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Al-Shahri MZ, Sroor M, Ghareeb WAS, Alhassanin S, Ateya HA. Discussion of the do-not-resuscitate (DNR) orders with the family caregivers of cancer patients: An example from a major cancer center in Saudi Arabia. Palliat Support Care 2024; 22:511-516. [PMID: 38126404 DOI: 10.1017/s1478951523001876] [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] [Indexed: 12/23/2023]
Abstract
OBJECTIVES To explore the views of the family caregivers (FCGs) about the "do-not-resuscitate" (DNR) discussions and decision-making processes that occurred during hospitalization in a Saudi cancer center. METHODS In this cross-sectional survey, the FCGs of inpatients with advanced cancer completed a self-administered questionnaire soon after giving the patients a DNR status designation by their oncologists. RESULTS Eighty-two FCGs participated in the study, with a median age of 36.5 years and male preponderance (70.7%). The FCGs were mostly sons (41.5%), daughters (14%), or brothers (11%) of patients. Only 13.4% of mentally competent patients had the chance to listen to the DNR discussion. The discussion mainly occurred in the ward corridor (48.8%) or another room away from the patients' rooms (35.4%). In 36.6% of cases, the discussion took ≤5 minutes. Half of the FCGs stated that the oncologists' justifications for the DNR decision were unconvincing. The majority (84.2%) of the FCGs felt that the healthcare providers should share the DNR decision-making with patients (1.2%), families (69.5%), or both (13.4%). FCGs ≤ 30 years of age were more supportive of giving patients' families a chance to participate in the DNR decision-making process (p = 0.012). SIGNIFICANCE OF RESULTS There is considerable room for improving the current practice of DNR discussions and decision-making processes in the studied setting. A readily feasible rectifying measure is to ensure the adequacy of time and privacy when planning for DNR discussions. We expect our findings to draw the attention of stakeholders to a compelling need for reviewing the current policies and processes, aiming to improve the experience of cancer patients and their FCGs.
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Affiliation(s)
- Mohammad Z Al-Shahri
- Palliative Care Medicine, Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Mahmoud Sroor
- Palliative Care Medicine, Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Kaser Al-Ainy Center of Clinical Oncology and Nuclear Medicine, Kaser El-Aini School of Medicine, Cairo University, Cairo, Egypt
| | - Wael Ali Said Ghareeb
- Palliative Care Medicine, Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Suzan Alhassanin
- Palliative Care Medicine, Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Clinical Oncology Department, Menoufia University, Shebin Elkom, Egypt
| | - Heba Aly Ateya
- Palliative Care Medicine, Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- National Cancer Institute, Cairo University, Cairo, Egypt
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Okubo M, Komukai S, Andersen LW, Berg RA, Kurz MC, Morrison LJ, Callaway CW. Duration of cardiopulmonary resuscitation and outcomes for adults with in-hospital cardiac arrest: retrospective cohort study. BMJ 2024; 384:e076019. [PMID: 38325874 PMCID: PMC10847985 DOI: 10.1136/bmj-2023-076019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 02/09/2024]
Abstract
OBJECTIVE To quantify time dependent probabilities of outcomes in patients after in-hospital cardiac arrest as a function of duration of cardiopulmonary resuscitation, defined as the interval between start of chest compression and the first return of spontaneous circulation or termination of resuscitation. DESIGN Retrospective cohort study. SETTING Multicenter prospective in-hospital cardiac arrest registry in the United States. PARTICIPANTS 348 996 adult patients (≥18 years) with an index in-hospital cardiac arrest who received cardiopulmonary resuscitation from 2000 through 2021. MAIN OUTCOME MEASURES Survival to hospital discharge and favorable functional outcome at hospital discharge, defined as a cerebral performance category score of 1 (good cerebral performance) or 2 (moderate cerebral disability). Time dependent probabilities of subsequently surviving to hospital discharge or having favorable functional outcome if patients pending the first return of spontaneous circulation at each minute received further cardiopulmonary resuscitation beyond the time point were estimated, assuming that all decisions on termination of resuscitation were accurate (that is, all patients with termination of resuscitation would have invariably failed to survive if cardiopulmonary resuscitation had continued for a longer period of time). RESULTS Among 348 996 included patients, 233 551 (66.9%) achieved return of spontaneous circulation with a median interval of 7 (interquartile range 3-13) minutes between start of chest compressions and first return of spontaneous circulation, whereas 115 445 (33.1%) patients did not achieve return of spontaneous circulation with a median interval of 20 (14-30) minutes between start of chest compressions and termination of resuscitation. 78 799 (22.6%) patients survived to hospital discharge. The time dependent probabilities of survival and favorable functional outcome among patients pending return of spontaneous circulation at one minute's duration of cardiopulmonary resuscitation were 22.0% (75 645/343 866) and 15.1% (49 769/328 771), respectively. The probabilities decreased over time and were <1% for survival at 39 minutes and <1% for favorable functional outcome at 32 minutes' duration of cardiopulmonary resuscitation. CONCLUSIONS This analysis of a large multicenter registry of in-hospital cardiac arrest quantified the time dependent probabilities of patients' outcomes in each minute of duration of cardiopulmonary resuscitation. The findings provide resuscitation teams, patients, and their surrogates with insights into the likelihood of favorable outcomes if patients pending the first return of spontaneous circulation continue to receive further cardiopulmonary resuscitation.
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Affiliation(s)
- Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Lars W Andersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael C Kurz
- Section of Emergency Medicine, Department of Medicine, University of Chicago School of Medicine, Chicago, IL, USA
| | - Laurie J Morrison
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
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Tanabe R, Hongo T, Obara T, Nojima T, Nakao A, Elmer J, Naito H, Yumoto T. Treatment patterns and clinician stress related to care of out-of-hospital cardiac arrest patients with a do not attempt resuscitation order. Resusc Plus 2023; 16:100507. [PMID: 38026140 PMCID: PMC10665952 DOI: 10.1016/j.resplu.2023.100507] [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: 09/15/2023] [Revised: 10/25/2023] [Accepted: 11/01/2023] [Indexed: 12/01/2023] Open
Abstract
Objective This research investigated treatment patterns for out-of-hospital cardiac arrest patients with Do Not Attempt Resuscitation orders in Japanese emergency departments and the associated clinician stress. Methods A cross-sectional survey was conducted at 9 hospitals in Okayama, Japan, targeting emergency department nurses and physicians. The questionnaire inquired about the last treated out-of-hospital cardiac arrest patient with a Do Not Attempt Resuscitation. We assessed emotional stress on a 0-10 scale and moral distress on a 1-5 scale among clinicians. Results Of 208 participants, 107 (51%) had treated an out-of-hospital cardiac arrest patient with a Do Not Attempt Resuscitation order in the past 6 months. Of these, 65 (61%) clinicians used a "slow code" due to perceived futility in resuscitation (42/65 [65%]), unwillingness to terminate resuscitation upon arrival (38/65 [59%]), and absence of family at the time of patient's arrival (35/65 [54%]). Female clinicians had higher emotional stress (5 vs. 3; P = 0.007) and moral distress (3 vs. 2; P = 0.002) than males. Nurses faced more moral distress than physicians (3 vs. 2; P < 0.001). Adjusted logistic regression revealed that having performed a "slow code" (adjusted odds ratio, 5.09 [95% CI, 1.68-17.87]) and having greater ethical concerns about "slow code" (adjusted odds ratio, 0.35 [95% CI, 0.19-0.58]) were associated with high stress levels. Conclusions The prevalent use of "slow code" for out-of-hospital cardiac arrest patients with Do Not Attempt Resuscitation orders underscores the challenges in managing these patients in clinical practice.
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Affiliation(s)
- Ryo Tanabe
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Takashi Hongo
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Takafumi Obara
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Tsuyoshi Nojima
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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Ishihara T, Sasaki R, Enomoto Y, Amagasa S, Yasuda M, Ohnishi S. Changes in pre- and in-hospital management and outcomes among children with out-of-hospital cardiac arrest between 2012 and 2017 in Kanto, Japan. Sci Rep 2023; 13:10092. [PMID: 37344630 DOI: 10.1038/s41598-023-37201-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/17/2023] [Indexed: 06/23/2023] Open
Abstract
Previously, the SOS-KANTO 2012 studies, conducted in the Kanto area of Japan, reported a summary of outcomes in patients with out-of-hospital cardiac arrest (OHCA). This sub-analysis of the SOS-KANTO study 2017 aimed to evaluate the neurological outcomes of paediatric OHCA patients, by comparing the SOS-KANTO 2012 and 2017 studies. All OHCA patients, aged < 18 years, who were transported to the participating hospitals by EMS personnel were included in both SOS-KANTO studies (2012 and 2017). The number of survival patients with favourable neurological outcomes (paediatric cerebral performance category 1 or 2) at 1 month did not improve between 2012 and 2017. There was no significant difference in achievement of pre-hospital return of spontaneous circulation (ROSC) [odds ratio (OR): 2.00, 95% confidence interval (95% CI): 0.50-7.99, p = 0.50] and favourable outcome at 1 month [OR: 0.67, 95% CI: 0.11-3.99, p = 1] between the two studies, matched by age, witnessed arrest, bystander CPR, aetiology of OHCA, and time from call to EMS arrival. Multivariable logistic regression showed no significant difference in the achievement of pre-hospital ROSC and favourable outcomes at 1 month between the two studies.
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Affiliation(s)
- Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Urayasu Hospital, Juntendo University, 2-1-1, Tomioka, Urayasu, Chiba, 279-0021, Japan.
| | - Ryuji Sasaki
- Division of Emergency and Transport Services, National Center for Child Health and Development, Tokyo, Japan
| | - Yuki Enomoto
- Department of Emergency and Critical Care Medicine, University of Tsukuba, Ibaragi, Japan
| | - Shunsuke Amagasa
- Division of Emergency and Transport Services, National Center for Child Health and Development, Tokyo, Japan
| | - Masato Yasuda
- Division of Emergency Medicine, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Shima Ohnishi
- Division of Emergency and Transport Services, National Center for Child Health and Development, Tokyo, Japan
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Park SY, Lim D, Ryu JH, Kim YH, Choi B, Kim SH. Modification of termination of resuscitation rule with compression time interval in South Korea. Sci Rep 2023; 13:1403. [PMID: 36697453 PMCID: PMC9876889 DOI: 10.1038/s41598-023-28789-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 01/24/2023] [Indexed: 01/26/2023] Open
Abstract
This study aimed to validate the predictive performance of the termination of resuscitation (TOR) rule and examine the compression time interval (CTI) as a criterion for modifying the rule. This retrospective observational study analyzed adult out-of-hospital cardiac arrest (OHCA) patients attended by emergency medical service (EMS) providers in mixed urban-rural areas in Korea in 2020 and 2021. We evaluated the predictive performance of basic life support (BLS) and the Korean Cardiac Arrest Research Consortium (KoCARC) TOR rule using the false-positive rate (FPR) and positive predictive value (PPV). We modified the age cutoff criterion and examined the CTI as a new criterion. According to the TOR rule, 1827 OHCA patients were classified into two groups. The predictive performance of the BLS TOR rule had an FPR of 11.7% (95% confidence interval (CI): 5.9-17.5) and PPV of 98.4% (97.6-99.2) for mortality, and an FPR of 3.6% (0.0-7.8) and PPV of 78.6% (75.9-81.3) for poor neurological outcomes at hospital discharge. The predictive performance of the KoCARC TOR rule had an FPR of 5.0% (1.1-8.9) and PPV of 98.9% (98.0-99.8) for mortality, and an FPR of 3.7% (0.0-7.8) and PPV of 50.0% (45.7-54.3) for poor neurological outcomes at hospital discharge. The modified cutoff value for age was 68 years, with an area under the receiver operating characteristic curve over 0.7. In the group that met the BLS TOR rule, the cutoff of the CTI for death was not determined and was 21 min for poor neurological outcomes. In the group that met the KoCARC TOR rule, the cutoff of the CTI for death and poor neurological outcomes at the time of hospital discharge was 25 min and 21 min, respectively. The BLS TOR and KoCARC TOR rules showed inappropriate predictive performance for mortality and poor neurological outcomes. However, the predictive performance of the TOR rule could be supplemented by modifying the age criterion and adding the CTI criterion of the KoCARC.
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Affiliation(s)
- Song Yi Park
- Department of Emergency Medicine, Dong-A University College of Medicine, Dong-A University Hospital, Busan, 49201, South Korea
| | - Daesung Lim
- Department of Emergency Medicine, Seoul Medical Center, Seoul, 02053, South Korea
| | - Ji Ho Ryu
- Department of Emergency Medicine, Pusan National University College of Medicine, Pusan National University Yangsan Hospital, Busan, 50612, South Korea
| | - Yong Hwan Kim
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, 51353, South Korea
| | - Byungho Choi
- Department of Emergency Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, 44033, South Korea
| | - Sun Hyu Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, 44033, South Korea.
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Hernandez SF, Agarwal S. Decoding code status after cardiac arrest. Resuscitation 2022; 181:37-39. [PMID: 36272617 DOI: 10.1016/j.resuscitation.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | - Sachin Agarwal
- Department of Neurology, Division of Critical Care & Hospitalist Neurology, Columbia University Irving Medical Center & New York Presbyterian Hospital, New York, United States.
