Cases Of Cardiopulmonary Resuscitation Research Articles

Cardiopulmonary Resuscitation Outcomes and Trainee Perception of Code Status Discussions in Patients with Cirrhosis.

Cardiopulmonary resuscitation (CPR) outcomes among patients with cirrhosis are poor, but factors associated with outcomes and provider awareness remain under-evaluated. We retrospectively investigated in-hospital CPR mortality among patients with cirrhosis, and, using these results, undertook an educational study among providers to improve knowledge of CPR outcomes and code status in patients with cirrhosis. We identified patients with cirrhosis admitted from 2012 to 2022 who underwent CPR at our center; the primary outcome was survival-to-discharge. A brief video based on these results was presented online to Internal Medicine residents, along with paired pre/post-surveys assessing attitudes toward holding code status conversations and knowledge of CPR outcomes in patients with cirrhosis. 97 cases of CPR were identified. 27 patients (28%) survived to discharge post-CPR. A history of liver decompensation was significantly associated with lower survival (OR 0.21, p < 0.05). 22 residents participated in the educational intervention; afterward, their estimation of survival after CPR for patients with cirrhosis significantly improved (p < 0.05). Mean confidence in answering patient questions about prognosis, measured from 1 to 5, also significantly improved (2.4-"a little confident" vs. 3.8-"confident", p < 0.05). 59% of surveyed residents identified impact on liver transplant candidacy as at least a "somewhat significant" barrier to code status conversations. We identified significant trainee uncertainty about outcomes in patients with cirrhosis. These deficits improved after an educational intervention and gave providers more confidence in holding informed code status conversations with patients with cirrhosis, a population that faces barriers to adequate code discussions.

Clinical analysis of patients with cardiopulmonary resuscitation in emergency department and establishment of prediction model of restoration of spontaneous circulation in hospital

To screen the independent influencing factors of restoration of spontaneous circulation (ROSC) in patients after cardiopulmonary resuscitation (CPR) and establish a predictive model, and explore its clinical value. A retrospective case control study was conducted. The clinical data of cardiac arrest patients admitted to the emergency department of Tangdu Hospital of Air Force Military Medical University and received CPR from January to July 2023 were analyzed, including general information, blood biochemical indicators, main cause of cardiac arrest, whether it was defibrillation rhythm, duration from admission to CPR, and whether ROSC was achieved. The clinical data between the patients whether achieved ROSC or not were compared. The binary multivariate Logistic regression analysis was used to screen the independent influencing factors of ROSC in in-hospital CPR patients. According to the above influencing factors, the ROSC prediction model was established, and the receiver operator characteristic curve (ROC curve) was drawn to evaluate the predictive value of the model for ROSC. A total of 235 patients who received CPR in the emergency department were enrolled, including 153 cases (65.11%) of in-hospital CPR and 82 cases (34.89%) of out-of-hospital CPR. The ROSC ratio was 30.21% (71/235). Among all patients, the majority were aged 61-80 years [40.43% (95/235)], and cardiogenic disease was the main cause of cardiac arrest [32.77% (77/235)]. Among 153 patients with in-hospital CPR, 89 were non-ROSC and 64 were ROSC with ROSC rate of 41.83%. Compared with the non-ROSC group, the patients in the ROSC group had lower blood lactic acid (Lac), N-terminal pro-brain natriuretic peptide (NT-proBNP), Lac/albumin (Alb) ratio (LAR), and ratio of non-defibrillation rhythm [Lac (mmol/L): 5.50 (2.33, 9.65) vs. 7.10 (3.50, 13.35), NT-proBNP (μg/L): 0.87 (0.20, 8.68) vs. 3.00 (0.58, 20.17), LAR: 0.14 (0.07, 0.29) vs. 0.19 (0.10, 0.43), non-defibrillation rhythm ratio: 68.75% (44/64) vs. 93.26% (83/89)], higher actual base excess (ABE) and Alb [ABE (mmol/L): -3.95 (-12.75, 0.23) vs. -7.50 (-13.50, -3.35), Alb (g/L): 38.13±7.03 vs. 34.09±7.81], and shorter duration from admission to CPR [hours: 3.25 (1.00, 14.00) vs. 8.00 (2.00, 27.50)], the differences were statistically significant (all P < 0.05). Binary multivariate Logistic regression analysis showed that LAR [odds ratio (OR) = 0.037, 95% confidence interval (95%CI) was 0.005-0.287], non-defibrillation rhythm (OR = 0.145, 95%CI was 0.049-0.426), and duration from admission to CPR (OR = 0.984, 95%CI was 0.972-0.997) were independent influencing factors for ROSC in hospitalized CPR patients (all P < 0.05). Based on the above influencing factors, a ROSC prediction model was constructed through regression analysis results. The ROC curve analysis showed that the area under the ROC curve (AUC) for predicting ROSC in in-hospital CPR patients was 0.757 (95%CI was 0.680-0.834), Yoden index was 0.429, sensitivity was 76.6%, and specificity was 66.3. LAR, non-defibrillation rhythm and duration from admission to CPR were independent influencing factors for ROSC in patients with in-hospital CPR. The ROSC prediction model established based on the above influencing factors has a good predictive value for ROSC of CPR patients in hospital, and can guide clinicians to evaluate the prognosis of patients through relevant indicators as early as possible.

