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Benbenishty J, Ganz FD, Lautrette A, Jaschinski U, Aggarwal A, Søreide E, Weiss M, Dybwik K, Çizmeci EA, Ackerman RCM, Estebanez-Montiel B, Ricou B, Robertsen A, Sprung CL, Avidan A. Variations in reporting of nurse involvement in end-of-life practices in intensive care units worldwide (ETHICUS-2): A prospective observational study. Int J Nurs Stud 2024; 155:104764. [PMID: 38657432 DOI: 10.1016/j.ijnurstu.2024.104764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND ICU nurses are most frequently at the patient's bedside, providing care for both patients and family members. They perform an essential role and are involved in decision-making. Despite this, research suggests that nurses have a limited role in the end-of-life decision-making process and are occasionally not involved. OBJECTIVE Explore global ICU nurse involvement in end of life decisions based on the physician's perceptions and sub-analyses from the ETHICUS-2 study. DESIGN This is a secondary analysis of a prospective multinational, observational study of the ETHICUS-2 study. SETTING End of life decision-making processes in ICU patients were studied during a 6-month period between Sept 1, 2015, and Sept 30, 2016, in 199 ICUs in 36 countries. INTERVENTION None. METHODS The ETHICUS II study instrument contained 20 questions. This sub-analysis addressed the four questions related to nurse involvement in end-of-life decision-making: Who initiated the end-of-life discussion? Was withholding or withdrawing treatment discussed with nurses? Was a nurse involved in making the end-of-life decision? Was there agreement between physicians and nurses? These 4 questions are the basis for our analysis. Global regions were compared. RESULTS Physicians completed 91.8 % of the data entry. A statistically significant difference was found between regions (p < 0.001) with Northern Europe and Australia/New Zealand having the most discussion with nurses and Latin America, Africa, Asia and North America the least. The percentages of end-of-life decisions in which nurses were involved ranged between 3 and 44 %. These differences were statistically significant. Agreement between physicians and nurses related to decisions resulted in a wide range of responses (27-86 %) (p < 0.001). There was a wide range of those who replied "not applicable" to the question of agreement between physicians and nurses on EOL decisions (0-41 %). CONCLUSION There is large variability in nurse involvement in end-of-life decision-making in the ICU. The most concerning findings were that in some regions, according to physicians, nurses were not involved in EOL decisions and did not initiate the decision-making process. There is a need to develop the collaboration between nurses and physicians. Nurses have valuable contributions for best possible patient-centered decisions and should be respected as important parts of the interdisciplinary team. TWEETABLE ABSTRACT Wide global differences were found in nurse end of life decision involvement, with low involvement in North and South America and Africa and higher involvement in Europe and Australia/New Zealand.
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Affiliation(s)
- Julie Benbenishty
- Hadassah Hebrew University Medical Center and School of Nursing Jerusalem Israel, PO Box 12000, Ein Kerem, Jerusalem 91120, Israel.
| | - Freda DeKeyser Ganz
- Hadassah Hebrew University Medical Center and School of Nursing Jerusalem Israel, PO Box 12000, Ein Kerem, Jerusalem 91120, Israel; Faculty of Life and Health Sciences, Jerusalem College of Technology, Jerusalem, Israel
| | - Alexandre Lautrette
- Department of Intensive Care Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Ulrich Jaschinski
- Department of Anaesthesiology and Critical Care, University Hospital Augsburg, Germany
| | - Avneep Aggarwal
- Department of General Anesthesiology, Department of Intensive Care and Resuscitation Cleveland Clinic, OH, USA
| | - Eldar Søreide
- Section for Quality and Patient Safety, Stavanger University Hospital and Faculty of Health Sciences University of Stavanger, Stavanger, Norway
| | - Manfred Weiss
- Clinic for Anaesthesiology and Intensive Care Medicine, University of Ulm, Germany
| | - Knut Dybwik
- Intensive Care Unit, Nordland Hospital, Bodø, Norway
| | - Elif Ayşe Çizmeci
- University of Toronto, Faculty of Medicine, Interdepartmental Division of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | | | - Bara Ricou
- Intensive Care of Geneva, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva Hospital and University of Geneva, Switzerland
| | - Annette Robertsen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway; Department of Anaesthesiology and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Ein Kerem Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Lascarrou JB, Ermel C, Cariou A, Laitio T, Kirkegaard H, Søreide E, Grejs AM, Reinikainen M, Colin G, Taccone FS, Le Gouge A, Skrifvars MB. Dysnatremia at ICU admission and functional outcome of cardiac arrest: insights from four randomised controlled trials. Crit Care 2023; 27:472. [PMID: 38041177 PMCID: PMC10693108 DOI: 10.1186/s13054-023-04715-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/30/2023] [Indexed: 12/03/2023] Open
Abstract
PURPOSE To evaluate the potential association between early dysnatremia and 6-month functional outcome after cardiac arrest. METHODS We pooled data from four randomised clinical trials in post-cardiac-arrest patients admitted to the ICU with coma after stable return of spontaneous circulation (ROSC). Admission natremia was categorised as normal (135-145 mmol/L), low, or high. We analysed associations between natremia category and Cerebral Performance Category (CPC) 1 or 2 at 6 months, with and without adjustment on the modified Cardiac Arrest Hospital Prognosis Score (mCAHP). RESULTS We included 1163 patients (581 from HYPERION, 352 from TTH48, 120 from COMACARE, and 110 from Xe-HYPOTHECA) with a mean age of 63 ± 13 years and a predominance of males (72.5%). A cardiac cause was identified in 63.6% of cases. Median time from collapse to ROSC was 20 [15-29] minutes. Overall, mean natremia on ICU admission was 137.5 ± 4.7 mmol/L; 211 (18.6%) and 31 (2.7%) patients had hyponatremia and hypernatremia, respectively. By univariate analysis, CPC 1 or 2 at 6 months was significantly less common in the group with hyponatremia (50/211 [24%] vs. 363/893 [41%]; P = 0.001); the mCAHP-adjusted odds ratio was 0.45 (95%CI 0.26-0.79, p = 0.005). The number of patients with hypernatremia was too small for a meaningful multivariable analysis. CONCLUSIONS Early hyponatremia was common in patients with ROSC after cardiac arrest and was associated with a poorer 6-month functional outcome. The mechanisms underlying this association remain to be elucidated in order to determine whether interventions targeting hyponatremia are worth investigating. Registration ClinicalTrial.gov, NCT01994772, November 2013, 21.
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Affiliation(s)
- Jean Baptiste Lascarrou
- Nantes Université, CHU Nantes, Movement - Interactions - Performance, MIP, UR 4334, 44000, Nantes, France.
- Médecine Intensive Reanimation, University Hospital Centre, Nantes, France.
- AfterROSC Network, Nantes, France.
- Service de Médecine Intensive Reanimation, CHU Nantes, 30 Boulevard Jean Monet, 44093, Nantes Cedex 9, France.
| | - Cyrielle Ermel
- Médecine Intensive Reanimation, University Hospital Centre, Nantes, France
| | - Alain Cariou
- AfterROSC Network, Nantes, France
- Université de Paris Cité, INSERM, Paris Cardiovascular Research Centre, Paris, France
- Médecine Intensive Reanimation, AP-HP, CHU Cochin, Paris, France
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, University of Turku, Turku, Finland
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine and Anaesthesiology and Intensive Care, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Intensive Care Unit, Department of Anaesthesiology, Stavanger University Hospital and Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Anders M Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Gwenhael Colin
- AfterROSC Network, Nantes, France
- Médecine Intensive Reanimation, CHD Vendee, La Roche Sur Yon, France
| | - Fabio Silvio Taccone
- AfterROSC Network, Nantes, France
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Tjomsland O, Thoresen C, Ingebrigtsen T, Søreide E, Frich JC. Reducing unwarranted variation: can a 'clinical dashboard' be helpful for hospital executive boards and top-level leaders? BMJ Lead 2023:leader-2023-000749. [PMID: 38053259 DOI: 10.1136/leader-2023-000749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 11/03/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND/AIM In the past decades, there has been an increasing focus on defining, identifying and reducing unwarranted variation in clinical practice. There have been several attempts to monitor and reduce unwarranted variation, but the experience so far is that these initiatives have failed to reach their goals. In this article, we present the initial process of developing a safety, quality and utilisation rate dashboard ('clinical dashboard') based on a selection of data routinely reported to executive boards and top-level leaders in Norwegian specialist healthcare. METHODS We used a modified version of Wennberg's categorisation of healthcare delivery to develop the dashboard, focusing on variation in (1) effective care and patient safety and (2) preference-sensitive and supply-sensitive care. RESULTS Effective care and patient safety are monitored with outcome measures such as 30-day mortality after hospital admission and 5-year cancer survival, whereas utilisation rates for procedures selected on cost and volume are used to follow variations in preference-sensitive and supply-sensitive care. CONCLUSION We argue that selecting quality indicators of patient safety, quality and utilisation rates and presenting them in a dashboard may help executive hospital boards and top-level leaders to focus on unwarranted variation.
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Affiliation(s)
- Ole Tjomsland
- Helse Sor-Ost RHF, Hamar, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | | | - Tor Ingebrigtsen
- Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
- Australian Institute of Health Innovation, Centre for Clinical Governance Research, University of New South Wales, Sydney, New South Wales, Australia
| | - Eldar Søreide
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Critical Care and Anaesthesiology Research Group, Helse Stavanger HF, Stavanger, Norway
| | - Jan C Frich
- Universitetet i Oslo Avdeling for samfunnsmedisin, Oslo, Norway
- Diakonhjemmet Hospital, Oslo, Norway
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Øyri SF, Søreide K, Søreide E, Tjomsland O. Learning from experience: a qualitative study of surgeons' perspectives on reporting and dealing with serious adverse events. BMJ Open Qual 2023; 12:bmjoq-2023-002368. [PMID: 37286299 DOI: 10.1136/bmjoq-2023-002368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/27/2023] [Indexed: 06/09/2023] Open
Abstract
INTRODUCTION In surgery, serious adverse events have effects on the patient journey, the patient outcome and may constitute a burden to the surgeon involved. This study aims to investigate facilitators and barriers to transparency around, reporting of and learning from serious adverse events among surgeons. METHODS Based on a qualitative study design, we recruited 15 surgeons (4 females and 11 males) with 4 different surgical subspecialties from four Norwegian university hospitals. The participants underwent individual semistructured interviews and data were analysed according to principles of inductive qualitative content analysis. RESULTS AND DISCUSSION We identified four overarching themes. All surgeons reported having experienced serious adverse events, describing these as part of 'the nature of surgery'. Most surgeons reported that established strategies failed to combine facilitation of learning with taking care of the involved surgeons. Transparency about serious adverse events was by some felt as an extra burden, fearing that openness on technical-related errors could affect their future career negatively. Positive implications of transparency were linked with factors such as minimising the surgeon's feeling of personal burden with positive impact on individual and collective learning. A lack of facilitation of individual and structural transparency factors could entail 'collateral damage'. Our participants suggested that both the younger generation of surgeons in general, and the increasing number of women in surgical professions, might contribute to 'maturing' the culture of transparency. CONCLUSION AND IMPLICATIONS This study suggests that transparency associated with serious adverse events is hampered by concerns at both personal and professional levels among surgeons. These results emphasise the importance of improved systemic learning and the need for structural changes; it is crucial to increase the focus on education and training curriculums and offer advice on coping strategies and establish arenas for safe discussions after serious adverse events.
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Affiliation(s)
- Sina Furnes Øyri
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Stavanger University Hospital, Stavanger, Norway
- SHARE Centre for Resilience in Healthcare, University of Stavanger, Stavanger, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- SAFER Surgery, Surgical Research Group, Stavanger University Hospital, Stavanger, Norway
| | - Eldar Søreide
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Stavanger University Hospital, Stavanger, Norway
| | - Ole Tjomsland
- South-Eastern Norway Regional Health Authority, Oslo, Norway
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Olsen SL, Nedrebø BS, Strand K, Søreide E, Kvaløy JT, Hansen BS. Reduction in omission events after implementing a Rapid Response System: a mortality review in a department of gastrointestinal surgery. BMC Health Serv Res 2023; 23:179. [PMID: 36810005 PMCID: PMC9945730 DOI: 10.1186/s12913-023-09159-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/07/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Hospitals worldwide have implemented Rapid Response Systems (RRS) to facilitate early recognition and prompt response by trained personnel to deteriorating patients. A key concept of this system is that it should prevent 'events of omission', including failure to monitor patients' vital signs, delayed detection, and treatment of deterioration and delayed transfer to an intensive care unit. Time matters when a patient deteriorates, and several in-hospital challenges may prevent the RRS from functioning adequately. Therefore, we must understand and address barriers for timely and adequate responses in cases of patient deterioration. Thus, this study aimed to investigate whether implementing (2012) and developing (2016) an RRS was associated with an overall temporal improvement and to identify needs for further improvement by studying; patient monitoring, omission event occurrences, documentation of limitation of medical treatment, unexpected death, and in-hospital- and 30-day mortality rates. METHODS We performed an interprofessional mortality review to study the trajectory of the last hospital stay of patients dying in the study wards in three time periods (P1, P2, P3) from 2010 to 2019. We used non-parametric tests to test for differences between the periods. We also studied overall temporal trends in in-hospital- and 30-day mortality rates. RESULTS Fewer patients experienced omission events (P1: 40%, P2: 20%, P3: 11%, P = 0.01). The number of documented complete vital sign sets, median (Q1,Q3) P1: 0 (0,0), P2: 2 (1,2), P3: 4 (3,5), P = 0.01) and intensive care consultations in the wards ( P1: 12%, P2: 30%, P3: 33%, P = 0.007) increased. Limitations of medical treatment were documented earlier (median days from admission were P1: 8, P2: 8, P3: 3, P = 0.01). In-hospital and 30-day mortality rates decreased during this decade (rate ratios 0.95 (95% CI: 0.92-0.98) and 0.97 (95% CI: 0.95-0.99)). CONCLUSION The RRS implementation and development during the last decade was associated with reduced omission events, earlier documentation of limitation of medical treatments, and a temporal reduction in the in-hospital- and 30-day mortality rates in the study wards. The mortality review is a suitable method to evaluate an RRS and provide a foundation for further improvement. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Siri Lerstøl Olsen
- Department of Quality and Health Technology, Faculty of Health Sciences, SHARE-Centre for Resilience in Healthcare, University of Stavanger, Kjell Arholms gate 43, 4036, Stavanger, Norway. .,Department of Emergency Medicine, Stavanger University Hospital, Stavanger, Norway.
| | - Bjørn S Nedrebø
- grid.412008.f0000 0000 9753 1393Department of Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
| | - Kristian Strand
- grid.412835.90000 0004 0627 2891Department of Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Eldar Søreide
- grid.18883.3a0000 0001 2299 9255Faculty of Health Sciences, University of Stavanger, Stavanger, Norway ,grid.412835.90000 0004 0627 2891Section for Quality and Patient Safety, Stavanger University Hospital, Stavanger, Norway
| | - Jan Terje Kvaløy
- grid.18883.3a0000 0001 2299 9255Department of Mathematics and Physics, Faculty of Science and Technology, University of Stavanger, Stavanger, Norway ,grid.412835.90000 0004 0627 2891Research Department, Stavanger University Hospital, Stavanger, Norway
| | - Britt Sætre Hansen
- grid.18883.3a0000 0001 2299 9255Department of Quality and Health Technology, Faculty of Health Sciences, SHARE—Centre for Resilience in Healthcare, University of Stavanger, Kjell Arholms gate 43, 4036 Stavanger, Norway ,grid.412835.90000 0004 0627 2891The Research Group for Nursing and Health Care Science, Stavanger University Hospital, Stavanger, Norway
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Abstract
OBJECTIVES The capability of a hospital's rapid response system (RRS) depends on various factors to reduce in-hospital cardiac arrests and mortality. Through system probing, this qualitative study targeted a more comprehensive understanding of how healthcare professionals manage the complexities of RRS in daily practice as well as identifying its challenges. METHODS We observed RRS through in situ simulations in 2 wards and conducted the debriefings as focus group interviews. By arranging a separate focus group interview, we included the perspectives of intensive care unit personnel. RESULTS Healthcare professionals appreciated the standardized use of the National Early Warning Score, when combined with clinical knowledge and experience, structured communication, and interprofessional collaboration. However, we identified salient challenges in RRS, for example, unwanted variation in recognition competence, and inconsistent routines in education and documentation. Furthermore, we found that a lack of interprofessional trust, different understandings of RRS protocol, and signs of low psychological safety in the wards disrupted collaboration. To help remedy identified challenges, healthcare professionals requested shared arenas for learning, such as in situ simulation training. CONCLUSIONS Through system probing, we described the inner workings of RRS and revealed the challenges that require more attention. Healthcare professionals depend on structured RRS education, training, and resources to operate such a system. In this study, they request interventions like in situ simulation training as an interprofessional educational arena to improve patient care. This is a relevant field for further research. The Consolidated Criteria for Reporting Qualitative Studies Checklist was followed to ensure rigor in the study.
