Showing papers on "Resuscitation published in 2019"
Pontifical Catholic University of Chile1, ICESI University2, University of São Paulo3, National University of La Plata4, University of the Republic5, American Society of Safety Engineers6, Universidade Federal do Rio Grande do Sul7, University of Paris-Sud8, Humanitas University9, Central University of Ecuador10
TL;DR: Among patients with septic shock, a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality.
Abstract: Importance Abnormal peripheral perfusion after septic shock resuscitation has been associated with organ dysfunction and mortality. The potential role of the clinical assessment of peripheral perfusion as a target during resuscitation in early septic shock has not been established. Objective To determine if a peripheral perfusion–targeted resuscitation during early septic shock in adults is more effective than a lactate level–targeted resuscitation for reducing mortality. Design, Setting, and Participants Multicenter, randomized trial conducted at 28 intensive care units in 5 countries. Four-hundred twenty-four patients with septic shock were included between March 2017 and March 2018. The last date of follow-up was June 12, 2018. Interventions Patients were randomized to a step-by-step resuscitation protocol aimed at either normalizing capillary refill time (n = 212) or normalizing or decreasing lactate levels at rates greater than 20% per 2 hours (n = 212), during an 8-hour intervention period. Main Outcomes and Measures The primary outcome was all-cause mortality at 28 days. Secondary outcomes were organ dysfunction at 72 hours after randomization, as assessed by Sequential Organ Failure Assessment (SOFA) score (range, 0 [best] to 24 [worst]); death within 90 days; mechanical ventilation–, renal replacement therapy–, and vasopressor-free days within 28 days; intensive care unit and hospital length of stay. Results Among 424 patients randomized (mean age, 63 years; 226 [53%] women), 416 (98%) completed the trial. By day 28, 74 patients (34.9%) in the peripheral perfusion group and 92 patients (43.4%) in the lactate group had died (hazard ratio, 0.75 [95% CI, 0.55 to 1.02];P = .06; risk difference, −8.5% [95% CI, −18.2% to 1.2%]). Peripheral perfusion–targeted resuscitation was associated with less organ dysfunction at 72 hours (mean SOFA score, 5.6 [SD, 4.3] vs 6.6 [SD, 4.7]; mean difference, −1.00 [95% CI, −1.97 to −0.02];P = .045). There were no significant differences in the other 6 secondary outcomes. No protocol-related serious adverse reactions were confirmed. Conclusions and Relevance Among patients with septic shock, a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality. Trial Registration ClinicalTrials.gov Identifier:NCT03078712
432 citations
TL;DR: Early norepinephrine was significantly associated with increased shock control by 6 hours in adults diagnosed with sepsis with hypotension and further studies are needed before this approach is introduced in clinical resuscitation practice.
Abstract: Rationale: Recent retrospective evidence suggests the efficacy of early norepinephrine administration during resuscitation; however, prospective data to support this assertion are scarce.Objectives...
181 citations
TL;DR: Future studies of resuscitation and survival after traumatic injury must include analysis of prehospital deaths to fully understand the outcomes of early interventions.
163 citations
TL;DR: Measurements every 1–2 h would give clinically relevant data about the decrease in lactate levels, and to talk about “lactate clearance” when actually describing a decrease in blood level is wrong and misleading.
Abstract: The problem with clearance Clearance is the removal of a substance from blood, expressed as a volume (milliliters) over time (minutes). However, changes in lactate levels are the sum of ongoing production and removal from the blood by excretion (e.g., urine, sweat) and its metabolism (e.g., uptake by cells as a direct source of energy, conversion to glucose by the liver). To talk about “lactate clearance” [1] when actually describing a decrease in blood level is wrong and misleading. Following the review of 96 studies, Vincent et al. [1] concluded that given recent evidence, measurements every 1–2 h would give clinically relevant data about the decrease in lactate levels.
147 citations
TL;DR: An updated in-hospital Utstein reporting template for cardiac arrest was developed by Representatives of the International Liaison Committee on Resuscitation iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018.