Abstract 9912: Cardiac Events Among Amyotrophic Lateral Sclerosis Patients in the United States; a Fresh Perspective From the 2019 National Inpatient Sample

Introduction: Respiratory distress and complications are the leading causes of death among Amyotrophic Lateral Sclerosis (ALS) patients. However, several studies have reported multiple cardiovascular complications linked with heart rate and rhythm. We, therefore, aim to investigate cardiovascular involvement among ALS patients further. Methods: Data from the 2019 National Inpatient Sample from the Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality (AHRQ), and partners were analyzed to estimate the presence of multiple cardiovascular events in patients with a diagnosis of Amyotrophic Lateral Sclerosis in the United States via their respective ICD-10 codes. The risk of cardiopulmonary resuscitations and mortality rates were also estimated via multivariate regression models, accounting for different variables. Results: We identified 12,865 cases of ALS in the United States. Different cardiac arrhythmias were recorded, such as supraventricular tachycardia (2.1%), ventricular tachycardia (1.7%), ventricular fibrillation (0.2%), and paroxysmal atrial fibrillation (3.8%), and long QT syndrome (0.6%). Several cases of heart blocks were also observed as 0.4% had a first degree, 0.3% had a second degree, and 0.3% had third-degree atrioventricular blocks. 10.7% also had a diagnosis of heart failure, and 565 (4.4%) patients had an old myocardial infarct. Finally, we found 160 (1.2%) cases of cardiopulmonary resuscitation, which had a higher risk of occurring among diabetics (aOR 1.922, 95%CI 1.383-2.670, p&lt;0.01) and patients with hypertension (aOR 1.516, 95% CI 1.007-2.134, p=0.017), while it was less common among Females (aOR 0.527,95% CI 0.368-0.755, p&lt;0.01). The adjusted odds ratio of death in ALS patients with cardiopulmonary resuscitation was 14.910 (95% CI 9.760-22.78, p&lt;0.01). Conclusions: Several cardiac arrhythmias can be observed among ALS patients. Cardiopulmonary resuscitation has a poorer outcome, and physicians treating ALS patients should be advised to watch for early changes, which may help reduce the need for CPR.

Predictors of Long-Term Survival after Cardiopulmonary Resuscitation

Introduction: Survival after cardiac arrest is one of the most important issues related to the safety and quality of patient care, and unexpected events such as failure to follow guidelines can endanger the patient's safety. Objective: This study aimed to determine the long-term survival after cardiopulmonary resuscitation and its predictors in patients with cardiac arrest. Materials and Methods: In this retrospective study, individual, disease-related, and 3-day follow-up-related factors were monitored after the cardiopulmonary resuscitation (CPR) in all patients with long-term survival after cardiac arrest (CA) who were discharged from the hospital between 2016 and 2019. Patients' survival or death after CPR was followed up by telephone interviews. The patient's survival time after discharge was calculated until the interview day. The obtained data were analyzed by the Kaplan-Meier and Cox regression tests. Results: Out of 1565 CPR cases (both In-Hospital Cardiac Arrest [IHCA] and Out-of-Hospital Cardiac Arrest [OHCA]), 667 were successful, of which 156 patients had long-term survival. The mean ±SD of the survival time for patients was 30.98 ±1.78 months. Significant variables in associations with long-term survival were old age (&gt;60 y) (HR=1.811, 95%CI;1.019-3.218, P=0.043), initial asystole rhythm (HR=4.199; 95%CI:2.129-8.282; P=0.001), ventricular tachycardia (VT) (HR=2.315; 95%CI:1.171-4.576; P=0.016), connection to mechanical ventilator (HR=1.992; 95%CI:1.229-3.229; P=0.005), cardiovascular disease (HR=1.795; 95%CI:1.111-2.901; P=0.017), and abnormal SpO2 (HR=2.447; 95%CI:1.507-3.972; P=0.001). Multivariate analysis also showed that asystole rhythm (P=0.001), VT (P=0.052), and prolonged duration of CPR (&gt;20 min) (P=0.043) significantly increase the risk of death. Conclusions: The major predictors in this study were age, initial rhythm, connection to a mechanical ventilator, CPR duration, cardiovascular disease, and SpO2 monitoring. Therefore, introducing post-resuscitation care protocols and conducting training programs and further studies are warranted.

