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Sandroni C, Skrifvars MB, Taccone FS. Brain monitoring after cardiac arrest. Curr Opin Crit Care 2023; 29:68-74. [PMID: 36762679 PMCID: PMC9994800 DOI: 10.1097/mcc.0000000000001023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW To describe the available neuromonitoring tools in patients who are comatose after resuscitation from cardiac arrest because of hypoxic-ischemic brain injury (HIBI). RECENT FINDINGS Electroencephalogram (EEG) is useful for detecting seizures and guiding antiepileptic treatment. Moreover, specific EEG patterns accurately identify patients with irreversible HIBI. Cerebral blood flow (CBF) decreases in HIBI, and a greater decrease with no CBF recovery indicates poor outcome. The CBF autoregulation curve is narrowed and right-shifted in some HIBI patients, most of whom have poor outcome. Parameters derived from near-infrared spectroscopy (NIRS), intracranial pressure (ICP) and transcranial Doppler (TCD), together with brain tissue oxygenation, are under investigation as tools to optimize CBF in patients with HIBI and altered autoregulation. Blood levels of brain biomarkers and their trend over time are used to assess the severity of HIBI in both the research and clinical setting, and to predict the outcome of postcardiac arrest coma. Neuron-specific enolase (NSE) is recommended as a prognostic tool for HIBI in the current postresuscitation guidelines, but other potentially more accurate biomarkers, such as neurofilament light chain (NfL) are under investigation. SUMMARY Neuromonitoring provides essential information to detect complications, individualize treatment and predict prognosis in patients with HIBI.
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Affiliation(s)
- Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario ‘Agostino Gemelli’- IRCCS
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Markus Benedikt Skrifvars
- Department of Emergency Medicine and Services, University of Helsinki
- Helsinki University Hospital, Helsinki, Finland
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
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Wihersaari L, Reinikainen M, Furlan R, Mandelli A, Vaahersalo J, Kurola J, Tiainen M, Pettilä V, Bendel S, Varpula T, Latini R, Ristagno G, Skrifvars MB. Neurofilament light compared to neuron-specific enolase as a predictor of unfavourable outcome after out-of-hospital cardiac arrest. Resuscitation 2022; 174:1-8. [PMID: 35245610 DOI: 10.1016/j.resuscitation.2022.02.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/22/2022] [Accepted: 02/24/2022] [Indexed: 11/28/2022]
Abstract
AIM We compared the prognostic abilities of neurofilament light (NfL) and neuron-specific enolase (NSE) in patients resuscitated from out-of-hospital cardiac arrest (OHCA) of various aetiologies. METHODS We analysed frozen blood samples obtained at 24 and 48 hours from OHCA patients treated in 21 Finnish intensive care units in 2010 and 2011. We defined unfavourable outcome as Cerebral Performance Category (CPC) 3-5 at 12 months after OHCA. We evaluated the prognostic ability of the biomarkers by calculating the area under the receiver operating characteristic curves (AUROCs [95% confidence intervals]) and compared these with a bootstrap method. RESULTS Out of 248 adult patients, 12-month outcome was unfavourable in 120 (48.4%). The median (interquartile range) NfL concentrations for patients with unfavourable and those with favourable outcome, respectively, were 688 (146-1804) pg/mL vs. 31 (17-61) pg/mL at 24 h and 1162 (147-4361) pg/mL vs. 36 (21-87) pg/mL at 48 h, p < 0.001 for both. The corresponding NSE concentrations were 13.3 (7.2-27.3) µg/L vs. 8.5 (5.8-13.2) µg/L at 24 h and 20.4 (8.1-56.6) µg/L vs. 8.2 (5.9-12.1) µg/L at 48 h, p < 0.001 for both. The AUROCs to predict an unfavourable outcome were 0.90 (0.86-0.94) for NfL vs. 0.65 (0.58-0.72) for NSE at 24 h, p < 0.001 and 0.88 (0.83-0.93) for NfL and 0.73 (0.66-0.81) for NSE at 48 h, p < 0.001. CONCLUSION Compared to NSE, NfL demonstrated superior accuracy in predicting long-term unfavourable outcome after OHCA.
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Affiliation(s)
- L Wihersaari
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.
| | - M Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - R Furlan
- Clinical Neuroimmunology Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS Ospedale San Raffaele, Milan, Italy
| | - A Mandelli
- Clinical Neuroimmunology Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS Ospedale San Raffaele, Milan, Italy
| | - J Vaahersalo
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J Kurola
- Centre for Prehospital Emergency Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - M Tiainen
- University of Helsinki and Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - V Pettilä
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - S Bendel
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - T Varpula
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - R Latini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - G Ristagno
- Department of Pathophysiology and Transplantation, University of Milan, Italy; Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M B Skrifvars
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Skrifvars MB, Sekhon M, Åneman EA. Monitoring and modifying brain oxygenation in patients at risk of hypoxic ischaemic brain injury after cardiac arrest. Crit Care 2021; 25:312. [PMID: 34461973 PMCID: PMC8406909 DOI: 10.1186/s13054-021-03678-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Markus Benedikt Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Erik Anders Åneman
- Southwestern Clinical School, University of New South Wales, Sydney, NSW, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- College of Health and Medicine, Australian National University, Canberra, NSW, Australia
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Liverpool, NSW, Australia
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Penketh JA, Nolan JP, Skrifvars MB, Rylander C, Frenell I, Tirkkonen J, Reynolds EC, Parr MJA, Aneman A. Airway management during in-hospital cardiac arrest: An international, multicentre, retrospective, observational cohort study. Resuscitation 2020; 153:143-148. [PMID: 32479867 DOI: 10.1016/j.resuscitation.2020.05.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 10/24/2022]
Abstract
AIM To determine the type of airway devices used during in-hospital cardiac arrest (IHCA) resuscitation attempts. METHODS International multicentre retrospective observational study of in-patients aged over 18 years who received chest compressions for cardiac arrest from April 2016 to September 2018. Patients were identified from resuscitation registries and rapid response system databases. Data were collected through review of resuscitation records and hospital notes. Airway devices used during cardiac arrest were recorded as basic (adjuncts or bag-mask), or advanced, including supraglottic airway devices, tracheal tubes or tracheostomies. Descriptive statistics and multivariable regression modelling were used for data analysis. RESULTS The final analysis included 598 patients. No airway management occurred in 36 (6%), basic airway device use occurred at any time in 562 (94%), basic airway device use without an advanced airway device in 182 (30%), tracheal intubation in 301 (50%), supraglottic airway in 102 (17%), and tracheostomy in 1 (0.2%). There was significant variation in airway device use between centres. The intubation rate ranged between 21% and 90% while supraglottic airway use varied between 1% and 45%. The choice of tracheal intubation vs. supraglottic airway as the second advanced airway device was not associated with immediate survival from the resuscitation attempt (odds ratio 0.81; 95% confidence interval 0.35-1.8). CONCLUSION There is wide variation in airway device use during resuscitation after IHCA. Only half of patients are intubated before return of spontaneous circulation and many are managed without an advanced airway. Further investigation is needed to determine optimal airway device management strategies during resuscitation following IHCA.
