European Resuscitation Council Guidelines for Resuscitation 2005

Survival to intensive care unit discharge among in-hospital cardiac arrest patients by applying audiovisual feedback device

AIMS

Survival rates after in-hospital cardiac arrest remain very low. Although there is evidence that the use of audiovisual feedback devices can improve compression components, there are no data on patient survival. Therefore, we conducted this study to analyse the survival rate of patients with in-hospital cardiac arrest after discharge from the intensive care unit.

METHODS AND RESULTS

This study was a secondary analysis of a prospective, randomized, controlled, parallel study of patients who received either standard manual chest compression or a real-time feedback device. Parametric and semi-parametric models were fitted to the data. Different survival time of length of stay was investigated by univariate and multiple analyses. Pearson's correlation between length of stay and hospital length of stay was obtained. A total of 900 patients with a mean survival time of 35 days were included. Intervention was associated with a higher length of stay. Relative time was significant in adjusted fitted log-normal regression for intervention group, female gender, and cardiopulmonary resuscitation in the night shift. A positive correlation between length of stay and hospital length of stay was found.

CONCLUSIONS

Implementation of feedback device improved survival and length of stay. Cardiopulmonary resuscitation performance during the night shift decreased the survival time, which could be due to the inexperienced staff available outside working hours.

Resuscitative thoracotomy

A trauma patient with cardiac tamponade may not survive transfer to the operating theatre for pericardial decompression. This article describes an approach to a resuscitative thoracotomy in the ED, which may be life-saving in these patients when a cardiothoracic surgeon is not immediately available.

Factors influencing termination of resuscitation in children: a qualitative analysis

BACKGROUND

Pediatric Advanced Life Support provides guidelines for resuscitating children in cardiopulmonary arrest. However, the role physicians' attitudes and beliefs play in decision-making when terminating resuscitation has not been fully investigated. This study aims to identify and explore the vital "non-medical" considerations surrounding the decision to terminate efforts by U.S.-based Pediatric Emergency Medicine (PEM) physicians.

METHODS

A phenomenological qualitative study was conducted using PEM physician experiences in terminating resuscitation within a large freestanding children's hospital. Semi-structured interviews were conducted with 17 physicians, sampled purposively for their relevant content experience, and continued until the point of content saturation. Resulting data were coded using conventional content analysis by 2 coders; intercoder reliability was calculated as κ of 0.91. Coding disagreements were resolved through consultation with other authors.

RESULTS

Coding yielded 5 broad categories of "non-medical" factors that influenced physicians' decision to terminate resuscitation: legal and financial, parent-related, patient-related, physician-related, and resuscitation. When relevant, each factor was assigned a directionality tag indicating whether the factor influenced physicians to terminate a resuscitation, prolong a resuscitation, or not consider resuscitation. Seventy-eight unique factors were identified, 49 of which were defined by the research team as notable due to the frequency of their mention or novelty of concept.

CONCLUSION

Physicians consider numerous "non-medical" factors when terminating pediatric resuscitative efforts. Factors are tied largely to individual beliefs, attitudes, and values, and likely contribute to variability in practice. An increased understanding of the uncertainty that exists around termination of resuscitation may help physicians in objective clinical decision-making in similar situations.

A comparison of cardiopulmonary resuscitation with standard manual compressions versus compressions with real-time audiovisual feedback: A randomized controlled pilot study

Background:

Strategies that improve cardiopulmonary resuscitation (CPR) guideline adherence may improve in-hospital cardiac arrest (IHCA) outcomes. Real-time audiovisual feedback (AVF) is one strategy identified by the American Heart Association and the International Liaison Committee on Resuscitation as an area needing further investigation. The aim of this study was to determine if in patients with IHCA, does the addition of a free-standing AVF device to standard manual chest compressions during CPR improve sustained return of spontaneous circulation (ROSC) rates (primary outcome) or CPR quality or guideline adherence (secondary outcomes).

Methods:

This was a prospective, randomized, controlled, parallel study of patients undergoing resuscitation with chest compressions for IHCA in the mixed medical-surgical intensive care units (ICUs) of two academic teaching hospitals. Patients were randomized to receive either standard manual chest compressions or compressions using the Cardio First Angel™ feedback device.

Results:

Sixty-seven individuals were randomized, and 22 were included. CPR quality evaluation and guideline adherence scores were improved in the intervention group (P = 0.0005 for both). The incidence of ROSC was similar between groups (P = 0.64), as was survival to ICU discharge (P = 0.088) and survival to hospital discharge (P = 0.095).

Conclusion:

The use of the Cardio First Angel™ compression feedback device improved adherence to publish CPR guidelines and CPR quality. The insignificant change in rates of ROSC and survival to ICU or hospital discharge may have been related to small sample size. Further clinical studies comparing AVF devices to standard manual compressions are needed, as are device head-to-head comparisons.

Diagnostic performance of the basic and advanced life support termination of resuscitation rules: A systematic review and diagnostic meta-analysis

AIM

To minimize termination of resuscitation (TOR) in potential survivors, the desired positive predictive value (PPV) for mortality and specificity of universal TOR-rules are ≥99%. In lack of a quantitative summary of the collective evidence, we performed a diagnostic meta-analysis to provide an overall estimate of the performance of the basic and advanced life support (BLS and ALS) termination rules.

DATA SOURCES

We searched PubMed/EMBASE/Web-of-Science/CINAHL and Cochrane (until September 2019) for studies on either or both TOR-rules in non-traumatic, adult cardiac arrest. PRISMA-DTA-guidelines were followed.