142 citations
North Bristol NHS Trust1, Imperial College Healthcare2, University of Texas Southwestern Medical Center3, University of Oslo4, University of Virginia5, University Hospital of Bern6, Boston Children's Hospital7, McGill University8, Beth Israel Deaconess Medical Center9, University of Texas at Arlington10, James Cook University Hospital11, Aarhus University12, University of Iowa13, University of Alberta14, University of Western Australia15, Saginaw Valley State University16, McMaster University17, Great Ormond Street Hospital for Children NHS Foundation Trust18, University of São Paulo19, University of Cologne20, Monash University21, University of Zurich22, Queen's University23, University of Toronto24, University of Pittsburgh25, National Taiwan University26, University of Calgary27, Yonsei University28, Deakin University29, University of Warwick30, North York General Hospital31, Federal University of São Paulo32, University of Southampton33, American Red Cross34, Universidad Peruana de Ciencias Aplicadas35, Rosalind Franklin University of Medicine and Science36, Florey Institute of Neuroscience and Mental Health37, Jichi Medical University38, Kyoto University39, Dalhousie University40, Seoul National University Hospital41, University of Washington42, Denver Health Medical Center43, Singapore General Hospital44, Stanford University45, University of Antwerp46, University of Melbourne47, Children's Hospital of Philadelphia48, University of Michigan49, Waikato Hospital50, Wayne State University51, Liverpool Hospital52, Heart of England NHS Foundation Trust53, Cornell University54, Michigan State University55, University of Milan56, University of Oxford57, Teikyo University58, Catholic University of the Sacred Heart59, University of Arkansas60, University of Birmingham61, University of Helsinki62, University of Oklahoma63, University of Western Ontario64, University of Padua65, Ottawa Hospital Research Institute66, Ghent University67, Vanderbilt University68
TL;DR: This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role for presyncope by first aid providers, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, and initial oxygen concentration during resuscitation of newborns.
Abstract: The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.
121 citations
TL;DR: Upper gastrointestinal bleeding is a common medical emergency, with a reported mortality of 2-10%.
Abstract: Upper gastrointestinal bleeding (UGIB) is a common medical emergency, with a reported mortality of 2-10%. Patients identified as being at very low risk of either needing an intervention or death can be managed as outpatients. For all other patients, intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/L are recommended. After resuscitation is initiated, proton pump inhibitors (PPIs) and the prokinetic agent erythromycin may be administered, with antibiotics and vasoactive drugs recommended in patients who have cirrhosis. Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk, such as those with hemodynamic instability. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices) and for high risk non-variceal bleeding (for example, injection, thermal probes, or clips for lesions with active bleeding or non-bleeding visible vessel). Patients who require endoscopic therapy for ulcer bleeding should receive high dose proton pump inhibitors after endoscopy, whereas those who have variceal bleeding should continue taking antibiotics and vasoactive drugs. Recurrent ulcer bleeding is treated with repeat endoscopic therapy, with subsequent bleeding managed by interventional radiology or surgery. Recurrent variceal bleeding is generally treated with transjugular intrahepatic portosystemic shunt. In patients who require antithrombotic agents, outcomes appear to be better when these drugs are reintroduced early.
118 citations
TL;DR: The writing group reaffirmed the 2015 pediatric advanced life support guideline recommendation that either lidocaine or amiodarone may be used to treat pediatric patients with shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.
Abstract: This 2019 focused update to the American Heart Association pediatric advanced life support guidelines follows the 2018 and 2019 systematic reviews performed by the Pediatric Life Support Task Force of the International Liaison Committee on Resuscitation. It aligns with the continuous evidence review process of the International Liaison Committee on Resuscitation, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendations for advanced airway management in pediatric cardiac arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac arrest, and pediatric targeted temperature management during post-cardiac arrest care. The writing group analyzed the systematic reviews and the original research published for each of these topics. For airway management, the writing group concluded that it is reasonable to continue bag-mask ventilation (versus attempting an advanced airway such as endotracheal intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation protocols and teams are readily available, extracorporeal cardiopulmonary resuscitation should be considered for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it is reasonable to use targeted temperature management of 32°C to 34°C followed by 36°C to 37.5°C, or to use targeted temperature management of 36°C to 37.5°C, for pediatric patients who remain comatose after resuscitation from out-of-hospital cardiac arrest or in-hospital cardiac arrest.
115 citations
University of Pennsylvania1, University of Virginia2, Brown University3, Royal Women's Hospital4, Leiden University5, University of Amsterdam6, University of Melbourne7, University of Alberta8, Sharp HealthCare9, Qatar Airways10, University of Ulm11, Pennsylvania Hospital12, University of Freiburg13, University of California, Davis14, University of Michigan15, Seoul National University16, Sungkyunkwan University17, Boston Children's Hospital18, Tufts University19, Christiana Care Health System20, Loma Linda University21, Saitama Medical University22
TL;DR: Among extremely preterm infants requiring resuscitation at birth, a ventilation strategy involving 2 sustained inflations, compared with standard intermittent positive pressure ventilation, did not reduce the risk of BPD or death at 36 weeks’ postmenstrual age.
