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Linderman GC, Lin W, Becher RD, Maung AA, Bhattacharya B, Davis KA, Schuster KM. Increased mortality with resuscitative endovascular balloon occlusion of the aorta only mitigated by strong unmeasured confounding: An expanded analysis using the National Trauma Data Bank. J Trauma Acute Care Surg 2021; 91:790-797. [PMID: 33951027 PMCID: PMC8547242 DOI: 10.1097/ta.0000000000003265] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is being increasingly adopted to manage noncompressible torso hemorrhage, but a recent analysis of the 2015 to 2016 Trauma Quality Improvement Project (TQIP) data set showed that placement of REBOA was associated with higher rates of death, lower extremity amputation, and acute kidney injury (AKI). We expand this analysis by including the 2017 data set, quantifying the potential role of residual confounding, and distinguishing between traumatic and ischemic lower extremity amputation. METHODS This retrospective study used the 2015 to 2017 TQIP database and included patients older than 18 years, with signs of life on arrival, who had no aortic injury and were not transferred. Resuscitative endovascular balloon occlusions of the aorta placed after 2 hours were excluded. We adjusted for baseline variables using propensity scores with inverse probability of treatment weighting. A sensitivity analysis was then conducted to determine the strength of an unmeasured confounder (e.g., unmeasured shock severity/response to resuscitation) that could explain the effect on mortality. Finally, lower extremity injury patterns of patients undergoing REBOA were inspected to distinguish amputation indicated for traumatic injury from complications of REBOA placement. RESULTS Of 1,392,482 patients meeting the inclusion criteria, 187 underwent REBOA. After inverse probability of treatment weighting, all covariates were balanced. The risk difference for mortality was 0.21 (0.14-0.29) and for AKI was 0.041 (-0.007 to 0.089). For the mortality effect to be explained by an unmeasured confounder, it would need to be stronger than any observed in terms of its relationship with mortality and with REBOA placement. Eleven REBOA patients underwent lower extremity amputation; however, they all suffered severe traumatic injury to the lower extremity. CONCLUSION There is no evidence in the TQIP data set to suggest that REBOA causes amputation, and the evidence for its effect on AKI is considerably weaker than previously reported. The increased mortality effect of REBOA is confirmed and could only be nullified by a potent confounder. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Affiliation(s)
- George C. Linderman
- Department of Surgery, Yale School of Medicine
- Applied Mathematics Program, Department of Mathematics, Yale University
| | - Winston Lin
- Department of Statistics and Data Science, Yale University
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Donaldson RI, Graham TL, Fisher TC, Armstrong J, Buchanan OJ, Cambridge J, Ross JD. Efficacy of past, present, and future fluid strategies in an improved large animal model of non-compressible intra-abdominal hemorrhage. J Trauma Acute Care Surg 2021; 91:S99-S106. [PMID: 34324472 DOI: 10.1097/ta.0000000000003200] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Noncompressible hemorrhage is a leading cause of potentially survivable combat death, with the vast majority of such deaths occurring in the out-of-hospital environment. While large animal models of this process are important for device and therapeutic development, clinical practice has changed over time and past models must follow suit. Developed in conjunction with regulatory feedback, this study presents a modernized, out-of-hospital, noncompressible hemorrhage model, in conjunction with a randomized study of past, present, and future fluid options following a hypotensive resuscitation protocol consistent with current clinical practice. METHODS We performed a randomized controlled experiment comparing three fluid resuscitation options in Yorkshire swine. Baseline data from animals of same size from previous experiments were analyzed (n = 70), and mean systolic blood pressure was determined, with a permissive hypotension resuscitation target defined as a 25% decrease from normal (67 mm Hg). After animal preparation, a grade IV to V liver laceration was induced. Animals bled freely for a 10-minute "time-to-responder" period, after which resuscitation occurred with randomized fluid in boluses to the goal target: 6% hetastarch in lactated electrolyte injection (HEX), normal saline (NS), or fresh whole blood (FWB). Animals were monitored for a total simulated "delay to definitive care" period of 2 hours postinjury. RESULTS At the end of the 2-hour study period, 8.3% (1 of 12 swine) of the HEX group, 50% (6 of 12 swine) of the NS group, and 75% (9 of 12 swine) of the FWB had survived (p = 0.006), with Holm-Sidak pairwise comparisons showing a significant difference between HEX and FWB and (p = 0.005). Fresh whole blood had significantly higher systemic vascular resistance and hemoglobin levels compared with other groups (p = 0.003 and p = 0.001, respectively). CONCLUSION Survival data support the movement away from HEX toward NS and, preferably, FWB in clinical practice and translational animal modeling. The presented model allows for future research including basic science, as well as translational studies of novel diagnostics, therapeutics, and devices.
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Affiliation(s)
- Ross I Donaldson
- From the Critical Innovations LLC (R.I.D., T.C.F., J.A., O.J.B., J.C.); Department of Emergency Medicine (R.I.D.), David Geffen School of Medicine at UCLA, Los Angeles; Department of Emergency Medicine (R.I.D.), Harbor-UCLA Medical Center, Torrance; Department of Epidemiology (R.I.D.), UCLA Fielding School of Public Health, Los Angeles, California; Charles T Dotter Department of Interventional Radiology (T.L.G., J.D.R.), Oregon Health and Science University, Portland, Oregon; and Military and Health Research Foundation (T.L.G., J.D.R.), Laurel, Maryland
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Jiang S, Wu M, Lu X, Zhong Y, Kang X, Song Y, Fan Z. Is restrictive fluid resuscitation beneficial not only for hemorrhagic shock but also for septic shock?: A meta-analysis. Medicine (Baltimore) 2021; 100:e25143. [PMID: 33761680 PMCID: PMC9282070 DOI: 10.1097/md.0000000000025143] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 02/21/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Whether to use limited fluid resuscitation (LFR) in patients with hemorrhagic shock or septic shock remains controversial. This research was aimed to assess the pros and cons of utilizing LFR in hemorrhagic shock or septic shock patients. METHODS PubMed, Cochrane Library, Embase, Web of science, CNKI, VIP, and Wan Fang database searches included for articles published before December 15, 2020. Randomized controlled trials of LFR or adequate fluid resuscitation in hemorrhagic shock or septic shock patients were selected. RESULT This meta-analysis including 28 randomized controlled trials (RCTs) and registered 3288 patients. The 7 of 27 RCTs were the patients with septic shock. Others were traumatic hemorrhagic shock patients. Comparing LFR or adequate fluid resuscitation in hemorrhagic shock or septic shock patients, the summary odds ratio (OR) was 0.50 (95% confidence interval [CI] 0.42-0.60, P < .00001) for mortality, 0.46 (95% CI 0.31-0.70, P = .0002) for multiple organ dysfunction syndrome (MODS), 0.35 (95% CI 0.25-0.47) for acute respiratory distress syndrome (ARDS), and 0.33 (95% CI 0.20-0.56) for disseminated intravascular coagulation (DIC). CONCLUSION Limited fluid resuscitation is the benefit of both traumatic hemorrhagic shock patients and septic shock patients.
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Affiliation(s)
- Shuaiyu Jiang
- Graduate School
- Department of Emergency Medicine, Zhongshan Hospital, Dalian University, Dalian, China
| | - Mengmeng Wu
- Graduate School
- Department of Emergency Medicine, Zhongshan Hospital, Dalian University, Dalian, China
| | - Xiaoguang Lu
- Department of Emergency Medicine, Zhongshan Hospital, Dalian University, Dalian, China
| | - Yilong Zhong
- Graduate School
- Department of Emergency Medicine, Zhongshan Hospital, Dalian University, Dalian, China
| | - Xin Kang
- Department of Emergency Medicine, Zhongshan Hospital, Dalian University, Dalian, China
| | - Yi Song
- Department of Emergency Medicine, Zhongshan Hospital, Dalian University, Dalian, China
| | - Zhiwei Fan
- Department of Emergency Medicine, Zhongshan Hospital, Dalian University, Dalian, China
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Gomez H, Priyanka P, Bataineh A, Keener CM, Clermont G, Kellum JA. Effects of 5% Albumin Plus Saline Versus Saline Alone on Outcomes From Large-Volume Resuscitation in Critically Ill Patients. Crit Care Med 2021; 49:79-90. [PMID: 33165027 PMCID: PMC7746571 DOI: 10.1097/ccm.0000000000004706] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To compare 5% albumin with 0.9% saline for large-volume resuscitation (> 60 mL/Kg within 24 hr), on mortality and development of acute kidney injury. DESIGN Retrospective cohort study. SETTING Patients admitted to ICUs in 13 hospitals across Western Pennsylvania. We analyzed two independent cohorts, the High-Density Intensive Care databases: High-Density Intensive Care-08 (July 2000 to October 2008, H08) and High-Density Intensive Care-15 (October 2008 to December 2014, H15). PATIENTS Total of 18,629 critically ill patients requiring large-volume resuscitation. INTERVENTIONS Five percent of albumin in addition to saline versus 0.9% saline. MEASUREMENTS AND MAIN RESULTS After excluding patients with acute kidney injury prior to large-volume resuscitation, 673 of 2,428 patients (27.7%) and 1,814 of 16,201 patients (11.2%) received 5% albumin in H08 and H15, respectively. Use of 5% albumin was associated with decreased 30-day mortality by multivariate regression in H08 (odds ratio 0.65; 95% CI 0.49-0.85; p = 0.002) and in H15 (0.52; 95% CI 0.44-0.62; p < 0.0001) but was associated with increased acute kidney injury in H08 (odds ratio 1.98; 95% CI 1.56-2.51; p < 0.001) and in H15 (odds ratio 1.75; 95% CI 1.58-1.95; p < 0.001). However, 5% albumin was not associated with persistent acute kidney injury and resulted in decreased major adverse kidney event at 30, 90, and 365 days. Propensity matched analysis confirmed similar associations with mortality and acute kidney injury. CONCLUSIONS During large-volume resuscitation, 5% albumin was associated with reduced mortality and major adverse kidney event at 30, 90, and 365 days. However, a higher rate of acute kidney injury of any stage was observed that did not translate into persistent renal dysfunction.
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Affiliation(s)
- Hernando Gomez
- The Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA
- CRISMA (Clinical Research Investigation and Systems Modeling of Acute illness) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Priyanka Priyanka
- The Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA
| | - Ayham Bataineh
- The Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA
- Division of Nephrology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Gilles Clermont
- CRISMA (Clinical Research Investigation and Systems Modeling of Acute illness) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - John A. Kellum
- The Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA
- CRISMA (Clinical Research Investigation and Systems Modeling of Acute illness) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
- Division of Nephrology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
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Malik AO, Nallamothu BK, Trumpower B, Kennedy M, Krein SL, Chinnakondepalli KM, Hejjaji V, Chan PS. Association Between Hospital Debriefing Practices With Adherence to Resuscitation Process Measures and Outcomes for In-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes 2020; 13:e006695. [PMID: 33201736 DOI: 10.1161/circoutcomes.120.006695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Identifying actionable resuscitation practices that vary across hospitals could improve adherence to process measures or outcomes after in-hospital cardiac arrest (IHCA). We sought to examine whether hospital debriefing frequency after IHCA varies across hospitals and whether hospitals which routinely perform debriefing have higher rates of process-of-care compliance or survival. Methods We conducted a nationwide survey of hospital resuscitation practices in April of 2018, which were then linked to data from the Get With The Guidelines-Resuscitation national registry for IHCA. Hospitals were categorized according to their reported frequency of debriefing immediately after IHCA; rarely (0%-20% of all IHCA cases), occasionally (21%-80%), and frequently (81%-100%). Hospital-level rates of timely defibrillation (≤2 minutes), epinephrine administration (≤5 minutes), survival to discharge, return of spontaneous circulation, and neurologically intact survival were comparted for patients with IHCA from 2015 to 2017. Results Overall, there were 193 hospitals comprising 44 477 IHCA events. Mean patient age was 65±16, 41% were females, and 68% were of White race. Across hospitals, 84 (43.5%) rarely performed debriefings immediately after an IHCA, 82 (42.5%) performed debriefing sessions occasionally, and 27 (14.0%) performed debriefing frequently. There was no association between higher reported debriefing frequency and hospital rates of timely defibrillation and epinephrine administration. Mean hospital rates of risk-standardized survival to discharge were similar across debriefing frequency groups (rarely 25.6%; occasionally 26.0%; frequently 25.2%, P=0.72), as were hospital rates of risk-adjusted return of spontaneous circulation (rarely 72.2%; occasionally 73.0%; frequently 70.0%, P=0.06) and neurologically intact survival (rarely 21.9%, occasionally 22.2%, frequently 21.1%, P=0.75). Conclusions In a large contemporary nationwide quality improvement registry, hospitals varied widely in how often they conducted debriefings immediately after IHCA. However, hospital debriefing frequency was not associated with better adherence to timely delivery of epinephrine or defibrillation or higher rates of IHCA survival.