RESULTS

There were 19 studies: 16 reported on the BLS-rule (205.073 patients, TOR-advice in 57%), 11 on the ALS-rule (161.850 patients, TOR-advice in 24%). Pooled specificities were 0.95 (0.89-0.98) and 0.98 (0.95-1.00) respectively, with a PPV of 0.99 (0.99-1.00) and 1.00 (0.99-1.00). Specificities were significantly lower in non-Western than Western regions: 0.84 (0.73-0.92) vs. 0.99 (0.97-0.99), p < 0.001 for the BLS rule. For the ALS-rule, specificities were 0.94 (0.87-0.97) vs. 1.00 (0.99-1.00), p < 0.001. For non-Western regions, 16 (BLS) or 6 (ALS) out of 100 potential survivors met the TOR-criteria. Meta-regression demonstrated decreasing performance in settings with lower rates of in-field shocks.

CONCLUSIONS

Despite an overall high PPV, this meta-analysis highlights a clinically important variation in diagnostic performance of the BLS and ALS TOR-rules. Lower specificity and PPV were seen in non-Western regions, and populations with lower rates of in-field defibrillation. Improved insight in the varying diagnostic performance is highly needed, and local validation of the rules is warranted to prevent in-field termination of potential survivors.

Are physicians on the same page about do-not-resuscitate? To examine individual physicians' influence on do-not-resuscitate decision-making: a retrospective and observational study

Background

Individual physicians and physician-associated factors may influence patients’/surrogates’ autonomous decision-making, thus influencing the practice of do-not-resuscitate (DNR) orders. The objective of this study was to examine the influence of individual attending physicians on signing a DNR order.

Methods

This study was conducted in closed model, surgical intensive care units in a university-affiliated teaching hospital located in Northern Taiwan. The medical records of patients, admitted to the surgical intensive care units for the first time between June 1, 2011 and December 31, 2013 were reviewed and data collected. We used Kaplan–Meier survival curves with log-rank test and multivariate Cox proportional hazards models to compare the time from surgical intensive care unit admission to do-not-resuscitate orders written for patients for each individual physician. The outcome variable was the time from surgical ICU admission to signing a DNR order.

Results

We found that each individual attending physician’s likelihood of signing do-not-resuscitate orders for their patients was significantly different from each other. Some attending physicians were more likely to write do-not-resuscitate orders for their patients, and other attending physicians were less likely to do so.

Conclusion

Our study reported that individual attending physicians had influence on patients’/surrogates’ do-not-resuscitate decision-making. Future studies may be focused on examining the reasons associated with the difference of each individual physician in the likelihood of signing a do-not-resuscitate order.

Real-time compression feedback for patients with in-hospital cardiac arrest: a multi-center randomized controlled clinical trial

Objective

To determine if real-time compression feedback using a non-automated hand-held device improves patient outcomes from in-hospital cardiac arrest (IHCA).

Methods

We conducted a prospective, randomized, controlled, parallel study (no crossover) of patients with IHCA in the mixed medical–surgical intensive care units (ICUs) of eight academic hospitals. Patients received either standard manual chest compressions or compressions performed with real-time feedback using the Cardio First Angel™ (CFA) device. The primary outcome was sustained return of spontaneous circulation (ROSC), and secondary outcomes were survival to ICU and hospital discharge.

Results

One thousand four hundred fifty-four subjects were randomized; 900 were included. Sustained ROSC was significantly improved in the CFA group (66.7% vs. 42.4%, P < 0.001), as was survival to ICU discharge (59.8% vs. 33.6%) and survival to hospital discharge (54% vs. 28.4%, P < 0.001). Outcomes were not affected by intra-group comparisons based on intubation status. ROSC, survival to ICU, and hospital discharge were noted to be improved in inter-group comparisons of non-intubated patients, but not intubated ones.

Conclusion

Use of the CFA compression feedback device improved event survival and survival to ICU and hospital discharge.

Trial registration

The study was registered with Clinicaltrials.gov (NCT02845011), registered retrospectively on July 21, 2016.

Characteristics of jugular bulb oxygen saturation in patients after cardiac arrest: A prospective study

BACKGROUND

Using cerebral oxygen venous saturation post-cardiac arrest (CA) is limited because of a small sample size and prior to establishment of target temperature management (TTM). We aimed to describe variations in jugular bulb oxygen saturation during intensive care in relation to neurological outcome at 6 months post- CA in cases where TTM 33°C was applied.

METHOD

Prospective observational study in patients over 18 years, comatose immediately after resuscitation from CA. Patients were treated with TTM 33°C M and received a jugular bulb catheter within the first 26 hours post-CA. Neurological outcome was assessed at 6 months using the Cerebral Performance Categories (CPC) and dichotomized into good (CPC 1-2) and poor outcome (CPC 3-5).

RESULTS

Seventy-five patients were included and 37 (49%) patients survived with a good outcome at 6 months post-CA. No differences were found between patients with good outcome and poor outcome in jugular bulb oxygen saturation. Higher values were seen in differences in oxygen content between central venous oxygen saturation and jugular bulb oxygen saturation in patients with good outcome compared to patients with poor outcome at 6 hours (12 [8-21] vs 5 [-0.3 to 11]% P = .001) post-CA. Oxygen extraction fraction from the brain illustrated lower values in patients with poor outcome compared to patients with good outcome at 96 hours (14 [9-23] vs 31 [25-34]% P = .008).

CONCLUSIONS

Oxygen delivery and extraction differed in patients with a good outcome compared to those with a poor outcome at single time points. Based on the present findings, the usefulness of jugular bulb oxygen saturation for prognostic purposes is uncertain in patients treated with TTM 33°C post-CA.

