Delayed time to defibrillation after intraoperative and periprocedural cardiac arrest

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

INTRODUCTION

Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines.

MATERIAL AND METHODS

The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.

RESULTS

This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy.

CONCLUSIONS

Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

INTRODUCTION

Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines.

MATERIAL AND METHODS

The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.

RESULTS

This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy.

CONCLUSION

Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.

Management of Intraoperative Cardiac Arrest

Perioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient's comorbidities and coexisting anesthetic or surgically related pathophysiology ultimately leading to better outcomes. This article reviews the most probable causes of intraoperative arrest and their management.

Cryopreservation of Animals and Cryonics: Current Technical Progress, Difficulties and Possible Research Directions

The basis of cryonics or medical cryopreservation is to safely store a legally dead subject until a time in the future when technology and medicine will permit reanimation after eliminating the disease or cause of death. Death has been debunked as an event occurring after cardiac arrest to a process where interjecting its progression can allow for reversal when feasible. Cryonics technology artificially halts further damages and injury by restoring respiration and blood circulation, and rapidly reducing temperature. The body can then be preserved at this extremely low temperature until the need for reanimation. Presently, the area has attracted numerous scientific contributions and advancement but the practice is still flooded with challenges. This paper presents the current progression in cryonics research. We also discuss obstacles to success in the field, and identify the possible solutions and future research directions.

Early or late booster for basic life support skill for laypeople: a simulation-based randomized controlled trial

PURPOSE

Retention of skills and knowledge has been shown to be poor after resuscitation training. The effect of a "booster" is controversial and may depend on its timing. We compared the effectiveness of an early versus late booster session after Basic Life Support (BLS) training for skill retention at 4 months.

METHODS

We performed a single-blind randomized controlled trial in a simulation environment. Eligible participants were adult laypeople with no BLS training or practice in the 6 months prior to the study. We provided participants with formal BLS training followed by an immediate BLS skills post-test. We then randomized participants to one of three groups: control, early booster, or late booster. Based on their group allocation, participants attended a brief BLS refresher at either 3 weeks after training (early booster), at 2 months after training (late booster), or not at all (control). All participants underwent a BLS skills retention test at 4 months. We measured BLS skill performance according to the Heart and Stroke Foundation's skills testing checklist for adult CPR and the use of an automated external defibrillator.

RESULTS

A total of 80 laypeople were included in the analysis (control group, n = 28; early booster group, n = 23; late booster group, n = 29). The late booster group achieved better skill retention (mean difference in checklist score at retention compared to the immediate post-test = - 0.8 points out of 15, [95% CI - 1.7, 0.2], P = 0.10) compared to the early booster (- 1.3, [- 2.6, 0.0], P = 0.046) and control group (- 3.2, [- 4.7, - 1.8], P < 0.001).

CONCLUSION

A late booster session improves BLS skill retention at 4 months in laypeople.

TRIAL REGISTRATION NUMBER

NCT02998723.

A Conceptual Framework to Reduce Inpatient Preventable Deaths

BACKGROUND

Efforts to reduce preventable deaths in the in-hospital setting should target both cardiopulmonary arrest (CPA) prevention and optimal resuscitation. This requires consideration of a broad range of clinical issues and processes. A comprehensive, integrated system of care (SOC) that links data collection with a modular education program to reduce preventable deaths has not been defined.

METHODS

This study was conducted in two urban university hospitals from 2005 to 2009. The Advanced Resuscitation Training (ART) program was implemented in 2007, incorporating hands-on resuscitative skills and in-hospital-specific training with an institutional resuscitation database. Linkage between the database and training modules occurs via the ART Matrix, which classifies all CPA events into the following etiologies: sepsis, hemorrhage, pulmonary embolus, heart failure, tachyarrhythmias, bradyarrhythmias, acute respiratory distress syndrome, non-intubated pulmonary disease, obstructive apnea, traumatic brain injury, ischemic brain injury, and intracranial mass lesions. This taxonomy was validated using descriptive statistics, before-and-after analysis evaluating CPA incidence, and multivariate logistic regression to predict CPA survival.