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Affiliation(s)
- J A Penketh
- Intensive Care Unit, Liverpool Hospital, Sydney, Australia; Intensive Care Unit, Royal United Hospital, Bath, United Kingdom.
| | - J P Nolan
- Intensive Care Unit, Royal United Hospital, Bath, United Kingdom; Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom.
| | - M B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - C Rylander
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - I Frenell
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - J Tirkkonen
- Intensive Care Unit, Liverpool Hospital, Sydney, Australia; Intensive Care Unit, Tampere University Hospital, Finland.
| | - E C Reynolds
- Intensive Care Unit, Liverpool Hospital, Sydney, Australia; Intensive Care Unit, Royal United Hospital, Bath, United Kingdom.
| | - M J A Parr
- Intensive Care Unit, Liverpool Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia.
| | - A Aneman
- Intensive Care Unit, Liverpool Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia.
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Harrois A, Anstey JR, Taccone FS, Udy AA, Citerio G, Duranteau J, Ichai C, Badenes R, Prowle JR, Ercole A, Oddo M, Schneider A, van der Jagt M, Wolf S, Helbok R, Nelson DW, Skrifvars MB, Cooper DJ, Bellomo R. Correction to: Serum sodium and intracranial pressure changes after desmopressin therapy in severe traumatic brain injury patients: a multi-centre cohort study. Ann Intensive Care 2019; 9:136. [PMID: 31802308 PMCID: PMC6892991 DOI: 10.1186/s13613-019-0610-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- A Harrois
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia. .,Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, APHP, Université Paris Sud, 78 Rue du Général Leclerc, 94270, Le Kremlin Bicêtre, France.
| | - J R Anstey
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - F S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - A A Udy
- Intensive Care Unit, The Alfred Hospital, Melbourne, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - G Citerio
- School of Medicine and Surgery, University Milano Bicocca-Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - J Duranteau
- Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, APHP, Université Paris Sud, 78 Rue du Général Leclerc, 94270, Le Kremlin Bicêtre, France
| | - C Ichai
- Université Côte d'Azur, Centre hospitalier Universitaire de Nice, Service de Réanimation Polyvalente, Hôpital Pasteur 2, Nice, France
| | - R Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - J R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - A Ercole
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M Oddo
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Centre Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - A Schneider
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Centre Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - M van der Jagt
- Department of Intensive Care, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - S Wolf
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - R Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - D W Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - M B Skrifvars
- Division of Intensive Care, Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - D J Cooper
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - R Bellomo
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia.,Department of Intensive Care, Austin Health, Melbourne, VIC, Australia.,School of Medicine, University of Melbourne, Melbourne, Australia
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Harrois A, Anstey JR, Taccone FS, Udy AA, Citerio G, Duranteau J, Ichai C, Badenes R, Prowle JR, Ercole A, Oddo M, Schneider A, van der Jagt M, Wolf S, Helbok R, Nelson DW, Skrifvars MB, Cooper DJ, Bellomo R. Serum sodium and intracranial pressure changes after desmopressin therapy in severe traumatic brain injury patients: a multi-centre cohort study. Ann Intensive Care 2019; 9:99. [PMID: 31486921 PMCID: PMC6728106 DOI: 10.1186/s13613-019-0574-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 08/26/2019] [Indexed: 12/24/2022] Open
Abstract
Background In traumatic brain injury (TBI) patients desmopressin administration may induce rapid decreases in serum sodium and increase intracranial pressure (ICP). Aim In an international multi-centre study, we aimed to report changes in serum sodium and ICP after desmopressin administration in TBI patients. Methods We obtained data from 14 neurotrauma ICUs in Europe, Australia and UK for severe TBI patients (GCS ≤ 8) requiring ICP monitoring. We identified patients who received any desmopressin and recorded daily dose, 6-hourly serum sodium, and 6-hourly ICP. Results We studied 262 severe TBI patients. Of these, 39 patients (14.9%) received desmopressin. Median length of treatment with desmopressin was 1 [1–3] day and daily intravenous dose varied between centres from 0.125 to 10 mcg. The median hourly rate of decrease in serum sodium was low (− 0.1 [− 0.2 to 0.0] mmol/L/h) with a median period of decrease of 36 h. The proportion of 6-h periods in which the rate of natremia correction exceeded 0.5 mmol/L/h or 1 mmol/L/h was low, at 8% and 3%, respectively, and ICPs remained stable. After adjusting for IMPACT score and injury severity score, desmopressin administration was independently associated with increased 60-day mortality [HR of 1.83 (1.05–3.24) (p = 0.03)]. Conclusions In severe TBI, desmopressin administration, potentially representing instances of diabetes insipidus is common and is independently associated with increased mortality. Desmopressin doses vary markedly among ICUs; however, the associated decrease in natremia rarely exceeds recommended rates and median ICP values remain unchanged. These findings support the notion that desmopressin therapy is safe.
