Part 4: Conflict of interest management before, during, and after the 2010 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Prediction of return of spontaneous circulation in out-of-hospital cardiac arrest with non-shockable initial rhythm using point-of-care testing: a retrospective observational study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a public health concern, and many studies have been conducted on return of spontaneous circulation (ROSC) and its prognostic factors. Rotational thromboelastometry (ROTEM^®), a point-of-care testing (POCT) method, has been useful for predicting ROSC in patients with OHCA, but very few studies have focused on patients with non-shockable rhythm. We examined whether the parameters of POCT could predict ROSC in patients with OHCA and accompanying non-shockable rhythm.

METHODS

This is a single-center, retrospective observational study. Complete blood count, blood gas, and ROTEM POCT measurements were used. This study included patients with non-traumatic OHCA aged 18 years or older who were transported to the emergency department and evaluated using POCT between January 2013 and December 2021. The patients were divided into the ROSC and non-ROSC groups. Prehospital information and POCT parameters were compared using receiver operating characteristic (ROC) curve analysis, and further logistic regression analysis was performed.

RESULTS

Sixty-seven and 135 patients were in the ROSC and non-ROSC groups, respectively. The ROC curves showed a high area under the curve (AUC) for K⁺ of 0.77 (95% confidence interval [CI]: 0.71-0.83) and EXTEM amplitude 5 min after clotting time (A5) of 0.70 (95%CI: 0.62-0.77). The odds ratios for ROSC were as follows: female sex 3.67 (95%CI: 1.67-8.04); K⁺ 0.64 (95%CI: 0.48-0.84); and EXTEM A5 1.03 (95%CI: 1.01-1.06).

CONCLUSION

In OHCA patients with non-shockable rhythm, K⁺ level and the ROTEM parameter EXTEM A5 may be useful in predicting ROSC.

The International Liaison Committee on Resuscitation-Review of the last 25 years and vision for the future

2017 marks the 25th anniversary of the International Liaison Committee on Resuscitation (ILCOR). ILCOR was formed in 1992 to create a forum for collaboration among principal resuscitation councils worldwide. Since then, ILCOR has established and distinguished itself for its pioneering vision and leadership in resuscitation science. By systematically assessing the evidence for resuscitation standards and guidelines and by identifying national and regional differences, ILCOR reached consensus on international resuscitation guidelines in 2000, and on international science and treatment recommendations in 2005, 2010 and 2015. However, local variation and contextualization of guidelines are evident by subtle differences in regional and national resuscitation guidelines. ILCOR's efforts to date have enhanced international cooperation, and progressively more transparent and systematic collection and analysis of pertinent scientific evidence. Going forward, this sets the stage for ILCOR to pursue its vision to save more lives globally through resuscitation.

An Interventional Quality Improvement Study to Assess the Compliance to Cardiopulmonary Resuscitation Documentation in an Indian Teaching Hospital

Background

Cardiopulmonary resuscitation (CPR) should be performed as per the international guidelines; however, compliance to these guidelines is difficult to assess. This study was conducted to determine the compliance to American Heart Association (2010) guideline on CPR documentation by among resident physicians before and after resident training (two arms).

Methods

This pre-postinterventional quality improvement study was conducted in a referral center, North India. Data of hospitalized in-hospital CPR patients were collected in the form of quality indicators (checklists) as defined by the guideline and compared between two arms of before-after resident training. Residents were given appropriate training in CPR technique as per the guideline. The compliance of CPR documentation was assessed pre- and post-intervention.

Results

The baseline arm compliance of various components of CPR documentation was low. The postintervention arm compliances of all components significantly increased (baseline, 2.5% to postintervention, 15.11%, P = 0.03). Individual components assessed were documentation of assessment of responsiveness (65% to 77.9%, P = 0.19), assessment of breathing (37.5% to 58.1%, P = 0.03), assessment of carotid pulse (62.5% to 79%, P = 0.05), rate of chest compressions (20% to 39.5%, P = 0.04), airway management (62.5% to 82.5%, P = 0.02), and compressions to breaths ratio (12.5% to 31.4%, P = 0.02). Documentation of chest compression rate compared to nondocumentation (12 of 42 vs. 11 of 84, P = 0.04) was independently associated with a higher rate of return of spontaneous circulation. The study however did not show any survival benefits.

Conclusions

This study establishes that the compliance to CPR documentation is poor as assessed by CPR documentation content and quality, which improves after physician training, but not up to the mark level (100%) that may be due to busy Indian hospital settings and human behavioral factors. Due to ethical constraints of live CPR assessment, this document checklist approach may be considered as an internal quality assessment method for CPR compliance. Furthermore, correct instruction in CPR technique along with proper documentation of the procedure is required, followed up with periodic re-education during the residency period and beyond.