Prognostic Impact of In-Hospital Use of Mechanical Cardiopulmonary Resuscitation Devices Compared with Manual Cardiopulmonary Resuscitation: A Nationwide Population-Based Observational Study in South Korea.

Background and Objectives: This study analyzed the prognostic impact of mechanical cardiopulmonary resuscitation (CPR) devices in out-of-hospital cardiac arrest (OHCA) patients, in comparison to manual CPR. Materials and Methods: This study was a nationwide population-based observational study in South Korea. Data were retrospectively collected from 142,905 OHCA patients using the South Korean Out-of-Hospital Cardiac Arrest Surveillance database. We included adult OHCA patients who received manual or mechanical CPR in the emergency room. The primary outcome was survival at discharge and the secondary outcome was sustained return of spontaneous circulation (ROSC). Statistical analysis included propensity score matching and multivariate logistic regression. Results: A total of 19,045 manual CPR and 1125 mechanical CPR cases (671 AutoPulseTM vs. 305 ThumperTM vs. 149 LUCASTM) were included. In the matched multivariate analyses, all mechanical CPR devices were associated with a lower ROSC than that of manual CPR. AutoPulseTM was associated with lower survival in the multivariate analysis after matching (aOR with 95% CI: 0.57 (0.33–0.96)), but the other mechanical CPR devices were associated with similar survival to discharge as that of manual CPR. Witnessed arrest was commonly associated with high ROSC, but the use of mechanical CPR devices and cardiac origin arrest were associated with low ROSC. Only target temperature management was the common predictor for high survival. Conclusions: The mechanical CPR devices largely led to similar survival to discharge as that of manual CPR in OHCA patients; however, the in-hospital use of the AutoPulseTM device for mechanical CPR may significantly lower survival compared to manual CPR.

Analysis of avoidable cardiopulmonary resuscitation incidents with a part-time rapid response system in place.

Background:Although a rapid response system (RRS) can reduce the incidence of cardiopulmonary resuscitation (CPR) in general wards, avoidable CPR cases still occur. This study aimed to investigate the incidence and causes of avoidable CPR.Methods:We retrospectively reviewed the medical records of all adult patients who received CPR between April 2013 and March 2016 (35 months) at a tertiary teaching hospital where a part-time RRS was introduced in October 2012. Four experts reviewed all of the CPR cases and determined whether each event was avoidable.Results:A total of 192 CPR cases were identified, and the incidence of CPR was 0.190 per 1,000 patient admissions. Of these, 56 (29.2%) were considered potentially avoidable, with the most common cause being doctor error (n=32, 57.1%), followed by delayed do-not-resuscitate (DNR) placement (n=12, 21.4%) and procedural complications (n=5, 8.9%). The percentage of avoidable CPR was significantly lower in the RRS operating time group than in the RRS non-operating time group (20.7% vs. 35.5%; P=0.026). Among 44 avoidable CPR events (excluding cases related to DNR issues), the rapid response team intervened in only three cases (6.8%), and most of the avoidable CPR cases (65.9%) occurred during the non-operating time.Conclusions:A significant number of avoidable CPR events occurred with a well-functioning, part-time RRS in place. However, RRS operation does appear to lower the occurrence of avoidable CPR. Thus, it is necessary to extend RRS operation time and modify RRS activation criteria. Moreover, policy and cultural changes are needed prior to implementing a full-time RRS.

Dribbling death: a case of cardiopulmonary resuscitation in a recreational athlete

Dribbling death: a case of cardiopulmonary resuscitation in a recreational athlete

Resuscitation Care in Out-Of-Hospital Cardiac Arrest: a Survey of the Emergency Medical Services Personnel in the Republic of Crimea

