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Ilich A, Gernsheimer TB, Triulzi DJ, Herren H, Brown SP, Holle LA, Lucas AT, de Laat B, El Kassar N, Wolberg AS, May S, Key NS. Absence of hyperfibrinolysis may explain lack of efficacy of tranexamic acid in hypoproliferative thrombocytopenia. Blood Adv 2023; 7:900-908. [PMID: 36044391 PMCID: PMC10025092 DOI: 10.1182/bloodadvances.2022008255] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/29/2022] [Accepted: 08/21/2022] [Indexed: 11/20/2022] Open
Abstract
The American Trial Using Tranexamic Acid (TXA) in Thrombocytopenia (A-TREAT, NCT02578901) demonstrated no superiority of TXA over placebo in preventing World Health Organization (WHO) grade 2 or higher bleeding in patients with severe thrombocytopenia requiring supportive platelet transfusion following myeloablative therapy for hematologic disorders. In this ancillary study, we sought to determine whether this clinical outcome could be explained on the basis of correlative assays of fibrinolysis. Plasma was collected from A-TREAT participants (n = 115) before the initiation of study drug (baseline) and when TXA was at steady-state trough concentration (follow-up). Global fibrinolysis was measured by 3 assays: euglobulin clot lysis time (ECLT), plasmin generation (PG), and tissue-type plasminogen activator (tPA)-challenged clot lysis time (tPA-CLT). TXA was quantified in follow-up samples by tandem mass spectrometry. Baseline samples did not demonstrate fibrinolytic activation by ECLT or tPA-CLT. Furthermore, neither ECLT nor levels of plasminogen activator inhibitor-1, tPA, plasminogen, alpha2-antiplasmin, or plasmin-antiplasmin complexes were associated with a greater risk of WHO grade 2+ bleeding. TXA trough concentrations were highly variable (range, 0.7-10 μg/mL) and did not correlate with bleeding severity, despite the fact that plasma TXA levels correlated strongly with pharmacodynamic assessments by PG (Spearman r, -0.78) and tPA-CLT (r, 0.74). We conclude that (1) no evidence of fibrinolytic activation was observed in these patients with thrombocytopenia, (2) trough TXA concentrations varied significantly between patients receiving the same dosing schedule, and (3) tPA-CLT and PG correlated well with TXA drug levels.
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Affiliation(s)
- Anton Ilich
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Terry B. Gernsheimer
- Department of Medicine/Hematology and Seattle Cancer Care Alliance, University of Washington, Seattle, WA
| | | | - Heather Herren
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Siobhan P. Brown
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Lori A. Holle
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Andrew T. Lucas
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
| | - Bas de Laat
- Synapse Research Institute, Maastricht, The Netherlands
| | - Nahed El Kassar
- Division of Blood Diseases and Resources, National Heart Lung and Blood Institute, Washington, DC
| | - Alisa S. Wolberg
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Susanne May
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Nigel S. Key
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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2
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Grunau B, Kime N, Leroux B, Rea T, Van Belle G, Menegazzi JJ, Kudenchuk PJ, Vaillancourt C, Morrison LJ, Elmer J, Zive DM, Le NM, Austin M, Richmond NJ, Herren H, Christenson J. Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. JAMA 2020; 324:1058-1067. [PMID: 32930759 PMCID: PMC7492914 DOI: 10.1001/jama.2020.14185] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 07/15/2020] [Indexed: 12/16/2022]
Abstract
Importance There is wide variability among emergency medical systems (EMS) with respect to transport to hospital during out-of-hospital cardiac arrest (OHCA) resuscitative efforts. The benefit of intra-arrest transport during resuscitation compared with continued on-scene resuscitation is unclear. Objective To determine whether intra-arrest transport compared with continued on-scene resuscitation is associated with survival to hospital discharge among patients experiencing OHCA. Design, Setting, and Participants Cohort study of prospectively collected consecutive nontraumatic adult EMS-treated OHCA data from the Resuscitation Outcomes Consortium (ROC) Cardiac Epidemiologic Registry (enrollment, April 2011-June 2015 from 10 North American sites; follow-up until the date of hospital discharge or death [regardless of when either event occurred]). Patients treated with intra-arrest transport (exposed) were matched with patients in refractory arrest (at risk of intra-arrest transport) at that same time (unexposed), using a time-dependent propensity score. Subgroups categorized by initial cardiac rhythm and EMS-witnessed cardiac arrests were analyzed. Exposures Intra-arrest transport (transport initiated prior to return of spontaneous circulation), compared with continued on-scene resuscitation. Main Outcomes and Measures The primary outcome was survival to hospital discharge, and the secondary outcome was survival with favorable neurological outcome (modified Rankin scale <3) at hospital discharge. Results The full cohort included 43 969 patients with a median age of 67 years (interquartile range, 55-80), 37% were women, 86% of cardiac arrests occurred in a private location, 49% were bystander- or EMS-witnessed, 22% had initial shockable rhythms, 97% were treated by out-of-hospital advanced life support, and 26% underwent intra-arrest transport. Survival to hospital discharge was 3.8% for patients who underwent intra-arrest transport and 12.6% for those who received on-scene resuscitation. In the propensity-matched cohort, which included 27 705 patients, survival to hospital discharge occurred in 4.0% of patients who underwent intra-arrest transport vs 8.5% who received on-scene resuscitation (risk difference, 4.6% [95% CI, 4.0%- 5.1%]). Favorable neurological outcome occurred in 2.9% of patients who underwent intra-arrest transport vs 7.1% who received on-scene resuscitation (risk difference, 4.2% [95% CI, 3.5%-4.9%]). Subgroups of initial shockable and nonshockable rhythms as well as EMS-witnessed and unwitnessed cardiac arrests all had a significant association between intra-arrest transport and lower probability of survival to hospital discharge. Conclusions and Relevance Among patients experiencing out-of-hospital cardiac arrest, intra-arrest transport to hospital compared with continued on-scene resuscitation was associated with lower probability of survival to hospital discharge. Study findings are limited by potential confounding due to observational design.
