Rhythms and outcomes of adult in-hospital cardiac arrest Meaney, Peter A; Nadkarni, Vinay M; Kern, Karl B ...
Critical care medicine,
2010-January, 2010, 2010-Jan, 2010-01-00, 20100101, Letnik:
38, Številka:
1
Journal Article
Recenzirano
OBJECTIVE:To determine the relationship of electrocardiographic rhythm during cardiac arrest with survival outcomes.
DESIGN:Prospective, observational study.
SETTING:Total of 411 hospitals in the ...National Registry of Cardiopulmonary Resuscitation.
PATIENTS:Total of 51,919 adult patients with pulseless cardiac arrests from April 1999 to July 2005.
MEASUREMENTS AND MAIN RESULTS:Registry data collected included first documented rhythm, patient demographics, pre-event data, event data, and survival and neurologic outcome data. Of 51,919 indexed cardiac arrests, first documented pulseless rhythm was ventricular tachycardia (VT) in 3810 (7%), ventricular fibrillation (VF) in 8718 (17%), pulseless electrical activity (PEA) in 19,262 (37%) and asystole 20,129 (39%). Subsequent VT/VF (that is, VT or VF occurring during resuscitation for PEA or asystole) occurred in 5154 (27%), with first documented rhythm of PEA and 4988 (25%) with asystole. Survival to hospital discharge rate was not different between those with first documented VF and VT (37% each, adjusted odds ratio OR) 1.08; 95% confidence interval CI 0.95–1.23). Survival to hospital discharge was slightly more likely after PEA than asystole (12% vs. 11%, adjusted OR 1.1; 95% CI 1.00–1.18), Survival to discharge was substantially more likely after first documented VT/VF than PEA/asystole (adjusted OR 1.68; 95% CI 1.55–1.82). Survival to discharge was also more likely after PEA/asystole without subsequent VT/VF compared with PEA/asystole with subsequent VT/VF (14% vs. 7% for PEA without vs. with subsequent VT/VF; 12% vs. 8% for asystole without vs. with subsequent VT/VF; adjusted OR 1.60; 95% CI, 1.44–1.80).
CONCLUSIONS:Survival to hospital discharge was substantially more likely when the first documented rhythm was shockable rather than nonshockable, and slightly more likely after PEA than asystole. Survival to hospital discharge was less likely following PEA/asystole with subsequent VT/VF compared to PEA/asystole without subsequent VT/VF.
Pediatric cardiopulmonary resuscitation (CPR) for >20 minutes has been considered futile after pediatric in-hospital cardiac arrests. This concept has recently been questioned, although the effect of ...CPR duration on outcomes has not recently been described. Our objective was to determine the relationship between CPR duration and outcomes after pediatric in-hospital cardiac arrests.
We examined the effect of CPR duration for pediatric in-hospital cardiac arrests from the Get With The Guidelines-Resuscitation prospective, multicenter registry of in-hospital cardiac arrests. We included 3419 children from 328 U.S. and Canadian Get With The Guidelines-Resuscitation sites with an in-hospital cardiac arrest between January 2000 and December 2009. Patients were stratified into 5 patient illness categories: surgical cardiac, medical cardiac, general medical, general surgical, and trauma. Survival to discharge was 27.9%, but only 19.0% of all cardiac arrest patients had favorable neurological outcomes. Between 1 and 15 minutes of CPR, survival decreased linearly by 2.1% per minute, and rates of favorable neurological outcome decreased by 1.2% per minute. Adjusted probability of survival was 41% for CPR duration of 1 to 15 minutes and 12% for >35 minutes. Among survivors, favorable neurological outcome occurred in 70% undergoing <15 minutes of CPR and 60% undergoing CPR >35 minutes. Compared with general medical patients, surgical cardiac patients had the highest adjusted odds ratios for survival and favorable neurological outcomes, 2.5 (95% confidence interval, 1.8-3.4) and 2.7 (95% confidence interval, 2.0-3.9), respectively.
CPR duration was independently associated with survival to hospital discharge and neurological outcome. Among survivors, neurological outcome was favorable for the majority of patients. Performing CPR for >20 minutes is not futile in some patient illness categories.
