In-Hospital Cardiac Arrest: A Review Andersen, Lars W; Holmberg, Mathias J; Berg, Katherine M ...
JAMA : the journal of the American Medical Association,
03/2019, Letnik:
321, Številka:
12
Journal Article
Recenzirano
IMPORTANCE: In-hospital cardiac arrest is common and associated with a high mortality rate. Despite this, in-hospital cardiac arrest has received little attention compared with other high-risk ...cardiovascular conditions, such as stroke, myocardial infarction, and out-of-hospital cardiac arrest. OBSERVATIONS: In-hospital cardiac arrest occurs in over 290 000 adults each year in the United States. Cohort data from the United States indicate that the mean age of patients with in-hospital cardiac arrest is 66 years, 58% are men, and the presenting rhythm is most often (81%) nonshockable (ie, asystole or pulseless electrical activity). The cause of the cardiac arrest is most often cardiac (50%-60%), followed by respiratory insufficiency (15%-40%). Efforts to prevent in-hospital cardiac arrest require both a system for identifying deteriorating patients and an appropriate interventional response (eg, rapid response teams). The key elements of treatment during cardiac arrest include chest compressions, ventilation, early defibrillation, when applicable, and immediate attention to potentially reversible causes, such as hyperkalemia or hypoxia. There is limited evidence to support more advanced treatments. Post–cardiac arrest care is focused on identification and treatment of the underlying cause, hemodynamic and respiratory support, and potentially employing neuroprotective strategies (eg, targeted temperature management). Although multiple individual factors are associated with outcomes (eg, age, initial rhythm, duration of the cardiac arrest), a multifaceted approach considering both potential for neurological recovery and ongoing multiorgan failure is warranted for prognostication and clinical decision-making in the post–cardiac arrest period. Withdrawal of care in the absence of definite prognostic signs both during and after cardiac arrest should be avoided. Hospitals are encouraged to participate in national quality-improvement initiatives. CONCLUSIONS AND RELEVANCE: An estimated 290 000 in-hospital cardiac arrests occur each year in the United States. However, there is limited evidence to support clinical decision making. An increased awareness with regard to optimizing clinical care and new research might improve outcomes.
Abstract Lactate levels are commonly evaluated in acutely ill patients. Although most often used in the context of evaluating shock, lactate levels can be elevated for many reasons. While tissue ...hypoperfusion may be the most common cause of elevation, many other etiologies or contributing factors exist. Clinicians need to be aware of the many potential causes of lactate level elevation as the clinical and prognostic importance of an elevated lactate level varies widely by disease state. Moreover, specific therapy may need to be tailored to the underlying cause of elevation. The present review is based on a comprehensive PubMed search between the dates of January 1, 1960, to April 30, 2013, using the search term lactate or lactic acidosis combined with known associations, such as shock, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine, malignancy, liver, toxins, overdose, and medication. We provide an overview of the pathogenesis of lactate level elevation followed by an in-depth look at the varied etiologies, including medication-related causes. The strengths and weaknesses of lactate as a diagnostic/prognostic tool and its potential use as a clinical end point of resuscitation are discussed. The review ends with some general recommendations on the management of patients with elevated lactate levels.
The fundamentals of cardiac resuscitation include the immediate provision of high-quality cardiopulmonary resuscitation combined with rapid defibrillation (as appropriate). These mainstays of therapy ...set the groundwork for other possible interventions such as medications, advanced airways, extracorporeal cardiopulmonary resuscitation, and post–cardiac arrest care, including targeted temperature management, cardiorespiratory support, and percutaneous coronary intervention. Since 2015, an increased number of studies have been published evaluating some of these interventions, requiring a reassessment of their use and impact on survival from cardiac arrest. This 2019 focused update to the American Heart Association advanced cardiovascular life support guidelines summarizes the most recent published evidence for and recommendations on the use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest. It includes revised recommendations for all 3 areas, including the choice of advanced airway devices and strategies during cardiac arrest (eg, bag-mask ventilation, supraglottic airway, or endotracheal intubation), the training and retraining required, the administration of standard-dose epinephrine, and the decisions involved in the application of extracorporeal cardiopulmonary resuscitation and its potential impact on cardiac arrest survival.
Observational studies are prone to a number of biases. One of these is immortal time bias. In this manuscript, we discuss immortal time bias as it pertains to post-cardiac arrest research and ...describes a related bias which we term “resuscitation time bias”. This bias can occur when studying exposures during cardiac arrest. In this unique situation, an exposure is more likely to occur the longer the cardiac arrest continues. Since length of resuscitation is strongly associated with worse outcome, this will bias the results toward a harmful effect of the exposure. We discuss this bias and present methods to account for it.