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Affiliation(s)
- Ali O Malik
- University of Missouri Kansas City (A.O.M., M.K., V.H., P.S.C.)
- Saint Lukes' Mid America Heart Institute, Kansas City, MO (A.O.M., K.M.C., V.H., P.S.C.)
| | | | - Brad Trumpower
- University of Missouri Kansas City (A.O.M., M.K., V.H., P.S.C.)
- University of Michigan, Ann Arbor (B.K.N., B.T., S.L.K.)
| | | | - Sarah L Krein
- University of Michigan, Ann Arbor (B.K.N., B.T., S.L.K.)
- VA Ann Arbor Healthcare System, MI (S.L.K.)
| | | | - Vittal Hejjaji
- University of Missouri Kansas City (A.O.M., M.K., V.H., P.S.C.)
- Saint Lukes' Mid America Heart Institute, Kansas City, MO (A.O.M., K.M.C., V.H., P.S.C.)
| | - Paul S Chan
- University of Missouri Kansas City (A.O.M., M.K., V.H., P.S.C.)
- Saint Lukes' Mid America Heart Institute, Kansas City, MO (A.O.M., K.M.C., V.H., P.S.C.)
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Jentzer JC, Herrmann J, Prasad A, Barsness GW, Bell MR. Utility and Challenges of an Early Invasive Strategy in Patients Resuscitated From Out-of-Hospital Cardiac Arrest. JACC Cardiovasc Interv 2020; 12:697-708. [PMID: 31000007 DOI: 10.1016/j.jcin.2019.01.245] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/09/2019] [Accepted: 01/15/2019] [Indexed: 12/16/2022]
Abstract
Out-of-hospital cardiac arrest (OHCA) is frequently triggered by acute myocardial ischemia. Coronary angiography is an important component of post-resuscitation care for patients with OHCA without an evident noncardiac cause, to identify underlying coronary artery disease and allow revascularization. Most patients undergoing coronary angiography after OHCA have obstructive coronary artery disease, and nearly one-half of patients have acute coronary occlusion. Early coronary angiography and percutaneous coronary intervention after OHCA have been associated with improved survival in observational studies, but these studies demonstrate selection bias, and randomized trials are lacking. Selection of patients for coronary angiography after OHCA can be challenging, particularly in comatose patients whose outcomes are driven primarily by anoxic brain injury. As for other patients with acute coronary syndromes, patients with ST-segment elevation after OHCA have a high probability of acute coronary occlusion warranting emergent coronary angiography. Patients with cardiogenic shock after OHCA are a high-risk population also requiring emergent coronary angiography. Among patients in stable condition after OHCA without ST-segment elevation, other clinical predictors can be used to identify those needing early coronary angiography to identify obstructive coronary artery disease. Despite the challenges with early neurological prognostication in comatose patients with OHCA, those with multiple objective markers of poor prognosis appear less likely to benefit from revascularization, and early coronary angiography may be reasonably deferred in appropriately selected patients meeting these criteria. The authors propose an algorithm to guide patient selection for coronary angiography after OHCA that combines clinical predictors of acute coronary occlusion and early clinical predictors of severe brain injury.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Abstract
The use of extracorporeal cardiopulmonary resuscitation (E‐CPR) for the treatment of patients with out‐of‐hospital cardiac arrest who do not respond to conventional cardiopulmonary resuscitation CPR) has increased significantly in the past 10 years, in response to case reports and observational studies reporting encouraging results. However, no randomized controlled trials comparing E‐CPR with conventional CPR have been published to date. The evidence from systematic reviews of the available observational studies is conflicting. The inclusion criteria for published E‐CPR studies are variable, but most commonly include witnessed arrest, immediate bystander CPR, an initial shockable rhythm, and an estimated time from CPR start to establishment of E‐CPR (low‐flow time) of <60 minutes. A shorter low‐flow time has been consistently associated with improved survival. In an effort to reduce low‐flow times, commencement of E‐CPR in the prehospital setting has been reported and is currently under investigation. The provision of an E‐CPR service, whether hospital based or prehospital, carries considerable cost and technical challenges. Despite increased adoption, many questions remain as to which patients will derive the most benefit from E‐CPR, when and where to implement E‐CPR, optimal post‐arrest E‐CPR care, and whether this complex invasive intervention is cost‐effective. Results of ongoing trials are awaited to determine whether E‐CPR improves survival when compared with conventional CPR.
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Affiliation(s)
- Mark Dennis
- Sydney Medical SchoolUniversity of SydneyAustralia
- Department of CardiologyRoyal Prince Alfred HospitalSydneyAustralia
| | - Sean Lal
- Sydney Medical SchoolUniversity of SydneyAustralia
- Department of CardiologyRoyal Prince Alfred HospitalSydneyAustralia
| | - Paul Forrest
- Sydney Medical SchoolUniversity of SydneyAustralia
- Department of AnaesthesiaRoyal Prince Alfred HospitalSydneyAustralia
| | - Alistair Nichol
- University College Dublin‐Clinical Research CentreSt Vincent’s University HospitalDublinIreland
- School of Public Health and Preventive MedicineMonash UniversityMelbourneAustralia
- Department of Intensive CareThe Alfred HospitalMelbourneAustralia
| | - Lionel Lamhaut
- INSERM U970 Team 4 “Sudden Death Expertise Center”ParisFrance
- Paris Descartes UniversityParisFrance
- SAMU de Paris‐DAR Necker University Hospital‐Assistance Public Hopitaux de ParisParisFrance
| | - Richard J. Totaro
- Department of Intensive CareRoyal Prince Alfred HospitalSydneyAustralia
| | - Brian Burns
- Greater Sydney Area Helicopter Emergency Medical ServiceNew South Wales, Ambulance Service???Australia
| | - Claudio Sandroni
- Istituto Anestesiologia e Rianimazione Università Cattolica del Sacro Cuore – Policlinico Universitario Agostino Gemelli – IRCCSRomeItaly
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Callcut RA, Simpson KN, Baraniuk S, Fox EE, Tilley BC, Holcomb JB. Cost-effectiveness evaluation of the PROPPR trial transfusion protocols. Transfusion 2020; 60:922-931. [PMID: 32358836 PMCID: PMC7567498 DOI: 10.1111/trf.15784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND There have been no prior investigations of the cost effectiveness of transfusion strategies for trauma resuscitation. The Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study was a Phase III multisite, randomized trial in 680 subjects comparing the efficacy of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with the 1:1:2 ratio. We hypothesized that 1:1:1 transfusion results in an acceptable incremental cost-effectiveness ratio, when estimated using patients' age-specific life expectancy and cost of care during the 30-day PROPPR trial period. STUDY DESIGN AND METHODS International Classification of Diseases, Ninth Revision codes were prospectively collected, and subjects were matched 1:2 to subjects in the Healthcare Utilization Program State Inpatient Data to estimate cost weights. We used a decision tree analysis, combined with standard costs and estimated years of expected survival to determine the cost effectiveness of the two treatments. RESULTS The 1:1:1 group had higher overall costs for the blood products but were more likely to achieve hemostasis and decreased hemorrhagic death by 24 hours (p = 0.006). For every 100 patients treated in the 1:1:1 group, eight more achieved hemostasis than in the 1:1:2 group. At 30 days, the total hospital cost per 100 patients was $5.6 million in the 1:1:1 group compared with $5.0 million in the 1:1:2 group. For each 100 patients, the 1:1:1 group had 218.5 more years of life expectancy. This was at a cost of $2994 per year gained. CONCLUSION The 1:1:1 transfusion ratio in severely injured hemorrhaging trauma patients is a very cost-effective strategy for increasing hemostasis and decreasing trauma deaths.
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Affiliation(s)
- Rachael A. Callcut
- Division of General Surgery, Department of Surgery, School of Medicine, University of California San Francisco, San Francisco, California
| | - Kit N. Simpson
- Department of Healthcare Leadership & Management, Medical University of South Carolina, Charleston, South Carolina
| | - Sarah Baraniuk
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
| | - Erin E. Fox
- Center for Translational Injury Research and Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Barbara C. Tilley
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
| | - John B. Holcomb
- Division of Acute Care Surgery, Department of Surgery, Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
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Gad MM, Simons-Linares CR. Is aggressive intravenous fluid resuscitation beneficial in acute pancreatitis? A meta-analysis of randomized control trials and cohort studies. World J Gastroenterol 2020; 26:1098-1106. [PMID: 32206000 PMCID: PMC7081000 DOI: 10.3748/wjg.v26.i10.1098] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/12/2020] [Accepted: 02/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is conflincting evidence on the intravenous fluid (IVF) strategy for acute pancreatitis (AP). We perform a metaanalysis of the available evidence.
AIM To investigate if aggressive IVF therapy in AP patients is beneficial to decrease mortality and improve outcomes.
METHODS Metaanalysis of available randomized controlled trials and cohort studies comparing aggressive IVF vs non-aggressive IVF resuscitation.
RESULTS There was no significant difference in mortality between the aggressive (n = 1229) and non-aggressive IVF (n = 1397) patients. Patients receiving aggressive IVF therapy had higher risk for acute kidney injury and acute respiratory distress syndrome. There also was no significant difference in the overall incidence of systemic inflammatory response syndrome, persistent organ failure, pancreatic necrosis when comparing both study groups.
CONCLUSION Early aggressive IVF therapy did not improve mortality. Moreover, aggressive IVF therapy could potentially increase the risk for acute kidney injury and pulmonary edema leading to respiratory failure and mechanical ventilation. Studies are needed to investigate which subset of AP patients could benefit from aggressive IVF therapy.