RESULTS

A total of 336 inpatients suffered a cardiopulmonary arrest during the study period-187 in the pre-ART period and 149 in the post-ART period. The vast majority of CPA events were categorized using the ART Matrix with high inter-observer reliability. As anticipated, changes in CPA incidence and survival were observed for some Matrix categories but not others following ART implementation. In addition, multivariate logistic regression revealed strong independent associations between taxonomy classifications and outcome.

CONCLUSION

A novel SOC using a unique taxonomy for arrest classification appears to be effective at reducing inpatient CPA incidence and outcome.

Simulation-based Assessment of the Management of Critical Events by Board-certified Anesthesiologists

Background

We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods.

Methods

A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant’s technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist.

Results

Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance.

Conclusions

Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.

Cognitive Aids for Role Definition (CARD) to improve interprofessional team crisis resource management: An exploratory study

This study aimed to assess the perceived value of the Cognitive Aids for Role Definition (CARD) protocol for simulated intraoperative cardiac arrests. Sixteen interprofessional operating room teams completed three consecutive simulated intraoperative cardiac arrest scenarios: current standard, no CARD; CARD, no CARD teaching; and CARD, didactic teaching. Each team participated in a focus group interview immediately following the third scenario; data were transcribed verbatim and qualitatively analysed. After 6 months, participants formed eight new teams randomised to two groups (CARD or no CARD) and completed a retention intraoperative cardiac arrest simulation scenario. All simulation sessions were video recorded and expert raters assessed team performance. Qualitative analysis of the 16 focus group interviews revealed 3 thematic dimensions: role definition in crisis management; logistical issues; and the "real life" applicability of CARD. Members of the interprofessional team perceived CARD very positively. Exploratory quantitative analysis found no significant differences in team performance with or without CARD (p > 0.05). In conclusion, qualitative data suggest that the CARD protocol clarifies roles and team coordination during interprofessional crisis management and has the potential to improve the team performance. The concept of a self-organising team with defined roles is promising for patient safety.

Validity and reliability assessment of detailed scoring checklists for use during perioperative emergency simulation training

INTRODUCTION

Few valid and reliable grading checklists have been published for the evaluation of performance during simulated high-stakes perioperative event management. As such, the purposes of this study were to construct valid scoring checklists for a variety of perioperative emergencies and to determine the reliability of scores produced by these checklists during continuous video review.

METHODS

A group of anesthesiologists, intensivists, and educators created a set of simulation grading checklists for the assessment of the following scenarios: severe anaphylaxis, cerebrovascular accident, hyperkalemic arrest, malignant hyperthermia, and acute coronary syndrome. Checklist items were coded as critical or noncritical. Nonexpert raters evaluated 10 simulation videos in a random order, with each video being graded 4 times. A group of faculty experts also graded the videos to create a reference standard to which nonexpert ratings were compared. P < 0.05 was considered significant.

RESULTS

Team leaders in the simulation videos were scored by the expert panel as having performed 56.5% of all items on the checklist (range, 43.8%-84.0%), and 67.2% of the critical items (range, 30.0%-100%). Nonexpert raters agreed with the expert assessment 89.6% of the time (95% confidence interval, 87.2%-91.6%). No learning curve development was found with repetitive video assessment or checklist use. The κ values comparing nonexpert rater assessments to the reference standard averaged 0.76 (95% confidence interval, 0.71-0.81).

CONCLUSIONS

The findings indicate that the grading checklists described are valid, are reliable, and could be used in perioperative crisis management assessment.

A novel configuration of a traditional rapid response team decreases non-intensive care unit arrests and overall hospital mortality

BACKGROUND

In-hospital cardiopulmonary arrest (CPA) accounts for substantial morbidity and mortality. Rapid response teams (RRTs) are designed to prevent non-intensive care unit (ICU) CPA through early detection and intervention. However, existing evidence has not consistently demonstrated a clear benefit.

OBJECTIVE

To explore the effectiveness of a novel RRT program design to decrease non-ICU CPA and overall hospital mortality.

