Preamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular Risk S50

The goals of the American College of Cardiology (ACC) and the American Heart Association (AHA) are to prevent cardiovascular diseases (CVD); improve the management of people who have these diseases through professional education and research; and develop guidelines, standards, and policies that promote optimal patient care and cardiovascular health. Toward these objectives, the ACC and AHA have collaborated with the National Heart, Lung, and Blood Institute (NHLBI) and stakeholder and professional organizations to develop …

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2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk

There is increasing recognition that systematic post–cardiac arrest care after return of spontaneous circulation (ROSC) can improve the likelihood of patient survival with good quality of life. This is based in part on the publication of results of randomized controlled clinical trials as well as a description of the post–cardiac arrest syndrome. 1–3 Post–cardiac arrest care has significant potential to reduce early mortality caused by hemodynamic instability and later morbidity and mortality from multiorgan failure and brain injury. 3,4 This section summarizes our evolving understanding of the hemodynamic, neurological, and metabolic abnormalities encountered in patients who are initially resuscitated from cardiac arrest. The initial objectives of post–cardiac arrest care are to ● Optimize cardiopulmonary function and vital organ perfusion. ● After out-of-hospital cardiac arrest, transport patient to an appropriate hospital with a comprehensive post–cardiac arrest treatment system of care that includes acute coronary interventions, neurological care, goal-directed critical care, and hypothermia. ● Transport the in-hospital post–cardiac arrest patient to an appropriate critical-care unit capable of providing comprehensive post–cardiac arrest care. ● Try to identify and treat the precipitating causes of the arrest and prevent recurrent arrest.

http://www.kardio.hu/feltoltott/dokumentumok/fajl_201148104747Cardiopulm_resuscit_Pt9_Post_cardiac.pdf

Part 9: Post-Cardiac Arrest Care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

https://genoplivning.dk/wp-content/uploads/2013/07/european-resuscitation-council-guidelines-for-resuscitation-2010-section-4-adult-advanced-life-support.pdf

European Resuscitation Council Guidelines for Resuscitation 2010 Section 4 Adult advanced life support

Measuring Health: A Guide to Rating Scales and Questionnaires

The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.

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Part 8: Adult Advanced Cardiovascular Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Nonsteroidal antiinflammatory drugs (NSAIDs) are commonly combined with intravenous morphine patient-controlled analgesia to relieve postoperative pain. NSAIDs have a documented 30-50% sparing effect on morphine consumption. However, most of the studies have not demonstrated a decrease in morphine adverse effects. A meta-analysis of randomized controlled trials was performed to evaluate the risk of morphine adverse effects in patients treated with NSAIDs. Twenty-two prospective, randomized, double-blind studies including 2,307 patients were selected. NSAIDs decreased significantly postoperative nausea and vomiting by 30%, nausea alone by 12%, vomiting alone by 32% and sedation by 29%. A regression analysis yielded findings indicating that morphine consumption was positively correlated with the incidence of nausea and vomiting. Pruritus, urinary retention, and respiratory depression were not significantly decreased by NSAIDs.

Effects of nonsteroidal antiinflammatory drugs on patient-controlled analgesia morphine side effects: meta-analysis of randomized controlled trials

Background Acetaminophen is commonly used for the management of perioperative pain. However, there is a marked discrepancy between the extent to which acetaminophen is used and the available evidence for an analgesic effect after major surgery. The aim of this systematic review is to determine the morphine-sparing effect of acetaminophen combined with patient-controlled analgesia (PCA) with morphine and to evaluate its effects on opioid-related adverse effects. Methods MEDLINE and the Cochrane Library were searched to select randomized controlled trials which compared PCA morphine alone with PCA morphine plus acetaminophen administered orally or intravenously. Studies were evaluated for their quality based on the Oxford Quality Scale. Outcome measures were morphine consumption over the first 24 h after surgery, patient satisfaction and the incidence of morphine side-effects, including nausea and vomiting, sedation, urinary retention, pruritus and/or respiratory depression. Results Seven prospective randomized controlled trials, including 265 patients in the group with PCA morphine plus acetaminophen and 226 patients in the group with PCA morphine alone, were selected. Acetaminophen administration was not associated with a decrease in the incidence of morphine-related adverse effects or an increase in patient satisfaction. Adding acetaminophen to PCA was associated with a morphine-sparing effect of 20% (mean, −9 mg; CI −15 to −3 mg; P =0.003) over the first postoperative 24 h. Conclusion Acetaminophen combined with PCA morphine induced a significant morphine-sparing effect but did not change the incidence of morphine-related adverse effects in the postoperative period.