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Affiliation(s)
- Mohamed M Gad
- Internal Medicine Department, Medicine Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - C. Roberto Simons-Linares
- Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, United States
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10
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KC A, Ewald U, Basnet O, Gurung A, Pyakuryal SN, Jha BK, Bergström A, Eriksson L, Paudel P, Karki S, Gajurel S, Brunell O, Wrammert J, Litorp H, Målqvist M. Effect of a scaled-up neonatal resuscitation quality improvement package on intrapartum-related mortality in Nepal: A stepped-wedge cluster randomized controlled trial. PLoS Med 2019; 16:e1002900. [PMID: 31498784 PMCID: PMC6733443 DOI: 10.1371/journal.pmed.1002900] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 08/12/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Improving quality of intrapartum care will reduce intrapartum stillbirth and neonatal mortality, especially in resource-poor settings. Basic neonatal resuscitation can reduce intrapartum stillbirth and early neonatal mortality, if delivered in a high-quality health system, but there is a dearth of evidence on how to scale up such evidence-based interventions. We evaluated the scaling up of a quality improvement (QI) package for neonatal resuscitation on intrapartum-related mortality (intrapartum stillbirth and first day mortality) at hospitals in Nepal. METHODS AND FINDINGS We conducted a stepped-wedge cluster randomized controlled trial in 12 hospitals over a period of 18 months from April 14, 2017, to October 17, 2018. The hospitals were assigned to one of four wedges through random allocation. The QI package was implemented in a stepped-wedge manner with a delay of three months for each step. The QI package included improving hospital leadership on intrapartum care, building health workers' competency on neonatal resuscitation, and continuous facilitated QI processes in clinical units. An independent data collection system was set up at each hospital to gather data on mortality through patient case note review and demographic characteristics of women using semi-structured exit interviews. The generalized linear mixed model (GLMM) and multivariate logistic regression were used for analyses. During this study period, a total of 89,014 women-infant pairs were enrolled. The mean age of the mother in the study period was 24.0 ± 4.3 years, with 54.9% from disadvantaged ethnic groups and 4.0% of them illiterate. Of the total birth cohort, 54.4% were boys, 16.7% had gestational age less than 37 weeks, and 17.1% had birth weight less than 2,500 grams. The incidence of intrapartum-related mortality was 11.0 per 1,000 births during the control period and 8.0 per 1,000 births during the intervention period (adjusted odds ratio [aOR], 0.79; 95% CI, 0.69-0.92; p = 0.002; intra-cluster correlation coefficient [ICC], 0.0286). The incidence of early neonatal mortality was 12.7 per 1,000 live births during the control period and 10.1 per 1,000 live births during the intervention period (aOR, 0.89; 95% CI, 0.78-1.02; p = 0.09; ICC, 0.1538). The use of bag-and-mask ventilation for babies with low Apgar score (<7 at 1 minute) increased from 3.2% in the control period to 4.0% in the intervention period (aOR, 1.52; 95% CI, 1.32-1.77, p = 0.003). There were two major limitations to the study; although a large sample of women-infant pairs were enrolled in the study, the clustering reduced the power of the study. Secondly, the study was not sufficiently powered to detect reduction in early neonatal mortality with the number of clusters provided. CONCLUSION These results suggest scaled-up implementation of a QI package for neonatal resuscitation can reduce intrapartum-related mortality and improve clinical care. The QI intervention package is likely to be effective in similar settings. More implementation research is required to assess the sustainability of QI interventions and quality of care. TRIAL REGISTRATION ISRCTN30829654.
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Affiliation(s)
- Ashish KC
- Department of Women’s and Children’s Health; Uppsala University, Uppsala, Sweden
- Society of Public Health Physician Nepal, Kathmandu, Nepal
- * E-mail:
| | - Uwe Ewald
- Department of Women’s and Children’s Health; Uppsala University, Uppsala, Sweden
| | | | | | | | - Bijay Kumar Jha
- Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
| | - Anna Bergström
- Department of Women’s and Children’s Health; Uppsala University, Uppsala, Sweden
- UCL Institute for Global Health (IGH), University College London, London, United Kingdom
| | - Leif Eriksson
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Prajwal Paudel
- Nepal Health Research Council, RamshahPath, Kathmandu, Nepal
| | | | | | - Olivia Brunell
- Department of Women’s and Children’s Health; Uppsala University, Uppsala, Sweden
| | - Johan Wrammert
- Department of Women’s and Children’s Health; Uppsala University, Uppsala, Sweden
| | - Helena Litorp
- Department of Women’s and Children’s Health; Uppsala University, Uppsala, Sweden
| | - Mats Målqvist
- Department of Women’s and Children’s Health; Uppsala University, Uppsala, Sweden
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11
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Gando S, Wada T. Disseminated intravascular coagulation in cardiac arrest and resuscitation. J Thromb Haemost 2019; 17:1205-1216. [PMID: 31102491 DOI: 10.1111/jth.14480] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [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] [Received: 02/20/2019] [Revised: 05/02/2019] [Accepted: 05/06/2019] [Indexed: 12/13/2022]
Abstract
The aims of this review are to demonstrate that the changes in coagulation and fibrinolysis observed in cardiac arrest and resuscitation can be recognized as disseminated intravascular coagulation (DIC), and to discuss the probability of DIC being a therapeutic target. The appearance of triggers of DIC, such as damage-associated molecular patterns, inflammatory cytokines, and adrenaline, is associated with platelet activation, marked thrombin generation and fibrin formation, insufficient anticoagulation pathways, and increased fibrinolysis by tissue-type plasminogen activator, followed by the suppression of fibrinolysis by plasminogen activator inhibitor-1, in patients with cardiac arrest and resuscitation. Simultaneous neutrophil activation and endothelial injury associated with glycocalyx perturbation have been observed in these patients. The degree of these changes is more severe in patients with prolonged precardiac arrest hypoxia and long no-flow and low-flow times, patients without return of spontaneous circulation, and non-survivors. Animal and clinical studies have confirmed decreased cerebral blood flow and microvascular fibrin thrombosis in vital organs, including the brain. The clinical diagnosis of DIC in patients with cardiac arrest and resuscitation is associated with multiple organ dysfunction, as assessed with the sequential organ failure assessment score, and increased mortality. This review confirms that the coagulofibrinolytic changes in cardiac arrest and resuscitation meet the definition of DIC proposed by the ISTH, and that DIC is associated with organ dysfunction and poor patient outcomes. This evidence implies that established DIC should be considered to be one of the main therapeutic targets in post-cardiac arrest syndrome.
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Affiliation(s)
- Satoshi Gando
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
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12
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Petrone P, Pérez-Jiménez A, Rodríguez-Perdomo M, Brathwaite CEM, Joseph DK. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the Management of Trauma Patients: A Systematic Literature Review. Am Surg 2019; 85:654-662. [PMID: 31267908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) represents an innovative method by which noncompressible bleeding in the torso can be mitigated until definitive treatment can be obtained. To perform a systematic review of the literature on the use of the REBOA in trauma patients. An English and Spanish literature search was performed using MEDLINE, PubMed, and Scopus, from 1948 to 2018. Keywords used were aortic balloon occlusion, resuscitative endovascular balloon, REBOA, hemorrhage, and resuscitative endovascular balloon occlusion of the aorta. The eligilibility criteria included only original and human subject articles. Nontrauma patients, nonbleeding pathology, letters, single case reports, reviews, and pediatric patients were excluded. Two hundred forty-six articles were identified, of which 17 articles were included in this review. The total number of patients was 1340; 69 per cent were men and 31 per cent women. In 465 patients, the aortic zone location was described: 83 per cent the balloon was placed in aortic zone I and 16 per cent in zone III. Systolic blood pressure increased at an average of 52 mmHg before and after aortic occlusion. Although 32 patients (2.4%) presented clinical complications derived from the procedure, no mortality was reported. The trauma-related mortality rate was 58 per cent (776/1340). REBOA is a useful resource for the management of noncompressive torso hemorrhage with promising results in systolic blood pressure and morbidity. Indications for its use include injuries in zones 1 and 3, whereas it is not clear for zone 2 injuries. Additional studies are needed to define the benefits of this procedure.
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Bekdache O, Paradis T, Shen YBH, Elbahrawy A, Grushka J, Deckelbaum DL, Khwaja K, Fata P, Razek T, Beckett A. Resuscitative endovascular balloon occlusion of the aorta (REBOA): a scoping review protocol concerning indications-advantages and challenges of implementation in traumatic non-compressible torso haemorrhage. BMJ Open 2019; 9:e027572. [PMID: 30782953 PMCID: PMC6368000 DOI: 10.1136/bmjopen-2018-027572] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Haemorrhage remains the leading cause of preventable death in trauma. Damage control measures applied to patients in extremis in order to control exsanguinating bleeding from non-compressible torso injuries use different techniques to limit blood flow from the aorta to the rest of the body. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is regaining momentum recently as an adjunct measure that can provide the same results using less invasive approaches. This scoping review aims to provide a comprehensive understanding of the existing literature on REBOA. The objective is to analyse evidence and non-evidence-based medical reports and to describe current gaps in the literature about the best indication and implementation strategies for REBOA. METHODS AND ANALYSIS Using the five-stage framework of Arksey and O'Malley's scoping review methodology as a guide, we will perform a systematic search in the following databases: MEDLINE, EMBASE, BIOSIS, COCHRANE CENTRAL, PUBMED and SCOPUS from the earliest available publications. The aim is to identify diverse studies related to the topic of REBOA. For a comprehensive search, we will explore organisational websites, key journals and hand-search reference lists of key studies. Data will be charted and sorted using a descriptive analytical approach. ETHICS AND DISSEMINATION Ethics approval is not necessary as the data are collected from publicly available sources and there will be no consultative phase. The results will be disseminated through presentations at local, national, clinical and medical education conferences and through publication in a peer-reviewed journal.
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Affiliation(s)
- Omar Bekdache
- Department of Trauma and Acute Surgical Care, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tiffany Paradis
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Yu Bai He Shen
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Aly Elbahrawy
- Department of Trauma and Acute Surgical Care, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Surgery, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Jeremy Grushka
- Department of Trauma and Acute Surgical Care, McGill University Health Centre, Montreal, Quebec, Canada
| | - Dan L Deckelbaum
- Department of Trauma and Acute Surgical Care, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kosar Khwaja
- Department of Trauma and Acute Surgical Care, McGill University Health Centre, Montreal, Quebec, Canada
| | - Paola Fata
- Department of Trauma and Acute Surgical Care, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tarek Razek
- Department of Trauma and Acute Surgical Care, McGill University Health Centre, Montreal, Quebec, Canada
| | - Andrew Beckett
- Department of Trauma and Acute Surgical Care, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Surgery, Royal Canadian Medical Services, Montreal, Quebec, Canada
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Coult J, Blackwood J, Sherman L, Rea TD, Kudenchuk PJ, Kwok H. Ventricular Fibrillation Waveform Analysis During Chest Compressions to Predict Survival From Cardiac Arrest. Circ Arrhythm Electrophysiol 2019; 12:e006924. [PMID: 30626208 PMCID: PMC6532650 DOI: 10.1161/circep.118.006924] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Quantitative measures of the ventricular fibrillation (VF) ECG waveform can assess myocardial physiology and predict cardiac arrest outcomes, making these measures a candidate to help guide resuscitation. Chest compressions are typically paused for waveform measure calculation because compressions cause ECG artifact. However, such pauses contradict resuscitation guideline recommendations to minimize cardiopulmonary resuscitation interruptions. We evaluated a comprehensive group of VF measures with and without ongoing compressions to determine their performance under both conditions for predicting functionally-intact survival, the study's primary outcome. METHODS Five-second VF ECG segments were collected with and without chest compressions before 2755 defibrillation shocks from 1151 out-of-hospital cardiac arrest patients. Twenty-four individual measures and 3 combination measures were implemented. Measures were optimized to predict functionally-intact survival (Cerebral Performance Category score ≤2) using 460 training cases, and their performance evaluated using 691 independent test cases. RESULTS Measures predicted functionally-intact survival on test data with an area under the receiver operating characteristic curve ranging from 0.56 to 0.75 (median, 0.73) without chest compressions and from 0.53 to 0.75 (median, 0.69) with compressions ( P<0.001 for difference). Of all measures evaluated, the support vector machine model ranked highest both without chest compressions (area under the receiver operating characteristic curve, 0.75; 95% CI, 0.73-0.78) and with compressions (area under the receiver operating characteristic curve, 0.75; 95% CI, 0.72-0.78; P=0.75 for difference). CONCLUSIONS VF waveform measures predict functionally-intact survival when calculated during chest compressions, but prognostic performance is generally reduced compared with compression-free analysis. However, support vector machine models exhibited similar performance with and without compressions while also achieving the highest area under the receiver operating characteristic curve. Such machine learning models may, therefore, offer means to guide resuscitation during uninterrupted cardiopulmonary resuscitation.