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Affiliation(s)
- Siri Lerstøl Olsen
- From the Department of Quality and Health Technology, The Faculty of Health Sciences, SHARE—Centre for Resilience in Healthcare, University of Stavanger
- Stavanger University Hospital, Stavanger, Norway
| | | | - Britt Sætre Hansen
- From the Department of Quality and Health Technology, The Faculty of Health Sciences, SHARE—Centre for Resilience in Healthcare, University of Stavanger
- Stavanger University Hospital, Stavanger, Norway
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Larsen AI, Grejs AM, Vistisen ST, Strand K, Skadberg Ø, Jeppesen AN, Duez CHV, Kirkegaard H, Søreide E. Kinetics of 2 different high-sensitive troponins during targeted temperature management in out-of-hospital cardiac arrest patients with acute myocardial infarction: a post hoc sub-study of a randomised clinical trial. BMC Cardiovasc Disord 2022; 22:342. [PMID: 35907787 PMCID: PMC9339199 DOI: 10.1186/s12872-022-02778-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 07/13/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Short term hypothermia has been suggested to have cardio protective properties in acute myocardial infarction (AMI) by reducing infarct size as assessed by troponins. There are limited data on the kinetics of these biomarkers in comatose out-of-hospital cardiac arrest (OHCA) patients, with and without AMI, undergoing targeted temperature management (TTM) in the ICU.
Purpose The aim of this post hoc analyses was to evaluate and compare the kinetics of two high-sensitivity cardiac troponins in OHCA survivors, with and without acute myocardial infarction (AMI), during TTM of different durations [24 h (standard) vs. 48 h (prolonged)]. Methods In a sub-cohort (n = 114) of the international, multicentre, randomized controlled study “TTH48” we measured high-sensitive troponin T (hs-cTnT), high-sensitive troponin I (hs-cTnI) and CK-MB at the following time points: Arrival, 24 h, 48 h and 72 h from reaching the target temperature range of 33 ± 1 °C. All patients diagnosed with an AMI at the immediate coronary angiogram (CAG)—18 in the 24-h group and 25 in the 48-h group—underwent PCI with stent implantation. There were no stent thromboses.
Results Both the hs-cTnT and hs-cTnI changes over time were highly influenced by the cause of OHCA (AMI vs. non-AMI). In contrast to non-AMI patients, both troponins remained elevated at 72 h in AMI patients. There was no difference between the two time-differentiated TTM groups in the kinetics for the two troponins.
Conclusion In comatose OHCA survivors with an aetiology of AMI levels of both hs-cTnI and hs-cTnT remained elevated for 72 h, which is in contrast to the well-described kinetic profile of troponins in normotherm AMI patients. There was no difference in kinetic profile between the two high sensitive assays. Different duration of TTM did not influence the kinetics of the troponins. Trial registration: Clinicaltrials.gov Identifier: NCT01689077, 20/09/2012.
Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02778-4.
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Affiliation(s)
- Alf Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway. .,Department of Clinical Sciences, University of Bergen, Bergen, Norway.
| | - Anders Morten Grejs
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Simon Tilma Vistisen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kristian Strand
- Department of Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Øyvind Skadberg
- Laboratory of Clinical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | - Anni Nørgaard Jeppesen
- Division for Heart- Lung- and Vascular Surgery, Anaesthesiology section, Aarhus University Hospital, Aarhus, Denmark
| | - Christophe H V Duez
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Research Centre for Emergency Medicine, Emergency Department, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Kirkegaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Research Centre for Emergency Medicine, Emergency Department, Aarhus University Hospital, Aarhus, Denmark
| | - Eldar Søreide
- Department of Clinical Sciences, University of Bergen, Bergen, Norway.,Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway
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Kirkegaard H, Grejs AM, Gudbjerg S, Duez C, Jeppesen A, Hassager C, Laitio T, Storm C, Taccone FS, Skrifvars MB, Søreide E. Electrolyte profiles with induced hypothermia: A sub study of a clinical trial evaluating the duration of hypothermia after cardiac arrest. Acta Anaesthesiol Scand 2022; 66:615-624. [PMID: 35218019 PMCID: PMC9311071 DOI: 10.1111/aas.14053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/20/2022] [Accepted: 02/16/2022] [Indexed: 11/29/2022]
Abstract
Background Electrolyte disturbances can result from targeted temperature treatment (TTM) in out‐of‐hospital cardiac arrest (OHCA) patients. This study explores electrolyte changes in blood and urine in OHCA patients treated with TTM. Methods This is a sub‐study of the TTH48 trial, with the inclusion of 310 unconscious OHCA patients treated with TTM at 33°C for 24 or 48 h. Over a three‐day period, serum concentrations were obtained on sodium potassium, chloride, ionized calcium, magnesium and phosphate, as were results from a 24‐h diuresis and urine electrolyte concentration and excretion. Changes over time were analysed with a mixed‐model multivariate analysis of variance with repeated measurements. Results On admission, mean ± SD sodium concentration was 138 ± 3.5 mmol/l, which increased slightly but significantly (p < .05) during the first 24 h. Magnesium concentration stayed within the reference interval. Median ionized calcium concentration increased from 1.11 (IQR 1.1–1.2) mmol/l during the first 24 h (p < .05), whereas median phosphate concentration dropped to 1.02 (IQR 0.8–1.2) mmol/l (p < .05) and stayed low. During rewarming, potassium concentrations increased, and magnesium and ionizes calcium concentration decreased (p < .05). Median 24‐h diuresis results on days one and two were 2198 and 2048 ml respectively, and the electrolyte excretion mostly stayed low in the reference interval. Conclusions Electrolytes mostly remained within the reference interval. A temporal change occurred in potassium, magnesium and calcium concentrations with TTM’s different phases. No hypothermia effect on diuresis was detected, and urine excretion of electrolytes mostly stayed low.
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Affiliation(s)
- Hans Kirkegaard
- Research Center for Emergency Medicine, Emergency Department Aarhus University Hospital Aarhus Denmark
- Research Center for Emergency Medicine, Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Anders M. Grejs
- Department of Intensive Care Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Simon Gudbjerg
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
| | - Christophe Duez
- Department of Intensive Care Aarhus University Hospital Aarhus Denmark
| | - Anni Jeppesen
- Department of Intensive Care Aarhus University Hospital Aarhus Denmark
| | - Christian Hassager
- Department of Cardiology Rigshospitalet Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management Turku University Hospital, University of Turku Finland
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care Charité‐Universitätsmedizin Berlin Berlin Germany
| | - Fabio Silvio Taccone
- Department of Intensive Care Erasme Hospital, Université Libre de Bruxelles Brussels Belgium
| | - Markus B. Skrifvars
- Department of Anaesthesiology, Intensive Care and Paine Medicine University of Helsinki, Helsinki University Hospital Helsinki Finland
- Department of Emergency Care and Services University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group Stavanger University Hospital Stavanger Norway
- Department of Clinical Medicine University of Bergen Bergen Norway
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Paramanathan S, Grejs AM, Søreide E, Duez CHV, Jeppesen AN, Reinertsen ÅJ, Strand K, Kirkegaard H. Quantitative pupillometry in comatose out-of-hospital cardiac arrest patients: A post-hoc analysis of the TTH48 trial. Acta Anaesthesiol Scand 2022; 66:880-886. [PMID: 35488868 PMCID: PMC9545910 DOI: 10.1111/aas.14078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/01/2022] [Accepted: 04/16/2022] [Indexed: 12/01/2022]
Abstract
Background Quantitative pupillometry is an objective method to examine pupil reaction and subsequently grade the response on a neurological pupil index (NPi) scale from 0 to 5. The aim of the present sub‐study was to explore the long‐term prognostic value of NPi in comatose out‐of‐hospital cardiac arrest patients undergoing targeted temperature management (TTM). Methods This planned sub‐study of the “Targeted temperature management for 48 versus 24 h and neurological outcome after out‐of‐hospital cardiac arrest: A randomized clinical trial.” NPi was assessed from admission and throughout day 3 and linked to the Cerebral Performance Categories score at 6 months. We compared the prognostic performance of NPi in 65 patients randomized to a target temperature of 33 ± 1°C for 24 or 48 h. Results The NPi values were not different between TTM groups (p > .05). When data were pooled, NPi was strongly associated with neurological outcome at day 1 with a mean NPi of 3.6 (95% CI 3.4–3.8) versus NPi 3.9 (3.6–4.1) in the poor versus good outcome group, respectively (p < .01). At day 2, NPi values were 3.6 (3.1–4.0) and 4.1 (3.9–4.2) (p = .01) and at day 3, the values were 3.3 (2.6–4.0) and 4.3 (4.1–4.6), respectively (p < .01). The prognostic ability of NPi, defined by area under the receiver operating characteristic curve was best at day three. Conclusion Quantitative pupillometry measured by NPi was not different in the two TTM groups, but overall, significantly associated with good and poor neurological outcomes at 6 months. NPI has a promising diagnostic accuracy, but larger studies are warranted.
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Affiliation(s)
| | - Anders Morten Grejs
- Department of Intensive Care Medicine Aarhus University Hospital Aarhus Denmark
- Research Center for Emergency Medicine, Emergency Department, Aarhus University Hospital and Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Eldar Søreide
- Critical Care and Anesthesiology Research Group Stavanger University Hospital Stavanger Norway
- Department of Clinical Medicine University of Bergen Bergen Norway
| | - Christophe Henri Valdemar Duez
- Research Center for Emergency Medicine, Emergency Department, Aarhus University Hospital and Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Anni Nørgaard Jeppesen
- Research Center for Emergency Medicine, Emergency Department, Aarhus University Hospital and Department of Clinical Medicine Aarhus University Aarhus Denmark
- Department of Cardiothoracic and Vascular Surgery Aarhus University Hospital Aarhus Denmark
| | - Åse Johanne Reinertsen
- Critical Care and Anesthesiology Research Group Stavanger University Hospital Stavanger Norway
| | - Kristian Strand
- Department of Intensive Care Stavanger University Hospital Stavanger Norway
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Emergency Department, Aarhus University Hospital and Department of Clinical Medicine Aarhus University Aarhus Denmark
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P, Roy S, Das S, Sarkar SA, Dutta ML, Roy P, Iyer S, Qiu H, Krishna B, Sampath S, Pattnaik R, Kasi CK, Shah J, Dongre A, Reza Hashemian SM, Nooraei N, Raessi Estabragh R, Malekmohammad M, Gonzalez M, Khoundabi B, Mobasher M, Mohd Yunos N, Kassim M, Voon CM, Das SS, Azauddin SNS, Dorasamy D, Tai LL, Mat Nor MB, Silesky J, Zarudin N, Hasan MS, Jamaluddin MFH, Othman Jailani MI, Kayashta G, Adhikari A, Pangeni R, Hashmi M, Joseph S, Akhtar A, Cerny V, Qadeer A, Memon I, Ali SM, Idrees F, Kamal S, Hanif S, Rehman AU, Taqi A, Hussain T, Farooq A, Nielsen J, Khaskheli S, Hayat M, Indraratna K, Beane A, Haniffa R, Samaranayake U, Mathanalagan S, Gunaratne A, Mithraratne N, Thilakasiri K, Jibaja M, Pilimatalawwe C, Dilhani YAH, Fernando M, Ranatunge K, Samarasinghe L, Vaas M, Edirisooriya M, Sigera C, Arumoli J, De Silva K, Pham T, Kudavidanage B, Pinto V, Dissanayake L, Chittawatanarat K, Kongpolprom N, Silachamroon U, Pornsuriyasak P, Petnak T, Singhatas P, Tangsujaritvijit V, Wrigge H, 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Jovanovic B, Surbatovic M, Veljovic M, Van Haren F. Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies. The Lancet Global Health 2022; 10:e227-e235. [PMID: 34914899 PMCID: PMC8766316 DOI: 10.1016/s2214-109x(21)00485-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/05/2021] [Accepted: 10/01/2021] [Indexed: 12/19/2022] Open
Abstract
Background Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001). Interpretation Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding No funding.
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Bach HM, Duez CHV, Jeppesen AN, Strand K, Søreide E, Kirkegaard H, Grejs AM. MR-proANP and NT-proBNP During Targeted Temperature Management Following Out-of-Hospital Cardiac Arrest: A Post hoc Analysis of the TTH48 Trial. Ther Hypothermia Temp Manag 2021; 12:82-89. [PMID: 34375135 DOI: 10.1089/ther.2021.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We aimed to evaluate the effect of prolonged targeted temperature management (TTM) in patients with out-of-hospital cardiac arrest (OHCA) on the levels of midregional pro-atrial natriuretic peptide (MR-proANP) and N-terminal pro b-type natriuretic peptide (NT-proBNP) and assess their potential as prognostic biomarkers. A preplanned post hoc analysis of "Targeted temperature management for 48 h vs 24 h and neurologic outcome after out-of-hospital cardiac arrest: A randomized clinical trial (TTH48 trial)," where patients were randomized to TTM at 33°C ± 1°C of standard duration (24 hours) versus prolonged (48 hours). Blood samples were drawn from patients with OHCA at two Scandinavian university hospitals at admission to the ICU and at 24, 48, and 72 hours after reaching the target temperature. Primary outcome was levels of MR-proANP and NT-proBNP. Secondary outcome was cerebral performance category (CPC 1-5) at 6 months. Samples from 114 patients were analyzed. Prolonged TTM significantly decreased the levels of MR-proANP and NT-proBNP at 48 hours compared with standard 24 hours-TTM (p < 0.01). However, there were no significant differences at other time points. Patients with poor outcome (CPC 3-5) had a statistically significantly increased MR-proANP level at 24 hours (p < 0.01) and 72 hours (p < 0.01) compared with the good outcome group (CPC 1-2). Prognostic performance was best at 24 hours for both MR-proANP and NT-proBNP; with an AUC of 0.73 (confidence interval [95% CI]: 0.63-0.83) and 0.72 (95 % CI: 0.59-0.85), respectively. Prolonged TTM lowered the levels of both MR-proANP and NT-proBNP at 48 hours. MR-proANP may add prognostic information in postcardiac arrest patients. ClinicalTrials.gov ID: NCT01689077.
