This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple ...advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.
Decline of the North American avifauna Rosenberg, Kenneth V; Dokter, Adriaan M; Blancher, Peter J ...
Science (American Association for the Advancement of Science),
10/2019, Letnik:
366, Številka:
6461
Journal Article
Recenzirano
Odprti dostop
Species extinctions have defined the global biodiversity crisis, but extinction begins with loss in abundance of individuals that can result in compositional and functional changes of ecosystems. ...Using multiple and independent monitoring networks, we report population losses across much of the North American avifauna over 48 years, including once-common species and from most biomes. Integration of range-wide population trajectories and size estimates indicates a net loss approaching 3 billion birds, or 29% of 1970 abundance. A continent-wide weather radar network also reveals a similarly steep decline in biomass passage of migrating birds over a recent 10-year period. This loss of bird abundance signals an urgent need to address threats to avert future avifaunal collapse and associated loss of ecosystem integrity, function, and services.
The efficiency of rapid response teams (RRTs) is decreased by delays in activation of RRT (afferent limb failure, ALF). We categorized ALF by organ systems and investigated correlations with the ...vital signs subsequently observed by the RRT and associations with mortality.
International, multicentre, retrospective cohort study including adult RRT patients without treatment limitations in 2017–2018 in one Australian and two Finnish tertiary hospitals.
A total of 5,568 RRT patients’ first RRT activations were included. In 927 patients (17%) ALF was present within 4 h before the RRT call, most commonly for respiratory criteria (419 patients, 7.5%). In 3516 patients (63%) overall, and in 756 (82%) of ALF patients, the RRT observed abnormal vital signs upon arrival. The organ-specific ALF corresponded to the RRT observations in 52% of cases for respiratory criteria, in 60% for haemodynamic criteria, in 55% for neurological criteria and in 52% of cases for multiple organ criteria. Only ALF for respiratory criteria was associated with increased hospital mortality (OR 1.71, 95% CI 1.29–2.27), whereas all, except haemodynamic, criteria at the time of RRT review were associated with increased hospital mortality.
Vital signs were rarely normal upon RRT arrival in patients with ALF, while organ-specific ALF corresponded to subsequent RRT observations in just over half of cases. Our results suggest that systems mandating timely responses to abnormal respiratory criteria in particular may have potential to improve deteriorating patient outcomes.
Cardiopulmonary resuscitation prioritises treatment for cardiac arrests from a primary cardiac cause, which make up the majority of treated cardiac arrests. Early chest compressions and, when ...indicated, a defibrillation shock from a bystander give the best chance of survival with a good neurological status. Cardiac arrest can also be caused by special circumstances, such as asphyxia, trauma, pulmonary embolism, accidental hypothermia, anaphylaxis, or COVID-19, and during pregnancy or perioperatively. Cardiac arrests in these circumstances represent an increasing proportion of all treated cardiac arrests, often have a preventable cause, and require additional interventions to correct a reversible cause during resuscitation. The evidence for treating these conditions is mostly of low or very low certainty and further studies are needed. Irrespective of the cause, treatments for cardiac arrest are time sensitive and most effective when given early—every minute counts.
Abstract Aim This study assessed the level of agreement on CPR decisions among intensive care doctors and specialist physicians and surgeons, and the barriers to documenting do not attempt ...resuscitation (DNAR) orders for ward patients during Medical Emergency Team (MET) calls. Methods We prospectively assessed all patients having MET calls for 11 months. If the intensive care doctor on the MET considered a DNAR order appropriate for the patient, the primary care clinician was contacted to: (1) confirm agreement or disagreement with a DNAR order and (2) give reasons as to why a DNAR order was not considered or documented prior to the MET call. Results In the study period, the MET attended 1458 patients. A DNAR order was considered appropriate in 129 cases. In 116 (90%), the primary care clinician agreed with a DNAR order at the time of the MET. Common reasons given by primary care clinicians for not documenting DNAR orders included acute or unexpected deterioration (22.5%), awaiting family discussion (22.5%), actively treating the patient for a reversible condition (17.1%), not knowing the patient well enough (10.9%) and resuscitation status not yet discussed by team (10.9%). Conclusions This study shows a high level of agreement on DNAR orders among intensive care doctors, physicians and surgeons for deteriorating ward patients. Barriers to timely documentation need to be addressed. Delay in documentation and communication of DNAR orders is common. The MET system provides an opportunity to identify patients for whom a DNAR order should be considered.
The Importance and Benefits of Species Gascon, Claude; Brooks, Thomas M.; Contreras-MacBeath, Topiltzin ...
Current biology,
05/2015, Letnik:
25, Številka:
10
Journal Article
Recenzirano
Odprti dostop
Humans depend on biodiversity in myriad ways, yet species are being rapidly lost due to human activities. The ecosystem services approach to conservation tries to establish the value that society ...derives from the natural world such that the true cost of proposed development actions becomes apparent to decision makers. Species are an integral component of ecosystems, and the value they provide in terms of services should be a standard part of ecosystem assessments. However, assessing the value of species is difficult and will always remain incomplete. Some of the most difficult species’ benefits to assess are those that accrue unexpectedly or are wholly unanticipated. In this review, we consider recent examples from a wide variety of species and a diverse set of ecosystem services that illustrate this point and support the application of the precautionary principle to decisions affecting the natural world.
Gascon et al. give examples of unexpected benefits species provide to humanity.