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Affiliation(s)
- Jason Coult
- Department of Bioengineering, University of Washington,
Seattle, WA
- Center for Progress in Resuscitation, University of
Washington, Seattle, WA
| | - Jennifer Blackwood
- Center for Progress in Resuscitation, University of
Washington, Seattle, WA
- King County Emergency Medical Services, Seattle King County
Department of Public Health, Seattle, WA
| | - Lawrence Sherman
- Department of Bioengineering, University of Washington,
Seattle, WA
- Center for Progress in Resuscitation, University of
Washington, Seattle, WA
- Department of Medicine, University of Washington School of
Medicine, Seattle, WA
| | - Thomas D. Rea
- Center for Progress in Resuscitation, University of
Washington, Seattle, WA
- King County Emergency Medical Services, Seattle King County
Department of Public Health, Seattle, WA
- Department of Medicine, University of Washington School of
Medicine, Seattle, WA
| | - Peter J. Kudenchuk
- Center for Progress in Resuscitation, University of
Washington, Seattle, WA
- King County Emergency Medical Services, Seattle King County
Department of Public Health, Seattle, WA
- Division of Cardiology, University of Washington School of
Medicine, Seattle, WA
| | - Heemun Kwok
- Center for Progress in Resuscitation, University of
Washington, Seattle, WA
- Department of Emergency Medicine, University of Washington
School of Medicine, Seattle, WA
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15
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Zou Y, Ma K, Xiong JB, Xi CH, Deng XJ. Comparison of the effects of albumin and crystalloid on mortality among patients with septic shock: systematic review with meta-analysis and trial sequential analysis. SAO PAULO MED J 2018; 136:421-432. [PMID: 30570093 PMCID: PMC9907763 DOI: 10.1590/1516-3180.2017.0285281017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 10/28/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND This study aimed to compare the effects on mortality of albumin and crystalloid, used for fluid resuscitation among adult patients with septic shock, through conducting a meta-analysis and trial sequential analysis (TSA). DESIGN AND SETTING Meta-analysis and TSA conducted at Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China. METHODS Data were collected from several major databases including MEDLINE, EMBASE, Clinical Trials.gov and Cochrane Central Register of Controlled Trials. Studies that compared the effects of albumin therapy versus crystalloid therapy on mortality among adult septic shock patients were eligible for inclusion in the analyses. The study name, year of publication, country of the trial, albumin concentration, type of crystalloid and all reported mortalities at different follow-up endpoints were extracted. RESULTS Compared with crystalloid, albumin did not decrease all-cause mortality at the final follow-up. However, in TSA, the required information size was not achieved in all groups, which means that the effect size was not definitive and further RCTs are needed to confirm or deny these findings. CONCLUSIONS Compared with crystalloid solutions, albumin was unable to decrease all-cause mortality. However, TSA indicated that these results could be false-negative. Additional randomized controlled trials are needed to clarify this discrepancy.
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Affiliation(s)
- Yan Zou
- MD. Associate Professor, Department of Intensive Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China.
| | - Ke Ma
- MD. Associate Professor, Department of Emergency Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China.
| | - Ji-Bin Xiong
- MD. Assistant Professor, Department of Hyperbaric Oxygen Therapy, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China.
| | - Cai-Hua Xi
- MD. Associate Professor, Department of Intensive Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China.
| | - Xiao-Jun Deng
- MD. Associate Professor, Department of Intensive Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China.
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16
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Siegrist V, Eken C, Nickel CH, Mata R, Hertwig R, Bingisser R. End-of-life decisions in emergency patients: prevalence, outcome and physician effect. QJM 2018; 111:549-554. [PMID: 29860409 DOI: 10.1093/qjmed/hcy112] [Citation(s) in RCA: 7] [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] [Received: 04/04/2018] [Revised: 05/08/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND End-of-life decisions (EOLD) represent potentially highly consequential decisions often made in acute situations, such as 'do not attempt resuscitation' (DNAR) choices at emergency presentation. AIM We investigated DNAR decisions in an emergency department (ED) to assess prevalence, associated patient characteristics, potential medical and economic consequences and estimate contributions of patients and physicians to DNAR decisions. DESIGN Single-centre retrospective observation, including ED patients with subsequent hospitalization between 2012 and 2016. Primary outcome was a DNAR decision and associated patient characteristics. Secondary outcomes were mortality, admission to intensive care unit and use of resources. METHODS Associations between DNAR and patient characteristics were analysed using logistic mixed effects models, results were reported as odds ratios (OR). Median odds ratios (MOR) were used to estimate patient and physician contributions to variability in DNAR. RESULTS Patients of 10 458 were attended by 315 physicians. DNAR was the choice in 23.3% of patients. Patients' characteristics highly associated with DNAR were age (OR = 4.0, 95% CI = 3.6-4.3) and non-trauma presentation (OR = 2.3, 95% CI = 1.9-2.9). In-hospital mortality was significantly higher (OR = 5.4, CI = 4.0-7.3), and use of resources was significantly lower (OR = 0.7, CI = 0.6-0.8) in patients choosing DNAR. There was a significant effect on DNAR by both patient (MOR = 1.8) and physician (MOR = 2.0). CONCLUSIONS DNAR choices are common in emergency patients and closely associated with age and non-trauma presentation. Mortality was significantly higher, and use of resources significantly lower in DNAR patients. Evidence of a physician effect raises questions about the choice autonomy of emergency patients in the process of EOLD.
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Affiliation(s)
- V Siegrist
- Emergency Department, University Hospital Basel
- Center for Cognitive and Decision Sciences, University of Basel, Basel, Switzerland
| | - C Eken
- Emergency Department, University Hospital Basel
| | - C H Nickel
- Emergency Department, University Hospital Basel
| | - R Mata
- Center for Cognitive and Decision Sciences, University of Basel, Basel, Switzerland
| | - R Hertwig
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
| | - R Bingisser
- Emergency Department, University Hospital Basel
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Kontouli Z, Staikou C, Iacovidou N, Mamais I, Kouskouni E, Papalois A, Papapanagiotou P, Gulati A, Chalkias A, Xanthos T. Resuscitation with centhaquin and 6% hydroxyethyl starch 130/0.4 improves survival in a swine model of hemorrhagic shock: a randomized experimental study. Eur J Trauma Emerg Surg 2018; 45:1077-1085. [PMID: 30006694 DOI: 10.1007/s00068-018-0980-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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] [Received: 01/04/2018] [Accepted: 07/10/2018] [Indexed: 01/07/2023]
Abstract
PURPOSE To investigate the effects of the combination of centhaquin and 6% hydroxyethyl starch 130/0.4 (HES 130/0.4) in a swine model of hemorrhagic shock. METHODS Twenty Landrace-Large White pigs were instrumented and subjected to hemorrhagic shock. The animals were randomly allocated in two experimental groups, the control (group CO, n = 10) and the centhaquin groups (0.015 mg/kg, n = 10, group CH). Acute hemorrhage was induced by stepwise blood withdrawal (18 mL/min) from the internal jugular vein until MAP decreased to 40-45 mmHg, whereas anesthesia remained constant. All animals received HES 130/0.4 solution in the resuscitation phase until their mean arterial pressure (MAP) reached 90% of the baseline. The animals were observed for 60 min, during which no further resuscitation was attempted. RESULTS The total amount of blood and the bleeding time did not differ significantly between group CO and group CH (120 ± 13 vs. 120 ± 14 mL, p = 0.6; 20 ± 2 vs. 20 ± 1 min, p = 0.62, respectively). During the hemorrhagic phase, only a difference in heart rate (97.6 ± 4.4 vs. 128.4 ± 3.6 beats/min, p = 0.038) was observed between the two groups. The time required to reach the target MAP was significantly shorter in the centhaquin group compared to controls (13.7 ± 0.4 vs. 19.6 ± 0.84 min, p = 0.012). During the resuscitation phase, a statistical significant difference was observed in MAP (75.2 ± 1.6 vs. 89.8 ± 2.1 mmHg, p = 0.02) between group CO and group CH. During the observation phase, a statistical significant difference was observed in SVR (1109 ± 32.65 vs. 774.6 ± 21.82 dyn s/cm5, p = 0.039) and cardiac output (5.82 ± 0.31 vs. 6.9 ± 0.78 L/min, p = 0.027) between the two groups. Two animals of group CO and seven animals of group CH survived for 24 h (p = 0.008). We observed a marked increase in microvascular capillary permeability in group CO compared to group CH, with the wet/dry weight ratio being significantly higher in group CO compared to group CH (4.8 ± 1.6 vs. 3.08 ± 0.6, p < 0.001). CONCLUSIONS The combination of centhaquin 0.015 mg/kg and HES 130/0.4 resulted in shorter time to target MAP, lower wet-to-dry ratio, and better survival rates after resuscitation from hemorrhagic shock.
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Affiliation(s)
- Zinais Kontouli
- Postgraduate Study Program (MSc) "Cardiopulmonary Resuscitation", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Chryssoula Staikou
- Department of Anesthesiology, Medical School, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nicoletta Iacovidou
- Postgraduate Study Program (MSc) "Cardiopulmonary Resuscitation", Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neonatology, Medical School, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | - Ioannis Mamais
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Health Sciences, European University Cyprus, Nicosia, Cyprus
- Department of Life Sciences, European University Cyprus, Nicosia, Cyprus
| | - Evaggelia Kouskouni
- Postgraduate Study Program (MSc) "Cardiopulmonary Resuscitation", Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Biopathology, Medical School, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Anil Gulati
- Department of Pharmaceutical Sciences, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | - Athanasios Chalkias
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece.
- Department of Anesthesiology and Perioperative Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larisa, Greece.
- , Larisa, Greece.
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18
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Duchesne J, Majoue C, Duke M, Robledo R, Achord C, McHale L, Davis B, Nahapetyan L. Impact of Trauma-Certified Registered Nurse Anesthetists Team on Intra-Operative Resuscitation and Postoperative Outcomes of Trauma Patients. Am Surg 2018; 84:93-98. [PMID: 29428034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
A Trauma Certified Registered Nurse Anesthetists Team (TCT) was created and trained to provide trauma-focused anesthesia and resuscitation. The purpose of this study was to examine patient outcomes after implementation of TCT. We conducted retrospective analyses of trauma patients managed with surgical intervention from March to December 2015. During the first five months, patients managed before the development of TCT were grouped No-TCT, patients managed after were grouped TCT. To assess outcomes, we used hospital and intensive care unit length of stay, ventilator days, and a validated 10-point intraoperative Apgar score (IOAS). IOAS is calculated using the estimated blood loss, lowest heart rate, and lowest mean arterial pressure during surgery. Higher IOAS are associated with significantly decreased complications and mortality after surgery. We used t test and nonparametric tests for analyses. Fifty two patients were included (mean age 39 years, 75% male; 46.2% managed with TCT). Patients in the No-TCT group had significantly lower use of vasopressors (0.019), lower mean IOAS (P = 0.02), and spent more days on ventilator (P = 0.005) than patients in the TCT. These results suggest that trauma centers should take into consideration implementation of TCT to improve intraoperative and overall outcomes.
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El-Shafy IA, Delgado J, Akerman M, Bullaro F, Christopherson NAM, Prince JM. Closed-Loop Communication Improves Task Completion in Pediatric Trauma Resuscitation. J Surg Educ 2018; 75:58-64. [PMID: 28780315 DOI: 10.1016/j.jsurg.2017.06.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/05/2017] [Accepted: 06/19/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Pediatric trauma care requires effective and clear communication in a time-sensitive manner amongst a variety of disciplines. Programs such as Crew Resource Management in aviation have been developed to systematically prevent errors. Similarly, teamSTEPPS has been promoted in healthcare with a strong focus on communication. We aim to evaluate the ability of closed-loop communication to improve time-to-task completion in pediatric trauma activations. METHODS All pediatric trauma activations from January to September, 2016 at an American College of Surgeons verified level I pediatric trauma center were video recorded and included in the study. Two independent reviewers identified and classified all verbal orders issued by the trauma team leader for order audibility, directed responsibility, check-back, and time-to-task-completion. The impact of pre-notification and level of activation on time-to-task-completion was also evaluated. All analyses were performed using SAS® version 9.4(SAS Institute Inc., Cary, NC). RESULTS In total, 89 trauma activation videos were reviewed, with 387 verbal orders identified. Of those, 126(32.6%) were directed, 372(96.1%) audible, and 101(26.1%) closed-loop. On average each order required 3.85 minutes to be completed. There was a significant reduction in time-to-task-completion when closed-loop communication was utilized (p < 0.0001). Orders with closed-loop communication were completed 3.6 times sooner as compared to orders with an open-loop [HR = 3.6 (95% CI: 2.5, 5.3)]. There was not a significant difference in time-to-task-completion with respect to pre-notification by emergency service providers (p < 0.6100). [HR = 1.1 (95% CI: 0.9, 1.3)]. There was also not a significant difference in time-to-task-completion with respect to level of trauma team activation (p < 0.2229). [HR = 1.3 (95% CI: 0.8, 2.1)]. CONCLUSION While closed-loop communication prevents medical errors, our study highlights the potential to increase the speed and efficiency with which tasks are completed in the setting of pediatric trauma resuscitation. Trauma drills and systems of communication that emphasize the use of closed-loop communication should be incorporated into the training of trauma team leaders. LEVEL OF EVIDENCE This is a prospective observational study with intervention level II evidence.