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Affiliation(s)
- Brian Grunau
- Departments of Emergency Medicine and the Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, Canada
- University of British Columbia, Vancouver, Canada
| | - Noah Kime
- Department of Medicine, University of Washington, Seattle
| | - Brian Leroux
- Department of Medicine, University of Washington, Seattle
| | - Thomas Rea
- Department of Medicine, University of Washington, Seattle
| | | | - James J. Menegazzi
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Laurie J. Morrison
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Nancy M. Le
- Oregon Health and Science University, Portland
| | - Michael Austin
- Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
| | - Neal J. Richmond
- Metropolitan Area EMS Authority/Emergency Physicians Advisory Board, Ft Worth, Texas
| | - Heather Herren
- Department of Medicine, University of Washington, Seattle
| | - Jim Christenson
- Departments of Emergency Medicine and the Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, Canada
- University of British Columbia, Vancouver, Canada
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3
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Lupton JR, Schmicker RH, Aufderheide TP, Blewer A, Callaway C, Carlson JN, Colella MR, Hansen M, Herren H, Nichol G, Wang H, Daya MR. Racial disparities in out-of-hospital cardiac arrest interventions and survival in the Pragmatic Airway Resuscitation Trial. Resuscitation 2020; 155:152-158. [PMID: 32795597 DOI: 10.1016/j.resuscitation.2020.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/24/2020] [Accepted: 08/03/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prior studies have reported racial disparities in survival from out-of-hospital cardiac arrest (OHCA). However, these studies did not evaluate the association of race with OHCA course of care and outcomes. The purpose of this study was to evaluate racial disparities in OHCA airway placement success and patient outcomes in the multicenter Pragmatic Airway Resuscitation Trial (PART). METHOD We conducted a secondary analysis of adult OHCA patients enrolled in PART. The parent trial randomized subjects to initial advanced airway management with laryngeal tube or endotracheal intubation. For this analysis, the primary independent variable was patient race categorized by emergency medical services (EMS) as white, black, Hispanic, other, and unknown. We used general estimating equations to examine the association of race with airway attempt success, 72-h survival, and survival to hospital discharge, adjusting for sex, age, witness status, bystander cardiopulmonary resuscitation (CPR), initial rhythm, arrest location, and PART randomization cluster. RESULTS Of 3002 patients, EMS-assessed race as 1537 white, 860 black, 163 Hispanic, 90 other, and 352 unknown. Initial shockable rhythms (13.8% vs. 21.5%, p < 0.001), bystander CPR (35.6% vs. 51.4%, p < 0.001), and survival to hospital discharge (7.6% vs. 10.8%, p = 0.011) were lower for black compared to white patients. After adjustment for confounders, no difference was seen in airway success, 72-h survival, and survival to hospital discharge by race. CONCLUSIONS In one of the largest studies evaluating differences in prehospital airway interventions and outcomes by EMS-assessed race for OHCA patients, we found no significant adjusted differences between airway success or survival outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | - Matt Hansen
- Oregon Health & Science University, United States
| | - Heather Herren
- University of Washington School of Medicine, United States
| | - Graham Nichol
- University of Washington School of Medicine, United States
| | - Henry Wang
- University of Texas Health Science Center at Houston, United States
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4
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Lupton JR, Schmicker RH, Stephens S, Carlson JN, Callaway C, Herren H, Idris AH, Sopko G, Puyana JCJ, Daya MR, Wang H, Hansen M. Outcomes With the Use of Bag-Valve-Mask Ventilation During Out-of-hospital Cardiac Arrest in the Pragmatic Airway Resuscitation Trial. Acad Emerg Med 2020; 27:366-374. [PMID: 32220129 DOI: 10.1111/acem.13927] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/22/2019] [Accepted: 10/26/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND While emergency medical services (EMS) often use endotracheal intubation (ETI) or supraglottic airways (SGA), some patients receive only bag-valve-mask (BVM) ventilation during out-of-hospital cardiac arrests (OHCA). Our objective was to compare patient characteristics and outcomes for BVM ventilation to advanced airway management (AAM) in adults with OHCA. METHODS Using data from the Pragmatic Airway Resuscitation Trial, we identified patients receiving AAM (ETI or a SGA), BVM ventilation only (BVM-only), and BVM ventilation as a rescue after at least one failed attempt at advanced airway placement (BVM-rescue). The outcomes were return of spontaneous circulation (ROSC), 72-hour survival, survival to hospital discharge, neurologically intact survival (Modified Rankin Scale ≤ 3), and the presence of aspiration on a chest radiograph. Comparisons were made using generalized mixed-effects models while adjusting for age, sex, initial rhythm, EMS-witnessed status, bystander cardiopulmonary resuscitation, response time, study cluster, and advanced life support first on scene. RESULTS Of 3,004 patients enrolled, there were 282 BVM-only, 2,129 AAM, and 156 BVM-rescue patients with complete covariates. Shockable initial rhythms (34% vs. 18.6%) and EMS-witnessed arrests (21.6% vs. 11.3%) were more likely in BVM-only than AAM but similar between BVM-rescue and AAM. Compared to AAM, BVM-only patients had similar ROSC (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 0.96 to 1.73), but higher 72-hour survival (OR = 1.96, 95% CI = 1.42 to 2.69), survival to discharge (OR = 4.47, 95% CI = 3.03 to 6.59), and neurologically intact survival (OR = 7.05, 95% CI = 4.40 to 11.3). Compared to AAM, BVM-rescue patients had similar ROSC (OR = 0.73, 95% CI = 0.47 to 1.12) and 72-hour survival (OR = 1.08, 95% CI = 0.66 to 1.77) but higher survival to discharge (OR = 2.15, 95% CI = 1.17 to 3.95) and neurologically intact survival (OR = 2.64, 95% CI = 1.20 to 5.81). Aspiration incidence was similar. CONCLUSIONS Bag-valve-mask-only ventilation is associated with improved OHCA outcomes. Despite similar rates of ROSC and 72-hour survival, BVM-rescue ventilation was associated with improved survival to discharge and neurologically intact survival compared to successful AAM.
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Affiliation(s)
| | | | | | | | | | | | | | - George Sopko
- National Heart, Lung, and Blood Institute Bethesda MD
| | | | | | - Henry Wang
- University of Texas Health Science Center at Houston Houston TX
| | - Matt Hansen
- Oregon Health and Science University Portland OR
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5
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Okubo M, Schmicker RH, Wallace DJ, Idris AH, Nichol G, Austin MA, Grunau B, Wittwer LK, Richmond N, Morrison LJ, Kurz MC, Cheskes S, Kudenchuk PJ, Zive DM, Aufderheide TP, Wang HE, Herren H, Vaillancourt C, Davis DP, Vilke GM, Scheuermeyer FX, Weisfeldt ML, Elmer J, Colella R, Callaway CW. Variation in Survival After Out-of-Hospital Cardiac Arrest Between Emergency Medical Services Agencies. JAMA Cardiol 2019; 3:989-999. [PMID: 30267053 DOI: 10.1001/jamacardio.2018.3037] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Emergency medical services (EMS) deliver essential initial care for patients with out-of-hospital cardiac arrest (OHCA), but the extent to which patient outcomes vary between different EMS agencies is not fully understood. Objective To quantify variation in patient outcomes after OHCA across EMS agencies. Design, Setting, and Participants This observational cohort study was conducted in the Resuscitation Outcomes Consortium (ROC) Epistry, a prospective multicenter OHCA registry at 10 sites in North America. Any adult with OHCA treated by an EMS from April 2011 through June 2015 was included. Data analysis occurred from May 2017 to March 2018. Exposure Treating EMS agency. Main Outcomes and Measures The primary outcome was survival to hospital discharge. Secondary outcomes were return of spontaneous circulation at emergency department arrival and favorable functional outcome at hospital discharge (defined as a modified Rankin scale score ≤3). Multivariable hierarchical logistic regression models were used to adjust confounders and clustering of patients within EMS agencies, and calculated median odds ratios (MORs) were used to quantify the extent of residual variation in outcomes between EMS agencies. Results We identified 43 656 patients with OHCA treated by 112 EMS agencies. At EMS agency level, we observed large variations in survival to hospital discharge (range, 0%-28.9%; unadjusted MOR, 1.43 [95% CI, 1.34-1.54]), return of spontaneous circulation on emergency department arrival (range, 9.0%-57.1%; unadjusted MOR, 1.53 [95% CI, 1.43-1.65]), and favorable functional outcome (range, 0%-20.4%; unadjusted MOR, 1.54 [95% CI, 1.40-1.73]). This variation persisted despite adjustment for patient-level and EMS agency-level factors known to be associated with outcomes (adjusted MOR for survival 1.56 [95% CI 1.44-1.73]; adjusted MOR for return of spontaneous circulation at emergency department arrival, 1.50 [95% CI, 1.41-1.62]; adjusted MOR for functionally favorable survival, 1.53 [95% CI, 1.37-1.78]). After restricting analysis to those who survived more than 60 minutes after hospital arrival and including hospital treatment characteristics, the variation persisted (adjusted MOR for survival, 1.49 [95% CI, 1.36-1.69]; adjusted MOR for functionally favorable survival, 1.34 [95% CI, 1.20-1.59]). Conclusions and Relevance We found substantial variations in patient outcomes after OHCA between a large group of EMS agencies in North America that were not explained by documented patient-level and EMS agency-level variables.