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Affiliation(s)
| | | | | | - Kristian Strand
- Department of Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Eldar Søreide
- Critical Care and Anesthesiology Research Group and Department of Clinical Medicine, Stavanager University Hospital, Stavanger, Norway
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Emergency Department and Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Morten Grejs
- Department of Intensive Care, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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12
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De Fazio C, Skrifvars MB, Søreide E, Grejs AM, Di Bernardini E, Jeppesen AN, Storm C, Kjaergaard J, Laitio T, Rasmussen BS, Tianen M, Kirkegaard H, Taccone FS. Quality of targeted temperature management and outcome of out-of-hospital cardiac arrest patients: A post hoc analysis of the TTH48 study. Resuscitation 2021; 165:85-92. [PMID: 34166741 DOI: 10.1016/j.resuscitation.2021.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/21/2021] [Accepted: 06/10/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND No data are available on the quality of targeted temperature management (TTM) provided to out-of-hospital cardiac arrest (OHCA) patients and its association with outcome. METHODS Post hoc analysis of the TTH48 study (NCT01689077), which compared the effects of prolonged TTM at 33 °C for 48 h to standard 24-h TTM on neurologic outcome. Admission temperature, speed of cooling, rewarming rates, precision (i.e. temperature variability), overcooling and overshooting as post-cooling fever (i.e. >38.0 °C) were collected. A specific score, ranging from 1 to 9, was computed to define the "quality of TTM". RESULTS On a total of 352 patients, most had a moderate quality of TTM (n = 217; 62% - score 4-6), while 80 (23%) patients had a low quality of TTM (score 1-3) and only 52 (16%) a high quality of TTM (score 7-9). The proportion of patients with unfavorable neurological outcome (UO; Cerebral Performance Category of 3-5 at 6 months) was similar between the different quality of TTM groups (p = 0.90). Although a shorter time from arrest to target temperature and a lower proportion of time outside the target ranges in the TTM 48-h than in the TTM 24-h group, quality of TTM was similar between groups. Also, the proportion of patients with UO was similar between the different quality of TTM groups when TTM 48-h and TTM 24-h were compared. CONCLUSIONS In this study, high quality of TTM was provided to a small proportion of patients. However, quality of TTM was not associated with patients' outcome.
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Affiliation(s)
- Chiara De Fazio
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Anders M Grejs
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Eugenio Di Bernardini
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Anni Nørgaard Jeppesen
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Denmark
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jesper Kjaergaard
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, University of Turku, Turku, Finland
| | - Bodil Sten Rasmussen
- Department of Anesthesiology and Intensive Care Medicine, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Marjaana Tianen
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Department of Emergency Medicine and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Denmark
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium.
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Evald L, Brønnick K, Duez CHV, Grejs AM, Jeppesen AN, Søreide E, Kirkegaard H, Nielsen JF. Younger age is associated with higher levels of self-reported affective and cognitive sequelae six months post-cardiac arrest. Resuscitation 2021; 165:148-153. [PMID: 33887400 DOI: 10.1016/j.resuscitation.2021.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 02/01/2021] [Accepted: 04/10/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Affective and cognitive sequelae are frequently reported in cardiac arrest survivors; however, little is known about the risk factors. We assessed the hypothesis that self-reported affective and cognitive sequelae six months after OHCA may be associated with demography, acute care and cerebral outcome. METHODS This is a sub-study of the multicentre "Target Temperature Management for 48 vs. 24 h and Neurologic Outcome after Out-of-Hospital Cardiac Arrest: A Randomised Clinical Trial" (the TTH48 trial) investigating the effect of prolonged TTM at 33 ± 1 °C. We invited patients with good outcome on the Cerebral Performances Categories (CPC score ≤ 2) to answer questionnaires on anxiety, depression, emotional distress, perceived stress and cognitive failures six months post OHCA. RESULTS In total 79 of 111 eligible patients were included in the analysis. There were no significant differences in baseline characteristics between the included group and the group lost to follow-up. Younger age was a negative predictor across all self-reported outcomes, even when controlling for gender, ROSC time, treatment allocation, cognitive impairment and global outcome (CPC 1 or 2). Female gender was a predictor of anxiety, though this should be interpreted cautiously as only eight women participated. A CPC score of 2 score was a negative predictor of self-reported affective outcomes, albeit not for self-reported cognitive failures. CONCLUSION Younger age was associated with higher levels of self-reported affective and cognitive sequelae six months post OHCA. Female gender may be associated with self-reported anxiety. A higher CPC score may be a proxy for self-reported affective sequelae.
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Affiliation(s)
- Lars Evald
- Hammel Neurorehabilitation Clinic and University Research Centre, Hammel, Denmark.
| | - Kolbjørn Brønnick
- Department of Psychiatry, Stavanger University Hospital, Stavanger, Norway
| | - Christophe Henri Valdemar Duez
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anders Morten Grejs
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anni Nørgaard Jeppesen
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
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14
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Brønnick K, Evald L, Duez CHV, Grejs AM, Jeppesen AN, Kirkegaard H, Nielsen JF, Søreide E. Biomarker prognostication of cognitive impairment may be feasible even in out-of hospital cardical arrest survivors with good neurological outcome. Resuscitation 2021; 162:396-402. [PMID: 33631291 DOI: 10.1016/j.resuscitation.2021.02.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/04/2021] [Accepted: 02/11/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients surviving out-of hospital cardicac arrest, with good neurological outcome according to Cerebral Performance Category, frequently have neuropsychological impairment. We studied whether biomarker data (S-100b and neuron-specific enolase) obtained during the ICU stay predicted cognitive impairment 6 months after resuscitation. METHODS Patients (N = 79) with a CPC-score ≤2 were recruited from two trial sites taking part in the TTH48 trial comparing targeted temperature management (TTM) for 48 h vs. 24 h at 33 ± 1 °C. We assessed patients 6 months after the OHCA. We measured biomarkers S-100b and NSE at arrival and at 24, 48 and 72 h after reaching the target temperature of 33 ± 1 °C. Four cognitive domain z-scores were calculated, and global cognitive impairment was defined as z < -1.67 on at least 3 out of 13 cognitive tests. Non-parametric correlations were used to assess the relationship between cognitive domain and biomarkers. ROC curves were used to assess prediction of cognitive impairment from the biomarkers. Logistic regression was used to investigate whether TTM duration moderated biomarker prediction of cognitive impairment. RESULTS Cognitive impairment was present in 22% of the patients with memory impairment being the most common. The biomarkers correlated significantly with several cognitive domain scores and NSE at 48 h predicted cognitive impairment with 100% sensitivity and 56% specificity. The predictive properties of NSE at 48 h was unaffected by duration of TTM. CONCLUSIONS Early biomarker prognostication of cognitive impairment is feasible even in OHCA survivors with good neurological outcome as defined by CPC. NSE at 48 h predicted cognitive impairment.
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Affiliation(s)
- Kolbjørn Brønnick
- Department of Public Health, University of Stavanger, Stavanger, Norway; Centre for Age-Related Medicine (SESAM), Helse Stavanger, Stavanger, Norway.
| | - Lars Evald
- Hammel Neurorehabilitation Centre and University Research Clinic, Hammel, Denmark
| | - Christophe Henri Valdemar Duez
- Research Center for Emergency Medicine, Emergency Department and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anders Morten Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anni Nørgaard Jeppesen
- Research Center for Emergency Medicine, Emergency Department and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Emergency Department and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | | | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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15
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Hästbacka J, Kirkegaard H, Søreide E, Taccone FS, Rasmussen BS, Storm C, Kjaergaard J, Laitio T, Duez CHV, Jeppesen AN, Grejs AM, Skrifvars MB. Severe or critical hypotension during post cardiac arrest care is associated with factors available on admission - a post hoc analysis of the TTH48 trial. J Crit Care 2020; 61:186-190. [PMID: 33181415 DOI: 10.1016/j.jcrc.2020.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 09/03/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE We explored whether severe or critical hypotension can be predicted, based on patient and resuscitation characteristics in out-of-hospital cardiac arrest (OHCA) patients. We also explored the association of hypotension with mortality and neurological outcome. MATERIALS AND METHODS We conducted a post hoc analysis of the TTH48 study (NCT01689077), where 355 out-of-hospital cardiac arrest (OHCA) patients were randomized to targeted temperature management (TTM) treatment at 33 °C for either 24 or 48 h. We recorded hypotension, according to four severity categories, within four days from admission. We used multivariable logistic regression analysis to test association of admission data with severe or critical hypotension. RESULTS Diabetes mellitus (OR 3.715, 95% CI 1.180-11.692), longer ROSC delay (OR 1.064, 95% CI 1.022-1.108), admission MAP (OR 0.960, 95% CI 0.929-0.991) and non-shockable rhythm (OR 5.307, 95% CI 1.604-17.557) were associated with severe or critical hypotension. Severe or critical hypotension was associated with increased mortality and poor neurological outcome at 6 months. CONCLUSIONS Diabetes, non-shockable rhythm, longer delay to ROSC and lower admission MAP were predictors of severe or critical hypotension. Severe or critical hypotension was associated with poor outcome.
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Affiliation(s)
- Johanna Hästbacka
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Hans Kirkegaard
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Bodil Steen Rasmussen
- Department of Anesthesiology and Intensive Care Medicine, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Finland
| | - Christophe Henri Valdemar Duez
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anni N Jeppesen
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anders M Grejs
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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16
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Paramanathan S, Grejs AM, Jeppesen AN, Søreide E, Kirkegaard H, Duez CHV. Copeptin as a Prognostic Marker in Prolonged Targeted Temperature Management After Out-of-Hospital Cardiac Arrest. Ther Hypothermia Temp Manag 2020; 11:216-222. [PMID: 32985950 DOI: 10.1089/ther.2020.0030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aim was to investigate blood concentrations of copeptin and the prognostication in 24 versus 48 hours of targeted temperature management (TTM) in patients resuscitated after out-of-hospital cardiac arrest. This is an exploratory biomarker substudy of the trial entitled; "Targeted temperature management for 48 vs 24 hours and neurologic outcome after out-of-hospital-cardiac-arrest: A randomized clinical trial." Patients were randomized to target temperature of 33°C ± 1°C for 24 (TTM24) or 48 (TTM48) hours. The primary outcome was copeptin concentrations compared with TTM at admission, 24, 48, and 72 hours (t24, t48, and t72) after reaching target temperature. Secondary outcomes were the association between copeptin and cerebral performance category (CPC) score after 6 months, and copeptin level between cerebral or noncerebral causes of death. Blood samples from 117 patients were analyzed from two Scandinavian sites. No significant differences in copeptin concentrations were found between TTM24 versus TTM48 at admission 211.3 μg/L (148-276.6) versus 179.8 μg/L (127-232.6) (p = 0.45), t24: 23.3 μg/L (16.5-30.2) versus 18.6 μg/L (13.3-23.9) (p = 0.25), t48: 28.8 μg/L (20.6-36.9) versus 19.7 μg/L (14.3-25.1) (p = 0.06), and t72: 23.3 μg/L (13.8-26.8) versus 31.6 μg/L (22-41.2) (p = 0.05). Copeptin concentrations were significantly higher in poor neurological outcome group at t24, t48, and t72 (p < 0.01), but not at admission (p = 0.19). The prognostic ability of copeptin (area under the receiver operating characteristic curve) was at admission: 0.59 (95% confidence intervals: 0.46-0.72), t24: 0.74 (0.63-0.86), t48: 0.8 (0.7-0.9), and t72: 0.76 (0.65-0.87). Copeptin levels were not significantly different in noncerebral compared with cerebral causes at admission: p = 0.41, t24: p = 0.52, t48: p = 0.15, and t72: p = 0.38. There were no differences in the level of copeptin in TTM24 versus TTM48. Blood concentrations of copeptin were associated with CPC at 6 months, and no association between levels of copeptin and cerebral versus noncerebral causes of death was observed.
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Affiliation(s)
| | - Anders Morten Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anni Nørgaard Jeppesen
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Critical Care and Anesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
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Ebner F, Riker RR, Haxhija Z, Seder DB, May TL, Ullén S, Stammet P, Hirsch K, Forsberg S, Dupont A, Friberg H, McPherson JA, Søreide E, Dankiewicz J, Cronberg T, Nielsen N. The association of partial pressures of oxygen and carbon dioxide with neurological outcome after out-of-hospital cardiac arrest: an explorative International Cardiac Arrest Registry 2.0 study. Scand J Trauma Resusc Emerg Med 2020; 28:67. [PMID: 32664989 PMCID: PMC7362652 DOI: 10.1186/s13049-020-00760-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 07/02/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Exposure to extreme arterial partial pressures of oxygen (PaO2) and carbon dioxide (PaCO2) following the return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA) is common and may affect neurological outcome but results of previous studies are conflicting. METHODS Exploratory study of the International Cardiac Arrest Registry (INTCAR) 2.0 database, including 2162 OHCA patients with ROSC in 22 intensive care units in North America and Europe. We tested the hypothesis that exposure to extreme PaO2 or PaCO2 values within 24 h after OHCA is associated with poor neurological outcome at discharge. Our primary analyses investigated the association between extreme PaO2 and PaCO2 values, defined as hyperoxemia (PaO2 > 40 kPa), hypoxemia (PaO2 < 8.0 kPa), hypercapnemia (PaCO2 > 6.7 kPa) and hypocapnemia (PaCO2 < 4.0 kPa) and neurological outcome. The secondary analyses tested the association between the exposure combinations of PaO2 > 40 kPa with PaCO2 < 4.0 kPa and PaO2 8.0-40 kPa with PaCO2 > 6.7 kPa and neurological outcome. To define a cut point for the onset of poor neurological outcome, we tested a model with increasing and decreasing PaO2 levels and decreasing PaCO2 levels. Cerebral Performance Category (CPC), dichotomized to good (CPC 1-2) and poor (CPC 3-5) was used as outcome measure. RESULTS Of 2135 patients eligible for analysis, 700 were exposed to hyperoxemia or hypoxemia and 1128 to hypercapnemia or hypocapnemia. Our primary analyses did not reveal significant associations between exposure to extreme PaO2 or PaCO2 values and neurological outcome (P = 0.13-0.49). Our secondary analyses showed no significant associations between combinations of PaO2 and PaCO2 and neurological outcome (P = 0.11-0.86). There was no PaO2 or PaCO2 level significantly associated with poor neurological outcome. All analyses were adjusted for relevant co-variates. CONCLUSIONS Exposure to extreme PaO2 or PaCO2 values in the first 24 h after OHCA was common, but not independently associated with neurological outcome at discharge.