Abstract: Importance Preterm infants must establish regular respirations at delivery. Sustained inflations may establish lung volume faster than short inflations. Objective To determine whether a ventilation strategy including sustained inflations, compared with standard intermittent positive pressure ventilation, reduces bronchopulmonary dysplasia (BPD) or death at 36 weeks’ postmenstrual age without harm in extremely preterm infants. Design, Setting, and Participants Unmasked, randomized clinical trial (August 2014 to September 2017, with follow-up to February 15, 2018) conducted in 18 neonatal intensive care units in 9 countries. Preterm infants 23 to 26 weeks’ gestational age requiring resuscitation with inadequate respiratory effort or bradycardia were enrolled. Planned enrollment was 600 infants. The trial was stopped after enrolling 426 infants, following a prespecified review of adverse outcomes. Interventions The experimental intervention was up to 2 sustained inflations at maximal peak pressure of 25 cm H2O for 15 seconds using a T-piece and mask (n = 215); standard resuscitation was intermittent positive pressure ventilation (n = 211). Main Outcome and Measures The primary outcome was the rate of BPD or death at 36 weeks’ postmenstrual age. There were 27 prespecified secondary efficacy outcomes and 7 safety outcomes, including death at less than 48 hours. Results Among 460 infants randomized (mean [SD] gestational age, 25.30 [0.97] weeks; 50.2% female), 426 infants (92.6%) completed the trial. In the sustained inflation group, 137 infants (63.7%) died or survived with BPD vs 125 infants (59.2%) in the standard resuscitation group (adjusted risk difference [aRD], 4.7% [95% CI, −3.8% to 13.1%];P = .29). Death at less than 48 hours of age occurred in 16 infants (7.4%) in the sustained inflation group vs 3 infants (1.4%) in the standard resuscitation group (aRD, 5.6% [95% CI, 2.1% to 9.1%];P = .002). Blinded adjudication detected an imbalance of rates of early death possibly attributable to resuscitation (sustained inflation: 11/16; standard resuscitation: 1/3). Of 27 secondary efficacy outcomes assessed by 36 weeks’ postmenstrual age, 26 showed no significant difference between groups. Conclusions and Relevance Among extremely preterm infants requiring resuscitation at birth, a ventilation strategy involving 2 sustained inflations, compared with standard intermittent positive pressure ventilation, did not reduce the risk of BPD or death at 36 weeks’ postmenstrual age. These findings do not support the use of ventilation with sustained inflations among extremely preterm infants, although early termination of the trial limits definitive conclusions. Trial Registration clinicaltrials.gov Identifier:NCT02139800
114 citations
TL;DR: The volume of intravenous fluids administered during sepsis resuscitation is independently associated with the degree of glycocalyx degradation, suggesting a potential mechanism by which intravenous fluid resuscitation strategies may induce iatrogenic endothelial injury.
Abstract: Intravenous fluids, an essential component of sepsis resuscitation, may paradoxically worsen outcomes by exacerbating endothelial injury. Preclinical models suggest that fluid resuscitation degrades the endothelial glycocalyx, a heparan sulfate-enriched structure necessary for vascular homeostasis. We hypothesized that endothelial glycocalyx degradation is associated with the volume of intravenous fluids administered during early sepsis resuscitation. We used mass spectrometry to measure plasma heparan sulfate (a highly sensitive and specific index of systemic endothelial glycocalyx degradation) after 6 h of intravenous fluids in 56 septic shock patients, at presentation and after 24 h of intravenous fluids in 100 sepsis patients, and in two groups of non-infected patients. We compared plasma heparan sulfate concentrations between sepsis and non-sepsis patients, as well as between sepsis survivors and sepsis non-survivors. We used multivariable linear regression to model the association between volume of intravenous fluids and changes in plasma heparan sulfate. Consistent with previous studies, median plasma heparan sulfate was elevated in septic shock patients (118 [IQR, 113–341] ng/ml 6 h after presentation) compared to non-infected controls (61 [45–79] ng/ml), as well as in a second cohort of sepsis patients (283 [155–584] ng/ml) at emergency department presentation) compared to controls (177 [144–262] ng/ml). In the larger sepsis cohort, heparan sulfate predicted in-hospital mortality. In both cohorts, multivariable linear regression adjusting for age and severity of illness demonstrated a significant association between volume of intravenous fluids administered during resuscitation and plasma heparan sulfate. In the second cohort, independent of disease severity and age, each 1 l of intravenous fluids administered was associated with a 200 ng/ml increase in circulating heparan sulfate (p = 0.006) at 24 h after enrollment. Glycocalyx degradation occurs in sepsis and septic shock and is associated with in-hospital mortality. The volume of intravenous fluids administered during sepsis resuscitation is independently associated with the degree of glycocalyx degradation. These findings suggest a potential mechanism by which intravenous fluid resuscitation strategies may induce iatrogenic endothelial injury.