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Affiliation(s)
- Ibrahim Abd El-Shafy
- Department of Surgery, Hofstra Northwell School of Medicine, Cohen Children׳s Medical Center, New Hyde Park, New York; Feinstein Institute for Medical Research, Manhasset, New York; Department of Surgery, Maimonadies Medical Center, Brooklyn, New York
| | - Jennifer Delgado
- Department of Surgery, Hofstra Northwell School of Medicine, Cohen Children׳s Medical Center, New Hyde Park, New York
| | | | - Francesca Bullaro
- Department of Surgery, Hofstra Northwell School of Medicine, Cohen Children׳s Medical Center, New Hyde Park, New York
| | - Nathan A M Christopherson
- Department of Surgery, Hofstra Northwell School of Medicine, Cohen Children׳s Medical Center, New Hyde Park, New York; Department of Surgery, Maimonadies Medical Center, Brooklyn, New York
| | - Jose M Prince
- Department of Surgery, Hofstra Northwell School of Medicine, Cohen Children׳s Medical Center, New Hyde Park, New York; Feinstein Institute for Medical Research, Manhasset, New York; Trauma Institute, Northwell Health System, New York.
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20
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Mader TJ, Westafer LM, Nathanson BH, Villarroel N, Coute RA, McNally BF. Targeted Temperature Management Effectiveness in the Elderly: Insights from a Large Registry. Ther Hypothermia Temp Manag 2017; 7:222-230. [PMID: 28557694 PMCID: PMC5712789 DOI: 10.1089/ther.2017.0015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 10/19/2022] Open
Abstract
Targeted temperature management (TTM) is recommended for all comatose adult out-of-hospital cardiac arrest (OHCA) patients with shockable first documented rhythm. However, studies examining the use and benefits of TTM among patients aged 75 and older are lacking. Using the Cardiac Arrest Registry to Enhance Survival (CARES) dataset registry from 2013 to 2015. Study criteria included being 75 years of age or older, survival to hospital admission, and known in-hospital mortality and CPC (Cerebral Performance Categories Scale) Scores. The study outcomes were in-hospital mortality and poor neurologic outcomes (CPC Scores 3 or 4) at hospital discharge among survivors. Hierarchical logistic regression and propensity score matching were used for multivariable adjustment. Two thousand nine hundred eighty-two patients met study inclusion criteria. One thousand three hundred fifty-seven (45.5%) received TTM in the admitting hospital. Receipt of TTM was more likely among men, those with a shockable first documented rhythm, and those with their event witnessed. There was no significant association with TTM and in-hospital mortality among patients with ventricular fibrillation (odds ratio [OR] = 0.88; 95% confidence interval [CI] [0.62-1.25]), p = 0.487 within the cohort. However, patients with a nonshockable first rhythm receiving TTM had higher odds of in-hospital mortality (p < 0.001). Propensity score results showed a modest association with TTM and increased mortality (OR) = 1.22, 95% CI [1.01-1.47]; p = 0.036 and no association with poor neurologic outcome (OR = 1.18; 95% CI [0.82-1.69]; p = 0.379) in the elderly. TTM is often provided to OHCA patients over age 75 though the benefits, particularly among nonshockable first documented rhythm patients are unclear. A randomized trial is needed to definitively answer who among OHCA event survivors aged 75 and older should receive this treatment.
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Affiliation(s)
- Timothy J. Mader
- Department of Emergency Medicine, Baystate Medical Center, Springfield, Massachusetts
| | - Lauren M. Westafer
- Department of Emergency Medicine, Baystate Medical Center, Springfield, Massachusetts
| | | | - Nadia Villarroel
- Department of Emergency Medicine, Baystate Medical Center, Springfield, Massachusetts
| | - Ryan A. Coute
- Kansas City University of Medicine and Biosciences, Kansas City, Missouri
| | - Bryan F. McNally
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
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Chung JJ, Earl-Royal EC, Delgado MK, Pascual JL, Reilly PM, Wiebe DJ, Holena DN. Where We Fail: Location and Timing of Failure to Rescue in Trauma. Am Surg 2017; 83:250-256. [PMID: 28316308 PMCID: PMC5858556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Failure to rescue (FTR) is an outcome metric that reflects a center's ability to prevent mortality after a major complication. Identifying the timing and location of FTR events could help target efforts to reduce FTR rates. We sought to characterize the timing and location of FTR occurrences at our center, hypothesizing that FTR rates would be highest early after injury and in settings of lower intensity of care. We used data, prospectively collected from 2009 to 2013, on patients ≥16 years old with minimum Abbreviated Injury Score ≥2 from a single institution. Major complications (per Pennsylvania Trauma Systems Foundation definitions), mortality, and FTR rates were examined by location [prehospital, emergency department, operating room, intensive care unit (ICU), and interventional radiology] and by day post admission. Kruskal-Wallis and chi-squared tests were used to compare variables (P = 0.05). Major complications occurred in 899/6150 (14.6%) of patients [median age: 42, interquartile range (IQR): 25-57; 56% African American, 73% male, 76% blunt; median Injury Severity Score: 10, IQR: 5-17]. Of 899, 111 died (FTR = 12.4%). Compared with non-FTR cases, FTR cases had earlier complications (median day 1 (IQR: 0-4) versus 5 (IQR: 2-8), P < 0.001). FTR rates were highest in the prehospital (55%), emergency department (38%), and operating room (36%) settings, but the greatest number of FTR cases occurred in the ICU (52/111, 47%). FTR rates were highest early after injury, but the majority of cases occurred in the ICU. Efforts to reduce institutional FTR rates should focus on complications that occur in the ICU setting.
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Diercks DB, Al-Khatib SM, Link MS. Resuscitation Science in Circulation: A Timely Topic. Circulation 2016; 134:2033-2034. [PMID: 27994020 DOI: 10.1161/circulationaha.116.026473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Deborah B Diercks
- From Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas (D.B.D.); Duke University Medical Center, Department of Medicine, Electrophysiology Section, Durham, NC (S.M.A.-K.); and Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (M.S.L.)
| | - Sana M Al-Khatib
- From Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas (D.B.D.); Duke University Medical Center, Department of Medicine, Electrophysiology Section, Durham, NC (S.M.A.-K.); and Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (M.S.L.)
| | - Mark S Link
- From Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas (D.B.D.); Duke University Medical Center, Department of Medicine, Electrophysiology Section, Durham, NC (S.M.A.-K.); and Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (M.S.L.).
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Abstract
The study objective of this article was to evaluate percutaneous dilatational tracheostomy (PDT) for emergent airway access. This is a case series of 9 patients who presented over a 58-month period. All patients were in severe respiratory difficulty where intubation by conventional means was unsuccessful. All 9 patients were successfully intubated using PDT technique. No technical complications were noted, specifically bleeding, extratracheal placement, or prolonged procedure time. Six patients ultimately died, 2 from anoxic encephalopathy due to failed resuscitation and 4 from comorbid illness. Three patients ultimately survived to hospital discharge. The authors conclude that PDT can effectively establish a surgical airway in an emergent setting. The major advantage of this technique is the ability to gain and maintain competence in an elective, controlled environment. The authors believe that PDT may play a role in the management of the emergent surgical airway.
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Affiliation(s)
- Mark J Ault
- Division of General Internal Medicine, Cedars-Sinai Medical Center and University of California Los Angeles School of Medicine, CA, USA.
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Kalina M. Implementation of an Acute Care Surgery Service in a Community Hospital: Impact on Hospital Efficiency and Patient Outcomes. Am Surg 2016; 82:79-84. [PMID: 26802862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
A service led by acute care surgeons managing trauma, critically ill surgical, and emergency general surgery patients via an acute care surgery model of patient care improves hospital efficiency and patient outcomes at university-affiliated hospitals and American College of Surgeons-verified trauma centers. Our goal was to determine whether an acute care surgeon led service, entitled the Surgical Trauma and Acute Resuscitative Service (STARS) that implemented an acute care surgery model of patient care, could improve hospital efficiency and patient outcomes at a community hospital. A total of 492 patient charts were reviewed, which included 230 before the implementation of the STARS [pre-STARS (control)] and 262 after the implementation of the STARS [post-STARS (study)]. Demographics included age, gender, Acute Physiology and Chronic Health Evaluation 2 score, and medical comorbidities. Efficiency data included length of stay in emergency department (ED-LOS), length of stay in surgical intensive care unit (SICU-LOS), and length of stay in hospital (H-LOS), and total in hospital charges. Average age was 64.1 + 16.4 years, 255 males (51.83%) and 237 females (48.17%). Average Acute Physiology and Chronic Health Evaluation 2 score was 11.9 + 5.8. No significant differences in demographics were observed. Average decreases in ED-LOS (9.7 + 9.6 hours, pre-STARS versus 6.6 + 4.5 hours, post-STARS), SICU-LOS (5.3 + 9.6 days, pre-STARS versus 3.5 + 4.8 days, post-STARS), H-LOS (12.4 + 12.7 days, pre-STARS versus 11.4 + 11.3 days, post-STARS), and total in hospital charges ($419,602.6 + $519,523.0 pre-STARS to $374,816.7 + $411,935.8 post-STARS) post-STARS. Regression analysis revealed decreased ED-LOS-2.9 hours [P = 0.17; 95% confidence interval (CI): -7.0, 1.2], SICU-LOS-6.3 days (P < 0.001; 95% CI: -9.3, -3.2), H-LOS-7.6 days (P = 0.001; 95% CI: -12.1, -3.1), and 3.4 times greater odds of survival (P = 0.04; 95% CI: 1.1, 10.7) post-STARS. In conclusion, implementation of the STARS improved hospital efficiency and patient outcomes at a community hospital.
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Affiliation(s)
- Michael Kalina
- Department of Surgery, Capital Health, Hopewell, New Jersey, USA
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Li ZH, Zhao YL, Zhu W, Yang G. The significance of mild hypothermia therapy on patients with successful resuscitation of cardiac arrest. Eur Rev Med Pharmacol Sci 2015; 19:2860-2865. [PMID: 26241541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To investigate the clinical significance of mild hypothermia therapy in patients with resuscitation of cardiac arrest and analyze the possible molecular mechanism. PATIENTS AND METHODS Ninety-six patients with successful resuscitation of cardiac arrest in ICU were hospitalized from June 2009 to July 2014. They were divided into a control group (n=37 cases) and an observation group (n=59 cases). All patients received high-grade life support treatment immediately after resuscitation. The treatment for the control group was combined with normal temperature treatment while the treatment for the observation group was combined with mild hypothermia therapy. RESULTS 1. Glasgow coma scale (GCS) scores of the patients in the two groups increased gradually after treatment as the APACHE II scores decreased. Comparisons within the group showed significant differences (p < 0.05). The GCS scores of the observation group were significantly increased compared to those in the control group, and the APACHE score decreased significantly. The differences between the groups were statistically significant (p < 0.05). 2. The serum lactic acid, sCD14, S100 β protein and TNF-a level of patients in two groups all decreased after treatment. The difference was statistically significant (p < 0.05 =. 3. The 24h and 7d survival rates of patients in the observation group are higher than that in the control group (p < 0.05). CONCLUSIONS The early treatment of hypothermia, can improve the outcome of patients with cardiac arrest.