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Affiliation(s)
- Florian Ebner
- Lund University, Helsingborg Hospital, Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Charlotte Yhlens Gata 10, S-251 87, Helsingborg, Sweden.
| | - Richard R Riker
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Zana Haxhija
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - David B Seder
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Teresa L May
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Susann Ullén
- Clinical Studies Sweden, Skane University Hospital, Lund, Sweden
| | - Pascal Stammet
- Medical and Health Directorate, National Fire and Rescue Corps, Luxembourg City, Luxembourg
| | - Karen Hirsch
- Stanford Neurocritical Care Program, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Sune Forsberg
- Department of Intensive Care, Norrtälje Hospital, Center for Resuscitation,Karolinska Institute, Solna, Sweden
| | - Allison Dupont
- Department of Cardiology, Northeast Georgia Medical Center, Gainesville, GA, USA
| | - Hans Friberg
- Department of Clinical Sciences, Anesthesiology and Intensive Care, Lund University, Skane University Hospital, Malmö, Sweden
| | | | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Lund University, Skane University Hospital, Lund, Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Lund University, Helsingborg Hospital, Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Charlotte Yhlens Gata 10, S-251 87, Helsingborg, Sweden
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Grand J, Hassager C, Skrifvars MB, Tiainen M, Grejs AM, Jeppesen AN, Duez CHV, Rasmussen BS, Laitio T, Nee J, Taccone F, Søreide E, Kirkegaard H. Haemodynamics and vasopressor support during prolonged targeted temperature management for 48 hours after out-of-hospital cardiac arrest: a post hoc substudy of a randomised clinical trial. Eur Heart J Acute Cardiovasc Care 2020; 10:2048872620934305. [PMID: 32551835 DOI: 10.1177/2048872620934305] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/16/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Comatose patients admitted after out-of-hospital cardiac arrest frequently experience haemodynamic instability and anoxic brain injury. Targeted temperature management is used for neuroprotection; however, targeted temperature management also affects patients' haemodynamic status. This study assessed the haemodynamic status of out-of-hospital cardiac arrest survivors during prolonged (48 hours) targeted temperature management at 33°C. METHODS Analysis of haemodynamic and vasopressor data from 311 patients included in a randomised, clinical trial conducted in 10 European hospitals (the TTH48 trial). Patients were randomly allocated to targeted temperature management at 33°C for 24 (TTM24) or 48 (TTM48) hours. Vasopressor and haemodynamic data were reported hourly for 72 hours after admission. Vasopressor load was calculated as norepinephrine (µg/kg/min) plus dopamine(µg/kg/min/100) plus epinephrine (µg/kg/min). RESULTS After 24 hours, mean arterial pressure (mean±SD) was 74±9 versus 75±9 mmHg (P=0.19), heart rate was 57±16 and 55±14 beats/min (P=0.18), vasopressor load was 0.06 (0.03-0.15) versus 0.08 (0.03-0.15) µg/kg/min (P=0.22) for the TTM24 and TTM48 groups, respectively. From 24 to 48 hours, there was no difference in mean arterial pressure (Pgroup=0.32) or lactate (Pgroup=0.20), while heart rate was significantly lower (average difference 5 (95% confidence interval 2-8) beats/min, Pgroup<0.0001) and vasopressor load was significantly higher in the TTM48 group (Pgroup=0.005). In a univariate Cox regression model, high vasopressor load was associated with mortality in univariate analysis (hazard ratio 1.59 (1.05-2.42) P=0.03), but not in multivariate analysis (hazard ratio 0.77 (0.46-1.29) P=0.33). CONCLUSIONS In this study, prolonged targeted temperature management at 33°C for 48 hours was associated with higher vasopressor requirement but no sign of any detrimental haemodynamic effects.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Rigshospitalet - Copenhagen University Hospital, Denmark
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet - Copenhagen University Hospital, Denmark
| | - Markus B Skrifvars
- Department of Anesthesia and Intensive Care, Helsinki University Hospital and University of Helsinki, Finland
| | - Marjaana Tiainen
- Department of Anesthesia and Intensive Care, Helsinki University Hospital and University of Helsinki, Finland
| | - Anders M Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Denmark
| | | | | | - Bodil S Rasmussen
- Anaesthesiology and Intensive Care, Aalborg University Hospital, Denmark
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, Finland
| | - Jens Nee
- Department of Intensive Care Medicine, Charité - Universitaetsmedizin Berlin, Germany
| | | | - Eldar Søreide
- Critical Care and Anesthesiology Research Group, Stavanger University Hospital, Norway
- Department of Clinical Medicine, University of Bergen, Norway
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Aarhus University Hospital and Aarhus University, Denmark
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19
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Strand K, Søreide E, Kirkegaard H, Taccone FS, Grejs AM, Duez CHV, Jeppesen AN, Storm C, Rasmussen BS, Laitio T, Hassager C, Toome V, Hästbacka J, Skrifvars MB. The influence of prolonged temperature management on acute kidney injury after out-of-hospital cardiac arrest: A post hoc analysis of the TTH48 trial. Resuscitation 2020; 151:10-17. [PMID: 32087257 DOI: 10.1016/j.resuscitation.2020.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 12/27/2019] [Accepted: 01/22/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common after cardiac arrest and targeted temperature management (TTM). The impact of different lengths of cooling on the development of AKI has not been well studied. In this study of patients included in a randomised controlled trial of TTM at 33 °C for 24 versus 48 h after cardiac arrest (TTH48 trial), we examined the influence of prolonged TTM on AKI and the incidence and factors associated with the development of AKI. We also examined the impact of AKI on survival. METHODS This study was a sub-study of the TTH48 trial, which included patients cooled to 33 ± 1 °C after out-of-hospital cardiac arrest for 24 versus 48 h. AKI was classified according to the KDIGO AKI criteria based on serum creatinine and urine output collected until ICU discharge for a maximum of seven days. Survival was followed for up to six months. The association of admission factors on AKI was analysed with multivariate analysis and the association of AKI on mortality was analysed with Cox regression using the time to AKI as a time-dependent covariate. RESULTS Of the 349 patients included in the study, 159 (45.5%) developed AKI. There was no significant difference in the incidence, severity or time to AKI between the 24- and 48-h groups. Serum creatinine values had significantly different trajectories for the two groups with a sharp rise occurring during rewarming. Age, time to return of spontaneous circulation, serum creatinine at admission and body mass index were independent predictors of AKI. Patients with AKI had a higher mortality than patients without AKI (hospital mortality 36.5% vs 12.5%, p < 0.001), but only AKI stages 2 and 3 were independently associated with mortality. CONCLUSIONS We did not find any association between prolonged TTM at 33 °C and the risk of AKI during the first seven days in the ICU. AKI is prevalent after cardiac arrest and TTM and occurs in almost half of all ICU admitted patients and more commonly in the elderly, with an increasing BMI and longer arrest duration. AKI after cardiac arrest is an independent predictor of time to death.
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Affiliation(s)
- Kristian Strand
- Department of Intensive Care, Stavanger University Hospital, Norway.
| | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway; Department Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine and Emergency Department, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | | | - Anders Morten Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Christophe Henri Valdemar Duez
- Research Centre for Emergency Medicine and Emergency Department, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Anni Nørgaard Jeppesen
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Denmark
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-University, Berlin, Germany
| | - Bodil Steen Rasmussen
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Finland
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet and Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Valdo Toome
- Department of Intensive Cardiac Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Johanna Hästbacka
- Department of Anaesthesiology, Intensive Care and Paine Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital, Finland
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20
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Holm A, Kirkegaard H, Taccone F, Søreide E, Grejs A, Duez C, Jeppesen A, Toome V, Hassager C C, Rasmussen BS, Laitio T, Storm C, Hästbacka J, Skrifvars MB. Cold fluids for induction of targeted temperature management: A sub-study of the TTH48 trial. Resuscitation 2020; 148:90-97. [PMID: 31962179 DOI: 10.1016/j.resuscitation.2019.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/28/2019] [Accepted: 11/29/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pre-intensive care unit (ICU) induction of targeted temperature management (TTM) with cold intravenous (i.v.) fluids does not appear to improve outcomes after in out-of-hospital cardiac arrest (OHCA). We hypothesized that this may be due to ineffective cooling and side effects. METHODS A post hoc analysis of a sub-group of patients (n = 352) in the TTH48 trial (NCT01689077) who received or did not receive pre-ICU cooling using cold i.v. fluids. Data collection included patient characteristics, cardiac arrest factors, cooling methods, side effects and continuous core temperature measurements. The primary endpoint was the time to target temperature (TTT, <34 °C), and the secondary endpoints included the incidence of circulatory side effects, abnormal electrolyte levels and hypoxia within the first 24 h of ICU care. A difference of 1 h in the TTT was determined as clinically significant a priori. RESULTS Of 352 patients included in the present analysis, 110 received pre-ICU cold fluids. The median time to the return of spontaneous circulation (ROSC) and TTT in the pre-ICU cold fluids group was longer than that of the group that did not receive pre-ICU cold fluids (318 vs. 281 min, p < 0.01). In a linear regression model including the treatment centre, body mass index (BMI), chronic heart failure, diabetes mellitus and time to ROSC, the use of pre-ICU cold i.v. fluids was not associated with a shorter time to the target temperature (standardized beta coefficient: 0.06, 95% CI for B -49 and 16, p = 0.32). According to the receipt or not of pre-ICU cold i.v. fluids, there was no difference in the proportion of patients with hypoxia on ICU admission (1.8% vs. 3.3%, p = 0.43) or the proportion of patients with electrolyte abnormalities (hyponatremia: 1.8% vs. 2.9% p = 0.54; hypokalaemia: 1.8% vs. 4.5%, p = 0.20). Furthermore, there was no difference in hospital mortality between the groups. CONCLUSIONS The initiation of TTM with cold i.v. fluids before ICU arrival did not decrease the TTT. We detected no significant between-group difference in mortality or the incidence of side effects according to the administration or not of pre-ICU cold i.v fluids.
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Affiliation(s)
- Aki Holm
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Department of Emergency Medicine and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Fabio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway; Department Clinical Medicine, University of Bergen, Bergen, Norway
| | - Anders Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Christophe Duez
- Research Center for Emergency Medicine, Department of Emergency Medicine and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anni Jeppesen
- Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Valdo Toome
- Department of Intensive Cardiac Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Christian Hassager C
- Department of Cardiology, Rigshospitalet and Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Bodil S Rasmussen
- Department of Anesthesiology and Intensive Care Medicine, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Finland
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Johanna Hästbacka
- Department of Anesthesiology, Intensive Care and Paine Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Markus B Skrifvars
- Department of Anesthesiology, Intensive Care and Paine Medicine, University of Helsinki and Helsinki University Hospital, Finland; Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland.
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21
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Hjorthaug GA, Søreide E, Nordsletten L, Madsen JE, Reinholt FP, Niratisairak S, Dimmen S. Short-term perioperative parecoxib is not detrimental to shaft fracture healing in a rat model. Bone Joint Res 2019; 8:472-480. [PMID: 31728186 PMCID: PMC6825043 DOI: 10.1302/2046-3758.810.bjr-2018-0341.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objectives Experimental studies indicate that non-steroidal anti-inflammatory drugs (NSAIDs) may have negative effects on fracture healing. This study aimed to assess the effect of immediate and delayed short-term administration of clinically relevant parecoxib doses and timing on fracture healing using an established animal fracture model. Methods A standardized closed tibia shaft fracture was induced and stabilized by reamed intramedullary nailing in 66 Wistar rats. A ‘parecoxib immediate’ (Pi) group received parecoxib (3.2 mg/kg bodyweight twice per day) on days 0, 1, and 2. A ‘parecoxib delayed’ (Pd) group received the same dose of parecoxib on days 3, 4, and 5. A control group received saline only. Fracture healing was evaluated by biomechanical tests, histomorphometry, and dual-energy x-ray absorptiometry (DXA) at four weeks. Results For ultimate bending moment, the median ratio between fractured and non-fractured tibia was 0.61 (interquartile range (IQR) 0.45 to 0.82) in the Pi group, 0.44 (IQR 0.42 to 0.52) in the Pd group, and 0.50 (IQR 0.41 to 0.75) in the control group (n = 44; p = 0.068). There were no differences between the groups for stiffness, energy, deflection, callus diameter, DXA measurements (n = 64), histomorphometrically osteoid/bone ratio, or callus area (n = 20). Conclusion This study demonstrates no negative effect of immediate or delayed short-term administration of parecoxib on diaphyseal fracture healing in rats. Cite this article: G. A. Hjorthaug, E. Søreide, L. Nordsletten, J. E. Madsen, F. P. Reinholt, S. Niratisairak, S. Dimmen. Short-term perioperative parecoxib is not detrimental to shaft fracture healing in a rat model. Bone Joint Res 2019;8:472–480. DOI: 10.1302/2046-3758.810.BJR-2018-0341.R1.
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Affiliation(s)
- G A Hjorthaug
- Department of Orthopedic Surgery, Martina Hansens Hospital, Sandvika, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo (UIO), Oslo, Norway; Experimental Orthopedic Research, Institute for Surgical Research, Oslo University Hospital (OUS), Oslo, Norway
| | - E Søreide
- Division of Orthopedic Surgery, OUS, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, UIO, Oslo, Norway; Experimental Orthopedic Research, Institute for Surgical Research, OUS, Oslo, Norway
| | - L Nordsletten
- Division of Orthopedic Surgery, OUS, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, UIO, Oslo, Norway; Experimental Orthopedic Research, Institute for Surgical Research, OUS, Oslo, Norway
| | - J E Madsen
- Division of Orthopedic Surgery, OUS, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, UIO, Oslo, Norway; Experimental Orthopedic Research, Institute for Surgical Research, OUS, Oslo, Norway
| | | | - S Niratisairak
- Institute of Clinical Medicine, Faculty of Medicine, UIO, Oslo, Norway; Biomechanics Lab, Division of Orthopedic Surgery, OUS, Oslo, Norway
| | - S Dimmen
- Department of Orthopedic Surgery, Lovisenberg Diaconal Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, UIO, Oslo, Norway; Experimental Orthopedic Research, Institute for Surgical Research, OUS, Oslo, Norway
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22
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Johnsson J, Wahlström J, Dankiewicz J, Annborn M, Agarwal S, Dupont A, Forsberg S, Friberg H, Hand R, Hirsch KG, May T, McPherson JA, Mooney MR, Patel N, Riker RR, Stammet P, Søreide E, Seder DB, Nielsen N. Functional outcomes associated with varying levels of targeted temperature management after out-of-hospital cardiac arrest - An INTCAR2 registry analysis. Resuscitation 2019; 146:229-236. [PMID: 31706964 DOI: 10.1016/j.resuscitation.2019.10.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/21/2019] [Accepted: 10/24/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) has been recommended in international guidelines since 2005. The TTM-trial published in 2013 showed no difference in survival or neurological outcome for patients randomised to 33 °C or 36 °C, and many hospitals have changed practice. The optimal utilization of TTM is still debated. This study aimed to analyse if a difference in temperature goal was associated with outcome in an unselected international registry population. METHODS This is a retrospective observational study based on a prospective registry - the International Cardiac Arrest Registry 2. Patients were categorized as receiving TTM in the lower range at 32-34 °C (TTM-low) or at 35-37 °C (TTM-high). Primary outcome was good functional status defined as cerebral performance category (CPC) of 1-2 at hospital discharge and secondary outcome was adverse events related to TTM. A logistic regression model was created to evaluate the independent effect of temperature by correcting for clinical and demographic factors associated with outcome. RESULTS Of 1710 patients included, 1242 (72,6%) received TTM-low and 468 (27,4%) TTM-high. In patients receiving TTM-low, 31.3% survived with good outcome compared to 28.8% in the TTM-high group. There was no significant association between temperature and outcome (p = 0.352). In analyses adjusted for baseline differences the OR for a good outcome with TTM-low was 1.27, 95% CI (0.94-1.73). Haemodynamic instability leading to discontinuation of TTM was more common in TTM-low. CONCLUSIONS No significant difference in functional outcome at hospital discharge was found in patients receiving lower- versus higher targeted temperature management.