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Affiliation(s)
- A Harrois
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia. .,Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, APHP, Université Paris Sud, 78 Rue du Général Leclerc, 94270, Le Kremlin Bicêtre, France.
| | - J R Anstey
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - F S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - A A Udy
- Intensive Care Unit, The Alfred Hospital, Melbourne, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - G Citerio
- School of Medicine and Surgery, University Milano Bicocca-Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - J Duranteau
- Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, APHP, Université Paris Sud, 78 Rue du Général Leclerc, 94270, Le Kremlin Bicêtre, France
| | - C Ichai
- Université Côte d'Azur, Centre hospitalier Universitaire de Nice, Service de Réanimation Polyvalente, Hôpital Pasteur 2, Nice, France
| | - R Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - J R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - A Ercole
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M Oddo
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Centre Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - A Schneider
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Centre Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - M van der Jagt
- Department of Intensive Care, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - S Wolf
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - R Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - D W Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - M B Skrifvars
- Division of Intensive Care, Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - D J Cooper
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - R Bellomo
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia.,Department of Intensive Care, Austin Health, Melbourne, VIC, Australia.,School of Medicine, University of Melbourne, Melbourne, Australia
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Yeung J, Matsuyama T, Bray J, Reynolds J, Skrifvars MB. Does care at a cardiac arrest centre improve outcome after out-of-hospital cardiac arrest? - A systematic review. Resuscitation 2019; 137:102-115. [PMID: 30779976 DOI: 10.1016/j.resuscitation.2019.02.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/08/2019] [Accepted: 02/11/2019] [Indexed: 02/07/2023]
Abstract
AIM To perform a systematic review to answer 'In adults with attempted resuscitation after non-traumatic cardiac arrest does care at a specialised cardiac arrest centre (CAC) compared to care in a healthcare facility not designated as a specialised cardiac arrest centre improve patient outcomes?' METHODS The PRISMA guidelines were followed. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 1st August 2018. Randomised controlled trials (RCTs) and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using ROBINS-I tool and GRADEpro respectively. Primary outcomes were survival to 30 days with favourable neurological outcomes and survival to hospital discharge with favourable neurological outcomes. Secondary outcomes were survival to 30 days, survival to hospital discharge and return of spontaneous circulation (ROSC) post-hospital arrival for patients with ongoing resuscitation. This systematic review was registered in PROSPERO (CRD 42018093369) RESULTS: We included data from 17 observational studies on out-of-hospital cardiac arrest (OHCA) patients in meta-analyses. Overall, the certainty of evidence was very low. Pooling data from only adjusted analyses, care at CAC was not associated with increased likelihood of survival to 30 days with favourable neurological outcome (OR 2.92, 95% CI 0.68-12.48) and survival to 30 days (OR 2.14, 95% CI 0.73-6.29) compared to care at other hospitals. Whereas patients cared for at CACs had improved survival to hospital discharge with favourable neurological outcomes (OR 2.22, 95% CI 1.74-2.84) and survival to hospital discharge (OR 1.85, 95% CI 1.46-2.34). CONCLUSIONS Very low certainty of evidence suggests that post-cardiac arrest care at CACs is associated with improved outcomes at hospital discharge. There remains a need for high quality data to fully elucidate the impact of CACs.
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Affiliation(s)
- J Yeung
- Warwick Medical School, University of Warwick, United Kingdom.
| | - T Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - J Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne Australia
| | - J Reynolds
- Department of Emergency Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - M B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
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Lång M, Raj R, Skrifvars MB, Reinikainen M, Bendel S. In Reply: Early Moderate Hyperoxemia does not Predict Outcome After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2018; 80:E253. [PMID: 28327970 DOI: 10.1093/neuros/nyx034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Maarit Lång
- Department of Intensive Care Medicine, Kuopio University Hospital, KYS, Kuopio, Finland
| | - Rahul Raj
- Department of Intensive Care Medicine, Helsinki University Central Hospital, HUS, Helsinki, Finland
| | | | - Matti Reinikainen
- Department of Intensive Care Medicine, North Karelia Central Hospital, Joensuu, Finland
| | - Stepani Bendel
- Department of Intensive Care Medicine, Kuopio University Hospital, KYS, Kuopio, Finland
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9
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Raj R, Bendel S, Reinikainen M, Hoppu S, Laitio R, Ala-Kokko T, Curtze S, Skrifvars MB. Costs, outcome and cost-effectiveness of neurocritical care: a multi-center observational study. Crit Care 2018; 22:225. [PMID: 30236140 PMCID: PMC6148794 DOI: 10.1186/s13054-018-2151-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 08/07/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Neurocritical illness is a growing healthcare problem with profound socioeconomic effects. We assessed differences in healthcare costs and long-term outcome for different forms of neurocritical illnesses treated in the intensive care unit (ICU). METHODS We used the prospective Finnish Intensive Care Consortium database to identify all adult patients treated for traumatic brain injury (TBI), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) and acute ischemic stroke (AIS) at university hospital ICUs in Finland during 2003-2013. Outcome variables were one-year mortality and permanent disability. Total healthcare costs included the index university hospital costs, rehabilitation hospital costs and social security costs up to one year. All costs were converted to euros based on the 2013 currency rate. RESULTS In total 7044 patients were included (44% with TBI, 13% with ICH, 27% with SAH, 16% with AIS). In comparison to TBI, ICH was associated with the highest risk of death and permanent disability (OR 2.6, 95% CI 2.1-3.2 and OR 1.7, 95% CI 1.4-2.1), followed by AIS (OR 1.9, 95% CI 1.5-2.3 and OR 1.5, 95% CI 1.3-1.8) and SAH (OR 1.8, 95% CI 1.5-2.1 and OR 0.8, 95% CI 0.6-0.9), after adjusting for severity of illness. SAH was associated with the highest mean total costs (€51,906) followed by ICH (€47,661), TBI (€43,916) and AIS (€39,222). Cost per independent survivor was lower for TBI (€58,497) and SAH (€96,369) compared to AIS (€104,374) and ICH (€178,071). CONCLUSION Neurocritical illnesses are costly and resource-demanding diseases associated with poor outcomes. Intensive care of patients with TBI or SAH more commonly result in independent survivors and is associated with lower total treatments costs compared to ICH and AIS.
