Showing papers on "Resuscitation published in 2016"
TL;DR: Resuscitative endovascular balloon occlusion of the aorta has emerged as a viable alternative to open AO in centers that have developed this capability in patients requiring AO.
Abstract: INTRODUCTIONAortic occlusion (AO) for resuscitation in traumatic shock remains controversial. Resuscitative endovascular balloon occlusion of the aorta (REBOA) offers an emerging alternative.METHODSThe American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Ac
378 citations
TL;DR: In this article, the authors provided recommendations for the management of patients with acute overt lower gastrointestinal bleeding, where they assessed the patients' hemodynamic status with intravascular volume resuscitation started as needed.
347 citations
TL;DR: A protocol restricting resuscitations fluid successfully reduced volumes of resuscitation fluid compared with a standard care protocol in adult ICU patients with septic shock, pointing towards benefit with fluid restriction.
Abstract: We assessed the effects of a protocol restricting resuscitation fluid vs. a standard care protocol after initial resuscitation in intensive care unit (ICU) patients with septic shock. We randomised 151 adult patients with septic shock who had received initial fluid resuscitation in nine Scandinavian ICUs. In the fluid restriction group fluid boluses were permitted only if signs of severe hypoperfusion occurred, while in the standard care group fluid boluses were permitted as long as circulation continued to improve. The co-primary outcome measures, resuscitation fluid volumes at day 5 and during ICU stay, were lower in the fluid restriction group than in the standard care group [mean differences −1.2 L (95 % confidence interval −2.0 to −0.4); p < 0.001 and −1.4 L (−2.4 to −0.4) respectively; p < 0.001]. Neither total fluid inputs and balances nor serious adverse reactions differed statistically significantly between the groups. Major protocol violations occurred in 27/75 patients in the fluid restriction group. Ischaemic events occurred in 3/75 in the fluid restriction group vs. 9/76 in the standard care group (odds ratio 0.32; 0.08–1.27; p = 0.11), worsening of acute kidney injury in 27/73 vs. 39/72 (0.46; 0.23–0.92; p = 0.03), and death by 90 days in 25/75 vs. 31/76 (0.71; 0.36–1.40; p = 0.32). A protocol restricting resuscitation fluid successfully reduced volumes of resuscitation fluid compared with a standard care protocol in adult ICU patients with septic shock. The patient-centred outcomes all pointed towards benefit with fluid restriction, but our trial was not powered to show differences in these exploratory outcomes. NCT02079402.
274 citations
TL;DR: For children with in-hospital CPR of ≥10 minutes duration, E-CPR was associated with improved survival to hospital discharge and survival with favorable neurological outcome compared with C-Cpr.
Abstract: Background—Although extracorporeal cardiopulmonary resuscitation (E-CPR) can result in survival after failed conventional CPR (C-CPR), no large, systematic comparison of pediatric E-CPR and continu...
166 citations
TL;DR: Shorter resuscitation duration was associated with likelihood of favorable outcome at hospital discharge, andSubjects with favorable case features were more likely to survive prolonged resuscitation up to 47 minutes, but subjects with initial shockable cardiac rhythm, witnessed cardiac arrest, and bystander cardiopulmonary resuscitation were morelikely to survive with favorable outcome after prolonged efforts.
Abstract: Background:Little evidence guides the appropriate duration of resuscitation in out-of-hospital cardiac arrest, and case features justifying longer or shorter durations are ill defined. We estimated...
165 citations
TL;DR: In patients with septic shock, AKI is common and associated with adverse outcomes, but it is not influenced by protocolized resuscitation compared with usual care, and recovery status at hospital discharge is determined.
Abstract: Rationale: Septic shock is a common cause of acute kidney injury (AKI), and fluid resuscitation is a major part of therapy.Objectives: To determine if structured resuscitation designed to alter fluid, blood, and vasopressor use affects the development or severity of AKI or outcomes.Methods: Ancillary study to the ProCESS (Protocolized Care for Early Septic Shock) trial of alternative resuscitation strategies (two protocols vs. usual care) for septic shock.Measurements and Main Results: We studied 1,243 patients and classified AKI using serum creatinine and urine output. We determined recovery status at hospital discharge, examined rates of renal replacement therapy and fluid overload, and measured biomarkers of kidney damage. Among patients without evidence of AKI at enrollment, 37.6% of protocolized care and 38.1% of usual care patients developed kidney injury (P = 0.90). AKI duration (P = 0.59) and rates of renal replacement therapy did not differ between study arms (6.9% for protocolized care and 4.3% ...