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Affiliation(s)
- Jesper Johnsson
- Department of Anaesthesiology and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden; Department of Clinical Sciences, Lund University, Lund, Sweden.
| | | | - Josef Dankiewicz
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Martin Annborn
- Department of Anaesthesiology and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden; Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, New York City, United States
| | - Allison Dupont
- Department of Cardiology, Eastern Georgia, United States
| | - Sune Forsberg
- Department of Intensive Care, Norrtälje Hospital, Center for Resuscitation Science, Karolinska Institute, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Lund University, Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | - Robert Hand
- Department of Medical Services, Eastern Maine Medical Center, United States
| | - Karen G Hirsch
- Department of Neurology, Stanford University, United States
| | - Teresa May
- Department of Critical Care Services, Maine Medical Center, Portland, ME, United States
| | | | - Michael R Mooney
- Minneapolis Heart Institute, Abbott North-Western Hospital, United States
| | - Nainesh Patel
- Department of Cardiology, Lehigh Valley Health Network, PA, United States
| | - Richard R Riker
- Department of Critical Care Services, Maine Medical Center, Portland, ME, United States
| | - Pascal Stammet
- Medical and Health Department, National Fire and Rescue Corps, Luxembourg
| | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - David B Seder
- Department of Critical Care Services, Maine Medical Center, Portland, ME, United States
| | - Niklas Nielsen
- Department of Anaesthesiology and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden; Department of Clinical Sciences, Lund University, Lund, Sweden
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23
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May TL, Lary CW, Riker RR, Friberg H, Patel N, Søreide E, McPherson JA, Undén J, Hand R, Sunde K, Stammet P, Rubertsson S, Belohlvaek J, Dupont A, Hirsch KG, Valsson F, Kern K, Sadaka F, Israelsson J, Dankiewicz J, Nielsen N, Seder DB, Agarwal S. Correction to: Variability in functional outcome and treatment practices by treatment center after out-of-hospital cardiac arrest: analysis of International Cardiac Arrest Registry. Intensive Care Med 2019; 45:1176. [PMID: 31317207 DOI: 10.1007/s00134-019-05687-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The original version of this article unfortunately contained a mistake.
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Affiliation(s)
- Teresa L May
- Department of Critical Care Services, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.
- Clinical and Translational Science Institute, Tufts University, Boston, ME, 02111, USA.
| | - Christine W Lary
- Center for Outcomes Research, Maine Medical Center, Portland, ME, USA
| | - Richard R Riker
- Department of Critical Care Services, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Hans Friberg
- Department of Anesthesia and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden
| | - Nainesh Patel
- Division of Cardiovascular Medicine, Lehigh Valley Hospital and Health Network, Allentown, PA, USA
| | - Eldar Søreide
- Critical Care and Anesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway
- Department Clinical Medicine, University of Bergen, Bergen, Norway
| | - John A McPherson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Johan Undén
- Department of Clinical Sciences, Lund University, Getingevägen, 22185, Lund, Sweden
- Department of Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | - Robert Hand
- Department of Critical Care, Eastern Maine Medical Center, Bangor, ME, USA
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Pascal Stammet
- Medical Department National Rescue Services, Luxembourg, 14, rue Stümper, 2557, Luxembourg, Luxembourg
| | - Sten Rubertsson
- Department of Surgical Sciences/Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Jan Belohlvaek
- Department of Internal Medicine II, Cardiovascular Medicine, General Teaching Hospital and 1st Medical School, Charles University in Prague, Prague, Czech Republic
| | - Allison Dupont
- Department of Cardiology, Northeast Georgia Medical Center, Gainesville, Georgia, USA
| | - Karen G Hirsch
- Stanford Neurocritical Care Program, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Felix Valsson
- Department of Anesthesia and Intensive Care, Landspitali University Hospital, Reykyavik, Iceland
| | - Karl Kern
- Division of Cardiology, Sarver Heart Center, University of Arizona, Tucson, USA
| | - Farid Sadaka
- Mercy Hospital St Louis, St Louis University, St. Louis, MO, USA
| | - Johan Israelsson
- Department of Internal Medicine, Division of Cardiology, Kalmar County Hospital, Kalmar, Sweden
| | - Josef Dankiewicz
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences, Anesthesia and Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - David B Seder
- Department of Critical Care Services, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia-Presbyterian Medical Center, New York, NY, USA
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24
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May TL, Lary CW, Riker RR, Friberg H, Patel N, Søreide E, McPherson JA, Undén J, Hand R, Sunde K, Stammet P, Rubertsson S, Belohlvaek J, Dupont A, Hirsch KG, Valsson F, Kern K, Sadaka F, Israelsson J, Dankiewicz J, Nielsen N, Seder DB, Agarwal S. Variability in functional outcome and treatment practices by treatment center after out-of-hospital cardiac arrest: analysis of International Cardiac Arrest Registry. Intensive Care Med 2019; 45:637-646. [PMID: 30848327 PMCID: PMC6486427 DOI: 10.1007/s00134-019-05580-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/22/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE Functional outcomes vary between centers after out-of-hospital cardiac arrest (OHCA) and are partially explained by pre-existing health status and arrest characteristics, while the effects of in-hospital treatments on functional outcome are less understood. We examined variation in functional outcomes by center after adjusting for patient- and arrest-specific characteristics and evaluated how in-hospital management differs between high- and low-performing centers. METHODS Analysis of observational registry data within the International Cardiac Arrest Registry was used to perform a hierarchical model of center-specific risk standardized rates for good outcome, adjusted for demographics, pre-existing functional status, and arrest-related factors with treatment center as a random effect variable. We described the variability in treatments and diagnostic tests that may influence outcome at centers with adjusted rates significantly above and below registry average. RESULTS A total of 3855 patients were admitted to an ICU following cardiac arrest with return of spontaneous circulation. The overall prevalence of good outcome was 11-63% among centers. After adjustment, center-specific risk standardized rates for good functional outcome ranged from 0.47 (0.37-0.58) to 0.20 (0.12-0.26). High-performing centers had faster time to goal temperature, were more likely to have goal temperature of 33 °C, more likely to perform unconscious cardiac catheterization and percutaneous coronary intervention, and had differing prognostication practices than low-performing centers. CONCLUSIONS Center-specific differences in outcomes after OHCA after adjusting for patient-specific factors exist. This variation could partially be explained by in-hospital management differences. Future research should address the contribution of these factors to the differences in outcomes after resuscitation.
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Affiliation(s)
- Teresa L May
- Department of Critical Care Services, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA. .,Clinical and Translational Science Institute, Tufts University, Boston, ME, 02111, USA.
| | - Christine W Lary
- Center for Outcomes Research, Maine Medical Center, Portland, ME, USA
| | - Richard R Riker
- Department of Critical Care Services, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Hans Friberg
- Department of Anesthesia and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden
| | - Nainesh Patel
- Division of Cardiovascular Medicine, Lehigh Valley Hospital and Health Network, Allentown, PA, USA
| | - Eldar Søreide
- Critical Care and Anesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway.,Department Clinical Medicine, University of Bergen, Bergen, Norway
| | - John A McPherson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Johan Undén
- Department of Clinical Sciences, Lund University, Getingevägen, 22185, Lund, Sweden.,Department of Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | - Robert Hand
- Department of Critical Care, Eastern Maine Medical Center, Bangor, ME, USA
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Pascal Stammet
- Medical Department National Rescue Services, Luxembourg, 14, rue Stümper, 2557, Luxembourg, Luxembourg
| | - Stein Rubertsson
- Department of Surgical Sciences/Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Jan Belohlvaek
- Department of Internal Medicine II, Cardiovascular Medicine, General Teaching Hospital and 1st Medical School, Charles University in Prague, Prague, Czech Republic
| | - Allison Dupont
- Department of Cardiology, Northeast Georgia Medical Center, Gainesville, Georgia, USA
| | - Karen G Hirsch
- Stanford Neurocritical Care Program, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Felix Valsson
- Department of Anesthesia and Intensive Care, Landspitali University Hospital, Reykyavik, Iceland
| | - Karl Kern
- Division of Cardiology, Sarver Heart Center, University of Arizona, Tucson, USA
| | - Farid Sadaka
- Mercy Hospital St Louis, St Louis University, St. Louis, MO, USA
| | - Johan Israelsson
- Department of Internal Medicine, Division of Cardiology, Kalmar County Hospital, Kalmar, Sweden
| | - Josef Dankiewicz
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences, Anesthesia and Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - David B Seder
- Department of Critical Care Services, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia-Presbyterian Medical Center, New York, NY, USA
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25
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Evald L, Brønnick K, Duez CHV, Grejs AM, Jeppesen AN, Søreide E, Kirkegaard H, Nielsen JF. Prolonged targeted temperature management reduces memory retrieval deficits six months post-cardiac arrest: A randomised controlled trial. Resuscitation 2018; 134:1-9. [PMID: 30572070 DOI: 10.1016/j.resuscitation.2018.12.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/09/2018] [Accepted: 12/10/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cognitive sequelae, most frequently memory, attention, and executive dysfunctions, occur commonly in out-of-hospital cardiac arrest (OHCA) survivors. Targeted temperature management (TTM) following OHCA is associated with improved cognitive function. However, the relationship between the duration of TTM and cognitive outcome remains unclear. We hypothesised that OHCA survivors that were subjected to prolonged TTM of 48 h (TTM48) would exhibit better cognitive functions compared to those subjected to standard TTM of 24 h (TTM24) six months post-OHCA. METHODS A predefined, cognitive post-hoc sub-study was conducted on the multicentre clinical trial: "Target Temperature Management for 48 vs. 24 h and Neurologic Outcome after out-of-hospital cardiac arrest: A Randomised Clinical Trial" (the TTH48 trial). OHCA survivors with perceived good cognitive outcome (CPC score ≤ 2) were invited to a neuropsychological assessment of memory, attention, and executive functions six months post-OHCA. RESULTS In total, 79 patients were included in the study. Multivariate regression analysis revealed that TTM48 was associated with a significant better performance on three of 13 cognitive tests specific to memory retrieval after adjusting for age at follow-up and time to return of spontaneous circulation. Overall, patients in the TTM24 group were almost three times more likely (RR = 2.9 (95% CI 1.1-7.4)), p = 0.02) to be cognitively impaired. CONCLUSIONS This study reports an association between the duration of TTM and cognitive outcome. In OHCA survivors with perceived good cognitive outcome (CPC ≤ 2), TTM48 was associated with reduced memory retrieval deficits and lower relative risk of cognitive impairment six months after OHCA compared to standard TTM24. ClinicalTrials.gov (identifier: NCT01689077).
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Affiliation(s)
- Lars Evald
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Denmark.
| | - Kolbjørn Brønnick
- Department of Psychiatry, Stavanger University Hospital, Stavanger, Norway
| | - Christophe Henri Valdemar Duez
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anders Morten Grejs
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anni Nørgaard Jeppesen
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Jørgen Feldbæk Nielsen
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Denmark
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26
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Kirkegaard H, Taccone FS, Skrifvars MB, Søreide E. How long should comatose patients resuscitated from cardiac arrest be cooled? J Thorac Dis 2018; 10:E761-E763. [PMID: 30505521 DOI: 10.21037/jtd.2018.09.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Hans Kirkegaard
- Research Center for Emergency Medicine, Emergency Department & Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Markus B Skrifvars
- Department of Emergency Care and Services and Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Eldar Søreide
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway and Department of Clinical Medicine, University of Bergen, Bergen, Norway
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27
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Mathiesen WT, Birkenes TS, Lund H, Ushakova A, Søreide E, Bjørshol CA. Public knowledge and expectations about dispatcher assistance in out-of-hospital cardiac arrest. J Adv Nurs 2018; 75:783-792. [PMID: 30375018 DOI: 10.1111/jan.13886] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 08/22/2018] [Accepted: 10/02/2018] [Indexed: 11/30/2022]
Abstract
AIM To assess the factors associated with the knowledge and expectations among the general public about dispatcher assistance in out-of-hospital cardiac arrest incidents. BACKGROUND In medical dispatch centres, emergency calls are frequently operated by specially trained nurses as dispatchers. In cardiac arrest incidents, efficient communication between the dispatcher and the caller is vital for prompt recognition and treatment of the cardiac arrest. DESIGN A cross-sectional observational survey containing six questions and seven demographic items. METHOD From January-June 2017 we conducted standardized interviews among 500 members of the general public in Norway. In addition to explorative statistical methods, we used multivariate logistic analysis. RESULTS Most participants expected cardiopulmonary resuscitation instructions, while few expected "help in deciding what to do." More than half regarded the bystanders present to be responsible for the decision to initiate cardiopulmonary resuscitation. Most participants were able to give the correct emergency medical telephone number. The majority knew that the emergency call would not be terminated until the ambulance arrived at the scene. However, only one-third knew that the emergency telephone number operator was a trained nurse. CONCLUSION The public expect cardiopulmonary resuscitation instructions from the emergency medical dispatcher. However, the majority assume it is the responsibility of the bystanders to make the decision to initiate cardiopulmonary resuscitation or not. Based on these findings, cardiopulmonary resuscitation training initiatives and public campaigns should focus more on the role of the emergency medical dispatcher as the team leader of the first resuscitation team in cardiac arrest incidents.
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Affiliation(s)
- Wenche T Mathiesen
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway.,Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway
| | | | - Helene Lund
- Emergency Medical Communication Centre, Division of Prehospital Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Anastasia Ushakova
- Department of Research, Stavanger University Hospital, Stavanger, Norway
| | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Conrad A Bjørshol
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway.,The Regional Centre for Emergency Medical Research and Development (RAKOS), Clinic of Prehospital Medicine, Stavanger University Hospital, Stavanger, Norway
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Schjørring OL, Toft‐Petersen AP, Kusk KH, Mouncey P, Sørensen EE, Berezowicz P, Bestle MH, Bülow H, Bundgaard H, Christensen S, Iversen SA, Kirkeby‐Garstad I, Krarup KB, Kruse M, Laake JH, Liboriussen L, Læbel RL, Okkonen M, Poulsen LM, Russell L, Sjövall F, Sunde K, Søreide E, Waldau T, Walli AR, Perner A, Wetterslev J, Rasmussen BS. Intensive care doctors' preferences for arterial oxygen tension levels in mechanically ventilated patients. Acta Anaesthesiol Scand 2018; 62:1443-1451. [PMID: 29926908 DOI: 10.1111/aas.13171] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/01/2018] [Accepted: 05/04/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Oxygen is liberally administered in intensive care units (ICUs). Nevertheless, ICU doctors' preferences for supplementing oxygen are inadequately described. The aim was to identify ICU doctors' preferences for arterial oxygenation levels in mechanically ventilated adult ICU patients. METHODS In April to August 2016, an online multiple-choice 17-part-questionnaire was distributed to 1080 ICU doctors in seven Northern European countries. Repeated reminder e-mails were sent. The study ended in October 2016. RESULTS The response rate was 63%. When evaluating oxygenation 52% of respondents rated arterial oxygen tension (PaO2 ) the most important parameter; 24% a combination of PaO2 and arterial oxygen saturation (SaO2 ); and 23% preferred SaO2 . Increasing, decreasing or not changing a default fraction of inspired oxygen of 0.50 showed preferences for a PaO2 around 8 kPa in patients with chronic obstructive pulmonary disease, a PaO2 around 10 kPa in patients with healthy lungs, acute respiratory distress syndrome or sepsis, and a PaO2 around 12 kPa in patients with cardiac or cerebral ischaemia. Eighty per cent would accept a PaO2 of 8 kPa or lower and 77% would accept a PaO2 of 12 kPa or higher in a clinical trial of oxygenation targets. CONCLUSION Intensive care unit doctors preferred PaO2 to SaO2 in monitoring oxygen treatment when peripheral oxygen saturation was not included in the question. The identification of PaO2 as the preferred target and the thorough clarification of preferences are important when ascertaining optimal oxygenation targets. In particular when designing future clinical trials of higher vs lower oxygenation targets in ICU patients.