111 citations
North Bristol NHS Trust1, Imperial College Healthcare2, University of Texas Southwestern Medical Center3, Oslo University Hospital4, University of Virginia5, University Hospital of Bern6, University of Bern7, McGill University8, Beth Israel Deaconess Medical Center9, University of Texas at Arlington10, James Cook University Hospital11, Aarhus University12, University of Iowa13, University of Alberta14, University of Newcastle15, Saginaw Valley State University16, McMaster University17, Great Ormond Street Hospital for Children NHS Foundation Trust18, University of São Paulo19, University of Cologne20, Alfred Hospital21, University of Zurich22, Queen's University23, University of Toronto24, University of Pittsburgh25, Allegheny Health Network26, International Federation of Red Cross and Red Crescent Societies27, Helsinki University Central Hospital28, National Taiwan University29, Alberta Children's Hospital30, Yonsei University31, Deakin University32, University of Warwick33, Northern General Hospital34, Royal Women's Hospital35, Federal University of São Paulo36, University of Southampton37, St. Michael's GAA, Sligo38, Boston Children's Hospital39, American Red Cross40, National Heart Foundation of Australia41, Rosalind Franklin University of Medicine and Science42, Aarhus University Hospital43, Hospital for Sick Children44, Monash Medical Centre45, Jichi Medical University46, Kyoto University47, Dalhousie University48, University of Washington Medical Center49, University of Calgary50, Denver Health Medical Center51, Mater Health Services52, Singapore General Hospital53, European Resuscitation Council54, Stanford University55, Middlemore Hospital56, University of Melbourne57, Royal Melbourne Hospital58, Children's Hospital of Philadelphia59, University of Michigan60, Waikato Hospital61, Wayne State University62, Liverpool Hospital63, Heart of England NHS Foundation Trust64, Cornell University65, Michigan State University66, University of Milan67, University of Oxford68, Teikyo University69, Agostino Gemelli University Polyclinic70, Catholic University of the Sacred Heart71, Arkansas Children's Hospital72, University of Arkansas73, University of Birmingham74, St. Marianna University School of Medicine75, University of Helsinki76, London Health Sciences Centre77, University of Padua78, University of Ottawa79, Ottawa Hospital80, Ghent University81, Memorial Hospital of South Bend82, Hamilton Health Sciences83, Vanderbilt University84
TL;DR: This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role for presyncope by first aid providers, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, and initial oxygen concentration during resuscitation of newborns.
TL;DR: In case of OHCA, women are less often resuscitated by bystanders than men, which is likely explained by lower rate of SIR in women, which can only partly be explained by resuscitation characteristics.
Abstract: AIMS: Previous studies on sex differences in out-of-hospital cardiac arrest (OHCA) had limited scope and yielded conflicting results. We aimed to provide a comprehensive overall view on sex differences in care utilization, and outcome of OHCA. METHODS AND RESULTS: We performed a population-based cohort-study, analysing all emergency medical service (EMS) treated resuscitation attempts in one province of the Netherlands (2006-2012). We calculated odds ratios (ORs) for the association of sex and chance of a resuscitation attempt by EMS, shockable initial rhythm (SIR), and in-hospital treatment using logistic regression analysis. Additionally, we provided an overview of sex differences in overall survival and survival at successive stages of care, in the entire study population and in patients with SIR. We identified 5717 EMS-treated OHCAs (28.0% female). Women with OHCA were less likely than men to receive a resuscitation attempt by a bystander (67.9% vs. 72.7%; P < 0.001), even when OHCA was witnessed (69.2% vs. 73.9%; P < 0.001). Women who were resuscitated had lower odds than men for overall survival to hospital discharge [OR 0.57; 95% confidence interval (CI) 0.48-0.67; 12.5% vs. 20.1%; P < 0.001], survival from OHCA to hospital admission (OR 0.88; 95% CI 0.78-0.99; 33.6% vs. 36.6%; P = 0.033), and survival from hospital admission to discharge (OR 0.49, 95% CI 0.40-0.60; 33.1% vs. 51.7%). This was explained by a lower rate of SIR in women (33.7% vs. 52.7%; P < 0.001). After adjustment for resuscitation parameters, female sex remained independently associated with lower SIR rate. CONCLUSION: In case of OHCA, women are less often resuscitated by bystanders than men. When resuscitation is attempted, women have lower survival rates at each successive stage of care. These sex gaps are likely explained by lower rate of SIR in women, which can only partly be explained by resuscitation characteristics.
TL;DR: Crystalloids are less effective than colloids at stabilizing hemodynamic endpoints; guidance on when to switch is urgently required in the ICU.
TL;DR: Assessment of witnessed, pulseless cardiac arrests occurring at 538 hospitals during a 9-yr period indicates that CPR did not occur immediately at 0 min in 5.7% of patients despite guidelines for instantaneous initiation.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicRapid response to witnessed, pulseless cardiac arrest is associated with increased survival.What This Article Tells Us That Is NewAssessment of witnessed, pulseless cardiac arrests occurring at 538 hospitals during a 9-yr period indicates that
TL;DR: Failure to reach 30by3 was associated with increased odds of in-hospital mortality, irrespective of comorbidities, and predictors of inadequate resuscitation can be identified, potentially leading to interventions to improve survival.
