COVID-19 CPR-Impact of Personal Protective Equipment during a Simulated Cardiac Arrest in Times of the COVID-19 Pandemic: A Prospective Comparative Trial.

Background: Guidelines of cardiopulmonary resuscitation (CPR) recommend the use of personal protective equipment (PPE) during the resuscitation of COVID-19 patients. Data on the effects of PPE on rescuers' stress level and quality of CPR are sparse and conflicting. This trial investigated the effects of PPE on team performance in simulated cardiac arrests. Methods: During the pandemic period, 198 teams (689 participants) performed CPR with PPE in simulated cardiac arrests (PPE group) and were compared with 423 (1451 participants) performing in identical scenarios in the pre-pandemic period (control group). Video recordings were used for data analysis. The primary endpoint was hands-on time. Secondary endpoints included a further performance of CPR and the perceived task load assessed by the NASA task-load index. Results: Hands-on times were lower in PPE teams than in the control group (86% (83−89) vs. 90% (87−93); difference 3, 95% CI for difference 3−4, p < 0.0001). Moreover, PPE teams made fewer change-overs and delayed defibrillation and administration of drugs. PPE teams perceived higher task loads (57 (44−67) vs. 63 (53−71); difference 6, 95% CI for difference 5−8, p < 0.0001) and scored higher in the domains physical and temporal demand, performance, and effort. Leadership allocation had no effect on primary and secondary endpoints. Conclusions: Having to wear PPE during CPR is an additional burden in an already demanding task. PPE is associated with an increase in perceived task load, lower hands-on times, fewer change-overs, and delays in defibrillation and the administration of drugs. (German study register number DRKS00023184).

The Impact of Withdrawn vs. Agitated Relatives during Resuscitation on Team Workload: A Single-Center Randomised Simulation-Based Study.

Background: Guidelines recommend that relatives be present during cardiopulmonary resuscitation (CPR). This randomised trial investigated the effects of two different behaviour patterns of relatives on rescuers' perceived stress and quality of CPR. Material and methods: Teams of three to four physicians were randomised to perform CPR in the presence of no relatives (control group), a withdrawn relative, or an agitated relative, played by actors according to a scripted role, and to three different models of leadership (randomly determined by the team or tutor or left open). The scenarios were video-recorded. Hands-on time was primary, and the secondary outcomes comprised compliance to CPR algorithms, perceived workload, and the influence of leadership. Results: 1229 physicians randomised to 366 teams took part. The presence of a relative did not affect hands-on time (91% [87−93] vs. 92% [88−94] for "withdrawn" and 92 [88−93] for "agitated" relatives; p = 0.15). The teams interacted significantly less with a "withdrawn" than with an "agitated" relative (11 [7−16]% vs. 23 [15−30]% of the time spent for resuscitation, p < 0.01). The teams confronted with an "agitated" relative showed more unsafe defibrillations, higher ventilation rates, and a delay in starting CPR (all p < 0.05 vs. control). The presence of a relative increased frustration, effort, and perceived temporal demands (all <0.05 compared to control); in addition, an "agitated" relative increased mental demands and total task load (both p < 0.05 compared to "withdrawn" and control group). The type of leadership condition did not show any effects. Conclusions: Interaction with a relative accounted for up to 25% of resuscitation time. Whereas the presence of a relative per se increased the task load in different domains, only the presence of an "agitated" relative had a marginal detrimental effect on CPR quality (GERMAN study registers number DRKS00024761).

A beginner's view of end of life care on German intensive care units.