Abstract
Background
Clinical frailty among older adults admitted to intensive care has been proposed as an important determinant of patient outcomes. Among this group of patients, an acute episode of ...delirium is also common, but its relationship to frailty and increased risk of mortality has not been extensively explored. Therefore, the aim of this study was to explore the relationship between clinical frailty, delirium and hospital mortality of older adults admitted to intensive care.
Methods
This study is part of a Delirium in Intensive Care (Deli) Study. During the initial 6-month baseline period, clinical frailty status on admission to intensive care, among adults aged 50 years or more; acute episodes of delirium; and the outcomes of intensive care and hospital stay were explored.
Results
During the 6-month baseline period, 997 patients, aged 50 years or more, were included in this study. The average age was 71 years (IQR, 63–79); 55% were male (
n
= 537). Among these patients, 39.2% (95% CI 36.1–42.3%,
n
= 396) had a Clinical Frailty Score (CFS) of 5 or more, and 13.0% (
n
= 127) had at least one acute episode of delirium. Frail patients were at greater risk of an episode of delirium (17% versus 10%, adjusted rate ratio (
adj
RR) = 1.71, 95% confidence interval (CI) 1.20–2.43,
p
= 0.003), had a longer hospital stay (2.6 days, 95% CI 1–7 days,
p
= 0.009) and had a higher risk of hospital mortality (19% versus 7%,
adj
RR = 2.54, 95% CI 1.72–3.75,
p
< 0.001), when compared to non-frail patients. Patients who were frail and experienced an acute episode of delirium in the intensive care had a 35% rate of hospital mortality versus 10% among non-frail patients who also experienced delirium in the ICU.
Conclusion
Frailty and delirium significantly increase the risk of hospital mortality. Therefore, it is important to identify patients who are frail and institute measures to reduce the risk of adverse events in the ICU such as delirium and, importantly, to discuss these issues in an open and empathetic way with the patient and their families.
To investigate in-hospital cardiac arrests (IHCAs) according to the Ustein template in hospitals with mature systems utilizing rapid response teams (RRTs), with a special reference to preceding RRT ...factors and factors associated with a favourable neurological outcome (cerebral performance category (CPC) 1–2) at hospital discharge.
Multicentre, retrospective cohort study between 2017–2018 including two Finnish and one Australian university affiliated tertiary hospitals.
A total 309 IHCAs occurred with an incidence of 0.78 arrests per 1000 hospital admissions. The median age of the patients was 72 years, 63% were male and 73% had previously lived a fully independent life with a median Charlson comorbidity index of two. Before the IHCA, 16% of the patients had been reviewed by RRTs and 26% of the patients fulfilled RRT activation criteria in the preceding 8 h of the IHCA. Return of spontaneous circulation was achieved in 53% of the patients and 28% were discharged from hospital with CPC 1–2. In a multivariable model, younger age, no pre-arrest RRT criteria, arrest in normal work hours, witnessed arrest and shockable initial rhythm were independently associated with CPC 1–2 at hospital discharge.
In hospitals with mature rapid response systems most IHCA patients live a fully independent life with low burden of comorbid diseases before their hospital admission, the IHCA incidence is low and outcome better than traditionally believed. Deterioration before IHCA is present in a significant number of patients and improved monitoring and earlier interventions may further improve outcomes.
Temperature control with target temperature management (TTM) after cardiac arrest has been endorsed by expert societies and adopted in international clinical practice guidelines but recent evidence ...challenges the use of hypothermic TTM.
Systematic review and Bayesian meta-analysis of clinical trials on adult survivors from cardiac arrest undergoing TTM for at least 12 h comparing TTM versus no TTM or with a separation > 2 °C between intervention and control groups using the PubMed/MEDLINE, EMBASE, CENTRAL databases from inception to 1 September 2021 (PROSPERO CRD42021248140). All randomised and quasi-randomised controlled trials were considered. The risk ratio and 95% confidence interval for death (primary outcome) and unfavourable neurological recovery (secondary outcome) were captured using the original study definitions censored up to 180 days after cardiac arrest. Bias was assessed using the updated Cochrane risk-of-bias for randomised trials tool and certainty of evidence assessed using the Grading of Recommendation Assessment, Development and Evaluation methodology. A hierarchical robust Bayesian model-averaged meta-analysis was performed using both minimally informative and data-driven priors and reported by mean risk ratio (RR) and its 95% credible interval (95% CrI).
In seven studies (three low bias, three intermediate bias, one high bias, very low to low certainty) recruiting 3792 patients the RR by TTM 32-34 °C was 0.95 95% CrI 0.78-1.09 for death and RR 0.93 95% CrI 0.84-1.02 for unfavourable neurological outcome. The posterior probability for no benefit (RR ≥ 1) by TTM 32-34 °C was 24% for death and 12% for unfavourable neurological outcome. The posterior probabilities for favourable treatment effects of TTM 32-34 °C were the highest for an absolute risk reduction of 2-4% for death (28-53% chance) and unfavourable neurological outcome (63-78% chance). Excluding four studies without active avoidance of fever in the control arm reduced the probability to achieve an absolute risk reduction > 2% for death or unfavourable neurological outcome to ≤ 50%.
The posterior probability distributions did not support the use of TTM at 32-34 °C compared to 36 °C also including active control of fever to reduce the risk of death and unfavourable neurological outcome at 90-180 days. Any likely benefit of hypothermic TTM is smaller than targeted in RCTs to date.
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