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Dermer J, James S, Palmer C, Craft J, Christensen M. Exploring nurses' experiences of performing basic life support in hospital wards: An inductive thematic analysis. Nurse Educ Pract 2024; 76:103929. [PMID: 38461591 DOI: 10.1016/j.nepr.2024.103929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 02/05/2024] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
AIM The aim of this study was to undertake an in-depth exploration of the lived experiences of in-hospital, non-intensive care, ward-based nurses' experiences of real-life CPR events. BACKGROUND There is growing evidence suggesting that may nurses not be able to successfully perform in a cardiac arrest situation. Reasons include a lack of clear leadership at the arrest, performance anxiety, role confusion and knowledge and skill degradation over time. METHODS In-depth semi-structured interviews were conducted with fifteen ward-based hospital nurses from three hospitals. Interviews were recorded, transcribed verbatim and inductive thematic analysis was completed using NVivo 12 software. FINDINGS Four main themes emerged from data. The main themes are: (1) Not Being able to Perform When it Matters, (2) Working Really Well as a Team, (3) Reflecting on the Experience: The Good, the Bad & the Ugly and (4) Learning to get it Right for Next Time CONCLUSION: Performing BLS is a stressful and anxiety-provoking experience for ward-based nurses. Anxiety levels appear to decrease slightly only when nurses have had at least one previous real-life experience with resuscitation. Current BLS education does not prepare nurses for the complexities of resuscitation. Future BLS education should focus on in-depth scenarios, including interdisciplinary team training and with greater frequency than the current yearly mandatory sessions. Listening to the lived experiences of nurses who have performed BLS has given much needed insight into approaches that educators can use to improve BLS education delivery.
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Affiliation(s)
- J Dermer
- School of Nursing, Midwifery & Paramedicine, University of the Sunshine Coast, Australia
| | - S James
- School of Nursing, Midwifery & Paramedicine, University of the Sunshine Coast, Australia
| | - C Palmer
- School of Nursing, Midwifery & Paramedicine, University of the Sunshine Coast, Australia
| | - J Craft
- School of Nursing, Midwifery & Paramedicine, University of the Sunshine Coast, Australia
| | - M Christensen
- School of Nursing, Midwifery & Paramedicine, University of the Sunshine Coast, Australia; School of Nursing, Hong Kong Polytechnic University, Hong Kong; Interdisciplinary Centre for Qualitative Research, Hong Kong Polytechnic University, Hong Kong.
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2
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Trummer G, Benk C, Pooth JS, Wengenmayer T, Supady A, Staudacher DL, Damjanovic D, Lunz D, Wiest C, Aubin H, Lichtenberg A, Dünser MW, Szasz J, Dos Reis Miranda D, van Thiel RJ, Gummert J, Kirschning T, Tigges E, Willems S, Beyersdorf F. Treatment of Refractory Cardiac Arrest by Controlled Reperfusion of the Whole Body: A Multicenter, Prospective Observational Study. J Clin Med 2023; 13:56. [PMID: 38202063 PMCID: PMC10780178 DOI: 10.3390/jcm13010056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
Background: Survival following cardiac arrest (CA) remains poor after conventional cardiopulmonary resuscitation (CCPR) (6-26%), and the outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) are often inconsistent. Poor survival is a consequence of CA, low-flow states during CCPR, multi-organ injury, insufficient monitoring, and delayed treatment of the causative condition. We developed a new strategy to address these issues. Methods: This all-comers, multicenter, prospective observational study (69 patients with in- and out-of-hospital CA (IHCA and OHCA) after prolonged refractory CCPR) focused on extracorporeal cardiopulmonary support, comprehensive monitoring, multi-organ repair, and the potential for out-of-hospital cannulation and treatment. Result: The overall survival rate at hospital discharge was 42.0%, and a favorable neurological outcome (CPC 1+2) at 90 days was achieved for 79.3% of survivors (CPC 1+2 survival 33%). IHCA survival was very favorable (51.7%), as was CPC 1+2 survival at 90 days (41%). Survival of OHCA patients was 35% and CPC 1+2 survival at 90 days was 28%. The subgroup of OHCA patients with pre-hospital cannulation showed a superior survival rate of 57.1%. Conclusions: This new strategy focusing on repairing damage to multiple organs appears to improve outcomes after CA, and these findings should provide a sound basis for further research in this area.
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Affiliation(s)
- Georg Trummer
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Jan-Steffen Pooth
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Department of Emergency Medicine, Medical Center—University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Tobias Wengenmayer
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Alexander Supady
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Dawid L. Staudacher
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Domagoj Damjanovic
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center, 93042 Regensburg, Germany;
| | - Clemens Wiest
- Department of Internal Medicine II, University Medical Center, 93042 Regensburg, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany (A.L.)
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany (A.L.)
| | - Martin W. Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020 Linz, Austria
| | - Johannes Szasz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020 Linz, Austria
| | - Dinis Dos Reis Miranda
- Department of Adult Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Robert J. van Thiel
- Department of Adult Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr University Bochum, 44791 Bad Oeynhausen, Germany
| | - Thomas Kirschning
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr University Bochum, 44791 Bad Oeynhausen, Germany
| | - Eike Tigges
- Asklepios Klinik St. Georg, Heart and Vascular Center, Department of Cardiology and Intensive Care Medicine, 20099 Hamburg, Germany
| | - Stephan Willems
- Asklepios Klinik St. Georg, Heart and Vascular Center, Department of Cardiology and Intensive Care Medicine, 20099 Hamburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
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Singh S, Rout A, Chaudhary R, Garg A, Tantry US, Gurbel PA. Oxygen Targets After Cardiac Arrest: A Meta-analysis of Randomized Controlled Trials. Am J Ther 2023; 30:e509-e518. [PMID: 37921678 PMCID: PMC10809880 DOI: 10.1097/mjt.0000000000001636] [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] [Indexed: 11/04/2023]
Abstract
BACKGROUND Optimal oxygen saturation target in patients resuscitated after cardiac arrest is unknown. Previous randomized controlled trials (RCTs) comparing restrictive oxygen therapy with liberal therapy have shown conflicting results. STUDY QUESTION We performed a meta-analysis of available RCTs to consolidate the contrasting findings regarding the oxygen targets after cardiac arrest. DATA SOURCES We searched electronic databases for RCTs comparing restrictive versus liberal oxygen targets in patients resuscitated after cardiac arrest. STUDY DESIGN End points of interest were mortality, unfavorable neurological outcomes, and rearrests. Random-effects meta-analysis was performed to estimate the risk ratio (RR) with a 95% confidence interval (CI). RESULTS Eight RCTs with 1641 patients (restrictive n = 833, liberal n = 808) were included in the analysis. The oxygen targets were defined by either saturation, partial pressure (PaO2), or supplementation rates. The mean age and male percentage were 63 years and 80%, respectively. There was no significant difference observed in the 2 groups for overall mortality (RR = 0.91, 95% CI = 0.75-1.10, P = 0.33), unfavorable neurological outcomes (RR = 0.93, 95% CI = 0.74-1.18, P = 0.56), and rearrests (RR = 0.67, 95% CI = 0.22-1.98, P = 0.47). CONCLUSIONS Overall, this meta-analysis shows no significant difference in mortality, unfavorable neurological outcomes, and rearrests when using restrictive or liberal oxygen targets in patients after cardiac arrest. The limitations in the newer trials should be kept in mind while interpreting the overall results.
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Affiliation(s)
- Sahib Singh
- Department of Medicine, Sinai Hospital of Baltimore, Baltimore, MD
| | - Amit Rout
- Division of Cardiology, University of Louisville, Louisville, KY
| | - Rahul Chaudhary
- Division of Cardiology, University of Pittsburgh, Pittsburgh, PA
| | - Aakash Garg
- Cardiology Associates of Schenectady, St. Peter’s Health Partners, Albany, NY
| | - Udaya S. Tantry
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD
| | - Paul A. Gurbel
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD
- Division of Cardiology, Sinai Hospital of Baltimore, Baltimore, MD
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Dermer J, James S, Palmer C, Christensen M, Craft J. Factors affecting ward nurses' basic life support experiences: An integrative literature review. Int J Nurs Pract 2023; 29:e13120. [PMID: 36502807 DOI: 10.1111/ijn.13120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/25/2022] [Accepted: 11/19/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Performing cardiopulmonary resuscitation in non-critical care hospital wards is a stressful event for the registered nurse; stress may negatively affect performance. Delays in initiating basic life support and following current basic life support algorithms have been reported globally. AIM The aim of this review was to investigate factors that can affect registered nurses' experiences of performing basic life support. METHODS Using the five-step integrative literature review method from Whittemore and Knafl, this review searched articles published between January 2000 and June 2022 for qualitative and quantitative primary studies from the databases CINAHL Complete (EBSCO), Medline (Web of Science), Scopus and PubMed. RESULTS Nine studies from eight countries met the inclusion criteria and were appraised here. Five themes relating to factors affecting the performance of basic life support were found during this review: staff interaction issues, confidence concerns, fear of harm and potential litigation, defibrillation concerns and basic life support training issues. CONCLUSIONS This review revealed several concerns experienced by registered nurses in performing basic life support and highlights a lack of research. Factors affecting nurses' experiences need to be understood. This will allow education to focus on consideration of human factors, or non-technical skills during basic life support training, as well as technical skills, to improve outcomes for patients experiencing an in-hospital cardiopulmonary arrest.
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Affiliation(s)
- Jennifer Dermer
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast Caboolture, Caboolture, Queensland, Australia
| | - Steven James
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast Moreton Bay, Petrie, Queensland, Australia
| | - Christine Palmer
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast Caboolture, Caboolture, Queensland, Australia
| | - Martin Christensen
- School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Judy Craft
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast Caboolture, Caboolture, Queensland, Australia
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Crescioli E, Lass Klitgaard Klitgaard T, Perner A, Lilleholt Schjørring O, Steen Rasmussen B. Lower versus higher oxygenation targets in hypoxaemic ICU patients after cardiac arrest. Resuscitation 2023:109838. [PMID: 37196799 DOI: 10.1016/j.resuscitation.2023.109838] [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: 02/16/2023] [Revised: 04/18/2023] [Accepted: 05/09/2023] [Indexed: 05/19/2023]
Abstract
AIM To investigate the effects of lower versus higher oxygenation targets in adult intensive care unit (ICU) patients with hypoxaemic respiratory failure after cardiac arrest. METHODS Subgroup analysis of the international Handling Oxygenation Targets in the ICU (HOT-ICU) trial which randomised 2928 adults with acute hypoxaemia to targets of arterial oxygenation of 8 kPa or 12 kPa in the ICU for up to 90 days. Here, we report all outcomes up to one year in the subgroup of patients enrolled after cardiac arrest. RESULTS The HOT-ICU trial included 335 patients after cardiac arrest: 149 in the lower-oxygenation group and 186 in the higher-oxygenation group. At 90 days, 96/147 patients (65.3%) in the lower-oxygenation group and 111/185 patients (60.0%) in the higher-oxygenation group had died (adjusted relative risk (RR) 1.09, 95% confidence interval (CI) 0.92-1.28, p=0.32); similar results were found at one year (adjusted RR 1.05, 95% CI 0.90-1.21, p=0.53). Serious adverse events (SAEs) in the ICU occurred in 23% of patients in the lower-oxygenation group and 38% in the higher-oxygenation group (adjusted RR 0.61, 95% CI 0.43-0.86, p=0.005); the difference was mainly due to more new episodes of shock in the higher-oxygenation group. No statistically significant differences were observed in other secondary outcomes. CONCLUSION A lower oxygenation target in adult ICU patients with hypoxaemic respiratory failure after cardiac arrest did not result in lower mortality, but fewer SAEs occurred in this group compared to the higher-oxygenation group. All analyses are exploratory only, large-scale trials are needed for confirmation. CLINICAL TRIAL REGISTRY Clinicaltrials.gov number NCT03174002 (registered May 30, 2017); EudraCT 2017-000632-34 (registered February 14, 2017).
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Affiliation(s)
- Elena Crescioli
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | | | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Manteiga-Urbón JL, Fernández-Méndez F, Otero-Agra M, Fernández-Méndez M, Santos-Folgar M, Insa-Calderon E, Sobrido-Prieto M, Barcala-Furelos R, Martínez-Isasi S. Brief Training of Technical Bleeding Control Skills-A Pilot Study with Security Forces. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2494. [PMID: 36767862 PMCID: PMC9915853 DOI: 10.3390/ijerph20032494] [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: 12/22/2022] [Revised: 01/17/2023] [Accepted: 01/24/2023] [Indexed: 06/18/2023]
Abstract
Uncontrolled external bleeding is a common cause of preventable death, and due to the environment in which these events often occur, e.g., in hostile environments, the state security forces are usually the first responders, and in many cases, if they are injured their partners provide the initial assistance. The tourniquet is a fast, effective, and easy-to-learn intervention, although there is a knowledge gap concerning training techniques. The objective is to evaluate the effectiveness of a bleeding control training program on a high-fidelity mannequin in a simulated critical situation in a law enforcement training environment. A quasi-experimental study was carried out with 27 members of the state security forces. They underwent brief theoretical-practical training and were evaluated via a scenario involving a critically ill patient in a hostile environment. The results showed that no member of the state security forces completed all the tourniquet placement steps, 26 (96%) prepared the tourniquet correctly, 21 (77.8%) placed it on the leg, and all the participants adjusted the band to the thickness of the injured limb and secured the windlass to the triangular flange of the device. However, only 23 (85.2%) of the participants placed it effectively. The participants, who were members of the state security forces, were able to effectively resolve a critical situation with active bleeding in a simulation scenario with a high-fidelity mannequin after completing theoretical-practical training.