Introduction. The choice of the ways for optimizing management of out-of-hospital cardiac arrest by emergency medical services (EMS) should be based on the evidence from existing practice of resuscitation care. The study was aimed at evaluating personal experience of cardiopulmonary resuscitation (CPR) performance, timing of last training in resuscitation and level of self-perceived knowledge and skills of CPR among the employees of the EMS of the Republic of Crimea, as well as to assess their beliefs on significance of individual CPR procedures in terms of influence on success of resuscitation and to study their perceptions on factors that may have positive or negative impact on effectiveness of resuscitation care.Material and methods. An anonymous survey of the EMS personnel of the Republic of Crimea was conducted in July–December 2019. The questionnaire was utilized to collect demographic data, information on experience of conducting CPR for the last year, on a current practice of CPR debriefings and timing of last CPR training. The participants assessed their knowledge and skills of CPR and their perception of influence of early implementation of individual CPR procedures on success of resuscitation on a 5-point Likert scale, and indicated factors, that may limit or enhance the effectiveness of resuscitation.Results. A total of 251 specialist of the EMS participated in the survey, including 63 physicians, 129 feldshers and 4 nurses of ambulance teams, 45 dispatchers and 5 senior officers of the EMS stations, which corresponds to 28.8% of physicians, 13.0% of feldsher/nursing staff and 17.4% of dispatcher specialists of the republic. Percentage of male respondents was 35.5%, mean age — 41.5 years, mean duration of EMS work experience — 15.5 years. The mean declared number of cases of CPR conducted in the last 12 months was 2.2 (range: 0–20), and 23.5% specialists of the ambulance teams have not participated in any CPR attempt over the last year. About 60.2% respondents were trained in CPR within the last year. When compared to other specialists of ambulance teams, feldshers who work alone (without a coworker), were significantly less commonly performing a real-life resuscitation (p=0.008) or receiving training in CPR (p=0.020). Dispatchers were least covered with resuscitation training (only 33.3% were trained within the last year) and had the lowest level of CPR knowledge and skills. 25.9% of the specialists had an erroneous judgement that early drug administration and/or tracheal intubation have higher influence on success of resuscitation when compared to chest compressions and/or defibrillation. The level of knowledge and skills of CPR depend on the timing of last training (p&lt;0.001).Conclusions. The experience of participation in real-life attempts of CPR is severely limited for considerable part of the EMS employees, and many specialists have not been trained in resuscitation for a long time. The perceptions of the EMS specialists regarding the importance of individual CPR procedures are not always compliant with the statements of current international CPR guidelines. In order to enhance the effectiveness of resuscitation care in the Republic of Crimea, it is advisable to monitor the coverage of the EMS employees with resuscitation training and the rates of their participation in resuscitation attempts, as well as to perform additional targeted training in CPR, in particular, using alternative methods of education.

Minimizing Pulse Check Duration Through Educational Video Review.

IntroductionThe American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) recommend pulse checks of less than 10 seconds. We assessed the effect of video review-based educational feedback on pulse check duration with and without point-of-care ultrasound (POCUS).MethodsCameras recorded cases of CPR in the emergency department (ED). Investigators reviewed resuscitation videos for ultrasound use during pulse check, pulse check duration, and compression-fraction ratio. Investigators reviewed health records for patient outcomes. Providers received written feedback regarding pulse check duration and compression-fraction ratio. Researchers reviewed selected videos in multidisciplinary grand round presentations, with research team members facilitating discussion. These presentations highlighted strategies that include the following: limit on pulse check duration; emphasis on compressions; and use of “record, then review” method for pulse checks with POCUS. The primary endpoint was pulse check duration with and without POCUS.ResultsOver 19 months, investigators reviewed 70 resuscitations with a total of 325 pulse checks. The mean pulse check duration was 11.5 ± 8.8 seconds (n = 224) and 13.8 ± 8.6 seconds (n = 101) without and with POCUS, respectively. POCUS pulse checks were significantly longer than those without POCUS (P = 0.001). Mean pulse check duration per three-month block decreased statistically significantly from study onset to the final study period (from 17.2 to 10 seconds [P<0.0001]) overall; decreased from 16.6 to 10.5 seconds (P<0.0001) without POCUS; and with POCUS from 19.8 to 9.88 seconds (P<0.0001) with POCUS. Pulse check times decreased significantly over the study period of educational interventions. The strongest effect size was found in POCUS pulse check duration (P = −0.3640, P = 0.002).ConclusionConsistent with previous studies, POCUS prolonged pulse checks. Educational interventions were associated with significantly decreased overall pulse-check duration, with an enhanced effect on pulse checks involving POCUS. Performance feedback and video review-based education can improve CPR by increasing chest compression-fraction ratio.

Survival after in-hospital cardiopulmonary resuscitation from 2003 to 2013: An observational study before legislation on the life-sustaining treatment decision-making act of Korean patients.