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Affiliation(s)
- O. L. Schjørring
- Department of Anaesthesia and Intensive Care Medicine Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - A. P. Toft‐Petersen
- Department of Clinical Medicine Aalborg University Aalborg Denmark
- Intensive Care National Audit & Research Centre (ICNARC) London UK
| | - K. H. Kusk
- Clinical Nursing Research Unit Aalborg University Hospital Aalborg Denmark
| | - P. Mouncey
- Intensive Care National Audit & Research Centre (ICNARC) London UK
| | - E. E. Sørensen
- Department of Clinical Medicine Aalborg University Aalborg Denmark
- Clinical Nursing Research Unit Aalborg University Hospital Aalborg Denmark
| | - P. Berezowicz
- Department of Anaesthesia and Intensive Care Medicine Vejle Hospital Vejle Denmark
| | - M. H. Bestle
- Department of Anaesthesia and Intensive Care Medicine Nordsjaellands Hospital Hillerød Denmark
| | - H.‐H. Bülow
- Department of Anaesthesia and Intensive Care Medicine Holbæk Hospital Holbæk Denmark
| | - H. Bundgaard
- Department of Anaesthesia and Intensive Care Randers Hospital Randers Denmark
| | - S. Christensen
- Department of Anaesthesia and Intensive Care Medicine Aarhus University Hospital Skejby Denmark
| | - S. A. Iversen
- Department of Anaesthesia and Intensive Care Medicine Slagelse Hospital Slagelse Denmark
| | - I. Kirkeby‐Garstad
- Department of Anaesthesia and Intensive Care Medicine St. Olav's Hospital Trondheim Norway
- Norwegian University of Science and Technology (NTNU) Trondheim Norway
| | - K. B. Krarup
- Department of Anaesthesia and Intensive Care Odense University Hospital Odense Denmark
| | - M. Kruse
- Department of Anaesthesia and Intensive Care North Denmark Regional Hospital Hjørring Denmark
| | - J. H. Laake
- Division of Emergencies and Critical Care Rikshospitalet Oslo University Hospital Oslo Norway
| | - L. Liboriussen
- Department of Anaesthesia and Intensive Care Medicine Viborg Hospital Viborg Denmark
| | - R. L. Læbel
- Department of Anaesthesia and Intensive Care Medicine Regional Hospital West Jutland Herning Denmark
| | - M. Okkonen
- Department of Perioperative, Intensive Care and Pain Medicine Helsinki University Hospital Helsinki Finland
| | - L. M. Poulsen
- Department of Anaesthesia and Intensive Care Medicine Zealand University Hospital Køge Denmark
| | - L. Russell
- Department of Anaesthesia and Intensive Care Medicine Hvidovre Hospital Hvidovre Denmark
| | - F. Sjövall
- Department of Intensive Care and Perioperative Medicine Skåne University Hospital Malmö Sweden
- Department of Clinical Science Lund University Lund Sweden
| | - K. Sunde
- Department of Anaeshesiology Oslo University Hospital Ullevål Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - E. Søreide
- Department of Anaesthesia and Intensive Care Medicine Stavanger University Hospital Stavanger Norway
| | - T. Waldau
- Department of Anaesthesia and Intensive Care Medicine Herlev Hospital Herlev Denmark
| | - A. R. Walli
- Department of Anaesthesia and Intensive Care Medicine Zealand University Hospital Roskilde Denmark
| | - A. Perner
- Department of Intensive Care Rigshospitalet Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - J. Wetterslev
- Copenhagen Trial Unit Rigshospitalet Centre for Clinical Intervention Research Copenhagen Denmark
| | - B. S. Rasmussen
- Department of Anaesthesia and Intensive Care Medicine Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
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29
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Kirkegaard H, Taccone FS, Skrifvars MB, Søreide E. Prolonged targeted temperature management in patients suffering from out-of-hospital cardiac arrest. J Thorac Dis 2018; 10:E752-E754. [PMID: 30505518 DOI: 10.21037/jtd.2018.09.78] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Hans Kirkegaard
- Research Center for Emergency Medicine, Emergency Department and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Eldar Søreide
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway and Department of Clinical Medicine, University of Bergen, Bergen, Norway
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30
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Kessler U, Bjorke-Bertheussen J, Søreide E, Hunderi PA, Bache-Mathiesen L, Oedegaard KJ, Sartorius A, Schoeyen H. Remifentanil as an adjunct to anaesthesia for electroconvulsive therapy fails to confer long-term benefits. Br J Anaesth 2018; 121:1282-1289. [PMID: 30442255 DOI: 10.1016/j.bja.2018.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 06/12/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Adding the μ-opioid receptor agonist remifentanil to agents used to induce general anaesthesia in electroconvulsive therapy (ECT) can reduce the required doses of induction agents and their unfavourable effects on seizure threshold and quality. However, whether remifentanil has favourable long-term treatment effects in terms of response and remission rates, speed of response and remission, and side-effects has not been studied. METHODS This retrospective, register-based cohort study involved patients with major depression consecutively treated at two units at different hospitals in Norway with the same ECT procedure. Both units used thiopental for ECT anaesthesia, but only one unit added remifentanil (R+; n=47; 541 sessions), whereas the other did not (R-; n=119; 1166 sessions). A Cox proportional hazards model for interval-censored data was conducted to examine the effects of remifentanil on the time to response and remission from depressive symptoms, whilst adjusting for age, sex, and baseline depression score. RESULTS Both R+ and R- patients showed substantial reductions of depressive symptoms, with no difference in the response (76% in both groups) or remission (63% vs 65%) rate. However, R+ patients responded (hazard ratio=0.59; 95% confidence interval: 0.4-0.8) and remitted (hazard ratio=0.72; 95% confidence interval: 0.5-1.0) more slowly, and reported more often side-effects of nausea (30% vs 8%; P<0.001), dizziness (22% vs 8%; P=0.027), and headache (48% vs 23%; P=0.004). CONCLUSIONS The use of adjunctive remifentanil was associated with more short-term side-effects and no favourable long-term clinical outcomes. The practice of routinely adding remifentanil to barbiturate anaesthesia should therefore be reconsidered.
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Affiliation(s)
- U Kessler
- Department of Psychiatry, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | | | - E Søreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway
| | - P A Hunderi
- Department of Anaesthesiology and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - L Bache-Mathiesen
- National Service Center for Medical Quality Registries, Region Western Norway, Haukeland University Hospital, Bergen, Norway
| | - K J Oedegaard
- Department of Psychiatry, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - A Sartorius
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - H Schoeyen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Psychiatry, Stavanger University Hospital, Stavanger, Norway
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Dieckmann P, Birkvad Rasmussen M, Issenberg SB, Søreide E, Østergaard D, Ringsted C. Long-term experiences of being a simulation-educator: A multinational interview study. Med Teach 2018; 40:713-720. [PMID: 29793384 DOI: 10.1080/0142159x.2018.1471204] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The long-term reactions, experiences and reflections of simulation educators have not been explored. In a semistructured, exploratory interview study, the experiences of simulation educators in either Advanced Life Support (ALS) or Crisis Resource Management (CRM) courses in Denmark, Norway and the USA were analyzed. Three overarching themes were identified: (1) general reflections on simulation-based teaching, (2) transfer of knowledge and skills from the simulation setting to clinical settings and (3) more overarching transformations in simulation educators, simulation participants, and the healthcare system. Where ALS was deemed as high on the efficiency dimension of learning, CRM courses were described as high on the innovation dimension. General reflections, transfer and transformations described were related to differences in course principles. The results are relevant for career planning, faculty development and understanding simulation as social practice.
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Affiliation(s)
- P Dieckmann
- a Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources, Capital Region of Denmark , Copenhagen , Denmark
- b Department of Clinical Medicine , University of Copenhagen , Copenhagen , Denmark
| | - M Birkvad Rasmussen
- a Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources, Capital Region of Denmark , Copenhagen , Denmark
| | - S B Issenberg
- c University of Miami Gordon Center for Simulation and Innovation in Medical Education , Miami , USA
| | - E Søreide
- d Stavanger University Hospital, Critical Care and Anesthesiology Research Group , Stavanger , Norway
- e Department of Clinical Medicine , University of Bergen , Bergen , Norway
| | - D Østergaard
- a Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources, Capital Region of Denmark , Copenhagen , Denmark
- b Department of Clinical Medicine , University of Copenhagen , Copenhagen , Denmark
| | - C Ringsted
- f Center for Health Science Education , University of Aarhus , Aarhus , Denmark
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32
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Tjoflåt I, John Melissa T, Mduma E, Hansen BS, Karlsen B, Søreide E. How do Tanzanian hospital nurses perceive their professional role? A qualitative study. Nurs Open 2018; 5:323-328. [PMID: 30062026 PMCID: PMC6056436 DOI: 10.1002/nop2.139] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 02/14/2018] [Indexed: 11/28/2022] Open
Abstract
AIM To describe the experiences of Tanzanian nurses, how they perceive their role as a professional nurse and their experience with nursing care in a general hospital. DESIGN This study is explorative, descriptive and qualitative. METHODS The data were collected in 2015 by means of 10 semi-structured interviews and was analysed using qualitative content analysis. RESULTS The data analysis revealed two themes with corresponding sub-themes related to Tanzanian nurses' perception with their professional role and experiences with nursing care: (1) Feeling professional pride; (2) Experiencing limitations and inadequacy. The findings indicate that the Tanzanian nurses possess a strong professional pride and commitment to serve and care for their patients. The nurses do their best to provide high -quality nursing care but are faced with staffing shortages and limited materials that are beyond their control. Such limitations leave them feeling unable to fulfil their role and responsibilities.
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Affiliation(s)
- Ingrid Tjoflåt
- Faculty of Social ScienceDepartment of Health StudiesUniversity of StavangerStavangerNorway
| | | | - Estomih Mduma
- Haydom Lutheran HospitalHaydomTanzania
- Department of ResearchStavanger University HospitalStavangerNorway
| | - Britt S. Hansen
- Faculty of Social ScienceDepartment of Health StudiesUniversity of StavangerStavangerNorway
| | - Bjørg Karlsen
- Faculty of Social ScienceDepartment of Health StudiesUniversity of StavangerStavangerNorway
| | - Eldar Søreide
- Stavanger University HospitalUniversity of StavangerStavangerNorway
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Mathiesen WT, Bjørshol CA, Kvaløy JT, Søreide E. Effects of modifiable prehospital factors on survival after out-of-hospital cardiac arrest in rural versus urban areas. Crit Care 2018; 22:99. [PMID: 29669574 PMCID: PMC5907488 DOI: 10.1186/s13054-018-2017-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 03/21/2018] [Indexed: 11/20/2022]
Abstract
Background The modifiable prehospital system factors, bystander cardiopulmonary resuscitation (CPR), emergency medical services (EMS), response time, and EMS physician attendance, may affect short- and long-term survival for both rural and urban out-of-hospital cardiac arrest (OHCA) patients. We studied how such factors influenced OHCA survival in a mixed urban/rural region with a high survival rate after OHCA. Methods We analyzed the association between modifiable prehospital factors and survival to different stages of care in 1138 medical OHCA patients from an Utstein template-based cardiac arrest registry, using Kaplan-Meier type survival curves, univariable and multivariable logistic regression and mortality hazard plots. Results We found a significantly higher probability for survival to hospital admission (OR: 1.84, 95% CI 1.43–2.36, p < 0.001), to hospital discharge (OR: 1.51, 95% CI 1.08–2.11, p = 0.017), and at 1 year (OR: 1.58, 95% CI 1.11–2.26, p = 0.012) in the urban group versus the rural group. In patients receiving bystander CPR before EMS arrival, the odds of survival to hospital discharge increased more than threefold (OR: 3.05, 95% CI 2.00–4.65, p < 0.001). However, bystander CPR was associated with increased patient survival to discharge only in urban areas (survival probability 0.26 with CPR vs. 0.08 without CPR, p < 0.001). EMS response time ≥ 10 min was associated with decreased survival (OR: 0.61, 95% CI 0.45–0.83, p = 0.002), however, only in urban areas (survival probability 0.15 ≥ 10 min vs. 0.25 < 10 min, p < 0.001). In patients with prehospital EMS physician attendance, no significant differences were found in survival to hospital discharge (OR: 1.37, 95% CI 0.87–2.16, p = 0.17). In rural areas, patients with EMS physician attendance had an overall better survival to hospital discharge (survival probability 0.17 with EMS physician vs. 0.05 without EMS physician, p = 0.019). Adjusted for modifiable factors, the survival differences remained. Conclusions Overall, OHCA survival was higher in urban compared to rural areas, and the effect of bystander CPR, EMS response time and EMS physician attendance on survival differ between urban and rural areas. The effect of modifiable factors on survival was highest in the prehospital stage of care. In patients surviving to hospital admission, there was no significant difference in in-hospital mortality or in 1 year mortality between OHCA in rural versus urban areas.
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Affiliation(s)
- Wenche Torunn Mathiesen
- Critical Care and Anesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway. .,Norwegian Air Ambulance Foundation, Department of Research and Development, Drøbak, Norway. .,Stavanger University Hospital, Forskningens Hus, Armauer Hansensgate 2, P.O. box: 8100, 4068, Stavanger, Norway.
| | - Conrad Arnfinn Bjørshol
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Jan Terje Kvaløy
- Research Department, Stavanger University Hospital, Stavanger, Norway.,Department of Mathematics and Physics, University of Stavanger, Stavanger, Norway
| | - Eldar Søreide
- Critical Care and Anesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Søreide E, Mellin-Olsen J, Brazzi L, De Robertis E. Reply to: emergency medicine is about collaboration, not monopolisation. Eur J Anaesthesiol 2018; 35:232. [PMID: 29381594 DOI: 10.1097/eja.0000000000000756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Eldar Søreide
- From the Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger (ES), Department of Anaesthesia and Intensive Care Medicine, Baerum Hospital, Sandvika, Norway (JM-O), Department of Surgical Science, University of Turin, Department of Anaesthesia and Intensive Care, AOU Città della Salute e della Scienza, Turin (LB), and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples 'Federico II', Naples, Italy (EDR)
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Tjoflåt I, Våga BB, Søreide E. Implementing simulation in a nursing education programme: a case report from Tanzania. Adv Simul (Lond) 2018; 2:17. [PMID: 29450018 PMCID: PMC5806360 DOI: 10.1186/s41077-017-0048-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 08/17/2017] [Indexed: 11/18/2022] Open
Abstract
This paper presents a description of, and some reflections around, the experience of implementing simulation-based education within a nursing education programme in a low-income context. The students in the nursing education programme found the simulation sessions to be useful, motivating and a realistic learning method. Our experience may provide useful insight for other nursing education programmes in low-income contexts. It looks like a deeper knowledge about the feasibility of simulation-based education from both the teacher and student perspective is necessary.
