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Pocock H, Deakin CD, Lall R, Michelet F, Contreras A, Ainsworth-Smith M, King P, Devrell A, Smith DE, Perkins GD. Protocol for a cluster randomised controlled feasibility study of Prehospital Optimal Shock Energy for Defibrillation (POSED). Resusc Plus 2022; 12:100310. [PMID: 36238581 PMCID: PMC9550652 DOI: 10.1016/j.resplu.2022.100310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/07/2022] [Accepted: 09/14/2022] [Indexed: 11/25/2022] Open
Abstract
AIMS The Prehospital Optimal Shock Energy for Defibrillation (POSED) study will assess the feasibility of conducting a cluster randomised controlled study of clinical effectiveness in UK ambulance services to identify the optimal shock energy for defibrillation. METHODS POSED is a pragmatic, allocation concealed, open label, cluster randomised, controlled feasibility study. Defibrillators within a single UK ambulance service will be randomised in an equal ratio to deliver one of three shock strategies 120-150-200 J, 150-200-200 J, 200-200-200 J. Consecutive adults (≥18 years) presenting with out of hospital cardiac arrest requiring defibrillation will be eligible. The study plans to enrol 90 patients (30 in each group). Patients (or their relatives for non-survivors) will be informed about trial participation after the initial emergency has resolved. Survivors will be invited to consent to participate in follow-up (i.e., at 30 days or discharge).The primary feasibility outcome is the proportion of eligible patients who receive the randomised study intervention. Secondary feasibility outcomes will include recruitment rate, adherence to allocated treatment and data completeness. Clinical outcomes will include Return of an Organised Rhythm (ROOR) at 2 minutes post-shock, refibrillation rate, Return of Spontaneous Circulation (ROSC) at hospital handover, survival and neurological outcome at 30 days. CONCLUSION The POSED study will assess the feasibility of a large-scale trial and explore opportunities to optimise the trial protocol.Trial registration: ISRCTN16327029.
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Key Words
- AE, Adverse Event
- AOR, Adjusted Odds Ratio
- B-CPR, Bystander CPR
- BTE, Biphasic Truncated Exponential waveform
- CAD, Computer Aided Despatch
- CONSORT, CONsolidated Standards Of Reporting Trials
- CPMS, Central Portfolio Management System
- CPR, Cardiopulmonary Resuscitation
- CRF, Case Report Form
- Cardiopulmonary Resuscitation
- Defibrillation
- Electric Countershock
- Feasibility study
- GCP, Good Clinical Practice
- HRA, Health Research Authority
- ICA, Integrated Clinical and practitioner Academic programme
- ILCOR, International Liaison Committee on Resuscitation
- ISRCTN, International Standard Registered Clinical/social sTudy Number
- J, Joules
- JRCALC, Joint Royal Colleges Ambulance Liaison Committee
- NIHR, National Institute for Health and care Research
- OHCA, Out-of-Hospital Cardiac Arrest
- OR, Odds Ratio
- Out-of-Hospital Cardiac Arrest
- PEA, Pulseless Electrical Activity
- POSED, Prehospital Optimal Shock Energy for Defibrillation
- PPI, Patient and Public Involvement
- REC, Research Ethics Committee
- RFA, Rankin Focused Assessment
- ROOR, Return of Organised Rhythm
- ROSC, Return of Spontaneous Circulation
- SMG, Study Management Group
- SOC, Study Oversight Committee
- SPIRIT, Standard Protocol Items: Recommendations for Intervention Trials
- ToF, Termination of Fibrillation
- VF, Ventricular Fibrillation
- Ventricular Fibrillation
- WCTU, Warwick Clinical Trials Unit
- ePR, Electronic Patient Record
- mRS, Modified Rankin Scale
- pVT, Pulseless Ventricular Tachycardia
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Affiliation(s)
- Helen Pocock
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry CV4 7AL, United Kingdom,South Central Ambulance Service NHS Foundation Trust, Southern House, Sparrowgrove, Otterbourne, Winchester, SO21 2RU, United Kingdom,Corresponding author at: Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry CV4 7AL, United Kingdom.