The '2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care' increased the focus on methods to ensure that high-quality cardiopulmonary ...resuscitation (CPR) is performed in all resuscitation attempts. There are 5 critical components of high-quality CPRminimize interruptions in chest compressions, provide compressions of adequate rate and depth, avoid leaning between compressions, and avoid excessive ventilation. Although it is clear that high-quality CPR is the primary component in influencing survival from cardiac arrest, there is considerable variation in monitoring, implementation, and quality improvement. As such, CPR quality varies widely between systems and locations. Victims often do not receive high-quality CPR because of provider ambiguity in prioritization of resuscitative efforts during an arrest. This ambiguity also impedes the development of optimal systems of care to increase survival from cardiac arrest. This consensus statement addresses the following key areas of CPR quality for the trained rescuermetrics of CPR performance; monitoring, feedback, and integration of the patient’s response to CPR; team-level logistics to ensure performance of high-quality CPR; and continuous quality improvement on provider, team, and systems levels. Clear definitions of metrics and methods to consistently deliver and improve the quality of CPR will narrow the gap between resuscitation science and the victims, both in and out of the hospital, and lay the foundation for further improvements in the future.
IMPORTANCE: Nearly 6000 hospitalized children in the United States receive cardiopulmonary resuscitation (CPR) annually. Little is known about whether the survival of these children is influenced by ...the time of the event (eg, nighttime or weekends). Differences in survival could have important implications for hospital staffing, training, and resource allocation. OBJECTIVE: To determine whether outcomes after pediatric in-hospital cardiac arrests differ during nights and weekends compared with days/evenings and weekdays. DESIGN, SETTING, AND PARTICIPANTS: This study included a total of 354 hospitals participating in the American Heart Association’s Get With the Guidelines–Resuscitation registry from January 1, 2000, to December 12, 2012. Index cases (12 404 children) from all children younger than 18 years of age receiving CPR for at least 2 minutes were included. Data analysis was performed in December 2014 and June 2016. We aggregated hourly blocks of time, using previously defined time intervals of day/evening and night, as well as weekend. Multivariable logistic regression models were used to examine the effect of independent variables on survival to hospital discharge. We used a combination of a priori variables based on previous literature (including age, first documented rhythm, location of event in hospital, extracorporeal CPR, and hypotension as the cause of arrest), as well as variables that were identified in bivariate generalized estimating equation models, and maintained significance of P ≤ .15 in the final multivariable models. MAIN OUTCOMES AND MEASURES: The primary outcome measure was survival to hospital discharge, and secondary outcomes included return of circulation lasting more than 20 minutes and 24-hour survival. RESULTS: Of 12 404 children (56.0% were male), 8731 (70.4%) experienced a return of circulation lasting more than 20 minutes, 7248 (58.4%) survived for 24 hours, and 4488 (36.2%) survived to hospital discharge. After adjusting for potential confounders, we found that the rate of survival to hospital discharge was lower during nights than during days/evenings (adjusted odds ratio, 0.88 95% CI, 0.80-0.97; P = .007) but was not different between weekends and weekdays (adjusted odds ratio, 0.92 95% CI, 0.84-1.01; P = .09). CONCLUSIONS AND RELEVANCE: The rate of survival to hospital discharge was lower for pediatric CPR events occurring at night than for CPR events occurring during daytime and evening hours, even after adjusting for many potentially confounding patient-, event-, and hospital-related factors.
To investigate the effectiveness of brief bedside cardiopulmonary resuscitation (CPR) training to improve the skill retention of hospital-based pediatric providers. We hypothesized that a low-dose, ...high-frequency training program (booster training) would improve CPR skill retention.
CPR recording/feedback defibrillators were used to evaluate CPR quality during simulated arrest. Basic life support-certified, hospital-based providers were randomly assigned to 1 of 4 study arms: (1) instructor-only training; (2) automated defibrillator feedback only; (3) instructor training combined with automated feedback; and (4) control (no structured training). Each session (time: 0, 1, 3, and 6 months after training) consisted of a pretraining evaluation (60 seconds), booster training (120 seconds), and a posttraining evaluation (60 seconds). Excellent CPR was defined as chest compression (CC) depth ≥ one-third anterior-posterior chest depth, rate ≥90 and ≤120 CC per minute, ≤20% of CCs with incomplete release (>2500 g), and no flow fraction ≤ 0.30.
Eighty-nine providers were randomly assigned; 74 (83%) completed all sessions. Retention of CPR skills was 2.3 times (95% confidence interval CI: 1.1-4.5; P=.02) more likely after 2 trainings and 2.9 times (95% CI: 1.4-6.2; P=.005) more likely after 3 trainings. The automated defibrillator feedback only group had lower retention rates compared with the instructor-only training group (odds ratio: 0.41 95% CI: 0.17-0.97; P = .043).
Brief bedside booster CPR training improves CPR skill retention. Our data reveal that instructor-led training improves retention compared with automated feedback training alone. Future studies should investigate whether bedside training improves CPR quality during actual pediatric arrests.
OBJECTIVE:In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of ...a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events.