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Affiliation(s)
- Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert H Schmicker
- Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle
| | - David J Wallace
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ahamed H Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, Seattle
| | - Michael A Austin
- Department of Emergency Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Grunau
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lynn K Wittwer
- Clark County Emergency Medical Services, Vancouver, Washington
| | | | - Laurie J Morrison
- Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael C Kurz
- Department of Emergency Medicine, University of Alabama at Birmingham
| | - Sheldon Cheskes
- Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter J Kudenchuk
- Division of Cardiology, Department of Medicine, University of Washington, Seattle
| | - Dana M Zive
- Department of Emergency Medicine, Oregon Health and Science University, Portland
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee
| | - Henry E Wang
- Department of Emergency Medicine, University of Texas Health Science Center at Houston, Houston
| | - Heather Herren
- Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle
| | - Christian Vaillancourt
- Department of Emergency Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel P Davis
- Department of Emergency Medicine, University of California, San Diego
| | - Gary M Vilke
- Department of Emergency Medicine, University of California, San Diego
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Myron L Weisfeldt
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Riccardo Colella
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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6
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Starks MA, Schmicker RH, Peterson ED, May S, Buick JE, Kudenchuk PJ, Drennan IR, Herren H, Jasti J, Sayre M, Stub D, Vilke GM, Stephens SW, Chang AM, Nuttall J, Nichol G. Association of Neighborhood Demographics With Out-of-Hospital Cardiac Arrest Treatment and Outcomes: Where You Live May Matter. JAMA Cardiol 2019; 2:1110-1118. [PMID: 28854308 DOI: 10.1001/jamacardio.2017.2671] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance We examined whether resuscitation care and outcomes vary by the racial composition of the neighborhood where out-of-hospital cardiac arrests (OHCAs) occur. Objective To evaluate the association between bystander treatments (cardiopulmonary resuscitation and automatic external defibrillation) and timing of emergency medical services personnel on OHCA outcomes according to the racial composition of the neighborhood where the OHCA event occurred. Design, Setting, and Participants This retrospective observational cohort study examined patients with OHCA from January 1, 2008, to December 31, 2011, using data from the Resuscitation Outcomes Consortium. Neighborhoods where OHCA occurred were classified by census tract, based on percentage of black residents: less than 25%, 25% to 50%, 51% to 75%, or more than 75%. Multilevel mixed-effects logistic regression modeling examined the association between racial composition of neighborhoods and OHCA survival, adjusting for patient, neighborhood, and treatment characteristics. Main Outcomes and Measures Survival to discharge, return of spontaneous circulation on emergency department arrival, and favorable neurologic status at discharge. Results We examined 22 816 adult patients with nontraumatic OHCA at Resuscitation Outcomes Consortium sites in the United States. The median age of patients with OHCA was 64 years (interquartile range [IQR], 51-78). Compared with patients who experienced OHCA in neighborhoods with a lower proportion of black residents, those in neighborhoods with more than 75% black residents were slightly younger, were more frequently women, had lower rates of initial shockable rhythm, and less frequently experienced OHCA in a public location. The percentage of patients with OHCA receiving bystander cardiopulmonary resuscitation or a lay automatic external defibrillation was inversely associated with the percentage of black residents in neighborhoods. Compared with OHCA in predominantly white neighborhoods (<25% black), those with OHCA in mixed to majority black neighborhoods had lower adjusted survival rates to hospital discharge (25%-50% black: odds ratio, 0.76; 95% CI, 0.61-0.93; 51%-75% black: odds ratio, 0.67; 95% CI, 0.49-0.90; >75% black: odds ratio, 0.63; 95% CI, 0.50-0.79; P < .001). There was similar mortality risk for black and white patients with OHCA in each neighborhood racial quantile. When the primary model included geographic site, there was an attenuated nonsignificant association between racial composition in a neighborhood and survival. Conclusions and Relevance Those with OHCA in predominantly black neighborhoods had the lowest rates of bystander cardiopulmonary resuscitation and automatic external defibrillation use and significantly lower likelihood for survival compared with predominantly white neighborhoods. Improving bystander treatments in these neighborhoods may improve cardiac arrest survival.
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Affiliation(s)
| | | | - Eric D Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | | | - Jason E Buick
- Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Ian R Drennan
- Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Dion Stub
- Alfred and Western Hospital, Baker IDI Heart and Diabetes Institute, Monash University, Melbourne, Victoria, Australia
| | - Gary M Vilke
- University of California, San Diego Health System, San Diego
| | | | - Anna M Chang
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
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7
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Carlson JN, Zive D, Griffiths D, Brown KN, Schmicker RH, Herren H, Sopko G, DiFiore S, Climer D, Herdeman C, Idris A, Nichol G, Wang HE. Variations in the application of exception from informed consent in a multicenter clinical trial. Resuscitation 2019; 135:1-5. [PMID: 30572072 PMCID: PMC6939445 DOI: 10.1016/j.resuscitation.2018.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/08/2018] [Accepted: 12/10/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Exception from infor med consent (EFIC) is allowed using federal regulations 21 CFR 50.24 and facilitates research on patients with critical conditions such as cardiac arrest. Little is known regarding the differences in the application of EFIC requirements such as community consultation (CC), public disclosure (PD) and patient notification. We sought to characterize variations in the fulfillment of EFIC requirements in a national multicenter clinical trial in the United States. METHODS We determined the strategies for fulfillment of EFIC requirements at five regional coordinating centers of the Pragmatic Airway Resuscitation Trial (PART), a cluster-crossover randomized trial comparing airway devices in out-of-hospital cardiac arrest. We collected information from the including site demographics, how CC and PD were implemented, methods undertaken by the site investigative team to meet the local IRB's interpretation, and patient notification timing (post-enrollment). We analyzed the data using descriptive statistics. RESULTS Sites had multiple approaches to CC, including social media advertising, random digit dialing surveys, working with city officials, and websites with embedded surveys. All sites used more than one approach for conducting CC. Public Disclosure activities included press releases through various means, website documentation, and letters to community members and local officials. Time from CC to study approval ranged from 42 days to 253 days. CONCLUSION EFIC implementation varies across sites and highlight community and regional variation. Different EFIC approaches may be needed to effectively accomplish the goals of community consultation, public disclosure, and patient notification.
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Affiliation(s)
- Jestin N Carlson
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA.
| | - Dana Zive
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - Denise Griffiths
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - Karen N Brown
- Department of Emergency Medicine University of Alabama at Birmingham, Birmingham, AL
| | - Robert H Schmicker
- Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle, WA
| | - Heather Herren
- Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle, WA
| | - George Sopko
- National Heart, Lung and Blood Institute, Bethesda, MD
| | - Sara DiFiore
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Dixie Climer
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Caroline Herdeman
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Ahamed Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Graham Nichol
- Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA
| | - Henry E Wang
- Department of Emergency Medicine University of Alabama at Birmingham, Birmingham, AL; Department of Emergency Medicine, University of Texas Health Science Center at Houston, Houston, TX
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8
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Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA 2018; 320:769-778. [PMID: 30167699 PMCID: PMC6583103 DOI: 10.1001/jama.2018.7044] [Citation(s) in RCA: 223] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown. OBJECTIVE To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA. DESIGN, SETTING, AND PARTICIPANTS Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017. INTERVENTIONS Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals. MAIN OUTCOMES AND MEASURES The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score ≤3), and key adverse events. RESULTS Among 3004 enrolled patients (median [interquartile range] age, 64 [53-76] years, 1829 [60.9%] men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% [95% CI, 0.2%-5.6%]; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% [95% CI, 0.3%-6.8%]; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% [95% CI, 0.6%-4.8%]; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% [95% CI, 0.3%-3.8%]; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%). CONCLUSIONS AND RELEVANCE Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02419573.