Abstract: Objectives Rapid fluid resuscitation has become standard in sepsis care, despite "low-quality" evidence and absence of guidelines for populations "at risk" for volume overload. Our objectives include as follows: 1) identify predictors of reaching a 30 mL/kg crystalloid bolus within 3 hours of sepsis onset (30by3); 2) assess the impact of 30by3 and fluid dosing on clinical outcomes; 3) examine differences in perceived "at-risk" volume-sensitive populations, including end-stage renal disease, heart failure, obesity, advanced age, or with documentation of volume "overload" by bedside examination. Design Retrospective cohort study. All outcome analyses controlled for sex, end-stage renal disease, heart failure, sepsis severity (severe sepsis vs septic shock), obesity, Mortality in Emergency Department Sepsis score, and time to antibiotics. Setting Urban, tertiary care center between January 1, 2014, and May 31, 2017. Patients Emergency Department treated adults (age ≥18 yr; n = 1,032) with severe sepsis or septic shock. Interventions Administration of IV fluids by bolus. Measurements and main results In total, 509 patients received 30by3 (49.3%). Overall mortality was 17.1% (n = 176), with 20.4% mortality in the shock group. Patients who were elderly (odds ratio, 0.62; 95% CI, 0.46-0.83), male (odds ratio, 0.66; CI, 0.49-0.87), obese (odds ratio, 0.18; CI, 0.13-0.25), or with end-stage renal disease (odds ratio, 0.23; CI, 0.13-0.40), heart failure (odds ratio, 0.42; CI, 0.29-0.60), or documented volume "overload" (odds ratio, 0.30; CI, 0.20-0.45) were less likely to achieve 30by3. Failure to meet 30by3 had increased odds of mortality (odds ratio, 1.52; CI, 1.03-2.24), delayed hypotension (odds ratio, 1.42; CI, 1.02-1.99), and increased ICU stay (~2 d) (β = 2.0; CI, 0.5-3.6), without differential effects for "at-risk" groups. Higher fluid volumes administered by 3 hours correlated with decreased mortality, with a plateau effect between 35 and 45 mL/kg (p Conclusions Failure to reach 30by3 was associated with increased odds of in-hospital mortality, irrespective of comorbidities. Predictors of inadequate resuscitation can be identified, potentially leading to interventions to improve survival. These findings are retrospective and require future validation.
TL;DR: It is demonstrated that a restrictive resuscitation strategy can successfully reduce the amount of IV fluid administered to patients with severe sepsis and septic shock compared with usual care, and further support that a Restrictive IV fluid strategy should be explored in a larger multicenter trial.
Abstract: Objectives:It is unclear if a low- or high-volume IV fluid resuscitation strategy is better for patients with severe sepsis and septic shock.Design:Prospective randomized controlled trial.Setting:Two adult acute care hospitals within a single academic system.Patients:Patients with severe sepsis and
TL;DR: Despite countless advancements in trauma care a survivability gap still exists in the prehospital setting, and shifting resuscitation from the hospital to the point of injury has shown great promise in decreasing mortality among the severely injured.
TL;DR: The view that the management of polytrauma patients has been substantially improved over the past 3 decades is supported, as multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place.
Abstract: Objectives Sustained changes in resuscitation and transfusion management have been observed since the turn of the millennium, along with an ongoing discussion of surgical management strategies. The aims of this study are threefold: a) to evaluate the objective changes in resuscitation and mass transfusion protocols undertaken in major level I trauma centers; b) to summarize the improvements in diagnostic options for early risk profiling in multiply injured patients and c) to assess the improvements in surgical treatment for acute major fractures in the multiply injured patient. Methods I. A systematic review of the literature (comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases) and a concomitant data base (from a single Level I center) analysis were performed. Two authors independently extracted data using a pre-designed form. A pooled analysis was performed to determine the changes in the management of polytraumatized patients after the change of the millennium. II. A data base from a level I trauma center was utilized to test any effects of treatment changes on outcome. Inclusion criteria: adult patients, ISS > 16, admission Results I. From the electronic databases, 5141 articles were deemed to be relevant. 169 articles met the inclusion criteria and a manual review of reference lists of key articles identified an additional 22 articles. II. Out of 3668 patients, 2694 (73.4%) were male, the mean ISS was 28.2 (SD 15.1), mean NISS was 37.2 points (SD 17.4 points) and the average length of stay was 17.0 days (SD 18.7 days) with a mean length of ICU stay of 8.2 days (SD 10.5 days), and a mean ventilation time of 5.1 days (SD 8.1 days). Both surgical management and nonsurgical strategies have changed over time. Damage control resuscitation, dynamic analyses of coagulopathy and lactate clearance proved to sharpen the view of the worsening trauma patient and facilitated the prevention of further complications. The subsequent surgical care has become safer and more balanced, avoiding overzealous initial surgeries, while performing early fixation, when patients are physiologically stable or rapidly improving. Severe chest trauma and soft tissue injuries require further evaluation. Conclusions Multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place. Moreover, improvement in mortality rates and complications associated with several factors were also observed. These findings support the view that the management of polytrauma patients has been substantially improved over the past 3 decades.