161 citations
TL;DR: The MRC refractory VF/VT protocol is feasible and led to a high functionally favorable survival rate with few complications, and no significant ECMO‐related complications were encountered.
Abstract: Background In 2015, the Minnesota Resuscitation Consortium (MRC) implemented an advanced perfusion and reperfusion life support strategy designed to improve outcome for patients with out‐of‐hospital refractory ventricular fibrillation/ventricular tachycardia (VF/VT). We report the outcomes of the initial 3‐month period of operations.
Methods and Results Three emergency medical services systems serving the Minneapolis–St. Paul metro area participated in the protocol. Inclusion criteria included age 18 to 75 years, body habitus accommodating automated Lund University Cardiac Arrest System (LUCAS) cardiopulmonary resuscitation (CPR), and estimated transfer time from the scene to the cardiac catheterization laboratory of ≤30 minutes. Exclusion criteria included known terminal illness, Do Not Resuscitate/Do Not Intubate status, traumatic arrest, and significant bleeding. Refractory VF/VT arrest was defined as failure to achieve sustained return of spontaneous circulation after treatment with 3 direct current shocks and administration of 300 mg of intravenous/intraosseous amiodarone. Patients were transported to the University of Minnesota, where emergent advanced perfusion strategies (extracorporeal membrane oxygenation; ECMO), followed by coronary angiography and primary coronary intervention (PCI), were performed, when appropriate. Over the first 3 months of the protocol, 27 patients were transported with ongoing mechanical CPR. Of these, 18 patients met the inclusion and exclusion criteria. ECMO was placed in 83%. Seventy‐eight percent of patients had significant coronary artery disease with a high degree of complexity and 67% received PCI. Seventy‐eight percent of patients survived to hospital admission and 55% (10 of 18) survived to hospital discharge, with 50% (9 of 18) achieving good neurological function (cerebral performance categories 1 and 2). No significant ECMO‐related complications were encountered.
Conclusions The MRC refractory VF/VT protocol is feasible and led to a high functionally favorable survival rate with few complications.
158 citations
TL;DR: Determining the efficacy of WB with regard to reducing the number of blood products transfused in the first 24 hours or improving recipient survival will require a larger randomized trial.
Abstract: BACKGROUNDThe transfusion of cold-stored uncrossmatched whole blood (WB) has not been extensively used in civilian trauma resuscitation. This report details the initial experience with the safety and feasibility of using WB in this setting after a change of practice at a Level 1 trauma center was in
144 citations
TL;DR: Assessment of different methods of heart rate assessment in newborn infants at birth found palpation and auscultation being the least accurate and electrocardiogram being the most accurate and Doppler ultrasound shows potential for clinical use.
Abstract: Background: Heart rate assessment immediately after birth in newborn infants is critical to the correct guidance of resuscitation efforts. There are disagreements
134 citations
TL;DR: On the basis of time intervals from the shockable arrest groups, prehospital resuscitation efforts should be continued for at least 40 minutes in all adults with bystander-witnessed out-of-hospital cardiac arrest.
Abstract: Background—During out-of-hospital cardiac arrest, it is unclear how long prehospital resuscitation efforts should be continued to maximize lives saved. Methods and Results—Between 2005 and 2012, we...
131 citations
TL;DR: Normal coagulation using the cell-based model of haemostasis and the pathophysiology of acute traumatic coagulopathy are reviewed, highlighting critical goals for the trauma patient in different phases of care.
Abstract: Acute Traumatic Coagulopathy occurs immediately after massive trauma when shock, hypoperfusion, and vascular damage are present. Mechanisms for this acute coagulopathy include activation of protein C, endothelial glycocalyx disruption, depletion of fibrinogen, and platelet dysfunction. Hypothermia and acidaemia amplify the endogenous coagulopathy and often accompany trauma. These multifactorial processes lead to decreased clot strength, autoheparinization, and hyperfibrinolysis. Furthermore, the effects of aggressive crystalloid administration, haemodilution from inappropriate blood product transfusion, and prolonged surgical times may worsen clinical outcomes. We review normal coagulation using the cell-based model of haemostasis and the pathophysiology of acute traumatic coagulopathy. Developed trauma systems reduce mortality, highlighting critical goals for the trauma patient in different phases of care. Once patients reach a trauma hospital, certain triggers reliably indicate when they require massive transfusion and specialized trauma care. These triggers include base deficit, international normalized radio (INR), systolic arterial pressure, haemoglobin concentration, and temperature. Early identification for massive transfusion is critically important, as exsanguination in the first few hours of trauma is a leading cause of death. To combat derangements caused by massive haemorrhage, damage control resuscitation is a technique that addresses each antagonist to normal haemostasis. Components of damage control resuscitation include damage control surgery, permissive hypotension, limited crystalloid administration, haemostatic resuscitation, and correction of hyperfibrinolysis.