METHODS

This study was conducted from the start of fiscal year 2005 to 2011. In November 2007, our hospitals implemented RRTs as part of a novel resuscitation program. Charge nurses from each inpatient unit underwent training as unit-specific RRT members. Additionally, all inpatient staff received annual training in RRT concepts including surveillance and recognition of deterioration. We compared the incidence of ICU and non-ICU CPA from first complete preimplementation year 2006 to postimplementation years 2007 to 2011. Overall hospital mortality was also reported.

RESULTS

The incidence of non-ICU CPA decreased, whereas the incidence of ICU CPA remained unchanged. Overall hospital mortality also decreased (2.12% to 1.74%, P < 0.001). The year-over-year change in RRT activations was inversely related to the change in Code Blue activations for each inpatient unit (r = -0.68, P < 0.001).

CONCLUSION

Our novel RRT program was associated with a decreased incidence of non-ICU CPA and improved hospital mortality.

Continuous administration of landiolol reduced QT dispersion in postoperative patients

STUDY OBJECTIVE

To determine the changes in QT dispersion (QTD) in the standard electrocardiogram (ECG) of postoperative patients and the effect of landiolol on QTD.

DESIGN

Randomized, prospective, double-blinded study.

PATIENTS

40 postsurgical patients.

INVENTIONS

Patients were allocated to three groups: Control group patients (Group C) were administered saline and patients in the landiolol groups (Group L2 and Group L5) were infused landiolol 2 μg/kg/min and 5 μg/kg/min, respectively. All infusions were started at midnight and discontinued at 6 o'clock in the morning.

MEASUREMENTS

Heart rate (HR), systolic (SBP) and diastolic (DBP) invasive blood pressure, and ECG were recorded at 0 (immediately before infusion), at 3 o'clock, and 6 o'clock (immediately before termination). The ECG wave was recorded electronically and QTD was analyzed using PC software. Heart rate, blood pressure, QT interval, and QTD were compared as changes from baseline values.

MAIN RESULTS

In Groups L2 and L5, HR was significantly decreased, approximately 10 bpm. Both SBP and DBP showed a decreasing trend at 3 o'clock. Absolute QT interval was prolonged in all groups; however, the decrease in QTD occurred in Group L5.

CONCLUSIONS

Continuous administration of landiolol prevents the increase in QTD found on the morning in postoperative patients. Landiolol demonstrated a possible antiarrhythmic effect by improving the imbalance of repolarization.

Predictors of Functional Outcome after Intraoperative Cardiac Arrest

Background:

Few outcome data are available about intraoperative cardiac arrest (IOCA). The authors studied 90-day functional outcomes and their determinants in patients admitted to the intensive care unit after IOCA.

Methods:

Patients admitted to 11 intensive care units in a period of 2000–2013 were studied retrospectively. The main outcome measure was a day-90 Cerebral Performance Category score of 1 or 2.

Results:

Of the 140 patients (61 women and 79 men; median age, 60 yr [interquartile range, 46 to 70]), 131 patients (93.6%) had general anesthesia, 80 patients (57.1%) had emergent surgery, and 73 patients (52.1%) had IOCA during surgery. First recorded rhythms were asystole in 73 patients (52.1%), pulseless electrical activity in 44 patients (31.4%), and ventricular fibrillation/ventricular tachycardia in 23 patients (16.4%). Median times from collapse to cardiopulmonary resuscitation and return of spontaneous circulation were 0 min (0 to 0) and 10 min (5 to 20), respectively. Postcardiac arrest shock was identified in 114 patients (81.4%). Main causes of IOCA were preoperative complications (n = 46, 32.9%), complications of anesthesia (n = 39, 27.9%), and complications of surgical procedures (n = 36, 25.7%). On day 90, 63 patients (45.3%) were alive with Cerebral Performance Category score 1/2. Independent predictors of day-90 Cerebral Performance Category score 1/2 were day-1 Logistic Organ Dysfunction score (odds ratio, 0.78 per point; 95% CI, 0.71 to 0.87; P = 0.0001), ventricular fibrillation/tachycardia as first recorded rhythm (odds ratio, 4.78; 95% CI, 1.38 to 16.53; P = 0.013), and no epinephrine therapy during postcardiac arrest syndrome (odds ratio, 3.14; 95% CI, 1.29 to 7.65; P = 0.012).