TL;DR: For the clinician caring for patients with sepsis today, the initial administration of 20 mL/kg of intravenous balanced crystalloid, followed by consideration of the risks and benefits of subsequent fluid administration represents a reasonable approach.
Abstract: Among critically ill adults, sepsis remains both common and lethal. In addition to antibiotics and source control, fluid resuscitation is a fundamental sepsis therapy. The physiology of fluid resuscitation for sepsis, however, is complex. A landmark trial found early goal-directed sepsis resuscitation reduced mortality, but 3 recent multicenter trials did not confirm this benefit. Multiple trials in resource-limited settings have found increased mortality with early fluid bolus administration in sepsis, and the optimal approach to early sepsis resuscitation across settings remains unknown. After initial resuscitation, excessive fluid administration may contribute to edema and organ dysfunction. Using dynamic variables such as passive leg raise testing can predict a patient's hemodynamic response to fluid administration better than static variables such as central venous pressure. Whether using measures of "fluid responsiveness" to guide fluid administration improves patient outcomes, however, remains unknown. New evidence suggests improved patient outcomes with the use of balanced crystalloids compared to saline in sepsis. Albumin may be beneficial in septic shock, but other colloids such as starches, dextrans, and gelatins appear to increase the risk of death and acute kidney injury. For the clinician caring for patients with sepsis today, the initial administration of 20 mL/kg of intravenous balanced crystalloid, followed by consideration of the risks and benefits of subsequent fluid administration represents a reasonable approach. Additional research is urgently needed to define the optimal dose, rate, and composition of intravenous fluid during the management of patients with sepsis and septic shock.
TL;DR: The notion that fluid resuscitation with unbuffered electrolyte solutions may cause harm and their use should be cautioned is supported and the effects of lower volumes of buffered solutions should be evaluated further.
TL;DR: Although the mortality of patients matched to those with eWLST was high, these data showed excess mortality with eElderly age, initial non-shockable rhythm, increased ischemic time, shock on admission, out-of-hospital arrest, and admission in the United States were each independently associated with e WLST.
TL;DR: Low-dose AVP during the resuscitation of trauma patients in hemorrhagic shock decreases blood product requirements, and additional research is necessary to determine whether including AVP improves morbidity or mortality.
Abstract: Importance Current therapies for traumatic blood loss focus on hemorrhage control and blood volume replacement. Severe hemorrhagic shock, however, is associated with a state of arginine vasopressin (AVP) deficiency, and supplementation of this hormone may decrease the need for blood products in resuscitation. Objective To determine whether low-dose supplementation of AVP in patients with trauma (hereinafter referred to as trauma patients) and with hemorrhagic shock decreases their need for transfused blood products during resuscitation. Design, Setting, and Participants This randomized, double-blind placebo-controlled clinical trial included adult trauma patients (aged 18-65 years) who received at least 6 U of any blood product within 12 hours of injury at a single urban level 1 trauma center from May 1, 2013, through May 31, 2017. Exclusion criteria consisted of prehospital cardiopulmonary resuscitation, emergency department thoracotomy, corticosteroid use, chronic renal insufficiency, coronary artery disease, traumatic brain injury requiring any neurosurgical intervention, pregnancy, prisoner status, or AVP administration before enrollment. Data were analyzed from May 1, 2013, through May 31, 2017, using intention to treat and per protocol. Interventions After administration of an AVP bolus (4 U) or placebo, participants received AVP (≤0.04 U/min) or placebo for 48 hours to maintain a mean arterial blood pressure of at least 65 mm Hg. Main Outcomes The primary outcome was total volume of blood product transfused. Secondary end points included total volume of crystalloid transfused, vasopressor requirements, secondary complications, and 30-day mortality. Results One hundred patients underwent randomization (49 to the AVP group and 51 to the placebo group). Patients were primarily young (median age, 27 years [interquartile range {IQR}, 22-25 years]) and male (n = 93) with penetrating trauma (n = 79). Cohort characteristics before randomization were well balanced. At 48 hours, patients who received AVP required significantly less blood products (median, 1.4 [IQR, 0.5-2.6] vs 2.9 [IQR, 1.1-4.8] L;P = .01) but did not differ in requirements for crystalloids (median, 9.9 [IQR, 7.9-13.0] vs 11.0 [8.9-15.0] L;P = .22) or vasopressors (median, 400 [IQR, 0-5900] vs 1400 [IQR, 200-7600] equivalent units;P = .22). Although the groups had similar rates of mortality (6 of 49 [12%] vs 6 of 51 [12%];P = .94) and total complications (24 of 44 [55%] vs 30 of 47 [64%];P = .37), the AVP group had less deep venous thrombosis (5 of 44 [11%] vs 16 of 47 [34%];P = .02). Conclusions and Relevance Low-dose AVP during the resuscitation of trauma patients in hemorrhagic shock decreases blood product requirements. Additional research is necessary to determine whether including AVP improves morbidity or mortality. Trial Registration ClinicalTrials.gov identifier:NCT01611935
TL;DR: As a specific indicator of resuscitation outcome, lactate clearance alone is superior to ScvO2 alone during a standard resuscitation paradigm, and to guide resuscitation and normalize lactate levels in patients, repeating lactate measurements every 2 hours until the patient has met a lactates clearance of 10% or greater may be helpful.