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Affiliation(s)
- Ingrid Tjoflåt
- 1Faculty of Health Sciences, University of Stavanger, 4036 Stavanger, Norway
| | - Bodil Bø Våga
- 1Faculty of Health Sciences, University of Stavanger, 4036 Stavanger, Norway
| | - Eldar Søreide
- 2Stavanger University Hospital, Helse Stavanger HF, Postboks 8100, 4068 Stavanger, Norway
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Kirkegaard H, Søreide E, de Haas I, Pettilä V, Taccone FS, Arus U, Storm C, Hassager C, Nielsen JF, Sørensen CA, Ilkjær S, Jeppesen AN, Grejs AM, Duez CHV, Hjort J, Larsen AI, Toome V, Tiainen M, Hästbacka J, Laitio T, Skrifvars MB. Targeted Temperature Management for 48 vs 24 Hours and Neurologic Outcome After Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA 2017; 318:341-350. [PMID: 28742911 PMCID: PMC5541324 DOI: 10.1001/jama.2017.8978] [Citation(s) in RCA: 227] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE International resuscitation guidelines recommend targeted temperature management (TTM) at 33°C to 36°C in unconscious patients with out-of-hospital cardiac arrest for at least 24 hours, but the optimal duration of TTM is uncertain. OBJECTIVE To determine whether TTM at 33°C for 48 hours results in better neurologic outcomes compared with currently recommended, standard, 24-hour TTM. DESIGN, SETTING, AND PARTICIPANTS This was an international, investigator-initiated, blinded-outcome-assessor, parallel, pragmatic, multicenter, randomized clinical superiority trial in 10 intensive care units (ICUs) at 10 university hospitals in 6 European countries. Three hundred fifty-five adult, unconscious patients with out-of-hospital cardiac arrest were enrolled from February 16, 2013, to June 1, 2016, with final follow-up on December 27, 2016. INTERVENTIONS Patients were randomized to TTM (33 ± 1°C) for 48 hours (n = 176) or 24 hours (n = 179), followed by gradual rewarming of 0.5°C per hour until reaching 37°C. MAIN OUTCOMES AND MEASURES The primary outcome was 6-month neurologic outcome, with a Cerebral Performance Categories (CPC) score of 1 or 2 used to define favorable outcome. Secondary outcomes included 6-month mortality, including time to death, the occurrence of adverse events, and intensive care unit resource use. RESULTS In 355 patients who were randomized (mean age, 60 years; 295 [83%] men), 351 (99%) completed the trial. Of these patients, 69% (120/175) in the 48-hour group had a favorable outcome at 6 months compared with 64% (112/176) in the 24-hour group (difference, 4.9%; 95% CI, -5% to 14.8%; relative risk [RR], 1.08; 95% CI, 0.93-1.25; P = .33). Six-month mortality was 27% (48/175) in the 48-hour group and 34% (60/177) in the 24-hour group (difference, -6.5%; 95% CI, -16.1% to 3.1%; RR, 0.81; 95% CI, 0.59-1.11; P = .19). There was no significant difference in the time to mortality between the 48-hour group and the 24-hour group (hazard ratio, 0.79; 95% CI, 0.54-1.15; P = .22). Adverse events were more common in the 48-hour group (97%) than in the 24-hour group (91%) (difference, 5.6%; 95% CI, 0.6%-10.6%; RR, 1.06; 95% CI, 1.01-1.12; P = .04). The median length of intensive care unit stay (151 vs 117 hours; P < .001), but not hospital stay (11 vs 12 days; P = .50), was longer in the 48-hour group than in the 24-hour group. CONCLUSIONS AND RELEVANCE In unconscious survivors from out-of-hospital cardiac arrest admitted to the ICU, targeted temperature management at 33°C for 48 hours did not significantly improve 6-month neurologic outcome compared with targeted temperature management at 33°C for 24 hours. However, the study may have had limited power to detect clinically important differences, and further research may be warranted. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01689077.
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Affiliation(s)
- Hans Kirkegaard
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Inge de Haas
- Department of Anesthesiology and Intensive Care Medicine, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Ville Pettilä
- Division of Intensive Care, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Urmet Arus
- Department of Intensive Cardiac Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Hassager
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jørgen Feldbæk Nielsen
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Denmark
| | - Christina Ankjær Sørensen
- Department of Anesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Susanne Ilkjær
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Denmark
| | - Anni Nørgaard Jeppesen
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anders Morten Grejs
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Christophe Henri Valdemar Duez
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Jakob Hjort
- Department of Clinical Medicine, Aarhus University, Denmark
| | - Alf Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Norway
- Department of Clinical Science, University of Bergen, Norway
| | - Valdo Toome
- Department of Anesthesiology, Intensive Care and Emergency Medicine, North Estonia Medical Centre, Tallinn, Estonia
| | - Marjaana Tiainen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Finland
| | - Johanna Hästbacka
- Division of Intensive Care, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Timo Laitio
- Department of Anesthesiology and Intensive Care, Turku University Hospital and University of Turku, Finland
| | - Markus B. Skrifvars
- Division of Intensive Care, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University Melbourne, Australia
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Grejs AM, Nielsen BRR, Juhl-Olsen P, Gjedsted J, Sloth E, Heiberg J, Frederiksen CA, Jeppesen AN, Duez CHV, Hamre PD, Søreide E, Kirkegaard H. Effect of prolonged targeted temperature management on left ventricular myocardial function after out-of-hospital cardiac arrest − A randomised, controlled trial. Resuscitation 2017; 115:23-31. [DOI: 10.1016/j.resuscitation.2017.03.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 03/12/2017] [Accepted: 03/14/2017] [Indexed: 12/20/2022]
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Hyldmo PK, Horodyski M, Conrad BP, Aslaksen S, Røislien J, Prasarn M, Rechtine GR, Søreide E. Does the novel lateral trauma position cause more motion in an unstable cervical spine injury than the logroll maneuver? Am J Emerg Med 2017; 35:1630-1635. [PMID: 28511807 DOI: 10.1016/j.ajem.2017.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 05/08/2017] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Prehospital personnel who lack advanced airway management training must rely on basic techniques when transporting unconscious trauma patients. The supine position is associated with a loss of airway patency when compared to lateral recumbent positions. Thus, an inherent conflict exists between securing an open airway using the recovery position and maintaining spinal immobilization in the supine position. The lateral trauma position is a novel technique that aims to combine airway management with spinal precautions. The objective of this study was to compare the spinal motion allowed by the novel lateral trauma position and the well-established log-roll maneuver. METHODS Using a full-body cadaver model with an induced globally unstable cervical spine (C5-C6) lesion, we investigated the mean range of motion (ROM) produced at the site of the injury in six dimensions by performing the two maneuvers using an electromagnetic tracking device. RESULTS Compared to the log-roll maneuver, the lateral trauma position caused similar mean ROM in five of the six dimensions. Only medial/lateral linear motion was significantly greater in the lateral trauma position (1.4mm (95% confidence interval [CI] 0.4, 2.4mm)). CONCLUSIONS In this cadaver study, the novel lateral trauma position and the well-established log-roll maneuver resulted in comparable amounts of motion in an unstable cervical spine injury model. We suggest that the lateral trauma position may be considered for unconscious non-intubated trauma patients.
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Affiliation(s)
- Per Kristian Hyldmo
- Department of Research, Norwegian Air Ambulance Foundation, Drøbak, Norway; Trauma Unit, Sørlandet Hospital, Kristiansand, Norway.
| | - MaryBeth Horodyski
- Department of Orthopedics & Rehabilitation, University of Florida, Gainesville, Florida, USA.
| | - Bryan P Conrad
- Department of Orthopedics & Rehabilitation, University of Florida, Gainesville, Florida, USA; Nike Inc., Portland, Oregon, USA
| | - Sindre Aslaksen
- Division of EMS, Sørlandet Hospital, Kristiansand, Norway; Norwegian Air Ambulance, Drøbak, Norway.
| | - Jo Røislien
- Department of Health Studies, University of Stavanger, Stavanger, Norway.
| | - Mark Prasarn
- Department of Orthopedics, University of Texas, Huston, Texas, USA.
| | - Glenn R Rechtine
- Bay Pines VAHCS, Bay Pines, Florida, USA; University of South Florida, Tampa, Florida, USA
| | - Eldar Søreide
- Stavanger University Hospital, Stavanger, Norway; Network for Medical Sciences, University of Stavanger, Stavanger, Norway.
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Affiliation(s)
- Eldar Søreide
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Conrad Bjørshol
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
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Søreide E, Skuthe J. Tore Tobiassen. Tidsskriftet 2017; 137:17-0793. [DOI: 10.4045/tidsskr.17.0793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Grejs AM, Gjedsted J, Thygesen K, Lassen JF, Rasmussen BS, Jeppesen AN, Duez CHV, Søreide E, Kirkegaard H. The Extent of Myocardial Injury During Prolonged Targeted Temperature Management After Out-of-Hospital Cardiac Arrest. Am J Med 2017; 130:37-46. [PMID: 27477668 DOI: 10.1016/j.amjmed.2016.06.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 06/17/2016] [Accepted: 06/20/2016] [Indexed: 12/23/2022]
Abstract
AIM The aim of this study is to evaluate the extent of myocardial injury by cardiac biomarkers during prolonged targeted temperature management of 24 hours vs 48 hours after out-of-hospital cardiac arrest. METHODS This randomized Scandinavian multicenter study compares the extent of myocardial injury quantified by area under the curve (AUC) of cardiac biomarkers during prolonged targeted temperature management at 33°C ± 1°C of 24 hours and 48 hours, respectively. Through a period of 2.5 years, 161 comatose out-of-hospital cardiac arrest patients were randomized to targeted temperature management for 24 hours (n = 77) or 48 hours (n = 84). The AUC was calculated using both high-sensitivity cardiac troponin T (hs-cTnTAUC) and creatine kinase-myocardial band (CK-MBAUC) that were based upon measurements of these biomarkers every 6 hours upon admission until 96 hours after reaching target temperature. RESULTS The median hs-cTnTAUC of 33,827 ng/L/h (interquartile range [IQR] 11,366-117,690) of targeted temperature management at 24 hours did not differ significantly from that of 28,973 ng/L/h (IQR 10,656-163,655) at 48 hours. In contrast, the median CK-MBAUC of 1829 μg/L/h (IQR 800-6799) during targeted temperature management at 24 hours was significantly lower than that of 2428 μg/L/h (IQR 1163-10,906) within targeted temperature management at 48 hours, P <.05. CONCLUSION This study of comatose out-of-hospital cardiac arrest survivors showed no difference between the extents of myocardial injury estimated by hs-cTnTAUC of prolonged targeted temperature management of 48 hours vs 24 hours, although the CK-MBAUC was significantly higher during 48 hours vs 24 hours. Hence, it seems unlikely that the duration of targeted temperature management has a beneficial effect on the extent of myocardial injury after out-of-hospital cardiac arrest, and may even have a worsening effect.
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Affiliation(s)
- Anders Morten Grejs
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark.
| | - Jakob Gjedsted
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | | | - Jens Flensted Lassen
- Department of Cardiology, Rigshospitalet, University Hospital of Copenhagen, Denmark
| | - Bodil Steen Rasmussen
- Department of Anesthesiology and Intensive Care Medicine, Aalborg University, Denmark; Department of Clinical Medicine, Aalborg University, Denmark
| | - Anni Nørgaard Jeppesen
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Christophe Henri Valdemar Duez
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Eldar Søreide
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Norway; Department of Clinical Medicine, University of Bergen, Norway
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
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Kirkegaard H, Pedersen AR, Pettilä V, Hjort J, Rasmussen BS, de Haas I, Nielsen JF, Ilkjær S, Kaltoft A, Jeppesen AN, Grejs AM, Duez CHV, Larsen AI, Toome V, Arus U, Taccone FS, Storm C, Laitio T, Skrifvars MB, Søreide E. A statistical analysis protocol for the time-differentiated target temperature management after out-of-hospital cardiac arrest (TTH48) clinical trial. Scand J Trauma Resusc Emerg Med 2016; 24:138. [PMID: 27894327 PMCID: PMC5127087 DOI: 10.1186/s13049-016-0334-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 11/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The TTH48 trial aims to determine whether prolonged duration (48 hours) of targeted temperature management (TTM) at 33 (±1) °C results in better neurological outcomes compared to standard duration (24 hours) after six months in comatose out-of-hospital cardiac arrest (OHCA) patients. METHODS TTH48 is an investigator-initiated, multicentre, assessor-blinded, randomised, controlled superiority trial of 24 and 48 hours of TTM at 33 (±1) ° C performed in 355 comatose OHCA patients aged 18 to 80 years who were admitted to ten intensive care units (ICUs) in six Northern European countries. The primary outcome of the study is the Cerebral Performance Category (CPC) score observed at six months after cardiac arrest. CPC scores of 1 and 2 are defined as good neurological outcomes, and CPC scores of 3, 4 and 5 are defined as poor neurological outcomes. The secondary outcomes are as follows: mortality within six months after cardiac arrest, CPC at hospital discharge, Glasgow Coma Scale (GCS) score on day 4, length of stay in ICU and at hospital and the presence of any adverse events such as cerebral, circulatory, respiratory, gastrointestinal, renal, metabolic measures, infection or bleeding. With the planned sample size, we have 80% power to detect a 15% improvement in good neurological outcomes at a two-sided statistical significance level of 5%. DISCUSSION We present a detailed statistical analysis protocol (SAP) that specifies how primary and secondary outcomes should be evaluated. We also predetermine covariates for adjusted analyses and pre-specify sub-groups for sensitivity analyses. This pre-planned SAP will reduce analysis bias and add validity to the findings of this trial on the effect of length of TTM on important clinical outcomes after cardiac arrest. TRIAL REGISTRATION ClinicalTrials.gov: NCT01689077 , 17 September 2012.
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Affiliation(s)
- Hans Kirkegaard
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark. .,Research Center for Emergency Medicine, Aarhus University, Aarhus, Denmark.
| | - Asger Roer Pedersen
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Aarhus, Denmark
| | - Ville Pettilä
- Division of Intensive Care, Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland.,Division of Intensive Care, Department of Anaesthesiology and Intensive Care Medicine, Helsinki University, Helsinki, Finland.,Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jakob Hjort
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Inge de Haas
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Jørgen Feldbæk Nielsen
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Aarhus, Denmark
| | - Susanne Ilkjær
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Kaltoft
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anni Nørgaard Jeppesen
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark.,Research Center for Emergency Medicine, Aarhus University, Aarhus, Denmark
| | - Anders Morten Grejs
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark.,Research Center for Emergency Medicine, Aarhus University, Aarhus, Denmark
| | - Christophe Henri Valdemar Duez
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark.,Research Center for Emergency Medicine, Aarhus University, Aarhus, Denmark
| | - Alf Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Valdo Toome
- Department of Anaesthesiology, Intensive Care and Emergency Medicine, North Estonia Medical Centre, Tallinn, Estonia
| | - Urmet Arus
- Department of Intensive Cardiac Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasmus Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Timo Laitio
- Department of Anaesthesiology and Intensive Care, University of Turku, Turku, Finland.,Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, Turku, Finland
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland.,Division of Intensive Care, Department of Anaesthesiology and Intensive Care Medicine, Helsinki University, Helsinki, Finland.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University Melbourne, Monash, Australia
| | - Eldar Søreide
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Hyldmo PK, Horodyski MB, Conrad BP, Dubose DN, Røislien J, Prasarn M, Rechtine GR, Søreide E. Safety of the lateral trauma position in cervical spine injuries: a cadaver model study. Acta Anaesthesiol Scand 2016; 60:1003-11. [PMID: 26952653 PMCID: PMC5069596 DOI: 10.1111/aas.12714] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/11/2016] [Accepted: 02/12/2016] [Indexed: 11/29/2022]
Abstract
Background Endotracheal intubation is not always an option for unconscious trauma patients. Prehospital personnel are then faced with the dilemma of maintaining an adequate airway without risking deleterious movement of a potentially unstable cervical spine. To address these two concerns various alternatives to the classical recovery position have been developed. This study aims to determine the amount of motion induced by the recovery position, two versions of the HAINES (High Arm IN Endangered Spine) position, and the novel lateral trauma position (LTP). Method We surgically created global cervical instability between the C5 and C6 vertebrae in five fresh cadavers. We measured the rotational and translational (linear) range of motion during the different maneuvers using an electromagnetic tracking device and compared the results using a general linear mixed model (GLMM) for regression. Results In the recovery position, the range of motion for lateral bending was 11.9°. While both HAINES positions caused a similar range of motion, the motion caused by the LTP was 2.6° less (P = 0.037). The linear axial range of motion in the recovery position was 13.0 mm. In comparison, the HAINES 1 and 2 positions showed significantly less motion (−5.8 and −4.6 mm, respectively), while the LTP did not (−4.0 mm, P = 0.067). Conclusion Our results indicate that in unconscious trauma patients, the LTP or one of the two HAINES techniques is preferable to the standard recovery position in cases of an unstable cervical spine injury.