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Affiliation(s)
| | - Felipe Fernández-Méndez
- REMOSS Research Group, University of Vigo, 36005 Pontevedra, Spain
- School of Nursing, University of Vigo, 36005 Pontevedra, Spain
| | - Martín Otero-Agra
- REMOSS Research Group, University of Vigo, 36005 Pontevedra, Spain
- School of Nursing, University of Vigo, 36005 Pontevedra, Spain
| | - María Fernández-Méndez
- REMOSS Research Group, University of Vigo, 36005 Pontevedra, Spain
- School of Nursing, University of Vigo, 36005 Pontevedra, Spain
| | - Myriam Santos-Folgar
- REMOSS Research Group, University of Vigo, 36005 Pontevedra, Spain
- School of Nursing, University of Vigo, 36005 Pontevedra, Spain
| | - Esther Insa-Calderon
- ESIMar (Mar Nursing School), Parc de Salut Mar, Universitat Pompeu Fabra Affiliated, 08003 Barcelona, Spain
- SDHEd (Social Determinants and Health Education Research Group), IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
| | - María Sobrido-Prieto
- Departamento de Ciencias da Saúde, Universidade de A Coruña (UDC), Campus de Esteiro, 15403 Ferrol, Spain
| | - Roberto Barcala-Furelos
- REMOSS Research Group, University of Vigo, 36005 Pontevedra, Spain
- Simulation and Intensive Care Unit of Santiago (SICRUS) Research Group, Health Research Institute of Santiago, University Hospital of Santiago de Compostela-CHUS, 15706 Santiago Compostela, Spain
- Faculty of Education and Sport Sciences, University of Vigo, 36005 Pontevedra, Spain
| | - Santiago Martínez-Isasi
- Simulation and Intensive Care Unit of Santiago (SICRUS) Research Group, Health Research Institute of Santiago, University Hospital of Santiago de Compostela-CHUS, 15706 Santiago Compostela, Spain
- CLINURSID Research Group, Psychiatry, Radiology, Public Health, Nursing and Medicine Department, Universidade de Santiago de Compostela, 15782 Santiago de Compostela, Spain
- Faculty of Nursing, Universidade de Santiago de Compostela, 15782 Santiago de Compostela, Spain
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7
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Shimoda-Sakano TM, Paiva EF, Schvartsman C, Reis AG. Factors associated with survival and neurologic outcome after in-hospital cardiac arrest in children: A cohort study. Resusc Plus 2023; 13:100354. [PMID: 36686327 PMCID: PMC9852640 DOI: 10.1016/j.resplu.2022.100354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/26/2022] [Accepted: 12/28/2022] [Indexed: 01/13/2023] Open
Abstract
Aim In-hospital paediatric cardiopulmonary resuscitation (CPR) survival has been improving in high-income countries. This study aimed to analyse factors associated with survival and neurological outcome after paediatric CPR in a middle-income country. Methods This observational study of in-hospital cardiac arrest using Utstein-style registry included patients <18 years old submitted to CPR between 2015 and 2020, at a high-complexity hospital. Outcomes were survival and neurological status assessed using Paediatric Cerebral Performance Categories score at prearrest, discharge, and after 180 days. Results Of 323 patients who underwent CPR, 108 (33.4%) survived to discharge and 93 (28.8%) after 180 days. In multivariable analysis, lower survival at discharge was associated with liver disease (OR 0.060, CI 0.007-0.510, p = 0.010); vasoactive drug infusion before cardiac arrest (OR 0.145, CI 0.065-0.325, p < 0.001); shock as the immediate cause (OR 0.183, CI 0.069-0.486, p = 0.001); resuscitation > 30 min (OR 0.070, CI 0.014-0.344, p = 0.001); and bicarbonate administration during CPR (OR 0.318, CI 0.130-0.780, p = 0.01). The same factors remained associated with lower survival after 180 days. Neurological outcome was analysed in the 93 survivors after 180 days following CPR. Prearrest neurological dysfunction was observed in 31.4%, and neurological prognosis was favourable in 79.7% at discharge and similar after 180 days. Conclusion In-hospital paediatric cardiac arrest patients with complex chronic conditions had lower survival associated with liver disease, shock as cause of cardiac arrest, vasoactive drug infusion before cardiac arrest, bicarbonate administration during CPR, and prolonged resuscitation. Most survivors had favourable neurological outcome.
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Affiliation(s)
- Tania M. Shimoda-Sakano
- University of Sao Paulo Children Institute, São Paulo, SP, Brazil
- Corresponding author at: R. Santa Justina, 215 ap 62, CEP 04545-041 São Paulo, Brazil.
| | | | | | - Amelia G. Reis
- University of Sao Paulo Children Institute, São Paulo, SP, Brazil
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8
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Oghifobibi OA, Toader AE, Nicholas MA, Nelson BP, Alindogan NG, Wolf MS, Kline AE, Nouraie SM, Bondi CO, Iordanova B, Clark RS, Bayır H, Loughran PA, Watkins SC, St Croix CM, Kochanek PM, Vazquez AL, Manole MD. Resuscitation with epinephrine worsens cerebral capillary no-reflow after experimental pediatric cardiac arrest: An in vivo multiphoton microscopy evaluation. J Cereb Blood Flow Metab 2022; 42:2255-2269. [PMID: 35854408 PMCID: PMC9670003 DOI: 10.1177/0271678x221113022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Epinephrine is the principal resuscitation therapy for pediatric cardiac arrest (CA). Clinical data suggest that although epinephrine increases the rate of resuscitation, it fails to improve neurological outcome, possibly secondary to reductions in microvascular flow. We characterized the effect of epinephrine vs. placebo administered at resuscitation from pediatric asphyxial CA on microvascular and macrovascular cortical perfusion assessed using in vivo multiphoton microscopy and laser speckle flowmetry, respectively, and on brain tissue oxygenation (PbO2), behavioral outcomes, and neuropathology in 16-18-day-old rats. Epinephrine-treated rats had a more rapid return of spontaneous circulation and brisk immediate cortical reperfusion during 1-3 min post-CA vs. placebo. However, at the microvascular level, epinephrine-treated rats had penetrating arteriole constriction and increases in both capillary stalling (no-reflow) and cortical capillary transit time 30-60 min post-CA vs. placebo. Placebo-treated rats had increased capillary diameters post-CA. The cortex was hypoxic post-CA in both groups. Epinephrine treatment worsened reference memory performance vs. shams. Hippocampal neuron counts did not differ between groups. Resuscitation with epinephrine enhanced immediate reperfusion but produced microvascular alterations during the first hour post-resuscitation, characterized by vasoconstriction, capillary stasis, prolonged cortical transit time, and absence of compensatory cortical vasodilation. Targeted therapies mitigating the deleterious microvascular effects of epinephrine are needed.
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Affiliation(s)
- Onome A Oghifobibi
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA
| | - Andrew E Toader
- Department of Electrical and Computer Engineering, University of Pittsburgh, Pittsburgh, USA
| | - Melissa A Nicholas
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA
| | - Brittany P Nelson
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA
| | - Nicole G Alindogan
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA
| | - Michael S Wolf
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Anthony E Kline
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA.,Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, USA
| | - Seyed M Nouraie
- Department of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Corina O Bondi
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA.,Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, USA
| | - Bistra Iordanova
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, USA
| | - Robert Sb Clark
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA.,Children's Neuroscience Institute, UPMC Children's Hospital, Pittsburgh, USA
| | - Hülya Bayır
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA.,Children's Neuroscience Institute, UPMC Children's Hospital, Pittsburgh, USA
| | | | - Simon C Watkins
- Department of Cell Biology, Center for Biologic Imaging University of Pittsburgh, Pittsburgh, USA
| | - Claudette M St Croix
- Department of Cell Biology, Center for Biologic Imaging University of Pittsburgh, Pittsburgh, USA
| | - Patrick M Kochanek
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA.,Children's Neuroscience Institute, UPMC Children's Hospital, Pittsburgh, USA
| | - Alberto L Vazquez
- Department of Radiology, University of Pittsburgh, Pittsburgh, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, USA
| | - Mioara D Manole
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA.,Children's Neuroscience Institute, UPMC Children's Hospital, Pittsburgh, USA
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9
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Bernard SA, Bray JE, Smith K, Stephenson M, Finn J, Grantham H, Hein C, Masters S, Stub D, Perkins GD, Dodge N, Martin C, Hopkins S, Cameron P. Effect of Lower vs Higher Oxygen Saturation Targets on Survival to Hospital Discharge Among Patients Resuscitated After Out-of-Hospital Cardiac Arrest: The EXACT Randomized Clinical Trial. JAMA 2022; 328:1818-1826. [PMID: 36286192 PMCID: PMC9608019 DOI: 10.1001/jama.2022.17701] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The administration of a high fraction of oxygen following return of spontaneous circulation in out-of-hospital cardiac arrest may increase reperfusion brain injury. OBJECTIVE To determine whether targeting a lower oxygen saturation in the early phase of postresuscitation care for out-of-hospital cardiac arrest improves survival at hospital discharge. DESIGN, SETTING, AND PARTICIPANTS This multicenter, parallel-group, randomized clinical trial included unconscious adults with return of spontaneous circulation and a peripheral oxygen saturation (Spo2) of at least 95% while receiving 100% oxygen. The trial was conducted in 2 emergency medical services and 15 hospitals in Victoria and South Australia, Australia, between December 11, 2017, and August 11, 2020, with data collection from ambulance and hospital medical records (final follow-up date, August 25, 2021). The trial enrolled 428 of a planned 1416 patients. INTERVENTIONS Patients were randomized by paramedics to receive oxygen titration to achieve an oxygen saturation of either 90% to 94% (intervention; n = 216) or 98% to 100% (standard care; n = 212) until arrival in the intensive care unit. MAIN OUTCOMES AND MEASURES The primary outcome was survival to hospital discharge. There were 9 secondary outcomes collected, including hypoxic episodes (Spo2 <90%) and prespecified serious adverse events, which included hypoxia with rearrest. RESULTS The trial was stopped early due to the COVID-19 pandemic. Of the 428 patients who were randomized, 425 were included in the primary analysis (median age, 65.5 years; 100 [23.5%] women) and all completed the trial. Overall, 82 of 214 patients (38.3%) in the intervention group survived to hospital discharge compared with 101 of 211 (47.9%) in the standard care group (difference, -9.6% [95% CI, -18.9% to -0.2%]; unadjusted odds ratio, 0.68 [95% CI, 0.46-1.00]; P = .05). Of the 9 prespecified secondary outcomes collected during hospital stay, 8 showed no significant difference. A hypoxic episode prior to intensive care was observed in 31.3% (n = 67) of participants in the intervention group and 16.1% (n = 34) in the standard care group (difference, 15.2% [95% CI, 7.2%-23.1%]; OR, 2.37 [95% CI, 1.49-3.79]; P < .001). CONCLUSIONS AND RELEVANCE Among patients achieving return of spontaneous circulation after out-of-hospital cardiac arrest, targeting an oxygen saturation of 90% to 94%, compared with 98% to 100%, until admission to the intensive care unit did not significantly improve survival to hospital discharge. Although the trial is limited by early termination due to the COVID-19 pandemic, the findings do not support use of an oxygen saturation target of 90% to 94% in the out-of-hospital setting after resuscitation from cardiac arrest. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03138005.
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Affiliation(s)
- Stephen A Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Alfred Hospital, Melbourne, Victoria, Australia
| | - Janet E Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Alfred Hospital, Melbourne, Victoria, Australia
- Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Michael Stephenson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Judith Finn
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia
| | - Hugh Grantham
- Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia
- SA Ambulance Service, Adelaide, South Australia, Australia
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Cindy Hein
- Flinders University, Adelaide, South Australia, Australia
| | - Stacey Masters
- Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia
| | - Dion Stub
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Natasha Dodge
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Catherine Martin
- Monash University, Data Science and AI Platform, Melbourne, Victoria, Australia
| | | | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Alfred Hospital, Melbourne, Victoria, Australia
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Lauridsen KG, Løfgren B, Brogaard L, Paltved C, Hvidman L, Krogh K. Cardiopulmonary Resuscitation Training for Healthcare Professionals: A Scoping Review. Simul Healthc 2022; 17:170-182. [PMID: 34652328 DOI: 10.1097/sih.0000000000000608] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
SUMMARY STATEMENT The optimal strategy for training cardiopulmonary resuscitation (CPR) for healthcare professionals remains to be determined. This scoping review aimed to describe the emerging evidence for CPR training for healthcare professionals.We screened 7605 abstracts and included 110 studies in this scoping review on CPR training for healthcare professionals. We assessed the included articles for evidence for the following topics: training duration, retraining intervals, e-learning, virtual reality/augmented reality/gamified learning, instructor-learner ratio, equipment and manikins, other aspects of contextual learning content, feedback devices, and feedback/debriefing. We found emerging evidence supporting the use of low-dose, high-frequency training with e-learning to achieve knowledge, feedback devices to perform high-quality chest compressions, and in situ team simulations with debriefings to improve the performance of provider teams.