Conclusions:

By day 90, 45% of IOCA survivors had good functional outcomes. The main outcome predictors were directly related to IOCA occurrence and postcardiac arrest syndrome; they suggest that the intensive care unit management of postcardiac arrest syndrome may be amenable to improvement.

Predictors of survival from perioperative cardiopulmonary arrests: a retrospective analysis of 2,524 events from the Get With The Guidelines-Resuscitation registry

BACKGROUND

Perioperative cardiopulmonary arrests are uncommon and little is known about rates and predictors of in-hospital survival.

METHODS

Using the Get With The Guidelines®-Resuscitation national in-hospital resuscitation registry, we identified all patients aged 18 yr or older who experienced an index, pulseless cardiac arrest in the operating room or within 24 h postoperatively. The primary outcome was survival to hospital discharge, and the secondary outcome was neurologically intact recovery among survivors. Multivariable logistic regression models using generalized estimating equation models were used to identify independent predictors of survival and neurologically intact survival.

RESULTS

A total of 2,524 perioperative cardiopulmonary arrests were identified from 234 hospitals. The overall rate of survival to discharge was 31.7% (799/2,524), including 41.8% (254/608) for ventricular tachycardia and ventricular fibrillation, 30.5% (296/972) for asystole, and 26.4% (249/944) for pulseless electrical activity. Ventricular fibrillation and pulseless ventricular tachycardia were independently associated with improved survival. Asystolic arrests occurring in the operating room and postanesthesia care unit were associated with improved survival when compared to other perioperative locations. Among patients with neurological status assessment at discharge, the rate of neurologically intact survival was 64.0% (473/739). Prearrest neurological status at admission, patient age, inadequate natural airway, prearrest ventilatory support, duration of event, and event location were significant predictors of neurological status at discharge.

CONCLUSION

Among patients with a perioperative cardiac arrest, one in three survived to hospital discharge, and good neurological outcome was noted in two of three survivors.

Simulation curriculum can improve medical student assessment and management of acute coronary syndrome during a clinical practice exam

BACKGROUND

It has been noted that increased focus on learning acute care skills is needed in undergraduate medical curricula. This study investigated whether a simulation-based curriculum improved a senior medical student's ability to manage acute coronary syndrome as measured during a clinical performance examination (CPX). The authors hypothesized that simulation training would improve overall performance when compared with targeted didactics or historical controls.

METHODS

All 4th-year medical students (n = 291) over 2 years at the authors' institution were included in this study. In the 3rd year of medical school, the "control" group received no intervention, the "didactic" group received a targeted didactic curriculum, and the "simulation" group participated in small group simulation training and the didactic curriculum. For intergroup comparison on the CPX, the authors calculated the percentage of correct actions completed by the student. Data are presented as mean ± standard deviation with significance defined as P < 0.05.

RESULTS

There was a significant improvement in overall performance with simulation versus both didactics and control (P < 0.001). Performance on the physical examination component was significantly better in simulation versus both didactics and control, as was for diagnosis: simulation versus both didactics and control (P < 0.02 for all comparisons).

CONCLUSIONS

Simulation training had a modest impact on overall CPX performance in the management of a simulated acute coronary syndrome. Additional studies are needed to evaluate how to further improve curricula regarding unstable patients.

The effect of adherence to ACLS protocols on survival of event in the setting of in-hospital cardiac arrest

AIM

Advanced Cardiac Life Support (ACLS) algorithms are the default standard of care for in-hospital cardiac arrest (IHCA) management. However, adherence to published guidelines is relatively poor. The records of 149 patients who experienced IHCA were examined to begin to understand the association between overall adherence to ACLS protocols and successful return of spontaneous circulation (ROSC).