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Affiliation(s)
- R Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Topeliuksenkatu 5, PB 266, 00029 HUS, Helsinki, Finland.
| | - S Bendel
- Department of Intensive Care, Kuopio University Hospital & University of Eastern Finland, Kuopio, Finland
| | - M Reinikainen
- Department of Intensive Care, North Karelia Central Hospital, Joensuu, Finland
| | - S Hoppu
- Department of Intensive Care, Tampere University Hospital & University of Tampere, Tampere, Finland
| | - R Laitio
- Department of Intensive Care, Turku University Hospital & University of Turku, Turku, Finland
| | - T Ala-Kokko
- Department of Intensive Care, Oulu University Hospital & University of Oulu, Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, Oulu, Finland
| | - S Curtze
- Department of Neurology, Helsinki University Hospital & University of Helsinki, Helsinki, Finland
| | - M B Skrifvars
- Department Anesthesia, Intensive Care and Pain Medicine and Department of Emergency Care and Services, Helsinki University Hospital & University of Helsinki, Helsinki, Finland
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Lång M, Raj R, Skrifvars MB, Koivisto T, Lehto H, Kivisaari R, von Und Zu Fraunberg M, Reinikainen M, Bendel S. Early Moderate Hyperoxemia Does Not Predict Outcome After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2016; 78:540-5. [PMID: 26562823 DOI: 10.1227/neu.0000000000001111] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Targeting hyperoxemia is common practice in neurocritical care settings, but the safety of hyperoxemia has been questioned. OBJECTIVE To investigate the independent effect of hyperoxemia on outcome in patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS We included 432 patients with aneurysmal SAH on mechanical ventilation for at least 24 hours after intensive care unit (ICU) admission. Arterial blood gas levels were calculated as time-weighted averages (TWAs) of all blood gas measurements during the first 24 hours in the ICU. Patients were categorized into 3 TWA-PaO2 bands (low, <97.5 mm Hg; intermediate, 97.5-150 mm Hg; high, ≥150 mm Hg). Outcome measures were unfavorable outcome at 3 months (Glasgow Outcome Scale score 1-3) and mortality. Multivariate logistic regression analysis was used to assess the independent effect of oxygen on outcome. RESULTS Overall, 28% of patients died, and a total of 53% had an unfavorable outcome at 3 months. Patients with an unfavorable outcome had significantly higher TWA-PaO2 levels compared with patients with a favorable outcome (137 mm Hg vs 118 mm Hg, P < .001). Multivariate analysis demonstrated no significant association between TWA-PaO2 bands and unfavorable outcome (with intermediate PaO2 as a reference, odds ratio [OR] for low PaO2 1.05, 95% confidence interval [CI]: 0.52-2.12, P = .89; OR for high PaO2: 1.09, 95% CI: 0.61-1.97, P = .77) or mortality (with intermediate PaO2 as reference, the OR for low PaO2 was 0.67 (95% CI: 0.30-1.46, P = .31), and the OR for high PaO2 was 0.73 (95% CI: 0.38-1.40, P = .34). CONCLUSION Early moderate hyperoxemia may not increase or decrease the risk of a poor outcome in mechanically ventilated aneurysmal SAH patients.
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Affiliation(s)
- Maarit Lång
- *Department of Intensive Care Medicine, Kuopio University Hospital, Kuopio, Finland; ‡Department of Neurosurgery, University of Helsinki, Helsinki University Central Hospital, Helsinki, Finland; §Division of Intensive Care, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland; ¶Department of Neurosurgery, Kuopio University Hospital, Kuopio, Finland; ‖Department of Intensive Care Medicine, North Karelia Central Hospital, Joensuu, Finland
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Heinonen JA, Schramko AA, Skrifvars MB, Litonius E, Backman JT, Mervaala E, Rosenberg PH. The effects of intravenous lipid emulsion on hemodynamic recovery and myocardial cell mitochondrial function after bupivacaine toxicity in anesthetized pigs. Hum Exp Toxicol 2016; 36:365-375. [DOI: 10.1177/0960327116650010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Local anesthetic toxicity is thought to be mediated partly by inhibition of cardiac mitochondrial function. Intravenous (i.v.) lipid emulsion may overcome this energy depletion, but doses larger than currently recommended may be needed for rescue effect. In this randomized study with anesthetized pigs, we compared the effect of a large dose, 4 mL/kg, of i.v. 20% Intralipid® ( n = 7) with Ringer’s acetate ( n = 6) on cardiovascular recovery after a cardiotoxic dose of bupivacaine. We also examined mitochondrial respiratory function in myocardial cell homogenates analyzed promptly after needle biopsies from the animals. Bupivacaine plasma concentrations were quantified from plasma samples. Arterial blood pressure recovered faster and systemic vascular resistance rose more rapidly after Intralipid than Ringer’s acetate administration ( p < 0.0001), but Intralipid did not increase cardiac index or left ventricular ejection fraction. The lipid-based mitochondrial respiration was stimulated by approximately 30% after Intralipid ( p < 0.05) but unaffected by Ringer’s acetate. The mean (standard deviation) area under the concentration–time curve (AUC) of total bupivacaine was greater after Intralipid (105.2 (13.6) mg·min/L) than after Ringer’s acetate (88.1 (7.1) mg·min/L) ( p = 0.019). After Intralipid, the AUC of the lipid-un-entrapped bupivacaine portion (97.0 (14.5) mg·min/L) was 8% lower than that of total bupivacaine ( p < 0.0001). To conclude, 4 mL/kg of Intralipid expedited cardiovascular recovery from bupivacaine cardiotoxicity mainly by increasing systemic vascular resistance. The increased myocardial mitochondrial respiration and bupivacaine entrapment after Intralipid did not improve cardiac function.