BACKGROUND: Little is known about importance and implementation of end-of-life care (EOLC) in German intensive care units (ICU). This survey analyses preferences and differences in training between "medical" (internal medicine, neurology) and "surgical" (surgery, anaesthesiology) residents during intensive care rotation. METHODS: This is a point-prevalence study, in which intensive care medicine course participants of one educational course were surveyed. Physicians from multiple ICU and university as well as non-university hospitals and all care levels were asked to participate. The questionnaire was composed of a paper and an electronic part. Demographic and structural data were prompted and EOLC data (48 questions) were grouped into six categories considering importance and implementation: category 1 (important, always implemented), 2 (important, sometimes implemented), 3 (important, never implemented) and 4-6 (unimportant, implementation always, sometimes, never). The trial is registered at the "Deutsches Register für klinische Studien (DRKS)", Study number DRKS00026619, registered on September 10th 2021, www.drks.de . RESULTS: Overall, 194/ 220 (88%) participants responded. Mean age was 29.7 years, 55% were female and 60% had scant ICU working experience. There were 64% medical and 35% surgical residents. Level of care and size of ICU differed significantly between medical and surgical (both p < 0.001). Sufficient implementation was stated for 66% of EOLC questions, room for improvement (category 2 and 3) was seen in 25, and 8% were classified as irrelevant (category 6). Areas with the most potential for improvement included prognosis and outcome and patient autonomy. There were no significant differences between medical and surgical residents. CONCLUSIONS: Even though EOLC is predominantly regarded as sufficiently implemented in German ICU of all specialties, our survey unveiled still 25% room for improvement for medical as well as surgical ICU residents. This is important, as areas of improvement potential may be addressed with reasonable effort, like individualizing EOLC procedures or setting up EOLC teams. Health care providers as well as medical societies should emphasize EOLC training in their curricula.

Impact of family presence during cardiopulmonary resuscitation on team performance and perceived task load: a prospective randomised simulator-based trial.

OBJECTIVES: Guidelines recommend family presence to be offered during cardiopulmonary resuscitation (CPR). Data on the effects of family presence on the quality of CPR and rescuers' workload and stress levels are sparse and conflicting. This randomised trial investigated the effects of family presence on quality of CPR, and rescuers' perceived stress. DESIGN: Prospective randomised single-blind trial. SETTING: Voluntary workshops of educational courses. PARTICIPANTS: 1085 physicians (565 men) randomised to 325 teams entered the trial. 318 teams completed the trial without protocol violation. INTERVENTIONS: Teams were randomised to a family presence group (n=160) or a control group (n=158) and to three versions of leadership: (a) designated at random, (b) designated by the team or (c) left open. Thereafter, teams were confronted with a simulated cardiac arrest which was video-recorded. Trained actors played a family member according a scripted role. MAIN OUTCOME MEASURES: The primary endpoint was hands-on time. Secondary outcomes included interaction time, rescuers' perceived task load and adherence to CPR algorithms. RESULTS: Teams interacted with the family member during 24 (17-36) % of the time spent for resuscitation. Family presence had no effect on hands-on time (88% (84%-91%) vs 89% (85%-91%); p=0.18). Family presence increased frustration (60 (30-75) vs 45 (30-70); p<0.001) and perceived temporal (75 (55-85) vs 70 (50-80); p=0.001) and mental demands (75 (60-85) vs 70 (55-80); p=0.009), but had no relevant effect on CPR performance markers. Leadership condition had no effects. CONCLUSIONS: Interacting with a family member occupied about a quarter of the time spent for CPR. While this additional task was associated with an increase in frustration and perceived temporal and mental demands, family presence had no relevant negative effect on the quality of CPR. TRIAL REGISTRATION NUMBER: DRKS00024759.

U SO CARE-The Impact of Cardiac Ultrasound during Cardiopulmonary Resuscitation: A Prospective Randomized Simulator-Based Trial.