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Affiliation(s)
- Henry E. Wang
- Department of Emergency Medicine, University of Texas Health Science Center at Houston
- Department of Emergency Medicine, University of Alabama at Birmingham
| | - Robert H. Schmicker
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle
| | - Mohamud R. Daya
- Department of Emergency Medicine, Oregon Health and Science University, Portland
| | | | - Ahamed H. Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Jestin N. Carlson
- Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, Pennsylvania
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Heather Herren
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle
| | - Matthew Hansen
- Department of Emergency Medicine, Oregon Health and Science University, Portland
| | - Neal J. Richmond
- MedStar Mobile Healthcare, Fort Worth, Texas
- currently with Department of Emergency Medicine, John Peter Smith Health Network, Fort Worth, Texas
| | | | - Tom P. Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee
| | - Randal E. Gray
- Department of Emergency Medicine, University of Alabama at Birmingham
| | - Pamela C. Gray
- Department of Emergency Medicine, University of Alabama at Birmingham
| | | | - Pamela C. Owens
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | | | | | - Susanne J. May
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle
| | - George R. Sopko
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Myron L. Weisfeldt
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Graham Nichol
- Departments of Emergency Medicine and Medicine, Harborview Center for Prehospital Emergency Care, University of Washington, Seattle
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9
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Salcido DD, Schmicker RH, Kime N, Buick JE, Cheskes S, Grunau B, Zellner S, Zive D, Aufderheide TP, Koller AC, Herren H, Nuttall J, Sundermann ML, Menegazzi JJ. Effects of intra-resuscitation antiarrhythmic administration on rearrest occurrence and intra-resuscitation ECG characteristics in the ROC ALPS trial. Resuscitation 2018; 129:6-12. [PMID: 29803703 DOI: 10.1016/j.resuscitation.2018.05.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 09/11/2017] [Revised: 05/11/2018] [Accepted: 05/23/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Intra-resuscitation antiarrhythmic drugs may improve resuscitation outcomes, in part by avoiding rearrest, a condition associated with poor out-of-hospital cardiac arrest (OHCA) outcomes. However, antiarrhythmics may also alter defibrillation threshold. The objective of this study was to investigate the relationship between rearrest and intra-resuscitation antiarrhythmic drugs in the context of the Resuscitation Outcomes Consortium (ROC) amiodarone, lidocaine, and placebo (ALPS) trial. HYPOTHESIS Rearrest rates would be lower in cases treated with amiodarone or lidocaine, versus saline placebo, prior to first return of spontaneous circulation (ROSC). We also hypothesized antiarrhythmic effects would be quantifiable through analysis of the prehospital electrocardiogram. METHODS We conducted a secondary analysis of the ROC ALPS trial. Cases that first achieved prehospital ROSC after randomized administration of study drug were included in the analysis. Rearrest, defined as loss of pulses following ROSC, was ascertained from emergency medical services records. Rearrest rate was calculated overall, as well as by ALPS treatment group. Multivariable logistic regression models were constructed to assess the association between treatment group and rearrest, as well as rearrest and both survival to hospital discharge and survival with neurologic function. Amplitude spectrum area, median slope, and centroid frequency of the ventricular fibrillation (VF) ECG were calculated and compared across treatment groups. RESULTS A total of 1144 (40.4%) cases with study drug prior to first ROSC were included. Rearrest rate was 44.0% overall; 42.9% for placebo, 45.7% for lidocaine, and 43.0% for amiodarone. In multivariable logistic regression models, ALPS treatment group was not associated with rearrest, though rearrest was associated with poor survival and neurologic outcomes. AMSA and median slope measures of the first available VF were associated with rearrest case status, while median slope and centroid frequency were associated with ALPS treatment group. CONCLUSION Rearrest rates did not differ between antiarrhythmic and placebo treatment groups. ECG waveform characteristics were correlated with treatment group and rearrest. Rearrest was inversely associated with survival and neurologic outcomes.
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Affiliation(s)
| | | | - Noah Kime
- University of Washington, Seattle, WA, United States
| | - Jason E Buick
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto ON, Canada
| | - Sheldon Cheskes
- Sunnybrook Center for Prehospital Medicine, Toronto, ON, Canada
| | - Brian Grunau
- University of British Columbia, Vancouver, BC, Canada
| | | | - Dana Zive
- Oregon Health Sciences University, Portland, OR, United States
| | | | | | | | - Jack Nuttall
- Oregon Health Sciences University, Portland, OR, United States
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10
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Hansen M, Schmicker RH, Newgard CD, Grunau B, Scheuermeyer F, Cheskes S, Vithalani V, Alnaji F, Rea T, Idris AH, Herren H, Hutchison J, Austin M, Egan D, Daya M. Time to Epinephrine Administration and Survival From Nonshockable Out-of-Hospital Cardiac Arrest Among Children and Adults. Circulation 2018; 137:2032-2040. [PMID: 29511001 DOI: 10.1161/circulationaha.117.033067] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/21/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Previous studies have demonstrated that earlier epinephrine administration is associated with improved survival from out-of-hospital cardiac arrest (OHCA) with shockable initial rhythms. However, the effect of epinephrine timing on patients with nonshockable initial rhythms is unclear. The objective of this study was to measure the association between time to epinephrine administration and survival in adults and children with emergency medical services (EMS)-treated OHCA with nonshockable initial rhythms. METHODS We performed a secondary analysis of OHCAs prospectively identified by the Resuscitation Outcomes Consortium network from June 4, 2011, to June 30, 2015. We included patients of all ages with an EMS-treated OHCA and an initial nonshockable rhythm. We excluded those with return of spontaneous circulation in <10 minutes. We conducted a subgroup analysis involving patients <18 years of age. The primary exposure was time (minutes) from arrival of the first EMS agency to the first dose of epinephrine. Secondary exposure was time to epinephrine dichotomized as early (<10 minutes) or late (≥10 minutes). The primary outcome was survival to hospital discharge. We adjusted for Utstein covariates and Resuscitation Outcomes Consortium study site. RESULTS From 55 568 EMS-treated OHCAs, 32 101 patients with initial nonshockable rhythms were included. There were 12 238 in the early group, 14 517 in the late group, and 5346 not treated with epinephrine. After adjusting for potential confounders, each minute from EMS arrival to epinephrine administration was associated with a 4% decrease in odds of survival for adults, odds ratio=0.96 (95% confidence interval, 0.95-0.98). A subgroup analysis (n=13 290) examining neurological outcomes showed a similar association (adjusted odds ratio, 0.94 per minute; 95% confidence interval, 0.89-0.98). When epinephrine was given late in comparison with early, odds of survival were 18% lower (odds ratio, 0.82; 95% confidence interval, 0.68-0.98). In a pediatric analysis (n=595), odds of survival were 9% lower (odds ratio, 0.91; 95% confidence interval, 0.81-1.01) for each minute delay in epinephrine. CONCLUSIONS Among OHCAs with nonshockable initial rhythms, the majority of patients were administered epinephrine >10 minutes after EMS arrival. Each minute delay in epinephrine administration was associated with decreased survival and unfavorable neurological outcomes. EMS agencies should consider strategies to reduce epinephrine administration times in patients with initial nonshockable rhythms.
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Affiliation(s)
- Matthew Hansen
- Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland (M.H., M.D.).
| | | | | | | | - Frank Scheuermeyer
- Department of Emergency Medicine, St Paul's Hospital (F.S.), University of British Columbia, Vancouver, Canada
| | - Sheldon Cheskes
- Sunnybrook Center for Prehospital Medicine, Department of Family and Community Medicine, Division of Emergency Medicine, Li Ka Shing Knowledge Institute of St. Michaels Hospital (S.C.)
| | - Veer Vithalani
- Office of the Medical Director, MedStar Mobile Healthcare, Fort Worth, TX (V.V.)
| | - Fuad Alnaji
- Department of Pediatrics, University of Ottawa, Ontario, Canada (F.A.)
| | - Thomas Rea
- Department of Internal Medicine (T.R.), University of Washington, Seattle
| | - Ahamed H Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas (A.H.I.)
| | | | - Jamie Hutchison
- Departments of Critical Care and Pediatrics (J.H.), University of Toronto, Ontario, Canada
| | - Mike Austin
- Department of Emergency Medicine, The Ottawa Hospital, Ontario, Canada (M.A.)
| | - Debra Egan
- National Center for Complimentary and Integrative Health, National Institutes of Health, Bethesda, MD (D.E.)
| | - Mohamud Daya
- Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland (M.H., M.D.)
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11
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Cheskes S, Schmicker RH, Rea T, Morrison LJ, Grunau B, Drennan IR, Leroux B, Vaillancourt C, Schmidt TA, Koller AC, Kudenchuk P, Aufderheide TP, Herren H, Flickinger KH, Charleston M, Straight R, Christenson J. The association between AHA CPR quality guideline compliance and clinical outcomes from out-of-hospital cardiac arrest. Resuscitation 2017; 116:39-45. [PMID: 28476474 DOI: 10.1016/j.resuscitation.2017.05.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [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: 03/02/2017] [Revised: 04/09/2017] [Accepted: 05/01/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Measures of chest compression fraction (CCF), compression rate, compression depth and pre-shock pause have all been independently associated with improved outcomes from out-of-hospital (OHCA) cardiac arrest. However, it is unknown whether compliance with American Heart Association (AHA) guidelines incorporating all the aforementioned metrics, is associated with improved survival from OHCA. METHODS We performed a secondary analysis of prospectively collected data from the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest database. As per the 2015 American Heart Association (AHA) guidelines, guideline compliant cardiopulmonary resuscitation (CPR) was defined as CCF >0.8, chest compression rate 100-120/minute, chest compression depth 50-60mm, and pre-shock pause <10s. Multivariable logistic regression models controlling for Utstein variables were used to assess the relationship between global guideline compliance and survival to hospital discharge and neurologically intact survival with MRS ≤3. Due to potential confounding between CPR quality metrics and cases that achieved early ROSC, we performed an a priori subgroup analysis restricted to patients who obtained ROSC after ≥10min of EMS resuscitation. RESULTS After allowing for study exclusions, 19,568 defibrillator records were collected over a 4-year period ending in June 2015. For all reported models, the reference standard included all cases who did not meet all CPR quality benchmarks. For the primary model (CCF, rate, depth), there was no significant difference in survival for resuscitations that met all CPR quality benchmarks (guideline compliant) compared to the reference standard (OR 1.26; 95% CI: 0.80, 1.97). When the dataset was restricted to patients obtaining ROSC after ≥10min of EMS resuscitation (n=4,158), survival was significantly higher for those resuscitations that were guideline compliant (OR 2.17; 95% CI: 1.11, 4.27) compared to the reference standard. Similar findings were obtained for neurologically intact survival with MRS ≤3 (OR 3.03; 95% CI: 1.12, 8.20). CONCLUSIONS In this observational study, compliance with AHA guidelines for CPR quality was not associated with improved outcomes from OHCA. Conversely, when restricting the cohort to those with late ROSC, compliance with guidelines was associated with improved clinical outcomes. Strategies to improve overall guideline compliance may have a significant impact on outcomes from OHCA.