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Affiliation(s)
- JA Heinonen
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - AA Schramko
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - MB Skrifvars
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - E Litonius
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - JT Backman
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - E Mervaala
- Department of Pharmacology, University of Helsinki, Helsinki, Finland
| | - PH Rosenberg
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Efendijev I, Raj R, Reinikainen M, Hoppu S, Skrifvars MB. Differences in long-term mortality after out-of-hospital, in-hospital and intensive care unit cardiac arrests in finland. Intensive Care Med Exp 2015. [PMCID: PMC4798269 DOI: 10.1186/2197-425x-3-s1-a846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Ristagno G, Latini R, Plebani M, Zaninotto M, Vaahersalo J, Masson S, Tiainen M, Kurola J, Gaspari F, Milani V, Pettilä V, Skrifvars MB. Copeptin levels are associated with organ dysfunction and death in the intensive care unit after out-of-hospital cardiac arrest. Crit Care 2015; 19:132. [PMID: 25886856 PMCID: PMC4415235 DOI: 10.1186/s13054-015-0831-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 02/20/2015] [Indexed: 01/20/2023]
Abstract
Introduction We studied associations of the stress hormones copeptin and cortisol with outcome and organ dysfunction after out-of-hospital cardiac arrest (OHCA). Methods Plasma was obtained after consent from next of kin in the FINNRESUSCI study conducted in 21 Finnish intensive care units (ICUs) between 2010 and 2011. We measured plasma copeptin (pmol/L) and free cortisol (nmol/L) on ICU admission (245 patients) and at 48 hours (additional 33 patients). Organ dysfunction was categorised with 24-hour Sequential Organ Failure Assessment (SOFA) scores. Twelve-month neurological outcome (available in 276 patients) was classified with cerebral performance categories (CPC) and dichotomised into good (CPC 1 or 2) or poor (CPC 3 to 5). Data are presented as medians and interquartile ranges (IQRs). A Mann–Whitney U test, multiple linear and logistic regression tests with odds ratios (ORs) 95% confidence intervals (CIs) and beta (B) values, repeated measure analysis of variance, and receiver operating characteristic curves with area under the curve (AUC) were performed. Results Patients with a poor 12-month outcome had higher levels of admission copeptin (89, IQR 41 to 193 versus 51, IQR 29 to 111 pmol/L, P = 0.0014) and cortisol (728, IQR 522 to 1,017 versus 576, IQR 355 to 850 nmol/L, P = 0.0013). Copeptin levels fell between admission and 48 hours (P <0.001), independently of outcome (P = 0.847). Cortisol levels did not change between admission and 48 hours (P = 0.313), independently of outcome (P = 0.221). The AUC for predicting long-term outcome was weak for copeptin (0.62, 95% CI 0.55 to 0.69) and cortisol (0.62, 95% CI 0.54 to 0.69). With logistic regression, admission copeptin (standard deviation (SD) increase OR 1.4, 95% CI 1.03 to 1.98) and cortisol (SD increase OR 1.5, 95% CI 1.1 to 2.0) predicted ICU mortality but not 12-month outcome. Admission factors correlating with SOFA were shockable rhythm (B −1.3, 95% CI −2.2 to −0.5), adrenaline use (B 1.1, 95% CI 0.2 to 2.0), therapeutic hypothermia (B 1.3 95% CI 0.4-2.2), and copeptin (B 0.04, 95% CI 0.02 to 0.07). Conclusions Admission copeptin and free cortisol were not of prognostic value regarding 12-month neurological outcome after OHCA. Higher admission copeptin and cortisol were associated with ICU death, and copeptin predicted subsequent organ dysfunction. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0831-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Giuseppe Ristagno
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Via La Masa, 19 - 20156 Milano, Milan, Italy.
| | - Roberto Latini
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Via La Masa, 19 - 20156 Milano, Milan, Italy.
| | - Mario Plebani
- Department of Laboratory Medicine, University-Hospital of Padova, Via Giustiniani 2, 35128, Padova, Italy.
| | - Martina Zaninotto
- Department of Laboratory Medicine, University-Hospital of Padova, Via Giustiniani 2, 35128, Padova, Italy.
| | - Jukka Vaahersalo
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland.
| | - Serge Masson
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Via La Masa, 19 - 20156 Milano, Milan, Italy.
| | - Marjaana Tiainen
- Department of Neurology, Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland.
| | - Jouni Kurola
- Centre for Prehospital Emergency Care, Kuopio University Hospital, P.O. Box 100, FI 70029, Kuopio, Finland.
| | - Flavio Gaspari
- Laboratory of Pharmacokinetics and Clinical Chemistry, IRCCS-Istituto di Ricerche Farmacologiche 'Mario Negri', Villa Camozzi, 24020, Ranica, Italy.
| | - Valentina Milani
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Via La Masa, 19 - 20156 Milano, Milan, Italy.
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland.
| | - Markus Benedikt Skrifvars
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland.