We analyzed cardiopulmonary resuscitation (CPR) rates, deaths preceded by CPR, and survival trends after in-hospital CPR, using a sample of nationwide Korean claims data for the period 2003 to 2013.The Korean National Health Insurance Service–National Sample Cohort is a stratified random sample of 1,025,340 subjects selected from among approximately 46 million Koreans. We evaluated the annual incidence of CPR per 1000 admissions in various age groups, hospital deaths preceded by CPR, and survival rate following in-hospital CPR. Analyses of the relationships between survival and patient and hospital characteristics were performed using logistic regression analysis.A total of 5918 in-hospital CPR cases from 2003 to 2013 were identified among eligible patients. The cumulative incidence of in-hospital CPR was 3.71 events per 1000 admissions (95% confidence interval 3.62–3.80). The CPR rate per 1000 admissions was highest among the oldest age group, and the rate decreased throughout the study period in all groups except the youngest age group. Hospital deaths were preceded by in-hospital CPR in 18.1% of cases, and the rate decreased in the oldest age group. The survival-to-discharge rate in all study subjects was 11.7% during study period, while the 6-month and 1-year survival rates were 8.0% and 7.2%, respectively. Survival tended to increase throughout the study period; however, this was not the case in the oldest age group. Age and malignancy were associated with lower survival rates, whereas myocardial infarction and diabetes mellitus were associated with higher survival rates.Our result shows that hospital deaths were preceded by in-hospital CPR in 18.1% of case, and the survival-to-discharge rate in all study subjects was 11.7% during the study period. Survival tended to increase throughout the study period except for the oldest age group. Our results provide reliable data that can be used to inform judicious decisions on the implementation of CPR, with the ultimate goal of optimizing survival rates and resource utilization.

Neonatal hospice care utilization in a tertiary hospital in Taiwan before and after the legalization of life-sustaining treatment withdrawal.

The advancements in neonatal critical care have not only improved the outcomes of extreme prematurity but also prolonged the process of death in terminally ill neonates. This study analyzed the characteristics of neonates who died at a single tertiary center in Taiwan. The utilization of neonatal hospice care before and after the legalization of life-sustaining treatment (LST) withdrawal in Taiwan in 2013 was also compared. This study enrolled the neonatal mortality cases in the Taipei Veterans General Hospital during January 2008 to December 2017 through chart review. Data on birth history, primary diagnosis, complications, and death circumstances were recorded and analyzed. In total, 105 neonatal deaths were analyzed. The circumstances of death were as follows: 22 (21%) cases of full LST and cardiopulmonary resuscitation (CPR) performed until death; 63 (60%) cases of LST initiated but no more CPR after do-not-resuscitate (DNR) consents signed; 8 (7.6%) cases of LST withdrawn; 4 (3.8%) cases of DNR signed without LST initiation; 3 (2.9%) cases of CPR not performed, although no DNR signed; and 5 (4.8%) cases of discharge against medical advice under critical condition. The incidence of written DNR consents (57.9% in 2008-2009 vs 93.8% in 2016-2017; p = 0.02) showed an increasing trend. Regarding the incidence of comorbidities, renal failure rate was higher in the DNR group than in the non-DNR group (p = 0.002). There was an increasing trend for written DNR consent and the utilization of neonatal hospice care. Renal failure, as a comorbidity, was significantly associated with the written DNR consent in the neonates. Further studies to evaluate the factors associated with neonatal hospice care utilization are suggested.

Liver rupture as a complication in cardiopulmonary resuscitation for cardiac arrest after vaginal hysterectomy

Liver rupture is a rare, yet life-threatening complication of cardiopulmonary resuscitation. It occurs as a complication in 0.6-3% cases of cardiopulmonary resuscitation. Its early diagnostics and urgent surgical treatment is thus very important in order to prevent an undesired outcome for the patient. This paper presents diagnostics and treatment of liver rupture resulting as a complication of cardiopulmonary resuscitation (CPR) due to cardiac arrest in the early postoperative period after vaginal hysterectomy performed for uterine myomatosis in a 50-year-old patient.

Prehospital Advanced Resuscitation with Video Direct Medical Control Using Mobile Smart Device

Introduction:The prognosis for out-of-hospital cardiac arrest (OHCA) remains controversial if a smart device or video is used. In this study, a system was used that provides advanced cardiac life support (ACLS) with direct medical control through remote video calls for OHCA patients. The study investigated how this system will improve survival.Aim:The effect of video remote direct medical control using a mobile smart device for cardiac arrest was the main objective of this research.Methods:Medical origin OHCA patients over 18 years old for one year were included in the video remote direct medical attempt. Trauma, intoxication, environmental origin, and family disagreement were excluded. The advanced field resuscitation was performed by paramedics with video communication-based medical direction, who were dispatched simultaneously by two ambulances. Video communication was performed by a mobile application or video call. The results and opinions were recorded in a mobile application and a specific website. We analyzed the general characteristics and outcomes of the prehospital ACLS using video communication.Results:A total of 11,054 consecutive out-of-hospital cardiopulmonary resuscitation cases were recorded, and 3,352 underwent prehospital ALS using video call. Prehospital ROSC was 23.3%, survival upon hospital arrival was 13.6%, survival admission was 19.5%, survival discharge was 10.6%, and survival with good neurologic outcome was 6.0%. The reasons for no prehospital ALS included no request from a provider (29.1%), cardiac arrest during transport (20.9%), communication failure (11.6%), and family refusal (11.1%).Discussion:As a result of providing prehospital ACLS with direct medical direction through remote video calls to cardiac arrest patients, the prehospital ROSC rate, survival admission, and discharge rate improved. Advantages of this type of medical control by video communication were ease of control of the patient`s family, more precise communication with paramedics, and continuous confirmation of the real patient’s status and monitoring parameters.