| | - Charles D. Deakin
- South Central Ambulance Service NHS Foundation Trust, Southern House, Sparrowgrove, Otterbourne, Winchester, SO21 2RU, United Kingdom,University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, United Kingdom
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry CV4 7AL, United Kingdom
| | - Felix Michelet
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry CV4 7AL, United Kingdom
| | - Abraham Contreras
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry CV4 7AL, United Kingdom
| | - Mark Ainsworth-Smith
- South Central Ambulance Service NHS Foundation Trust, Southern House, Sparrowgrove, Otterbourne, Winchester, SO21 2RU, United Kingdom
| | - Phil King
- South Central Ambulance Service NHS Foundation Trust, Southern House, Sparrowgrove, Otterbourne, Winchester, SO21 2RU, United Kingdom
| | - Anne Devrell
- PPI Representative, Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom
| | - Debra E. Smith
- PPI Representative, Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry CV4 7AL, United Kingdom,University Hospitals Birmingham NHS Foundation Trust, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham B9 5SS, United Kingdom
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Akhtar W, Gamble B, Kiff K, Wypych-Zych A, Raj B, Takata J, Gil FR, Hurtado A, Rosenberg A, Bowles CT. Mechanical life support algorithm developed by simulation for inpatient emergency management of recipients of implantable left ventricular assist devices. Resusc Plus 2022; 10:100254. [PMID: 35669526 PMCID: PMC9162943 DOI: 10.1016/j.resplu.2022.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/23/2022] [Accepted: 05/16/2022] [Indexed: 12/01/2022] Open
Abstract
Background Published guidance concerning emergency management of left ventricular assist device (LVAD) recipients is both limited and lacking in consensus which increases the risk of delayed and/or inappropriate actions. Methods In our specialist tertiary referral centre we developed, by iteration, a novel in-hospital resuscitation algorithm for LVAD emergencies which we validated through simulation and assessment of our multi-disciplinary team. A Mechanical Life Support course was established to provide theoretical and practical education combined with simulation to consolidate knowledge and confidence in algorithm use. We assessed these measures using confidence scoring, a key performance indicator (the time taken to restart LVAD function) and a multiple-choice question (MCQ) examination. Results The mean baseline staff confidence score in management of LVAD emergencies was 2.4 ± 1.2 out of a maximum of 5 (n = 29). After training with simulation, mean confidence score increased to 3.5 ± 0.8 (n = 13). Clinical personnel who were provided with the novel resuscitation algorithm were able to reduce time taken to restart LVAD function from a mean value of 49 ± 8.2 seconds (pre-training) to 20.4 ± 5 seconds (post-training) (n = 42, p < 0.0001). The Mechanical Life Support course increased mean confidence from 2.5 ± 1.2 to 4 ± 0.6 (n = 44, p < 0.0001) and mean MCQ score from 18.7 ± 3.4 to 22.8 ± 2.6, out of a maximum of 28 (n = 44, p < 0.0001). Conclusion We present a simplified LVAD Advanced Life Support algorithm to aid the crucial first minutes of resuscitation where basic interventions are likely to be critical in assuring good patient outcomes.
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Key Words
- ALS, Advanced Life Support
- Advanced life support
- CALS, Cardiac Advanced Life Support
- CPR, Cardio-Pulmonary Resuscitation
- Cardiac arrest
- DNAR, do not attempt resuscitation order
- ECMO, Extracorporeal Membrane Oxygenation
- ETCO2, End Tidal Carbon Dioxide, kPa Kilopascal
- LVAD
- LVAD, Left Ventricular Assist Device
- Left ventricular assist device
- MAP, Mean Arterial Pressure
- MCQ, multiple-choice exam
- MDT, multi-disciplinary team
- MLS, Mechanical Life Support
- Mechanical circulatory support
- Resuscitation
- VF, Ventricular Fibrillation
- VT, Ventricular Tachycardia
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Affiliation(s)
- Waqas Akhtar
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
| | - Brigitte Gamble
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
| | - Kristine Kiff
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
| | | | - Binu Raj
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
| | - Junko Takata
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
| | - Fernando Riesgo Gil
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
| | - Ana Hurtado
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
| | - Alex Rosenberg
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
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Kavsur R, Becher MU, Nassan W, Sedaghat A, Aksoy A, Schrickel JW, Nickenig G, Tiyerili V. CHA 2DS 2-VASC score predicts coronary artery disease progression and mortality after ventricular arrhythmia in patients with implantable cardioverter-defibrillator. Int J Cardiol Heart Vasc 2021; 34:100802. [PMID: 34095451 PMCID: PMC8165543 DOI: 10.1016/j.ijcha.2021.100802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/06/2021] [Accepted: 05/15/2021] [Indexed: 11/14/2022]
Abstract
Aim The CHA2DS2-VASC score has expanded its use beyond the initial purpose of predicting the risk of stroke in patients with atrial fibrillation. We aimed to investigate the value of the CHA2DS2-VASC score as a risk assessment tool to predict relevant coronary artery disease (CAD) leading to percutaneous coronary intervention (PCI), and all-cause mortality after detected ventricular arrhythmia (VA) in patients with an Implantable Cardioverter-Defibrillator (ICD). Methods A total of 183 ICD-patients who underwent coronary angiography after VA were included and classified according to their CHA2DS2-VASC score in a low(1-3), intermediate(4-5) and high(6-8) score group. We evaluated the predictive value of CHA2DS2-VASC score for the presence of relevant CAD leading to percutaneous coronary intervention (PCI), as well as late all-cause mortality. Results A total of 60 patients (32.8%) had significant CAD and underwent successful PCI. After adjustment for relevant parameters such as ischemic cardiomyopathy, angina pectoris, left ventricular ejection fraction, CHA2DS2-VASC score remained the only independent predictor of CAD leading to PCI [HR 1.73 (1.07–2.80)]. The Area under curve was 0.64 (0.56–72, p = 0.002). Kaplan-Meier analysis and log-rank showed an increased three-year mortality of ICD-patients with an intermediate or high score after VA (p = 0.003). Multivariate cox-regression analysis revealed that CHA2DS2-VASC score was also independently associated with all-cause mortality following adjustment for clinically relevant variables (HR 2.20, 1.17–4.14). Conclusions CHA2DS2-VASC score can be a predictor of CAD leading to PCI in ICD-patients after VA. ICD-Patients with a high score have an increased risk for reduced three-year all-cause mortality after VA.