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Fallenius M, Raj R, Reinikainen M, Bendel S, Skrifvars MB. Association between high arterial oxygen tension and long-term survival after intracerebral hemorrhage. Crit Care 2015. [PMCID: PMC4472686 DOI: 10.1186/cc14545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Efendijev I, Raj R, Hoppu S, Skrifvars MB, Reinikainen M. Need for therapeutic interventions as a predictor of mortality in intensive care. Crit Care 2015. [PMCID: PMC4472829 DOI: 10.1186/cc14640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Skrifvars MB, Raj R, Bendel S, Selander T, Kivisaari R, Siironen J, Reinikainen M. Predicting 6-month mortality of patients with traumatic brain injury: usefulness of common severity scores. Crit Care 2014. [PMCID: PMC4069432 DOI: 10.1186/cc13669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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Skrifvars MB, Vayrynen T, Kuisma M, Castren M, Parr MJ, Silfverstople J, Svensson L, Jonsson L, Herlitz J. 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. Resuscitation 2010; 81:679-84. [PMID: 20381229 DOI: 10.1016/j.resuscitation.2010.01.033] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 01/21/2010] [Accepted: 01/31/2010] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- M B Skrifvars
- Department of Intensive Care, Liverpool Hospital, University of New South Wales, Sydney, Australia.
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Skrifvars MB, Castren M, Nurmi J, Thoren AB, Aune S, Herlitz J. Do patient characteristics or factors at resuscitation influence long-term outcome in patients surviving to be discharged following in-hospital cardiac arrest? J Intern Med 2007; 262:488-95. [PMID: 17875186 DOI: 10.1111/j.1365-2796.2007.01846.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Few studies have focused on factors influencing long-term outcome following in-hospital cardiac arrest. The present study assesses whether long-term outcome is influenced by difference in patient factors or factors at resuscitation. METHODS An analysis of cardiac arrest data collected from one Swedish tertiary hospital and from five Finnish secondary hospitals supplemented with data on 1 year survival. Multiple logistic regression analysis was used to identify factors associated with survival at 12 months. RESULTS A total of 441 patients survived to hospital discharge following in-hospital cardiac arrest and 359 (80%) were alive at 12 months. Factors independently associated with survival [odds ratio (OR) >1 indicates increased survival and <1 decreased survival] at 12 months were; age [OR 0.95, 95% confidence interval (CI) 0.93-0.98], renal disease (OR 0.3, CI 0.1-0.9), good functional status at discharge (OR 4.9, CI 1.3-18.9), arrest occurring at (compared with arrests on general wards) emergency wards (OR 4.7, CI 1.4-15.3), cardiac care unit (OR 2.8, CI 1.2-6.4), intensive care unit (OR 2.4, CI 1.1-5.7), ward for thoracic surgery (OR 10.2, CI 2.6-40.1) and unit for interventional radiology (OR 13.3, CI 3.4-52.0). There was no difference in initial rhythm, delay to defibrillation or delay to return of spontaneous circulation between survivors and nonsurvivors. CONCLUSION Several patient factors, mainly age, functional status and co-morbid disease, influence long-term survival following cardiac arrest in hospital. The location where the arrest occurred also influences survival, but initial rhythm, delay to defibrillation and to return of spontaneous circulation do not.
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Affiliation(s)
- M B Skrifvars
- Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Finland.
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Skrifvars MB, Castrén M, Aune S, Thoren AB, Nurmi J, Herlitz J. Variability in survival after in-hospital cardiac arrest depending on the hospital level of care. Resuscitation 2007; 73:73-81. [PMID: 17250948 DOI: 10.1016/j.resuscitation.2006.08.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Revised: 08/17/2006] [Accepted: 08/23/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND Survival after in-hospital cardiac arrest (IHCA) differs considerably between hospitals. This study tries to determine whether this difference is due to patient selection because of the hospital level of care or to effective resuscitation management. METHODS Prospectively collected data on management of in-hospital cardiac arrests from Sahlgrenska Hospital, a tertiary hospital in Gothenburg, Sweden (cohort one) and from five Finnish secondary hospitals (cohort two). A multiple logistic regression model was created for predicting survival to hospital discharge. RESULTS A total of 954 cases from Sahlgrenska Hospital and 624 patients from the hospitals in Finland were included. The delay to defibrillation was longer at Sahlgrenska than at the five Finnish secondary hospitals (p=0.045). Significant predictors of survival were: (1) age below median (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.5-2.8); (2) no diabetes (OR 1.9, CI 1.2-2.9); (3) arrests occurring during office hours (OR 1.5, CI 1.1-2.2); (4) witnessed cardiac arrest (OR 6.3, CI 2.6-15.3); (5) ventricular fibrillation or ventricular tachycardia as the initial rhythm (OR 4.9, CI 3.5-6.7); (6) location of the arrest (compared to arrests in general wards, GW): thoracic surgery and heart transplantation ward (OR 2.9, CI 1.5-5.9), interventional radiology (OR 4.8, CI 1.9-12.0) and other in-hospital locations (3.0, CI 1.6-5.7) and (7) hospital (compared to arrests at Sahlgrenska Hospital); arrests at Etelä-Karjala Central Hospital [CH] (OR 0.3, CI 0.1-0.7), Päijät-Hame CH (OR 0.3, CI 0.1-0.8) and Seinäjoki CH (OR 0.4, CI 0.3-0.7). CONCLUSION The comparison of survival following IHCA between different hospitals is difficult, there seems to be undefined factors greatly associated with outcome. A great variability in survival within different hospital areas probably because of differences in patient selection, patient surveillance and resuscitation management was also noted. A locally implemented strong in-hospital chain of survival is probably the only way to improve outcome following IHCA.
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Affiliation(s)
- M B Skrifvars
- Helsinki EMS, Helsinki University Hospital, P.O. Box 112, FIN-00099 Helsinki, Finland.