TL;DR: The findings of improved SpO2 and higher Apgar score, and the absence of negative consequences encourages further studies with longer follow-up on the effects of resuscitation with an intact umbilical cord.
Abstract: Experiments have shown improved cardiovascular stability in lambs if umbilical cord clamping is postponed until positive pressure ventilation is started. Studies on intact cord resuscitation on human term infants are sparse. The purpose of this study was to evaluate differences in clinical outcomes in non-breathing infants between groups, one where resuscitation is initiated with an intact umbilical cord (intervention group) and one group where cord clamping occurred prior to resuscitation (control group). Randomized controlled trial, inclusion period April to August 2016 performed at a tertiary hospital in Kathmandu, Nepal. Late preterm and term infants born vaginally, non-breathing and in need of resuscitation according to the ‘Helping Babies Breathe’ algorithm were randomized to intact cord resuscitation or early cord clamping before resuscitation. Main outcome measures were saturation by pulse oximetry (SpO2), heart rate and Apgar at 1, 5 and 10 minutes after birth. At 10 minutes after birth, SpO2 (SD) was significantly higher in the intact cord group compared to the early cord clamping group, 90.4 (8.1) vs 85.4 (2.7) %, P < .001). In the intact cord group, 57 (44%) had SpO2 < 90% after 10 minutes, compared to 93 (100%) in the early cord clamping group, P < 0.001. SpO2 was also significantly higher in the intervention (intact cord) group at one and five minutes after birth. Heart rate was lower in the intervention (intact cord) group at one and five minutes and slightly higher at ten minutes, all significant findings. Apgar score was significantly higher at one, five and ten minutes. At 5 minutes, 23 (17%) had Apgar score < 7 in the intervention (intact cord) group compared to 26 (27%) in the early cord clamping group, P < .07. Newborn infants in the intervention (intact cord) group started to breathe and establish regular breathing earlier than in the early cord clamping group. This study provides new and important information on the effects of resuscitation with an intact umbilical cord. The findings of improved SpO2 and higher Apgar score, and the absence of negative consequences encourages further studies with longer follow-up. Clinicaltrials.gov NCT02727517
, 2016/4/4
TL;DR: A systematic review and meta-analysis provides the scientific summary of initial Fio2 in term and late preterm newborns who receive respiratory support at birth and found certainty of evidence was low for short-term mortality and hypoxic-ischemic encephalopathy and very low for neurodevelopmental impairment.
Abstract: CONTEXT: The International Liaison Committee on Resuscitation prioritized to rigorously review the initial fraction of inspired oxygen (Fio2) during resuscitation of newborns. OBJECTIVE: This systematic review and meta-analysis provides the scientific summary of initial Fio2 in term and late preterm newborns (≥35 weeks’ gestation) who receive respiratory support at birth. DATA SOURCES: Medline, Embase, Evidence Based Medicine Reviews, and Cumulative Index to Nursing and Allied Health Literature were searched between January 1, 1980 and August 10, 2018. STUDY SELECTION: Studies were selected by pairs of independent reviewers in 2 stages, with a Cohen’s κ of 0.8 and 1.0. DATA EXTRACTION: Pairs of independent reviewers extracted data, appraised risk of bias, and assessed Grading of Recommendations Assessment, Development and Evaluation certainty of evidence. RESULTS: Five randomized controlled trials (RCTs) and 5 quasi RCTs included 2164 patients. Room air (Fio2 0.21) was associated with a statistically significant benefit in short-term mortality compared with 100% oxygen (Fio2 1.0) (7 RCTs; n = 1469; risk ratio [RR] = 0.73; 95% confidence interval [CI]: 0.57 to 0.94). No significant differences were observed in neurodevelopmental impairment (2 RCTs; n = 360; RR = 1.41; 95% CI: 0.77 to 2.60) or hypoxic-ischemic encephalopathy (5 RCTs; n = 1315; RR = 0.89; 95% CI: 0.68 to 1.18). LIMITATIONS: The Grading of Recommendations Assessment, Development and Evaluation certainty of evidence was low for short-term mortality and hypoxic-ischemic encephalopathy and very low for neurodevelopmental impairment. CONCLUSIONS: Room air has a 27% relative reduction in short-term mortality compared with Fio2 1.0 for initiating neonatal resuscitation ≥35 weeks’ gestation.
TL;DR: In this article, the hypothesis that elevated postresuscitation mean arterial blood pressure is associated with neurologic outcome was tested and it was shown that elevated blood pressure after resuscitation from cardiac arrest may be protective.