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Lauridsen KG, Djärv T, Breckwoldt J, Tjissen JA, Couper K, Greif R. Pre-arrest Prediction of Survival Following In-hospital Cardiac Arrest: A Systematic Review of Diagnostic Test Accuracy Studies. Resuscitation 2022; 179:141-151. [PMID: 35933060 DOI: 10.1016/j.resuscitation.2022.07.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 02/01/2023]
Abstract
AIM To evaluate the test accuracy of pre-arrest clinical decision tools for in-hospital cardiac arrest survival outcomes. METHODS We searched Medline, Embase, and Cochrane Library from inception through January 2022 for randomized and non-randomized studies. We used the Quality Assessment of Diagnostic Accuracy Studies framework to evaluate risk of bias, and Grading of Recommendations Assessment, Development and Evaluation methodology to evaluate certainty of evidence. We report sensitivity, specificity, positive predictive outcome, and negative predictive outcome for prediction of survival outcomes. PROSPERO CRD42021268005. RESULTS We searched 2517 studies and included 23 studies using 13 different scores: 12 studies investigating 8 different scores assessing survival outcomes and 11 studies using 5 different scores to predict neurological outcomes. All were historical cohorts/ case control designs including adults only. Test accuracy for each score varied greatly. Across the 12 studies investigating 8 different scores assessing survival to hospital discharge/ 30-day survival, the negative predictive values (NPVs) for the prediction of survival varied from 55.6% to 100%. The GO-FAR score was evaluated in 7 studies with NPVs for survival with cerebral performance category (CPC) 1 ranging from 95.0% to 99.2%. Two scores assessed survival with CPC ≤2 and these were not externally validated. Across all prediction scores, certainty of evidence was rated as very low. CONCLUSIONS We identified very low certainty evidence across 23 studies for 13 different pre-arrest prediction scores to outcome following IHCA. No score was sufficiently reliable to support its use in clinical practice. We identified no evidence for children.
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Affiliation(s)
- Kasper G Lauridsen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark; Emergency Department, Randers Regional Hospital, Randers, Denmark; Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, U.S.A.
| | - Therese Djärv
- Medical Unit of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden; Center for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Jan Breckwoldt
- Institute of Anesthesiology, Zurich University Hospital, Zurich, Switzerland
| | - Janice A Tjissen
- Department of Paediatrics, University of Western Ontario, London, Canada
| | - Keith Couper
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, United Kingdom; Critical care unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham. United Kingdom
| | - Robert Greif
- Department of Anesthesiology and Pain Therapy, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland; School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
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Goto Y, Funada A, Maeda T, Goto Y. Termination-of-resuscitation rule in the emergency department for patients with refractory out-of-hospital cardiac arrest: a nationwide, population-based observational study. Crit Care 2022; 26:137. [PMID: 35578295 PMCID: PMC9109290 DOI: 10.1186/s13054-022-03999-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background In Japan, emergency medical service (EMS) providers are prohibited from field termination-of-resuscitation (TOR) in out-of-hospital cardiac arrest (OHCA) patients. In 2013, we developed a TOR rule for emergency department physicians (Goto’s TOR rule) immediately after hospital arrival. However, this rule is subject to flaws, and there is a need for revision owing to its relatively low specificity for predicting mortality compared with other TOR rules in the emergency department. Therefore, this study aimed to develop and validate a modified Goto’s TOR rule by considering prehospital EMS cardiopulmonary resuscitation (CPR) duration. Methods We analysed the records of 465,657 adult patients with OHCA from the All-Japan Utstein registry from 2016 to 2019 and divided them into two groups: development (n = 231,363) and validation (n = 234,294). The primary outcome measures were specificity, false-positive rate (FPR), and positive predictive value (PPV) of the revised TOR rule in the emergency department for predicting 1-month mortality. Results Recursive partitioning analysis for the development group in predicting 1-month mortality revealed that a modified Goto’s TOR rule could be defined if patients with OHCA met the following four criteria: (1) initial asystole, (2) unwitnessed arrest by any laypersons, (3) EMS-CPR duration > 20 min, and (4) no prehospital return of spontaneous circulation (ROSC). The specificity, FPR, and PPV of the rule for predicting 1-month mortality were 99.2% (95% confidence interval [CI], 99.0–99.4%), 0.8% (0.6–1.0%), and 99.8% (99.8–99.9%), respectively. The proportion of patients who fulfilled the rule and the area under the receiver operating curve (AUC) was 27.5% (95% CI 27.3–27.7%) and 0.904 (0.902–0.905), respectively. In the validation group, the specificity, FPR, PPV, proportion of patients who met the rule, and AUC were 99.1% (95% CI 98.9–99.2%), 0.9% (0.8–1.1%), 99.8% (99.8–99.8%), 27.8% (27.6–28.0%), and 0.889 (0.887–0.891), respectively. Conclusion The modified Goto’s TOR rule (which includes the following four criteria: initial asystole, unwitnessed arrest, EMS-CPR duration > 20 min, and no prehospital ROSC) with a > 99% predictor of 1-month mortality is a reliable tool for physicians treating refractory OHCAs immediately after hospital arrival. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03999-x.
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Affiliation(s)
- Yoshikazu Goto
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa, 920-8640, Japan.
| | - Akira Funada
- Department of Cardiology, Osaka Saiseikai Senri Hospital, Tukumodai 1-1-6, Suita, 565-0862, Japan
| | - Tetsuo Maeda
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa, 920-8640, Japan
| | - Yumiko Goto
- Department of Cardiology, Yawata Medical Center, Yawata I 12-7, Komatsu, 923-8551, Japan
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Goharani R, Vahedian-Azimi A, Pourhoseingholi MA, Amanpour F, Rosano GMC, Sahebkar A. Survival to intensive care unit discharge among in-hospital cardiac arrest patients by applying audiovisual feedback device. ESC Heart Fail 2021; 8:4652-4660. [PMID: 34716684 PMCID: PMC8712865 DOI: 10.1002/ehf2.13628] [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: 09/09/2021] [Accepted: 09/13/2021] [Indexed: 11/12/2022] Open
Abstract
Aims Survival rates after in‐hospital cardiac arrest remain very low. Although there is evidence that the use of audiovisual feedback devices can improve compression components, there are no data on patient survival. Therefore, we conducted this study to analyse the survival rate of patients with in‐hospital cardiac arrest after discharge from the intensive care unit. Methods and results This study was a secondary analysis of a prospective, randomized, controlled, parallel study of patients who received either standard manual chest compression or a real‐time feedback device. Parametric and semi‐parametric models were fitted to the data. Different survival time of length of stay was investigated by univariate and multiple analyses. Pearson's correlation between length of stay and hospital length of stay was obtained. A total of 900 patients with a mean survival time of 35 days were included. Intervention was associated with a higher length of stay. Relative time was significant in adjusted fitted log‐normal regression for intervention group, female gender, and cardiopulmonary resuscitation in the night shift. A positive correlation between length of stay and hospital length of stay was found. Conclusions Implementation of feedback device improved survival and length of stay. Cardiopulmonary resuscitation performance during the night shift decreased the survival time, which could be due to the inexperienced staff available outside working hours.
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Affiliation(s)
- Reza Goharani
- Anesthesiology Research Center, Anesthesia and Critical Care Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Vahedian-Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mohamad Amin Pourhoseingholi
- Department of Health System Research, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzaneh Amanpour
- Department of Health System Research, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Giuseppe M C Rosano
- Centre for Clinical and Basic Research, Department of Medical Sciences, IRCCS San Raffaele Pisana, via della Pisana, 235, Rome, 00163, Italy
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.,Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland.,School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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10
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Nazeha N, Ong MEH, Limkakeng AT, Ye JJ, Joiner AP, Blewer A, Shahidah N, Nadarajan GD, Mao DR, Graves N. A hypothetical implementation of 'Termination of Resuscitation' protocol for out-of-hospital cardiac arrest. Resusc Plus 2021; 6:100092. [PMID: 34223357 PMCID: PMC8244430 DOI: 10.1016/j.resplu.2021.100092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/28/2021] [Indexed: 11/29/2022] Open
Abstract
A proportion of out of hospital cardiac arrests are associated with poor prognoses. Prolonged resuscitation on medically futile cases results in financial burden for the health system and distress for health care workers. ‘Termination of Resuscitation’ protocols enable ceasing resuscitation efforts for certain cases. Successfully adopting a protocol over existing practices demonstrates fewer cases transported to hospital, fewer emergency treatments and fewer inpatient bed days used. The protocol can lead to reduced costs and fewer non-beneficial hospital admissions.
Background Out-of-hospital cardiac arrests with negligible chance of survival are routinely transported to hospital and many are pronounced dead thereafter. This leads to some potentially avoidable costs. The ‘Termination of Resuscitation’ protocol allows paramedics to terminate resuscitation efforts onsite for medically futile cases. This study estimates the changes in frequency of costly events that might occur when the protocol is applied to out-of-hospital cardiac arrests, as compared to existing practice. Methods We used Singapore data from the Pan-Asian Resuscitation Outcomes Study, from 1 Jan 2014 to 31 Dec 2017. A Markov model was developed to summarise the events that would occur in two scenarios, existing practice and the implementation of a Termination of Resuscitation protocol. The model was evaluated for 10,000 hypothetical patients with a cycle duration of 30 days after having a cardiac arrest. Probabilistic sensitivity analysis accounted for uncertainties in the outcomes: number of urgent transports and emergency treatments, inpatient bed days, and total number of deaths. Results For every 10,000 patients, existing practice resulted in 1118 (95% Uncertainty Interval 1117 to 1119) additional urgent transports to hospital and subsequent emergency treatments. There were 93 (95% Uncertainty Interval 66 to 120) extra inpatient bed days used, and 3 fewer deaths (95% Uncertainty Interval 2 to 4) in comparison to using the protocol. Conclusion The findings provide some evidence for adopting the Termination of Resuscitation protocol. This policy could lead to a reduction in costs and non-beneficial hospital admissions, however there may be a small increase in the number of avoidable deaths.
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Affiliation(s)
- Nuraini Nazeha
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.,Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Jinny J Ye
- Department of Emergency Medicine, Durham Veterans Affairs Medical Center, Durham, NC, United States
| | - Anjni Patel Joiner
- Division of Emergency Medicine, Duke University Hospital, Durham, NC, United States.,Duke Global Health Institute, Duke University, Durham, NC, United States
| | - Audrey Blewer
- Department of Family Medicine and Community Health and Department of Population Health Sciences, Duke University School of Medicine, NC, United States
| | - Nur Shahidah
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Desmond Renhao Mao
- Department of Acute and Emergency Care, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Nicholas Graves
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
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11
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Jung H, Lee MJ, Cho JW, Lee SH, Lee SH, Mun YH, Chung HS, Kim YH, Kim GM, Park SY, Jeon JC, Kim C. External validation of multimodal termination of resuscitation rules for out-of-hospital cardiac arrest patients in the COVID-19 era. Scand J Trauma Resusc Emerg Med 2021; 29:19. [PMID: 33504366 PMCID: PMC7838848 DOI: 10.1186/s13049-021-00834-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 01/12/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Futile resuscitation for out-of-hospital cardiac arrest (OHCA) patients in the coronavirus disease (COVID)-19 era can lead to risk of disease transmission and unnecessary transport. Various existing basic or advanced life support (BLS or ALS, respectively) rules for the termination of resuscitation (TOR) have been derived and validated in North America and Asian countries. This study aimed to evaluate the external validation of these rules in predicting the survival outcomes of OHCA patients in the COVID-19 era. METHODS This was a multicenter observational study using the WinCOVID-19 Daegu registry data collected during February 18-March 31, 2020. The subjects were patients who showed cardiac arrest of presumed cardiac etiology. The outcomes of each rule were compared to the actual patient survival outcomes. The sensitivity, specificity, false positive value (FPV), and positive predictive value (PPV) of each TOR rule were evaluated. RESULTS In total, 170 of the 184 OHCA patients were eligible and evaluated. TOR was recommended for 122 patients based on the international basic life support termination of resuscitation (BLS-TOR) rule, which showed 85% specificity, 74% sensitivity, 0.8% FPV, and 99% PPV for predicting unfavorable survival outcomes. When the traditional BLS-TOR rules and KoCARC TOR rule II were applied to our registry, one patient met the TOR criteria but survived at hospital discharge. With regard to the FPV (upper limit of 95% confidence interval < 5%), specificity (100%), and PPV (> 99%) criteria, only the KoCARC TOR rule I, which included a combination of three factors including not being witnessed by emergency medical technicians, presenting with an asystole at the scene, and not experiencing prehospital shock delivery or return of spontaneous circulation, was found to be superior to all other TOR rules. CONCLUSION Among the previous nine BLS and ALS TOR rules, KoCARC TOR rule I was most suitable for predicting poor survival outcomes and showed improved diagnostic performance. Further research on variations in resources and treatment protocols among facilities, regions, and cultures will be useful in determining the feasibility of TOR rules for COVID-19 patients worldwide.
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Affiliation(s)
- Haewon Jung
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, 680, Gukchaebosang-ro, Jung-gu, Daegu, 41944 Republic of Korea
| | - Mi Jin Lee
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, 680, Gukchaebosang-ro, Jung-gu, Daegu, 41944 Republic of Korea
| | - Jae Wan Cho
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, 680, Gukchaebosang-ro, Jung-gu, Daegu, 41944 Republic of Korea
| | - Sang Hun Lee
- Department of Emergency Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Suk Hee Lee
- Department of Emergency Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - You Ho Mun
- Department of Emergency Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Han-sol Chung
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, 680, Gukchaebosang-ro, Jung-gu, Daegu, 41944 Republic of Korea
- Department of Emergency Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | - Yang Hun Kim
- Department of Emergency Medicine, Daegu Fatima Hospital, Daegu, Republic of Korea
| | - Gyun Moo Kim
- Department of Emergency Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Sin-youl Park
- Department of Emergency Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Jae Cheon Jeon
- Department of Emergency Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Changho Kim
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, 680, Gukchaebosang-ro, Jung-gu, Daegu, 41944 Republic of Korea
- Department of Emergency Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | - on behalf of the WinCOVID-19 consortium
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, 680, Gukchaebosang-ro, Jung-gu, Daegu, 41944 Republic of Korea
- Department of Emergency Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
- Department of Emergency Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
- Department of Emergency Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
- Department of Emergency Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
- Department of Emergency Medicine, Daegu Fatima Hospital, Daegu, Republic of Korea
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12
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Park HA, Ahn KO, Lee EJ, Park JO. Association between Survival and Time of On-Scene Resuscitation in Refractory Out-of-Hospital Cardiac Arrest: A Cross-Sectional Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:E496. [PMID: 33435406 PMCID: PMC7826551 DOI: 10.3390/ijerph18020496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 11/16/2022]
Abstract
It is estimated that over 60% of out-of-hospital cardiac arrest (OHCA) patients with a shockable rhythm are refractory to current treatment, never achieve return of spontaneous circulation, or die before they reach the hospital. Therefore, we aimed to identify whether field resuscitation time is associated with survival rate in refractory OHCA (rOHCA) with a shockable initial rhythm. This cross-sectional retrospective study extracted data of emergency medical service (EMS)-treated patients aged ≥ 15 years with OHCA of suspected cardiac etiology and shockable initial rhythm confirmed by EMS providers from the OHCA registry database of Korea. A multivariable logistic regression analysis was conducted for survival to discharge and good neurological outcomes in the scene time interval groups. The median scene time interval for the non-survival and survival to discharge patients were 16 (interquartile range (IQR) 13-21) minutes and 14 (IQR 12-16) minutes, respectively. In this study, for rOHCA patients with a shockable rhythm, continuing CPR for more than 15 min on the scene was associated with a decreased chance of survival and good neurological outcome. In particular, we found that in the patients whose transport time interval was >10 min, the longer scene time interval was negatively associated with the neurological outcome.