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Abstract
BACKGROUND The in-hospital Utstein Guidelines may be used to evaluate resuscitation strategies. This study utilized the Utstein template prospectively to examine changes in outcome and outcome-related factors after resuscitation outside critical care areas over a 10-year period. METHODS Seinäjoki Central Hospital (460 beds) is a secondary hospital in Finland with acute care activities. In 1993, the in-hospital cardiac arrest management was remodelled; an intensive care unit-based resuscitation team was formed and prospective data collection began (modified according to the Utstein Guidelines in 1997). An analysis of resuscitation attempts outside critical care areas between 1993 and 2002 was performed. To monitor developments, the patients were divided into two groups (first period, 1993-97; second period, 1998-2002). Variables independently associated with survival were identified using multiple logistic regression analysis. RESULTS During the 10-year period, resuscitation was attempted in 183 patients. Survival to discharge was 6% during the first period and 16% during the second (P = 0.048). The corresponding figures for survival at 1 year from the event were 3% and 10% (P = 0.064). Independent predictors of survival were ventricular fibrillation or ventricular tachycardia as the initial rhythm [odds ratio (OR), 9.8; confidence interval (CI), 3.2-30.3] and cardiac arrest occurring during the second period (OR, 3.3; CI, 1.1-10.1). CONCLUSION Prospective Utstein style data collection proved to be a valuable tool for the evaluation of management and outcome following in-hospital cardiac arrest. Increased survival was seen over 10 years outside critical care areas. Organizational changes, including cardiopulmonary resuscitation training for ward personnel and standardized resuscitation management, may have contributed to this change.
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Affiliation(s)
- M B Skrifvars
- Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland.
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Skrifvars MB, Kuisma M, Boyd J, Määttä T, Repo J, Rosenberg PH, Castren M. The use of undiluted amiodarone in the management of out-of-hospital cardiac arrest. Acta Anaesthesiol Scand 2004; 48:582-7. [PMID: 15101852 DOI: 10.1111/j.0001-5172.2004.00386.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The Resuscitation 2000 Guidelines recommends amiodarone as the antiarrhythmic drug of choice in treatment of resistant ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Amiodarone has been associated with side-effects and difficulty of administration, due to recommended dilution, rendering it suboptimal for out-of-hospital cardiac arrest (CA) management. In the present study we report experiences and side-effects of the use of undiluted amiodarone in CA management in Helsinki Emergency Medical Service (EMS) during a 2-year period. METHODS On October 1, the Resuscitation 2000 Guidelines were put into practice in Helsinki EMS. Thus, in the cardiac arrest treatment protocol, after three ineffective shocks and 1 mg of adrenaline (epinephrine), a bolus of 300 mg of undiluted amiodarone (Cordarone 50 mg ml(-1), Sanofi-Synthelabo, Helsinki, Finland) was administered into a vein located as centrally as possible. The Helsinki EMS performs systematic data collection according to the Utstein Guidelines. The blood pressure levels, heart rates and the need for vasopressors, of the patients with sustained return of spontaneous circulation (ROSC), were collected from the ambulance charts. RESULTS During October 1, 2000 and September 30, 2002, 712 patients were considered for resuscitation and 566 were resuscitated. The initial rhythms were as follows: 32% had VF/VT, 36% had asystole and 32% had pulseless electrical activity (PEA). Of the 180 patients with VF/VT, 75 (42%) received undiluted amiodarone in addition to other resuscitative measures. Of the patients with asystole or PEA, 12 (6%) and 18 (10%), respectively, received amiodarone. The blood pressure levels and the need vasopressors after ROSC and during transportation to the hospital were similar among the patients who received and those who did not receive amiodarone. CONCLUSIONS The present study suggests that amiodarone can be administered undiluted without unmanageable haemodynamical side-effects in the treatment of out-of-hospital cardiac arrest. This is likely to save time and simplifies the treatment protocol in the prehospital setting.
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Affiliation(s)
- M B Skrifvars
- Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland
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Skrifvars MB, Pettilä V, Rosenberg PH, Castrén M. A multiple logistic regression analysis of in-hospital factors related to survival at six months in patients resuscitated from out-of-hospital ventricular fibrillation. Resuscitation 2003; 59:319-28. [PMID: 14659601 DOI: 10.1016/s0300-9572(03)00238-7] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The impact of the immediate in-hospital post-resuscitation care after out-hospital cardiac arrest is not well known. Based on treatment variables and laboratory findings a multiple logistic regression model was created for the prediction of survival at 6 months from the event. MATERIALS AND METHODS A retrospective study of the hospital charts of patients successfully resuscitated and treated in one of three community hospitals from 1998 to 2000. In addition to several pre-hospital variables, the mean 72 h values of clinical features such as blood pressure, blood glucose concentration and initiated treatment used, were included in a forward multiple logistic regression model predicting survival at 6 months from the event. RESULTS The charts of 98 out of a total of 102 patients were sufficiently complete and included in the analysis. Variables independently associated with survival were age, delay before a return of spontaneous circulation, mean blood glucose and serum potassium, and the use of beta-blocking agents during post-resuscitation care. When those patients who were assigned a 'do not attempt to resuscitate' (DNAR) order during the first 72 h of treatment were excluded from the analysis blood glucose, blood potassium and the use beta-blocking agents remained independently associated with survival. CONCLUSION This study suggests that in-hospital factors are associated with survival from out-of-hospital cardiac arrest. The mean blood glucose and serum potassium during the first 72 h of treatment and the use of beta-blocking agents were significantly and independently associated with survival.
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Affiliation(s)
- M B Skrifvars
- Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, P.O. Box 340, FIN-00029 HUS Helsinki, Finland.