BACKGROUND: Actual cardiopulmonary resuscitation (CPR) guidelines recommend point-of-care ultrasound (POCUS); however, data on POCUS during CPR are sparse and conflicting. This randomized trial investigated the effects of POCUS during CPR on team performance and diagnostic accuracy. METHODS: Intensive Care and Emergency Medicine residents performed CPR with or without available POCUS in simulated cardiac arrests. The primary endpoint was hands-on time. Data analysis was performed using video recordings. RESULTS: Hands-on time was 89% (87-91) in the POCUS and 92% (89-94) in the control group (difference 3, 95% CI for difference 2-4, p < 0.001). POCUS teams had delayed defibrillator attachments (33 vs. 26 sec, p = 0.017) and first rhythm analysis (74 vs. 52 sec, p = 0.001). Available POCUS was used in 71%. Of the POCUS teams, 3 stated a POCUS-derived diagnosis, with 49 being correct and 42 followed by a correct treatment decision. Four teams made a wrong diagnosis and two made an inappropriate treatment decision. CONCLUSIONS: POCUS during CPR resulted in lower hands-on times and delayed rhythm analysis. Correct POCUS diagnoses occurred in 52%, correct treatment decisions in 44%, and inappropriate treatment decisions in 2%. Training on POCUS during CPR should focus on diagnostic accuracy and maintenance of high-quality CPR.

Hands-On Times, Adherence to Recommendations and Variance in Execution among Three Different CPR Algorithms: A Prospective Randomized Single-Blind Simulator-Based Trial.

BACKGROUND: Alternative cardiopulmonary resuscitation (CPR) algorithms, introduced to improve outcomes after cardiac arrest, have so far not been compared in randomized trials with established CPR guidelines. METHODS: 286 physician teams were confronted with simulated cardiac arrests and randomly allocated to one of three versions of a CPR algorithm: (1) current International Liaison Committee on Resuscitation (ILCOR) guidelines ("ILCOR"), (2) the cardiocerebral resuscitation ("CCR") protocol (3 cycles of 200 uninterrupted chest compressions with no ventilation), or (3) a local interpretation of the current guidelines ("Arnsberg", immediate insertion of a supraglottic airway and cycles of 200 uninterrupted chest compressions). The primary endpoint was percentage of hands-on time. RESULTS: Median percentage of hands-on time was 88 (interquartile range (IQR) 6) in "ILCOR" teams, 90 (IQR 5) in "CCR" teams (p = 0.001 vs. "ILCOR"), and 89 (IQR 4) in "Arnsberg" teams (p = 0.032 vs. "ILCOR"; p = 0.10 vs. "CCR"). "ILCOR" teams delivered fewer chest compressions and deviated more from allocated targets than "CCR" and "Arnsberg" teams. "CCR" teams demonstrated the least within-team and between-team variance. CONCLUSIONS: Compared to current ILCOR guidelines, two alternative CPR algorithms advocating cycles of uninterrupted chest compressions resulted in very similar hands-on times, fewer deviations from targets, and less within-team and between-team variance in execution.

Effects of Bag Mask Ventilation and Advanced Airway Management on Adherence to Ventilation Recommendations and Chest Compression Fraction: A Prospective Randomized Simulator-Based Trial.

The role of advanced airway management (AAM) in cardiopulmonary resuscitation (CPR) is currently debated as observational studies reported better outcomes after bag-mask ventilation (BMV), and the only prospective randomized trial was inconclusive. Adherence to CPR guidelines ventilation recommendations is unknown and difficult to assess in clinical trials. This study compared AAM and BMV with regard to adherence to ventilation recommendations and chest compression fractions in simulated cardiac arrests. A total of 154 teams of 3-4 physicians were randomized to perform CPR with resuscitation equipment restricting airway management to BMV only or equipment allowing for all forms of AAM. BMV teams ventilated 6 ± 6/min and AAM teams 19 ± 8/min (range 3-42/min; p < 0.0001 vs. BMV). 68/78 BMV teams and 23/71 AAM teams adhered to the ventilation recommendations (p < 0.0001). BMV teams had lower compression fractions than AAM teams (78 ± 7% vs. 86 ± 6%, p < 0.0001) resulting entirely from higher no-flow times for ventilation (9 ± 4% vs. 3 ± 3 %; p < 0.0001). Compared to BMV, AAM leads to significant hyperventilation and lower adherence to ventilation recommendations but favourable compression fractions. The cumulative effect of deviations from ventilation recommendations has the potential to blur findings in clinical trials.