Cardiac Magnetic Resonance Imaging (MRI) Findings in Arrhythmogenic Right Ventricular Dysplasia (ARVD) Compared with Echocardiography

Arrhythmogenic right ventricular dysplasia (ARVD) is an abnormality in the right side of the heart that may lead to sudden death. The study aims to compare cardiac MRI (magnetic resonance imaging findings) with echocardiography in patients with ARVD. For the cross-sectional study, patients with ARVD that were diagnosed using Task Force criteria were included, and their cardiac MRI findings were evaluated. Additionally, the right ventricle was divided into three levels-basal, middle, and apical-and each of them was also subdivided into three secondary segments. Gadolinium enhancement was evaluated in each segment. Overall, 39 patients were studied. Thirty-one patients (81%) were men. The average age of female and male patients was 37.8 ± 4.6 and 32.48 ± 5.8, respectively. The average ejection fraction found was 43 ± 9.4 and 42.8 ± 8.5% by MRI and echocardiography, respectively. Additionally, 46 and 35.8% of the patients had hypokinesia in the right ventricle, found based on MRI and echocardiography, respectively. The right ventricular aneurysm was found in 20.5 and 5.1% of patients based on MRI and echocardiography, respectively. The cardiac MRI managed to diagnose some cases which echocardiography was not able to detect. Thus, MRI plays an important role in presenting diagnostic data for the management of patients with ARVD and also making the diagnosis in suspicious patients definitive.

Emergency nurses’ attitudes towards the concept of witnessed resuscitation

Objective:

to review the most relevant evidence on the nurses’ attitudes towards witnessed resuscitation, in the inpatient and out-of-hospital spheres.

Method:

integrative literature review, covering the period from 2008 till 2015, using the databases PubMed, Lilacs and SciELO; in Spanish, English and Portuguese. The pediatric context was excluded from the study.

Results:

the synthesis of the data resulted in the inclusion of 10 articles, categorized as: positive attitudes and negative attitudes.

Conclusions:

discrepancies exist among the nurses from different contexts and geographical regions towards the concept; protocols need to be established for this situation, in view of the advantages evidenced in the literature, for the nursing professionals as well as the relatives. Witnessed resuscitation can represent an opportunity to understand and cope with the rational and irrational in the situation in a shared manner, as well as mitigate or dignify the mourning.

Acute brain lesions on magnetic resonance imaging in relation to neurological outcome after cardiac arrest

BACKGROUND

Magnetic resonance imaging (MRI) of the brain including diffusion-weighted imaging (DWI) is reported to have high prognostic accuracy in unconscious post-cardiac arrest (CA) patients. We documented acute MRI findings in the brain in both conscious and unconscious post-CA patients treated with target temperature management (TTM) at 32-34°C for 24 h as well as the relation to patients' neurological outcome after 6 months.

METHODS

A prospective observational study with MRI was performed regardless of the level of consciousness in post-CA patients treated with TTM. Neurological outcome was assessed using the Cerebral Performance Categories scale and dichotomized into good and poor outcome.

RESULTS

Forty-six patients underwent MRI at 3-5 days post-CA. Patients with good outcome had minor, mainly frontal and parietal, lesions. Acute hypoxic/ischemic lesions on MRI including DWI were more common in patients with poor outcome (P = 0.007). These lesions affected mostly gray matter (deep or cortical), with or without involvement of the underlying white matter. Lesions in the occipital and temporal lobes, deep gray matter and cerebellum showed strongest associations with poor outcome. Decreased apparent diffusion coefficient, was more common in patients with poor outcome.

CONCLUSIONS

Extensive acute hypoxic/ischemic MRI lesions in the cortical regions, deep gray matter and cerebellum detected by visual analysis as well as low apparent diffusion coefficient values from quantitative measurements were associated with poor outcome. Patients with good outcome had minor hypoxic/ischemic changes, mainly in the frontal and parietal lobes.

Case of a cardiac arrest patient who survived after extracorporeal cardiopulmonary resuscitation and 1.5 hours of resuscitation: A case report

RATIONALE

Per the American Heart Association guidelines, extracorporeal cardiopulmonary resuscitation should be considered for in-hospital patients with easily reversible cardiac arrest. However, there are currently no consensus recommendations regarding resuscitation for prolonged cardiac arrest cases.

PATIENT CONCERNS AND DIAGNOSIS

We encountered a 48-year-old man who survived a cardiac arrest that lasted approximately 1.5 hours. He visited a local hospital's emergency department complaining of chest pain and dyspnea that had started 3 days earlier. Immediately after arriving in the emergency department, a cardiac arrest occurred; he was transferred to our hospital for extracorporeal membrane oxygenation (ECMO).

INTERVENTIONS

Resuscitation was performed with strict adherence to the American Heart Association/American College of Cardiology advanced cardiac life support guidelines until ECMO could be placed.

OUTCOMES

On hospital day 7, he had a full neurologic recovery. On hospital day 58, additional treatments, including orthotopic heart transplantation, were considered necessary; he was transferred to another hospital.

LESSONS

To our knowledge, this is the first case in South Korea of patient survival with good neurologic outcomes after resuscitation that lasted as long as 1.5 hours. Documenting cases of prolonged resuscitation may lead to updated guidelines and improvement of outcomes of similar cases in future.

Influences of "do-not-resuscitate order" prohibition on CPR outcomes

OBJECTIVES

The aim of the study is to determine factors affecting the return of spontaneous circulation (ROSC) ratios, neurological outcomes at discharge, the ratio of living patients discharged from the hospital and due to Do not attempt resuscitation (DNAR) prohibition.