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Affiliation(s)
- Kasper Glerup Lauridsen
- From the Department of Medicine (K.G.L., B.L.), Randers Regional Hospital, Randers; Research Center for Emergency Medicine (K.G.L., B.L., K.K.), Aarhus University Hospital, Aarhus, Denmark; Center for Simulation, Innovation, and Advanced Education (K.G.L.), Children's Hospital of Philadelphia, Philadelphia; Department of Clinical Medicine (B.L.), Aarhus University; Department of Obstetrics and Gynaecology (L.B., L.H.), Aarhus University Hospital; Corporate HR Midtsim (C.P.) Central Denmark Region; and Department of Anesthesiology, Aarhus University Hospital (K.K.), Aarhus University Hospital, Aarhus, Denmark
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11
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Lacoste-Palasset T, Megarbane B, Deye N. Poisoning-related cardiac arrest: why prognosis should be better? Resuscitation 2022; 175:77-80. [PMID: 35489520 DOI: 10.1016/j.resuscitation.2022.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 04/15/2022] [Accepted: 04/18/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Thomas Lacoste-Palasset
- Réanimation Médicale et Toxicologique, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France
| | - Bruno Megarbane
- Réanimation Médicale et Toxicologique, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France; INSERM UMRS-1144, Université de Paris, Paris, France
| | - Nicolas Deye
- Réanimation Médicale et Toxicologique, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France; INSERM UMRS-942, MASCOT, Paris, France
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12
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Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S, Rogers CA. Supraglottic airway device versus tracheal intubation in the initial airway management of out-of-hospital cardiac arrest: the AIRWAYS-2 cluster RCT. Health Technol Assess 2022; 26:1-158. [PMID: 35426781 PMCID: PMC9082259 DOI: 10.3310/vhoh9034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND When a cardiac arrest occurs, cardiopulmonary resuscitation should be started immediately. However, there is limited evidence about the best approach to airway management during cardiac arrest. OBJECTIVE The objective was to determine whether or not the i-gel® (Intersurgical Ltd, Wokingham, UK) supraglottic airway is superior to tracheal intubation as the initial advanced airway management strategy in adults with non-traumatic out-of-hospital cardiac arrest. DESIGN This was a pragmatic, open, parallel, two-group, multicentre, cluster randomised controlled trial. A cost-effectiveness analysis accompanied the trial. SETTING The setting was four ambulance services in England. PARTICIPANTS Patients aged ≥ 18 years who had a non-traumatic out-of-hospital cardiac arrest and were attended by a participating paramedic were enrolled automatically under a waiver of consent between June 2015 and August 2017. Follow-up ended in February 2018. INTERVENTION Paramedics were randomised 1 : 1 to use tracheal intubation (764 paramedics) or i-gel (759 paramedics) for their initial advanced airway management and were unblinded. MAIN OUTCOME MEASURES The primary outcome was modified Rankin Scale score at hospital discharge or 30 days after out-of-hospital cardiac arrest, whichever occurred earlier, collected by assessors blinded to allocation. The modified Rankin Scale, a measure of neurological disability, was dichotomised: a score of 0-3 (good outcome) or 4-6 (poor outcome/death). The primary outcome for the economic evaluation was quality-adjusted life-years, estimated using the EuroQol-5 Dimensions, five-level version. RESULTS A total of 9296 patients (supraglottic airway group, 4886; tracheal intubation group, 4410) were enrolled [median age 73 years; 3373 (36.3%) women]; modified Rankin Scale score was known for 9289 patients. Characteristics were similar between groups. A total of 6.4% (311/4882) of patients in the supraglottic airway group and 6.8% (300/4407) of patients in the tracheal intubation group had a good outcome (adjusted difference in proportions of patients experiencing a good outcome: -0.6%, 95% confidence interval -1.6% to 0.4%). The supraglottic airway group had a higher initial ventilation success rate than the tracheal intubation group [87.4% (4255/4868) vs. 79.0% (3473/4397), respectively; adjusted difference in proportions of patients: 8.3%, 95% confidence interval 6.3% to 10.2%]; however, patients in the tracheal intubation group were less likely to receive advanced airway management than patients in the supraglottic airway group [77.6% (3419/4404) vs. 85.2% (4161/4883), respectively]. Regurgitation rate was similar between the groups [supraglottic airway group, 26.1% (1268/4865); tracheal intubation group, 24.5% (1072/4372); adjusted difference in proportions of patients: 1.4%, 95% confidence interval -0.6% to 3.4%], as was aspiration rate [supraglottic airway group, 15.1% (729/4824); tracheal intubation group, 14.9% (647/4337); adjusted difference in proportions of patients: 0.1%, 95% confidence interval -1.5% to 1.8%]. The longer-term outcomes were also similar between the groups (modified Rankin Scale: at 3 months, odds ratio 0.89, 95% confidence interval 0.69 to 1.14; at 6 months, odds ratio 0.91, 95% confidence interval 0.71 to 1.16). Sensitivity analyses did not alter the overall findings. There were no unexpected serious adverse events. Mean quality-adjusted life-years to 6 months were 0.03 in both groups (supraglottic airway group minus tracheal intubation group difference -0.0015, 95% confidence interval -0.0059 to 0.0028), and total costs were £157 (95% confidence interval -£270 to £583) lower in the tracheal intubation group. Although the point estimate of the incremental cost-effectiveness ratio suggested that tracheal intubation may be cost-effective, the huge uncertainty around this result indicates no evidence of a difference between groups. LIMITATIONS Limitations included imbalance in the number of patients in each group, caused by unequal distribution of high-enrolling paramedics; crossover between groups; and the fact that participating paramedics, who were volunteers, might not be representative of all paramedics in the UK. Findings may not be applicable to other countries. CONCLUSION Among patients with out-of-hospital cardiac arrest, randomisation to the supraglottic airway group compared with the tracheal intubation group did not result in a difference in outcome at 30 days. There were no notable differences in costs, outcomes and overall cost-effectiveness between the groups. FUTURE WORK Future work could compare alternative supraglottic airway types with tracheal intubation; include a randomised trial of bag mask ventilation versus supraglottic airways; and involve other patient populations, including children, people with trauma and people in hospital. TRIAL REGISTRATION This trial is registered as ISRCTN08256118. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and supported by the NIHR Comprehensive Research Networks and will be published in full in Health Technology Assessment; Vol. 26, No. 21. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jonathan R Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Kim Kirby
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
- Research, Audit and Improvement Department, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Sarah Black
- Research, Audit and Improvement Department, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Stephen J Brett
- Department of Surgery and Cancer, Imperial College Healthcare NHS Trust, London, UK
| | - Madeleine Clout
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Michelle J Lazaroo
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Jerry P Nolan
- Bristol Medical School, University of Bristol, Bristol, UK
- Department of Anaesthesia, Royal United Hospital, Bath, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Maria Robinson
- Research, Audit and Improvement Department, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Lauren J Scott
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | - Helena Smartt
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Adrian South
- Research, Audit and Improvement Department, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Elizabeth A Stokes
- Health Economic Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- National Institute for Health and Care Research Oxford Biomedical Research Centre, Oxford, UK
| | - Jodi Taylor
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew Thomas
- Intensive Care Unit, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Sarah Voss
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Sarah Wordsworth
- Health Economic Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- National Institute for Health and Care Research Oxford Biomedical Research Centre, Oxford, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
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13
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Xiao Y, Su C, Zhang G, Liang L, Jin T, Bradley J, Ornato JP, Tang W. Vitamin C Improves the Outcomes of Cardiopulmonary Resuscitation and Alters Shedding of Syndecan-1 and p38/MAPK Phosphorylation in a Rat Model. J Am Heart Assoc 2022; 11:e023787. [PMID: 35289183 PMCID: PMC9075447 DOI: 10.1161/jaha.121.023787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Post‐resuscitation syndrome, involves a severe inflammatory response following successful cardiopulmonary resuscitation. The potential mechanism of Vitamin C (VitC) after cardiopulmonary resuscitation on myocardial and cerebral function, duration of survival is undefined. Methods and Results A first set of experiments were done in 18 male Sprague‐Dawley rats for the investigation of short‐term follow‐up, randomized into 3 groups: (1) sham; (2) controls; (3) VitC. Ventricular fibrillation was electrically induced and untreated for 6 minutes. Cardiopulmonary resuscitation including chest compression and mechanical ventilation were then initiated and continued for 8 minutes followed by defibrillation. At 5 minutes after return of spontaneous circulation, either VitC (200 mg/kg) or placebo was administered by intravenous infusion with a syringe pump for half an hour. There were significant improvements in myocardial function and buccal microcirculation in rats treated with VitC after return of spontaneous circulation 4 hours compared with controls. VitC inhibited proinflammatory cytokines (interleukin‐6 and tumor necrosis factor‐α), SDC‐1 (Syndecan‐1), and hyaluronic acid in plasma compared with controls (P<0.01). VitC decreased reactive oxygen species production and inhibited p38/MAPK (mitogen‐activated protein kinase) pathway phosphorylation. A second set with 20 animals was used for assessing the neurological deficit score after return of spontaneous circulation 72 hours, randomized into 2 groups: 1) controls; 2) VitC. The survival rate and neurological deficit score after return of spontaneous circulation 72 hours were improved in VitC‐treated animals compared with those of the control group. Conclusions VitC reduces the severity of post‐resuscitation myocardial and cerebral dysfunction and improves the survival. The mechanisms may involve inhibiting transcription of inflammatory cytokines and oxidative stress, thus protecting the integrity of the vascular endothelium. Meanwhile VitC reduces shedding of SDC‐1 and alters p38/MAPK phosphorylation and microcirculation.
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Affiliation(s)
- Yan Xiao
- Department of Emergency and Critical Care Medicine The Second Affiliated Hospital of Soochow University Soochow China.,Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth University Richmond VA
| | - Chenglei Su
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth University Richmond VA.,Department of Emergency Medicine Center the Affiliated Hospital of Xuzhou Medical University Xuzhou Jiangsu China
| | - Guozhen Zhang
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth University Richmond VA
| | - Lian Liang
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth University Richmond VA
| | - Tao Jin
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth University Richmond VA
| | - Jennifer Bradley
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth University Richmond VA
| | - Joseph P Ornato
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth University Richmond VA.,Department of Emergency Medicine Virginia Commonwealth University Health System Richmond VA
| | - Wanchun Tang
- Weil Institute of Emergency and Critical Care ResearchVirginia Commonwealth University Richmond VA.,Department of Emergency Medicine Virginia Commonwealth University Health System Richmond VA
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14
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Peters M, Stipulante S, Cloes V, Mulder A, Lebrun F, Donneau AF, Ghuysen A. Can Video Assistance Improve the Quality of Pediatric Dispatcher-Assisted Cardiopulmonary Resuscitation? Pediatr Emerg Care 2022; 38:e451-e457. [PMID: 34009900 DOI: 10.1097/pec.0000000000002392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study aimed to evaluate the impact of adding video conferencing to dispatcher-assisted telephone cardiopulmonary resuscitation (CPR) on pediatric bystander CPR quality. METHODS We conducted a prospective, randomized manikin study among volunteers with no CPR training and among bachelor nurses. Volunteers randomly received either video or audio assistance in a 6-minute pediatric cardiac arrest scenario. The main outcome measures were the results of the Cardiff Test to assess compression and ventilation performance. RESULTS Of 255 candidates assessed for eligibility, 120 subjects were randomly assigned to 1 of the 4 following groups: untrained telephone-guided (U-T; n = 30) or video-guided (U-V; n = 30) groups and trained telephone-guided (T-T; n = 30) or video-guided (T-V; n = 30) groups. Cardiac arrest was appropriately identified in 86.7% of the U-T group and in 100% in the other groups (P = 0.0061). Hand positioning was adequate in 76.7% of T-T, 80% of T-V, and 60% of U-V, as compared with 23.4% of the U-T group (P = 0.0001). Fewer volunteers managed to deliver 2 rescue breaths/cycle (P = 0.0001) in the U-T (16.7%) compared with the U-V (43.3%), the T-T (56.7%), and the T-V groups (60%).Subjects in the video groups had a lower fraction of minute to ventilate as compared with the telephone groups (P = 0.0005). CONCLUSIONS In dispatcher-instructed children CPR simulation, using video assistance improves cardiac arrest recognition and CPR quality with more appropriate chest compression technique and ventilation delivering. The long interruptions in chest compression combined with the mixed success rate to deliver proper ventilation raise question about ventilation quality and its effectiveness.
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Affiliation(s)
- Michael Peters
- From the Department of Public Health, University of Liege
| | | | | | - André Mulder
- Department of Paediatric Critical Care, Centre Hospitalier Chrétien of Liège
| | - Frédéric Lebrun
- Department of Paediatric Critical Care, Centre Hospitalier Chrétien of Liège
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15
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CAVALIERE F, BIANCOFIORE G, BIGNAMI E, DE ROBERTIS E, GIANNINI A, GRASSO S, PIASTRA M, SCOLLETTA S, TACCONE FS, TERRAGNI P. A year in review in Minerva Anestesiologica 2021. Critical care. Minerva Anestesiol 2022; 88:89-100. [DOI: 10.23736/s0375-9393.21.16409-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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16
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Hafeez A, Novak A. Epinephrine should continue to be used in the treatment of out-of-hospital cardiac arrest. BMJ Evid Based Med 2021; 26:e15. [PMID: 32398237 DOI: 10.1136/bmjebm-2019-111318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Aqib Hafeez
- Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Alex Novak
- Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
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17
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Chelly J, Plantefève G, Kamel T, Bruel C, Nseir S, Lai C, Cirillo G, Skripkina E, Ehrminger S, Berdaguer-Ferrari FD, Le Marec J, Paul M, Autret A, Deye N. Incidence, clinical characteristics, and outcome after unexpected cardiac arrest among critically ill adults with COVID-19: insight from the multicenter prospective ACICOVID-19 registry. Ann Intensive Care 2021; 11:155. [PMID: 34773516 PMCID: PMC8590126 DOI: 10.1186/s13613-021-00945-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/27/2021] [Indexed: 01/28/2023] Open
Abstract
Background Initial reports have described the poor outcome of unexpected cardiac arrest (CA) in intensive care unit (ICU) among COVID-19 patients in China and the USA. However, there are scarce data on characteristics and outcomes of such CA patients in Europe. Methods Prospective registry in 35 French ICUs, including all in-ICU CA in COVID-19 adult patients with cardiopulmonary resuscitation (CPR) attempt. Favorable outcome was defined as modified Rankin scale ranging from 0 to 3 at day 90 after CA. Results Among the 2425 COVID-19 patients admitted to ICU from March to June 2020, 186 (8%) experienced in-ICU CA, of whom 146/186 (78%) received CPR. Among these 146 patients, 117 (80%) had sustained return of spontaneous circulation, 102 (70%) died in the ICU, including 48 dying within the first day after CA occurrence and 21 after withdrawal of life-sustaining therapy. Most of CA were non-shockable rhythm (90%). At CA occurrence, 132 patients (90%) were mechanically ventilated, 83 (57%) received vasopressors and 75 (51%) had almost three organ failures. Thirty patients (21%) had a favorable outcome. Sepsis-related organ failure assessment score > 9 before CA occurrence was the single parameter constantly associated with unfavorable outcome in multivariate analysis. Conclusions In-ICU CA incidence remains high among a large multicenter cohort of French critically ill adults with COVID-19. However, 21% of patients with CPR attempt remained alive at 3 months with good functional status. This contrasts with other recent reports showing poor outcome in such patients. Trial registration: This study was retrospectively registered in ClinicalTrials.gov (NTC04373759) in April 2020 (https://www.clinicaltrials.gov/ct2/show/NCT04373759?term=acicovid&draw=2&rank=1). Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00945-y.
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Affiliation(s)
- Jonathan Chelly
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon-La Seyne sur Mer, Hôpital Sainte Musse, 54 rue Henri Sainte Claire Deville, 83056, Toulon, France.
| | - Gaetan Plantefève
- Intensive Care Unit, Centre Hospitalier Victor Dupouy, Argenteuil, France
| | - Toufik Kamel
- Intensive Care Unit, Centre Hospitalier Régional d'Orléans, Orléans. Inserm UMR1153, ECSTRRA, Université de Paris, Paris, France
| | - Cédric Bruel
- Intensive Care Unit, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Saad Nseir
- Médecine Intensive Réanimation, CHU Lille, Inserm U1285, Université de Lille, CNRS, UMR 8576-UGSF, Unité de Glycobiologie Structurale et Fonctionnelle, Lille, France
| | - Christopher Lai
- Medical Intensive Care Unit, Hôpital de Bicêtre, Université Paris-Saclay, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Giulia Cirillo
- Intensive Care Department, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Elena Skripkina
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Sébastien Ehrminger
- Intensive Care Unit, Grand Hôpital de l'Est Francilien-site de Marne la Vallée, Jossigny, France
| | | | - Julien Le Marec
- Intensive Care Unit, Département R3S, Pitié-Salpétrière hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Sorbonne Université, Paris, France
| | - Marine Paul
- Intensive Care Unit, Centre Hospitalier de Versailles-site André Mignot, Le Chesnay, France
| | - Aurélie Autret
- Clinical Research Department, Centre Hospitalier Intercommunal Toulon-La Seyne sur Mer, Toulon, France
| | - Nicolas Deye
- Medical and Toxicological Intensive Care Unit, Inserm U942, Assistance Publique Hôpitaux de Paris (AP-HP), Centre Hospitalier Universitaire Lariboisière, Paris, France
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18
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Rezar R, Paar V, Seelmaier C, Pretsch I, Schwaiger P, Kopp K, Kaufmann R, Felder TK, Prinz E, Gemes G, Pistulli R, Hoppe UC, Wernly B, Lichtenauer M. Soluble suppression of tumorigenicity 2 as outcome predictor after cardiopulmonary resuscitation: an observational prospective study. Sci Rep 2021; 11:21756. [PMID: 34741120 PMCID: PMC8571342 DOI: 10.1038/s41598-021-01389-x] [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: 05/12/2021] [Accepted: 10/27/2021] [Indexed: 11/09/2022] Open
Abstract
Prognostication after cardiopulmonary resuscitation (CPR) is complex. Novel biomarkers like soluble suppression of tumorigenicity 2 (sST2) may provide an objective approach. A total of 106 post-CPR patients were included in this single-center observational prospective study. Serum sST2 levels were obtained 24 h after admission. Individuals were assigned to two groups: patients below and above the overall cohort’s median sST2 concentration. Primary outcome was a combined endpoint at 6 months (death or Cerebral Performance Category > 2); secondary endpoint 30-day mortality. A uni- and multivariate logistic regression analysis were conducted. Elevated sST2-levels were associated with an increased risk for the primary outcome (OR 1.011, 95% CI 1.004–1.019, p = 0.004), yet no patients with poor neurological outcome were observed at 6 months. The optimal empirical cut-off for sST2 was 46.15 ng/ml (sensitivity 81%, specificity 53%, AUC 0.69). Levels above the median (> 53.42 ng/ml) were associated with higher odds for both endpoints (death or CPC > 2 after 6 months: 21% vs. 49%, OR 3.59, 95% CI 1.53–8.45, p = 0.003; death after 30 days: 17% vs. 43.3%, OR 3.75, 95% CI 1.52–9.21, p = 0.003). A positive correlation of serum sST2 after CPR with mortality at 30 days and 6 months after cardiac arrest could be demonstrated.
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Affiliation(s)
- Richard Rezar
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria.
| | - Vera Paar
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Clemens Seelmaier
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Ingrid Pretsch
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Philipp Schwaiger
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Kristen Kopp
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Reinhard Kaufmann
- Department of Radiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Thomas K Felder
- Department of Laboratory Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Erika Prinz
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Geza Gemes
- Department of Anaesthesiology and Intensive Care Medicine, Krankenhaus Der Barmherzigen Brüder Graz, Graz, Austria
| | - Rudin Pistulli
- Department of Cardiology I-Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany
| | - Uta C Hoppe
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Bernhard Wernly
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria.,Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria.,Center for Public Health and Healthcare Research, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Michael Lichtenauer
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
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Brown TP, Perkins GD, Smith CM, Deakin CD, Fothergill R. Are there disparities in the location of automated external defibrillators in England? Resuscitation 2021; 170:28-35. [PMID: 34757059 PMCID: PMC8786665 DOI: 10.1016/j.resuscitation.2021.10.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/11/2021] [Accepted: 10/24/2021] [Indexed: 11/10/2022]
Abstract
Background Early defibrillation is an essential element of the chain of survival for out-of-hospital cardiac arrest (OHCA). Public access defibrillation (PAD) programmes aim to place automated external defibrillators (AED) in areas with high OHCA incidence, but there is sometimes a mismatch between AED density and OHCA incidence. Objectives This study aimed to assess whether there were any disparities in the characteristics of areas that have an AED and those that do not in England. Methods Details of the location of AEDs registered with English Ambulance Services were obtained from individual services or internet sources. Neighbourhood characteristics of lower layer super output areas (LSOA) were obtained from the Office for National Statistics. Comparisons were made between LSOAs with and without a registered AED. Results AEDs were statistically more likely to be in LSOAs with a lower residential but higher workplace population density, with people predominantly from a white ethnic background and working in higher socio-economically classified occupations (p < 0.05). There was a significant correlation between AED coverage and the LSOA Index of Multiple Deprivation (IMD) (r = 0.79, p = 0.007), with only 27.4% in the lowest IMD decile compared to about 45% in highest. AED density varied significantly across the country from 0.82/km2 in the north east to 2.97/km2 in London. Conclusions In England, AEDs were disproportionately placed in more affluent areas, with a lower residential population density. This contrasts with locations where OHCAs have previously occurred. Future PAD programmes should give preference to areas of higher deprivation and be tailored to the local community.
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Affiliation(s)
- Terry P Brown
- NIHR Applied Research Collaboration West Midlands, Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK.
| | - Gavin D Perkins
- NIHR Applied Research Collaboration West Midlands, Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK; Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK
| | | | - Charles D Deakin
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, Winchester SO21 2RU, UK; University Hospital Southampton NHS Foundation Trust, Southampton S16 6YD, UK
| | - Rachael Fothergill
- Clinical Audit & Research Unit, Clinical & Quality Directorate, London Ambulance Service NHS Trust, HQ Annexe, 8-20 Pocock Street, London SE1 0BW, UK
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20
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Le May M, Osborne C, Russo J, So D, Chong AY, Dick A, Froeschl M, Glover C, Hibbert B, Marquis JF, De Roock S, Labinaz M, Bernick J, Marshall S, Maze R, Wells G. Effect of Moderate vs Mild Therapeutic Hypothermia on Mortality and Neurologic Outcomes in Comatose Survivors of Out-of-Hospital Cardiac Arrest: The CAPITAL CHILL Randomized Clinical Trial. JAMA 2021; 326:1494-1503. [PMID: 34665203 PMCID: PMC8527358 DOI: 10.1001/jama.2021.15703] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Comatose survivors of out-of-hospital cardiac arrest experience high rates of death and severe neurologic injury. Current guidelines recommend targeted temperature management at 32 °C to 36 °C for 24 hours. However, small studies suggest a potential benefit of targeting lower body temperatures. OBJECTIVE To determine whether moderate hypothermia (31 °C), compared with mild hypothermia (34 °C), improves clinical outcomes in comatose survivors of out-of-hospital cardiac arrest. DESIGN, SETTING, AND PARTICIPANTS Single-center, double-blind, randomized, clinical superiority trial carried out in a tertiary cardiac care center in eastern Ontario, Canada. A total of 389 patients with out-of-hospital cardiac arrest were enrolled between August 4, 2013, and March 20, 2020, with final follow-up on October 15, 2020. INTERVENTIONS Patients were randomly assigned to temperature management with a target body temperature of 31 °C (n = 193) or 34 °C (n = 196) for a period of 24 hours. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality or poor neurologic outcome at 180 days. Neurologic outcome was assessed using the Disability Rating Scale, with poor neurologic outcome defined as a score greater than 5 (range, 0-29, with 29 being the worst outcome [vegetative state]). There were 19 secondary outcomes, including mortality at 180 days and length of stay in the intensive care unit. RESULTS Among 367 patients included in the primary analysis (mean age, 61 years; 69 women [19%]), 366 (99.7%) completed the trial. The primary outcome occurred in 89 of 184 patients (48.4%) in the 31 °C group and in 83 of 183 patients (45.4%) in the 34 °C group (risk difference, 3.0% [95% CI, 7.2%-13.2%]; relative risk, 1.07 [95% CI, 0.86-1.33]; P = .56). Of the 19 secondary outcomes, 18 were not statistically significant. Mortality at 180 days was 43.5% and 41.0% in patients treated with a target temperature of 31 °C and 34 °C, respectively (P = .63). The median length of stay in the intensive care unit was longer in the 31 °C group (10 vs 7 days; P = .004). Among adverse events in the 31 °C group vs the 34 °C group, deep vein thrombosis occurred in 11.4% vs 10.9% and thrombus in the inferior vena cava occurred in 3.8% and 7.7%, respectively. CONCLUSIONS AND RELEVANCE In comatose survivors of out-of-hospital cardiac arrest, a target temperature of 31 °C did not significantly reduce the rate of death or poor neurologic outcome at 180 days compared with a target temperature of 34 °C. However, the study may have been underpowered to detect a clinically important difference. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02011568.
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Affiliation(s)
- Michel Le May
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - Juan Russo
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Aun Yeong Chong
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Alexander Dick
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | | | | | - Sophie De Roock
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marino Labinaz
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jordan Bernick
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Shawn Marshall
- University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ronnen Maze
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - George Wells
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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21
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Dainty K, Seaton M, Cowan K, Laupacis A, Dorian P, Douma M, Garner J, Goldstein J, Shire D, Sinclair D, Thurlow C, Vaillancourt C. Partnering with survivors & families to determine research priorities for adult out-of-hospital cardiac arrest: A James Lind Alliance Priority Setting Partnership. Resusc Plus 2021; 7:100148. [PMID: 34286310 PMCID: PMC8274337 DOI: 10.1016/j.resplu.2021.100148] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/18/2021] [Accepted: 06/18/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Research priority setting in health care has historically been done by expert health care providers and researchers and has not involved patients, family or the public. Survivors & family members have been particularly absent from this process in the field of resuscitation research and specifically adult out of hospital cardiac arrest (OHCA). As such, we sought to conduct a priority setting exercise in partnership with survivors, lay responders and their families in order to ensure that their priorities were visible. We partnered with the James Lind Alliance (UK) and used their commonly used consensus methodology for Public Priority Setting Partnerships (PSPs) to identify research priorities that reflected the perspectives of all stakeholders. METHODS We used two rounds of public and health care professional surveys to create the initial priority lists. The initial survey collected open-ended questions while the second round consolidated the list of initial questions into a refined list for prioritization. This was done by reviewing existing evidence and thematic categorization by the multi-disciplinary steering committee. An in-person consensus workshop was conducted to come to consensus on the top ten priorities from all perspectives. The McMaster PPEET tool was used to measure engagement. RESULTS The initial survey yielded more than 425 responses and 1450 "questions" from survivors and family members (18%), lay responders, health care providers and others. The second survey asked participants to rank a short list of 125 questions. The final top 25 questions were brought to the in-person meeting, and a top ten were selected through the JLA consensus process. The final list of top ten questions included how to improve the rate of lay responder CPR, what interventions used at the scene of an arrest can improve resuscitation and survival, how survival can be improved in rural areas of Canada, what resuscitation medications are most effective, what care patient's family members need, what post-discharge support is needed for survivors, how communication should work for everyone involved with a cardiac arrest, what factors best predict neurologically intact survival, whether biomarkers/genetic tests are effective in predicting OHCA and more research on the short and long-term psycho-social impacts of OHCA on survivors. The PPEET showed overwhelmingly positive results for the patient and family engagement experience during the final workshop. CONCLUSIONS This inclusive research priority setting provides essential information for those doing resuscitation research internationally. The results provide a guide for priority areas of research and should drive our community to focus on questions that matter to survivors and their families in our work. In particular the Canadian Resuscitation Outcomes Consortium will be incorporating the top ten list into its strategic plan for the future.
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Affiliation(s)
- K.N. Dainty
- North York General Hospital and the Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - M.B. Seaton
- North York General Hospital, Toronto, Ontario, Canada
| | | | - A. Laupacis
- Li Ka Shing Knowledge Institute and Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - P. Dorian
- Unity Health Toronto and Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - M. Douma
- University of Dublin, Dublin, Ireland
| | - J. Garner
- Family member, Toronto, Ontario, Canada
| | - J. Goldstein
- Dalhousie Emergency Health Service, Halifax, Nova Scotia, Canada
| | - D. Shire
- Survivor, Toronto, Ontario, Canada
| | - D. Sinclair
- IWK Health Centre, Halifax, Nova Scotia, Canada
| | - C. Thurlow
- Survivor, Vancouver, British Columbia, Canada
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22
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Stokes EA, Lazaroo MJ, Clout M, Brett SJ, Black S, Kirby K, Nolan JP, Reeves BC, Robinson M, Rogers CA, Scott LJ, Smartt H, South A, Taylor J, Thomas M, Voss S, Benger JR, Wordsworth S. Cost-effectiveness of the i-gel supraglottic airway device compared to tracheal intubation during out-of-hospital cardiac arrest: Findings from the AIRWAYS-2 randomised controlled trial. Resuscitation 2021; 167:1-9. [PMID: 34126133 PMCID: PMC8525511 DOI: 10.1016/j.resuscitation.2021.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/07/2021] [Accepted: 06/02/2021] [Indexed: 11/23/2022]
Abstract
Aim Optimal airway management during out-of-hospital cardiac arrest (OHCA) is uncertain. Complications from tracheal intubation (TI) may be avoided with supraglottic airway (SGA) devices. The AIRWAYS-2 cluster randomised controlled trial (ISRCTN08256118) compared the i-gel SGA with TI as the initial advanced airway management (AAM) strategy by paramedics treating adults with non-traumatic OHCA. This paper reports the trial cost-effectiveness analysis. Methods A within-trial cost-effectiveness analysis of the i-gel compared with TI was conducted, with a six-month time horizon, from the perspective of the UK National Health Service (NHS) and personal social services. The primary outcome measure was quality-adjusted life years (QALYs), estimated using the EQ-5D-5L questionnaire. Multilevel linear regression modelling was used to account for clustering by paramedic when combining costs and outcomes. Results 9296 eligible patients were attended by 1382 trial paramedics and enrolled in the AIRWAYS-2 trial (4410 TI, 4886 i-gel). Mean QALYs to six months were 0.03 in both groups (i-gel minus TI difference −0.0015, 95% CI –0.0059 to 0.0028). Total costs per participant up to six months post-OHCA were £3570 and £3413 in the i-gel and TI groups respectively (mean difference £157, 95% CI –£270 to £583). Based on mean difference point estimates, TI was more effective and less costly than i-gel; however differences were small and there was great uncertainty around these results. Conclusion The small differences between groups in QALYs and costs shows no difference in the cost-effectiveness of the i-gel and TI when used as the initial AAM strategy in adults with non-traumatic OHCA.
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Affiliation(s)
- Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Oxford NIHR Biomedical Research Centre, Oxford, UK
| | - Michelle J Lazaroo
- Clinical Trials and Evaluation Unit (CTEU), Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Madeleine Clout
- Clinical Trials and Evaluation Unit (CTEU), Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Stephen J Brett
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sarah Black
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Kim Kirby
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK; University of the West of England, Glenside Campus, Bristol, UK
| | - Jerry P Nolan
- Bristol Medical School, University of Bristol, Bristol, UK; Department of Anaesthesia, Royal United Hospital, Bath, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit (CTEU), Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Maria Robinson
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit (CTEU), Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lauren J Scott
- Clinical Trials and Evaluation Unit (CTEU), Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Helena Smartt
- Clinical Trials and Evaluation Unit (CTEU), Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Adrian South
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Jodi Taylor
- Clinical Trials and Evaluation Unit (CTEU), Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK; Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew Thomas
- Intensive Care Unit, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Sarah Voss
- University of the West of England, Glenside Campus, Bristol, UK
| | | | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Oxford NIHR Biomedical Research Centre, Oxford, UK.
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23
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Rezar R, Lichtenauer M, Schwaiger P, Seelmaier C, Pretsch I, Ausserwinkler M, Reichle J, Jirak P, Jung C, Strohmer B, Hoppe UC, Wernly B. Thinking fast and slow: Lactate and MELD-XI (Model for End-Stage Liver Disease Excluding INR) are useful for estimating mortality after cardiopulmonary resuscitation. Minerva Anestesiol 2021; 87:1017-1024. [PMID: 33938680 DOI: 10.23736/s0375-9393.21.15420-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intensivists keep getting challenged with prognostication after cardiopulmonary resuscitation (CPR). The model for end-stage liver disease, excluding INR (MELD-XI) score has proven valuable for assessing illness severity. Serum lactate is a readily available and established indicator of general stress and tissue hypoxia. We aimed to evaluate the prognostic value of MELD-XI combined with serum lactate in patients after CPR. METHODS A retrospective analysis on 106 patients after CPR was performed. Multivariable Cox regression was performed to evaluate associations with 30-day mortality and neurological outcome by means of Cerebral Performance Category (CPC). An optimal cut-off was calculated by means of the Youden index. Patients were then divided into subgroups based on the optimal cut-offs for MELD-XI and serum lactate. RESULTS MELD-XI and lactate were independently associated with mortality. The respective cut-offs were MELD-XI >12 and lactate ≥2.5 mmol/L. Patients were split into three groups: lactate <2.5 mmol/L and MELD-XI ≤12 (low-risk; n=32), lactate ≥2.5 mmol/L or MELD-XI >12 (medium-risk; n=39), and lactate ≥ 2.5mmol/L and MELD-XI >12 (high-risk; n=33). The mortality rates were 6%, 26% and 61% in the low, medium and high-risk group. This combined model yielded in the highest predictive abilities (AUC 0.78 95%CI 0.68-0.85; p=0.03 vs. AUC 0.66 for SOFA score). Worse neurological outcome (CPC 3 or 4) was more common in the medium and high-risk group (6.25%, 10.3% and 9.1%). CONCLUSIONS The combination of MELD-XI and lactate concentration at ICU admission was superior to the more complex SOFA score for prediction of mortality after CPR.
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Affiliation(s)
- Richard Rezar
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria -
| | - Michael Lichtenauer
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Philipp Schwaiger
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Clemens Seelmaier
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Ingrid Pretsch
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Mathias Ausserwinkler
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Jochen Reichle
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Peter Jirak
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Bernhard Strohmer
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Uta C Hoppe
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Bernhard Wernly
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
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Patel JK, Sinha N, Hou W, Shah R, Qadeer A, Tran L, Parikh PB, Parnia S. Association of post-resuscitation inflammatory response with favorable neurologic outcomes in adults with in-hospital cardiac arrest. Resuscitation 2020; 159:54-59. [PMID: 33385467 DOI: 10.1016/j.resuscitation.2020.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 11/19/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Early prediction of mortality in adults after in-hospital cardiac arrest (IHCA) remains vital to optimizing treatment strategies. Inflammatory cytokines specific to early prognostication in this population have not been well studied. We evaluated whether novel inflammatory cytokines obtained from adults with IHCA helped predict favorable neurologic outcome. METHODS The study population included adults with IHCA who underwent ACLS-guided resuscitation between March 2014 and May 2019 at an academic tertiary medical center. Peripheral blood samples were obtained within 6, 24, 48, 72, and 96 h of IHCA and analysis of 15 cytokines were performed. The primary outcome of interest was presence of favorable neurologic outcome at hospital discharge, defined as a Glasgow Outcome Score of 4 or 5. RESULTS Of the 105 adults with IHCA studied, 27 (25.7%) were noted to have survival with a favorable neurologic outcome while 78 (74.3%) did not. Patients who survived with favorable neurologic outcome were more often men (88.9% vs 61.5%, p = 0.008) and had higher rates of ventricular tachyarrhythmias as their initial rhythm (34.6% vs 11.7%, p = 0.018). Levels of interleukin (IL)-6, IL-8, IL-10, and Tumor Necrosis Factor (TNF)-R1 within 6 or 24 h were significantly lower in patients with favorable neurologic outcome compared with those who had unfavorable neurologic outcome. In multivariable analysis, IL-10 levels within 6 h was the only independent predictor of favorable neurologic outcomes [odds ratio (OR) 0.895, 95% confidence interval 0.805-0.996, p = 0.041]. CONCLUSION In this contemporary observational study of adults with IHCA receiving ACLS-guided resuscitative and post-resuscitative care, inflammatory cytokines specific to early prognostication in adults with IHCA exist. Further larger scale studies examining the association of these inflammatory cytokines with prognosis are warranted.
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Affiliation(s)
- Jignesh K Patel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA.
| | - Niraj Sinha
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Wei Hou
- Division of Epidemiology and Biostatistics, Department of Family, Population, and Preventive Medicine, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Rian Shah
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Asem Qadeer
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Linh Tran
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Puja B Parikh
- Division of Cardiology, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Sam Parnia
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University Medical Center, New York, NY, USA
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Morley PT, Atkins DL, Finn JC, Maconochie I, Nolan JP, Rabi Y, Singletary EM, Wang TL, Welsford M, Olasveengen TM, Aickin R, Billi JE, Greif R, Lang E, Mancini ME, Montgomery WH, Neumar RW, Perkins GD, Soar J, Wyckoff MH, Morrison LJ. Evidence Evaluation Process and Management of Potential Conflicts of Interest: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156:A23-A34. [PMID: 33099418 DOI: 10.1016/j.resuscitation.2020.09.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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26
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OHCA (Out-of-Hospital Cardiac Arrest) and CAHP (Cardiac Arrest Hospital Prognosis) scores to predict outcome after in-hospital cardiac arrest: Insight from a multicentric registry. Resuscitation 2020; 156:167-173. [DOI: 10.1016/j.resuscitation.2020.09.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/02/2020] [Accepted: 09/14/2020] [Indexed: 12/13/2022]
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27
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Morley PT, Atkins DL, Finn JC, Maconochie I, Nolan JP, Rabi Y, Singletary EM, Wang TL, Welsford M, Olasveengen TM, Aickin R, Billi JE, Greif R, Lang E, Mancini ME, Montgomery WH, Neumar RW, Perkins GD, Soar J, Wyckoff MH, Morrison LJ. Evidence Evaluation Process and Management of Potential Conflicts of Interest: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S28-S40. [DOI: 10.1161/cir.0000000000000891] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Babini G, Ameloot K, Skrifvars MB. Cardiac function after cardiac arrest: what do we know? Minerva Anestesiol 2020; 87:358-367. [PMID: 32959631 DOI: 10.23736/s0375-9393.20.14574-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Postcardiac arrest myocardial dysfunction (PCAMD) is a frequent complication faced during post-resuscitation care that adversely impacts survival and neurological outcome. Both mechanical and electrical factors contribute to the occurrence of PCAMD. Prearrest ventricular function, the cause of cardiac arrest, global ischemia, resuscitation factors, ischemia/reperfusion injury and post-resuscitation treatments contribute to the severity of PCMAD. The pathophysiology of PCAMD is complex and include myocytes energy failure, impaired contractility, cardiac edema, mitochondrial damage, activation of inflammatory pathways and the coagulation cascade, persistent ischemic injury and myocardial stiffness. Hypotension and low cardiac output with vasopressor/inotropes need are frequent after resuscitation. However, clinical, hemodynamic and laboratory signs of shock are frequently altered by cardiac arrest pathophysiology and post-resuscitation treatment, potentially being misleading and not fully reflecting the severity of postcardiac arrest syndrome. Even if validated criteria are lacking, an extensive hemodynamic evaluation is useful to define a "benign" and a "malign" form of myocardial dysfunction and circulatory shock, potentially having treatment and prognostic implications. Cardiac output is frequently decreased after cardiac arrest, particularly in patients treated with target temperature management (TTM); however, it is not independently associated with outcome. Sinus bradycardia during TTM seems independently associated with survival and good neurological outcome, representing a promising prognostic indicator. Higher mean arterial pressure (MAP) seems to be associated with improved survival and cerebral function after cardiac arrest; however, two recent randomized clinical trials failed to replicate these results. Recommendations on hemodynamic optimization are relatively poor and are largely based on general principle of intensive care medicine.
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Affiliation(s)
- Giovanni Babini
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Emergency Medicine and Services, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium.,Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Markus B Skrifvars
- Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland -
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Backman S, Cronberg T, Rosén I, Westhall E. Reduced EEG montage has a high accuracy in the post cardiac arrest setting. Clin Neurophysiol 2020; 131:2216-2223. [DOI: 10.1016/j.clinph.2020.06.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/18/2020] [Accepted: 06/08/2020] [Indexed: 10/23/2022]
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Dick-Smith F, Elliott D, Martinez-Maldonado R, Power T. Comparing Real-Time Feedback Modalities to Support Optimal Cardiopulmonary Resuscitation for Undergraduate Nursing Students: A Quasi-Experimental Cross-Over Simulation Study. Clin Simul Nurs 2020. [DOI: 10.1016/j.ecns.2020.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Shimoda-Sakano TM, Schvartsman C, Reis AG. Epidemiology of pediatric cardiopulmonary resuscitation. J Pediatr (Rio J) 2020; 96:409-421. [PMID: 31580845 PMCID: PMC9432320 DOI: 10.1016/j.jped.2019.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/31/2019] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To analyze the main epidemiological aspects of prehospital and hospital pediatric cardiopulmonary resuscitation and the impact of scientific evidence on survival. SOURCE OF DATA This was a narrative review of the literature published at PubMed/MEDLINE until January 2019 including original and review articles, systematic reviews, meta-analyses, annals of congresses, and manual search of selected articles. SYNTHESIS OF DATA The prehospital and hospital settings have different characteristics and prognoses. Pediatric prehospital cardiopulmonary arrest has a three-fold lower survival rate than cardiopulmonary arrest in the hospital setting, occurring mostly at home and in children under 1year. Higher survival appears to be associated with age progression, shockable rhythm, emergency medical care, use of automatic external defibrillator, high-quality early life support, telephone dispatcher-assisted cardiopulmonary resuscitation, and is strongly associated with witnessed cardiopulmonary arrest. In the hospital setting, a higher incidence was observed in children under 1year of age, and mortality increased with age. Higher survival was observed with shorter cardiopulmonary resuscitation duration, occurrence on weekdays and during daytime, initial shockable rhythm, and previous monitoring. Despite the poor prognosis of pediatric cardiopulmonary resuscitation, an increase in survival has been observed in recent years, with good neurological prognosis in the hospital setting. CONCLUSIONS A great progress in the science of pediatric cardiopulmonary resuscitation has been observed, especially in developed countries. The recognition of the epidemiological aspects that influence cardiopulmonary resuscitation survival may direct efforts towards more effective actions; thus, studies in emerging and less favored countries remains a priority regarding the knowledge of local factors.
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Affiliation(s)
- Tania Miyuki Shimoda-Sakano
- Universidade de São Paulo (USP), Pediatria, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Pronto Socorro do Instituto da Criança, São Paulo, SP, Brazil; Sociedade de Pediatria de São Paulo (SPSP), Departamento de Emergência, Coordenação Ressuscitação Pediátrica, São Paulo, SP, Brazil; Sociedade de Cardiologia de São Paulo, Curso de PALS (Pediatric Advanced Life Support), São Paulo, SP, Brazil.
| | - Cláudio Schvartsman
- Universidade de São Paulo (USP), Pediatria, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Pronto Socorro do Instituto da Criança, São Paulo, SP, Brazil
| | - Amélia Gorete Reis
- Universidade de São Paulo (USP), Pediatria, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Pronto Socorro do Instituto da Criança, São Paulo, SP, Brazil; International Liaison Committee on Resuscitation (ILCOR), Brazil
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Shimoda‐Sakano TM, Schvartsman C, Reis AG. Epidemiology of pediatric cardiopulmonary resuscitation. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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McBride R, Ski CF, Thompson DR, Quinn T, Wilson MH. Championing survival: connecting the unknown network of responders to address out-of-hospital cardiac arrest. Scand J Trauma Resusc Emerg Med 2020; 28:49. [PMID: 32493504 PMCID: PMC7271506 DOI: 10.1186/s13049-020-00748-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/27/2020] [Indexed: 12/18/2022] Open
Abstract
Early intervention for out-of-hospital cardiac arrest (OHCA) presents a challenge for Emergency Medical Services (EMS) across Europe. Strategies designed to address this include education and training initiatives for citizens and building CPR skills capacity and awareness amongst health care professionals. However, there is a need to improve access to volunteer first responders who can commence CPR and defibrillate before the arrival of EMS. In the UK, initiatives such GoodSAM have integrated crowdsourcing technology with ambulance services to allow them autonomy in alerting responders to OHCAs which is parallel to an EMS dispatch. These services are building capacity to improve the initial 'call for help' and time to commence CPR and defibrillation if indicated. The next step is to identify and implement appropriate methods for public engagement, involvement and eventual networking of resources with statutory bodies such as local EMS. As crowdsourcing volunteer responders is at an early stage, there is a need to determine whether crowdsourcing is associated with patient outcomes, what its impact is on those responding to OHCA, whether it facilitates or impedes current services, and whether it is a safe and cost effective way to involve citizens to intervene in the community during cardiac arrest or other medical emergencies? Addressing such issues is likely to provide further insight into the role and effectiveness of new technologies and their potential impact on the wider community.
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Affiliation(s)
- Ronan McBride
- Ronan McBride, Anaesthetics, Theatres and Intensive Care Services, Southern Health and Social Care Trust, Portadown, UK
| | - Chantal F Ski
- School of Nursing and Midwifery, Queen's University Belfast, 97 Lisburn Rd, Belfast, UK.
| | - David R Thompson
- School of Nursing and Midwifery, Queen's University Belfast, 97 Lisburn Rd, Belfast, UK
| | - Tom Quinn
- Emergency, Cardiovascular and Critical Care Research Group, Kingston University London and St George's, London, UK
| | - Mark H Wilson
- Department of Neurosurgery, Imperial College London, London, UK
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Penketh JA, Nolan JP, Skrifvars MB, Rylander C, Frenell I, Tirkkonen J, Reynolds EC, Parr MJA, Aneman A. Airway management during in-hospital cardiac arrest: An international, multicentre, retrospective, observational cohort study. Resuscitation 2020; 153:143-148. [PMID: 32479867 DOI: 10.1016/j.resuscitation.2020.05.028] [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: 02/07/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 10/24/2022]
Abstract
AIM To determine the type of airway devices used during in-hospital cardiac arrest (IHCA) resuscitation attempts. METHODS International multicentre retrospective observational study of in-patients aged over 18 years who received chest compressions for cardiac arrest from April 2016 to September 2018. Patients were identified from resuscitation registries and rapid response system databases. Data were collected through review of resuscitation records and hospital notes. Airway devices used during cardiac arrest were recorded as basic (adjuncts or bag-mask), or advanced, including supraglottic airway devices, tracheal tubes or tracheostomies. Descriptive statistics and multivariable regression modelling were used for data analysis. RESULTS The final analysis included 598 patients. No airway management occurred in 36 (6%), basic airway device use occurred at any time in 562 (94%), basic airway device use without an advanced airway device in 182 (30%), tracheal intubation in 301 (50%), supraglottic airway in 102 (17%), and tracheostomy in 1 (0.2%). There was significant variation in airway device use between centres. The intubation rate ranged between 21% and 90% while supraglottic airway use varied between 1% and 45%. The choice of tracheal intubation vs. supraglottic airway as the second advanced airway device was not associated with immediate survival from the resuscitation attempt (odds ratio 0.81; 95% confidence interval 0.35-1.8). CONCLUSION There is wide variation in airway device use during resuscitation after IHCA. Only half of patients are intubated before return of spontaneous circulation and many are managed without an advanced airway. Further investigation is needed to determine optimal airway device management strategies during resuscitation following IHCA.
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Affiliation(s)
- J A Penketh
- Intensive Care Unit, Liverpool Hospital, Sydney, Australia; Intensive Care Unit, Royal United Hospital, Bath, United Kingdom.
| | - J P Nolan
- Intensive Care Unit, Royal United Hospital, Bath, United Kingdom; Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom.
| | - M B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - C Rylander
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - I Frenell
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - J Tirkkonen
- Intensive Care Unit, Liverpool Hospital, Sydney, Australia; Intensive Care Unit, Tampere University Hospital, Finland.
| | - E C Reynolds
- Intensive Care Unit, Liverpool Hospital, Sydney, Australia; Intensive Care Unit, Royal United Hospital, Bath, United Kingdom.
| | - M J A Parr
- Intensive Care Unit, Liverpool Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia.
| | - A Aneman
- Intensive Care Unit, Liverpool Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia.
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Haskins B, Smith K, Cameron P, Bernard S, Nehme Z, Murphy-Smith J, Metcalf M, Moussa R, Harvey D, Turnbull L, Dyson K. The impact of bystander relation and medical training on out-of-hospital cardiac arrest outcomes. Resuscitation 2020; 150:72-79. [PMID: 32194165 DOI: 10.1016/j.resuscitation.2020.02.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 02/11/2020] [Accepted: 02/27/2020] [Indexed: 01/29/2023]
Abstract
AIM In this study, we investigate the impact of bystander relation and medical training on survival to hospital discharge in out-of-hospital cardiac arrest (OHCA) patients receiving bystander cardiopulmonary resuscitation (CPR). METHODS A retrospective analysis was performed on non-traumatic OHCA patients receiving bystander CPR and Emergency Medical Service (EMS) attempted resuscitation from 2015 through 2017. Adjusted logistic regression was used to assess the association between related versus unrelated and layperson versus medically trained bystander CPR providers and survival to hospital discharge. RESULTS A total of 4464 OHCA were eligible for inclusion, of which 2385 (53.4%) received CPR from a relative, 468 (10.5%) from a work colleague or friend and 1611 (36.1%) from a stranger. Layperson's provided CPR in 3703 (83.0%) OHCA and medically trained professionals in 761 (17.0%). After adjustment for arrest characteristics, there was no difference in survival to hospital discharge between related versus unrelated CPR (adjusted odds ratio [AOR] 0.92, 95% confidence interval [CI]: 0.68-1.23, p = 0.555). However, bystander CPR by a medically trained provider rather than a layperson, was associated with an increase in the odds of survival by 47% (AOR 1.47, 95% CI: 1.09-2.00, p = 0.012) in the overall population and 73% (AOR 1.73, 95% CI: 1.21-2.49; p = 0.003) in patients with an initial shockable arrest. Adjusting for public access defibrillation significantly attenuated the effect of medically trained bystander CPR in initial shockable arrests (AOR 1.42, 95% CI: 0.97-2.07; p = 0.073). CONCLUSION This study supports ongoing efforts to crowdsource a larger number of first responders with medical training to OHCA patients to assist with the provision of CPR and early defibrillation.
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Affiliation(s)
- Brian Haskins
- NHMRC Centre of Research Excellence in Pre-hospital Emergency Care Australia and New Zealand (PEC-ANZ), Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Paramedicine, Monash University, Frankston, Victoria, Australia.
| | - Karen Smith
- NHMRC Centre of Research Excellence in Pre-hospital Emergency Care Australia and New Zealand (PEC-ANZ), Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Paramedicine, Monash University, Frankston, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Peter Cameron
- NHMRC Centre of Research Excellence in Pre-hospital Emergency Care Australia and New Zealand (PEC-ANZ), Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; The Alfred Hospital, Melbourne, Australia
| | - Steve Bernard
- NHMRC Centre of Research Excellence in Pre-hospital Emergency Care Australia and New Zealand (PEC-ANZ), Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia; The Alfred Hospital, Melbourne, Australia
| | - Ziad Nehme
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Jake Murphy-Smith
- Centre for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Matthew Metcalf
- Centre for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Rana Moussa
- Centre for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Douglas Harvey
- Centre for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Lauren Turnbull
- Centre for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Kylie Dyson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Unexpected cardiac arrests occurring inside the ICU: outcomes of a French prospective multicenter study. Intensive Care Med 2020; 46:1005-1015. [DOI: 10.1007/s00134-020-05992-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 02/26/2020] [Indexed: 11/30/2022]
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Resuscitation care bundles: The need to optimize individual care elements. Resuscitation 2020; 146:261-262. [DOI: 10.1016/j.resuscitation.2019.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/02/2019] [Indexed: 11/24/2022]
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Abstract
Cardiac surgical patients risk arrest from tamponade, profound bleeding, and hypovolemia, typically occurring within hours of intensive care admission and associated with diminished response to cardiopulmonary resuscitation (CPR). The Society of Thoracic Surgeons' evidence-based Expert Consensus Statement establishes a new standard for postsurgery arrest management, prioritizing defibrillation or pacing before CPR, restricting epinephrine use, and calling for prompt resternotomy if initial efforts fail. The protocol is summarized in a simple algorithm replacing advanced cardiac life support. This US cardiac surgical resuscitation standard is aligned with worldwide guidelines. Important information for protocol adoption and training is provided.
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Affiliation(s)
- S Jill Ley
- Surgical & Interval Services, California Pacific Medical Center, 1101 Van Ness Avenue #4403, San Francisco, CA 94109, USA.