METHODS

A retrospective chart review of medical records and code team worksheets was conducted for 75 patients who had ROSC after an IHCA event (SE group) and 74 who did not survive an IHCA event (DNS group). Protocol adherence was assessed using a detailed checklist based on the 2005 ACLS Update protocols. Several additional patient characteristics and circumstances were also examined as potential predictors of ROSC.

RESULTS

In unadjusted analyses, the percentage of correct steps performed was positively correlated with ROSC from an IHCA (p<0.01), and the number of errors of commission and omission were both negatively correlated with ROSC from an IHCA (p<0.01). In multivariable models, the percentage of correct steps performed and the number of errors of commission and omission remained significantly predictive of ROSC (p<0.01 and p<0.0001, respectively) even after accounting for confounders such as the difference in age and location of the IHCAs.

CONCLUSIONS

Our results show that adherence to ACLS protocols throughout an event is correlated with increased ROSC in the setting of cardiac arrest. Furthermore, the results suggest that, in addition to correct actions, both wrong actions and omissions of indicated actions lead to decreased ROSC after IHCA.

Use of an electronic decision support tool improves management of simulated in-hospital cardiac arrest

INTRODUCTION

Adherence to advanced cardiac life support (ACLS) guidelines during in-hospital cardiac arrest (IHCA) is associated with improved outcomes, but current evidence shows that sub-optimal care is common. Successful execution of such protocols during IHCA requires rapid patient assessment and the performance of a number of ordered, time-sensitive interventions. Accordingly, we sought to determine whether the use of an electronic decision support tool (DST) improves performance during high-fidelity simulations of IHCA.

METHODS

After IRB approval and written informed consent was obtained, 47 senior medical students were enrolled. All participants were ACLS certified and within one month of graduation. Each participant was issued an iPod Touch device with a DST installed that contained all ACLS management algorithms. Participants managed two scenarios of IHCA and were allowed to use the DST in one scenario and prohibited from using it in the other. All participants managed the same scenarios. Simulation sessions were video recorded and graded by trained raters according to previously validated checklists.

RESULTS

Performance of correct protocol steps was significantly greater with the DST than without (84.7% v 73.8%, p<0.001) and participants committed significantly fewer additional errors when using the DST (2.5 errors vs. 3.8 errors, p<0.012).

CONCLUSION

Use of an electronic DST provided a significant improvement in the management of simulated IHCA by senior medical students as measured by adherence to published guidelines.

Pediatric cardiopulmonary arrest in the postanesthesia care unit: analysis of data from the American Heart Association Get With The Guidelines-Resuscitation registry

BACKGROUND

Nearly 20% of anesthesia-related pediatric cardiopulmonary arrests (CPAs) occur during emergence or recovery. The aims of this study were to describe (i) the nature of pediatric postanesthesia care unit (PACU) CPA and subsequent outcomes and (ii) factors associated with mortality.

METHODS

Cardiopulmonary Arrests occurring in PACU in children (<18 years) were identified from the American Heart Association Get With The Guidelines-Resuscitation, multicenter CPA registry. Demographics, underlying conditions, cause(s) of CPA, monitoring, interventions and outcomes were extracted. Descriptive statistics were used to characterize data, and odds ratios (OR) with confidence intervals (CI) were calculated as appropriate to compare survivors and nonsurvivors.

RESULTS

Twenty seven CPA events were included: 67% in children <5 years and 30% in infants (<1 year). Most children (78%) had underlying comorbidities, including 15% with congenital heart disease. Respiratory issues were the most frequent causes of CPA (44%), but cardiac/hemodynamic causes were associated with nonsurvival (P = 0.01). Nonsurvival was also associated with older age (P = 0.02), weekend occurrence (P < 0.01), nonpediatric setting (P = 0.02) and occurrence at night (P = 0.04).

CONCLUSIONS

This study identified similar risk factors and underlying causes as described in previous reports of pediatric perioperative CPA, with higher mortality following a cardiac/hemodynamic cause.