MATERIAL AND METHODS

This is a retrospective observational study conducted on patients of cardiopulmonary resuscitation (CPR) performed in emergency department (ED) and intensive care units between February 2010 and February 2012.

RESULTS

A total of 469 patients were evaluated, and 266 eligible patients who did not have DNAR orders were included in the study. Overall, 45.1% of the adult in-hospital cardiac arrest victims returned to spontaneous circulation, and 5.3% survived to hospital discharge. Of the patients who were discharged alive from the hospital, 33.3% were discharged in poor neurologic conditions of Cerebral Performance Category (CPC) score 3 or 4. The ROSC ratio was reduced for the patients with malignancies compared to the patients with other preexisting conditions (OR: 12.783; 95% CI 2.967-55.072; p = 0.000). None of the patients with malignancies were discharged alive from the hospital. Only one patient with end-stage disease was discharged alive from hospital, and this patient's CPC score was 4.

DISCUSSION AND CONCLUSION

CPR has not increased the ROSC and alive discharge rates in patients with malignancy and end-state disease. DNAR order prohibition have been increased the futile CPR attempts. DNAR should be accepted as a human right that represents an honorable death option and whether a DNAR is order demanded should be specifically discussed with patients with malignancies and end-stage disease presenting to ED.

Conversion to shockable rhythms during resuscitation and survival for out-of hospital cardiac arrest

BACKGROUND

In out of hospital cardiac arrest (OHCA), the prognostic influence of conversion to shockable rhythms during resuscitation for initially non-shockable rhythms remains unknown. This study aimed to assess the relationship between initial and subsequent shockable rhythm and post-arrest survival and neurological outcomes after OHCA.

METHODOLOGY

This was a retrospective analysis of all OHCA cases collected from the Pan-Asian Resuscitation Outcomes Study (PAROS) registry in 7 countries in Asia between 2009 and 2012. We included OHCA cases of presumed cardiac etiology, aged 18-years and above and resuscitation attempted by EMS. We performed multivariate logistic regression analyses to assess the relationship between initial and subsequent shockable rhythm and survival and neurological outcomes. 2-stage seemingly unrelated bivariate probit models were developed to jointly model the survival and neurological outcomes. We adjusted for the clustering effects of country variance in all models.

RESULTS

40,160 OHCA cases met the inclusion criteria. There were 5356 OHCA cases (13.3%) with initial shockable rhythm and 33,974 (84.7%) with initial non-shockable rhythm. After adjustment of baseline and prehospital characteristics, OHCA with initial shockable rhythm (odds ratio/OR=6.10, 95% confidence interval/CI=5.06-7.34) and subsequent conversion to shockable rhythm (OR=2.00,95%CI=1.10-3.65) independently predicted better survival-to-hospital-discharge outcomes. Subsequent shockable rhythm conversion significantly improved survival-to-admission, discharge and post-arrest overall and cerebral performance outcomes in the multivariate logistic regression and 2-stage analyses.

CONCLUSION

Initial shockable rhythm was the strongest predictor for survival. However, conversion to subsequent shockable rhythm significantly improved post-arrest survival and neurological outcomes. This study suggests the importance of early resuscitation efforts even for initially non-shockable rhythms which has prognostic implications and selection of subsequent post-resuscitation therapy.

Factors influencing decision-making around family presence during resuscitation: a grounded theory study

AIM

The aim of this study was to examine factors impacting family presence during resuscitation practices in the acute care setting.

BACKGROUND

Family presence during resuscitation was introduced in the 1980s, so family members/significant others could be with their loved ones during life-threatening events. Evidence demonstrates important benefits; yet despite growing support from the public and endorsement from professional groups, family presence is practiced inconsistently and rationales for poor uptake are unclear.

DESIGN

Constructivist grounded theory design.

METHODS

Twenty-five health professionals, family members and patients informed the study. In-depth interviews were undertaken between October 2013-November 2014 to interpret and explain their meanings and actions when deciding whether to practice or participate in FPDR.

FINDINGS

The Social Construction of Conditional Permission explains the social processes at work when deciding to adopt or reject family presence during resuscitation. These processes included claiming ownership, prioritizing preferences and rights, assessing suitability, setting boundaries and protecting others/self. In the absence of formal policies, decision-making was influenced primarily by peoples' values, preferences and pre-existing expectations around societal roles and associated status between health professionals and consumers. As a result, practices were sporadic, inconsistent and often paternalistic rather than collaborative.

CONCLUSION

An increased awareness of the important benefits of family presence and the implementation of clinical protocols are recommended as an important starting point to address current variations and inconsistencies in practice. These measures would ensure future practice is guided by evidence and standards for health consumer safety and welfare rather than personal values and preferences of the individuals 'in charge' of permissions.

Attitudes of Doctors Working in Abant Izzet Baysal University Health Research and Application Center on Cardiopulmonary Resuscitation

OBJECTIVE

We aimed to evaluate the attitudes of doctors about cardiopulmonary resuscitation (CPR) in this research.

METHODS

Overall, 234 doctors who were working in Abant İzzet Baysal University Health Research and Application Center and who accepted to participate in this research were included. Research data were obtained by a questionnaire containing questions about demographic characteristics of doctors and their knowledge about CPR. Questionnaires were applied between 27.02.2012 and 04.06.2012. The chi-square test was used for categorical variables. A value of p<0.05 was considered statistically significant.