Extracorporeal Life Support in Adult Patients: A Global Perspective of the Last Decade.

Extracorporeal life support (ECLS) is an external medical device to treat critically ill patients with cardiovascular and respiratory failure. In a nutshell, ECLS is only a "bridging" mechanism that provides life support while the heart and/or the lungs is recovering either by therapeutic medical interventions, transplantation, or spontaneously. Extracorporeal life support has been developed since 1950s, and many studies were conducted to improve ECLS techniques, but unfortunately, the survival rate was not improved. Because of Dr Bartlett's success in using ECLS to treat neonates with severe respiratory distress in 1975, ECLS is made as a standard lifesaving therapy for neonates with severe respiratory distress. However, its use for adult patients remains debatable. The objectives of this study are to outline and provide a general overview of the use of ECLS especially for adult patients for the past 10 years and to elaborate on the challenges encountered by each stakeholder involved in ECLS. The data used for this study were extracted from the ELSO Registry Report of January 2018. Results of this study revealed that the number of ECLS centers and the use of ECLS are increasing over the year for the past decade. There was also a shift of the patient's age category from neonatal to adult patients. However, the survival rates for adult patients are relatively low especially for cardiac and extracorporeal cardiopulmonary resuscitation cases. To date, the complications are still the major challenge of ECLS. Other challenges encountered by the stakeholders in ECLS are the limited amount of well-trained and experienced ECLS teams and centers, the limited government expenditure on health, and the lack of improvement and development of ECLS techniques and devices. Further studies are needed to evaluate the value of ECLS for adult patients.

Effect of Speciallist Palliative Care Service on End-of Life Care in Patients with Hematologic Malignancies

Previous research demonstrated that patients with hematologic malignancies have a high probability receiving intensive care at their end-of-life (EOL). In this study, we assessed EOL quality measures in patients with hematologic malignancies before and after starting the provision of a specialist palliative care service.We conducted a retrospective cohort study in Komaki City Hospital. Provision of the specialist palliative care service was started in our hospital on April 1, 2012. We reviewed the medical records of all adult patients who died of hematologic malignancies between April 1, 2007 and March 31, 2017. Patients who had been cared for in the Departments of Hematology and Palliative Care were included. This study was approved by the institutional review board of Komaki City Hospital. We assessed the prevalence and trends of multiple measures of intensive EOL care established in the peer-reviewed literature. Intensive EOL care was defined as the occurrence of at least one of the following acts: 1) cardiopulmonary resuscitation (CPR) in the last 30 days of life, 2) intubation in the last 30 days of life, 3) intensive care unit (ICU) admission in the last 30 days of life, 4) chemotherapy use within the last 14 days of life, 5) receiving red cell transfusions within the 7 days before death, and 6) receiving platelet transfusion within the 7 days before death. Analysis of frequencies was performed using Fisher's exact test for 2 x 2 tables. The Cochran-Armitage test was used to test for trends over time.A total of 351 consecutive patients who died from hematologic malignancies were identified: 176 before and 175 after April 1, 2012. The median age at death was 73 years old. These included 150 patients with non-Hodgkin lymphoma, 113 with acute myeloid leukemia, 63 with multiple myeloma, 11 with acute lymphoblastic leukemia, 8 with chronic lymphocytic leukemia, and 5 with Hodgkin lymphoma. A total of 69 (39%) received specialist palliative care consultation and 24 (14%) died in the palliative care unit (PCU) after April 2012. Deaths in the PCU increased from 1 (2%) in 2012 to 8 (27%) in 2016 (P for trend <0.001). The median time from palliative care referral to death was 26 days (interquartile range [IQR]: 10-49 days). The length of stay in the PCU was 16 days (IQR: 9.5-22.5 days).Cases of CPR in the last 30 days of life decreased from 4 (13%) in 2007 to 0 in 2016 (P for trend <0.001). Intubations in the last 30 days of life also decreased from 2 (6%) in 2007 to 1 (3%) in 2016 (P for trend 0.046). Platelet transfusions within 7 days before death decreased from 18 (56%) in 2007 to 14 (47%) in 2016 (P for trend 0.031). There were no significant decreases in ICU admissions in the last 30 days of life, chemotherapy use within the last 14 days of life, or receiving red cell transfusions within 7 days before death from 2007 to 2016. Patients receiving at least one act of intensive EOL care significantly decreased from 23 (72%) in 2007 to 19 (63%) in 2016 (P for trend 0.019).Compared with patients with acute leukemia (AL), those with malignant lymphoma (ML) were more likely to receive specialist palliative care consultation (49% vs. 27%, respectively; P=0.010) and die in the PCU (21% vs. 5%, respectively; P=0.007). In patients with ML, deaths in the PCU increased from 1 (5%) in 2012 to 7 (50%) in 2016 (P for trend <0.001).In patients with ML, cases of chemotherapy use within the last 14 days of life decreased from 5 (22%) in 2007 to 2 (14%) in 2016 (P for trend 0.030). Patients with ML who received palliative care consultation were less likely to receive platelet transfusion within 7 days before death compared with those who did not (28% vs. 51%, respectively; P=0.041). In patients with ML, those receiving at least one act of intensive EOL care significantly decreased from 11 (65%) in 2007 to 5 (35%) in 2016 (P for trend <0.001). In patients with AL, there was no significant difference in chemotherapy use within the last 14 days of life or receiving transfusions within 7 days before death between patients who received specialist palliative care and those who did not. All patients with AL received at least one act of intensive EOL care in 2016.These findings suggest that specialist palliative care improved the quality of EOL care in patients with hematologic malignancies, especially in those with ML. However, in patients with AL, EOL care is still suboptimal with the provision of specialist palliative care. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Frequency and intensity of pulmonary bone marrow and fat embolism due to manual or automated chest compressions during cardiopulmonary resuscitation.