Journal Article•
TL;DR: Adult basic life support and automated external defibrillation – Interactions between the emergency medical dispatcher, the bystander who provides CPR and the timely deployment of an AED is critical.
Abstract: Adult basic life support and automated external defibrillation – Interactions between the emergency medical dispatcher, the bystander who provides CPR and the timely deployment of an AED is critical. All CPR providers should perform chest compressions, those who are trained and able should combine chest compressions and rescue breaths in the ratio 30:2. Defibrillation within 3–5 min of collapse can produce survival rates as high as 50–70%. Adult advanced life support – Continued emphasis on minimally interrupted high-quality chest compressions, paused briefly only to enable specific interventions, including interruptions for less than 5 s to attempt defibrillation. Use of self-adhesive pads for defibrillation. Waveform capnography to confirm and continually monitor tracheal tube placement, quality of CPR and to provide an early indication of return of spontaneous circulation. Cardiac arrest in special circumstances – Special causes: hypoxia; hypo-/hyperkalemia, and other electrolyte disorders; hypo-/hyperthermia; hypovolemia; tension pneumothorax; tamponade; thrombosis; toxins. Special environments are specialised healthcare facilities, commercial airplanes or air ambulances, field of play, outside environment or the scene of a mass casualty incident. Special patients are those with severe comorbidities and with specific physiological conditions. Post resuscitation care is new to the ERC Guidelines. Targeted temperature management remains, now aiming at 36°C instead of the previously recommended 32 – 34°C. Pediatric life support – For chest compressions, the lower sternum should be depressed by at least one third the anterior-posterior diameter of the chest (4 cm for the infant and 5 cm for the child). For cardioversion of a supraventricular tachycardia (SVT), the initial dose has been revised to 1 J kg–1. Resuscitation and support of transition of babies at birth – For uncompromised babies, a delay in cord clamping of at least one minute from the complete delivery of the infant, is now recommended for term and preterm babies. Tracheal intubation should not be routine in the presence of meconium and should only be performed for suspected tracheal obstruction. Ventilatory support of term infants should start with air. Acute coronary syndrome (ACS) – Pre-hospital recording of a 12-lead electrocardiogram (ECG) is recommended in patients with suspected ST segment elevation acute myocardial infarction (STEMI). Patients with acute chest pain with presumed ACS do not need supplemental oxygen unless they present with signs of hypoxia, dyspnea, or heart failure. In geographic regions where PCI facilities exist and are available, direct triage and transport for PCI is preferred to pre-hospital fibrinolysis for STEMI. First aid is included for the first time in the 2015 ERC Guidelines. Principles of education in resuscitation – Directive CPR feedback devices are useful for improving compression rate, depth, release, and hand position. Whilst optimal intervals for retraining are not known, frequent ‘low dose’ retraining may be beneficial. Training in non-technical skills is an essential adjunct to technical skills. The ethics of resuscitation and end-of-life decisions – Ethical principles in the context of patient-centered health care: autonomy, beneficence, non-maleficence; justice and equal access. The need for harmonisation in legislation, jurisdiction, terminology and practice still remains within Europe.
TL;DR: In patients with hypoxic-ischaemic brain injury following CPR, more than 10% of deaths were due to brain death, and more than 40 % of brain-dead patients could donate organs, suggesting patients who are unconscious after resuscitation from cardiac arrest, especially when resuscitated using e-CPR, should be carefully screened for signs of brain death.