Part 2: Evidence Evaluation and Management of Conflicts of Interest: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

The process for evaluating the resuscitation science has evolved considerably over the past 2 decades. The current process, which incorporates the use of the GRADE methodology, culminated in the 2015 CoSTR publication, which in turn will inform the international resuscitation councils’ guideline development processes. Over the next few years, the process will continue to evolve as ILCOR moves toward a more continuous evaluation of the resuscitation science.

Neonatal resuscitation: in pursuit of evidence gaps in knowledge

Guidelines for the techniques of resuscitating newly born infants have undergone major revisions over the past 25 years. The International Liaison Committee on Resuscitation (ILCOR) is committed to "periodically developing and publishing a consensus on resuscitation science" every five years with the most recent Consensus on Science and Treatment Recommendations (CoSTR) statement published in 2010. The CoSTR document is used as a basis for developing specific resuscitation guidelines felt to be appropriate for implementation in respective countries. A "gaps in knowledge" summary is created at the conclusion of a cycle. It is a goal that identification of these knowledge gaps will stimulate investigators to pursue more targeted studies to help close the gaps. The current document is based on the "gaps in knowledge" summary for neonatal resuscitation that was created at the conclusion of the 2005-2010 ILCOR cycle.

Novel biomarkers in diagnosing cardiac ischemia in the emergency department: a systematic review

BACKGROUND

Novel biomarkers of myocardial ischemia and inflammatory processes have the potential to improve diagnostic accuracy of acute coronary syndrome (ACS) within a shorter time interval after symptom onset.

OBJECTIVE

The objective was to review the recent literature and evaluate the evidence for use of novel biomarkers in diagnosing ACS in patients presenting with chest pain or symptoms suggestive of cardiac ischemia to the emergency department or chest pain unit.

METHODS

A literature search was performed in MEDLINE, EMBASE, Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, and NHSEED for studies from 2004 to 2010. We used the inclusion criteria: (1) human subjects, (2) peer-reviewed articles, (3) enrolled patients with ACS, acute myocardial infarction or undifferentiated signs and symptoms suggestive of ACS, and (4) English language or translated manuscripts. Two reviewers conducted a hierarchical selection and assessment using a scale developed by the International Liaison Committee on Resuscitation.

RESULTS

Out of a total 3194 citations, 58 articles evaluating 37 novel biomarkers were included for final review. Forty-one studies did not support the use of their respective biomarkers. Seventeen studies supported the use of 5 biomarkers, particularly when combined with cardiac-specific troponin: heart fatty acid-binding protein, ischemia-modified albumin, B-type natriuretic peptide, copeptin, and matrix metalloproteinase-9.

CONCLUSION

In patients presenting to the emergency department with chest pain or symptoms suggestive of cardiac ischemia, there is inadequate evidence to suggest the routine testing of novel biomarkers in isolation. However, several novel biomarkers have the potential to improve the sensitivity of diagnosing ACS when combined with cardiac-specific troponin.

[ILCOR 2010 recommendations. The evidence evaluation process in resuscitation]

The consensus document on the Science of Resuscitation and Emergency Cardiac Care with ILCOR Treatment Recommendations is an invaluable tool for quickly, simply and rigorously establishing the evidence on which the Resuscitation Guidelines 2010 are fundamented. We present a method that has been used in the review process according to evidence-based medicine, which can be considered a role model for both individual and collective use in clinical practice, not only in the field of resuscitation but also in other areas of medicine.

The role of hypothermia in post-cardiac arrest patients with return of spontaneous circulation: a systematic review

OBJECTIVES

To update a comprehensive systematic review of the use of therapeutic hypothermia after cardiac arrest that was undertaken initially as part of the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. The specific question addressed was: 'in post-cardiac arrest patients with a return of spontaneous circulation, does the induction of mild hypothermia improve morbidity or mortality when compared with usual care?'

METHODS

Pubmed was searched using ("heart arrest" or "cardiopulmonary resuscitation") AND "hypothermia, induced" using 'Clinical Queries' search strategy; EmBASE was searched using (heart arrest) OR (cardiopulmonary resuscitation) AND hypothermia; The Cochrane database of systematic reviews; ECC EndNote Library for "hypothermia" in abstract OR title. Excluded were animal studies, reviews and editorials, surveys of implementation, analytical models, reports of single cases, pre-arrest or during arrest cooling and group where the intervention was not hypothermia alone.

RESULTS

77 studies met the criteria for further review. Of these, four were meta-analyses (LOE 1); seven were randomised controlled trials (LOE 1), although six of these were from the same set of patients; nine were non-randomised, concurrent controls (LOE 2); 15 were trials with retrospective controls (LOE 3); 40 had no controls (LOE 4); and one was extrapolated from a non-cardiac arrest group (LOE 5).

CONCLUSION

There is evidence supporting the use of mild therapeutic hypothermia to improve neurological outcome in patients who remain comatose following the return of spontaneous circulation after a cardiac arrest; however, much of the evidence is from low-level, observational studies. Of seven randomised controlled trials, six use data from the same patients.