Iatrogenic consequences of cardiopulmonary resuscitation (CPR) include sternal or rib fractures, pulmonary bone marrow embolisms (BME) and fat embolisms (FE). This report aimed to analyze the frequency and intensity of pulmonary BME and FE in fatal cases receiving final CPR efforts with the use of automated chest compression devices (ACCD) or manual chest compressions (mCC). The study cohort (all cardiac causes of death, no ante-mortem fractures) consisted of 15 cases for each group 'ACCD', 'mCC' and 'no CPR'. Lung tissue samples were retrieved and stained with hematoxylin eosin (n = 4 each) and Sudan III (n = 2 each). Evaluation was conducted microscopically for any existence of BME or FE, the frequency of BME-positive vessels, vessel size for BME and the graduation according to Falzi for FE. The data were compared statistically using non-parametric analyses. All groups were matched except for CPR duration (ACCD > mCC) but this time interval was linked to the existence of pulmonary BME (p = 0.031). Both entities occur in less than 25% of all cases following unsuccessful CPR. BME was only detectable in CPR cases, but was similar between ACCD and mCC cases for BME frequency (p = 0.666), BME intensity (p = 0.857) and the size of BME-affected pulmonary vessels (p = 0.075). If any, only mild pulmonary FE (grade I) was diagnosed without differences in the CPR method (p = 0.624). There was a significant correlation between existence of BME and FE (p = 0.043). Given the frequency, intensity and size of pulmonary BME and FE following CPR, these conditions may unlikely be considered as causative for death in case of initial survival but can be found in lower frequencies in autopsy histology.

Videographic Assessment of the Quality of EMS to ED Handoff Communication During Pediatric Resuscitations

Background: The National Association of Emergency Medical Services (EMS) Physicians emphasizes the importance of high quality communication between EMS providers and emergency department (ED) staff for providing safe, effective care. The Joint Commission has identified ineffective handoff communication as a contributing factor in 80% of serious medical errors. The quality of handoff communication from EMS to ED teams for critically ill pediatric patients needs further exploration.Objective: This study assessed the quality of handoff communication between EMS and ED staff during pediatric medical resuscitations.Methods/Design: We conducted a retrospective review of video recordings of pediatric patients who required critical care (“resuscitation”) in the ED between January 2014 and February 2016 at a Level 1 pediatric trauma center. Handoff quality between EMS and emergency department teams was assessed for completeness, timeliness, and efficiency. Institutional review board approval was obtained.Results: Sixty-eight resuscitations were reviewed; 28% presented in cardiac arrest, requiring cardiopulmonary resuscitation (CPR). Completeness of information communicated was variable and included chief complaint (88%), prehospital interventions (81%), physical exam findings (63%), medical history (59%), age (56%), and weight (20%). Completeness of specific vital sign reporting included: respiratory rate (53%), heart rate (43%), oxygen saturation (39%), and blood pressure (31%). Timeliness of communication included median patient handoff and report times of 50 seconds [IQR 30,74] and 108 seconds [IQR 62,252], respectively. Inefficient communication occurred in 87% of handoffs, including interruptions by ED staff (51%), questions from the ED physician team leader asking for information already communicated (40%), and questions by ED physician team leader requesting information not yet communicated (65%). When comparing non-CPR to CPR cases, only timeliness of patient handoff was significantly different for those patients receiving prehospital CPR.Conclusion: Handoff communication between EMS and ED teams during pediatric resuscitation was frequently incomplete and inefficient. Future educational and quality improvement interventions could aim to improve the quality of handoff communication for this patient population.