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Affiliation(s)
- Hang A Park
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si 18450, Korea;
- Department of Epidemiology, School of Public Health, Seoul National University, Seoul 08826, Korea
| | - Ki Ok Ahn
- Department of Emergency Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang-si 10475, Korea;
| | - Eui Jung Lee
- Department of Emergency Medicine, College of Medicine, Korea University, Seoul 02841, Korea;
| | - Ju Ok Park
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si 18450, Korea;
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13
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Abe A, Kobayashi M, Kohno T, Takeuchi M, Hashiguchi S, Mimura M, Fujisawa D. Patient participation and associated factors in the discussions on do-not-attempt-resuscitation and end-of-life disclosure: a retrospective chart review study. BMC Palliat Care 2021; 20:6. [PMID: 33407388 PMCID: PMC7789264 DOI: 10.1186/s12904-020-00698-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/15/2020] [Indexed: 11/30/2022] Open
Abstract
Background Patient participation is a key foundation of advance care planning (ACP). However, a patient himself/herself may be left out from sensitive conversations such as end-of-life (EOL) care discussions. The objectives of this study were to investigate patients’ participation rate in the discussion of Cardiopulmonary Resuscitation (CPR) / Do-Not-Attempt-Resuscitation (DNAR) order, and in the discussion that the patient is at his/her EOL stage (EOL disclosure), and to explore their associated factors. Methods This is a retrospective chart review study. The participants were all the patients who were hospitalized and died in a university-affiliated teaching hospital (tertiary medical facility) in central Tokyo, Japan during the period from April 2018 to March 2019. The following patients were excluded: (1) cardiopulmonary arrest on arrival; (2) stillbirth; (3) under 18 years old at the time of death; and (4) refusal by their bereaved family. Presence or absence of CPR/DNAR discussion and EOL disclosure, patients’ involvement in those discussions, and their associated factors were investigated. Results CPR/DNAR discussions were observed in 336 out of the 358 patients (93.9%). However, 224 of these discussions were carried out without a patient (patient participation rate 33.3%). Male gender (odds ratio (OR) = 2.37 [95% confidence interval (CI) 1.32–4.25]), living alone (OR = 2.51 [1.34–4.71]), and 1 year or more from the date of diagnosis (OR = 1.78 [1.03–3.10]) were associated with higher patient’s participation in CPR/DNAR discussions. The EOL disclosure was observed in 341 out of the 358 patients (95.3%). However, 170 of the discussions were carried out without the patient (patient participation rate 50.1%). Patients who died of cancer (OR = 2.41[1.45–4.03]) and patients without mental illness (OR=2.41 [1.11–5.25]) were more likely to participate in EOL disclosure. Conclusions In this clinical sample, only up to half of the patients participated in CPR/DNAR discussions and EOL disclosure. Female, living with family, a shorter period from the diagnosis, non-cancer, and mental illness presence are risk factors for lack of patients’ participation in CPR/DNAR or EOL discussions. Further attempts to facilitate patients’ participation, based on their preference, are warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-020-00698-8.
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Affiliation(s)
- Akiko Abe
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan. .,Palliative Care Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan.
| | - Masato Kobayashi
- Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-shi, Tokyo, Japan
| | - Mari Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Palliative Care Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Saori Hashiguchi
- Palliative Care Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan.,Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Daisuke Fujisawa
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Palliative Care Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan.,Division of Patient Safety, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
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14
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Okada A, Okada Y, Kandori K, Nakajima S, Okada N, Matsuyama T, Kitamura T, Hiromichi N, Iiduka R. Associations between initial serum pH value and outcomes of pediatric out-of-hospital cardiac arrest. Am J Emerg Med 2020; 40:89-95. [PMID: 33360395 DOI: 10.1016/j.ajem.2020.12.032] [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: 09/02/2020] [Revised: 12/06/2020] [Accepted: 12/10/2020] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Pediatric out-of-hospital cardiac arrest (OHCA) is one of the most critical conditions seen in the emergency department (ED). Although initial serum pH value is reported to be associated with outcome in adult OHCA patients, the association is unclear in pediatric OHCA patients. Thus, we aimed to identify the association between initial pH value and outcome among pediatric OHCA patients. METHODS This study was a retrospective analysis of a multicenter prospective cohort registry (Japanese Association for Acute Medicine out-of-hospital cardiac arrest registry) from 87 hospitals in Japan. We included pediatric OHCA patients younger than 16 years of age who were registered in this registry between June 2014 and December 2017. Of the 34,754 patients in the database, 458 patients were ultimately included in the analysis. We equally divided the patients into four groups, based on their initial pH value, and conducted a multivariate logistic regression analysis to calculate the adjusted odds ratios of the initial pH value on hospital arrival with their 95% confidence intervals for the primary outcome. RESULTS The median (interquartile range) age was 1 (0-6) year, and 77.9% (357/458) of the first monitored rhythm was asystole. The primary outcome was 1-month survival. The overall 1-month survival was 13.3% (61/458), and a 1-month favorable neurologic outcome was seen in 5.2% (24/458) of cases. The adjusted odds ratios and 95% confidence intervals for the pH 6.81-6.64, pH 6.63-6.47, pH <6.47, and pH unknown groups compared with the pH ≥6.82 group for 1-month survival were 0.39 (0.16-0.97), 0.13 (0.04-0.44), 0.03 (0.00-0.24), and 0.07 (0.02-0.21), respectively. CONCLUSIONS This study demonstrated the association between the initial pH value on hospital arrival and 1-month survival among pediatric OHCA patients.
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Affiliation(s)
- Asami Okada
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, 355-5 Haruobicho Kamigyoku, Kyoto 602-8026, Japan
| | - Yohei Okada
- Preventive Services, School of Public Health, Kyoto University, Yoshida-honmachi, Sakyo-ku, Kyoto 606-8501, Japan; Department of Primary care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan.
| | - Kenji Kandori
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, 355-5 Haruobicho Kamigyoku, Kyoto 602-8026, Japan
| | - Satoshi Nakajima
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, 355-5 Haruobicho Kamigyoku, Kyoto 602-8026, Japan; Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Narumiya Hiromichi
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, 355-5 Haruobicho Kamigyoku, Kyoto 602-8026, Japan
| | - Ryoji Iiduka
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, 355-5 Haruobicho Kamigyoku, Kyoto 602-8026, Japan
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15
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Fernández EDM, Martín GM, Herrera MJ. Family witnessed resuscitation and invasive procedures: Patient and family opinions. Nurs Ethics 2020; 28:645-655. [PMID: 33325307 DOI: 10.1177/0969733020968171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Family presence during invasive procedures and cardiopulmonary resuscitation (FPDR) is a highly controversial issue, with divergence of opinion among health professionals, with clinical evidence in favor, and with barriers to its implementation in comprehensive patient care. Many international organizations support health policies for its implementation, but it is not a widespread practice. Little research has been conducted on this subject from the perspective of patients and families. OBJECTIVE To learn opinions, perceptions, and desires of family members and patients in terms of family presence during invasive procedures and cardiopulmonary resuscitation. METHOD Qualitative descriptive study, using semi-structured interviews with relatives and patients regarding their experiences and perceptions about FPDR (n = 18) from 8 October 2017 to 8 March 2018. The interviews were recorded and transcribed verbatim for later analysis using the method of content analysis. ETHICAL CONSIDERATIONS This study has the approval of the Clinical Research Ethics Committee of the Fundació Unió Catalana d'Hospitals and ethical considerations were carefully regarded throughout the study. RESULTS Three significant categories were identified: knowledge, respect for rights, and accompaniment of the patient, relating FPDR to courage, emotional support, and trust in professionals. CONCLUSION FPDR is an unusual practice; it is not offered to patients or their families, and it is not considered a patient's right, although most of the interviewees support it. The desire for accompaniment is conditioned by the courage and knowledge of the accompanying persons, as well as the degree of invasiveness of the procedures. The results of this study provide information for a change of vision in patient-centered care.
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Affiliation(s)
- Eva de Mingo Fernández
- 16777Universitat Rovira i Virgili (URV), Spain; Consorci Sanitari Alt Penedès i Garraf, Spain
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16
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Lauridsen KG, Baldi E, Smyth M, Perkins GD, Greif R. Clinical decision rules for termination of resuscitation during in-hospital cardiac arrest: A systematic review of diagnostic test accuracy studies. Resuscitation 2020; 158:23-29. [PMID: 33197522 DOI: 10.1016/j.resuscitation.2020.10.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/29/2020] [Accepted: 10/27/2020] [Indexed: 02/01/2023]
Abstract
AIM To assess whether any clinical decision rule for patients sustaining an in-hospital cardiac arrest (IHCA) can predict mortality or survival with poor neurological outcome. METHODS We searched online databases from inception through July 2020 for randomized controlled trials and non-randomized studies. Two reviewers assessed studies for inclusion. We followed PRISMA guidelines for Diagnostic Test Accuracy Studies, used the Quality Assessment of Diagnostic Accuracy Studies framework to evaluate risk of bias, and Grading of Recommendations Assessment, Development and Evaluation methodology to evaluate certainty of evidence. We assessed predictive values for no return of spontaneous circulation (ROSC), death before hospital discharge, and survival with unfavorable neurological outcome. RESULTS Out of 6436 studies, 92 studies were selected for full-text screening. We included 3 observational studies describing the derivation and external validation for the UN10 rule (Unwitnessed arrest; Nonshockable rhythm; 10 min of resuscitation without ROSC) amongst patients suffering from IHCA. No studies were identified for clinical implementation. Positive Predicted Values (PPV) for death before hospital discharge for the three studies were 100% (95% CI: 97.1%-100%), 98.9% (95% CI: 96.5%-99.7%), and 93.7% (95% CI: 93.3%-94.0%). One study reported a PPV for prediction of survival with unfavorable neurological outcome, 95.2% (95% CI: 94.9%-95.6%). The level of evidence was rated as very low certainty. CONCLUSIONS We identified very low certainty evidence for one clinical decision rule (the UN-10 rule) that was unable to reliably predict mortality or survival with unfavorable neurological outcome for adults suffering from IHCA. We identified no evidence for children. PROSPERO CRD42020164091.
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Affiliation(s)
- Kasper G Lauridsen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Medicine, Randers Regional Hospital, Randers, Denmark; Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, USA.
| | - Enrico Baldi
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy
| | - Michael Smyth
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, United Kingdom
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, United Kingdom
| | - Robert Greif
- Department of Anesthesiology and Pain Therapy, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland; School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
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17
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Hinkelbein J, Kerkhoff S, Adler C, Ahlbäck A, Braunecker S, Burgard D, Cirillo F, De Robertis E, Glaser E, Haidl TK, Hodkinson P, Iovino IZ, Jansen S, Johnson KVL, Jünger S, Komorowski M, Leary M, Mackaill C, Nagrebetsky A, Neuhaus C, Rehnberg L, Romano GM, Russomano T, Schmitz J, Spelten O, Starck C, Thierry S, Velho R, Warnecke T. Cardiopulmonary resuscitation (CPR) during spaceflight - a guideline for CPR in microgravity from the German Society of Aerospace Medicine (DGLRM) and the European Society of Aerospace Medicine Space Medicine Group (ESAM-SMG). Scand J Trauma Resusc Emerg Med 2020; 28:108. [PMID: 33138865 PMCID: PMC7607644 DOI: 10.1186/s13049-020-00793-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With the "Artemis"-mission mankind will return to the Moon by 2024. Prolonged periods in space will not only present physical and psychological challenges to the astronauts, but also pose risks concerning the medical treatment capabilities of the crew. So far, no guideline exists for the treatment of severe medical emergencies in microgravity. We, as a international group of researchers related to the field of aerospace medicine and critical care, took on the challenge and developed a an evidence-based guideline for the arguably most severe medical emergency - cardiac arrest. METHODS After the creation of said international group, PICO questions regarding the topic cardiopulmonary resuscitation in microgravity were developed to guide the systematic literature research. Afterwards a precise search strategy was compiled which was then applied to "MEDLINE". Four thousand one hundred sixty-five findings were retrieved and consecutively screened by at least 2 reviewers. This led to 88 original publications that were acquired in full-text version and then critically appraised using the GRADE methodology. Those studies formed to basis for the guideline recommendations that were designed by at least 2 experts on the given field. Afterwards those recommendations were subject to a consensus finding process according to the DELPHI-methodology. RESULTS We recommend a differentiated approach to CPR in microgravity with a division into basic life support (BLS) and advanced life support (ALS) similar to the Earth-based guidelines. In immediate BLS, the chest compression method of choice is the Evetts-Russomano method (ER), whereas in an ALS scenario, with the patient being restrained on the Crew Medical Restraint System, the handstand method (HS) should be applied. Airway management should only be performed if at least two rescuers are present and the patient has been restrained. A supraglottic airway device should be used for airway management where crew members untrained in tracheal intubation (TI) are involved. DISCUSSION CPR in microgravity is feasible and should be applied according to the Earth-based guidelines of the AHA/ERC in relation to fundamental statements, like urgent recognition and action, focus on high-quality chest compressions, compression depth and compression-ventilation ratio. However, the special circumstances presented by microgravity and spaceflight must be considered concerning central points such as rescuer position and methods for the performance of chest compressions, airway management and defibrillation.