DESIGN, SETTING, AND PATIENTS:Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU.
INTERVENTIONS:Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers.
MEASUREMENTS AND MAIN RESULTS:Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for ≥ 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed “excellent cardiopulmonary resuscitation,” prospectively defined as a chest compression depth ≥ 38 mm, rate ≥ 100/min, ≤ 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91–6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01–7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9–10.6; p < 0.01).
CONCLUSION:Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.
Microwave tomography recovers images of tissue dielectric properties, which appear to be specific for breast cancer, with low-cost technology that does not present an exposure risk, suggesting the ...modality may be a good candidate for monitoring neoadjuvant chemotherapy.
Eight patients undergoing neoadjuvant chemotherapy for locally advanced breast cancer were imaged longitudinally five to eight times during the course of treatment. At the start of therapy, regions of interest (ROIs) were identified from contrast-enhanced magnetic resonance imaging studies. During subsequent microwave examinations, subjects were positioned with their breasts pendant in a coupling fluid and surrounded by an immersed antenna array. Microwave property values were extracted from the ROIs through an automated procedure and statistical analyses were performed to assess short term (30 days) and longer term (four to six months) dielectric property changes.
Two patient cases (one complete and one partial response) are presented in detail and demonstrate changes in microwave properties commensurate with the degree of treatment response observed pathologically. Normalized mean conductivity in ROIs from patients with complete pathological responses was significantly different from that of partial responders (P value = 0.004). In addition, the normalized conductivity measure also correlated well with complete pathological response at 30 days (P value = 0.002).
These preliminary findings suggest that both early and late conductivity property changes correlate well with overall treatment response to neoadjuvant therapy in locally advanced breast cancer. This result is consistent with earlier clinical outcomes that lesion conductivity is specific to differentiating breast cancer from benign lesions and normal tissue.
This focused update to the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care follows the Pediatric Task Force of the International ...Liaison Committee on Resuscitation evidence review. It aligns with the International Liaison Committee on Resuscitation’s continuous evidence review process, and updates are published when the International Liaison Committee on Resuscitation completes a literature review based on new science. This update provides the evidence review and treatment recommendation for chest compression–only CPR versus CPR using chest compressions with rescue breaths for children <18 years of age. Four large database studies were available for review, including 2 published after the “2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” Two demonstrated worse 30-day outcomes with chest compression–only CPR for children 1 through 18 years of age, whereas 2 studies documented no difference between chest compression–only CPR and CPR using chest compressions with rescue breaths. When the results were analyzed for infants <1 year of age, CPR using chest compressions with rescue breaths was better than no CPR but was no different from chest compression–only CPR in 1 study, whereas another study observed no differences among chest compression–only CPR, CPR using chest compressions with rescue breaths, and no CPR. CPR using chest compressions with rescue breaths should be provided for infants and children in cardiac arrest. If bystanders are unwilling or unable to deliver rescue breaths, we recommend that rescuers provide chest compressions for infants and children.
Serious childhood illnesses (SCI), defined as severe pneumonia, severe dehydration, sepsis, and severe malaria, remain major contributors to amenable child mortality worldwide. Inadequate recognition ...and treatment of SCI are factors that impact child mortality in Botswana. Skills assessments of providers caring for SCI have not been validated in low and middle-income countries.
To establish preliminary inter-rater reliability, validity evidence, and feasibility for an assessment of providers who care for SCI using simulated patients and remote video capture in community clinic settings in Botswana.
This was a pilot study. Four scenarios were developed via a modified Delphi technique and implemented at primary care clinics in Kweneng, Botswana. Sessions were video captured and independently reviewed. Response process and internal structure analysis utilized intra-class correlation (ICC) and Fleiss' Kappa. A structured log was utilized for feasibility of remote video capture.
Eleven subjects participated. Scenarios of Lower Airway Obstruction (ICC = 0.925, 95%CI 0.695-0.998) and Hypovolemic Shock from Severe Dehydration (ICC = 0.892, 95%CI 0.596-0.997) produced excellent ICC among raters while Lower Respiratory Tract Infection (LRTI, ICC = 0, 95%CI -0.034-0.97) and LRTI + Distributive Shock from Sepsis (0.365, 95%CI -0.025-0.967) were poor. Oxygen therapy (0.707), arranging transport (0.706), and fluid administration (0.701) demonstrated substantial task reliability.
Initial development of an assessment tool demonstrates many, but not all, criteria for validity evidence. Some scenarios and tasks demonstrate excellent reliability among raters, but others may be limited by manikin design and study implementation. Remote simulation assessment of some skills by clinic-based providers in global health settings is reliable and feasible.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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