Procedural sedation in non-intubated children with severe trauma - A single center study

BackgroundNon-intubated children frequently undergo emergent procedures in the trauma-bay. This study evaluates whether patients treated with procedural sedation have an increased risk for severe adverse events. MethodsRetrospective analysis of 1182 children with an injury severity score (ISS) of greater than 15. ResultsOf the 565 patients who were spontaneously breathing on arrival, 455 were hemodynamically stable with a Glasgow Coma Score of 15, 201 of whom were treated with sedation; 144 (71.6%) had computerized tomography scan, 35 (17.5%) wound debridement, and 22 (10.9%) fracture reduction. Sedation patients had an ISS of 20 (interquartile range 17–25). There were no death cases, no cases of cardiopulmonary resuscitation, and no cases of neurologic sequelae on hospital discharge. There were 2 (1%) cases of unanticipated endotracheal intubation. ConclusionsNon-intubated patients who were hemodynamically stable with a Glasgow Coma Score of 15 had a low risk for severe adverse events due to sedation.

The Cardiac Risk Factors of Coronary Artery Disease and its relationship with Cardiopulmonary resuscitation: A retrospective study.

BackgroundCardiovascular diseases are considered as the most prevalent serious disease in developed countries, and act as the number one cause of death among men and women in all ages and from all races.AimThe present research aims at determining the relationship between risk factors of cardiovascular diseases and consequences of cardiopulmonary resuscitation (CPR).MethodsThe present study is a retrospective analytic-cross sectional research performed on 100 patients in need for CPR (successful and unsuccessful) during March 2017 – June 2017. As research instrument, a pre-designed checklist was used including demographic information, clinical and medical information, and the information related to modifiable and non-modifiable risk factors of cardiovascular diseases.ResultsObtained results indicated that, 57.1% of the successful CPR cases were administered on men, while 55.1% of unsuccessful CPR cases were administered on women. The patients diagnosed with myocardial infarction were in further need for CPR (rate of successful CPR: 66.7%, and rate of unsuccessful CPR: 61.9%). Significant associations were found between CPR duration, post-CPR survival time (survival time after CPR), systolic blood pressure, diastolic blood pressure, triglyceride level, diabetes, fasting blood sugar level, and body mass index, in one hand, and type of CPR, on the other hand (p < 0.05).ConclusionResults of the present research showed that, there is a significant relationship between modifiable risk factors of cardiovascular diseases and consequences of CPR.

Quality of Cardiopulmonary Resuscitation in Emergency Department Based on the AHA 2015 Guidelines; a Brief Report.

Adhering to existing guidelines on cardiopulmonary resuscitation (CPR) can increase the survival rate of the patients. The present study has been designed with the aim of determining the quality of CPR performed in the emergency department based on the latest protocol by the American heart association (AHA). In this prospective cross-sectional study CPR process was audited in patients above 18 years old in need of CPR presenting to the emergency departments of 3 teaching hospitals based on the AHA 2015 guidelines. Less than 60% agreement was considered as fail, 60-70% as poor, 70-80% as moderate, 80-90% as good, and 90-100% as excellent. 80 cases of CPR were audited (55% male). Location of arrest was the hospital in 58 (72.5%) cases and 48 (60.0%) of the cases happened during the day. 28 (35.0%) cases had orotracheal intubation before the initiation of CPR. 30 (37.5%) patients had a shockable rhythm at the initiation of CPR. Based on the findings, out of the 31 studied items, 9 (29.03%) had excellent agreement, 10 (32.25%) had good, 4 (12.90%) had moderate, 2 (6.45%) had poor, and 6 (19.35%) had fail agreement rate. Based on the findings of the present study, the quality of applying the principles of basic and advanced CPR in the emergency department of the studied hospital had intermediate, poor and fail agreement with the recommendations of the AHA 2015 in at least one third of the cases.