RESULTS

It was determined that 90% of the participants included in the study applied and/or observed CPR, and 62% of participants did not attend any CPR course. In addition, 64.1% of the doctors were found to be aware of guidelines prepared every 5 years. Although 65.2% of the doctors who attended a course previously gave a correct answer for the question about the number of cardiac compressions during adult CPR, 47.6% of the doctors who did not attend a course gave the correct answer (p=0.014). Additionally, 71.9% of participants who attended a course previously and 51.7% of participants who did not replied correctly to the question 'What should be done immediately after defibrillation during CPR?' And also the results for the question about how many joules is necessary to begin defibrillation with a monophasic defibrillator were statistically significant according to the attendance for a CPR course (p<0.005).

CONCLUSION

In this study, we have identified the lack of knowledge of the doctors about resuscitation.

Further deliberating the relationship between do-not-resuscitate and the increased risk of death

Few studies have examined the outcome of do-not-resuscitate (DNR) patients in surgical intensive care units (SICUs). This study deliberated the association between a DNR decision and the increased risk of death methodologically and ethically. This study was conducted in three SICUs. We collected patients’ demographic characteristics, clinical characteristics, and the status of death/survival at SICU and hospital discharge. We used Kaplan–Meier survival curves to compare the time from SICU admission to the end of SICU stay for the DNR and non-DNR patients. Differences in the Kaplan-Meier curves were tested using log-rank tests. We also conducted a Cox proportional hazards model to account for the effect of a DNR decision on mortality. We found that having a DNR order was associated with an increased risk of death during the SICU stay (aRR = 2.39, p < 0.01) after adjusting for severity of illness upon SICU admission and other confounding variables. To make the conclusion that a DNR order is causally related to an increased risk of death, or that a DNR order increases the risk of death is absolutely questionable. By clarifying this key point, we expect that the discussion of DNR between healthcare professionals and patients/surrogate decision-makers will not be hampered or delayed.

Termination of resuscitation in the prehospital setting: A comparison of decisions in clinical practice vs. recommendations of a termination rule

BACKGROUND

Of the proposed algorithms that provide guidance for in-field termination of resuscitation (TOR) decisions, the guidelines for cardiopulmonary resuscitation (CPR) refer to the basic and advanced life support (ALS)-TOR rules. To assess the potential consequences of implementation of the ALS-TOR rule, we performed a case-by-case evaluation of our in-field termination decisions and assessed the corresponding recommendations of the ALS-TOR rule.

METHODS

Cohort of non-traumatic out-of-hospital cardiac arrest (OHCA)-patients who were resuscitated by the ALS-practising emergency medical service (EMS) in the Nijmegen area (2008-2011). The ALS-TOR rule recommends termination in case all following criteria are met: unwitnessed arrest, no bystander CPR, no shock delivery, no return of spontaneous circulation (ROSC).

RESULTS

Of the 598 cases reviewed, resuscitative efforts were terminated in the field in 46% and 15% survived to discharge. The ALS-TOR rule would have recommended in-field termination in only 6% of patients, due to high percentages of witnessed arrests (73%) and bystander CPR (54%). In current practice, absence of ROSC was the most important determinant of termination [aOR 35.6 (95% CI 18.3-69.3)]. Weaker associations were found for: unwitnessed and non-public arrests, non-shockable initial rhythms and longer EMS-response times.

CONCLUSION

While designed to optimise hospital transportations, application of the ALS-TOR rule would almost double our hospital transportation rate to over 90% of OHCA-cases due to the favourable arrest circumstances in our region. Prior to implementation of the ALS-TOR rule, local evaluation of the potential consequences for the efficiency of triage is to be recommended and initiatives to improve field-triage for ALS-based EMS-systems are eagerly awaited.

Coding, Constant Comparisons, and Core Categories: A Worked Example for Novice Constructivist Grounded Theorists

Grounded theory method has been described extensively in the literature. Yet, the varying processes portrayed can be confusing for novice grounded theorists. This article provides a worked example of the data analysis phase of a constructivist grounded theory study that examined family presence during resuscitation in acute health care settings. Core grounded theory methods are exemplified, including initial and focused coding, constant comparative analysis, memo writing, theoretical sampling, and theoretical saturation. The article traces the construction of the core category "Conditional Permission" from initial and focused codes, subcategories, and properties, through to its position in the final substantive grounded theory.

The Outcome of Patients With 2 Different Protocols of Do-Not-Resuscitate Orders: An Observational Cohort Study

Lack of clarity about the exact clinical implications of do-not-resuscitate (DNR) has caused confusion that has been addressed repeatedly in the literature. To provide improved understanding about the portability of DNR and the medical care provided to DNR patients, the state of Ohio passed a Do-Not-Resuscitate Law in 1998, which clearly pointed out 2 different protocols of do-not-resuscitate: DNR comfort care (DNRCC) and DNR comfort care arrest (DNRCC-Arrest). The objective of this study was to examine the outcome of patients with the 2 different protocols of DNR orders.This is a retrospective observational study conducted in a medical intensive care unit (MICU) in a hospital located in Northeast Ohio. The medical records of the initial admissions to the MICU during data collection period were concurrently and retrospectively reviewed. The association between 2 variables was examined using Chi-squared test or Student's t-test. The outcome of DNRCC, DNRCC-Arrest, and No-DNR patients were compared using multivariate logistic regression analysis.The total of 188 DNRCC-Arrest, 88 DNRCC, and 2051 No-DNR patients were included in this study. Compared with the No-DNR patients, the DNRCC (odds ratio = 20.77, P < 0.01) and DNRCC-Arrest (odds ratio = 3.69, P < 0.01) patients were more likely to die in the MICU. Furthermore, the odds of dying during MICU stay for DNRCC patients were 7.85 times significantly higher than that for DNRCC-Arrest patients (odds ratio = 7.85, P < 0.01).Given Do-Not-Resuscitate Law in Ohio, we examined the outcome of the 2 different protocols of DNR orders, and to compare with the conventional DNR orders. Similar to conventional DNR, DNDCC and DNRCC-Arrest were both associated with the increased risk of death. Patients with DNRCC were more likely to be associated with increased risk of death than those with DNRCC-Arrest.