Preoperative and intraoperative predictors of postoperative acute respiratory distress syndrome in a general surgical population

BACKGROUND

Acute respiratory distress syndrome (ARDS) is a devastating condition with an estimated mortality exceeding 30%. There are data suggesting risk factors for ARDS development in high-risk populations, but few data are available in lower incidence populations. Using risk-matched analysis and a combination of clinical and research data sets, we determined the incidence and risk factors for the development of ARDS in this general surgical population.

METHODS

We conducted a review of common adult surgical procedures completed between June 1, 2004 and May 31, 2009 using an anesthesia information system. This data set was merged with an ARDS registry and an institutional death registry. Preoperative variables were subjected to multivariate analysis. Matching and multivariate regression was used to determine intraoperative factors associated with ARDS development.

RESULTS

In total, 50,367 separate patient admissions were identified, and 93 (0.2%) of these patients developed ARDS. Preoperative risk factors for ARDS development included American Society of Anesthesiologist status 3-5 (odds ratio [OR] 18.96), emergent surgery (OR 9.34), renal failure (OR 2.19), chronic obstructive pulmonary disease (OR 2.16), number of anesthetics during the admission (OR 1.37), and male sex (OR 1.65). After matching, intraoperative risk factors included drive pressure (OR 1.17), fraction inspired oxygen (OR 1.02), crystalloid administration in liters (1.43), and erythrocyte transfusion (OR 5.36).

CONCLUSIONS

ARDS is a rare condition postoperatively in the general surgical population and is exceptionally uncommon in low American Society of Anesthesiologists status patients undergoing scheduled surgery. Analysis after matching suggests that ARDS development is associated with median drive pressure, fraction inspired oxygen, crystalloid volume, and transfusion.

Trends in survival after in-hospital cardiac arrest

BACKGROUND

Despite advances in resuscitation care in recent years, it is not clear whether survival and neurologic function after in-hospital cardiac arrest have improved over time.

METHODS

We identified all adults who had an in-hospital cardiac arrest at 374 hospitals in the Get with the Guidelines-Resuscitation registry between 2000 and 2009. Using multivariable regression, we examined temporal trends in risk-adjusted rates of survival to discharge. Additional analyses explored whether trends were due to improved survival during acute resuscitation or postresuscitation care and whether they occurred at the expense of greater neurologic disability in survivors.

RESULTS

Among 84,625 hospitalized patients with cardiac arrest, 79.3% had an initial rhythm of asystole or pulseless electrical activity, and 20.7% had ventricular fibrillation or pulseless ventricular tachycardia. The proportion of cardiac arrests due to asystole or pulseless electrical activity increased over time (P<0.001 for trend). Risk-adjusted rates of survival to discharge increased from 13.7% in 2000 to 22.3% in 2009 (adjusted rate ratio per year, 1.04; 95% confidence interval [CI], 1.03 to 1.06; P<0.001 for trend). Survival improvement was similar in the two rhythm groups and was due to improvement in both acute resuscitation survival and postresuscitation survival. Rates of clinically significant neurologic disability among survivors decreased over time, with a risk-adjusted rate of 32.9% in 2000 and 28.1% in 2009 (adjusted rate ratio per year, 0.98; 95% CI, 0.97 to 1.00; P=0.02 for trend).

CONCLUSIONS

Both survival and neurologic outcomes after in-hospital cardiac arrest have improved during the past decade at hospitals participating in a large national quality-improvement registry. (Funded by the American Heart Association.).

Validation of a detailed scoring checklist for use during advanced cardiac life support certification

INTRODUCTION

Defining valid, reliable, defensible, and generalizable standards for the evaluation of learner performance is a key issue in assessing both baseline competence and mastery in medical education. However, before setting these standards of performance, the reliability of the scores yielding from a grading tool must be assessed. Accordingly, the purpose of this study was to assess the reliability of scores generated from a set of grading checklists used by nonexpert raters during simulations of American Heart Association (AHA) Megacodes.