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Affiliation(s)
| | | | - Tom Rea
- University of Washington, Seattle, Washington, United States
| | | | - Brian Grunau
- University of British Columbia, Vancouver, British, Colombia
| | | | - Brian Leroux
- University of Washington, Seattle, Washington, United States
| | | | - Terri A Schmidt
- Oregon Health and Sciences University, Portland, Oregon, United States
| | - Allison C Koller
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Peter Kudenchuk
- University of Washington, Seattle, Washington, United States
| | | | - Heather Herren
- University of Washington, Seattle, Washington, United States
| | | | - Mark Charleston
- Tualatin Valley Fire & Rescue, Portland, Oregon, United States
| | - Ron Straight
- University of British Columbia, Vancouver, British, Colombia
| | - Jim Christenson
- University of British Columbia, Vancouver, British, Colombia
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12
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Salcido DD, Schmicker RH, Buick JE, Cheskes S, Grunau B, Kudenchuk P, Leroux B, Zellner S, Zive D, Aufderheide TP, Koller AC, Herren H, Nuttall J, Sundermann ML, Menegazzi JJ. Compression-to-ventilation ratio and incidence of rearrest-A secondary analysis of the ROC CCC trial. Resuscitation 2017; 115:68-74. [PMID: 28392369 DOI: 10.1016/j.resuscitation.2017.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/14/2017] [Accepted: 04/03/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Previous work has demonstrated that when out-of-hospital cardiac arrest (OHCA) patients achieve return of spontaneous circulation (ROSC), but subsequently have another cardiac arrest prior to hospital arrival (rearrest), the probability of survival to hospital discharge is significantly decreased. Additionally, few modifiable factors for rearrest are known. We sought to examine the association between rearrest and compression-to-ventilation ratio during cardiopulmonary resuscitation (CPR) and to confirm the association between rearrest and outcomes. HYPOTHESIS Rearrest incidence would be similar between cases treated with 30:2 or continuous chest compression (CCC) CPR, but inversely related to survival and good neurological outcome. METHODS We conducted a secondary analysis of a large randomized-controlled trial of CCC versus 30:2 CPR for the treatment of OHCA between 2011 and 2015 among 8 sites of the Resuscitation OUTCOMES: Consortium (ROC). Patients were randomized through an emergency medical services (EMS) agency-level cluster randomization design to receive either 30:2 or CCC CPR. Case data were derived from prehospital patient care reports, digital defibrillator files, and hospital records. The primary analysis was an as-treated comparison of the proportion of patients with a rearrest for patients who received 30:2 versus those who received CCC. In addition, we assessed the association between rearrest and both survival to hospital discharge and favorable neurological outcome (Modified Rankin Score≤3) in patients with and without ROSC upon ED arrival using multivariable logistic regression adjusting for age, sex, initial rhythm and measures of CPR quality. RESULTS There were 14,109 analyzable cases that were determined to have definitively received either CCC or 30:2 CPR. Of these, 4713 had prehospital ROSC and 2040 (43.2%) had at least one rearrest. Incidence of rearrest was not significantly different between patients receiving CCC and 30:2 (44.1% vs 41.8%; adjusted OR: 1.01; 95% CI: 0.88, 1.16). Rearrest was significantly associated with lower survival (23.3% vs 36.9%; adjusted OR: 0.46; 95%CI: 0.36-0.51) and worse neurological outcome (19.4% vs 30.2%; adjusted OR: 0.46; 95%CI: 0.38, 0.55). CONCLUSION Rearrest occurrence was not significantly different between patients receiving CCC and 30:2, and was inversely associated with survival to hospital discharge and MRS.
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Affiliation(s)
| | | | | | - Sheldon Cheskes
- Sunnybrook Center for Prehospital Medicine, Toronto, ON, Canada
| | - Brian Grunau
- University of British Columbia, Vancouver, BC, Canada
| | | | - Brian Leroux
- University of Washington, Seattle, WA, United States
| | | | - Dana Zive
- Oregon Health Sciences University, Portland, OR, United States
| | | | | | | | - Jack Nuttall
- Oregon Health Sciences University, Portland, OR, United States
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13
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Drennan IR, Case E, Verbeek PR, Reynolds JC, Goldberger ZD, Jasti J, Charleston M, Herren H, Idris AH, Leslie PR, Austin MA, Xiong Y, Schmicker RH, Morrison LJ. A comparison of the universal TOR Guideline to the absence of prehospital ROSC and duration of resuscitation in predicting futility from out-of-hospital cardiac arrest. Resuscitation 2016; 111:96-102. [PMID: 27923115 DOI: 10.1016/j.resuscitation.2016.11.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [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: 08/16/2016] [Revised: 11/08/2016] [Accepted: 11/21/2016] [Indexed: 01/27/2023]
Abstract
INTRODUCTION The Universal Termination of Resuscitation (TOR) Guideline accurately identifies potential out-of-hospital cardiac arrest (OHCA) survivors. However, implementation is inconsistent with some Emergency Medical Service (EMS) agencies using absence of return of spontaneous circulation (ROSC) as sole criterion for termination. OBJECTIVE To compare the performance of the Universal TOR Guideline with the single criterion of no prehospital ROSC. Second, to determine factors associated with survival for patients transported without a ROSC. Lastly, to compare the impact of time to ROSC as a marker of futility to the Universal TOR Guideline. DESIGN Retrospective, observational cohort study. PARTICIPANTS Non-traumatic, adult (≥18 years) OHCA patients of presumed cardiac etiology treated by EMS providers. SETTING ROC-PRIMED and ROC-Epistry post ROC-PRIMED databases between 2007 and 2011. OUTCOMES Primary outcome was survival to hospital discharge and the secondary outcome was functional survival. We used multivariable regression to evaluate factors associated with survival in patients transported without a ROSC. RESULTS 36,543 treated OHCAs occurred of which 9467 (26%) were transported to hospital without a ROSC. Patients transported without a ROSC who met the Universal TOR Guideline for transport had a survival of 3.0% (95% CI 2.5-3.4%) compared to 0.7% (95% CI 0.4-0.9%) in patients who met the Universal TOR Guideline for termination. The Universal TOR Guideline identified 99% of survivors requiring continued resuscitation and transportation to hospital including early identification of survivors who sustained a ROSC after extended durations of CPR. CONCLUSION Using absence of ROSC as a sole predictor of futility misses potential survivors. The Universal TOR Guideline remains a strong predictor of survival.
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Affiliation(s)
- Ian R Drennan
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, 30 Bond St. Toronto, Ontario M5B 1W8, Canada.
| | - Erin Case
- Clinical Trial Center, University of Washington Department of Biostatistics, Seattle, WA 98103, United States.
| | - P Richard Verbeek
- Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Joshua C Reynolds
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, United States.
| | - Zachary D Goldberger
- University of Washington School of Medicine, Department of Internal Medicine, Division of Cardiology, Harborview Medical Center, Seattle, WA, United States.
| | - Jamie Jasti
- Resuscitation Research Centre, Department of Emergency Medicine, Medical College of Wisconsin, WI, United States.
| | | | - Heather Herren
- ROC Clinical Trial Center, University of Washington, Seattle, WA, United States.
| | - Ahamed H Idris
- Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, United States.
| | - Paul R Leslie
- British Columbia Emergency Health Services, British Columbia, Canada.
| | - Michael A Austin
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.
| | - Yan Xiong
- Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, United States.
| | - Robert H Schmicker
- Clinical Trial Center, University of Washington Department of Biostatistics, Seattle, WA 98103, United States.
| | - Laurie J Morrison
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Division of Emergency Medicine, Department of Medicine, University of Toronto, Ontario, Canada.