Abstract: The occurrence of brain death in patients with hypoxic-ischaemic brain injury after resuscitation from cardiac arrest creates opportunities for organ donation. However, its prevalence is currently unknown. Systematic review. MEDLINE via PubMed, ISI Web of Science and the Cochrane Database of Systematic Reviews were searched for eligible studies (2002–2016). The prevalence of brain death in adult patients resuscitated from cardiac arrest and the rate of organ donation among brain dead patients were summarised using a random effect model with double-arcsine transformation. The quality of evidence (QOE) was evaluated according to the GRADE guidelines. 26 studies [16 on conventional cardiopulmonary resuscitation (c-CPR), 10 on extracorporeal CPR (e-CPR)] included a total of 23,388 patients, 1830 of whom developed brain death at a mean time of 3.2 ± 0.4 days after recovery of circulation. The overall prevalence of brain death among patients who died before hospital discharge was 12.6 [10.2–15.2] %. Prevalence was significantly higher in e-CPR vs. c-CPR patients (27.9 [19.7–36.6] vs. 8.3 [6.5–10.4] %; p < 0.0001). The overall rate of organ donation among brain dead patients was 41.8 [20.2–51.0] % (9/26 studies, 1264 patients; range 0–100 %). The QOE was very low for both outcomes. In patients with hypoxic-ischaemic brain injury following CPR, more than 10 % of deaths were due to brain death. More than 40 % of brain-dead patients could donate organs. Patients who are unconscious after resuscitation from cardiac arrest, especially when resuscitated using e-CPR, should be carefully screened for signs of brain death.
TL;DR: Cerebral oximetry allows real-time, noninvasive cerebral oxygenation monitoring during cardiopulmonary resuscitation and is associated with return of spontaneous circulation and neurologically favorable survival to hospital discharge.
Abstract: Objectives:Cardiac arrest is associated with morbidity and mortality because of cerebral ischemia. Therefore, we tested the hypothesis that higher regional cerebral oxygenation during resuscitation is associated with improved return of spontaneous circulation, survival, and neurologic outcomes at ho
TL;DR: New approaches into the physiology of blood flow to the heart and brain during CPR provide an innovative, physiologically based road map to increase survival and quality of life after cardiac arrest.
Abstract: Outcomes after cardiac arrest remain poor more than a half a century after closed chest cardiopulmonary resuscitation (CPR) was first described. This review article is focused on recent insights into the physiology of blood flow to the heart and brain during CPR. Over the past 20 years, a greater understanding of heart-brain-lung interactions has resulted in novel resuscitation methods and technologies that significantly improve outcomes from cardiac arrest. This article highlights the importance of attention to CPR quality, recent approaches to regulate intrathoracic pressure to improve cerebral and systemic perfusion, and ongoing research related to the ways to mitigate reperfusion injury during CPR. Taken together, these new approaches in adult and pediatric patients provide an innovative, physiologically based road map to increase survival and quality of life after cardiac arrest.
TL;DR: The first report of transplantation of a graft salvaged by postischemia NMLP is presented, with a follow-up period of 15 months, derived from this technology’s unique ability to assess viability during storage.
TL;DR: Fluid resuscitation with human albumin is less likely to cause nephrotoxicity than with artificial colloids, and albumin infusion has the potential to preserve renal function in critically ill patients, and Sepsis is a candidate condition in which humanalbumin infusion to preserve kidneys function should be substantiated.
TL;DR: It was shown that resuscitation skills are retained even when training is interrupted for 3 years, and knowledge and skills after 6 years were equivalent in the group with 6 years training compared with 3 years training.
TL;DR: The resuscitation non-technical Team Emergency Assessment Measure (TEAM) was found to be feasible and quickly completed with minimal or no training, and leadership was rated notably lower than task and teamwork performance indicating a need for leadership training.
TL;DR: The subgroup of initial shockable rhythms showed a less pronounced association of time-to-ROSC with outcomes, and demonstrated higher resilience for neurologically intact survival after prolonged periods of resuscitation.
TL;DR: Early infusion of FC is feasible and increases plasma fibrinogen concentration during trauma resuscitation and larger trials are justified.