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Affiliation(s)
- Jochen Hinkelbein
- German Society of Aviation and Space Medicine (DGLRM), Munich, Germany. .,Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, 50937, Cologne, Germany. .,Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.
| | - Steffen Kerkhoff
- German Society of Aviation and Space Medicine (DGLRM), Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, 50937, Cologne, Germany.,Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany
| | - Christoph Adler
- Department of Internal Medicine III, Heart Centre of the University of Cologne, Cologne, Germany.,Fire Department City of Cologne, Institute for Security Science and Rescue Technology, Cologne, Germany
| | - Anton Ahlbäck
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Department of Anaesthesia and Intensive Care, Örebro University Hospital, Örebro, Sweden
| | - Stefan Braunecker
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Department of Anesthesiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Daniel Burgard
- Department of Cardiology and Angiology, Heart Center Duisburg, Evangelisches Klinikum Niederrhein, Duisburg, Germany
| | - Fabrizio Cirillo
- Department of Anaesthesia and Intensive Care, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Edoardo De Robertis
- Division of Anaesthesia, Analgesia, and Intensive Care, Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Eckard Glaser
- German Society of Aviation and Space Medicine (DGLRM), Munich, Germany.,Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,, Gerbrunn, Germany
| | - Theresa K Haidl
- Department of Psychiatry and Psychotherapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937, Cologne, Germany
| | - Pete Hodkinson
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Aerospace Medicine, Centre of Human and Applied Physiological Sciences, King's College, London, UK
| | - Ivan Zefiro Iovino
- Department of Anaesthesia and Intensive Care, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Stefanie Jansen
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Cologne, 50937, Cologne, Germany
| | | | - Saskia Jünger
- Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health (CERES), University of Cologne and University Hospital of Cologne, Cologne, Germany
| | - Matthieu Komorowski
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Exhibition road, London, SW7 2AZ, UK
| | - Marion Leary
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Christina Mackaill
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Accident and Emergency Department, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Alexander Nagrebetsky
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Christopher Neuhaus
- German Society of Aviation and Space Medicine (DGLRM), Munich, Germany.,Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Lucas Rehnberg
- University Hospital Southampton NHS Foundation Trust, Anaesthetic Department, Southampton, UK
| | | | - Thais Russomano
- Centre of Human and Applied Physiological Sciences, Kings College London, London, UK
| | - Jan Schmitz
- German Society of Aviation and Space Medicine (DGLRM), Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, 50937, Cologne, Germany.,Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany
| | - Oliver Spelten
- Department of Anaesthesiology and Intensive Care Medicine, Schön Klinik Düsseldorf, Am Heerdter Krankenhaus 2, 40549, Düsseldorf, Germany
| | - Clément Starck
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Anesthesiology Department, Brest University Hospital, Brest, France
| | - Seamus Thierry
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Anesthesiology Department, Bretagne Sud General Hospital, Lorient, France.,Medical and Maritime Simulation Center, Lorient, France.,Laboratory of Psychology, Cognition, Communication and Behavior, University of Bretagne Sud, Vannes, France
| | - Rochelle Velho
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, University Hospitals Birmingham, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Tobias Warnecke
- University Department for Anesthesia, Intensive and Emergency Medicine and Pain Management, Hospital Oldenburg, Oldenburg, Germany
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18
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Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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19
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Physicians' Characteristics Associated with Their Attitude to Family Presence during Adult Cardiopulmonary Resuscitation. BIOMED RESEARCH INTERNATIONAL 2020; 2020:4634737. [PMID: 33145349 PMCID: PMC7596451 DOI: 10.1155/2020/4634737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 08/06/2020] [Accepted: 09/30/2020] [Indexed: 11/17/2022]
Abstract
Healthcare providers have disparate views of family presence during cardiopulmonary resuscitation; however, the attitudes of physicians have not been investigated systematically. This study investigates the patterns and determinants of physicians' attitudes to FP during cardiopulmonary resuscitation in Saudi Arabia. A cross-sectional design was applied, where a sample of 1000 physicians was surveyed using a structured questionnaire. The study was conducted in the southern region of Saudi Arabia for over 11 months (February 2014-December 2014). The collected data was analyzed using the Pearson chi-square test. Spearman's correlation analysis and chi-square test of independence were used for the analysis of physicians' characteristics with their willingness to allow FP. 80% of physicians opposed FP during cardiopulmonary resuscitation. The majority of them believed that FP could lead to decreased bedside space, staff distraction, performance anxiety, interference with patient care, and breach of privacy. They also highlight FP to result in difficulty concerning stopping a futile cardiopulmonary resuscitation, psychological trauma to family members, professional stress among staff, and malpractice litigations. 77.9% mostly disagreed that FP could be useful in allaying family anxiety about the condition of the patient or removing their doubts about the care provided, improving family support and participation in patient care, or enhancing staff professionalism. Various concerns exist for FP during adult cardiopulmonary resuscitation, which must be catered when planning for FP execution.
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20
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Erogul M, Likourezos A, Meddy J, Terentiev V, Davydkina D, Monfort R, Pushkar I, Vu T, Achalla M, Fromm C, Marshall J. Post-traumatic Stress Disorder in Family-witnessed Resuscitation of Emergency Department Patients. West J Emerg Med 2020; 21:1182-1187. [PMID: 32970573 PMCID: PMC7514396 DOI: 10.5811/westjem.2020.6.46300] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 06/22/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Family presence during emergency resuscitations is increasingly common, but the question remains whether the practice results in psychological harm to the witness. We examine whether family members who witness resuscitations have increased post-traumatic stress disorder (PTSD) symptoms at one month following the event. Methods We identified family members of critically ill patients via our emergency department (ED) electronic health record. Patients were selected based on their geographic triage to an ED critical care room. Family members were called a median of one month post-event and administered the Impact of Event Scale-Revised (IES-R), a 22-item validated scale that measures post-traumatic distress symptoms and correlates closely with Diagnostic and Statistical Manual of Mental Disorders-IV criteria for post-traumatic stress disorder (PTSD). Family members were placed into two groups based on whether they stated they had witnessed the resuscitation (FWR group) or not witnessed the resuscitation (FNWR group). Data analyses included chi-square test, independent sample t-test, and linear regression controlling for gender and age. Results A convenience sample of 423 family members responded to the phone interview: 250 FWR and 173 FNWR. The FWR group had significantly higher mean total IES-R scores: 30.4 vs 25.6 (95% confidence interval [CI], −8.73 to −0.75; P<.05). Additionally, the FWR group had significantly higher mean score for the subscales of avoidance (10.6 vs 8.1; 95% CI, −4.25 to −0.94; P<.005) and a trend toward higher score for the subscale of intrusion (13.0 vs 11.4; 95% CI, −3.38 to .028; P = .054). No statistical significant difference was noted between the groups in the subscale of hyperarousal (6.95 vs 6.02; 95% CI, −2.08 to 0.22; P=.121). All findings were consistent after controlling for age, gender, and immediate family member (spouse, parent, children, and grandchildren). Conclusion Our results suggest that family members who witness ED resuscitations may be at increased risk of PTSD symptoms at one month. This is the first study that examines the effects of family visitation for an unsorted population of very sick patients who would typically be seen in the critical care section of a busy ED.
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Affiliation(s)
- Mert Erogul
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Antonios Likourezos
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Jodee Meddy
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Victoria Terentiev
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - D'anna Davydkina
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Ralph Monfort
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Illya Pushkar
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Thomas Vu
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Madhu Achalla
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Christian Fromm
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - John Marshall
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
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21
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Embong H, Md Isa SA, Harunarashid H, Abd Samat AH. Factors associated with prolonged cardiopulmonary resuscitation attempts in out-of-hospital cardiac arrest patients presenting to the emergency department. Australas Emerg Care 2020; 24:84-88. [PMID: 32847734 DOI: 10.1016/j.auec.2020.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/27/2020] [Accepted: 08/02/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is high variability among clinicians' decision of appropriate cardiopulmonary resuscitation (CPR) duration before deciding for termination of resuscitation. This study attempted to investigate factors associated with the decision to prolong resuscitation attempts in cardiac arrest patients treated in an emergencydepartment (ED). METHODS A retrospective study that evaluated two years of mortality registry starting in 2015 was conducted in the ED of University Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia. Adult out-hospital cardiac arrest (OHCA) patients treated in the ED were included. Multivariate logistic regression analysis was utilized for the exploration of factors associated with prolonged CPR attempts (> 30min). RESULTS The median CPR duration was 24min (range 2-68min). Four variables were independently associated with prolonged CPR attempts: younger age (OR, 0.97; 95% CI, 0.95-0.99; p<0.001), pre-existing heart disease (OR, 1.97; 95% CI, 1.07-3.65; p=0.031), occurrence of transient return of spontaneous circulation (ROSC) (OR, 2.38; 95% CI, 1.05-5.36; p=0.037), and access to the ED by nonemergency medical services (EMS) transport (OR, 1.92; 95% CI, 1.09-3.37; p=0.024). CONCLUSION Patient-related and access-related factors were associated with prolonged CPR attempts among OHCA patients resuscitated in the ED.
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Affiliation(s)
- Hashim Embong
- Department of Emergency Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia.
| | - Syakirah Anisa Md Isa
- Department of Emergency Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Husyairi Harunarashid
- Department of Emergency Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Azlan Helmy Abd Samat
- Department of Emergency Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia
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22
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Lin JJ, Huang CH, Chen WJ, Chuang PY, Chang WT, Chen WT, Tsai MS. Targeted temperature management and emergent coronary angiography are associated with improved outcomes in patients with prehospital return of spontaneous circulation. J Formos Med Assoc 2020; 119:1259-1266. [DOI: 10.1016/j.jfma.2020.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/18/2020] [Accepted: 03/25/2020] [Indexed: 10/24/2022] Open
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23
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Amnuaypattanapon K, Thanachartwet V, Desakorn V, Chamnanchanunt S, Pukrittayakamee S, Sahassananda D, Wattanathum A. Predictive model of return of spontaneous circulation among patients with out-of-hospital cardiac arrest in Thailand: The WATCH-CPR Score. Int J Clin Pract 2020; 74:e13502. [PMID: 32187434 DOI: 10.1111/ijcp.13502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/12/2020] [Accepted: 03/17/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest is an emergency that requires immediate management to save lives. However, some predictive scores for the immediate outcomes of patients with out-of-hospital cardiac arrest are difficult to use in clinical practice. AIMS This study aimed to identify predictors of sustained return of spontaneous circulation and to develop a predictive score. METHODS This prospective observational study evaluated sustained return of spontaneous circulation among out-of-hospital cardiac arrest patients in a Thai emergency department between July 2014 and March 2018. The baseline characteristics and prehospital and hospital findings were analysed. RESULTS Of 347 patients, 126 (36.3%) had sustained return of spontaneous circulation and 20 (5.8%) were discharged. Witnessed arrest (odds ratio = 2.9, 95% confidence interval 1.3-6.2), time from arrest to chest compression <15 min (odds ratio = 3.0, 95% confidence interval 1.3-7.0) and chest compression duration <30 min (odds ratio = 15.6, 95% confidence interval 8.7-28.0) predicted sustained return of spontaneous circulation; these were developed into the WATCH-CPR (Witnessed Arrest, Time from arrest to CHest compression-CPR duration) score. A score of ≥2 was optimal for predicting sustained return of spontaneous circulation, which provided an area under the receiver operating characteristic of 0.775 (95% confidence interval 0.724-0.825) and a sensitivity of 72.2% (95% confidence interval 63.4-79.6%) and specificity of 76.0% (95% confidence interval 69.8-81.4%). CONCLUSIONS The factors including witnessed arrest, time from arrest to chest compression and chest compression duration were developed as the WATCH-CPR score for predicting sustained return of spontaneous circulation among patients with out-of-hospital cardiac arrest.