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Affiliation(s)
- Z-H Li
- Department of Critical Care Medicine, Municipal Hospital affiliated to Xuzhou Medical College (Xuzhou First People's Hospital), Xuzhou, Jiangsu, China.
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Kim YW, Cha KC, Cha YS, Kim OH, Jung WJ, Kim TH, Han BK, Kim H, Lee KH, Choi E, Hwang SO. Shock duration after resuscitation is associated with occurrence of post-cardiac arrest acute kidney injury. J Korean Med Sci 2015; 30:802-7. [PMID: 26028935 PMCID: PMC4444483 DOI: 10.3346/jkms.2015.30.6.802] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/28/2015] [Indexed: 12/12/2022] Open
Abstract
This retrospective observational study investigated the clinical course and predisposing factors of acute kidney injury (AKI) developed after cardiac arrest and resuscitation. Eighty-two patients aged over 18 yr who survived more than 24 hr after cardiac arrest were divided into AKI and non-AKI groups according to the diagnostic criteria of the Kidney Disease/Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for AKI. Among 82 patients resuscitated from cardiac arrest, AKI was developed in 66 (80.5%) patients (AKI group) leaving 16 (19.5%) patients in the non-AKI group. Nineteen (28.8%) patients of the AKI group had stage 3 AKI and 7 (10.6%) patients received renal replacement therapy during admission. The duration of shock developed within 24 hr after resuscitation was shorter in the non-AKI group than in the AKI group (OR 1.02, 95% CI 1.01-1.04, P < 0.05). On Multiple logistic regression analysis, the only predisposing factor of post-cardiac arrest AKI was the duration of shock. In conclusion, occurrence and severity of post-cardiac arrest AKI is associated with the duration of shock after resuscitation. Renal replacement therapy is required for patients with severe degree (stage 3) post-cardiac arrest AKI.
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Affiliation(s)
- Yong Won Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kyoung Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yong Sung Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Oh Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Woo Jin Jung
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Tae Hoon Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Byoung Keun Han
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kang Hyun Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Eunhee Choi
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Yousaf UF, Hayat S, Afzal N. RESUSCITATION OF NEWBORNS IN HIGH RISK DELIVERIES. J Ayub Med Coll Abbottabad 2015; 27:343-345. [PMID: 26411112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND High risk deliveries are usually associated with increased neonatal mortality and morbidity. Neonatal resuscitation can appreciably affect the outcome in these types of deliveries. Presence of personnel trained in basic neonatal resuscitation at the time of delivery can play an important role in reducing perinatal complications in neonates at risk. The study was carried out to evaluate the effects of newborn resuscitation on neonatal outcome in high risk deliveries. METHODS This descriptive case series was carried out at the Department of Obstetrics and Gynecology, Jinnah Hospital, Lahore. Ninety consecutive high risk deliveries were included and attended by paediatricians trained in newborn resuscitation. Babies delivered by elective Caesarean section, normal spontaneous vaginal deliveries and still births were excluded. Neonatal resuscitation was performed in babies who failed to initiate breathing in the first minute after birth. Data was analyzed using SPSS-16.0. RESULTS A total of 90 high risk deliveries were included in the study. Emergency. caesarean section was the mode of delivery in 94.4% (n=85) cases and spontaneous vaginal delivery in 5.6% (n=5). Preterm pregnancy was the major high risk factor. Newborn resuscitation was required in 37.8% (n=34) of all high risk deliveries (p=0.013). All the new-borns who required resuscitation survived. CONCLUSION New-born resuscitation is required in high risk pregnancies and personnel trained in newborn resuscitation should be available at the time of delivery.
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Nau JY. [Deprived of blood and in induced-hypothermia: will they still be alive?]. Rev Med Suisse 2014; 10:1314-1315. [PMID: 25073305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Semple-Hess J, Campwala R. Pediatric submersion injuries: emergency care and resuscitation. Pediatr Emerg Med Pract 2014; 11:1-21; quiz 21-2. [PMID: 25090739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Drowning and submersion injuries are highly prevalent, yet preventable, causes of childhood mortality and morbidity. Although much of the resuscitation of the drowning pediatric victim is basic to all respiratory and cardiac arrest situations, there are some caveats for treatment of this type of injury. Risk factors for drowning victims include epilepsy, underlying cardiac dysrhythmias, hyperventilation, hypoglycemia, hypothermia, and alcohol and illicit drug use. Prehospital care should focus on restoring normal ventilation and circulation as quickly as possible to limit the extent of hypoxic insult. Diagnostic testing for symptomatic patients may include blood glucose level, arterial blood gas level, complete blood count, electrolytes levels, chest radiography, and cardiorespiratory monitoring with pulse oximetry and a rhythm strip. In this review, passive external, active external, and active internal rewarming techniques for treatment of hypothermic patients are discussed. A systematic approach to treatment and disposition or admission of pediatric drowning victims is also included, with extensive clinical pathways for quick reference.
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Naik AD. Peering inside the black box of patient-centered care. Circ Cardiovasc Qual Outcomes 2014; 7:347-9. [PMID: 24823950 DOI: 10.1161/circoutcomes.114.001038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Aanand D Naik
- From the Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, TX (A.D.N.); and Department of Medicine (Health Services Research), Baylor College of Medicine, Houston, TX (A.D.N.).
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Davis JS, Alsafran S, Richie CD, Moore JW, Namias N, Schulman CI. Time to resuscitate a sacred cow...with normal saline. Am Surg 2014; 80:301-306. [PMID: 24666873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Normal saline (NS) is not used for trauma resuscitation because of its potential for acidosis. Lactated Ringer's (LR) is preferred instead. However, the two crystalloids have never been compared in trauma patients. We hypothesized that NS would be an acceptable fluid for resuscitation in the trauma patient. In 2011, a Level I trauma center switched resuscitation fluid from LR to NS. Admissions before and after the change were retrospectively reviewed. Demographics, vitals, blood work, and fluid intake were recorded over 24 hours. Acidosis level, stratified by Injury Severity Score (ISS), was compared. Four hundred ten patients were included, 207 in the LR cohort and 203 in the NS. Chloride (LR 105.26 ± 4.75 vs NS 106.48 ± 4.19), base excess (-2.53 ± 3.77 vs -3.28 ± 4.15), pH (7.37 ± 0.08 vs 7.36 ± 0.07), and bicarbonate (22.83 ± 3.45 vs 21.65 ± 5.06) were statistically different but not clinically significant. This was also true when results were stratified by ISS. In addition, there was no difference in the number of blood gases drawn between the groups (584 vs 544, P = nonsignificant). NS resuscitation is a safe, viable alternative to LR in the trauma population studied. Its use carries a potentially substantial cost savings on a national level.
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Affiliation(s)
- James S Davis
- Division of Trauma and Critical Care, Jackson Memorial Hospital/University of Miami Burn Center, Miller School of Medicine University of Miami, Miami, Florida, USA
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Tobias AZ, Guyette FX, Seymour CW, Suffoletto BP, Martin-Gill C, Quintero J, Kristan J, Callaway CW, Yealy DM. Pre-resuscitation lactate and hospital mortality in prehospital patients. PREHOSP EMERG CARE 2014; 18:321-7. [PMID: 24548128 DOI: 10.3109/10903127.2013.869645] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Serum lactate elevations are associated with morbidity and mortality in trauma patients, but their value in prehospital medical patients prior to resuscitation is unknown. We sought to assess the distribution of blood lactate concentrations prior to intravenous (i.v.) resuscitation and examine the association of elevation on in-hospital death. METHODS A convenience sample of adult patients over 14 months who received an i.v. line by eight EMS agencies in Western Pennsylvania had lactate measurement prior to any i.v. treatment. We assessed the lactate values and any relationship between these and hospital mortality (our primary outcome) and admission to the intensive care unit (ICU). We also compared the ability of lactate to discriminate outcomes with a prehospital critical illness score using age, Glasgow Coma Score, and initial vital signs. RESULTS We included 673 patients, among whom 71 (11%) were admitted to the ICU and 21 (3.1%) died in-hospital. Elevated lactate (≥2 mmol/L) occurred in 307 (46%) patients and was strongly associated with hospital death after adjustment for known covariates (odds ratio = 3.57, 95% confidence interval [CI]: 1.10, 11.6). Lactate ≥2 mmol/L had a modest sensitivity (76%) and specificity (55%), and discrimination for hospital death (area under the curve [AUC] = 0.66, 95%CI: 0.56, 0.75). Compared to the prehospital critical illness score alone (AUC = 0.69, 95% CI: 0.59, 0.80), adding lactate to the score offered modest improvement (net reclassification improvement = 0.63, 95%CI: 0.23, 1.01, p < 0.05). CONCLUSIONS Initial lactate concentration in our prehospital medical patient population was associated with hospital mortality. However, it is a modest predictor of outcome, offering similar discrimination to a prehospital critical illness score.
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Madsen TE, Simmons J, Choo EK, Portelli D, McGregor AJ, Napoli AM. The DISPARITY Study: do gender differences exist in Surviving Sepsis Campaign resuscitation bundle completion, completion of individual bundle elements, or sepsis mortality? J Crit Care 2014; 29:473.e7-11. [PMID: 24559576 DOI: 10.1016/j.jcrc.2014.01.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [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] [Received: 08/02/2013] [Revised: 11/11/2013] [Accepted: 01/06/2014] [Indexed: 01/30/2023]
Abstract
PURPOSE Women in the emergency department are less likely to receive early goal directed therapy, but gender differences in the Surviving Sepsis Campaign (SSC) bundle completion have not been studied [1]. We hypothesized that women have lower SSC resuscitation bundle completion rates. MATERIALS AND METHODS This was a retrospective, observational study in a large urban academic ED at a national SSC site. Consecutive patients (age>18 years) admitted to intensive care with severe sepsis or septic shock and entered into the SSC database from October 2005 to February 2012 were included. Data on overall and individual bundle elements were exported from the database. Bivariate analyses were performed with chi-square tests and t-tests. Multiple logistic regression was then performed with gender as an effect modifier. RESULTS Eight hundred fourteen patients were enrolled. The mean age was 66 years;, 44.8% were women. There was no association between gender and bundle completion (aOR 0.83, 95% CI 0.58-1.16), controlling for age, race, Sequential Organ Failure Assessment, congestive heart failure, and coagulopathy. In-hospital mortality did not differ by gender. Women were less likely to receive antibiotics within 3 hours (60.5% vs. 68.8%, p=0.01) and less likely to reach a target ScvO2>70 (31.3% vs. 39.5%, P=.05). CONCLUSIONS There were no gender disparities in bundle completion or in-hospital mortality. Further research is needed to examine individual bundle elements and gender specific factors that may affect bundle completion and mortality.