Abstract: Objectives:Laboratory studies suggest elevated blood pressure after resuscitation from cardiac arrest may be protective; however, clinical data are limited. We sought to test the hypothesis that elevated postresuscitation mean arterial blood pressure is associated with neurologic outcome.Design:Prep
TL;DR: In this paper, the authors focus on the definition of birth asphyxia in the low resource setting, and compare it to the diagnosis in the resource replete setting, highlighting the importance of interruption of placental blood flow as it relates to morbidity and mortality.
Abstract: Birth asphyxia (BA), assumed to be related to intrapartum related hypoxia-ischemia, accounts for one million neonatal deaths annually. In the low resource setting BA is usually defined as a failure to initiate or sustain spontaneous breathing at birth. In the resource replete setting BA is a biochemical definition related to impaired gas exchange, due to interruption of placental blood flow (PBF). An umbilical arterial pH <7.00 referred to as severe fetal acidemia, reflects a degree of acidosis, where potential risk of adverse neurologic sequelae is increased. However, even with this degree of acidemia, the likelihood of mortality or adverse neurologic sequelae remains low. The aim is to focus on the definition of BA in the low resource setting, and compare it to the diagnosis in the resource replete setting, highlighting the importance of interruption of placental blood flow as it relates to morbidity and mortality. With asphyxia, the fetus aims to redistribute cardiac output to protect more vital organs e.g., brain, myocardium, and adrenal gland at the expense of decreased flow to organs such as kidney or intestine. In an experimental newborn model, animals subjected to asphyxia immediately develop primary apnea with bradycardia sustained blood pressure and normal pH. Recovery of respirations follows basic interventions, i.e. stimulation coupled with reversal of asphyxia. However, if asphyxia is sustained, secondary apnea manifests with bradycardia, hypotension, and pH <7.00. More intensive resuscitation including bag mask ventilation ± intubation ± cardio-pulmonary resuscitation may be necessary for correction upon reversal of asphyxia. Identification of a severely acidemic state (cord arterial pH < 7.00) in the newborn, may help to differentiate the truly asphyxiated intrapartum related cases that result in mortality, from those cases where mortality is related to delay in or ineffective basic resuscitation.
TL;DR: Outcomes after extracorporeal cardiopulmonary resuscitation reported by linking two national registries are encouraging, with encouraging results, but noncardiac diagnoses, preexisting renal insufficiency, longer time from onset of the cardiopUL pulmonary resuscitation event to extracornoreal membrane oxygenation initiation, and adverse events during the extracorporation course are associated with worse outcomes.
Abstract: Objectives:The aim of this study was to determine cardiac arrest– and extracorporeal membrane oxygenation–related risk factors associated with unfavorable outcomes after extracorporeal cardiopulmonary resuscitation.Design:We performed an analysis of merged data from the Extracorporeal Life Support O
TL;DR: CWB offers the benefit of a balanced resuscitation with improved trauma bay survival and higher mean hemoglobin at 24 hours, and a larger, prospective study is needed to determine whether it has a longer-term survival benefit for severely injured patients.
Abstract: BACKGROUND Cold-stored whole blood (CWB) provides a balance of red blood cells, plasma, and platelets in less anticoagulant volume than standard blood component therapy (BCT). We hypothesize that patients receiving CWB along with BCT have improved survival compared with patients receiving only BCT. METHODS We performed a dual-center case-match study of trauma patients who received CWB and BCT at two urban, Level-I Trauma Centers. Criteria to receive CWB included boys 16 years of older, women older than 50 years, SBP less than 90 mm Hg, and identifiable source of hemorrhage. We performed a 2:1 propensity match against any trauma patient who received 1 unit or greater of packed red cells during their initial trauma bay resuscitation. Endpoints included trauma bay mortality, 30-day mortality, laboratory values at 4 hours and 24 hours, and overall blood product utilization. Comparisons were made with Wilcoxon-ranked sum and Fisher's exact test, p less than 0.05 was significant. RESULTS Between both institutions, a total of 107 patients received CWB during the study period with 91 being matched to 182 BCT patients for analysis. Hemodynamic parameters of the patients in both groups at the time of presentation were similar. The CWB patients had higher mean hemoglobin (10 ± 2 g/dL vs. 11 ± 2 g/dL; p < 0.001) and hematocrit (29.2 ± 6.1% vs. 32.1 ± 5.8%; p < 0.001) at 24 hours. Importantly, trauma bay mortality was less in CWB patients (8.8% vs. 2.2%;p = 0.039). Thirty-day mortality was not different in CWB patients, and there were no differences in the total amount of blood products transfused at the 4-hour and 24-hour periods. CONCLUSION Cold-stored whole blood offers the benefit of a balanced resuscitation with improved trauma bay survival and higher mean hemoglobin at 24 hours. A larger, prospective study is needed to determine whether it has a longer-term survival benefit for severely injured patients. LEVEL OF EVIDENCE Therapeutic, level III.