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14
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Fink EL, Prince DK, Kaltman JR, Atkins DL, Austin M, Warden C, Hutchison J, Daya M, Goldberg S, Herren H, Tijssen JA, Christenson J, Vaillancourt C, Miller R, Schmicker RH, Callaway CW. Unchanged pediatric out-of-hospital cardiac arrest incidence and survival rates with regional variation in North America. Resuscitation 2016; 107:121-8. [PMID: 27565862 DOI: 10.1016/j.resuscitation.2016.07.244] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 07/23/2016] [Accepted: 07/29/2016] [Indexed: 11/18/2022]
Abstract
AIM Outcomes for pediatric out-of-hospital cardiac arrest (OHCA) are poor. Our objective was to determine temporal trends in incidence and mortality for pediatric OHCA. METHODS Adjusted incidence and hospital mortality rates of pediatric non-traumatic OHCA patients from 2007-2012 were analyzed using the 9 region Resuscitation Outcomes Consortium-Epidemiological Registry (ROC-Epistry) database. Children were divided into 4 age groups: perinatal (<3 days), infants (3days-1year), children (1-11 years), and adolescents (12-19 years). ROC regions were analyzed post-hoc. RESULTS We studied 1738 children with OHCA. The age- and sex-adjusted incidence rate of OHCA was 8.3 per 100,000 person-years (75.3 for infants vs. 3.7 for children and 6.3 for adolescents, per 100,000 person-years, p<0.001). Incidence rates differed by year (p<0.001) without overall linear trend. Annual survival rates ranged from 6.7-10.2%. Survival was highest in the perinatal (25%) and adolescent (17.3%) groups. Stratified by age group, survival rates over time were unchanged (all p>0.05) but there was a non-significant linear trend (1.3% increase) in infants. In the multivariable logistic regression analysis, infants, unwitnessed event, initial rhythm of asystole, and region were associated with worse survival, all p<0.001. Survival by region ranged from 2.6-14.7%. Regions with the highest survival had more cases of EMS-witnessed OHCA, bystander CPR, and increased EMS-defibrillation (all p<0.05). CONCLUSIONS Overall incidence and survival of children with OHCA in ROC regions did not significantly change over a recent 5year period. Regional variation represents an opportunity for further study to improve outcomes.
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Affiliation(s)
- Ericka L Fink
- Division of Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Faculty Pavilion, 2nd Floor, Pittsburgh, PA 15224, USA.
| | - David K Prince
- Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Jonathan R Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Dianne L Atkins
- Stead Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Michael Austin
- Department of Emergency Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Craig Warden
- Oregon Health & Science University Doernbecher Children's Hospital, Portland, OR, USA
| | - Jamie Hutchison
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mohamud Daya
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Scott Goldberg
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Heather Herren
- Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Janice A Tijssen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - James Christenson
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Christian Vaillancourt
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Ronna Miller
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert H Schmicker
- Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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15
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Wang HE, Prince DK, Stephens SW, Herren H, Daya M, Richmond N, Carlson J, Warden C, Colella MR, Brienza A, Aufderheide TP, Idris AH, Schmicker R, May S, Nichol G. Design and implementation of the Resuscitation Outcomes Consortium Pragmatic Airway Resuscitation Trial (PART). Resuscitation 2016; 101:57-64. [PMID: 26851059 PMCID: PMC4792760 DOI: 10.1016/j.resuscitation.2016.01.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 01/07/2016] [Accepted: 01/19/2016] [Indexed: 10/22/2022]
Abstract
Airway management is an important component of resuscitation from out-of-hospital cardiac arrest (OHCA). The optimal approach to advanced airway management is unknown. The Pragmatic Airway Resuscitation Trial (PART) will compare the effectiveness of endotracheal intubation (ETI) and Laryngeal Tube (LT) insertion upon 72-h survival in adult OHCA. Encompassing United States Emergency Medical Services agencies affiliated with the Resuscitation Outcomes Consortium (ROC), PART will use a cluster-crossover randomized design. Participating subjects will include adult, non-traumatic OHCA requiring bag-valve-mask ventilation. Trial interventions will include (1) initial airway management with ETI and (2) initial airway management with LT. The primary and secondary trial outcomes are 72-h survival and return of spontaneous circulation. Additional clinical outcomes will include airway management process and adverse events. The trial will enroll a total of 3000 subjects. Results of PART may guide the selection of advanced airway management strategies in OHCA.
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Affiliation(s)
- Henry E Wang
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, AL, United States.
| | - David K Prince
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, United States.
| | - Shannon W Stephens
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, AL, United States.
| | - Heather Herren
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, United States.
| | - Mohamud Daya
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States.
| | | | - Jestin Carlson
- St Vincent's Medical Center, Erie, PA, United States; Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
| | - Craig Warden
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States.
| | - M Riccardo Colella
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States.
| | - Ashley Brienza
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States.
| | - Ahamed H Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States.
| | - Robert Schmicker
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, United States.
| | - Susanne May
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, United States.
| | - Graham Nichol
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, United States.
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16
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Elmer J, Torres C, Aufderheide TP, Austin MA, Callaway CW, Golan E, Herren H, Jasti J, Kudenchuk PJ, Scales DC, Stub D, Richardson DK, Zive DM. Association of early withdrawal of life-sustaining therapy for perceived neurological prognosis with mortality after cardiac arrest. Resuscitation 2016; 102:127-35. [PMID: 26836944 DOI: 10.1016/j.resuscitation.2016.01.016] [Citation(s) in RCA: 265] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 12/29/2015] [Accepted: 01/18/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Withdrawing life-sustaining therapy because of perceived poor neurological prognosis (WLST-N) is a common cause of hospital death after out-of-hospital cardiac arrest (OHCA). Although current guidelines recommend against WLST-N before 72h (WLST-N<72), this practice is common and may increase mortality. We sought to quantify these effects. METHODS In a secondary analysis of a multicenter OHCA trial, we evaluated survival to hospital discharge and survival with favorable functional status (modified Rankin Score ≤3) in adults alive >1h after hospital admission. Propensity score modeling the probability of exposure to WLST-N<72 based on pre-exposure covariates was used to match unexposed subjects with those exposed to WLST-N<72. We determined the probability of survival and functionally favorable survival in the unexposed matched cohort, fit adjusted logistic regression models to predict outcomes in this group, and then used these models to predict outcomes in the exposed cohort. Combining these findings with current epidemiologic statistics we estimated mortality nationally that is associated with WLST-N<72. RESULTS Of 16,875 OHCA subjects, 4265 (25%) met inclusion criteria. WLST-N<72 occurred in one-third of subjects who died in-hospital. Adjusted analyses predicted that exposed subjects would have 26% survival and 16% functionally favorable survival if WLST-N<72 did not occur. Extrapolated nationally, WLST-N<72 may be associated with mortality in approximately 2300 Americans each year of whom nearly 1500 (64%) might have had functional recovery. CONCLUSIONS After OHCA, death following WLST-N<72 may be common and is potentially avoidable. Reducing WLST-N<72 has national public health implications and may afford an opportunity to decrease mortality after OHCA.
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Affiliation(s)
- Jonathan Elmer
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA; Department of Emergency Medicine, University of Pittsburgh, Iroquois Building Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA 15213, USA.
| | - Cesar Torres
- Department of Biostatistics, University of Washington, F-600, Health Sciences Building, NE Pacific Street, Seattle, WA 98195, USA
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, 9200W. Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Michael A Austin
- Department of Emergency Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Associate Medical Director Regional Paramedic Program Eastern Ontario, Canada
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Iroquois Building Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA 15213, USA
| | - Eyal Golan
- Interdepartmental Division of Critical Care and Department of Medicine, University of Toronto, Toronto, ON, Canada; Critical Care Medicine, University Health Network, 399 Bathurst Street, Room 2MCL-411J, M5T-2S8, Toronto, ON, Canada
| | - Heather Herren
- Resuscitations Outcome Consortium Clinical Trial Center, University of Washington, 1107 NE 45th St., Suite 505, Seattle, WA 98105-4680, USA
| | - Jamie Jasti
- Department of Emergency Medicine, Medical College of Wisconsin, 9200W. Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Peter J Kudenchuk
- Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195-6422, USA
| | - Damon C Scales
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D108, Toronto, ON, Canada M4 N 3M5
| | - Dion Stub
- St Paul's Hospital, Vancouver, BC, Canada; Baker IDI Institute Heart and Diabetes Institute, Melbourne, Australia
| | - Derek K Richardson
- Department of Emergency Medicine, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA 94110, USA
| | - Dana M Zive
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code CDW-EM, Portland, OR 97239, USA
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17
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Sutton RM, Case E, Brown SP, Atkins DL, Nadkarni VM, Kaltman J, Callaway C, Idris A, Nichol G, Hutchison J, Drennan IR, Austin M, Daya M, Cheskes S, Nuttall J, Herren H, Christenson J, Andrusiek D, Vaillancourt C, Menegazzi JJ, Rea TD, Berg RA. A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality--A report from the ROC epistry-cardiac arrest. Resuscitation 2015; 93:150-7. [PMID: 25917262 DOI: 10.1016/j.resuscitation.2015.04.010] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [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: 01/28/2015] [Revised: 03/20/2015] [Accepted: 04/11/2015] [Indexed: 10/23/2022]
Abstract
AIM High-quality cardiopulmonary resuscitation (CPR) may improve survival. The quality of CPR performed during pediatric out-of-hospital cardiac arrest (p-OHCA) is largely unknown. The main objective of this study was to describe the quality of CPR performed during p-OHCA resuscitation attempts. METHODS Prospective observational multi-center cohort study of p-OHCA patients ≥ 1 and < 19 years of age registered in the Resuscitation Outcomes Consortium (ROC) Epistry database. The primary outcome was an a priori composite variable of compliance with American Heart Association (AHA) guidelines for both chest compression (CC) rate and CC fraction (CCF). Event compliance was defined as a case with 60% or more of its minute epochs compliant with AHA targets (rate 100-120 min(-1); depth ≥ 38 mm; and CCF ≥ 0.80). In a secondary analysis, multivariable logistic regression was used to evaluate the association between guideline compliance and return of spontaneous circulation (ROSC). RESULTS Between December 2005 and December 2012, 2564 pediatric events were treated by EMS providers, 390 of which were included in the final cohort. Of these events, 22% achieved AHA compliance for both rate and CCF, 36% for rate alone, 53% for CCF alone, and 58% for depth alone. Over time, there was a significant increase in CCF (p < 0.001) and depth (p = 0.03). After controlling for potential confounders, there was no significant association between AHA guideline compliance and ROSC. CONCLUSIONS In this multi-center study, we have established that there are opportunities for professional rescuers to improve prehospital CPR quality. Encouragingly, CCF and depth both increased significantly over time.
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Affiliation(s)
- Robert M Sutton
- The Children's Hospital of Philadelphia, 34th Street, Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Erin Case
- Resuscitations Outcome Consortium, 1107 NE 45th Street, Suite 505, Seattle, WA 98105-4680, United States.
| | - Siobhan P Brown
- Resuscitations Outcome Consortium, 1107 NE 45th Street, Suite 505, Seattle, WA 98105-4680, United States.
| | - Dianne L Atkins
- University of Iowa Carver College of Medicine, Stead Family Department of Pediatrics, Iowa City, IA 52242, United States.
| | - Vinay M Nadkarni
- The Children's Hospital of Philadelphia, 34th Street, Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Jonathan Kaltman
- National Heart, Lung, and Blood Institute, 6701 Rockledge Drive, Bethesda, MD 20817, United States.
| | - Clifton Callaway
- University of Pittsburgh, 400A Iroquois, 3600 Forbes Avenue, Pittsburgh, PA 15260, United States.
| | - Ahamed Idris
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8579, United States.
| | - Graham Nichol
- Resuscitation Outcome Consortium Clinical Trial Center, University of Washington, Seattle, WA 98104, United States.
| | - Jamie Hutchison
- The Hospital for Sick Children, 555 University Avenue, Toronto, ON, Canada M5G 1X8.
| | - Ian R Drennan
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, Canada M5B 1W8.
| | - Michael Austin
- University of Ottawa, The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON, Canada K1Y 4E9.
| | - Mohamud Daya
- Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mailcode CDW-EM, Portland, OR 97239-3098, United States.
| | - Sheldon Cheskes
- Sunnybrook Center for Prehospital Medicine, 77 Browns Line, Toronto, ON, Canada M8W 3S2.
| | - Jack Nuttall
- Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, United States.
| | - Heather Herren
- Resuscitations Outcome Consortium, 1107 NE 45th Street, Suite 505, Seattle, WA 98105-4680, United States.
| | - James Christenson
- Department of Emergency Medicine, University of British Columbia Faculty of Medicine, Room 3300 3rd Floor, 910 West 10th Avenue, Vancouver, BC, Canada V5Z 1M9.
| | - Dug Andrusiek
- School of Medical Sciences, Faculty of Health, Engineering and Science, Edith Cowan University, Building 19, Room 129d, 270 Joondalup Dr. Joondalup, Western Australia 6023, Australia.
| | - Christian Vaillancourt
- University of Ottawa, The Ottawa Hospital Research Institute, The Ottawa Hospital, Civic Campus, Room F649, 1053 Carling Avenue, Ottawa, ON, Canada K1Y 4E9.
| | - James J Menegazzi
- University of Pittsburgh, 3600 Forbes Avenue, Pittsburgh, PA 15261, United States.
| | - Thomas D Rea
- University of Washington, 206 3rd Avenue South, Seattle, WA 98104, United States.
| | - Robert A Berg
- The Children's Hospital of Philadelphia, 34th Street, Civic Center Boulevard, Philadelphia, PA 19104, United States.
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18
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Wang HE, Schmicker RH, Herren H, Brown S, Donnelly JP, Gray R, Ragsdale S, Gleeson A, Byers A, Jasti J, Aguirre C, Owens P, Condle J, Leroux B. Classification of cardiopulmonary resuscitation chest compression patterns: manual versus automated approaches. Acad Emerg Med 2015; 22:204-11. [PMID: 25639554 DOI: 10.1111/acem.12577] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 08/26/2014] [Accepted: 09/20/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES New chest compression detection technology allows for the recording and graphical depiction of clinical cardiopulmonary resuscitation (CPR) chest compressions. The authors sought to determine the inter-rater reliability of chest compression pattern classifications by human raters. Agreement with automated chest compression classification was also evaluated by computer analysis. METHODS This was an analysis of chest compression patterns from cardiac arrest patients enrolled in the ongoing Resuscitation Outcomes Consortium (ROC) Continuous Chest Compressions Trial. Thirty CPR process files from patients in the trial were selected. Using written guidelines, research coordinators from each of eight participating ROC sites classified each chest compression pattern as 30:2 chest compressions, continuous chest compressions (CCC), or indeterminate. A computer algorithm for automated chest compression classification was also developed for each case. Inter-rater agreement between manual classifications was tested using Fleiss's kappa. The criterion standard was defined as the classification assigned by the majority of manual raters. Agreement between the automated classification and the criterion standard manual classifications was also tested. RESULTS The majority of the eight raters classified 12 chest compression patterns as 30:2, 12 as CCC, and six as indeterminate. Inter-rater agreement between manual classifications of chest compression patterns was κ = 0.62 (95% confidence interval [CI] = 0.49 to 0.74). The automated computer algorithm classified chest compression patterns as 30:2 (n = 15), CCC (n = 12), and indeterminate (n = 3). Agreement between automated and criterion standard manual classifications was κ = 0.84 (95% CI = 0.59 to 0.95). CONCLUSIONS In this study, good inter-rater agreement in the manual classification of CPR chest compression patterns was observed. Automated classification showed strong agreement with human ratings. These observations support the consistency of manual CPR pattern classification as well as the use of automated approaches to chest compression pattern analysis.