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Affiliation(s)
- Tracy E Madsen
- Division of Women's Health in Emergency Care, The Alpert Medical School of Brown University, Department of Emergency Medicine, Rhode Island Hospital, Providence, RI; The Alpert Medical School of Brown University, Department of Emergency Medicine, Rhode Island Hospital, Providence, RI.
| | - James Simmons
- Boston University School of Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Esther K Choo
- Division of Women's Health in Emergency Care, The Alpert Medical School of Brown University, Department of Emergency Medicine, Rhode Island Hospital, Providence, RI; The Alpert Medical School of Brown University, Department of Emergency Medicine, Rhode Island Hospital, Providence, RI
| | - David Portelli
- The Alpert Medical School of Brown University, Department of Emergency Medicine, Rhode Island Hospital, Providence, RI
| | - Alyson J McGregor
- Division of Women's Health in Emergency Care, The Alpert Medical School of Brown University, Department of Emergency Medicine, Rhode Island Hospital, Providence, RI; The Alpert Medical School of Brown University, Department of Emergency Medicine, Rhode Island Hospital, Providence, RI
| | - Anthony M Napoli
- Division of Women's Health in Emergency Care, The Alpert Medical School of Brown University, Department of Emergency Medicine, Rhode Island Hospital, Providence, RI; The Alpert Medical School of Brown University, Department of Emergency Medicine, Rhode Island Hospital, Providence, RI
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Duggan MJ, Rago A, Marini J, Beagle J, Peev M, Velmahos G, Sharma U, King DR. Development of a lethal, closed-abdomen, arterial hemorrhage model in noncoagulopathic swine. J Surg Res 2013; 187:536-41. [PMID: 24398305 DOI: 10.1016/j.jss.2013.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [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] [Received: 09/12/2013] [Revised: 11/19/2013] [Accepted: 12/06/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prehospital treatment for noncompressible abdominal bleeding, particularly due to large vascular injury, represents a significant unmet medical need on the battlefield and in civilian trauma. To date, few large animal models are available to assess new therapeutic interventions and hemostatic agents for prehospital hemorrhage control. METHODS We developed a novel, lethal, closed-abdomen injury model in noncoagulopathic swine by strategic placement of a cutting wire around the external iliac artery. The wire was externalized, such that percutaneous distraction would result in vessel transection leading to severe uncontrolled abdominal hemorrhage. Resuscitation boluses were administered at 5 and 12 min. RESULTS We demonstrated 86% mortality (12/14 animals) at 60 min, with a median survival time of 32 min. The injury resulted in rapid and massive hypotension and exsanguinating blood loss. The noncoagulopathic animal model incorporated clinically significant resuscitation and ventilation protocols based on best evidenced-based prehospital practices. CONCLUSION A new injury model is presented that enables screening of prehospital interventions designed to control noncompressible arterial hemorrhage.
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Affiliation(s)
- Michael J Duggan
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Adam Rago
- Arsenal Medical, Inc., Watertown, Massachusetts
| | - John Marini
- Arsenal Medical, Inc., Watertown, Massachusetts
| | - John Beagle
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Miroslav Peev
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - George Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Upma Sharma
- Arsenal Medical, Inc., Watertown, Massachusetts
| | - David R King
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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Long K, Heaney JB, Simms ER, McSwain NE, Duchesne JC. When enough is enough: impact of packed red blood cells in massive transfusion outcomes. Am Surg 2013; 79:810-814. [PMID: 23896250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Massive transfusion protocol (MTP) with fresh-frozen plasma and packed red blood cells (PRBCs) in a 1:1 ratio is one of the most common resuscitative strategies used in patients with severe hemorrhage. There are no studies to date that examine the best postoperative hematocrit range as a marker for survival after MTP. We hypothesize a postoperative hematocrit dose-dependent survival benefit in patients receiving MTP. This was a 53-month retrospective analysis of patients with intra-abdominal injuries requiring surgery and transfusion of 10 units PRBCs or more at a single Level I trauma center. Groups were defined by postoperative hematocrit (less than 21, 21 to 29, 29.1 to 39, and 39 or more). Kaplan-Meier (KM) survival probability was calculated. One hundred fifty patients requiring operative abdominal explorations and 10 units PRBCs or more were identified. There were no significant differences in demographics between groups. When comparing postoperative hematocrit groups, relative to a hematocrit of less than 21 per cent in KM survival analysis, an overall survival advantage was only evident in patients transfused to hematocrits 29.1 to 39 per cent (P < 0.03; odds ratio [OR], 0.284; 95% confidence interval [CI], 0.089 to 0.914). This survival advantage was not seen in the other groups (21 to 29: OR, 0.352; 95% CI, 0.103 to 1.195 or 39% or greater: OR, 0.107; 95% CI, 0.010 to 1.121). This is the first study to examine the impact of postoperative hematocrit as an indicator of survival after MTP in the trauma patient. Transfusion to hematocrits between 29.1 and 39 per cent conveyed a survival benefit, whereas resuscitation to supraphysiologic hematocrits 39 per cent or greater conveyed no additional survival benefit. This study highlights the need for judicious PRBC administration during MTP and its potential impact on survival in patients with postoperative supraphysiologic hematocrits.
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Affiliation(s)
- Kira Long
- Department of Surgery, Tulane University, New Orleans, Louisiana 70112, USA.
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Tanaka K. [Limits and challenges of resuscitation for the elderly in emergency and critical care center]. Nihon Rinsho 2013; 71:1084-1088. [PMID: 23855218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
In recent years, there has been an increase in the elderly ambulance. An increasing number of elderly patients require hospitalization. Old age brings with it an increased susceptibility to respiratory diseases. Bad prehospital ADL (activities of daily living) results in poor, survival rate and final ADL. At present, the elderly are facing physical, mental and social problems, and are having difficulty in receiving proper emergency and critical care treatment. There needs to be change in the quality of emergency and critical care, one that focuses on life-saving while maintaining ADL. There is an urgent need for restructuring of the regional emergency medical system and implementing measures for terminal care in emergency medical care for the elderly.
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Affiliation(s)
- Keiji Tanaka
- Emergency and Critical Care Medicine, School of Medicine, Showa University
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Abstract
BACKGROUND Colloids are widely used in the replacement of fluid volume. However, doubts remain as to which colloid is best. Different colloids vary in their molecular weight and therefore in the length of time they remain in the circulatory system. Because of this, and their other characteristics, they may differ in their safety and efficacy. OBJECTIVES To compare the effects of different colloid solutions in patients thought to need volume replacement. SEARCH METHODS We searched the Cochrane Injuries Specialised Register (searched 1 December 2011), the Cochrane Central Register of Controlled Trials 2011, issue 4 (The Cochrane Library); MEDLINE (Ovid) (1948 to November Week 3 2011); EMBASE (Ovid) (1974 to 2011 Week 47); ISI Web of Science: Science Citation Index Expanded (1970 to 1 December 2011); ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to 1 December 2011); CINAHL (EBSCO) (1982 to 1 December 2011); National Research Register (2007, Issue 1) and PubMed (searched 1 December 2011). Bibliographies of trials retrieved were searched, and for the initial version of the review drug companies manufacturing colloids were contacted for information (1999). SELECTION CRITERIA Randomised controlled trials comparing colloid solutions in critically ill and surgical patients thought to need volume replacement. DATA COLLECTION AND ANALYSIS Two review authors independently extracted the data and assessed the quality of the trials. The outcomes sought were death, amount of whole blood transfused, and incidence of adverse reactions. MAIN RESULTS Eighty-six trials, with a total of 5,484 participants, met the inclusion criteria. Quality of allocation concealment was judged to be adequate in 33 trials and poor or uncertain in the rest.Deaths were reported in 57 trials. For albumin or plasma protein fraction (PPF) versus hydroxyethyl starch (HES) 31 trials (n = 1719) reported mortality. The pooled relative risk (RR) was 1.06 (95% confidence interval (CI) 0.86 to 1.31). When the trials by Boldt were removed from the analysis the pooled RR was 0.90 (95% CI 0.68 to 1.20). For albumin or PPF versus gelatin, nine trials (n = 824) reported mortality. The RR was 0.89 (95% CI 0.65 to 1.21). Removing the study by Boldt from the analysis did not change the RR or CIs. For albumin or PPF versus dextran four trials (n = 360) reported mortality. The RR was 3.75 (95% CI 0.42 to 33.09). For gelatin versus HES 22 trials (n = 1612) reported mortality and the RR was 1.02 (95% CI 0.84 to 1.26). When the trials by Boldt were removed from the analysis the pooled RR was 1.03 (95% CI 0.84 to 1.27). RR was not estimable in the gelatin versus dextran and HES versus dextran groups.Forty-one trials recorded the amount of blood transfused; however, quantitative analysis was not possible due to skewness and variable reporting. Twenty-four trials recorded adverse reactions, with two studies reporting possible adverse reactions to gel and one to HES. AUTHORS' CONCLUSIONS From this review, there is no evidence that one colloid solution is more effective or safe than any other, although the CIs were wide and do not exclude clinically significant differences between colloids. Larger trials of fluid therapy are needed if clinically significant differences in mortality are to be detected or excluded.
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Affiliation(s)
- Frances Bunn
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK.
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Abstract
BACKGROUND Emergency missions can also be necessary for patients in the terminal phase of a progressive incurable disease. The emergency physician, accustomed to acting under strict procedures and whose training focuses on the restoration and stabilization of acutely threatened vital functions, can face severe difficulties when treating incurably ill patients in the terminal phase. This study investigates the number of such cases, patient symptoms and the events occurring during life-threatening emergencies of terminally ill patients. METHOD All cases of emergency events involving terminally ill patients were analyzed prospectively. In addition to the standardized protocol (following DIVI/Mind 2) an enquiry sheet was used, which contained an 8-item checklist specifically for terminally ill patients, to be filled out by the responding physician. RESULTS The total number of patients in the terminal phase identified by the emergency physician was 55 (0.72% of total cases) and of these patients 30 (55%) were tumor patients. The most frequent complaint observed was dyspnea (30 patients, 55%), followed by relatives of the patients experiencing the stress of caring for a terminally ill person (19 patients, 35%). The leading symptom of 6 patients (11%) was pain. Only 17 cases (30.9%) required transport of the patient to hospital for further treatment. CONCLUSION Every emergency physician can be confronted with an emergency involving a patient with a progressive incurable disease. The condition of each patient must be assessed for each medical decision. Not only medical, but also psychosocial, ethical and legal aspects have to be considered.
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Affiliation(s)
- R Laufenberg-Feldmann
- Klinik für Anästhesiologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131 Mainz, Deutschland.
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Abstract
BACKGROUND A respiratory function monitor is routinely used in neonatal intensive care units to continuously measure and display airway pressures, tidal volume and leak during ventilation. During positive pressure ventilation in the delivery room, clinical signs are used to monitor the effectiveness of ventilation. The additional use of a respiratory function monitor during positive pressure ventilation in the delivery room might help to improve the effectiveness of ventilation. OBJECTIVES To determine whether the use of a respiratory function monitor in addition to clinical assessment compared to clinical assessment alone in newborn infants resuscitated with positive pressure ventilation reduces mortality and morbidity. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2010), MEDLINE (January 1996 to March 2010), EMBASE (January 1980 to March 2010) and CINAHL (January 1982 to March 2010). Clinical trials registers and the abstracts of the Society for Pediatric Research and the European Society for Pediatric Research were searched from 2004 to 2009. No language restrictions were applied. SELECTION CRITERIA We planned to include randomised and quasi-randomised controlled trials and cluster trials that compared the use of a respiratory function monitor in addition to clinical assessment, compared to clinical assessment alone, in newborn infants resuscitated with positive pressure ventilation. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated the search results against the selection criteria. Data extraction and risk of bias assessment were not performed because there were no studies that met our inclusion criteria. MAIN RESULTS No studies were found meeting the criteria for inclusion in this review AUTHORS' CONCLUSIONS There is insufficient evidence to determine the efficacy and safety of a respiratory function monitor in addition to clinical assessment during positive pressure ventilation at neonatal resuscitation. Randomised clinical trials comparing positive pressure ventilation with and without a respiratory function monitor in addition to clinical assessment at neonatal resuscitation are warranted.