Two distinct Do-Not-Resuscitate protocols leaving less to the imagination: an observational study using propensity score matching

BACKGROUND

Do-Not-Resuscitate (DNR) patients tend to receive less medical care after the order is written. To provide a clearer approach, the Ohio Department of Health adopted the Do-Not-Resuscitate law in 1998, indicating two distinct protocols of DNR orders that allow DNR patients to choose the medical care: DNR Comfort Care (DNRCC), implying DNRCC patients receive only comfort care after the order is written; and DNR Comfort Care-Arrest (DNRCC-Arrest), implying that DNRCC-Arrest patients are eligible to receive aggressive interventions until cardiac or respiratory arrest. The aim of this study was to examine the medical care provided to patients with these two distinct protocols of DNR orders.

METHODS

Data were collected from August 2002 to December 2005 at a medical intensive care unit in a university-affiliated teaching hospital. In total, 188 DNRCC-Arrest patients, 88 DNRCC patients, and 2,051 non-DNR patients were included. Propensity score matching using multivariate logistic regression was used to balance the confounding variables between the 188 DNRCC-Arrest and 2,051 non-DNR patients, and between the 88 DNRCC and 2,051 non-DNR patients. The daily cost of intensive care unit (ICU) stay, the daily cost of hospital stay, the daily discretionary cost of ICU stay, six aggressive interventions, and three comfort care measures were used to indicate the medical care patients received. The association of each continuous variable and categorical variable with having a DNR order written was analyzed using Student's t-test and the χ2 test, respectively. The six aggressive interventions and three comfort care measures performed before and after the order was initiated were compared using McNemar's test.

RESULTS

DNRCC patients received significantly fewer aggressive interventions and more comfort care after the order was initiated. By contrast, for DNRCC-Arrest patients, the six aggressive interventions provided were not significantly decreased, but the three comfort care measures were significantly increased after the order was initiated. In addition, the three medical costs were not significantly different between DNRCC and non-DNR patients, or between DNRCC-Arrest and non-DNR patients.

CONCLUSIONS

When medical care provided to DNR patients is clearly indicated, healthcare professionals will provide the medical care determined by patient/surrogate decision-makers and healthcare professionals, rather than blindly decreasing medical care.

A case of survival after cardiac arrest and 3½ hours of resuscitation

Although survival rates after cardiac arrest remain low, new techniques are improving patients' outcomes. We present the case of a 40-year-old man who survived a cardiac arrest that lasted approximately 3½ hours. Resuscitation was performed with strict adherence to American Heart Association/American College of Cardiology Advanced Cardiac Life Support guidelines until bedside extracorporeal membrane oxygenation could be placed. A hypothermia protocol was initiated immediately afterwards. The patient had a full neurologic recovery and was bridged from dual ventricular assist devices to a total artificial heart. On hospital day 160, he underwent orthotopic heart and cadaveric kidney transplantation. On day 179, he was discharged from the hospital in ambulatory condition. To our knowledge, this is the only reported case in which a patient survived with good neurologic outcomes after a resuscitation that lasted as long as 3½ hours. Documented cases of resuscitation with good recovery after prolonged arrest give hope for improved overall outcomes in the future.

Families' stressors and needs at time of cardio-pulmonary resuscitation: a Jordanian perspective

Background:

During cardio-pulmonary resuscitation, family members, in some hospitals, are usually pushed to stay out of the resuscitation room. However, growing literature implies that family presence during resuscitation could be beneficial. Previous literature shows controversial belief whether or not a family member should be present during resuscitation of their relative. Some worldwide association such as the American Heart Association supports family-witnessed resuscitation and urge hospitals to develop policies to ease this process. The opinions on family-witnessed resuscitation vary widely among various cultures, and some hospitals are not applying such polices yet. This study explores family members’ needs during resuscitation in adult critical care settings.

Methods:

This is a part of larger study. The study was conducted in six hospitals in two major Jordanian cities. A purposive sample of seven family members, who had experience of having a resuscitated relative, was recruited over a period of six months. Semi-structured interview was utilised as the main data collection method in the study.

Findings:

The study findings revealed three main categories: families’ need for reassurance; families’ need for proximity; and families’ need for support. The need for information about patient’s condition was the most important need. Updating family members about patient’s condition would reduce their tension and improve their acceptance for the end result of resuscitation. All interviewed family members wanted the option to stay beside their loved one at end stage of their life. Distinctively, most of family members want this option for some religious and cultural reasons such as praying and supplicating to support their loved one.

Conclusions:

This study emphasizes the importance of considering the cultural and religious dimensions in any family-witnessed resuscitation programs. The study recommends that family members of resuscitated patients should be treated properly by professional communication and involving them in the treatment process. The implications concentrate on producing specific guidelines for allowing family-witnessed resuscitation in the Jordanian context. Finally, attaining these needs will in turn decrease stress of those witnessing resuscitation of their relative.

The impact of a father's presence during newborn resuscitation: a qualitative interview study with healthcare professionals

OBJECTIVE

To explore healthcare professionals' experiences around the time of newborn resuscitation in the delivery room, when the baby's father was present.