Abstract: Background Decreased plasma fibrinogen concentration shortly after injury is associated with higher blood transfusion needs and mortality. In North America and the UK, cryoprecipitate transfusion is the standard-of-care for fibrinogen supplementation during acute haemorrhage, which often occurs late during trauma resuscitation. Alternatively, fibrinogen concentrate (FC) can be beneficial in trauma resuscitation. However, the feasibility of its early infusion, efficacy and safety remain undetermined. The objective of this trial was to evaluate the feasibility, effect on clinical and laboratory outcomes and complications of early infusion of FC in trauma. Methods Fifty hypotensive (systolic arterial pressure ≤100 mm Hg) adult patients requiring blood transfusion were randomly assigned to either 6 g of FC or placebo, between Oct 2014 and Nov 2015 at a tertiary trauma centre. The primary outcome, feasibility, was assessed by the proportion of patients receiving the intervention (FC or placebo) within one h of hospital arrival. Plasma fibrinogen concentration was measured, and 28-day mortality and incidence of thromboembolic events were assessed. Results Overall, 96% (43/45) [95% CI 86–99%] of patients received the intervention within one h; 95% and 96% in the FC and placebo groups, respectively (P=1.00). Plasma fibrinogen concentrations remained higher in the FC group up to 12 h after admission with the largest difference at three h (2.9 mg dL − 1 vs. 1.8 mg dL − 1; P Conclusions Early infusion of FC is feasible and increases plasma fibrinogen concentration during trauma resuscitation. Larger trials are justified.
TL;DR: Experimental and clinical studies support the evidence that P (v-a) CO2 cannot serve as an indicator of tissue hypoxia, and should be regarded as a indicator of the adequacy of venous blood to wash out the total CO2 generated by the peripheral tissues.
Abstract: The mixed venous-to-arterial carbon dioxide (CO2) tension difference [P (v-a) CO2] is the difference between carbon dioxide tension (PCO2) in mixed venous blood (sampled from a pulmonary artery catheter) and the PCO2 in arterial blood. P (v-a) CO2 depends on the cardiac output and the global CO2 production, and on the complex relationship between PCO2 and CO2 content. Experimental and clinical studies support the evidence that P (v-a) CO2 cannot serve as an indicator of tissue hypoxia, and should be regarded as an indicator of the adequacy of venous blood to wash out the total CO2 generated by the peripheral tissues. P (v-a) CO2 can be replaced by the central venous-to-arterial CO2 difference (ΔPCO2), which is calculated from simultaneous sampling of central venous blood from a central vein catheter and arterial blood and, therefore, more easy to obtain at the bedside. Determining the ΔPCO2 during the resuscitation of septic shock patients might be useful when deciding when to continue resuscitation despite a central venous oxygen saturation (ScvO2) > 70% associated with elevated blood lactate levels. Because high blood lactate levels is not a discriminatory factor in determining the source of that stress, an increased ΔPCO2 (> 6 mmHg) could be used to identify patients who still remain inadequately resuscitated. Monitoring the ΔPCO2 from the beginning of the reanimation of septic shock patients might be a valuable means to evaluate the adequacy of cardiac output in tissue perfusion and, thus, guiding the therapy. In this respect, it can aid to titrate inotropes to adjust oxygen delivery to CO2 production, or to choose between hemoglobin correction or fluid/inotrope infusion in patients with a too low ScvO2 related to metabolic demand. The combination of P (v-a) CO2 or ΔPCO2 with oxygen-derived parameters through the calculation of the P (v-a) CO2 or ΔPCO2/arteriovenous oxygen content difference ratio can detect the presence of global anaerobic metabolism.
TL;DR: Transport for ECPR should be considered between 8 to 24 minutes of professional on-scene resuscitation, with 16 minutes balancing the risks and benefits of early and later transport, to improve outcomes for refractory out-of-hospital cardiac arrest.
TL;DR: A goal-directed algorithm for warming the severely injured patient that can be directly incorporated into current Advanced Trauma Life Support guidelines is synthesized and may help to reduce blood loss and improve morbidity and mortality in this population of patients.
Abstract: Hypothermia is present in up to two-thirds of patients with severe injury, although it is often disregarded during the initial resuscitation. Studies have revealed that hypothermia is associated with mortality in a large percentage of trauma cases when the patient’s temperature is below 32 °C. Risk factors include the severity of injury, wet clothing, low transport unit temperature, use of anesthesia, and prolonged surgery. Fortunately, associated coagulation disorders have been shown to completely resolve with aggressive warming. Selected passive and active warming techniques can be applied in damage control resuscitation. While treatment guidelines exist for acidosis and bleeding, there is no evidence-based approach to managing hypothermia in trauma patients. We synthesized a goal-directed algorithm for warming the severely injured patient that can be directly incorporated into current Advanced Trauma Life Support guidelines. This involves the early use of warming blankets and removal of wet clothing in the prehospital phase followed by aggressive rewarming on arrival at the hospital if the patient’s injuries require damage control therapy. Future research in hypothermia management should concentrate on applying this treatment algorithm and should evaluate its influence on patient outcomes. This treatment strategy may help to reduce blood loss and improve morbidity and mortality in this population of patients.