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Key Words
- AF, Atrial fibrillation
- CABG, Coronary artery bypass graft
- CAD, Coronary artery disease
- CK-MB, Creatine Kinase MB Isoenzyme
- Coronary angiography
- Coronary artery disease
- ICD, Implantable Cardioverter-Defibrillator
- Implantable Cardioverter Defibrillator
- LDL, Low-Density Lipoprotein
- LVEF, Left Ventricular Ejection Fraction
- PCI, Percutaneous Coronary Intervention
- VA, Ventricular Arrhythmia
- VF, Ventricular Fibrillation
- VT, Ventricular Tachycardia
- Ventricular fibrillation
- Ventricular tachycardia
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Affiliation(s)
- Refik Kavsur
- Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Marc Ulrich Becher
- Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Welat Nassan
- Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Alexander Sedaghat
- Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Adem Aksoy
- Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Jan Wilko Schrickel
- Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Georg Nickenig
- Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Vedat Tiyerili
- Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
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Taylor B, Joshi B, Hutchison L, Manivel V. Echocardiography does not prolong peri-shock pause in cardiopulmonary resuscitation using the COACH-RED protocol with non-expert sonographers in simulated cardiac arrest. Resusc Plus 2020; 4:100047. [PMID: 34223322 PMCID: PMC8244492 DOI: 10.1016/j.resplu.2020.100047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Focused echocardiography during peri-shock pause (PSP) can prognosticate and detect reversible causes in cardiac arrest but minimising interruptions to chest compressions improves outcome. The COACH-RED protocol was adapted from the COACHED protocol to systematically incorporate echocardiography into rhythm check without prolonging PSP beyond the recommended 10 s. The primary objective of this study was to test the feasibility of emergency nurses learning to perform all roles in the COACH-RED protocol. PSP duration and change in participant confidence were secondary outcomes. METHODS After an initial two-hour workshop, five ALS-trained nurses were assessed for the correct use of COACH-RED protocol, without critical error, in three simulated cardiac arrest scenarios of four cycles each. Assessments were repeated on days 7 and 35. On day 35, three COACHED scenarios were also assessed for comparison. Participant roles per scenario and cardiac rhythm per cycle were randomised. Participants completed questionnaires on their confidence levels. Sessions were videotaped for accurate measurement of PSP duration and results tabulated for simple comparison. Statistical analysis was not performed due to small sample size. RESULTS There were no critical errors, two minor team-leading errors and two minor echosonography errors. Minor errors occurred in separate scenarios resulting in a 100% pass rate overall by predetermined criteria. Echocardiographic recordings were 100% adequate. Overall median PSP was 9.35 s for COACH-RED and 6.94 s for COACHED. Sub-group analysis of COACH-RED revealed median PSP 10.80 s in shockable rhythms and 8.74 s (∼2 s less) in non-shockable rhythms. Mean participant confidence in performing COACH-RED improved from 1.6 to 4.6, on a 5-point scale. CONCLUSION The COACH-RED protocol can be effectively performed by ALS-trained nurses, in all roles of this protocol, including echocardiography, in a simulated environment, after a single training session. Using this protocol, focused echocardiography does not prolong PSP beyond 10 s.
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Key Words
- ALS, Advanced Life Support
- ARC, Australian Resuscitation Council
- Advanced cardiac life support
- CPR, Cardiopulmonary resuscitation
- Cardiac arrest
- Cardiopulmonary resuscitation
- ED, Emergency Department
- Echocardiography
- Education
- IQR, Interquartile Range
- Nursing
- PEA, Pulseless Electrical Activity
- PSP, Peri-Shock Pause
- SAH, Sydney Adventist Hospital
- Simulation training
- VF, Ventricular Fibrillation
- VT, Ventricular Tachycardia
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Affiliation(s)
- Benjamin Taylor
- Emergency Care, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia
| | - Bhushan Joshi
- Emergency Care, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia
| | - Leanne Hutchison
- Emergency Care, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia
| | - Vijay Manivel
- Emergency Care, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia
- The University of Sydney, Sydney, NSW 2000, Australia
- Emergency Department, Nepean Hospital, Kingswood, NSW 2747, Australia
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