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Affiliation(s)
- P. K. Hyldmo
- Department of Research Norwegian Air Ambulance Foundation Drøbak Norway
- Department of Anesthesiology and Intensive Care Sørlandet Hospital Kristiansand Norway
| | - M. B. Horodyski
- Department of Orthopedics & Rehabilitation University of Florida Gainesville Florida USA
| | - B. P. Conrad
- Department of Orthopedics & Rehabilitation University of Florida Gainesville Florida USA
- Nike Sport Research Lab Nike Inc. Beaverton Oregon USA
| | - D. N. Dubose
- Department of Orthopedics & Rehabilitation University of Florida Gainesville Florida USA
| | - J. Røislien
- Department of Health Studies University of Stavanger Stavanger Norway
- Department of Biostatistics University of Oslo Oslo Norway
| | - M. Prasarn
- Department of Orthopedics University of Texas Huston Texas USA
| | - G. R. Rechtine
- Bay Pines VA Hospital System Bay Pines Florida USA
- Department of Orthopedic Surgery University of South Florida Tampa Florida USA
| | - E. Søreide
- Department of Anesthesiology and Intensive Care Stavanger University Hospital Stavanger Norway
- Network for Medical Sciences University of Stavanger Stavanger Norway
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Tjoflåt I, Melissa TJ, Mduma E, Hansen BS, Søreide E. Mismatched expectations? Experiences of nurses in a low-income country working with visiting nurses from high-income countries. J Clin Nurs 2016; 26:1535-1544. [PMID: 27324119 DOI: 10.1111/jocn.13453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2016] [Indexed: 11/30/2022]
Abstract
AIM AND OBJECTIVES To describe how nurses in a rural hospital in a low-income country experience working with visiting nurses from high-income countries. BACKGROUND Nurses in low-income countries work with visiting nurses from high-income countries in various health projects. However, there is a paucity of studies examining how nurses in low-income countries experience working with nurses from such different backgrounds. DESIGN This study is descriptive, explorative and qualitative. METHODS The data were collected from 10 semi-structured interviews in 2015 and were analysed using qualitative content analysis. The study was conducted with ward nurses in a rural hospital in Tanzania, a sub-Saharan African country characterised as low-income country. FINDINGS The data analysis revealed two themes related to the local nurses' experiences of working with visiting nurses from high-income countries: (1) To do it our way and (2) Different expectations, benefits and limitations. CONCLUSION The findings strongly indicate that the local nurses expected foreign nurses to follow the local system and work under supervision. The local nurses appreciated opportunities to learn from working and sharing knowledge with foreign nurses, but simultaneously expressed that the gained knowledge should be adapted and implemented according to their local health system. RELEVANCE TO CLINICAL PRACTICE The findings can inform nurses, humanitarian organisations, hospitals and universities working in international collaborations.
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Affiliation(s)
- Ingrid Tjoflåt
- Department of Health Studies, Faculty of Social Science, University of Stavanger, Stavanger, Norway
| | | | - Estomih Mduma
- Research Centre, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania.,Department of Research, Stavanger University Hospital, Stavanger, Norway
| | - Britt Saetre Hansen
- Department of Health Studies, Faculty of Social Science, University of Stavanger, Stavanger, Norway.,University College Vestfold and Stavanger University Hospital, Stavanger, Norway
| | - Eldar Søreide
- Stavanger University Hospital and University of Stavanger, Stavanger, Norway
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Abstract
OBJECTIVE Cardiopulmonary resuscitation (CPR) provided by community citizens is of paramount importance for out-of-hospital cardiac arrest (OHCA) victims' survival. Fortunately, CPR rates by community citizens seem to be rising. However, the experience of providing CPR is rarely investigated. The aim of this study was to explore reactions and coping strategies in lay rescuers who have provided CPR to OHCA victims. METHODS, PARTICIPANTS This is a qualitative study of 20 lay rescuers who have provided CPR to 18 OHCA victims. We used a semistructured interview guide focusing on their experiences after providing CPR. SETTING The study was conducted in the Stavanger region of Norway, an area with very high bystander CPR rates. RESULTS Three themes emerged from the interview analysis: concern, uncertainty and coping strategies. Providing CPR had been emotionally challenging for all lay rescuers and, for some, had consequences in terms of family and work life. Several lay rescuers experienced persistent mental recurrences of the OHCA incident and had concerns about the outcome for the cardiac arrest victim. Unknown or fatal outcomes often caused feelings of guilt and were particularly difficult to handle. Several reported the need to be acknowledged for their CPR attempts. Health-educated lay rescuers seemed to be less affected than others. A common coping strategy was confiding in close relations, preferably the health educated. However, some required professional help to cope with the OHCA incident. CONCLUSIONS Lay rescuers experience emotional and social challenges, and some struggle to cope in life after providing CPR in OHCA incidents. Experiencing a positive patient outcome and being a health-educated lay rescuer seem to mitigate concerns. Common coping strategies are attempts to reduce uncertainty towards patient outcome and own CPR quality. Further studies are needed to determine whether an organised professional follow-up can mitigate the concerns and uncertainty of lay rescuers.
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Affiliation(s)
- Wenche Torunn Mathiesen
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway
| | - Conrad Arnfinn Bjørshol
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Geir Sverre Braut
- Department of Research, Stavanger University Hospital, Stavanger, Norway
- Stord/Haugesund University College, Haugesund, Norway
| | - Eldar Søreide
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
- Network for Medical Sciences, University of Stavanger, Stavanger, Norway
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47
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Kirkegaard H, Rasmussen BS, de Haas I, Nielsen JF, Ilkjær S, Kaltoft A, Jeppesen AN, Grejs A, Duez CHV, Larsen AI, Pettilä V, Toome V, Arus U, Taccone FS, Storm C, Skrifvars MB, Søreide E. Time-differentiated target temperature management after out-of-hospital cardiac arrest: a multicentre, randomised, parallel-group, assessor-blinded clinical trial (the TTH48 trial): study protocol for a randomised controlled trial. Trials 2016; 17:228. [PMID: 27142588 PMCID: PMC4855491 DOI: 10.1186/s13063-016-1338-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 04/06/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The application of therapeutic hypothermia (TH) for 12 to 24 hours following out-of-hospital cardiac arrest (OHCA) has been associated with decreased mortality and improved neurological function. However, the optimal duration of cooling is not known. We aimed to investigate whether targeted temperature management (TTM) at 33 ± 1 °C for 48 hours compared to 24 hours results in a better long-term neurological outcome. METHODS The TTH48 trial is an investigator-initiated pragmatic international trial in which patients resuscitated from OHCA are randomised to TTM at 33 ± 1 °C for either 24 or 48 hours. Inclusion criteria are: age older than 17 and below 80 years; presumed cardiac origin of arrest; and Glasgow Coma Score (GCS) <8, on admission. The primary outcome is neurological outcome at 6 months using the Cerebral Performance Category score (CPC) by an assessor blinded to treatment allocation and dichotomised to good (CPC 1-2) or poor (CPC 3-5) outcome. Secondary outcomes are: 6-month mortality, incidence of infection, bleeding and organ failure and CPC at hospital discharge, at day 28 and at day 90 following OHCA. Assuming that 50 % of the patients treated for 24 hours will have a poor outcome at 6 months, a study including 350 patients (175/arm) will have 80 % power (with a significance level of 5 %) to detect an absolute 15 % difference in primary outcome between treatment groups. A safety interim analysis was performed after the inclusion of 175 patients. DISCUSSION This is the first randomised trial to investigate the effect of the duration of TTM at 33 ± 1 °C in adult OHCA patients. We anticipate that the results of this trial will add significant knowledge regarding the management of cooling procedures in OHCA patients. TRIAL REGISTRATION NCT01689077.
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Affiliation(s)
- Hans Kirkegaard
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark.
| | - Bodil S Rasmussen
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Inge de Haas
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Jørgen Feldbæk Nielsen
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Hammel, Denmark
| | - Susanne Ilkjær
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Kaltoft
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anni Nørregaard Jeppesen
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anders Grejs
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Christophe Henri Valdemar Duez
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Alf Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Ville Pettilä
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland.,Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Valdo Toome
- Department of Anesthesiology, Intensive Care and Emergency Medicine, North Estonia Medical Centre, Tallinn, Estonia
| | - Urmet Arus
- Department of Intensive Cardiac Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Eldar Søreide
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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48
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Bjørshol CA, Sollid S, Flaatten H, Hetland I, Mathiesen WT, Søreide E. Great variation between ICU physicians in the approach to making end-of-life decisions. Acta Anaesthesiol Scand 2016; 60:476-84. [PMID: 26941116 DOI: 10.1111/aas.12640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 09/07/2015] [Accepted: 09/11/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION End-of-life (EOL) decision-making in the intensive care unit (ICU) is difficult, but is rarely practiced in simulated settings. We wanted to explore different strategies ICU physicians use when making EOL decisions, and whether attitudes towards EOL decisions differ between a small-group simulation setting and a large-group plenary setting. METHODS The study took place during a Scandinavian anaesthesiology and intensive care conference. The simulated ICU patient had a cancer disease with a grave prognosis, had undergone surgery, suffered from severe co-morbidities and had a son present demanding all possible treatment. The participants were asked to make a decision regarding further ICU care. We presented the same case scenario in a plenary session with voting opportunities. RESULTS In the simulation group (n = 48), ICU physicians used various strategies to come to an EOL decision: patient-oriented, family-oriented, staff-oriented and regulatory-oriented. The simulation group was more willing than the plenary group (n = 47) to readmit the patient to the ICU if the patient again would need respiratory support (32% vs. 8%, P < 0.001). Still, fewer participants in the simulation group than in the plenary group (21% vs. 38%, P = 0.019) considered the patient's life expectancy of living an independent life to be over 10%. CONCLUSION There was great variation between ICU physicians in the approach to making EOL decisions, and large variations in their life expectancy estimates. Participants in the simulation group were more willing to admit and readmit the patient to the ICU, despite being more pessimistic towards life expectancies. We believe simulation can be used more extensively in EOL decision-making training.
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Affiliation(s)
- C. A. Bjørshol
- Department of Anaesthesiology and Intensive Care; Stavanger University Hospital; Stavanger Norway
- Stavanger Acute Medicine Foundation for Education and Research; Stavanger University Hospital; Stavanger Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - S. Sollid
- Department of Research and Development; Norwegian Air Ambulance Foundation; Drøbak Norway
- Department of Health Care Sciences; University of Stavanger; Stavanger Norway
| | - H. Flaatten
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Department of Anaesthesiology and Intensive Care; Haukeland University Hospital; Bergen Norway
| | - I. Hetland
- Stavanger Acute Medicine Foundation for Education and Research; Stavanger University Hospital; Stavanger Norway
| | - W. T. Mathiesen
- Department of Anaesthesiology and Intensive Care; Stavanger University Hospital; Stavanger Norway
| | - E. Søreide
- Department of Anaesthesiology and Intensive Care; Stavanger University Hospital; Stavanger Norway
- Stavanger Acute Medicine Foundation for Education and Research; Stavanger University Hospital; Stavanger Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Department of Health Care Sciences; University of Stavanger; Stavanger Norway
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49
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Søreide E, Larsen AI. Post resuscitation care--some words of caution and a call for action. Scand J Trauma Resusc Emerg Med 2015; 23:89. [PMID: 26537006 PMCID: PMC4632340 DOI: 10.1186/s13049-015-0167-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 10/22/2015] [Indexed: 01/22/2023] Open
Abstract
This fall the European Resuscitation Council (ERC) and the European Cardiology Society (ESC) publish updated post resuscitation care guidelines. For these guidelines to have an impact they must be implemented into daily clinical practice. Newer studies imply that differences in hospital care explain much of the observed differences in survival after out-of-hospital cardiac arrest. A recent Nordic (Denmark, Finland, Iceland, Norway, Sweden) survey suggests worrisome variations in post resuscitation care provided and should urge us all to act in the coming years. One important step will be to build up resuscitation systems with integrated cardiac arrest centres in all the 5 Nordic countries and benchmark process of care, financial implications and survival.
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Affiliation(s)
- Eldar Søreide
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway. .,Network for Medical Sciences, University of Stavanger, Stavanger, Norway.
| | - Alf Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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50
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Hyldmo PK, Vist GE, Feyling AC, Rognås L, Magnusson V, Sandberg M, Søreide E. Does turning trauma patients with an unstable spinal injury from the supine to a lateral position increase the risk of neurological deterioration?--A systematic review. Scand J Trauma Resusc Emerg Med 2015; 23:65. [PMID: 26382216 PMCID: PMC4573694 DOI: 10.1186/s13049-015-0143-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 08/10/2015] [Indexed: 12/22/2022] Open
Abstract
Background Airway protection and spinal precautions are competing concerns in the treatment of unconscious trauma patients. The placement of such patients in a lateral position may facilitate the acquisition of an adequate airway. However, trauma dogma dictates that patients should be transported in the supine position to minimize spinal movement. In this systematic review, we sought to answer the following question: Given an existing spinal injury, will changing a patient’s position from supine to lateral increase the risk of neurological deterioration? Methods The review protocol was published in the PROSPERO database (Reg. no. CRD42012001190). We performed literature searches in PubMed, Medline, EMBASE, the Cochrane Library, CINAHL and the British Nursing Index and included studies of traumatic spinal injury, lateral positioning and neurological deterioration. The search was updated prior to submission. Two researchers independently completed each step in the review process. Results We identified 1,164 publications. However, none of these publications reported mortality or neurological deterioration with lateral positioning as an outcome measure. Twelve studies used movement of the injured spine with lateral positioning as an outcome measure; eleven of these investigations were cadaver studies. All of these cadaver studies reported spinal movement during lateral positioning. The only identified human study included eighteen patients with thoracic or lumbar spinal fractures; according to the study authors, the logrolling technique did not result in any neurological deterioration among these patients. Conclusions We identified no clinical studies demonstrating that rotating trauma patients from the supine position to a lateral position affects mortality or causes neurological deterioration. However, in various cadaver models, this type of rotation did produce statistically significant displacements of the injured spine. The clinical significance of these cadaver-based observations remains unclear. The present evidence for harm in rotating trauma patients from the supine position to a lateral position, including the logroll maneuver, is inconclusive. Electronic supplementary material The online version of this article (doi:10.1186/s13049-015-0143-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Per Kristian Hyldmo
- Norwegian Air Ambulance Foundation, Department of Research and Development, Drøbak, Norway. .,Department of Anesthesiology and Intensive Care, Sørlandet Hospital, Kristiansand, Norway.
| | - Gunn E Vist
- The Norwegian Knowledge Center for the Health Services, Oslo, Norway.
| | | | - Leif Rognås
- Pre-hospital Critical Care Services, Aarhus, Denmark.
| | - Vidar Magnusson
- Department of Anesthesiology, Landspitalinn University Hospital, Reykjavík, Iceland.
| | - Mårten Sandberg
- Faculty of Medicine, University of Oslo, Oslo, Norway. .,Air Ambulance Department, Oslo University Hospital, Oslo, Norway.
| | - Eldar Søreide
- Network for Medical Sciences, University of Stavanger, Stavanger, Norway. .,Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway.
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