DESIGN

A qualitative descriptive, retrospective design using the critical incident approach. Tape-recorded semistructured interviews were undertaken with healthcare professionals involved in newborn resuscitation. Participants recalled resuscitation events when the baby's father was present. They described what happened and how those present, including the father, responded. They also reflected upon the impact of the resuscitation and the father's presence on themselves. Participant responses were analysed using thematic analysis.

SETTING

A large teaching hospital in the UK.

PARTICIPANTS

Purposive sampling was utilised. It was anticipated that 35-40 participants would be recruited. Forty-nine potential participants were invited to take part. The final sample consisted of 37 participants including midwives, obstetricians, anaesthetists, neonatal nurse practitioners, neonatal nurses and paediatricians.

RESULTS

Four themes were identified: 'whose role?' 'saying and doing' 'teamwork' and 'impact on me'. While no-one was delegated to support the father during the resuscitation, midwives and anaesthetists most commonly took on this role. Participants felt the midwife was the most appropriate person to support fathers. All healthcare professional groups said they often did not know what to say to fathers during prolonged resuscitation. Teamwork was felt to be of benefit to all concerned, including the father. Some paediatricians described their discomfort when fathers came to the resuscitaire. None of the participants had received education and training specifically on supporting fathers during newborn resuscitation.

CONCLUSIONS

This is the first known study to specifically explore the experiences of healthcare professionals of the father's presence during newborn resuscitation. The findings suggest the need for more focused training about supporting fathers. There is also scope for service providers to consider ways in which fathers can be supported more readily during newborn resuscitation.

Medical ethics in pediatric critical care

Ethically charged situations are common in pediatric critical care. Most situations can be managed with minimal controversy within the medical team or between the team and patients/families. Familiarity with institutional resources, such as hospital ethics committees, and national guidelines, such as publications from the American Academy of Pediatrics, American Medical Association, or Society of Critical Care Medicine, are an essential part of the toolkit of any intensivist. Open discussion with colleagues and within the multidisciplinary team can also ensure that when difficult situations arise, they are addressed in a proactive, evidence-based, and collegial manner.

Balancing between closeness and distance: emergency medical services personnel's experiences of caring for families at out-of-hospital cardiac arrest and sudden death

INTRODUCTION

Out-of-hospital cardiac arrest (OHCA) is a lethal health problem that affects between 236,000 and 325,000 people in the United States each year. As resuscitation attempts are unsuccessful in 70-98% of OHCA cases, Emergency Medical Services (EMS) personnel often face the needs of bereaved family members.

PROBLEM

Decisions to continue or terminate resuscitation at OHCA are influenced by factors other than patient clinical characteristics, such as EMS personnel's knowledge, attitudes, and beliefs regarding family emotional preparedness. However, there is little research exploring how EMS personnel care for bereaved family members, or how they are affected by family dynamics and the emotional contexts. The aim of this study is to analyze EMS personnel's experiences of caring for families when patients suffer cardiac arrest and sudden death.

METHODS

The study is based on a hermeneutic lifeworld approach. Qualitative interviews were conducted with 10 EMS personnel from an EMS agency in southern Sweden.

RESULTS

The EMS personnel interviewed felt responsible for both patient care and family care, and sometimes failed to prioritize these responsibilities as a result of their own perceptions, feelings and reactions. Moving from patient care to family care implied a movement from well-structured guidance to a situational response, where the personnel were forced to balance between interpretive reasoning and a more direct emotional response, at their own discretion. With such affective responses in decision-making, the personnel risked erroneous conclusions and care relationships with elements of dishonesty, misguided benevolence and false hopes. The ability to recognize and respond to people's existential questions and needs was essential. It was dependent on the EMS personnel's balance between closeness and distance, and on their courage in facing the emotional expressions of the families, as well as the personnel's own vulnerability. The presence of family members placed great demands on mobility (moving from patient care to family care) in the decision-making process, invoking a need for ethical competence.

CONCLUSION

Ethical caring competence is needed in the care of bereaved family members to avoid additional suffering. Opportunities to reflect on these situations within a framework of care ethics, continuous moral education, and clinical ethics training are needed. Support in dealing with personal discomfort and clear guidelines on family support could benefit EMS personnel.

Applicability and results of Maastricht type 2 donation after cardiac death liver transplantation

Maastricht type 2 donation after cardiac death (DCD) donors suffer sudden and unexpected cardiac arrest, typically outside the hospital; they have significant potential to expand the donor pool. Herein, we analyze the results of transplanted livers and all potential donors treated under our type 2 DCD protocol. Cardiac arrest was witnessed; potential donors arrived at the hospital after attempts at resuscitation had failed. Death was declared based on the absence of cardiorespiratory activity during a 5-min no-touch period. Femoral vessels were cannulated to establish normothermic extracorporeal membrane oxygenation, which was maintained until organ recovery. From April 2002 to December 2010, there were 400 potential donors; 34 liver transplants were performed (9%). Among recipients, median age, model for end-stage liver disease and cold and reperfusion warm ischemic times were 55 years (49-60), 19 (14-21) and 380 (325-430) and 30 min (26-35), respectively. Overall, 236 (59%) and 130 (32%) livers were turned down due to absolute and relative contraindications to donate, respectively. One-year recipient and graft survivals were 82% and 70%, respectively (median follow-up 24 months). The applicability of type 2 DCD liver transplant was <10%; however, with better preservation technology and expanded transplant criteria, we may be able to improve this figure significantly.