TL;DR: Hemorrhagic shock is both a local and systemic disorder where blood loss may lead to levels of reduced oxygen delivery sufficient to cause tissue ischemia.
TL;DR: Early access to the CCL after cardiac arrest due to a shockable rhythm in a selected group of patients is feasible in a large metropolitan area in the United States and is associated with a 65% survival rate to hospital discharge with a good neurological outcome.
Abstract: Background In 2013 the Minnesota Resuscitation Consortium developed an organized approach for the management of patients resuscitated from shockable rhythms to gain early access to the cardiac catheterization laboratory (CCL) in the metro area of Minneapolis‐St. Paul.
Methods and Results Eleven hospitals with 24/7 percutaneous coronary intervention capabilities agreed to provide early (within 6 hours of arrival at the Emergency Department) access to the CCL with the intention to perform coronary revascularization for outpatients who were successfully resuscitated from ventricular fibrillation/ventricular tachycardia arrest. Other inclusion criteria were age >18 and <76 and presumed cardiac etiology. Patients with other rhythms, known do not resuscitate/do not intubate, noncardiac etiology, significant bleeding, and terminal disease were excluded. The primary outcome was survival to hospital discharge with favorable neurological outcome. Patients (315 out of 331) who were resuscitated from VT/VF and transferred alive to the Emergency Department had complete medical records. Of those, 231 (73.3%) were taken to the CCL per the Minnesota Resuscitation Consortium protocol while 84 (26.6%) were not taken to the CCL (protocol deviations). Overall, 197 (63%) patients survived to hospital discharge with good neurological outcome (cerebral performance category of 1 or 2). Of the patients who followed the Minnesota Resuscitation Consortium protocol, 121 (52%) underwent percutaneous coronary intervention, and 15 (7%) underwent coronary artery bypass graft. In this group, 151 (65%) survived with good neurological outcome, whereas in the group that did not follow the Minnesota Resuscitation Consortium protocol, 46 (55%) survived with good neurological outcome (adjusted odds ratio: 1.99; [1.07–3.72], P =0.03).
Conclusions Early access to the CCL after cardiac arrest due to a shockable rhythm in a selected group of patients is feasible in a large metropolitan area in the United States and is associated with a 65% survival rate to hospital discharge with a good neurological outcome.
TL;DR: Novel techniques have provided detailed quantitative insight into the determinants of microcirculatory and mitochondrial oxygenation and loss of coherence between the macrocirculation and the microcirculation was identified, which underlie the loss of hemodynamic coherence during unsuccessful resuscitation procedures.
Abstract: After shock, persistent oxygen extraction deficit despite the apparent adequate recovery of systemic hemodynamic and oxygen-derived variables has been a source of uncertainty and controversy. Dysfunction of oxygen transport pathways during intensive care underlies the sequelae that lead to organ failure, and the limitations of techniques used to measure tissue oxygenation in vivo have contributed to the lack of progress in this area. Novel techniques have provided detailed quantitative insight into the determinants of microcirculatory and mitochondrial oxygenation. These techniques, which are based on the oxygen-dependent quenching of phosphorescence or delayed luminescence are briefly reviewed. The application of these techniques to animal models of shock and resuscitation revealed the heterogeneous nature of oxygen distributions and the alterations in oxygen distribution in the microcirculation and in mitochondria. These studies identified functional shunting in the microcirculation as an underlying cause of oxygen extraction deficit observed in states of shock and resuscitation. The translation of these concepts to the bedside has been enabled by our development and clinical introduction of hand-held microscopy. This tool facilitates the direct observation of the microcirculation and its alterations at the bedside under the conditions of shock and resuscitation. Studies identified loss of coherence between the macrocirculation and the microcirculation, in which resuscitation successfully restored systemic circulation but did not alleviate microcirculatory perfusion alterations. Various mechanisms responsible for these alterations underlie the loss of hemodynamic coherence during unsuccessful resuscitation procedures. Therapeutic resolution of persistent heterogeneous microcirculatory alterations is expected to improve outcomes in critically ill patients.