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Bartlett ES, Valenzuela T, Idris A, Deye N, Glover G, Gillies MA, Taccone FS, Sunde K, Flint AC, Thiele H, Arrich J, Hemphill C, Holzer M, Skrifvars MB, Pittl U, Polderman KH, Ong MEH, Kim KH, Oh SH, Do Shin S, Kirkegaard H, Nichol G. Systematic review and meta-analysis of intravascular temperature management vs. surface cooling in comatose patients resuscitated from cardiac arrest. Resuscitation 2019; 146:82-95. [PMID: 31730898 DOI: 10.1016/j.resuscitation.2019.10.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 10/24/2019] [Accepted: 10/30/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To systematically review the effectiveness and safety of intravascular temperature management (IVTM) vs. surface cooling methods (SCM) for induced hypothermia (IH). METHODS Systematic review and meta-analysis. English-language PubMed, Embase and the Cochrane Database of Systematic Reviews were searched on May 27, 2019. The quality of included observational studies was graded using the Newcastle-Ottawa Quality Assessment tool. The quality of included randomized trials was evaluated using the Cochrane Collaboration's risk of bias tool. Random effects modeling was used to calculate risk differences for each outcome. Statistical heterogeneity and publication bias were assessed using standard methods. ELIGIBILITY Observational or randomized studies comparing survival and/or neurologic outcomes in adults aged 18 years or greater resuscitated from out-of-hospital cardiac arrest receiving IH via IVTM vs. SCM were eligible for inclusion. RESULTS In total, 12 studies met inclusion criteria. These enrolled 1573 patients who received IVTM; and 4008 who received SCM. Survival was 55.0% in the IVTM group and 51.2% in the SCM group [pooled risk difference 2% (95% CI -1%, 5%)]. Good neurological outcome was achieved in 40.9% in the IVTM and 29.5% in the surface group [pooled risk difference 5% (95% CI 2%, 8%)]. There was a 6% (95% CI 11%, 2%) lower risk of arrhythmia with use of IVTM and 15% (95% CI 22%, 7%) decreased risk of overcooling with use of IVTM vs. SCM. There was no significant difference in other evaluated adverse events between groups. CONCLUSIONS IVTM was associated with improved neurological outcomes vs. SCM among survivors resuscitated following cardiac arrest. These results may have implications for care of patients in the emergency department and intensive care settings after resuscitation from cardiac arrest.
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Affiliation(s)
- Emily S Bartlett
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States.
| | - Terence Valenzuela
- Department of Emergency Medicine, University of Arizona, Tucson, AZ, United States; Tucson Fire Department, Tucson, AZ, United States
| | - Ahamed Idris
- Departments of Emergency and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Nicolas Deye
- Medical Intensive Care Unit, Inserm U942, Lariboisiere Hospital, APHP, F-75010, Paris, France
| | - Guy Glover
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Michael A Gillies
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Fabio S Taccone
- Department of Intensive Care, Cliniques Universitaires de Bruxelles Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - 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
| | - Alexander C Flint
- Divison of Research, Kaiser Permanente, Oakland, CA, United States; Neuroscience Department, Kaiser Permanente, Redwood City, CA, United States
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Jasmin Arrich
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria; Center of Emergency Medicine, University of Jena, Faculty of Medicine, Jena, Germany
| | - Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA, United States
| | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Undine Pittl
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Kees H Polderman
- Essex Cardiothoracic Centre, Basildon, Essex, SS16 5NL, United Kingdom; Anglia Ruskin School of Medicine, Chelmsford, CM1 1SQ, United Kingdom; United General Hospital, Houston, TX, United States
| | - Marcus E H Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore; Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Ki Hong Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Department of Emergency Medicine and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Graham Nichol
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States; Department of Internal Medicine, University of Washington, Seattle, WA, United States; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA, United States
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Kimmoun A, Cariou A, Gayat E, Feliot E, Takagi K, Megarbane B, Mebazaa A, Deye N. One-year outcome of patients admitted after cardiac arrest compared to other causes of ICU admission. An ancillary analysis of the observational prospective and multicentric FROG-ICU study. Resuscitation 2019; 146:237-246. [PMID: 31678408 DOI: 10.1016/j.resuscitation.2019.10.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/02/2019] [Accepted: 10/23/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE While cardiac arrest (CA) patients discharged alive from intensive care unit (ICU) are considered to have good one-year survival but potential neurological impairment, comparisons with other ICU sub-populations non-admitted for CA purpose are still lacking. This study aimed to compare long-term outcome and health-related quality of life (HRQOL) between CA patients and patients admitted to ICU for all other causes. METHODS In 1635 patients discharged alive from 21 European ICUs in an ancillary analysis of a prospective multicentric cohort, we compared CA causes of ICU admission to all other causes of ICU admissions (named non-CAs). The primary endpoint was one-year survival rate after ICU discharge. Secondary endpoints included HRQOL at 3, 6 and 12 months after ICU discharge using the outcome survey short form-36 (SF36). Propensity score matching was used to consider the probability of having CA. RESULTS Of the 1635 patients, 1561 were included in this study comprised of 1447 non-CAs and 114 CAs. At one-year in the non-matched population, survival rate was greater in the CA group 89% versus the non-CA group 78% (log rank p = 0.0056). In the matched population, this difference persisted between CAs and non-CAs (log rank p = 0.049). The physical component summary of the SF36 scale was higher in the CA group than in the non-CA group at all time points in both non-matched and matched populations. CONCLUSIONS CA patients discharged alive from ICU have a better one-year survival and a better HRQOL specifically on physical functions than patients admitted to ICU for other causes. TRIAL REGISTRATION ClinicalTrials.gov NCT01367093; registered on June 6, 2011.
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Affiliation(s)
- Antoine Kimmoun
- Medical Intensive Care Unit, Nancy University Hospital, University of Lorraine, Nancy, France; UMR-S 942, INSERM, Paris, France; U1116, INSERM, Nancy, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris Cardiovascular Research Center-INSERM U970 (PARCC), Paris Sudden Death Expertise Center, Paris, France
| | - Etienne Gayat
- Department of Anesthesiology, Critical Care and Burn Unit, Saint Louis-Lariboisière University Hospitals, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot-Paris 7, Sorbonne Paris Cité, UMR-S 942, INSERM, Paris, France
| | - Elodie Feliot
- Department of Anesthesiology, Critical Care and Burn Unit, Saint Louis-Lariboisière University Hospitals, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot-Paris 7, Sorbonne Paris Cité, UMR-S 942, INSERM, Paris, France
| | - Koji Takagi
- Department of Anesthesiology, Critical Care and Burn Unit, Saint Louis-Lariboisière University Hospitals, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot-Paris 7, Sorbonne Paris Cité, UMR-S 942, INSERM, Paris, France
| | - Bruno Megarbane
- Medical Intensive Care Unit, Hôpitaux Universitaires Saint Louis-Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot-Paris 7, INSERM UMRS-1144, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesiology, Critical Care and Burn Unit, Saint Louis-Lariboisière University Hospitals, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot-Paris 7, Sorbonne Paris Cité, UMR-S 942, INSERM, Paris, France
| | - Nicolas Deye
- Medical Intensive Care Unit, Hôpitaux Universitaires Saint Louis-Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot-Paris 7, Sorbonne Paris Cité,UMR-S 942, INSERM, Paris, France.
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Ng KT, Teoh WY. The Effect of Prehospital Epinephrine in Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. Prehosp Disaster Med 2019; 34:532-539. [PMID: 31455452 DOI: 10.1017/s1049023x19004758] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Epinephrine has been recommended for out-of-hospital cardiac arrest (OHCA) resuscitation for nearly one century, but its efficacy and safety remain unclear in the literature. The primary aim of this review was to determine whether epinephrine increases the return of spontaneous circulation in OHCA patients. METHODS A systematic review and meta-analysis were conducted using the following databases: MEDLINE, EMBASE, and CENTRAL, from their inception until October 2018. All the randomized controlled trials (RCTs) were included. Observational studies, case reports, case series, and non-systematic reviews were excluded. RESULTS Two trials including 8,548 patients were eligible for inclusion in the data synthesis. In patients who received epinephrine during OHCA, the incidence of return of spontaneous circulation was increased, with an odds ratio (95%CI) of 4.25 (3.79-4.75), P <.001, high-quality of evidence. The number of patients transported to hospital was increased in patients who had prehospital epinephrine, with an odds ratio (95%CI) of 2.31 (2.11-2.53), P <.001, high-quality of evidence. The prehospital use of epinephrine was associated with an increased survival to hospital discharge, the odds ratio (95%CI) being 1.43 (1.10-1.87), P = .008, moderate-quality of evidence. No significant effect was noted on the favorable neurologic state of patient at hospital discharge, with an odds ratio (95%CI) of 1.21 (0.90-1.64), P = .21, moderate-quality of evidence. CONCLUSIONS This meta-analysis suggests that the prehospital use of epinephrine increases return of spontaneous circulation, transport of patients to hospital, and survival to hospital discharge for OHCA. However, no significant effects on favorable neurologic function at hospital discharge were demonstrated. The general quality of evidence ranged from moderate to high.
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Affiliation(s)
- K T Ng
- Medical Officer (Doctor), Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Jalan Universiti, Kuala Lumpur, Malaysia
| | - W Y Teoh
- Medical Student, University of Liverpool, School of Medicine, Liverpool, United Kingdom
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Modulating effects of immediate neuroprognosis on early coronary angiography and targeted temperature management following out-of-hospital cardiac arrest: A retrospective cohort study. Resuscitation 2019; 143:42-49. [DOI: 10.1016/j.resuscitation.2019.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/01/2019] [Accepted: 08/06/2019] [Indexed: 12/13/2022]
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Affiliation(s)
- Robert W Neumar
- Department of Emergency Medicine, Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor (R.W.N.)
| | - Gavin D Perkins
- Warwick Clinical Trials Unit and Heart of England NHS Foundation Trust, University of Warwick, Coventry, United Kingdom (G.D.P.)
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Yamamoto R, Suzuki M, Hayashida K, Yoshizawa J, Sakurai A, Kitamura N, Tagami T, Nakada TA, Takeda M, Sasaki J. Epinephrine during resuscitation of traumatic cardiac arrest and increased mortality: a post hoc analysis of prospective observational study. Scand J Trauma Resusc Emerg Med 2019; 27:74. [PMID: 31420058 PMCID: PMC6698003 DOI: 10.1186/s13049-019-0657-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/12/2019] [Indexed: 11/20/2022] Open
Abstract
Background The beneficial effect of epinephrine during resuscitation from out-of-hospital cardiac arrest (OHCA) has been inconclusive, and potential harm has been suggested, particularly in trauma victims. Although no significant improvement in neurological outcomes has been found among resuscitated patients using epinephrine, including trauma patients, the use of epinephrine is recommended in the Advanced Trauma Life Support protocol. Given that the use of vasopressors was reported to be associated with increased mortality in patients with massive bleeding, the undesirable effects of epinephrine during the resuscitation of traumatic OHCA should be elucidated. We hypothesised that resuscitation with epinephrine would increase mortality in patients with OHCA following trauma. Methods This study is a post-hoc analysis of a prospective, multicentre, observational study on patients with OHCA between January 2012 and March 2013. We included adult patients with traumatic OHCA who were aged ≥15 years and excluded those with missing survival data. Patient data were divided into epinephrine or no-epinephrine groups based on the use of epinephrine during resuscitation at the hospital. Propensity scores were developed to estimate the probability of being assigned to the epinephrine group using multivariate logistic regression analyses adjusted for known survival predictors. The primary outcome was survival 7 days after injury, which was compared among the two groups after propensity score matching. Results Of the 1125 adults with traumatic OHCA during the study period, 1030 patients were included in this study. Among them, 822 (79.8%) were resuscitated using epinephrine, and 1.1% (9/822) in the epinephrine group and 5.3% (11/208) in the no-epinephrine group survived 7 days after injury. The use of epinephrine was significantly associated with decreased 7-day survival (odds ratio = 0.20; 95% CI = 0.08–0.48; P < 0.01), and this result was confirmed by propensity score-matching analysis, in which 178 matched pairs were examined (adjusted odds ratio = 0.11; 95% CI = 0.01–0.85; P = 0.02). Conclusions The relationship between the use of epinephrine during resuscitation and decreased 7-day survival was found in patients with OHCA following trauma, and the propensity score-matched analyses validated the results. Resuscitation without epinephrine in traumatic OHCA should be further studied in a randomised controlled trial.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Masaru Suzuki
- Department of Emergency Medicine, Tokyo Dental College, Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa, Chiba, 272-8513, Japan
| | - Kei Hayashida
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Jo Yoshizawa
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Atsushi Sakurai
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyagutikamichou, Itabashi, Tokyo, 173-8610, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazushi, Chiba, 292-8535, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo, 206-8512, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba, 260-8677, Japan
| | - Munekazu Takeda
- Department of Critical Care and Emergency Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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Trummer G, Benk C, Beyersdorf F. Controlled automated reperfusion of the whole body after cardiac arrest. J Thorac Dis 2019; 11:S1464-S1470. [PMID: 31293795 DOI: 10.21037/jtd.2019.04.05] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Sudden circulatory arrest (CA) requiring cardiopulmonary resuscitation (CPR) has for decades been associated with high mortality and frequent neurological sequelae in the rarer survivors. The high mortality and morbidity are potentially related to a severe and global ischemia/reperfusion injury (IRI) of the whole body, especially the brain. Consequently, strategies to counteract this severe IRI may improve survival and neurological recovery of affected patients. Methods Based on the target to limit IRI in single organs, suitable parameters and methods were composed to form a global treatment concept, the CARL method (controlled automated reperfusion of the whole body). The concept centers on extracorporeal circulation, enhanced with readily available online monitoring. It allows for targeted adaption of different parameters (i.e., blood pressure and flow, temperature, oxygen content, electrolytes) during the reperfusion process, in the sense of a controlled reperfusion. Parameters and elements of the CARL method were extensively tested in a chronic animal model. An appropriate medical device, the system configuration "CIRD 1.0" (Controlled Integrated Resuscitation Device) is approved to be applied to patients. Results A set of parameters that support a limitation of a global IRI have been identified in over 250 animal experiments. Their specific targets and surveillance using adequate monitoring features are described. Using the CIRD in a single center, 14 patients with witnessed, but extremely prolonged CPR (51-120 minutes) have been treated with CARL. The outcome of these patients was favorable, with 7 of 14 patients regaining full consciousness and 6 of 7 allocated to Cerebral Performance Class (CPC) "1". Conclusions CA followed by CPR is associated with a very high mortality and frequent neurological sequelae. Limiting the occurring severe and global IRI may be a key to an improved survival and neurological recovery. Therefore, the therapeutic approach of CARL, which stands for a personalized, comprehensive therapy based on a readily available set of monitoring data and diagnostic findings, has been developed. First experience in patients indicates beneficial effects that call for further studies in the field of CARL.