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Affiliation(s)
- Kumpol Amnuaypattanapon
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Emergency Medicine, Thammasat University Hospital, Pathum Thani Province, Thailand
| | - Vipa Thanachartwet
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Varunee Desakorn
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Supat Chamnanchanunt
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Sasithon Pukrittayakamee
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Duangjai Sahassananda
- Information Technology Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Anan Wattanathum
- Pulmonary and Critical Care Division, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
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24
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Kojima S, Michikawa T, Matsui K, Ogawa H, Yamazaki S, Nitta H, Takami A, Ueda K, Tahara Y, Yonemoto N, Nonogi H, Nagao K, Ikeda T, Sato N, Tsutsui H. Association of Fine Particulate Matter Exposure With Bystander-Witnessed Out-of-Hospital Cardiac Arrest of Cardiac Origin in Japan. JAMA Netw Open 2020; 3:e203043. [PMID: 32301991 PMCID: PMC7165302 DOI: 10.1001/jamanetworkopen.2020.3043] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Out-of-hospital cardiac arrests (OHCAs) are a major public health concern and a leading cause of death worldwide. Exposure to ambient air pollution is associated with increases in morbidity and mortality and has been recognized as a leading contributor to global disease burden. OBJECTIVE To examine the association between short-term exposure to particulate matter with a diameter of 2.5 μm or smaller (PM2.5) and the incidence of OHCAs of cardiac origin and with the development of initial cardiac arrest rhythm. DESIGN, SETTING, AND PARTICIPANTS This case-control study used data from cases registered between January 1, 2005, and December 31, 2016, in the All-Japan Utstein Registry, a prospective, nationwide, population-based database for OHCAs across all 47 Japanese prefectures. These OHCA cases included patients who had bystander-witnessed OHCAs and for whom emergency medical services responders initiated resuscitation before hospital transfer. A case-crossover design was employed for the study analyses. A prefecture-specific, conditional logistic regression model to estimate odds ratios was applied, and a random-effects meta-analysis was used to obtain prefecture-specific pooled estimates. All analyses were performed from May 7, 2019, to January 23, 2020. MAIN OUTCOMES AND MEASURES The main outcome was the association of short-term PM2.5 exposure with the incidence of bystander-witnessed OHCAs of cardiac origin. The differences in the distribution of initial cardiac arrest rhythm in OHCAs among those with exposure to PM2.5 were also examined. RESULTS In total, 103 189 OHCAs witnessed by bystanders were included in the final analysis. Among the patients who experienced such OHCAs, the mean (SD) age was 75 (15.5) years, and 62 795 (60.9%) were men. Point estimates of the percentage increase for a 10-μg/m3 increase in PM2.5 at lag0-1 (difference in mean PM2.5 concentrations measured on the case day and 1 day before) demonstrated a statistically significantly higher incidence of OHCA across most of the 47 prefectures, without significant heterogeneity (I2 = 20.1%; P = .12). A stratified analysis found an association between PM2.5 exposure and OHCAs (% increase, 1.6; 95% CI, 0.1%-3.1%). An initial shockable rhythm, such as ventricular fibrillation or pulseless ventricular tachycardia (% increase, 0.6; 95% CI, -2.0% to 3.2%), was not associated with PM2.5 exposure. However, an initial nonshockable rhythm, such as pulseless electrical activity and asystole, was associated with PM2.5 exposure (% increase, 1.4; 95% CI, 0.1%-2.7%). CONCLUSIONS AND RELEVANCE Findings from this study suggest that increased PM2.5 concentration is associated with bystander-witnessed OHCA of cardiac origin that commonly presents with nonshockable rhythm. The results support measures to reduce PM2.5 exposure to prevent OHCAs of cardiac origin.
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Affiliation(s)
- Sunao Kojima
- Department of General Internal Medicine 3, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Takehiro Michikawa
- Department of Environmental and Occupational Health, School of Medicine, Toho University, Ota-ku, Tokyo, Japan
| | - Kunihiko Matsui
- Department of General Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Hisao Ogawa
- National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shin Yamazaki
- Centre for Health and Environmental Risk Research, National Institute for Environmental Studies, Tsukuba, Japan
| | - Hiroshi Nitta
- Centre for Health and Environmental Risk Research, National Institute for Environmental Studies, Tsukuba, Japan
| | - Akinori Takami
- Centre for Regional Environmental Research, National Institute for Environmental Studies, Tsukuba, Japan
| | - Kayo Ueda
- Environmental Health Sciences, Kyoto University Graduate School of Global Environmental Studies, Sakyo-ku, Kyoto, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Naohiro Yonemoto
- Department of Neuropsychopharmacology, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Hiroshi Nonogi
- Intensive Care Center, Shizuoka General Hospital, Shizuoka, Japan
| | - Ken Nagao
- Department of Cardiovascular Center, Nihon University Hospital, Chiyoda-ku, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Ota-ku, Tokyo, Japan
| | - Naoki Sato
- Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital, Kawaguchi, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
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25
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Campwala RT, Schmidt AR, Chang TP, Nager AL. Factors influencing termination of resuscitation in children: a qualitative analysis. Int J Emerg Med 2020; 13:12. [PMID: 32171233 PMCID: PMC7071657 DOI: 10.1186/s12245-020-0263-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/21/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Pediatric Advanced Life Support provides guidelines for resuscitating children in cardiopulmonary arrest. However, the role physicians' attitudes and beliefs play in decision-making when terminating resuscitation has not been fully investigated. This study aims to identify and explore the vital "non-medical" considerations surrounding the decision to terminate efforts by U.S.-based Pediatric Emergency Medicine (PEM) physicians. METHODS A phenomenological qualitative study was conducted using PEM physician experiences in terminating resuscitation within a large freestanding children's hospital. Semi-structured interviews were conducted with 17 physicians, sampled purposively for their relevant content experience, and continued until the point of content saturation. Resulting data were coded using conventional content analysis by 2 coders; intercoder reliability was calculated as κ of 0.91. Coding disagreements were resolved through consultation with other authors. RESULTS Coding yielded 5 broad categories of "non-medical" factors that influenced physicians' decision to terminate resuscitation: legal and financial, parent-related, patient-related, physician-related, and resuscitation. When relevant, each factor was assigned a directionality tag indicating whether the factor influenced physicians to terminate a resuscitation, prolong a resuscitation, or not consider resuscitation. Seventy-eight unique factors were identified, 49 of which were defined by the research team as notable due to the frequency of their mention or novelty of concept. CONCLUSION Physicians consider numerous "non-medical" factors when terminating pediatric resuscitative efforts. Factors are tied largely to individual beliefs, attitudes, and values, and likely contribute to variability in practice. An increased understanding of the uncertainty that exists around termination of resuscitation may help physicians in objective clinical decision-making in similar situations.
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Affiliation(s)
- Rashida T Campwala
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA, 90027, USA. .,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Anita R Schmidt
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA, 90027, USA
| | - Todd P Chang
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA, 90027, USA.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alan L Nager
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA, 90027, USA.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Vahedian-Azimi A, Rahimibashar F, Miller AC. A comparison of cardiopulmonary resuscitation with standard manual compressions versus compressions with real-time audiovisual feedback: A randomized controlled pilot study. Int J Crit Illn Inj Sci 2020; 10:32-37. [PMID: 32322552 PMCID: PMC7170341 DOI: 10.4103/ijciis.ijciis_84_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 02/03/2020] [Accepted: 01/02/2020] [Indexed: 01/05/2023] Open
Abstract
Background: Strategies that improve cardiopulmonary resuscitation (CPR) guideline adherence may improve in-hospital cardiac arrest (IHCA) outcomes. Real-time audiovisual feedback (AVF) is one strategy identified by the American Heart Association and the International Liaison Committee on Resuscitation as an area needing further investigation. The aim of this study was to determine if in patients with IHCA, does the addition of a free-standing AVF device to standard manual chest compressions during CPR improve sustained return of spontaneous circulation (ROSC) rates (primary outcome) or CPR quality or guideline adherence (secondary outcomes). Methods: This was a prospective, randomized, controlled, parallel study of patients undergoing resuscitation with chest compressions for IHCA in the mixed medical-surgical intensive care units (ICUs) of two academic teaching hospitals. Patients were randomized to receive either standard manual chest compressions or compressions using the Cardio First Angel™ feedback device. Results: Sixty-seven individuals were randomized, and 22 were included. CPR quality evaluation and guideline adherence scores were improved in the intervention group (P = 0.0005 for both). The incidence of ROSC was similar between groups (P = 0.64), as was survival to ICU discharge (P = 0.088) and survival to hospital discharge (P = 0.095). Conclusion: The use of the Cardio First Angel™ compression feedback device improved adherence to publish CPR guidelines and CPR quality. The insignificant change in rates of ROSC and survival to ICU or hospital discharge may have been related to small sample size. Further clinical studies comparing AVF devices to standard manual compressions are needed, as are device head-to-head comparisons.
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Affiliation(s)
- Amir Vahedian-Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Farshid Rahimibashar
- Department of Anesthesia and Critical Care, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Andrew C Miller
- Department of Emergency Medicine, East Carolina University Brody School of Medicine, Greenville, NC, USA
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27
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Sondergaard KB, Riddersholm S, Wissenberg M, Moller Hansen S, Barcella CA, Karlsson L, Bundgaard K, Lippert FK, Kjaergaard J, Gislason GH, Folke F, Torp-Pedersen C, Kragholm K. Out-of-hospital cardiac arrest: 30-day survival and 1-year risk of anoxic brain damage or nursing home admission according to consciousness status at hospital arrival. Resuscitation 2020; 148:251-258. [DOI: 10.1016/j.resuscitation.2019.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 11/06/2019] [Accepted: 12/06/2019] [Indexed: 01/16/2023]
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28
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Nas J, Kleinnibbelink G, Hannink G, Navarese EP, van Royen N, de Boer MJ, Wik L, Bonnes JL, Brouwer MA. Diagnostic performance of the basic and advanced life support termination of resuscitation rules: A systematic review and diagnostic meta-analysis. Resuscitation 2019; 148:3-13. [PMID: 31887367 DOI: 10.1016/j.resuscitation.2019.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/14/2019] [Accepted: 12/18/2019] [Indexed: 01/22/2023]
Abstract
AIM To minimize termination of resuscitation (TOR) in potential survivors, the desired positive predictive value (PPV) for mortality and specificity of universal TOR-rules are ≥99%. In lack of a quantitative summary of the collective evidence, we performed a diagnostic meta-analysis to provide an overall estimate of the performance of the basic and advanced life support (BLS and ALS) termination rules. DATA SOURCES We searched PubMed/EMBASE/Web-of-Science/CINAHL and Cochrane (until September 2019) for studies on either or both TOR-rules in non-traumatic, adult cardiac arrest. PRISMA-DTA-guidelines were followed. RESULTS There were 19 studies: 16 reported on the BLS-rule (205.073 patients, TOR-advice in 57%), 11 on the ALS-rule (161.850 patients, TOR-advice in 24%). Pooled specificities were 0.95 (0.89-0.98) and 0.98 (0.95-1.00) respectively, with a PPV of 0.99 (0.99-1.00) and 1.00 (0.99-1.00). Specificities were significantly lower in non-Western than Western regions: 0.84 (0.73-0.92) vs. 0.99 (0.97-0.99), p < 0.001 for the BLS rule. For the ALS-rule, specificities were 0.94 (0.87-0.97) vs. 1.00 (0.99-1.00), p < 0.001. For non-Western regions, 16 (BLS) or 6 (ALS) out of 100 potential survivors met the TOR-criteria. Meta-regression demonstrated decreasing performance in settings with lower rates of in-field shocks. CONCLUSIONS Despite an overall high PPV, this meta-analysis highlights a clinically important variation in diagnostic performance of the BLS and ALS TOR-rules. Lower specificity and PPV were seen in non-Western regions, and populations with lower rates of in-field defibrillation. Improved insight in the varying diagnostic performance is highly needed, and local validation of the rules is warranted to prevent in-field termination of potential survivors.
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Affiliation(s)
- Joris Nas
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands.
| | - Geert Kleinnibbelink
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands; Institute for Sport and Exercise Sciences, Liverpool John Moores University, 3 Byrom Street, L3 3AF Liverpool, UK
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eliano P Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Cardiovascular Institute Mater Dei Hospital, Bari, Italy; SIRIO MEDICINE Cardiovascular Network, Italy; Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Niels van Royen
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - Menko-Jan de Boer
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - Lars Wik
- Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS), Oslo University Hospital, Oslo, Norway
| | - Judith L Bonnes
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - Marc A Brouwer
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
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Culture and personal influences on cardiopulmonary resuscitation- results of international survey. BMC Med Ethics 2019; 20:102. [PMID: 31878920 PMCID: PMC6933623 DOI: 10.1186/s12910-019-0439-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 12/13/2019] [Indexed: 11/16/2022] Open
Abstract
Background The ethical principle of justice demands that resources be distributed equally and based on evidence. Guidelines regarding forgoing of CPR are unavailable and there is large variance in the reported rates of attempted CPR in in-hospital cardiac arrest. The main objective of this work was to study whether local culture and physician preferences may affect spur-of-the-moment decisions in unexpected in-hospital cardiac arrest. Methods Cross sectional questionnaire survey conducted among a convenience sample of physicians that likely comprise code team members in their country (Indonesia, Israel and Mexico). The questionnaire included details regarding respondent demographics and training, personal value judgments and preferences as well as professional experience regarding CPR and forgoing of resuscitation. Results Of the 675 questionnaires distributed, 617 (91.4%) were completed and returned. Country of practice and level of knowledge about resuscitation were strongly associated with avoiding CPR performance. Mexican physicians were almost twicemore likely to forgo CPR than their Israeli and Indonesian/Malaysian counterparts [OR1.84 (95% CI 1.03, 3.26), p = 0.038]. Mexican responders also placed greater emphasison personal and patient quality of life (p < 0.001). In multivariate analysis, degree of religiosity was most strongly associated with willingness to forgo CPR; orthodox respondents were more than twice more likely to report having forgone CPR for apatient they do not know than secular and observant respondents, regardless of the country of practice [OR 2.12 (95%CI 1.30, 3.46), p = 0.003]. Conclusions In unexpected in-hospital cardiac arrest the decision to perform or withhold CPR may be affected by physician knowledge and local culture as well as personal preferences. Physician CPR training should include information regarding predictors of patient outcome at as well as emphasis on differentiating between patient and personal preferences in an emergency.
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Reny D, Root S, Chreiman K, Browning R, Sims C. A Body of Evidence: Barriers to Family Viewing After Death by Gun Violence. J Surg Res 2019; 247:556-562. [PMID: 31757370 DOI: 10.1016/j.jss.2019.09.015] [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: 03/02/2019] [Revised: 07/26/2019] [Accepted: 09/13/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Gun violence remains a staggering public health care crisis. Although viewing the victim's body is essential to the grieving process, this practice is not universally practiced in the trauma bay and may not be supported by nurses. This study investigates how trauma nurses perceive bereavement and the potential barriers to family viewing after death by gun violence. METHODS A survey designed to assess demographics, current practices, knowledge of policies, and personal beliefs regarding family viewing after violent crime was sent electronically to members of the Society of Trauma Nurses. Participants were asked to rank the importance of 14 viewing barriers. Descriptive analysis and perception of barriers between those who did and did not permit viewing were compared using Mann-Whitney tests. *P < 0.05 is considered significant. RESULTS Of the 212 participants, the majority were white, female nurses (86%), aged 30 to 60 y who worked in an urban or suburban setting (58% and 30%). Only 15% had a written hospital policy with the majority not knowing if the police (68%) or medical examiner (74%) had written policies. Despite lack of guidelines, viewings did routinely occur (68%), but only 37% permitted touching. Nurses who did not permit viewing were more likely to rank legal concerns and trauma bay environment as significant barriers. CONCLUSIONS Although family viewing after gun violence frequently occurs in the trauma bay, there are significant barriers that are compounded by lack of formal policies. Collaboration with police and medical examiners could mitigate these fears while promoting a safe and more family-centered experience.