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Skrifvars MB, Hilden HM, Finne P, Rosenberg PH, Castrén M. Prevalence of 'do not attempt resuscitation' orders and living wills among patients suffering cardiac arrest in four secondary hospitals. Resuscitation 2003; 58:65-71. [PMID: 12867311 DOI: 10.1016/s0300-9572(03)00109-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the prevalence and implementation of 'do not resuscitate' orders, nowadays called 'do not attempt resuscitation' (DNAR) orders and living wills among patients suffering in-hospital cardiac arrest (CA) in whom cardiopulmonary resuscitation was not initiated. MATERIALS AND METHODS A prospective survey of CA patients conducted in four secondary hospitals during 2000-2001. The information collected included the presence of DNAR and a living will and the patients sociodemographic and disease factors and the reasons for not initiating resuscitation when no DNAR order was present. Data on the resuscitated patients were collected according to the Utstein recommendations (analyzed and published separately) and used for comparison. RESULTS During the study period, 1486 patients suffered CA without resuscitation being initiated. Data collection was successful in 1143 patients (77%), who were included in the study. Most of the patients (84.5%) had a DNAR order. The prevalence of DNAR orders differed between the participating hospitals (P<0.001), and between the wards of the hospital, with most DNAR orders in the cardiac care unit (100%) and medical wards (87%). The patients designated as DNAR were likely to be older (P<0.01) and of poorer functional status (P<0.001). Reasons for abstaining from resuscitation without a DNAR order were unwitnessed arrest (27%) and terminal disease (66%). Living wills were uncommon (1.5%). Patients with a living will were likely to have a DNAR order (P<0.01). CONCLUSION Most patients who suffered in-hospital CA without resuscitation had a DNAR order, and, for those who did not, terminal disease and medical futility were evident in most cases. Living wills were uncommon, but they appeared to have had some impact on treatment.
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Affiliation(s)
- M B Skrifvars
- Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, P.O. Box 340 FIN-00029 HUS, Helsinki, Finland.
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Skrifvars MB, Rosenberg PH, Finne P, Halonen S, Hautamäki R, Kuosa R, Niemelä H, Castrén M. Evaluation of the in-hospital Utstein template in cardiopulmonary resuscitation in secondary hospitals. Resuscitation 2003; 56:275-82. [PMID: 12628558 DOI: 10.1016/s0300-9572(02)00373-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The in-hospital Utstein template for cardiopulmonary resuscitation (CPR) was assessed in four secondary hospitals (334-441 beds) which did not have systematic data collection. MATERIALS AND METHODS The reports and outcome over a period of 12 months during the years 2000-2001 were evaluated. RESULTS Of a total of 1690 patients that had a cardiac arrest (CA), 204 (12%) were resuscitated. Information on the collected Utstein parameters were available as follows: initial rhythm in 91%, time interval from collapse to defibrillation (in case of ventricular fibrillation or ventricular tachycardia as initial rhythm) in 90%, time interval to return of spontaneous circulation (ROSC) in 83% and duration of resuscitation in 83%. ROSC was achieved in 69 patients (34%, CI 27-41%) and 34 (17%, CI 11-23%) survived to hospital discharge. Twenty patients showed satisfactory neurological recovery (10%, CI 6-14%). Eighteen (9%, CI 5-13%) patients were alive at 12 months from the event. Factors associated with survival to hospital discharge were VF/VT (P=0.007) as the initial rhythm and shorter interval to defibrillation (P=0.046). CONCLUSION The in-hospital Utstein template was logical but laborious and it provided tools for resuscitation management evaluation in the study hospitals. For continuous use, a slightly compressed model may be warranted. In the present material, the overall survival rate to hospital discharge was in line with previous reports but there were somewhat less neurologically satisfactory survivors. There is an evident need to improve the outcome of patients suffering CA on the wards. An important step is to reduce the time interval to defibrillation.
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Affiliation(s)
- M B Skrifvars
- Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, PO Box 340, FIN-00029 HUS, Helsinki, Finland.
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Skrifvars MB, Castrén M, Kurola J, Rosenberg PH. In-hospital cardiopulmonary resuscitation: organization, management and training in hospitals of different levels of care. Acta Anaesthesiol Scand 2002; 46:458-63. [PMID: 11952451 DOI: 10.1034/j.1399-6576.2002.460423.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND : During recent years in-hospital cardiopulmonary resuscitation (CPR) management has received much attention. This can be attributed to the Utstein model for in-hospital CPR developed in 1997. The present status of in-hospital resuscitation management in Finnish hospitals is not known. Therefore, a study was designed to describe the organization of training and clinical management of CPR in Finnish hospitals of different levels of care. METHODS : In the summer of 2000, we performed a cross-sectional mail survey throughout Finland, including all district, central and university hospitals. The questionnaire outlined in detail in-hospital resuscitation management and training. For analysis the hospitals were divided into primary, secondary and tertiary groups, depending on levels of care. RESULTS : Most hospitals (72%) reported having a physician or a nurse in charge of resuscitation management and training. Training in advanced life support was more common among nurses (80%) than among physicians (53%). Surprisingly, a majority of respondents (75%) reported that they felt training in CPR was insufficient. On the general wards and on wards treating cardiac patients, defibrillation was in most cases performed by a physician (91% and 51%, respectively), and less often by a nurse (16% and 31%, respectively). In the secondary and tertiary hospitals cardiac arrest was managed by a cardiac arrest team (53% and 62%, respectively) and in the primary hospitals by the ward physician (56%), anesthesiologist or emergency physician on call (44%). Most hospitals used do-not-resuscitate orders (83%) but only 33% of the hospitals had a unified style of notation. Systematic data collection was practised in 55% of hospitals, predominantly by using a model of their own. Only a few hospitals (11%) used the in-hospital Utstein model. CONCLUSION : Our study showed that more attention needs to be paid to CPR management in Finnish hospitals. At present, 25% of hospitals do not have an appointed physician or nurse in charge of organizing CPR management. The study also revealed a lack of regular organized training in resuscitation for physicians. Fifty-five per cent of hospitals practise systematic data collection, but only 11% according to the Utstein template; and without which further quality assurance is difficult.
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Affiliation(s)
- M B Skrifvars
- Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland.
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