Efficacy and safety of corticosteroid therapy in patients with cardiac arrest: A meta-analysis of randomized controlled trials

Emergency medicine updates: Cardiac arrest medications

INTRODUCTION

Cardiac arrest is a serious condition frequently managed in the emergency department (ED). Medications are a component of cardiac arrest management.

OBJECTIVE

This paper evaluates key evidence-based updates concerning medications used for patients in cardiac arrest.

DISCUSSION

Several medications have been evaluated for use in cardiac arrest. Routes of administration may include intravenous (IV) and intraosseous (IO). IV administration is recommended, though if an attempt at IV access is unsuccessful, IO access can be utilized. Epinephrine is a core component of guidelines, which recommend 1 mg in those with shockable rhythms if initial CPR and defibrillation are unsuccessful, while in nonshockable rhythms, guidelines recommend that epinephrine 1 mg be administered as soon as feasible. While epinephrine may improve rates of ROSC, it is not associated with improved survival with a favorable neurologic outcome. Evidence suggests the combination of vasopressin, steroids, and epinephrine may improve ROSC among those with in-hospital cardiac arrest, but there is no improvement in survival to discharge and survival with a favorable neurologic outcome. Antiarrhythmics (e.g., amiodarone, lidocaine, procainamide) likely do not improve short-term or long-term survival or neurologic outcomes, though guidelines state that amiodarone may be used in those with cardiac arrest and refractory pulseless ventricular tachycardia (pVT)/ventricular fibrillation (VF). Calcium and sodium bicarbonate should not be routinely administered in those with cardiac arrest. Beta-blockers may be considered in those with shock-resistant pVT/VF.

CONCLUSIONS

An understanding of literature updates concerning medication use in cardiac can improve the ED care of these patients.

Emergency medicine updates: Managing the patient with return of spontaneous circulation

INTRODUCTION

Patients with return of spontaneous circulation (ROSC) following cardiac arrest are a critically important population requiring close monitoring and targeted interventions in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the management of this condition.

OBJECTIVE

This paper provides evidence-based updates concerning the management of the post-ROSC patient.

DISCUSSION

The patient with ROSC following cardiac arrest is critically ill, including a post-cardiac arrest syndrome which may include hypoxic brain injury, myocardial dysfunction, systemic ischemia and reperfusion injury, and persistent precipitating pathophysiology. Initial priorities in the ED setting in the post-ROSC patient include supporting cardiopulmonary function, addressing and managing the underlying cause of arrest, minimizing secondary cerebral injury, and correcting physiologic derangements. Testing including laboratory assessment, electrocardiogram (ECG), and imaging are necessary, aiming to evaluate for the precipitating cause and assess end-organ injury. Computed tomography head-to-pelvis may be helpful in the post-ROSC patient, particularly when the etiology of arrest is unclear. There are several important components of management, including targeting a mean arterial pressure of at least 65 mmHg, preferably >80 mmHg, to improve end-organ and cerebral perfusion pressure. An oxygenation target of 92-98 % is recommended using ARDSnet protocol, along with carbon dioxide partial pressure values of 35-55 mmHg. Antibiotics should be reserved for those with evidence of infection but may be considered if the patient is comatose, intubated, and undergoing hypothermic targeted temperature management (TTM). Corticosteroids should not be routinely administered. While the majority of cardiac arrests in adults are associated with cardiovascular disease, not all post-ROSC patients require emergent coronary angiography. However, if the patient has ST-segment elevation on ECG following ROSC, emergent angiography and catheterization is recommended. This should also be considered if the patient had an initial history concerning for acute coronary syndrome or a presenting arrhythmia of ventricular fibrillation or pulseless ventricular tachycardia. TTM at 32-34° C does not appear to demonstrate improved outcomes compared with targeted normothermia, but fever should be avoided.

CONCLUSIONS

An understanding of literature updates can improve the ED care of patients post-ROSC.

Description of current status of implementation and management of cardiac arrest in China

Variation in the incidence, survival rate and factors associated with survival after cardiac arrest in China is reported. Some studies have tried to fill the knowledge gap regarding the epidemiology of cardiac arrest in China but were unable to identify reasons for the reported differences. Therefore, the purpose of this study was to describe Chinese management of cardiac arrest, particularly from the perspective of compression, ventilation, monitoring, treatment, and extracorporeal cardiopulmonary resuscitation. An online questionnaire with 56 questions was designed about demographic characteristics, management of cardiac arrest, compression, ventilation, treatment and medicine, as well as advanced life support and resuscitation skill training. A total of 814 copies of questionnaire were received from 23 provinces, 4 autonomous regions and 4 municipalities of China. Results were combined with official information on population density. Throughout China, hospitals resuscitate according to the guideline, however, there are still differences varies in implement with regard to chest compression, ventilation, medicine, monitoring, as well as advanced life support and resuscitation skills training because of economical and developmental level from different regions. All the startup of chest compression is manual, whereas mechanical compression instruments are increasingly involved in sequential resuscitation. Most of clinicians rotate during resuscitation every five cycles other than the guideline recommends every 2 min or when they are tired. About half of the participants don't build the advanced airway rather than use bag valve mask to ventilate, and 75% of the rest use mechanical ventilation whether they succeed to ROSC. Most of rescuers choose endotracheal intubation which is consistent with many other clinical trials results. Various compression feedback devices play increasingly significant roles in assessment of ROSC. More and more regional hospitals have access to ECPR and implement TTM, but still lead to various divergences. Thus, more elaborate clinical trials need to be designed to verify and explore every procedure in the CPR life cycle.

Effects of resistant starch supplementation on renal function and inflammatory markers in patients with chronic kidney disease: a meta-analysis of randomized controlled trials

BACKGROUND

Recent studies have shown that consumption of resistant starch (RS) has beneficial effects on the gut microbiota and immune function in patients with chronic kidney disease (CKD). The objective of this study was to evaluate the effects of RS on inflammation, uremic toxins, and renal function in patients with CKD through a systematic review and meta-analysis.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-2020. We included randomized controlled trials comparing RS supplementation to placebo. The National Library of Medicine (PubMed), Excerpta Medica Database (Embase), Cochrane Library, Web of Science, China National Knowledge Internet (CNKI) databases, and two gray literature sources - Baidu and Research Gate, were used for search, up to 28 August 2024. There was no limitation on publication date, but only manuscripts published in English and Chinese were included.

RESULTS

A total of 645 articles were retrieved. Ten articles met the inclusion criteria, and a total of 355 subjects were included. The analysis revealed that RS dietary intervention can significantly reduce indoxyl sulfate (IS) levels (SMD: -0.37, 95% confidence interval (CI): -0.70 to -0.04, p = .03) and blood urea nitrogen (BUN) levels (SMD: -0.30, 95% CI: -0.57 to -0.02, p = .03). There were no significant differences in the levels of interleukin-6 (IL-6), p-cresyl sulfate (p-CS), albumin, phosphorus, or tumor necrosis factor-α.

CONCLUSIONS

The RS diet has potential beneficial effects on uremic toxin levels and renal function indices in patients with CKD. RS supplementation can reduce uremic toxin levels and improve renal function but does not reduce the inflammatory response in patients with CKD. Nevertheless, results should be cautiously interpreted, because of the limited sample size and different treatment dosages. Further research is necessary to corroborate the beneficial effects of RS2 supplementation in this population.