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Affiliation(s)
- Danielle Reny
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah Root
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristen Chreiman
- Division of Traumatology, University of Pennsylvania, Surgical Critical Care, and Emergency Surgery, Philadelphia, Pennsylvania
| | - Rhonda Browning
- Division of Traumatology, University of Pennsylvania, Surgical Critical Care, and Emergency Surgery, Philadelphia, Pennsylvania
| | - Carrie Sims
- Division of Traumatology, University of Pennsylvania, Surgical Critical Care, and Emergency Surgery, Philadelphia, Pennsylvania.
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Glober NK, Tainter CR, Kim D. Reply to “the futility of resuscitating an out-of-hospital cardiac arrest cannot be summarized by three simple criteria”. Resuscitation 2019; 144:201-202. [DOI: 10.1016/j.resuscitation.2019.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/04/2019] [Indexed: 10/26/2022]
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Yurtseven A, Turan C, Akarca FK, Saz EU. Pediatric cardiac arrest in the emergency department: Outcome is related to the time of admission. Pak J Med Sci 2019; 35:1434-1440. [PMID: 31489021 PMCID: PMC6717451 DOI: 10.12669/pjms.35.5.487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objectives: Nights and weekends represent a potentially high-risk time for pediatric cardiac arrest (CA) patients in emergency departments. Data regarding night or weekend arrest and its impact on outcomes is controversial. The purpose of this study was to determine the relationship between cardiopulmonary resuscitation during the various emergency department shifts and survival to discharge. Methods: We conducted a retrospective, observational study of patients who had visited our Emergency Department for CAs from January 2014 to December 2016. Medical records and patient characteristics of 67 children with CA were retrieved from patient admission files. Results: The mean age was 54.7±7.3 months and 59% were male. Rates of survival to discharge 35% (11/31) within working hours’ vs. out of working hours 3% (1/36). Among the CAs presenting to the emergency department, the survival rates were higher for working hours than for non-working hours (OR: 37.6 (2.62-539.7), p: 008). The rate of return of spontaneous circulation within working hours was higher than that of non-working hours (71% vs.19%) (p<0.001). Patients who received chest compression for more than 10 minutes had the lowest survival rate (2%) (p<0.001), whereas better outcome was associated with in-hospital CA, younger age (less than 12 months) and respiratory failure. Conclusion: Survival rates from pediatric CAs were significantly lower during non-working hours. Poor outcome was associated with prolonged cardiopulmonary resuscitation, out of hospital CA and older age.
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Affiliation(s)
- Ali Yurtseven
- Ali Yurtseven, MD. Department of Pediatrics, Division of Emergency Medicine, Ege University School of Medicine, Izmir, Turkey
| | - Caner Turan
- Caner Turan, MD. Department of Pediatrics, Division of Emergency Medicine, Ege University School of Medicine, Izmir, Turkey
| | - Funda Karbek Akarca
- Funda Karbek Akarca, MD. Associate Professor, Department of Emergency Medicine, Ege University School of Medicine, Izmir, Turkey
| | - Eylem Ulas Saz
- Prof. Eylem Ulas Saz, MD. Department of Pediatrics, Division of Emergency Medicine, Ege University School of Medicine, Izmir, Turkey
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Lee MR, Yu KL, Kuo HY, Liu TH, Ko JC, Tsai JS, Wang JY. Outcome of stage IV cancer patients receiving in-hospital cardiopulmonary resuscitation: a population-based cohort study. Sci Rep 2019; 9:9478. [PMID: 31263137 PMCID: PMC6602946 DOI: 10.1038/s41598-019-45977-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/17/2019] [Indexed: 12/21/2022] Open
Abstract
The effects of cardiopulmonary resuscitation (CPR) on patients with advanced cancer remain to be elucidated. We identified a cohort of patients with stage-IV cancer who received in-hospital CPR from the Taiwan Cancer Registry and National Health Insurance claims database, along with a matched cohort without cancer who also received in-hospital CPR. The main outcomes were post-discharge survival and in-hospital mortality. In total, 3,446 stage-IV cancer patients who underwent in-hospital CPR after cancer diagnosis were identified during January 2009–June 2014. A vast majority of the patients did not survive to discharge (n = 2,854, 82.8%). The median post-discharge survival was 22 days; 10.1% (n = 60; 1.7% of all patients) of the hospital survivors received anticancer therapy after discharge. We created 1:1 age–, sex–, Charlson comorbidity index (CCI)–, and year of CPR–matched noncancer and stage-IV cancer cohorts (n = 3,425 in both; in-hospital mortality rate = 82.1% and 82.8%, respectively). Regression analysis showed that the stage-IV cancer cohort had shorter post-discharge survival than did the noncancer cohort. The outcome of patients with advanced cancer was poor. Even among the survivors, post-discharge survival was short, with only few patients receiving further anticancer therapy.
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Affiliation(s)
- Meng-Rui Lee
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Kai-Lun Yu
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hung-Yang Kuo
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung-Hao Liu
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen-Chung Ko
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jaw-Shiun Tsai
- Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Yoon JC, Kim YJ, Ahn S, Jin YH, Lee SW, Song KJ, Shin SD, Hwang SO, Kim WY. Factors for modifying the termination of resuscitation rule in out-of-hospital cardiac arrest. Am Heart J 2019; 213:73-80. [PMID: 31129440 DOI: 10.1016/j.ahj.2019.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 04/03/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND False positive rate (FPR) of the current basic life support (BLS) termination of resuscitation (TOR) rule in out-of-hospital cardiac arrest (OHCA) patients (not witnessed; no return of spontaneous circulation prior to transport; and no shocks were delivered) has been ethically challenging. We validated the current BLS TOR rule with using nationwide Korean Cardiac Arrest Research Consortium (KoCARC) registry and identified the factors for modifying the rules. METHODS This prospective, multicenter, registry-based study was performed using the nontraumatic OHCA registry data between October 2015 and June 2017. Independent factors associated with poor neurologic outcome were identified to propose new KoCARC TOR rules by using multivariable analysis. The diagnostic performances of the TOR rules were calculated respectively. RESULTS Among 4,360 OHCA patients, 2,801 (64.2%) satisfied all 3 criteria of the BLS TOR rule. The FPR and positive predictive value of the BLS TOR rule were 5.9% and 99.3%. Asystole as initial rhythm and age > 60 years were found as new factors for modifying the TOR rule. New KoCARC TOR rules, combination of asystole and age > 60 years with current TOR rule, showed lower FPR (0.3%-2.1%) and higher positive predictive value (99.7%-99.9%) for predicting poor neurologic outcome at discharge. CONCLUSIONS In this recent nationwide cohort, the current BLS TOR rule showed high FPR (5.9%) for predicting poor neurologic outcome. We anticipate that our new KoCARC TOR rules, application of 2 new factors (asystole as initial rhythm and age > 60 years) with BLS TOR rule, could reduce unwarranted death.
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Starks MA, Schmicker RH, Peterson ED, May S, Buick JE, Kudenchuk PJ, Drennan IR, Herren H, Jasti J, Sayre M, Stub D, Vilke GM, Stephens SW, Chang AM, Nuttall J, Nichol G. Association of Neighborhood Demographics With Out-of-Hospital Cardiac Arrest Treatment and Outcomes: Where You Live May Matter. JAMA Cardiol 2019; 2:1110-1118. [PMID: 28854308 DOI: 10.1001/jamacardio.2017.2671] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance We examined whether resuscitation care and outcomes vary by the racial composition of the neighborhood where out-of-hospital cardiac arrests (OHCAs) occur. Objective To evaluate the association between bystander treatments (cardiopulmonary resuscitation and automatic external defibrillation) and timing of emergency medical services personnel on OHCA outcomes according to the racial composition of the neighborhood where the OHCA event occurred. Design, Setting, and Participants This retrospective observational cohort study examined patients with OHCA from January 1, 2008, to December 31, 2011, using data from the Resuscitation Outcomes Consortium. Neighborhoods where OHCA occurred were classified by census tract, based on percentage of black residents: less than 25%, 25% to 50%, 51% to 75%, or more than 75%. Multilevel mixed-effects logistic regression modeling examined the association between racial composition of neighborhoods and OHCA survival, adjusting for patient, neighborhood, and treatment characteristics. Main Outcomes and Measures Survival to discharge, return of spontaneous circulation on emergency department arrival, and favorable neurologic status at discharge. Results We examined 22 816 adult patients with nontraumatic OHCA at Resuscitation Outcomes Consortium sites in the United States. The median age of patients with OHCA was 64 years (interquartile range [IQR], 51-78). Compared with patients who experienced OHCA in neighborhoods with a lower proportion of black residents, those in neighborhoods with more than 75% black residents were slightly younger, were more frequently women, had lower rates of initial shockable rhythm, and less frequently experienced OHCA in a public location. The percentage of patients with OHCA receiving bystander cardiopulmonary resuscitation or a lay automatic external defibrillation was inversely associated with the percentage of black residents in neighborhoods. Compared with OHCA in predominantly white neighborhoods (<25% black), those with OHCA in mixed to majority black neighborhoods had lower adjusted survival rates to hospital discharge (25%-50% black: odds ratio, 0.76; 95% CI, 0.61-0.93; 51%-75% black: odds ratio, 0.67; 95% CI, 0.49-0.90; >75% black: odds ratio, 0.63; 95% CI, 0.50-0.79; P < .001). There was similar mortality risk for black and white patients with OHCA in each neighborhood racial quantile. When the primary model included geographic site, there was an attenuated nonsignificant association between racial composition in a neighborhood and survival. Conclusions and Relevance Those with OHCA in predominantly black neighborhoods had the lowest rates of bystander cardiopulmonary resuscitation and automatic external defibrillation use and significantly lower likelihood for survival compared with predominantly white neighborhoods. Improving bystander treatments in these neighborhoods may improve cardiac arrest survival.
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Affiliation(s)
| | | | - Eric D Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | | | - Jason E Buick
- Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Ian R Drennan
- Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Dion Stub
- Alfred and Western Hospital, Baker IDI Heart and Diabetes Institute, Monash University, Melbourne, Victoria, Australia
| | - Gary M Vilke
- University of California, San Diego Health System, San Diego
| | | | - Anna M Chang
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
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Time of on-scene resuscitation in out of-hospital cardiac arrest patients transported without return of spontaneous circulation. Resuscitation 2019; 138:235-242. [DOI: 10.1016/j.resuscitation.2019.03.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/05/2019] [Accepted: 03/19/2019] [Indexed: 01/04/2023]
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Engel TW, Thomas C, Medado P, Bastani A, Reed B, Millis S, O'Neil BJ. End tidal CO 2 and cerebral oximetry for the prediction of return of spontaneous circulation during cardiopulmonary resuscitation. Resuscitation 2019; 139:174-181. [PMID: 30978377 DOI: 10.1016/j.resuscitation.2019.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/12/2019] [Accepted: 04/01/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND End Tidal CO2 (ETCO2) is a reasonable predictor of Return of Spontaneous Circulation (ROSC) in cardiac arrest (CA), though with many limitations. Cerebral Oximetry (CerOx) non-invasively measures brain O2 saturation and correlates with flow. OBJECTIVES This study compares ETCO2 and CerOx for ROSC prediction during both out of hospital (OHCA) and emergency department cardiac arrests (EDCA). METHODS We conducted a prospective study on CA patients resuscitated in the ED. ETCO2 and CerOx simultaneously measured during ED CPR. Data was analyzed with logistic regression modeling and area under the curve (AUC). RESULTS 176 patients were analyzed, 66.7% were witnessed, 52.8% had bystander CPR. EMS alert to ED arrival was 27.0 ± 10.6 min. Initial rhythm was 31.8% asystole, 27.8% PEA, 25.6% VF/VT with 26.1% achieving ROSC. AUC predictors of ROSC were: last 5 min trend [CerOx = 0.82 ; ETCO2 = 0.74], delta first to last [CerOx = 0.86 ; ETCO2 = 0.73], the penultimate minute [CerOx = 0.81 ; ETCO2 = 0.76], and final minute [CerOx = 0.89 ; ETCO2 = 0.77]. AUC comparison of simultaneous measurements (n = 125) revealed: last 5 min trend [CerOx = 0.80 ; ETCO2 = 0.79], delta first to last [CerOx = 0.83 ; ETCO2 = 0.75], penultimate minute [CerOx = 0.83 ETCO2 = 0.74], and final minute [CerOx = 0.89 ; ETCO2 = 0.75]. CONCLUSIONS Our data shows, both ETCO2 and rSO2 are good predictors of ROSC. We found CerOx superior to ETCO2 in predicting ROSC.