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Affiliation(s)
- Georg Trummer
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
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The effects of adrenaline in out of hospital cardiac arrest with shockable and non-shockable rhythms: Findings from the PACA and PARAMEDIC-2 randomised controlled trials. Resuscitation 2019; 140:55-63. [PMID: 31116964 DOI: 10.1016/j.resuscitation.2019.05.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/17/2019] [Accepted: 05/14/2019] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Previous research suggests there may be differences in the effects of adrenaline related to the initial cardiac arrest rhythm. The aim of this study was to assess the effect of adrenaline compared with placebo according to whether the initial cardiac arrest rhythm was shockable or non-shockable. METHODS Return of spontaneous circulation (ROSC), survival and neurological outcomes according to the initial arrest rhythm were compared amongst patients enrolled in the PARAMEDIC-2 randomised, placebo controlled trial. The results of the PARAMEDIC-2 and PACA out of hospital cardiac arrest trials were combined and meta-analysed. RESULTS The initial rhythm was known for 3929 (98.2%) in the placebo arm and 3919 (97.6%) in the adrenaline arm. The effect on the rate of ROSC of adrenaline relative to placebo was greater in patients with non-shockable cardiac rhythms (1002/3003 (33.4%) versus 222/3005 (7.4%), adjusted OR: 6.5, (95% CI 5.6-7.6)) compared with shockable rhythms 349/716 (48.7%) versus (208/702 (29.6%), adjusted OR: 2.3, 95%CI: 1.9-2.9)). The adjusted odds ratio for survival at discharge for non-shockable rhythms was 2.5 (1.3, 4.8) and 1.3 (0.9, 1.8) for shockable rhythms (P value for interaction 0.065) and 1.8 (0.8-4.1) and 1.1 (0.8-1.6) respectively for neurological outcome at discharge (P value for interaction 0.295). Meta-analysis found similar results. CONCLUSION Relative to placebo, the effects of adrenaline ROSC are greater for patients with an initially non-shockable rhythm than those with a shockable rhythms. Similar patterns are observed for longer term survival outcomes and favourable neurological outcomes, although the differences in effects are less pronounced. ISRCTN73485024.
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Abstract
BACKGROUND Adrenaline and vasopressin are widely used to treat people with cardiac arrest, but there is uncertainty about the safety, effectiveness and the optimal dose. OBJECTIVES To determine whether adrenaline or vasopressin, or both, administered during cardiac arrest, afford any survival benefit. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and DARE from their inception to 8 May 2018, and the International Liaison Committee on Resuscitation 2015 Advanced Life Support Consensus on Science and Treatment Recommendations. We also searched four trial registers on 5 September 2018 and checked the reference lists of the included studies and review papers to identify potential papers for review. SELECTION CRITERIA Any randomised controlled trial comparing: standard-dose adrenaline versus placebo; standard-dose adrenaline versus high-dose adrenaline; and adrenaline versus vasopressin, in any setting, due to any cause of cardiac arrest, in adults and children. There were no language restrictions. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials for review, assessed risks of bias and extracted data, resolving disagreements through re-examination of the trial reports and by discussion. We used risk ratios (RRs) with 95% confidence intervals (CIs) to compare dichotomous outcomes for clinical events. There were no continuous outcomes reported. We examined groups of trials for heterogeneity. We report the quality of evidence for each outcome, using the GRADE approach. MAIN RESULTS We included 26 studies (21,704 participants).Moderate-quality evidence found that adrenaline increased survival to hospital discharge compared to placebo (RR 1.44, 95% CI 1.11 to 1.86; 2 studies, 8538 participants; an increase from 23 to 32 per 1000, 95% CI 25 to 42). We are uncertain about survival to hospital discharge for high-dose compared to standard-dose adrenaline (RR 1.10, 95% CI 0.75 to 1.62; participants = 6274; studies = 10); an increase from 33 to 36 per 1000, 95% CI 24 to 53); standard-dose adrenaline versus vasopressin (RR 1.25, 95% CI 0.84 to 1.85; 6 studies; 2511 participants; an increase from 72 to 90 per 1000, 95% CI 60 to 133); and standard-dose adrenaline versus vasopressin plus adrenaline (RR 0.76, 95% CI 0.47 to 1.22; 3 studies; 3242 participants; a possible decrease from 24 to 18 per 1000, 95% CI 11 to 29), due to very low-quality evidence.Moderate-quality evidence found that adrenaline compared with placebo increased survival to hospital admission (RR 2.51, 95% CI 1.67 to 3.76; 2 studies, 8489 participants; an increase from 83 to 209 per 1000, 95% CI 139 to 313). We are uncertain about survival to hospital admission when comparing standard-dose with high-dose adrenaline, due to very low-quality evidence. Vasopressin may improve survival to hospital admission when compared with standard-dose adrenaline (RR 1.27, 95% CI 1.04 to 1.54; 3 studies, 1953 participants; low-quality evidence; an increase from 260 to 330 per 1000, 95% CI 270 to 400), and may make little or no difference when compared to standard-dose adrenaline plus vasopressin (RR 0.95, 95% CI 0.83 to 1.08; 3 studies; 3249 participants; low-quality evidence; a decrease from 218 to 207 per 1000 (95% CI 181 to 236).There was no evidence that adrenaline (any dose) or vasopressin improved neurological outcomes.The rate of return of spontaneous circulation (ROSC) was higher for standard-dose adrenaline versus placebo (RR 2.86, 95% CI 2.21 to 3.71; participants = 8663; studies = 3); moderate-quality evidence; an increase from 115 to 329 per 1000, 95% CI 254 to 427). We are uncertain about the effect on ROSC for the comparison of standard-dose versus high-dose adrenaline and standard-does adrenaline compared to vasopressin, due to very low-quality evidence. Standard-dose adrenaline may make little or no difference to ROSC when compared to standard-dose adrenaline plus vasopressin (RR 0.97, 95% CI 0.87 to 1.08; 3 studies, 3249 participants; low-quality evidence; a possible decrease from 299 to 290 per 1000, 95% CI 260 to 323).The source of funding was not stated in 11 of the 26 studies. The study drugs were provided by the manufacturer in four of the 26 studies, but neither drug represents a profitable commercial option. The other 11 studies were funded by organisations such as research foundations and government funding bodies. AUTHORS' CONCLUSIONS This review provides moderate-quality evidence that standard-dose adrenaline compared to placebo improves return of spontaneous circulation, survival to hospital admission and survival to hospital discharge, but low-quality evidence that it did not affect survival with a favourable neurological outcome. Very low -quality evidence found that high-dose adrenaline compared to standard-dose adrenaline improved return of spontaneous circulation and survival to admission. Vasopressin compared to standard dose adrenaline improved survival to admission but not return of spontaneous circulation, whilst the combination of adrenaline and vasopressin compared with adrenaline alone had no effect on these outcomes. Neither standard dose adrenaline, high-dose adrenaline,vasopressin nor a combination of adrenaline and vasopressin improved survival with a favourable neurological outcome. Many of these studies were conducted more than 20 years ago. Treatment has changed in recent years, so the findings from older studies may not reflect current practice.
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Affiliation(s)
- Judith Finn
- Curtin UniversityPrehospital, Resuscitation and Emergency Care Research Unit (PRECRU)Kent StreetBentleyWestern AustraliaAustralia6102
- St John Ambulance Western AustraliaBelmontAustralia
| | - Ian Jacobs
- Curtin UniversityPrehospital, Resuscitation and Emergency Care Research Unit (PRECRU)Kent StreetBentleyWestern AustraliaAustralia6102
- St John Ambulance Western AustraliaBelmontAustralia
| | | | - Simon Gates
- University of BirminghamCancer Research UK Clinical Trials Unit, School of Cancer Sciences, Institute of Cancer and Genomic SciencesBirminghamUKB15 2TT
| | - Gavin D Perkins
- University of WarwickWarwick Medical School and University Hospitals BirminghamCoventryUK
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Janssens U, Michels G. [Adrenaline in patients with out-of-hospital cardiac arrest : PARAMEDIC2 trial]. Med Klin Intensivmed Notfmed 2018; 114:63-67. [PMID: 30155726 DOI: 10.1007/s00063-018-0478-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/04/2018] [Indexed: 01/18/2023]
Affiliation(s)
- U Janssens
- Klinik für Innere Medizin, St.-Antonius-Hospital, Dechant-Deckers-Str. 8, 52249, Eschweiler, Deutschland.
| | - G Michels
- Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Köln, Deutschland
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Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, Regan S, Long J, Slowther A, Pocock H, Black JJM, Moore F, Fothergill RT, Rees N, O'Shea L, Docherty M, Gunson I, Han K, Charlton K, Finn J, Petrou S, Stallard N, Gates S, Lall R. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med 2018; 379:711-721. [PMID: 30021076 DOI: 10.1056/nejmoa1806842] [Citation(s) in RCA: 444] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Concern about the use of epinephrine as a treatment for out-of-hospital cardiac arrest led the International Liaison Committee on Resuscitation to call for a placebo-controlled trial to determine whether the use of epinephrine is safe and effective in such patients. METHODS In a randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest in the United Kingdom, paramedics at five National Health Service ambulance services administered either parenteral epinephrine (4015 patients) or saline placebo (3999 patients), along with standard care. The primary outcome was the rate of survival at 30 days. Secondary outcomes included the rate of survival until hospital discharge with a favorable neurologic outcome, as indicated by a score of 3 or less on the modified Rankin scale (which ranges from 0 [no symptoms] to 6 [death]). RESULTS At 30 days, 130 patients (3.2%) in the epinephrine group and 94 (2.4%) in the placebo group were alive (unadjusted odds ratio for survival, 1.39; 95% confidence interval [CI], 1.06 to 1.82; P=0.02). There was no evidence of a significant difference in the proportion of patients who survived until hospital discharge with a favorable neurologic outcome (87 of 4007 patients [2.2%] vs. 74 of 3994 patients [1.9%]; unadjusted odds ratio, 1.18; 95% CI, 0.86 to 1.61). At the time of hospital discharge, severe neurologic impairment (a score of 4 or 5 on the modified Rankin scale) had occurred in more of the survivors in the epinephrine group than in the placebo group (39 of 126 patients [31.0%] vs. 16 of 90 patients [17.8%]). CONCLUSIONS In adults with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group. (Funded by the U.K. National Institute for Health Research and others; Current Controlled Trials number, ISRCTN73485024 .).
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Affiliation(s)
- Gavin D Perkins
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Chen Ji
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Charles D Deakin
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Tom Quinn
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Jerry P Nolan
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Charlotte Scomparin
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Scott Regan
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - John Long
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Anne Slowther
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Helen Pocock
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - John J M Black
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Fionna Moore
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Rachael T Fothergill
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Nigel Rees
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Lyndsey O'Shea
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Mark Docherty
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Imogen Gunson
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Kyee Han
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Karl Charlton
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Judith Finn
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Stavros Petrou
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Nigel Stallard
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Simon Gates
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
| | - Ranjit Lall
- From the Warwick Clinical Trials Unit (G.D.P., C.J., C.S., S.R., J.L., S.P., S.G., R.L.) and Warwick Medical School (A.S., N.S.), University of Warwick, Coventry, University Hospitals Birmingham (G.D.P.) and the Cancer Research U.K. Clinical Trials Unit, University of Birmingham (S.G.), Birmingham, South Central Ambulance Service NHS Foundation Trust, Otterbourne (C.D.D., H.P., J.J.M.B.), Southampton Respiratory Biomedical Research Unit, National Institute for Health Research, Southampton (C.D.D.), Kingston University and St. George's, University of London (T.Q.), and the London Ambulance Service NHS Trust, (F.M., R.T.F.), London, Bristol Medical School, University of Bristol, Bristol, and Royal United Hospital, Bath (J.P.N.), Oxford University Hospitals NHS Foundation Trust, Oxford (J.J.M.B), South East Coast Ambulance Service, Crawley (F.M.), Welsh Ambulance Services NHS Trust, Swansea (N.R., L.O.), West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill (M.D., I.G.), and North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne (K.H., K.C.) - all in the United Kingdom; and Curtin University, Perth, WA (J.F.), and Monash University, Melbourne, VIC (J.F.) - both in Australia
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