Futile cardiopulmonary resuscitation for the benefit of others: An ethical analysis

It has been reported as an ethical problem within prehospital emergency care that ambulance professionals administer physiologically futile cardiopulmonary resuscitation (CPR) to patients having suffered cardiac arrest to benefit significant others. At the same time it is argued that, under certain circumstances, this is an acceptable moral practice by signalling that everything possible has been done, and enabling the grief of significant others to be properly addressed. Even more general moral reasons have been used to morally legitimize the use of futile CPR: That significant others are a type of patient with medical or care needs that should be addressed, that the interest of significant others should be weighed into what to do and given an equal standing together with patient interests, and that significant others could be benefited by care professionals unless it goes against the explicit wants of the patient. In this article we explore these arguments and argue that the support for providing physiologically futile CPR in the prehospital context fails. Instead, the strategy of ambulance professionals in the case of a sudden death should be to focus on the relevant care needs of the significant others and provide support, arrange for a peaceful environment and administer acute grief counselling at the scene, which might call for a developed competency within this field.

Mathematical modeling for prediction of survival from resuscitation based on computerized continuous capnography: proof of concept

OBJECTIVES

The objective was to describe a new method of studying correlations between real-time end tidal carbon dioxide (ETCO(2) ) data and resuscitation outcomes.

METHODS

This was a prospective cohort study of 30 patients who underwent cardiopulmonary resuscitation (CPR) in a university hospital. Sidestream capnograph data were collected during CPR and analyzed by a mathematician blinded to patient outcome. The primary outcome measure was to determine whether a meaningful relationship could be drawn between detailed computerized ETCO(2) characteristics and the return of spontaneous circulation (ROSC). Significance testing was performed for proof-of-concept purposes only.

RESULTS

Median patient age was 74 years (interquartile range [IQR] = 60-80 years; range = 16-92 years). Events were mostly witnessed (63%), with a median call-to-arrival time of 150 seconds (IQR = 105-255 seconds; range = 60-300 seconds). The incidence of ROSC was 57% (17 of 30), and of hospital discharge 20% (six of 30). Ten minutes after intubation, patients with ROSC had higher peak ETCO(2) values (p = 0.035), larger areas under the ETCO(2) curve (p = 0.016), and rising ETCO(2) slopes versus flat or falling slopes (p = 0.016) when compared to patients without ROSC. Cumulative maxETCO(2) > 20 mm Hg at all time points measured between 5 and 10 minutes postintubation best predicted ROSC (sensitivity = 0.88; specificity = 0.77; p < 0.001). Mathematical modeling targeted toward avoiding misdiagnosis of patients with recovery potential (fixed condition, false-negative rate = 0) demonstrated that cumulative maxETCO(2) (at 5-10 minutes) > 25 mm Hg or a slope greater than 0 measured between 0 and 8 minutes correctly predicted patient outcome in 70% of cases within less than 10 minutes of intubation.

CONCLUSIONS

This preliminary study suggests that computerized ETCO(2) carries potential as a tool for early, real-time decision-making during some resuscitations.

[Ethics of the cardiopulmonary resuscitation decisions]

Cardiopulmonary Resuscitation (CPR) must be attempted if indicated, not done if it is not indicated or if the patient does not accept or has previously rejected it and withdrawn it if it is ineffective. If CPR is considered futile, a Do-Not-Resuscitate Order (DNR) will be recorded. This should be made known to all physicians and nurses involved in patient care. It may be appropriate to limit life-sustaining-treatments for patients with severe anoxic encephalopathy, if the possibility of clinical evolution to brain death is ruled out. After CPR it is necessary to inform and support families and then review the process in order to make future improvements. After limitation of vital support, certain type of non-heart-beating-organ donation can be proposed. In order to acquire CPR skills, it is necessary to practice with simulators and, sometimes, with recently deceased, always with the consent of the family. Research on CPR is essential and must be conducted according to ethical rules and legal frameworks.

Comparison of Helsinki and European Resuscitation Council "do not attempt to resuscitate" guidelines, and a termination of resuscitation clinical prediction rule for out-of-hospital cardiac arrest patients found in asystole or pulseless electrical activity

BACKGROUND

The outcome of out-of-hospital cardiac arrest (OHCA) with a non-shockable rhythm is poor. For patients found in asystole or pulseless electrical activity (PEA), recent guidelines or rules that may be used include "do not attempt to resuscitate" (DNAR) guidelines from Helsinki, discontinuing resuscitation in the guidelines of the European Resuscitation Council and a clinical prediction rule from Canada. We compared these guidelines and the rule using a large Scandinavian dataset.

MATERIALS AND METHODS

The Swedish Cardiac Arrest Registry includes prospectively collected data on 44121 OHCA patients. We identified patients with asystole or PEA as the initial rhythm and excluded cases caused by trauma or drowning. The specificities and positive predictive values (PPVs) were calculated for the guidelines, and the clinical prediction rule for comparison.

RESULTS

A total of 20484 patients with non-shockable rhythms were identified; 85% had asystole and 15% PEA. The overall survival to hospital admission was 9% (n=1.861) and 1% (n=231) were alive at 1 month from the arrest. The specificity of the Helsinki guidelines in identifying non-survivors was 71% (95% confidence interval (CI): 65-77%) and the PPV was 99.4% (95% CI: 99.3-99.5), while the corresponding values for the European Resuscitation Council (ERC) was 95% (95% CI: 91.3-97.5) and 99.9% (95% CI: 99.9-99.9) and, for the prediction rule, 99.1% (95% CI: 96.7-99.9) and 99.9% (95% CI: 99.9-100.00), respectively.

CONCLUSION

In this comparison study, the Helsinki DNAR guidelines did not perform well enough in a general OHCA material to be widely adopted. The main reason for this was the unpredicted survival of patients with unwitnessed asystole. The clinical prediction rule and the recommendations of the ERC Guidelines worked well.