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Affiliation(s)
- Thomas W Engel
- Cook County Hospital Department of Emergency Medicine, 1420 W Erie St. APT 2 R, Chicago IL, 60642, United States
| | - Craig Thomas
- Central Michigan University College of Medicine, 2229 Whitemore Pl., Saginaw, MI, 48602, United States
| | - Patrick Medado
- Department of Emergency Medicine, Wayne State University, 6G UHC, 4201St., Antoine, Detroit, MI, 48201, United States
| | - Aveh Bastani
- Department of Emergency Medicine, Oakland University William Beaumont School of Medicine, 44201 Dequindre Rd, Troy, MI, 48085, United States
| | - Brian Reed
- Department of Emergency Medicine, Wayne State University, 6G UHC, 4201St., Antoine, Detroit, MI, 48201, United States
| | - Scott Millis
- Departments of Emergency Medicine and Rehabilitation Medicine, Wayne State University, 6G UHC, 4201St. Antoine, Detroit, MI, 48201, United States
| | - Brian J O'Neil
- Department of Emergency Medicine, Wayne State University, 6G UHC, 4201St., Antoine, Detroit, MI, 48201, United States.
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Georgiou L, Georgiou A. A critical review of the factors leading to cardiopulmonary resuscitation as the default position of hospitalized patients in the USA regardless of severity of illness. Int J Emerg Med 2019; 12:9. [PMID: 31179942 PMCID: PMC6416939 DOI: 10.1186/s12245-019-0225-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 02/19/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Physicians are occasionally faced with patients requesting full resuscitation against medical advice. More commonly, neither patients nor their family members make such a request, but physicians simply presume that providing cardiopulmonary resuscitation comports with the patient's wishes. In the USA, in contrast to other countries, a unilateral Do-Not-Resuscitate order by the physician is either forbidden by State Statute or not enforced by hospital policy. Unless otherwise specified, performing cardiopulmonary resuscitation on all hospitalized patients, regardless of the severity of the underlying illness, is the default position. Unlike other medical interventions, no deference is given to the medical judgment of the physician even when a patient is in the last days of a terminal illness. We examine the factors that have led to cardiopulmonary resuscitation having this unique status. MAIN BODY A review of the historical factors leading to cardiopulmonary resuscitation as the default position was undertaken. Articles published in the medical literature, lay-press articles, legislative enactments of law, and judicial opinions involving the issue of Do-Not-Resuscitate and cardiopulmonary resuscitation were reviewed regarding their impact on physician and hospital practice in the USA. CONCLUSION A critical review of the historical factors reveals that the rapid dissemination of cardiopulmonary training for the public, inaccuracies in the media regarding successful cardiopulmonary resuscitation, well-meaning legislative efforts with inadvertent consequences, and judicial interpretation outside the generally accepted concept of malpractice law have contributed to the situation faced by today's physicians and hospitals in the USA.
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Affiliation(s)
- Loukas Georgiou
- Rhodes College, 2000 North Parkway, Box 1641, Memphis, TN 38112 USA
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Goharani R, Vahedian-Azimi A, Farzanegan B, Bashar FR, Hajiesmaeili M, Shojaei S, Madani SJ, Gohari-Moghaddam K, Hatamian S, Mosavinasab SMM, Khoshfetrat M, Khabiri Khatir MA, Miller AC. Real-time compression feedback for patients with in-hospital cardiac arrest: a multi-center randomized controlled clinical trial. J Intensive Care 2019; 7:5. [PMID: 30693086 PMCID: PMC6341760 DOI: 10.1186/s40560-019-0357-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/03/2019] [Indexed: 01/29/2023] Open
Abstract
Objective To determine if real-time compression feedback using a non-automated hand-held device improves patient outcomes from in-hospital cardiac arrest (IHCA). Methods We conducted a prospective, randomized, controlled, parallel study (no crossover) of patients with IHCA in the mixed medical–surgical intensive care units (ICUs) of eight academic hospitals. Patients received either standard manual chest compressions or compressions performed with real-time feedback using the Cardio First Angel™ (CFA) device. The primary outcome was sustained return of spontaneous circulation (ROSC), and secondary outcomes were survival to ICU and hospital discharge. Results One thousand four hundred fifty-four subjects were randomized; 900 were included. Sustained ROSC was significantly improved in the CFA group (66.7% vs. 42.4%, P < 0.001), as was survival to ICU discharge (59.8% vs. 33.6%) and survival to hospital discharge (54% vs. 28.4%, P < 0.001). Outcomes were not affected by intra-group comparisons based on intubation status. ROSC, survival to ICU, and hospital discharge were noted to be improved in inter-group comparisons of non-intubated patients, but not intubated ones. Conclusion Use of the CFA compression feedback device improved event survival and survival to ICU and hospital discharge. Trial registration The study was registered with Clinicaltrials.gov (NCT02845011), registered retrospectively on July 21, 2016.
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Affiliation(s)
- Reza Goharani
- 1Anesthesiology Research Center, Anesthesia and Critical Care Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Vahedian-Azimi
- 2Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Behrooz Farzanegan
- 3Tracheal Diseases Research Center, Anesthesia and Critical Care Department, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farshid R Bashar
- 4Anesthesia and Critical Care Department, Hamedan University of Medical Sciences, Hamedan, Iran
| | - Mohammadreza Hajiesmaeili
- 1Anesthesiology Research Center, Anesthesia and Critical Care Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyedpouzhia Shojaei
- 1Anesthesiology Research Center, Anesthesia and Critical Care Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed J Madani
- 5Medicine Faculty, Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Keivan Gohari-Moghaddam
- 6Department of Internal Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sevak Hatamian
- 7Anesthesia and Critical Care Department, Alborz University of Medical Sciences, Karaj, Iran
| | - Seyed M M Mosavinasab
- 8Anesthesiology Research Center, Anesthesia Care Department, Modares Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoum Khoshfetrat
- 9Anesthesiology Research Center, Anesthesia and Critical Care Department, Khatam-o-anbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Mohammad A Khabiri Khatir
- 10Anesthesiology Research Center, Anesthesia and Critical Care Department, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Andrew C Miller
- 11Department of Emergency Medicine, Vident Medical Center, East Carolina University Brody School of Medicine, 600 Moye Blvd, Greenville, NC 27834 USA
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Grunau B, Scheuermeyer F, Kawano T, Helmer JS, Gu B, Haig S, Christenson J. North American validation of the Bokutoh criteria for withholding professional resuscitation in non-traumatic out-of-hospital cardiac arrest. Resuscitation 2019; 135:51-56. [PMID: 30639788 DOI: 10.1016/j.resuscitation.2019.01.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 12/04/2018] [Accepted: 01/03/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Certain subgroups of patients with out-of-hospital cardiac arrest (OHCA) may not benefit from treatment. Early identification of this cohort in the prehospital (EMS) setting prior to any resuscitative efforts would prevent futile medical therapy and more appropriately allocate EMS and hospital resources. We sought to validate a clinical criteria from Bokutoh, Japan that identified a subgroup of OHCAs for whom withholding resuscitation may be appropriate. METHODS We performed a secondary analysis of the "Trial of Continuous or Interrupted Chest Compressions during CPR", which enrolled EMS-treated adult non-traumatic OHCA. We classified patients as per the Bokutoh criteria ("Bokutoh Positive": age ≥ 73, unwitnessed arrest, non-shockable initial rhythm) and calculated test performance for the primary outcome of favourable neurologic outcome (mRS ≤ 3) at hospital discharge. We calculated the number of EMS-hours and hospital days per patient with a favourable neurologic outcome. RESULTS Of 26,148 patients in the parent trial, 5442 (21%) were "Bokutoh Positive", among whom 0.51% (95% CI 0.35- 0.75%) had favourable neurologic outcomes, and 1.2% (95% CI 0.92-1.5%) survived. The positive predictive value was 0.995 (95% CI 0.992-0.997). EMS and hospital-based resource utilization per favourable neurological outcome was 91 h and 199 days for in the "Bokutok Positive" group, respectively, and 5.7 h and 33 hospital days in the "Bokutok Negative" group. CONCLUSION In this validation of the Bokutoh criteria in a large North American cohort of OHCA patients, 0.51% meeting criteria had favourable neurological outcomes. This may rapidly and reliably identify the one-fifth of OHCA who are very unlikely to benefit from resuscitation.
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Affiliation(s)
- Brian Grunau
- Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; St. Paul's Hospital, Vancouver, British Columbia, Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.
| | - Frank Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; St. Paul's Hospital, Vancouver, British Columbia, Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Takahisa Kawano
- The Department of Emergency Medicine, University of Fukui Hospital, Fukui Prefecture, Japan
| | - Jennie S Helmer
- BC Emergency Health Services, Vancouver, British Columbia, Canada
| | - Bobby Gu
- Department of Family Practice, University of British Columbia, British Columbia, Canada
| | - Scott Haig
- BC Emergency Health Services, Vancouver, British Columbia, Canada
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; St. Paul's Hospital, Vancouver, British Columbia, Canada
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Goto Y, Funada A, Maeda T, Okada H, Goto Y. Field termination-of-resuscitation rule for refractory out-of-hospital cardiac arrests in Japan. J Cardiol 2018; 73:240-246. [PMID: 30580892 DOI: 10.1016/j.jjcc.2018.12.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 11/30/2018] [Accepted: 12/08/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Guidelines for cardiopulmonary resuscitation (CPR) recommend using the universal termination-of-resuscitation (TOR) rule to identify out-of-hospital cardiac arrest (OHCA) patients eligible for field termination of resuscitation, thus avoiding medically futile transportation to the hospital. However, in Japan, emergency medical services (EMS) personnel are forbidden from terminating CPR in the field and transport almost all patients with OHCA to hospitals. We aimed to develop and validate a novel TOR rule to identify patients eligible for field termination of CPR. METHODS We analyzed 540,478 patients with OHCA from 2011 to 2015 using a Japanese registry. Main outcome measures were specificity and positive predictive value (PPV) of the newly developed TOR rule in predicting 1-month mortality after OHCA. RESULTS Recursive partitioning analysis in the development group (n=434,208) showed that EMS personnel could consider TOR if patients with OHCA met all of the following five criteria: (1) initial asystole, (2) arrest unwitnessed by a bystander, (3) age ≥81 years, (4) no bystander-administered CPR or automated external defibrillator use before EMS arrival, and (5) no return of spontaneous circulation after EMS-initiated CPR for 14min. For patients meeting these criteria, specificity and PPV for predicting 1-month mortality were 99.2% [95% confidence interval (CI), 99.0-99.3%] and 99.7% (95% CI, 99.6-99.7%), respectively, for the development group and were 99.5% (95% CI, 99.3-99.7%) and 99.8% (95% CI, 99.7-99.9%), respectively, for the validation group. Implementation of this novel rule would reduce patient transports to hospitals by 10.6% in the development group and 10.4% in the validation group. CONCLUSIONS Having both high specificity and PPV of >99% for predicting 1-month mortality, our developed TOR rule may be applied in the field for Japanese patients with OHCA who meet all five criteria. Prospective validation studies and establishment of prehospital EMS protocol are required before implementing this rule.
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Affiliation(s)
- Yoshikazu Goto
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan.
| | - Akira Funada
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Tetsuo Maeda
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Hirofumi Okada
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Yumiko Goto
- Department of Cardiology, Yawata Medical Center, Komatsu, Japan
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Family Presence During Resuscitation: Physicians' Perceptions of Risk, Benefit, and Self-Confidence. Dimens Crit Care Nurs 2018; 37:167-179. [PMID: 29596294 DOI: 10.1097/dcc.0000000000000297] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Families often desire proximity to loved ones during life-threatening resuscitations and perceive clear benefits to being present. However, critical care nurses and physicians perceive risks and benefits. Whereas research is accumulating on nurses' perceptions of family presence, physicians' perspectives have not been clearly explicated. Psychometrically sound measures of physicians' perceptions are needed to create new knowledge and enhance collaboration among critical care nurses and physicians during resuscitation events. OBJECTIVE This study tests 2 new instruments that measure physicians' perceived risks, benefits, and self-confidence related to family presence during resuscitation. METHODS By a correlational design, a convenience sample of physicians (N = 195) from diverse clinical specialties in 1 hospital in the United States completed the Physicians' Family Presence Risk-Benefit Scale and Physicians' Family Presence Self-confidence Scale. RESULTS Findings supported the internal consistency reliability and construct validity of both new scales. Mean scale scores indicated that physicians perceived more risk than benefit and were confident in managing resuscitations with families present, although more than two-thirds reported feeling anxious. Higher self-confidence was significantly related to more perceived benefit and less perceived risk (P = .001). Younger physicians, family practice physicians, and physicians who previously had invited family presence expressed more positive perceptions (P = .05-.001). DISCUSSION These 2 new scales offer a means to assess key perceptions of physicians related to family presence. Further testing in diverse physician populations may further validate the scales and yield knowledge that can strengthen collaboration among critical care nurses and physicians and improve patient and family outcomes.