METHODS

The reliability of scores generated from a detailed set of checklists, when used by 4 nonexpert raters, was tested by grading team leader performance in 8 Megacode scenarios. Videos of the scenarios were reviewed and rated by trained faculty facilitators and a group of nonexpert raters. The videos were reviewed "continuously" and "with pauses." The grading made by 2 content experts served as the reference standard, and 4 nonexpert raters were used to test the reliability of the checklists.

RESULTS

Our results demonstrate that nonexpert raters are able to produce reliable grades when using the checklists under consideration, demonstrating excellent intrarater reliability and agreement with a reference standard. The results also demonstrate that nonexpert raters can be trained in the proper use of the checklist in a short amount of time, with no discernible learning curve thereafter. Finally, our results show that a single trained rater can achieve reliable scores of team leader performance during AHA Megacodes when using our checklist in a continuous mode because measures of agreement in total scoring were very strong [Lin's (Biometrics 1989;45:255-268) concordance correlation coefficient, 0.96; intraclass correlation coefficient, 0.97].

CONCLUSIONS

We have shown that our checklists can yield reliable scores, are appropriate for use by nonexpert raters, and are able to be used during continuous assessment of team leader performance during the review of a simulated Megacode. This checklist may be more appropriate for use by advanced cardiac life support instructors during Megacode assessments than the current tools provided by the AHA.

Anesthesia advanced circulatory life support

PURPOSE

The constellation of advanced cardiac life support (ACLS) events, such as gas embolism, local anesthetic overdose, and spinal bradycardia, in the perioperative setting differs from events in the pre-hospital arena. As a result, modification of traditional ACLS protocols allows for more specific etiology-based resuscitation.

PRINCIPAL FINDINGS

Perioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient's comorbidities and coexisting anesthetic or surgically related pathophysiology. When the health care provider identifies the probable cause of arrest, the practitioner has the ability to initiate medical management rapidly.

CONCLUSIONS

Recommendations for management must be predicated on expert opinion and physiological understanding rather than on the standards currently being used in the generation of ACLS protocols in the community. Adapting ACLS algorithms and considering the differential diagnoses of these perioperative events may prevent cardiac arrest.

Cardiac arrest in the operating room requiring prolonged resuscitation

PURPOSE

Prolonged cardiopulmonary resuscitation (CPR) is often associated with limited success and poor long-term outcomes. The purpose of this report is to present the case of a patient who suffered an unanticipated cardiac arrest in the operating room and survived following a prolonged period of CPR.

CLINICAL FEATURES

A previously healthy 53-yr-old male with inflammatory bowel disease was diagnosed with a perforated bowel and underwent emergency exploratory laparotomy under general anesthesia. Approximately two hours after induction of anesthesia, the patient experienced cardiac arrest, and for 55 min, he underwent CPR and defibrillation according to the Advanced Cardiac Life Support (ACLS) protocols. As the decision to terminate CPR was being considered, a return of spontaneous circulation was detected 56 min after the onset of cardiac arrest. The patient survived with no major organ failure or adverse neurological outcome. No definitive cause of cardiac arrest was diagnosed in the postoperative period. At the follow-up 14 months after the event, the patient had returned to the pre-arrest level of functioning. The results of our literature search showed that no upper limit for the duration of CPR has been defined. Good outcomes after prolonged CPR depend on the patient's pre-arrest condition and the etiology of the cardiac arrest.

CONCLUSION

Perioperative cardiac arrests are rare events, and there is little evidence to suggest an upper limit for the duration of resuscitation. Unknown etiologies and the presence of good patient predictors may support the continuation of prolonged CPR with good outcomes.

Outcomes research using quality improvement databases: evolving opportunities and challenges

The challenges to prospective randomized controlled trials have necessitated the exploration of observational data sets that support research into the predictors and modulators of preoperative adverse events. The primary purpose and design of quality improvement databases is quality assessment and improvement at the local, regional, or national level. However, these data can also provide the opportunity to robustly study specific questions related to patient outcomes with no additional clinical risk to the patient. The virtual explosion of anesthesia-related registries has opened seemingly limitless opportunities for outcomes research in addition to generating hypothesis for more rigorous prospective analysis.