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Affiliation(s)
- Georg M Schmölzer
- Department of Newborn Research, The Royal Women's Hospital, 20 Flemington Road, Parkville, Victoria, Australia, 3052
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Zink T. Reflections on an untimely death. Could volunteers from the United States have prevented a Nicaraguan woman's demise? Minn Med 2010; 93:28-31. [PMID: 20481164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Therese Zink
- Department of Family and Community Medicine, University of Minnesota, USA
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Jones AE, Brown MD, Trzeciak S, Shapiro NI, Garrett JS, Heffner AC, Kline JA. The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: a meta-analysis. Crit Care Med 2008; 36:2734-9. [PMID: 18766093 PMCID: PMC2737059 DOI: 10.1097/ccm.0b013e318186f839] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Quantitative resuscitation consists of structured cardiovascular intervention targeting predefined hemodynamic end points. We sought to measure the treatment effect of quantitative resuscitation on mortality from sepsis. DATA SOURCES We conducted a systematic review of the Cochrane Library, MEDLINE, EMBASE, CINAHL, conference proceedings, clinical practice guidelines, and other sources using a comprehensive strategy. STUDY SELECTION We identified randomized control trials comparing quantitative resuscitation with standard resuscitation in adult patients who were diagnosed with sepsis using standard criteria. The primary outcome variable was mortality. DATA ABSTRACTION Three authors independently extracted data and assessed study quality using standardized instruments; consensus was reached by conference. Preplanned subgroup analysis required studies to be categorized based on early (at the time of diagnosis) vs. late resuscitation implementation. We used the chi-square test and I to assess for statistical heterogeneity (p < 0.10, I > 25%). The primary analysis was based on the random effects model to produce pooled odds ratios with 95% confidence intervals. RESULTS The search yielded 29 potential publications; nine studies were included in the final analysis, providing a sample of 1001 patients. The combined results demonstrate a decrease in mortality (odds ratio 0.64, 95% confidence interval 0.43-0.96); however, there was statistically significant heterogeneity (p = 0.07, I = 45%). Among the early quantitative resuscitation studies (n = 6) there was minimal heterogeneity (p = 0.40, I = 2.4%) and a significant decrease in mortality (odds ratio 0.50, 95% confidence interval 0.37-0.69). The late quantitative resuscitation studies (n = 3) demonstrated no significant effect on mortality (odds ratio 1.16, 95% confidence interval 0.60-2.22). CONCLUSION This meta-analysis found that applying an early quantitative resuscitation strategy to patients with sepsis imparts a significant reduction in mortality.
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Affiliation(s)
- Alan E Jones
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA.
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Piankowski A, Skowroński R, Sidorowicz M, Owczuk R. [Selected factors affecting long-term outcomes of in-hospital resuscitation]. Anestezjol Intens Ter 2008; 40:22-27. [PMID: 19469094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Results of resuscitation attempts and subsequent survival rates can now be analysed, based on the Utstein templates. Few such reports have been published so far in Poland. METHODS We have retrospectively analysed the outcomes of in-hospital resuscitation attempts, performed during 30 months in a large university hospital.The buildings were spread over 5.72 hectares, with the longest distance between buildings being 500 m. The resuscitation team consisted of an anaesthesiologist and a specialized nurse equipped with a basic set containing airway equipment, intravenous cannulas and drugs. Resuscitation protocols were analysed according to the Utstein templates. RESULTS There were 198 resuscitation attempts registered. In 47% of the cases, the circulation returned, but 28% of the patients died within 24 hours. 11% were discharged home, however 9 patients died within the next 6 months. 6% of the resuscitated patients survived over 12 months and were rated grade 1 or 2 on the CPC (Cerebral Performance Category) scale.The 12-month survival rate correlated only with the time from cardiac arrest to the first adrenaline injection. The in-hospital survival rate (possibility of discharge) correlated with the duration of hospitalization before cardiac arrest, the first registered cardiac rhythm (defibrillation-susceptible), and the time to first defibrillation. DISCUSSION The most pronounced difference between the results of in-hospital and pre-hospital CPR was the primary cardiac rhythm associated with the cardiac arrest. Defibrillation-susceptible rhythm was observed in only 15% of cases, and was associated with immediate survival and hospital discharge, but not with 12-month survival. The time to administration of the first dose of adrenaline was a sole factor associated with 12 month survival.
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Babbs CF. Statistical analysis of joint short-term and long-term survival in resuscitation research. Resuscitation 2007; 75:323-31. [PMID: 17583410 DOI: 10.1016/j.resuscitation.2007.04.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2007] [Revised: 04/21/2007] [Accepted: 04/27/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To develop statistical tools that use combined initial survival data and post-resuscitation survival data to test the null hypothesis that true, population-wide outcomes following experimental CPR interventions are not different from control. METHOD A new test statistic, d(2), for evaluating Type 1 error is derived from a bivariate, two-dimensional analysis of categorical initial resuscitation and post-resuscitation survival data, which are statistically independent because they are obtained during non-overlapping periods of time. The d(2) test statistic, which is distributed as a chi-squared distribution, is derived from first principles and validated using Monte Carlo methods of computer simulation for thousands of clinical trials. RESULTS Under the null hypothesis, the normalized difference in the proportions of patients surviving the initial resuscitation period and the normalized difference in the proportions of such short-term survivors that also survive the post-resuscitation period are jointly distributed in a two-dimensional space as a bivariate standard normal distribution, against which observed intervention and control outcomes can be compared in a test of statistical significance. Typically this two-dimensional approach has greater statistical power to detect true differences, compared to conventional one-dimensional tests. Smaller group sizes (Ns) are usually required to reach statistical significance when both initial survival and post-resuscitation survival are considered together. Such two-dimensional analysis is easily extended to meta-analysis of multiple trials. CONCLUSIONS A straightforward, easy-to-use bivariate test for Type I errors in statistical inference can be done for resuscitation studies reporting both short-term and long-term survival data. Acceptance of such two-dimensional tests of the null hypothesis, as proposed by Hallstrom, can save time, money, effort, and disappointment in the difficult and sometimes frustrating field of resuscitation research.
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Affiliation(s)
- Charles F Babbs
- Department of Basic Medical Sciences, Purdue University, 1246 Lynn Hall, West Lafayette, IN 47907-1246, USA.
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Hsieh WS, Jeng SF, Hung YL, Chen PC, Chou HC, Tsao PN. Outcome and hospital cost for infants weighing less than 500 grams: a tertiary centre experience in Taiwan. J Paediatr Child Health 2007; 43:627-31. [PMID: 17688647 DOI: 10.1111/j.1440-1754.2007.01137.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [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
AIM To determine the outcome and hospital cost for infants weighing < or =500 g at a tertiary centre in Taiwan. METHODS We retrospectively reviewed the medical records of infants who were born alive with birthweight < or =500 g at the National Taiwan University Hospital from 1997 to 2004. Their outcome and hospital cost were analysed. RESULTS A total of 168 infants were included for analysis that 146 of them died after compassionate care in the delivery room and 22 received postnatal resuscitation. The infants who received resuscitation were more likely to have higher birthweights, older gestational ages and multiple births compared with those who received compassionate care. After resuscitation, five of the infants died and 17 were admitted to neonatal intensive care unit (NICU) for further management. Subsequently, 12 infants died and five infants survived to discharge. Two infants were discharged against advice and died within days. After exclusion of those receiving compassionate care, the NICU survival rate was 22.7% and the long-term survival rate was 13.6%. The most common early morbidities were respiratory distress syndrome, intraventricular haemorrhage and patent ductus arteriosus, whereas the late morbidities included cholestatic jaundice, retinopathy of prematurity and chronic lung disease. The average total hospital costs for the NICU survivors with birthweight < or =500 g was US $42,411 and the average hospital cost per day was US $350. CONCLUSION Exclusive compassionate care was given to the majority of the infants weighing < or =500 g in Taiwan. The survival rate remained low in these marginally viable infants.
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Affiliation(s)
- Wu-Shiun Hsieh
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
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Jones AE, Focht A, Horton JM, Kline JA. Prospective external validation of the clinical effectiveness of an emergency department-based early goal-directed therapy protocol for severe sepsis and septic shock. Chest 2007; 132:425-32. [PMID: 17573521 PMCID: PMC2703721 DOI: 10.1378/chest.07-0234] [Citation(s) in RCA: 189] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To determine the clinical effectiveness of implementing early goal-directed therapy (EGDT) as a routine protocol in the emergency department (ED). METHODS Prospective interventional study conducted over 2 years at an urban ED. Inclusion criteria included suspected infection, criteria for systemic inflammation, and either systolic BP < 90 mm Hg after a fluid bolus or lactate concentration >/= 4 mol/L. Exclusion criteria were age < 18 years, contraindication to a chest central venous catheter, and need for immediate surgery. We prospectively recorded preintervention clinical and mortality data on consecutive, eligible patients for 1 year when treatment was at the discretion of board-certified emergency physicians. We then implemented an EGDT protocol (the intervention) and recorded clinical data and mortality rates for 1 year. Prior to the first year, we defined a 33% relative reduction in mortality (relative mortality reduction that was found in the original EGDT trial) to indicate clinical effectiveness of the intervention. RESULTS We enrolled 79 patients in the preintervention year and 77 patients in the postintervention year. Compared with the preintervention year, patients in the postintervention year received significantly greater crystalloid volume (2.54 L vs 4.66 L, p < 0.001) and frequency of vasopressor infusion (34% vs 69%, p < 0.001) during the initial resuscitation. In-hospital mortality was 21 of 79 patients (27%) before intervention, compared with 14 of 77 patients (18%) after intervention (absolute difference, - 9%; 95% confidence interval, + 5 to - 21%). CONCLUSIONS Implementation of EGDT in our ED was associated with a 9% absolute (33% relative) mortality reduction. Our data provide external validation of the clinical effectiveness of EGDT to treat sepsis and septic shock in the ED.
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Affiliation(s)
- Alan E Jones
- Assistant Director of Research, Department of Emergency Medicine, 1000 Blythe Blvd, MEB 304e, Carolinas Medical Center, Charlotte, NC 28203, USA.
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Keenan SP, Dodek P, Martin C, Priestap F, Norena M, Wong H. Variation in length of intensive care unit stay after cardiac arrest: where you are is as important as who you are. Crit Care Med 2007; 35:836-41. [PMID: 17255864 DOI: 10.1097/01.ccm.0000257323.46298.a3] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [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
OBJECTIVE To determine whether hospital site is independently associated with length of intensive care unit (ICU) stay in those patients who die in hospital after experiencing a cardiac arrest. DESIGN Retrospective cohort study. SETTING Thirty-one Canadian ICUs, all but one being members of the Critical Care Research Network. PATIENTS All patients admitted to these ICUs after resuscitation from a cardiac arrest. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Retrospective analysis of prospectively collected clinical data. Using gamma regression with ICU length of stay as the dependent variable, we found the following variables to be independently associated with ICU length of stay: age, gender, Acute Physiology and Chronic Health Evaluation II score, Glasgow Coma Scale score, hospital size, and hospital site. CONCLUSIONS In this cohort of patients admitted to ICU after cardiac arrest, hospital site was strongly associated with ICU length of stay after controlling for patient-specific factors. Variation in processes of care among ICUs may point to opportunities for improvement.
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Affiliation(s)
- Sean P Keenan
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
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Akçay A, Baysal SU, Yavuz T. Factors influencing outcome of inpatient pediatric resuscitation. Turk J Pediatr 2006; 48:313-22. [PMID: 17290565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The aims of this study were: 1) To define the rate of long-term survivors (LTS) after cardiopulmonary resuscitation (CPR) in children; 2) To identify the predictors of survival in pediatric resuscitation; and 3) To assess the outcome six months after discharge. Three groups of patients were identified based on outcome: 1. Long-term survivors (LTS), who were discharged, 2. Short-term survivors (STS), who survived longer than 24 hours after CPR but not until discharge, and 3. Nonsurvivors (NS), who died within 24 hours after their arrest. Of the 67 patients, 10 (14.9%) children were STS, while 46 (68.7%) were NS. Only eleven (16.4%) were LTS who were eventually discharged from the hospital and six were alive six months after discharge. Four patients had neurological sequelae. Less than 5 minutes' duration of CPR and reactive pupils at the onset of cardiopulmonary arrest (CPA) were the most important factors that predicted long term survival. We suggest that a positive pupillary light reflex at the onset of CPA and the duration of CPR should be considered as important predictors of survival in children with CPA.
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Affiliation(s)
- Ahmet Akçay
- Department of Pediatrics, Pamukkale University Faculty of Medicine, Denizli, Turkey
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49
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Gross H. [Emergency rescue services cost a lot of money. However, no one pays for quality control]. MMW Fortschr Med 2006; 148:20. [PMID: 17036897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
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Finucane TE. Attempting Resuscitation in Nursing Homes: Cargo Cult or Resurrections? J Am Med Dir Assoc 2006; 7:399-400. [PMID: 16843243 DOI: 10.1016/j.jamda.2006.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Accepted: 05/02/2006] [Indexed: 11/20/2022]
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