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Gregers E, Kjærgaard J, Lippert F, Thomsen JH, Køber L, Wanscher M, Hassager C, Søholm H. Refractory out-of-hospital cardiac arrest with ongoing cardiopulmonary resuscitation at hospital arrival - survival and neurological outcome without extracorporeal cardiopulmonary resuscitation. Crit Care 2018; 22:242. [PMID: 30268147 PMCID: PMC6162879 DOI: 10.1186/s13054-018-2176-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 09/04/2018] [Indexed: 11/20/2022] Open
Abstract
Background The prognosis in refractory out-of-hospital cardiac arrest (OHCA) with ongoing cardiopulmonary resuscitation (CPR) at hospital arrival is often considered dismal. The use of extracorporeal cardiopulmonary resuscitation (eCPR) for perfusion enhancement during resuscitation has shown variable results. We aimed to investigate outcome in refractory OHCA patients managed conservatively without use of eCPR. Methods We included consecutive OHCA patients with refractory arrest or prehospital return of spontaneous circulation (ROSC) in the Copenhagen area in 2002–2011. Results A total of 3992 OHCA patients with resuscitation attempts were included; in 2599, treatment was terminated prehospital, and 1393 (35%) were brought to the hospital either with ROSC (n = 1285, 92%) or with refractory OHCA (n = 108, 8%). Of patients brought in with refractory OHCA, 56 (52%) achieved ROSC in the emergency department. There were no differences between patients with refractory OHCA or prehospital ROSC with regard to age, sex, comorbidities, or etiology of OHCA. Time to emergency medical services (EMS) arrival was similar, whereas time to ROSC (when ROSC was achieved) was longer in refractory OHCA patients (EMS, 6 (5–9] vs. 7 [5–10] min, p = 0.8; ROSC, 15 [9–22] vs. 27 [20–41] min, p < 0.001). Independent factors associated with transport with refractory OHCA instead of prehospital termination of therapy were OHCA in public (OR, 3.6 [95% CI, 2.2–5.8]; p < 0.001), witnessed OHCA (OR, 3.7 [2.0–7.1]; p < 0.001), shockable rhythm (OR, 3.0 [1.9–4.7]; p < 0.001), younger age (OR, 1.2 [1.1–1.2]; p < 0.001), and later calendar year (OR, 1.4 [1.2–1.6]; p < 0.001). Thirty-day survival was 20% in patients with refractory OHCA compared with 42% in patients with prehospital ROSC (p < 0.001). Four of 28 refractory OHCA patients with duration of resuscitation > 60 min achieved ROSC. No difference in favorable neurological outcome in patients surviving to discharge was found (prehospital ROSC 84% vs. refractory OHCA 86%; p = 0.7). Conclusions Survival after refractory OHCA with ongoing CPR at hospital arrival was significantly lower than among patients with prehospital ROSC. Despite a lower survival, the majority of survivors with both refractory OHCA and prehospital ROSC were discharged with a similar degree of favorable neurological outcome, indicating that continued efforts in spite of refractory OHCA are not in vain and may still lead to favorable outcome even without eCPR.
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Affiliation(s)
- Emilie Gregers
- Department of Cardiology 2142, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark.
| | - Jesper Kjærgaard
- Department of Cardiology 2142, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark
| | | | - Jakob H Thomsen
- Department of Cardiology 2142, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark
| | - Lars Køber
- Department of Cardiology 2142, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark
| | - Michael Wanscher
- Department of Cardiothoracic Anaesthesia 4142, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology 2142, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark
| | - Helle Søholm
- Department of Cardiology 2142, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark.,Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
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Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e691-e782. [PMID: 29685887 DOI: 10.1161/cir.0000000000000524] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
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Abstract
BACKGROUND The presence of patients' families during resuscitation has been an important practice issue. An American Association of Critical-Care Nurses (AACN) practice alert "Family Presence During Resuscitation and Invasive Procedures" supports family members of patients undergoing resuscitation being given the option of bedside presence. Parent Advocacy Group for Events of Resuscitation (PAGER) is an interdisciplinary collaborative in the pediatric intensive care unit. OBJECTIVES To ensure that patients' families are provided the option of being with their child during cardiopulmonary resuscitation. METHODS Resuscitation data were collected for 12 months by using the AACN practice alert audit tool. The Family Nurse Caring Belief Scale was administered to 150 pediatric intensive care unit nurses. PAGER nurses received crisis education. RESULTS Pediatric intensive care unit nurses were supportive of providing the option of family presence during resuscitation. Family Nurse Caring Belief Scale data revealed areas for improvement in family caring practices. PAGER was implemented with positive outcomes for 2 families. CONCLUSIONS PAGER has improved the care of families whose children experience cardiopulmonary resuscitation and should be implemented in pediatric critical care units. PAGER nurses are prepared to serve as role models in providing family-sensitive care during crisis.
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Affiliation(s)
- Tracy Ann Pasek
- Tracy Ann Pasek is a clinical nurse specialist, pain/pediatric intensive care unit, evidence-based practice and research, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pennsylvania.Jodi Licata is a clinical nurse leader, pediatric intensive care unit, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center.
| | - Jodi Licata
- Tracy Ann Pasek is a clinical nurse specialist, pain/pediatric intensive care unit, evidence-based practice and research, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pennsylvania.Jodi Licata is a clinical nurse leader, pediatric intensive care unit, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center
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Kuo C, Kuo C, Hsu S, Lin C, Weng Y. The Reliability of Modified Termination of Resuscitation Rules after Arrival at the Emergency Department. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791402100502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Pre-hospital termination of resuscitation (TOR) is not a usual practice in many cities. The current study aimed to examine the reliability of the modified basic life support (ED-BLS) and advanced life support (ED-ALS) rules for TOR after patient arrival at the emergency department (ED). Methods In this retrospective cohort study, adult non-traumatic cardiac arrest patients who received pre-hospital basic life support and defibrillator (BLS-D) mode of service in Taoyuan County in northern Taiwan during the study period were assessed. Data were retrieved from web-based registry records. Results Of the 1612 patients included, 40 (2.5%) achieved survival to discharge. The ED-ALS rule showed higher specificity (ED-ALS rule: 82.5% {95% confidence interval [CI]: 68.1-91.3} vs. ED-BLS rule: 50.0% {95%CI: 35.2-64.8}) and positive predictive value (ED-ALS rule: 99.0% {95% CI: 97.9-99.5} vs. ED-BLS rule: 98.6% {95%CI: 97.8-99.1}) than the ED-BLS rule in terms of predicting no survival to discharge after patient arrival at the ED. Among patients who fulfilled all criteria for the ED-BLS and ED-ALS rule, 20 (1.4%) and seven (1.0%) survived to discharge, respectively. Application of the ED-BLS and ED-ALS rules could have reduced further resuscitation efforts after arrival at the ED by 86.4% and 43.1%, respectively. Conclusion For non-traumatic out-of-hospital cardiac arrest patients who receive BLS-D service, the ED-ALS rule has a higher specificity and PPV than the ED-BLS rule to predict no survival to discharge after patient arrival at the ED. Using the ED-ALS rule to terminate resuscitation after arrival at the ED should be prospectively validated. (Hong Kong j.emerg.med. 2014;21:283-290)
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Chan KM, Lui CT, Tsui KL, Tang YH. Comparison of Clinical Prediction Rules for Termination of Resuscitation of Out-of-Hospital Cardiac Arrests on Arrival to Emergency Department. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791302000603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To compare the discriminative capacities of various termination of resuscitation (TOR) rules in the prediction of futile resuscitation in the emergency department (ED). Design Prospective cohort study. Setting 2 public hospitals in a cluster in Hong Kong. Methods The data were obtained from a Cardiac Arrest Registry of the EDs of two hospitals, including consecutive adult patients suffering from non-traumatic out-of-hospital cardiac arrest from 1st August 2010 to 30th June 2012. Those with return of spontaneous circulation before ED arrival and cases without resuscitation in the EDs were excluded. The modified basic life support (BLS), modified advanced life support (ALS) and neurologic TOR rules were applied to the cohort. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value were calculated. The outcome measures were survival to hospital admission (STA) and survival to discharge (STD). Results Totally 1125 cases were included. The mean age was 72.4. Return of spontaneous circulation and STA occurred in 302 patients and 9 had STD. Regarding the outcome of STD, the modified ALS and neurologic TOR rules had outperformed the modified BLS rule. The specificity and PPV were 100% for both rules in predicting death when the rules suggested TOR. Regarding the outcome of STA, the neurologic TOR rule had the highest specificity [84.4%; 95% confident interval (CI): 79.7-88.2%] and PPV (84.5%; 95% CI: 79.8-88.3%). Conclusions The modified ALS and neurologic TOR rules have similar discriminative capacities to predict STD. The neurologic TOR rule has the highest ability to predict STA in the ED. (Hong Kong j.emerg.med. 2013;20:343-351)
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Vincent C, Lederman Z. Family presence during resuscitation: extending ethical norms from paediatrics to adults. JOURNAL OF MEDICAL ETHICS 2017; 43:676-678. [PMID: 28232392 DOI: 10.1136/medethics-2016-103881] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 01/17/2017] [Accepted: 02/03/2017] [Indexed: 06/06/2023]
Abstract
Many families of patients hold the view that it is their right to be present during a loved one's resuscitation, while the majority of patients also express the comfort and support they would feel by having them there. Currently, family presence is more commonly accepted in paediatric cardiopulmonary resuscitation (CPR) than adult CPR. Even though many guidelines are in favour of this practice and recognise potential benefits, healthcare professionals are hesitant to support adult family presence to the extent that paediatric family presence is supported. However, in this paper, we suggest that the ethical case to justify family presence during paediatric resuscitation (P-FPDR) is weaker than the justification of family presence during adult resuscitation (A-FPDR). We go on to support this claim using three main arguments that people use in clinical ethics to justify FPDR. These include scarcity of evidence documenting disruption, psychological benefits to family members following the incident and respect for patient autonomy. We demonstrate that these arguments actually apply more strongly to A-FPDR compared with P-FPDR, thereby questioning the common attitude of healthcare professionals of allowing the latter while mostly opposing A-FPDR. Importantly, we do not wish to suggest that P-FPDR should not be allowed. Rather, we suggest that since P-FPDR is commonly (and should be) allowed, so should A-FPDR. This is because the aforementioned arguments that are used to justify FPDR in general actually make a stronger case for A-FPDR.
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Affiliation(s)
- Christine Vincent
- Human Biology, University of Virginia, Charlottesville, Virginia, USA
| | - Zohar Lederman
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Clinical Research Centre, Singapore, Singapore;
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Twibell R, Siela D, Riwitis C, Neal A, Waters N. A qualitative study of factors in nurses' and physicians' decision-making related to family presence during resuscitation. J Clin Nurs 2017; 27:e320-e334. [PMID: 28677220 DOI: 10.1111/jocn.13948] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2017] [Indexed: 10/19/2022]
Abstract
AIMS AND OBJECTIVES To explore the similarities and differences in factors that influence nurses' and physicians' decision-making related to family presence during resuscitation. BACKGROUND Despite the growing acceptance of family presence during resuscitation worldwide, healthcare professionals continue to debate the risks and benefits of family presence. As many hospitals lack a policy to guide family presence during resuscitation, decisions are negotiated by resuscitation teams, families and patients in crisis situations. Research has not clarified the factors that influence the decision-making processes of nurses and physicians related to inviting family presence. This is the first study to elicit written data from healthcare professionals to explicate factors in decision-making about family presence. DESIGN Qualitative exploratory-descriptive. METHODS Convenience samples of registered nurses (n = 325) and acute care physicians (n = 193) from a Midwestern hospital in the United States of America handwrote responses to open-ended questions about family presence. Through thematic analysis, decision-making factors for physicians and nurses were identified and compared. RESULTS Physicians and nurses evaluated three similar factors and four differing factors when deciding to invite family presence during resuscitation. Furthermore, nurses and physicians weighted the factors differently. Physicians weighted most heavily the family's potential to disrupt life-saving efforts and compromise patient care and then the family's knowledge about resuscitations. Nurses heavily weighted the potential for the family to be traumatised, the potential for the family to disrupt the resuscitation, and possible family benefit. CONCLUSIONS Nurses and physicians considered both similar and different factors when deciding to invite family presence. Physicians focused on the patient primarily, while nurses focused on the patient, family and resuscitation team. RELEVANCE TO CLINICAL PRACTICE Knowledge of factors that influence the decision-making of interprofessional colleagues can improve collaboration and communication in crisis events of family presence during resuscitation.
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Affiliation(s)
- Renee Twibell
- School of Nursing, Ball State University, Muncie, IN, USA.,Indiana University Health Ball Memorial Hospital, Muncie, IN, USA
| | - Debra Siela
- School of Nursing, Ball State University, Muncie, IN, USA
| | - Cheryl Riwitis
- Indiana University Health LifeLine, Indianapolis, IN, USA
| | - Alexis Neal
- Indiana University Health Ball Memorial Hospital, Muncie, IN, USA
| | - Nicole Waters
- Indiana University Health Ball Memorial Hospital, Muncie, IN, USA
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Grunau B, Puyat J, Wong H, Scheuermeyer FX, Reynolds JC, Kawano T, Singer J, Dick W, Christenson J. Gains of Continuing Resuscitation in Refractory Out-of-hospital Cardiac Arrest: A Model-based Analysis to Identify Deaths Due to Intra-arrest Prognostication. PREHOSP EMERG CARE 2017; 22:198-207. [PMID: 28841080 DOI: 10.1080/10903127.2017.1356412] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Prognostication bias, in which a clinician predicts a negative outcome and terminates resuscitation (TR) thereby ensuring a poor outcome, is a rarely identified limitation of out-of-hospital cardiac arrest (OHCA) research. We sought to estimate the number of deaths due to intra-arrest prognostication in a cohort of OHCA's, and use this data to estimate the incremental benefit of continuing resuscitation. METHODS This study examined a cohort of consecutive non-traumatic EMS-treated OHCAs from a provincial ambulance service, between 2007 and 2011 inclusive. We used Cox and logistic regression modeling, adjusting for Utstein covariates, to estimate the probability of ROSC, survival, and favorable neurological outcomes as a function of resuscitation time, and applied these models to estimate the number of missed survivors in those who had TR (prior to 20, 30, or 40 minutes). We determined the time juncture at which (1) the likelihood of survival fell below 1%, and (2) the proportion of survivors who had achieved ROSC exceeded 99%. RESULTS Of 5674 adult EMS-treated cases, 46% achieved ROSC, and 12% survived. The median time of TR was 27.0 minutes (IQR 19.0-35.0). Continuing resuscitation until 40 minutes yielded an estimated 17 additional survivors (95% CI 13-21), 10 (95% CI 7-13) with favorable neurological outcomes. The probability of survival of those in refractory arrest decreased below 1% at 28 minutes (95% CI 24-30 minutes). At 36 minutes (95% CI 34-38 minutes) >99% of survivors had achieved ROSC. CONCLUSION We identified possible deaths due to intra-arrest prognostication. Resuscitation should be continued for a minimum of 30 minutes in all patients, however for those with initial shockable rhythms 40 minutes appears to be warranted. Interventional trials and observational studies should standardize or adjust for duration of resuscitation prior to TR.
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