Differentiating acute bacterial infection from other causes of lower respiratory tract illness is challenging. In this trial, procalcitonin was investigated as a point-of-care test to aid in ...determining whether antibiotics were needed in the treatment of these illnesses.
BACKGROUND:Cardiac arrest in hospitalized children is associated with poor outcomes, but no contemporary study has reported whether the trends in survival have changed over time. In this study, we ...examined temporal trends in survival for pediatric patients with an in-hospital pulseless cardiac arrest and pediatric patients with a nonpulseless cardiopulmonary resuscitation event from 2000 to 2018.
METHODS:This was an observational study of hospitalized pediatric patients (≤18 years of age) who received cardiopulmonary resuscitation from January 2000 to December 2018 and were included in the Get With The Guidelines-Resuscitation registry, a United States–based in-hospital cardiac arrest registry. The primary outcome was survival to hospital discharge, and the secondary outcome was return of spontaneous circulation (binary outcomes). Generalized estimation equations were used to obtain unadjusted trends in outcomes over time. Separate analyses were performed for patients with a pulseless cardiac arrest and patients with a nonpulseless event (bradycardia with poor perfusion) requiring cardiopulmonary resuscitation. A subgroup analysis was conducted for shockable versus nonshockable initial rhythms in pulseless events.
RESULTS:A total of 7433 patients with a pulseless cardiac arrest and 5751 patients with a nonpulseless event were included for the analyses. For pulseless cardiac arrests, survival was 19% (95% CI, 11%–29%) in 2000 and 38% (95% CI, 34%–43%) in 2018, with an absolute change of 0.67% (95% CI, 0.40%–0.95%; P<0.001) per year, although the increase in survival appeared to stagnate following 2010. Return of spontaneous circulation also increased over time, with an absolute change of 0.83% (95% CI, 0.53%–1.14%; P<0.001) per year. We found no interaction between survival to hospital discharge and the initial rhythm. For nonpulseless events, survival was 57% (95% CI, 39%–75%) in 2000 and 66% (95% CI, 61%–72%) in 2018, with an absolute change of 0.80% (95% CI, 0.32%–1.27%; P=0.001) per year.
CONCLUSIONS:Survival has improved for pediatric events requiring cardiopulmonary resuscitation in the United States, with a 19% absolute increase in survival for in-hospital pulseless cardiac arrests and a 9% absolute increase in survival for nonpulseless events between 2000 and 2018. However, survival from pulseless cardiac arrests appeared to have reached a plateau following 2010.
To assess the use of extracorporeal cardiopulmonary resuscitation (ECPR), compared with manual or mechanical cardiopulmonary resuscitation (CPR), for out-of-hospital cardiac arrest (OHCA) and ...in-hospital cardiac arrest (IHCA) in adults and children.
The PRISMA guidelines were followed. We searched Medline, Embase, and Evidence-Based Medicine Reviews for randomized clinical trials and observational studies published before May 22, 2018. The population included adult and pediatric patients with OHCA and IHCA of any origin. Two investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the ROBINS-I tool. Outcomes included short-term and long-term survival and favorable neurological outcome.
We included 25 observational studies, of which 15 studies were in adult OHCA, 7 studies were in adult IHCA, and 3 studies were in pediatric IHCA. There were no studies in pediatric OHCA. No randomized trials were included. Results from individual studies were largely inconsistent, although several studies in adult and pediatric IHCA were in favor of ECPR. The risk of bias for individual studies was overall assessed to be critical, with confounding being the primary source of bias. The overall quality of evidence was assessed to be very low. Heterogeneity across studies precluded any meaningful meta-analyses.
There is inconclusive evidence to either support or refute the use of ECPR for OHCA and IHCA in adults and children. The quality of evidence across studies is very low.
Thiamine (vitamin B1) is a water-soluble vitamin essential for human health. Thiamine deficiency is causal and/or contributory in a number of debilitating diseases including beri-beri, the ...Wernicke-Korsakoff syndrome, optic neuropathy, and others. While thiamine deficiency is relatively rare in developed nations as a result of dietary supplementation, thiamine deficiency is more common in nutritionally compromised populations. Thiamine pyrophosphate, a thiamine derivative, is essential to the citric acid cycle and thiamine deficiency can result in impaired aerobic respiration and cellular energy production. Thiamine also plays an important role in the pentose phosphate pathway and other key metabolic processes. Although thiamine deficiency is a known cause of lactic acidosis, it has been recently evaluated as a potential contributor to refractory lactic acidosis and organ injury in septic shock and other shock states. In this article, we review the epidemiology of thiamine deficiency in septic shock and the existing evidence base supporting thiamine supplementation. We conclude that specific sepsis phenotypes may stand to benefit the most from thiamine supplementation, and efforts might be made to identify and supplement these patients early in their hospital course.
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