TL;DR: Patients with high syndecan-1 may represent a cohort at particular risk for intubation after large-volume fluid administration, and patients with high Syndicate-1 levels may representA cohort at particularly risk forIntubation in patients with a low syndecon-1 level.
TL;DR: The government's Cardiovascular Disease Outcomes Strategy for England set the ambitious, but achievable target of increasing survival from out-of-hospital cardiac arrest by 50%, leading to an additional 1000 lives saved each year.
Abstract: NHS England report that the ambulance services attempt to resuscitate approximately 28 000 people from out-of-hospital cardiac arrest each year (approximately 1 per 2000 inhabitants per year).1 The rate of initial success (return of spontaneous circulation) was 25%, with less than half of those who are successfully resuscitated initially surviving to go home from hospital (survival to discharge 7%–8%, 2011–2014).1 (see figure 1). The survival rates contrast sharply with those observed in the best-performing emergency medical services systems, which have survival rates of 20%–25%.2–4 In 2013, the government's Cardiovascular Disease Outcomes Strategy for England set the ambitious, but achievable target of increasing survival from out-of-hospital cardiac arrest by 50%, leading to an additional 1000 lives saved each year.
Figure 1
Summary of number of resuscitation attempts, return of spontaneous circulation (ROSC) and survival to discharge.
Improving outcomes from cardiac arrest requires improvements in one or more links in the chain of survival.5 The first link is early access. This step prioritises calling for help early in patients at risk of cardiac arrest (eg, those with chest pain) and those with signs of cardiac arrest (unresponsive and not breathing normally). An early response may allow cardiac arrest to be prevented or ensures trained staff arrive early to initiate/continue resuscitation. The second link highlights the critical importance of the bystander providing early cardiopulmonary resuscitation (CPR). Evidence from observational studies suggests that survival from cardiac arrest can be increased from twofold to fourfold with bystander CPR.6–8 Early defibrillation forms the third link as defibrillation within 3–5 min can produce survival rates as high as 50%–70%.9–11 The final link in the chain is early ALS and standardised postresuscitation care. These interventions are initiated by the emergency services, and continued during and after transfer of care to the hospitals.
Different strategies are needed …
TL;DR: Patients with good resuscitation outcomes have significantly higher NIRS saturations during resuscitation than their counterparts, and prolonged failure to obtain a NirS saturation higher than 30% may be included in a multimodal approach to the decision of terminating resuscitation efforts.
Abstract: Background
Tissue oximetry using near-infrared spectroscopy (NIRS) is a noninvasive monitor of cerebral oxygenation. This new technology has been used during cardiac arrest (CA) because of its ability to give measures in low-blood-flow situations. The aim of this study was to assess the evidence regarding the association between the types of NIRS measurements (mean, initial, and highest values) and resuscitation outcomes (return of spontaneous circulation [ROSC], survival to discharge, and good neurologic outcome) in patients undergoing cardiopulmonary resuscitation.
Methods
This review was registered (Prospero CRD42015017380) and is reported as per the PRISMA guidelines. Medline, Embase, and CENTRAL were searched. All studies, except case reports and case series of fewer than five patients, reporting on adults that had NIRS monitoring during CA were eligible for inclusion. Two reviewers assessed the quality of the included articles and extracted the data. The outcome effect was standardized using standardized mean difference (SMD).
Results
Twenty nonrandomized observational studies (15 articles and five conference abstracts) were included in this review, for a total of 2,436 patients. We found a stronger association between ROSC and mean NIRS values (SMD = 1.33; 95% confidence interval [CI] = 0.92 to 1.74) than between ROSC and initial NIRS measurements (SMD = 0.51; 95% CI = 0.23 to 0.78). There was too much heterogeneity among the highest NIRS measurements group to perform meta-analysis. Only two of the 75 patients who experienced ROSC had a mean NIRS saturation under 30%. Patients who survived to discharge and who had good neurologic outcome displayed superior combined initial and mean NIRS values than their counterparts (SMD = 1.63; 95% CI = 1.34 to 1.92; and SMD = 2.12; 95% CI = 1.14 to 3.10).
Conclusions
Patients with good resuscitation outcomes have significantly higher NIRS saturations during resuscitation than their counterparts. The types of NIRS measurements during resuscitation influenced the association between ROSC and NIRS saturation. Prolonged failure to obtain a NIRS saturation higher than 30% may be included in a multimodal approach to the decision of terminating resuscitation efforts (Class IIb, Level of Evidence C-Limited Data).