (LLD) position will improve transthoracic echocardiography (TTE) image quality. Despite this, no previous studies have been performed that study this practice. Our goal was to quantify the difference in image quality of TTE views between the supine and LLD positions.  Methods This was a prospective study in a single academic Emergency Department (ED) of a convenience sample of 30 patients. Three separate ED physicians performed TTE views in both the supine and LLD position on each patient. The order of position was randomized. Images were then reviewed on a previously validated TTE image quality scale by two blinded ED physicians with specialized training in ultrasound. The scale used a 0 to 5 (highest quality) metric for quality assessment. Interpretability of right ventricular and left ventricular function was also assessed. Results The mean image quality for the supine position was 2.85 (standard deviation {SD} 1.1) and 3.05 (SD 1.2) for the LLD position (p=0.044). In the subset of parasternal and apical windows, the mean quality for the supine position was 2.87 (SD 1.1) and 3.23 (SD 1.1) for the LLD position (p=0.003). The number of studies in which right ventricular function was interpretable was significantly higher in the LLD position (62% versus 42%, p=0.044). Conclusions There was a statistically significant increase in image quality when TTE was performed in the LLD position as compared to supine. This was especially pronounced in the apical four and parasternal windows.

Focused Transesophageal Echocardiography During Cardiac Arrest Resuscitation: JACC Review Topic of the Week

Focused transthoracic echocardiography (TTE) during cardiac arrest resuscitation can enable the characterization of myocardial activity, identify potentially treatable pathologies, assist with rhythm interpretation, and provide prognostic information. However, an important limitation of TTE is the difficulty obtaining interpretable images due to external and patient-related limiting factors. Over the last decade, focused transesophageal echocardiography (TEE) has been proposed as a tool that is ideally suited to image patients in extremis-those in cardiac arrest and periarrest states. In addition to the same diagnostic and prognostic role provided by TTE images, TEE provides unique advantages including the potential to optimize the quality of chest compressions, shorten cardiopulmonary resuscitation interruptions, guide resuscitative procedures, and provides a continuous image of myocardial activity. This review discusses the rationale, supporting evidence, opportunities, and challenges, and proposes a research agenda for the use of focused TEE in cardiac arrest with the goal to improve resuscitation outcomes.

Critical Care Transesophageal Echocardiography in Patients during the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has placed an extraordinary strain on healthcare systems across North America. Defining the optimal approach for managing a critically ill COVID-19 patient is rapidly changing. Goal-directed transesophageal echocardiography (TEE) is frequently used by physicians caring for intubated critically ill patients as a reliable imaging modality that is well suited to answer questions at bedside.

METHODS

A multidisciplinary (intensive care, critical care cardiology, and emergency medicine) group of experts in point-of-care echocardiography and TEE from the United States and Canada convened to review the available evidence, share experiences, and produce a consensus statement aiming to provide clinicians with a framework to maximize the safety of patients and healthcare providers when considering focused point-of-care TEE in critically ill patients during the COVID-19 pandemic.

RESULTS

Although transthoracic echocardiography can provide the information needed in most patients, there are specific scenarios in which TEE represents the modality of choice. TEE provides acute care clinicians with a goal-directed framework to guide clinical care and represents an ideal modality to evaluate hemodynamic instability during prone ventilation, perform serial evaluations of the lungs, support cardiac arrest resuscitation, and guide veno-venous ECMO cannulation. To aid other clinicians in performing TEE during the COVID-19 pandemic, we describe a set of principles and practical aspects for performing examinations with a focus on the logistics, personnel, and equipment required before, during, and after an examination.

CONCLUSIONS

In the right clinical scenario, TEE is a tool that can provide the information needed to deliver the best and safest possible care for the critically ill patients.

Effect of ulinastatin combined with mild therapeutic hypothermia on intestinal barrier dysfunction following cardiopulmonary resuscitation in rats

The aim of the present study was to investigate the effect of ulinastatin (UTI) alone or combined with mild therapeutic hypothermia (MTH) on intestinal barrier dysfunction following cardiopulmonary resuscitation (CPR) in rats. A total of 25 adult male Sprague-Dawley rats were randomly organized into five groups: Sham; control; UTI; MTH; and the combined group. The latter four groups were induced with the asphyxiated cardiac arrest rat model and treated with different interventions. After 6 h of treatment, the intestinal tissues of the rats were examined by electron microscopy, and the levels of intestinal malondialdehyde (MDA) and superoxide dismutase (SOD) were determined. The results of the present study indicated that the target temperature had successfully been attained in MTH and the combined group, and the other three groups of rats all survived at a normal temperature. In the rats treated with UTI or MTH, the epithelial cells exhibited pathological changes in their tight junctions and epithelial cell surface microvilli compared with the sham group. In the rats treated with a combination of UTI and MTH, whilst the epithelial cells exhibited a few slight changes, including mitochondrial edema, they were largely similar to the normal epithelial cells. However, there were significant differences in the levels of MDA and SOD between the different treatment groups. UTI combined with MTH may serve a protective role by suppressing oxidative stress in the small intestinal mucosa following CPR in rats compared with either UTI or MTH treatment alone.

Cardiopulmonary resuscitation practices in the Netherlands: results from a nationwide survey

Background

Survival rates after in-hospital cardiac arrest are low and vary across hospitals. The ERC guidelines state that more research is needed to explore factors that could influence survival. Research into the role of cardiopulmonary resuscitation (CPR) practices is scarce. The goal of this survey is to gain information about CPR practices among hospitals in the Netherlands.

Methods

A survey was distributed to all Dutch hospital organizations (n = 77). Items investigated were general hospital characteristics, pre-, peri- and post-resuscitation care. Characteristics were stratified by hospital teaching status.

Results

Out of 77 hospital organizations, 71 (92%) responded to the survey, representing 99 locations. Hospitals were divided into three categories: university hospitals (8%), teaching hospitals (64%) and non-teaching hospitals (28%). Of all locations, 96% used the most recent guidelines for Advanced Life Support and 91% reported the availability of a Rapid Response System. Training frequencies varied from twice a year in 41% and once a year in 53% of hospital locations. The role of CPR team leader and airway manager is most often fulfilled by (resident) anaesthetists in university hospitals (63%), by emergency department professionals in teaching hospitals (43%) and by intensive care professionals in non-teaching hospitals (72%). The role of airway manager is most often attributed to (resident) anaesthetists in university hospitals (100%), and to intensive care professionals in teaching (82%) and non-teaching hospitals (79%).

Conclusion

The majority of Dutch hospitals follow the ERC guidelines but there are differences in the presence of an ALS certified physician, intensity of training and participation of medical specialties in the fulfilment of roles within the CPR-team.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4166-2) contains supplementary material, which is available to authorized users.