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Affiliation(s)
- Henry E. Wang
- Department of Emergency Medicine; University of Alabama School of Medicine; Birmingham AL
| | - Robert H. Schmicker
- Clinical Trials Center; Department of Biostatistics; University of Washington; Seattle WA
| | - Heather Herren
- Clinical Trials Center; Department of Biostatistics; University of Washington; Seattle WA
| | - Siobhan Brown
- Clinical Trials Center; Department of Biostatistics; University of Washington; Seattle WA
| | - John P. Donnelly
- Department of Emergency Medicine; University of Alabama School of Medicine; Birmingham AL
| | - Randal Gray
- Department of Emergency Medicine; University of Alabama School of Medicine; Birmingham AL
| | - Sally Ragsdale
- Division of Cardiology; University of Washington; Seattle WA
| | - Andrew Gleeson
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; University of Ottawa; Ottawa Paramedic Service; Ottawa Ontario Canada
| | - Adam Byers
- Department of Emergency Medicine; St. Michael's Hospital; University of Toronto; Toronto Ontario Canada
| | - Jamie Jasti
- Department of Emergency Medicine; Medical College of Wisconsin; Milwaukee WI
| | - Christina Aguirre
- Providence Healthcare Research Institute; Emergency Research Department; St. Paul's University of Vancouver; Vancouver British Columbia Canada
| | - Pam Owens
- Department of Emergency Medicine; University of Texas Southwestern Medical Center; Dallas TX
| | - Joe Condle
- Department of Emergency Medicine; University of Pittsburgh; Pittsburgh PA
| | - Brian Leroux
- Clinical Trials Center; Department of Biostatistics; University of Washington; Seattle WA
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19
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Prasad SM, Massad MG, Chedrawy EG, Snow NJ, Yeh JT, Lele H, Tarakji A, Maniar HS, Herren H, Gay WA. Weathering the storm: how can thoracic surgery training programs meet the new challenges in the era of less-invasive technologies? J Thorac Cardiovasc Surg 2009; 137:1317-25, discussion 1326. [PMID: 19464440 DOI: 10.1016/j.jtcvs.2009.02.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Revised: 01/07/2009] [Accepted: 02/16/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The introduction of new technologies has shifted some resident index procedures to nonsurgical specialists. We examined the operative case volume of thoracic surgery residents during the last 6 years to objectively identify changes and trends. METHODS Program and resident data from 2002 to 2007 were entered into a database and analyzed. Program match information was obtained from the National Resident Matching Program. Resident operative experience and board examination results were obtained from the American Board of Thoracic Surgery. RESULTS A total of 795 residents qualified for the written American Board of Thoracic Surgery examination; 627 residents graduated from 2-year programs, and 168 residents graduated from 3-year programs. The total number of resident cases was higher in 3-year programs compared with 2-year programs in all 10 index categories studied (P < .01). The total volume of cases has not significantly increased in 2-year programs. The volume of coronary artery bypass graft surgeries decreased in every resident program model studied. The volume of general thoracic cases increased in all program models. Two-year, 2-resident programs had the lowest volume in 5 of the 10 categories, reaching significance in 3 categories. The written board pass rate was lower among 2-year programs than among 3-year programs (86% vs 95%, respectively, P = .003). CONCLUSION Training programs have so far weathered the storm by maintaining index volume with a new case mix, but significant trends in revascularization procedures are concerning. This study indicates a significant advantage in case volume and board pass rates among 3-year programs. Thoracic residency programs should be reorganized so that the number of residents does not exceed the capacity of the program to provide a meaningful experience.
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Affiliation(s)
- Sunil M Prasad
- Division of Cardiothoracic Surgery, University of Illinois at Chicago, Chicago, Ill 60612, USA.
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West-Thielke P, Herren H, Thielke J, Oberholzer J, Sankary H, Raofi V, Benedetti E, Kaplan B. Results of positive cross-match transplantation in African American renal transplant recipients. Am J Transplant 2008; 8:348-54. [PMID: 18190659 DOI: 10.1111/j.1600-6143.2007.02085.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Positive cross-match (PXM) renal transplantation has been utilized to address the issue of the increasing demand for transplantation with the shortage of suitable organs. Our primary objective was to analyze the outcomes of African American (AA) PXM renal transplant recipients utilizing AA negative cross-match (NXM) renal transplant recipients as a comparator group. This was a retrospective study consisting of all PXM patients who underwent a desensitization protocol and all AA NXM transplant recipients at the University of Illinois at Chicago from July 2001 to March 2007. We found that AA PXM recipients had significantly lower estimated glomerular filtration rate (eGFR) at 1 year than AA NXM (46.2 vs. 60.6, p = 0.007). AA PXM who experienced acute rejection within the first year were more likely to have an eGFR less than 30 mL/min/1.73 m(2) at 1 year compared to their NXM counterparts (45.5% vs. 12.5%, p = 0.034). Positive cross-match renal transplantation in AA seems to be associated with a high degree of AR and severe renal compromise at 1 year. Larger studies are needed to determine if protocols that are associated with good short-term outcomes in non-AA need to be modified for the AA population.
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Affiliation(s)
- P West-Thielke
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
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21
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Frenzer A, Gyr T, Schaer HM, Herren H, Krähenbühl S, Schaer M. [Triplet pregnancy with HELLP syndrome and transient diabetes insipidus]. Schweiz Med Wochenschr 1994; 124:687-91. [PMID: 8184305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A 35 year old primigravida with a triplet pregnancy developed polyuria and epigastric pain in the 31st week of pregnancy. During that week, emergency cesarean section was performed due to evidence of liver disease and imminent fetal hypoxia. Three girls were delivered who were healthy apart from transient neonatal respiration distress syndrome. Following surgery, the mother developed HELLP syndrome with hemolysis, increased transaminases and thrombocytopenia. She also developed diabetes insipidus with daily urine outputs of up to 7000 ml and poor response to desmopressin. Both the HELLP syndrome and the diabetes insipidus resolved spontaneously within ten days. In pregnant patients with right upper quadrant pain, HELLP syndrome or acute fatty liver of pregnancy should be considered. The association of diabetes insipidus with acute fatty liver of pregnancy is an established, but rare phenomenon. As far as is known, this is the first report of a patient presenting with a combination of HELLP syndrome and diabetes insipidus. Patients with HELLP syndrome have a good prognosis, if the diagnosis is early and the pregnancy terminated at the right time. With close supervision further pregnancies are possible.
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Affiliation(s)
- A Frenzer
- Medizinische Klinik, Universität Bern, Inselspital
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22
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Horber FF, Zürcher RM, Herren H, Crivelli MA, Robotti G, Frey FJ. Altered body fat distribution in patients with glucocorticoid treatment and in patients on long-term dialysis. Am J Clin Nutr 1986; 43:758-69. [PMID: 3706187 DOI: 10.1093/ajcn/43.5.758] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Fat distribution was assessed by computed tomography in normal volunteers (n = 42), patients on long-term dialysis (n = 18), and patients on glucocorticoids [renal transplant patients (n = 49), other diseases (n = 17)]. Patients on glucocorticoids had higher mediastinal (deep) and identical or increased posterior cervical, buccal, and midthigh (superficial) fat areas when compared with normal subjects. The pattern of fat distribution in dialysis patients mimicked the distribution observed in patients taking glucocorticoids. Healthy females had higher ratios of superficial to deep fat than healthy male subjects. Patients on prednisone or on dialysis lost this sex-associated difference in fat distribution. Since patients on prednisone exhibit increased or normal thigh fat depots in the presence of increased mediastinal fat, the current concept that glucocorticoids induce redistribution of body fat from peripheral to central fat compartments has to be revised. Furthermore, disease states and/or glucocorticoids abrogate sex-associated differences in body fat distribution.
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Herren H, Herren MP. [A psychomotor stimulation trial in early childhood]. Rev Neuropsychiatr Infant 1974; 22:237-61. [PMID: 4845737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Herren H. [Voice in psychosomatic development in children]. J Fr Otorhinolaryngol Audiophonol Chir Maxillofac (1967) 1971; 20:429-35. [PMID: 4251833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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25
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Herren H. [Interpretation of data gathered from psychologic examination of deaf children]. Rev Neuropsychiatr Infant 1967; 15:749-65. [PMID: 5602342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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