Effects of acetaminophen on morphine side-effects and consumption after major surgery: meta-analysis of randomized controlled trials

Data Sources:Searchofdatabases(1966toMarch2006) and bibliographies. Study Selection: Inclusion criteria were randomized comparison of epidural vs systemic analgesia lasting 24 hours or longer postoperatively and reporting of pulmonarycomplications,lungfunction,orgasexchange.Fiftyeight trials (5904 patients) were included. Data Extraction: Articles were reviewed and data extracted. Data were combined using fixed-effect and random-effects models. Data Synthesis: The odds of pneumonia were decreased with epidural analgesia (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.43-0.68), independent of site of surgery or catheter insertion, duration of analgesia,orregimen.Theeffectwasweakerintrialsthatused patient-controlled analgesia in controls (OR, 0.64; 95% CI,0.49-0.83)comparedwithtrialsthatdidnot(OR,0.30; 95% CI, 0.18-0.49) and in larger studies (OR, 0.62; 95% CI, 0.47-0.81) compared with smaller studies (OR, 0.37; 95% CI, 0.23-0.58). From 1971-2006, the incidence of pneumonia with epidural analgesia remained about 8% but decreased from 34% to 12% with systemic analgesia (P.001); consequently, the relative benefit of epidural analgesia decreased also. Epidural analgesia reduced the need for prolonged ventilation or reintubation, improved lung function and blood oxygenation, and increased the risk of hypotension, urinary retention, and pruritus. Technical failures occurred in 7%. Conclusion: Epidural analgesia protects against pneumonia following abdominal or thoracic surgery, although this beneficial effect has lessened over the last 35 years because of a decrease in the baseline risk.

Protective Effects of Epidural Analgesia on Pulmonary Complications After Abdominal and Thoracic Surgery

Objective To review the impact of epidural vs systemic analgesia on postoperative pulmonary complications. Data Sources Search of databases (1966 to March 2006) and bibliographies. Study Selection Inclusion criteria were randomized comparison of epidural vs systemic analgesia lasting 24 hours or longer postoperatively and reporting of pulmonary complications, lung function, or gas exchange. Fifty-eight trials (5904 patients) were included. Data Extraction Articles were reviewed and data extracted. Data were combined using fixed-effect and random-effects models. Data Synthesis The odds of pneumonia were decreased with epidural analgesia (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.43-0.68), independent of site of surgery or catheter insertion, duration of analgesia, or regimen. The effect was weaker in trials that used patient-controlled analgesia in controls (OR, 0.64; 95% CI, 0.49-0.83) compared with trials that did not (OR, 0.30; 95% CI, 0.18-0.49) and in larger studies (OR, 0.62; 95% CI, 0.47-0.81) compared with smaller studies (OR, 0.37; 95% CI, 0.23-0.58). From 1971-2006, the incidence of pneumonia with epidural analgesia remained about 8% but decreased from 34% to 12% with systemic analgesia ( P Conclusion Epidural analgesia protects against pneumonia following abdominal or thoracic surgery, although this beneficial effect has lessened over the last 35 years because of a decrease in the baseline risk.

https://jamanetwork.com/journals/jamasurgery/articlepdf/402012/srv80005_990_999.pdf

Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis.

To quantify benefit and harm of epidural analgesia, compared with systemic opioid analgesia, in adults having surgery under general anesthesia.

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Emmanuel Marret

Papers

Effects of nonsteroidal antiinflammatory drugs on patient-controlled analgesia morphine side effects: meta-analysis of randomized controlled trials

Effects of acetaminophen on morphine side-effects and consumption after major surgery: meta-analysis of randomized controlled trials

Protective Effects of Epidural Analgesia on Pulmonary Complications After Abdominal and Thoracic Surgery

Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis.

Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials.