Pediatric Post-Cardiac Arrest Care: A Scientific Statement From the American Heart Association.

Successful resuscitation from cardiac arrest results in a post-cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post-cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post-cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post-cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post-cardiac arrest care.

Combining qSOFA criteria with initial lactate levels: Improved screening of septic patients for critical illness.

OBJECTIVE: To determine if the addition of lactate to Quick Sequential Organ Failure Assessment (qSOFA) scoring improves emergency department (ED) screening of septic patients for critical illness. METHODS: This was a multicenter retrospective cohort study of consecutive adult patients admitted to the hospital from the ED with infectious disease-related illnesses. We recorded qSOFA criteria and initial lactate levels in the first 6 h of ED stay. Our primary outcome was a composite of hospital death, vasopressor use, and intensive care unit stay ≤72 h of presentation. Diagnostic test characteristics were determined for: 1) lactate levels ≥2 and ≥4; 2) qSOFA scores ≥1, ≥2, and =3; and 3) combinations of these. RESULTS: Of 3743 patients, 2584 had a lactate drawn ≤6 h of ED stay and 18% met the primary outcome. The qSOFA scores were ≥1, ≥2, and =3 in 59.2%, 22.0%, and 5.3% of patients, respectively, and 34.4% had a lactate level ≥2 and 7.9% had a lactate level ≥4. The combination of qSOFA ≥1 OR Lactate ≥2 had the highest sensitivity, 94.0% (95% CI: 91.3-95.9). CONCLUSIONS: The combination of qSOFA ≥1 OR Lactate ≥2 provides substantially improved sensitivity for the screening of critical illness compared to isolated lactate and qSOFA thresholds.

Association Between Early Hyperoxia Exposure After Resuscitation From Cardiac Arrest and Neurological Disability: Prospective Multicenter Protocol-Directed Cohort Study.

BACKGROUND: Studies examining the association between hyperoxia exposure after resuscitation from cardiac arrest and clinical outcomes have reported conflicting results. Our objective was to test the hypothesis that early postresuscitation hyperoxia is associated with poor neurological outcome. METHODS: This was a multicenter prospective cohort study. We included adult patients with cardiac arrest who were mechanically ventilated and received targeted temperature management after return of spontaneous circulation. We excluded patients with cardiac arrest caused by trauma or sepsis. Per protocol, partial pressure of arterial oxygen (Pao2) was measured at 1 and 6 hours after return of spontaneous circulation. Hyperoxia was defined as a Pao2 >300 mm Hg during the initial 6 hours after return of spontaneous circulation. The primary outcome was poor neurological function at hospital discharge, defined as a modified Rankin Scale score >3. Multivariable generalized linear regression with a log link was used to test the association between Pao2 and poor neurological outcome. To assess whether there was an association between other supranormal Pao2 levels and poor neurological outcome, we used other Pao2 cut points to define hyperoxia (ie, 100, 150, 200, 250, 350, 400 mm Hg). RESULTS: Of the 280 patients included, 105 (38%) had exposure to hyperoxia. Poor neurological function at hospital discharge occurred in 70% of patients in the entire cohort and in 77% versus 65% among patients with versus without exposure to hyperoxia respectively (absolute risk difference, 12%; 95% confidence interval, 1-23). Hyperoxia was independently associated with poor neurological function (relative risk, 1.23; 95% confidence interval, 1.11-1.35). On multivariable analysis, a 1-hour-longer duration of hyperoxia exposure was associated with a 3% increase in risk of poor neurological outcome (relative risk, 1.03; 95% confidence interval, 1.02-1.05). We found that the association with poor neurological outcome began at ≥300 mm Hg. CONCLUSIONS: Early hyperoxia exposure after resuscitation from cardiac arrest was independently associated with poor neurological function at hospital discharge.

Association Between Elevated Mean Arterial Blood Pressure and Neurologic Outcome After Resuscitation From Cardiac Arrest: Results From a Multicenter Prospective Cohort Study.

OBJECTIVES: Laboratory studies suggest elevated blood pressure after resuscitation from cardiac arrest may be protective; however, clinical data are limited. We sought to test the hypothesis that elevated postresuscitation mean arterial blood pressure is associated with neurologic outcome. DESIGN: Preplanned analysis of a prospective cohort study. SETTING: Six academic hospitals in the United States. PATIENTS: Adult, nontraumatic cardiac arrest patients treated with targeted temperature management after return of spontaneous circulation. INTERVENTIONS: Mean arterial blood pressure was measured noninvasively after return of spontaneous circulation and every hour during the initial 6 hours after return of spontaneous circulation. MEASURES AND MAIN RESULTS: We calculated the mean arterial blood pressure and a priori dichotomized subjects into two groups: mean arterial blood pressure 70-90 and greater than 90 mm Hg. The primary outcome was good neurologic function, defined as a modified Rankin Scale less than or equal to 3. The modified Rankin Scale was prospectively determined at hospital discharge. Of the 269 patients included, 159 (59%) had a mean arterial blood pressure greater than 90 mm Hg. Good neurologic function at hospital discharge occurred in 30% of patients in the entire cohort and was significantly higher in patients with a mean arterial blood pressure greater than 90 mm Hg (42%) as compared with mean arterial blood pressure 70-90 mm Hg (15%) (absolute risk difference, 27%; 95% CI, 17-37%). In a multivariable Poisson regression model adjusting for potential confounders, mean arterial blood pressure greater than 90 mm Hg was associated with good neurologic function (adjusted relative risk, 2.46; 95% CI; 2.09-2.88). Over ascending ranges of mean arterial blood pressure, there was a dose-response increase in probability of good neurologic outcome, with mean arterial blood pressure greater than 110 mm Hg having the strongest association (adjusted relative risk, 2.97; 95% CI, 1.86-4.76). CONCLUSIONS: Elevated blood pressure during the initial 6 hours after resuscitation from cardiac arrest was independently associated with good neurologic function at hospital discharge. Further investigation is warranted to determine if targeting an elevated mean arterial blood pressure would improve neurologic outcome after cardiac arrest.

Validation of a 5-item tool to measure patient assessment of clinician compassion in the emergency department.

BACKGROUND: To test if the 5-item compassion measure (a tool previously validated in the outpatient setting to measure patient assessment of clinician compassion) is a valid and reliable tool to quantify a distinct construct (i.e. clinical compassion) among patients evaluated in the emergency department (ED). METHODS: Cross-sectional study conducted in three academic emergency departments in the U.S. between November 2018 and April 2019. We enrolled adult patients who were evaluated in the EDs of the participating institutions and administered the 5-item compassion measure after completion of care in the ED. Validity testing was performed using confirmatory factor analysis. Cronbach's alpha was used to test reliability. Convergent validity with patient assessment of overall satisfaction questions was tested using Spearman correlation coefficients and we tested if the 5-item compassion measure assessed a construct distinct from overall patient satisfaction using confirmatory factor analysis. RESULTS: We analyzed 866 patient responses. Confirmatory factor analysis found all five items loaded well on a single construct and our model was found to have good fit. Reliability was excellent (Cronbach's alpha = 0.93) among the entire cohort. These results remained consistent on sub-analyses stratified by individual institutions. The 5-item compassion measure had moderate correlation with overall patient satisfaction (r = 0.66) and patient recommendation of the ED to friends and family (r = 0.57), but reflected a patient experience domain (i.e. compassionate care) distinctly different from patient satisfaction. CONCLUSIONS: The 5-item compassion measure is a valid and reliable tool to measure patient assessment of clinical compassion in the ED.

Comparison of qSOFA with current emergency department tools for screening of patients with sepsis for critical illness.

OBJECTIVE: We sought to compare the quick sequential organ failure assessment (qSOFA) to systemic inflammatory response syndrome (SIRS), severe sepsis criteria and lactate levels for their ability to identify ED patients with sepsis with critical illness. METHODS: We conducted this multicenter retrospective cohort study at five US hospitals, enrolling all adult patients admitted to these hospitals from their EDs with infectious disease-related illnesses from 1 January 2016 to 30 April 2016. We abstracted clinical variables for SIRS, severe sepsis and qSOFA scores, using values in the first 6 hours of ED stay. Our primary outcome was critical illness, defined as one or more of the composite outcomes of death, vasopressor use or intensive care unit (ICU) admission within 72 hours of presentation. We determined diagnostic test characteristics for qSOFA scores, SIRS, severe sepsis criteria and lactate level thresholds. MAIN RESULTS: Of 3743 enrolled patients, 512 (13.7%) had the primary composite outcome. The qSOFA scores were ≥1, >2 and 3 in 1839 (49.1%), 626 (16.7%) and 146 (3.9%) patients, respectively; 2202 (58.8%) met SIRS criteria and 1085 (29.0%) met severe sepsis criteria. qSOFA ≥1 and SIRS had similarly high sensitivity [86.1% (95% CI 82.8% to 89.0%) vs 86.7% (95% CI 83.5% to 89.5%)], but qSOFA ≥1 had higher specificity [56.7% (95% CI 55.0% to 58.5%) vs 45.6% (43.9% to 47.3%); mean difference 11.1% (95% CI 8.7% to 13.6%)]. qSOFA ≥2 had higher specificity than severe sepsis criteria [89.1% (88.0% to 90.2%) vs 77.5% (76.0% to 78.9%); mean difference 11.6% (9.8% to 13.4%)]. qSOFA ≥1 had greater sensitivity than a lactate level ≥2 (mean difference 24.6% (19.2% to 29.9%)). CONCLUSION: For patients admitted from the ED with infectious disease diagnoses, qSOFA criteria performed as well or better than SIRS criteria, severe sepsis criteria and lactate levels in predicting critical illness.

Association between postresuscitation partial pressure of arterial carbon dioxide and neurological outcome in patients with post-cardiac arrest syndrome.

BACKGROUND: Partial pressure of arterial CO2 (Paco(2)) is a regulator of cerebral blood flow after brain injury. Recent guidelines for the management of cardiac arrest recommend maintaining Paco(2) at 40 to 45 mm Hg after successful resuscitation; however, there is a paucity of data on the prevalence of Paco(2) derangements during the post-cardiac arrest period and its association with outcome. METHODS AND RESULTS: We analyzed a prospectively compiled and maintained cardiac arrest registry at a single academic medical center. Inclusion criteria are as follows: age ≥18, nontrauma arrest, and comatose after return of spontaneous circulation. We analyzed arterial blood gas data during 0 to 24 hours after the return of spontaneous circulation and determined whether patients had exposure to hypocapnia and hypercapnia (defined as Paco(2) ≤30 mm Hg and Paco(2) ≥50 mm Hg, respectively, based on previous literature). The primary outcome was poor neurological function at hospital discharge, defined as Cerebral Performance Category ≥3. We used multivariable logistic regression, with multiple sensitivity analyses, adjusted for factors known to predict poor outcome, to determine whether post-return of spontaneous circulation hypocapnia and hypercapnia were independent predictors of poor neurological function. Of 193 patients, 52 (27%) had hypocapnia only, 63 (33%) had hypercapnia only, 18 (9%) had both hypocapnia and hypercapnia exposure, and 60 (31%) had no exposure; 74% of patients had poor neurological outcome. Hypocapnia and hypercapnia were independently associated with poor neurological function, odds ratio 2.43 (95% confidence interval, 1.04-5.65) and 2.20 (95% confidence interval, 1.03-4.71), respectively. CONCLUSIONS: Hypocapnia and hypercapnia were common after cardiac arrest and were independently associated with poor neurological outcome. These data suggest that Paco(2) derangements could be potentially harmful for patients after resuscitation from cardiac arrest.

Arterial blood pressure and neurologic outcome after resuscitation from cardiac arrest*.

OBJECTIVES: Guidelines for post-cardiac arrest care recommend blood pressure optimization as one component of neuroprotection. Although some retrospective clinical studies suggest that postresuscitation hypotension may be harmful, and laboratory studies suggest that a postresuscitation hypertensive surge may be protective, empirical data are few. In this study, we prospectively measured blood pressure over time during the postresuscitation period and tested its association with neurologic outcome. DESIGN: Single center, prospective observational study from 2009 to 2012. PATIENTS: Inclusion criteria were age 18 years old or older, prearrest independent functional status, resuscitation from cardiac arrest, and comatose immediately after resuscitation. MEASUREMENTS AND MAIN RESULTS: Our research protocol measured blood pressure noninvasively every 15 minutes for the first 6 hours after resuscitation. We calculated the 0- to 6-hour time-weighted average mean arterial pressure and used multivariable logistic regression to test the association between increasing time-weighted average mean arterial pressures and good neurologic outcome, defined as Cerebral Performance Category 1 or 2 at hospital discharge. Among 151 patients, 44 (29%) experienced good neurologic outcome. The association between blood pressure and outcome appears to have a threshold effect at time-weighted average mean arterial pressure value of 70 mm Hg. This threshold (mean arterial pressure > 70 mm Hg) had the strongest association with good neurologic outcome (odds ratio, 4.11; 95% CI, 1.34-12.66; p = 0.014). A sustained intrinsic hypertensive surge was relatively uncommon and was not associated with neurologic outcome. CONCLUSIONS: We found that time-weighted average mean arterial pressure was associated with good neurologic outcome at a threshold of mean arterial pressure greater than 70 mm Hg.

Multiple organ dysfunction after return of spontaneous circulation in postcardiac arrest syndrome.

OBJECTIVES: Recent guidelines for the treatment of postcardiac arrest syndrome recommend optimization of vital organ perfusion after return of spontaneous circulation to reduce the risk of postresuscitation multiple organ injury. However, the prevalence of extracerebral multiple organ dysfunction in postcardiac arrest patients and its association with in-hospital mortality remain unclear. DESIGN: Single-center, prospective observational study. SETTING: Urban academic medical center. PATIENTS: Postcardiac arrest patients. Inclusion criteria were as follows: age older than 17 years, nontrauma cardiac arrest, and comatose after return of spontaneous circulation. INTERVENTIONS: We prospectively captured all extracerebral components of the Sequential Organ Failure Assessment score over the first 72 hours after return of spontaneous circulation. The primary outcome measure was in-hospital mortality. We used multivariate logistic regression to determine if multiple organ dysfunction (defined as the highest extracerebral Sequential Organ Failure Assessment score) was an independent predictor of death, after adjustment for the presence of cerebral injury (defined as not following commands at any point over 0-72 hr). MEASUREMENTS AND MAIN RESULTS: We enrolled 203 postcardiac arrest patients; 96% had some degree of extracerebral organ dysfunction and 66% had severe dysfunction in two or more extracerebral organ systems. The most common extracerebral organ failures were cardiovascular (i.e., vasopressor dependence) and respiratory (i.e., oxygenation impairment). The highest extracerebral Sequential Organ Failure Assessment score over 72 hours had an independent association with in-hospital mortality (odds ratio 1.95 [95% CI, 1.15-3.29]). Of the individual organ systems, only the cardiovascular and respiratory Sequential Organ Failure Assessment scores had an independent association with in-hospital mortality. CONCLUSIONS: The results of this study support the hypothesis that extracerebral organ dysfunction is common and associated with mortality in postcardiac arrest syndrome. This association appears to be driven by postresuscitation hemodynamic dysfunction and oxygenation impairment. Further research is needed to determine the value of hemodynamic and oxygenation optimization as a part of treatment strategies for patients with postcardiac arrest syndrome.

Relationship between supranormal oxygen tension and outcome after resuscitation from cardiac arrest.

BACKGROUND: Laboratory and recent clinical data suggest that hyperoxemia after resuscitation from cardiac arrest is harmful; however, it remains unclear if the risk of adverse outcome is a threshold effect at a specific supranormal oxygen tension, or is a dose-dependent association. We aimed to define the relationship between supranormal oxygen tension and outcome in postresuscitation patients. METHODS AND RESULTS: This was a multicenter cohort study using the Project IMPACT database (intensive care units at 120 US hospitals). Inclusion criteria were age >17 years, nontrauma, cardiopulmonary resuscitation preceding intensive care unit arrival, and postresuscitation arterial blood gas obtained. We excluded patients with hypoxia or severe oxygenation impairment. We defined the exposure by the highest partial pressure of arterial oxygen (PaO(2)) over the first 24 hours in the ICU. The primary outcome measure was in-hospital mortality. We tested the association between PaO(2) (continuous variable) and mortality using multivariable logistic regression adjusted for patient-oriented covariates and potential hospital effects. Of 4459 patients, 54% died. The median postresuscitation PaO(2) was 231 (interquartile range 149 to 349) mm Hg. Over ascending ranges of oxygen tension, we found significant linear trends of increasing in-hospital mortality and decreasing survival as functionally independent. On multivariable analysis, a 100 mm Hg increase in PaO(2) was associated with a 24% increase in mortality risk (odds ratio 1.24 [95% confidence interval 1.18 to 1.31]. We observed no evidence supporting a single threshold for harm from supranormal oxygen tension. CONCLUSION: In this large sample of postresuscitation patients, we found a dose-dependent association between supranormal oxygen tension and risk of in-hospital death.

Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality.

CONTEXT: Laboratory investigations suggest that exposure to hyperoxia after resuscitation from cardiac arrest may worsen anoxic brain injury; however, clinical data are lacking. OBJECTIVE: To test the hypothesis that postresuscitation hyperoxia is associated with increased mortality. DESIGN, SETTING, AND PATIENTS: Multicenter cohort study using the Project IMPACT critical care database of intensive care units (ICUs) at 120 US hospitals between 2001 and 2005. Patient inclusion criteria were age older than 17 years, nontraumatic cardiac arrest, cardiopulmonary resuscitation within 24 hours prior to ICU arrival, and arterial blood gas analysis performed within 24 hours following ICU arrival. Patients were divided into 3 groups defined a priori based on PaO(2) on the first arterial blood gas values obtained in the ICU. Hyperoxia was defined as PaO(2) of 300 mm Hg or greater; hypoxia, PaO(2) of less than 60 mm Hg (or ratio of PaO(2) to fraction of inspired oxygen <300); and normoxia, not classified as hyperoxia or hypoxia. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS: Of 6326 patients, 1156 had hyperoxia (18%), 3999 had hypoxia (63%), and 1171 had normoxia (19%). The hyperoxia group had significantly higher in-hospital mortality (732/1156 [63%; 95% confidence interval {CI}, 60%-66%]) compared with the normoxia group (532/1171 [45%; 95% CI, 43%-48%]; proportion difference, 18% [95% CI, 14%-22%]) and the hypoxia group (2297/3999 [57%; 95% CI, 56%-59%]; proportion difference, 6% [95% CI, 3%-9%]). In a model controlling for potential confounders (eg, age, preadmission functional status, comorbid conditions, vital signs, and other physiological indices), hyperoxia exposure had an odds ratio for death of 1.8 (95% CI, 1.5-2.2). CONCLUSION: Among patients admitted to the ICU following resuscitation from cardiac arrest, arterial hyperoxia was independently associated with increased in-hospital mortality compared with either hypoxia or normoxia.

Significance of arterial hypotension after resuscitation from cardiac arrest.

OBJECTIVE: Expert guidelines advocate hemodynamic optimization after return of spontaneous circulation (ROSC) from cardiac arrest despite a lack of empirical data on prevalence of post-ROSC hemodynamic abnormalities and their relationship with outcome. Our objective was to determine whether post-ROSC arterial hypotension predicts outcome among postcardiac arrest patients who survive to intensive care unit admission. DESIGN: Cohort study utilizing the Project IMPACT database (intensive care unit admissions from 120 U.S. hospitals) from 2001-2005. SETTING: One hundred twenty intensive care units. PATIENTS: Inclusion criteria were: 1) age > or =18 yrs; 2) nontrauma; and 3) received cardiopulmonary resuscitation before intensive care unit arrival. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Subjects were divided into two groups: 1) Hypotension Present--one or more documented systolic blood pressure <90 mm Hg within 1 hr of intensive care unit arrival; or 2) Hypotension Absent--all systolic blood pressure > or =90 mm Hg. The primary outcome was in-hospital mortality. The secondary outcome was functional status at hospital discharge among survivors. A total of 8736 subjects met the inclusion criteria. Overall mortality was 50%. Post-ROSC hypotension was present in 47% and was associated with significantly higher rates of mortality (65% vs. 37%) and diminished discharge functional status among survivors (49% vs. 38%), p < .001 for both. On multivariable analysis, post-ROSC hypotension had an odds ratio for death of 2.7 (95% confidence interval, 2.5-3.0). CONCLUSIONS: Half of postcardiac arrest patients who survive to intensive care unit admission die in the hospital. Post-ROSC hypotension is common, is a predictor of in-hospital death, and is associated with diminished functional status among survivors. These associations indicate that arterial hypotension after ROSC may represent a potentially treatable target to improve outcomes from cardiac arrest.

Goal-directed hemodynamic optimization in the post-cardiac arrest syndrome: a systematic review.

AIMS: The treatment recommendations from the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science (hosted by the American Heart Association) advocate a goal-directed treatment strategy for hemodynamic optimization after return of spontaneous circulation (ROSC) in post-cardiac arrest care. We performed a systematic review to (1) examine the available evidence for goal-directed hemodynamic support in the post-cardiac arrest syndrome, (2) determine the effect of such a treatment strategy on survival, and (3) define the specific hemodynamic goals, if any, that have been tested in clinical trials of post-cardiac arrest patients. METHODS: We conducted a systematic review of the Cochrane Library, MEDLINE, CINAHL, conference proceedings, clinical practice guidelines, and other sources using a comprehensive strategy to identify randomized controlled trials and quasi-experimental studies of goal-directed hemodynamic optimization in patients with ROSC after cardiac arrest. RESULTS: The comprehensive search yielded a total of 1184 potential publications and after a relevance screen, five studies were eligible for full article review. None of the studies were eligible for inclusion in the final analysis. CONCLUSIONS: To date, no clinical trials have examined hemodynamic optimization in post-cardiac arrest patients. Although clinical acumen may support the concept that hemodynamic derangements after ROSC should be normalized, there is currently no evidence available to indicate the best strategy for goal-directed hemodynamic support. The current study indicates the need for future clinical investigations designed to determine both the efficacy of hemodynamic optimization in post-cardiac arrest patients and the best endpoints to target as part of a goal-directed strategy.

Early arterial hypotension is common in the post-cardiac arrest syndrome and associated with increased in-hospital mortality.

AIM: After return of spontaneous circulation (ROSC) from cardiac arrest, profound myocardial stunning and systemic inflammation may cause hemodynamic alterations; however, the prevalence of post-ROSC hemodynamic instability and the strength of association with outcome have not been established. We tested the hypothesis that exposure to arterial hypotension after ROSC occurs commonly (>50%) and is an independent predictor of death. METHODS: Single-center retrospective cohort study of all post-cardiac arrest patients over 1 year. INCLUSION CRITERIA: (1) age >17; (2) non-trauma; (3) sustained ROSC after cardiac arrest. Using the Jones criteria, subjects were assigned to one of two groups based on the presence of hypotension within 6h after ROSC: (1) exposures-two or more systolic blood pressures (SBPs) <100mmHg or (2) non-exposures-less than two SBP <100mmHg. The primary outcome was in-hospital mortality. We compared mortality rates between groups and used multivariate logistic regression to determine if post-ROSC hypotension independently predicted death. RESULTS: 102 subjects met inclusion criteria. In-hospital mortality was 75%. Exposure to hypotension occurred in 66/102 (65%) and was associated with significantly higher mortality (83%) compared to non-exposures (58%, p=0.01). In a model controlling for common confounding variables (age, pre-arrest functional status, arrest rhythm, and provision of therapeutic hypothermia (HT)), early exposure to hypotension was a strong independent predictor of death (OR 3.5 [95% CI 1.3-9.6]). CONCLUSIONS: Early exposure to arterial hypotension after ROSC was common and an independent predictor of death. These data suggest that post-ROSC hypotension could potentially represent a therapeutic target in post-cardiac arrest care.

Association between chest compression rates and clinical outcomes following in-hospital cardiac arrest at an academic tertiary hospital.

AIMS: Recent guidelines for management of cardiac arrest recommend chest compression rates of 100-120 compressions/min. However, animal studies have found cardiac output to increase with rates up to 150 compressions/min. The objective of this study was to test the association between chest compression rates during cardiopulmonary resuscitation for in-hospital cardiac arrest (IHCA) and outcome. METHODS: We conducted a prospective observational study at a single academic medical center. INCLUSION CRITERIA: age≥18, IHCA, cardiopulmonary resuscitation performed. We analyzed chest compression rates measured by defibrillation electrodes, which recorded changes in thoracic impedance. The primary outcome was return of spontaneous circulation (ROSC). We used multivariable logistic regression to determine odds ratios for ROSC by chest compression rate categories (100-120, 121-140, >140 compressions/min), adjusted for chest compression fraction (proportion of time chest compressions provided) and other known predictors of outcome. We set 100-120 compressions/min as the reference category for the multivariable model. RESULTS: We enrolled 222 consecutive patients and found a mean chest compression rate of 139±15. Overall 53% achieved ROSC; among 100-120, 121-140, and >140 compressions/min, ROSC was 29%, 64%, and 49% respectively. A chest compression rate of 121-140 compressions/min had the greatest likelihood of ROSC, odds ratio 4.48 (95% CI 1.42-14.14). CONCLUSIONS: In this sample of adult IHCA patients, a chest compression rate of 121-140 compressions/min had the highest odds ratio of ROSC. Rates above the currently recommended 100-120 compressions/min may improve the chances of ROSC among IHCA patients.

Translating research to clinical practice: a 1-year experience with implementing early goal-directed therapy for septic shock in the emergency department.

OBJECTIVE: Early goal-directed therapy (EGDT) has been shown to decrease mortality in patients with severe sepsis and septic shock. Consensus guidelines now advocate EGDT for the first 6 h of sepsis resuscitation. However, EGDT has not yet been widely adopted in practice. A need for effective collaboration between emergency medicine and critical care medicine services has been identified as an obstacle for implementation. We aimed to determine if EGDT end points could reliably be achieved in real-world clinical practice. METHODS: EGDT was implemented as a collaborative emergency medicine/critical care quality improvement initiative. EGDT included the following: i.v. fluids (IVF) targeting central venous pressure > or = 8 mm Hg, vasopressors targeting mean arterial pressure > or = 65 mm Hg, and (if necessary) packed RBCs (PRBCs) and/or dobutamine targeting central venous oxygen saturation > or = 70%. A retrospective analysis was performed of emergency department (ED) patients with persistent sepsis-induced hypotension (systolic BP < 90 mm Hg despite 1.5 L of IVF) treated with EGDT during the first year of the initiative. Primary outcome measures included successful achievement of EGDT end points and time to achievement. A secondary analysis was performed comparing EGDT cases to historical control cases (nonprotocolized control subjects without invasive monitoring). RESULTS: All end points were achieved in 20 of 22 cases (91%). The median time to reach each end point was < or = 6 h. In the secondary analysis, patients (n = 38; EGDT, n = 22; pre-EGDT, n = 16) had similar age, do-not-resuscitate status, severity scores, hypotension duration, and vasopressor requirement (p = not significant). In the ED, EGDT used more IVF and included PRBC/dobutamine utilization, without any impact on the overall use of these therapies through the first 24 h in the ICU. EGDT was associated with decreased ICU pulmonary artery catheter (PAC) utilization (9.1% vs 43.7%, p = 0.01). CONCLUSIONS: With effective emergency medicine/critical care collaboration, we demonstrate that EGDT end points can reliably be achieved in real-world sepsis resuscitation. ED-based EGDT appears to decrease ICU PAC utilization.

Bipolar disorder screening among adult patients in an urban emergency department setting.

OBJECTIVE: We sought to derive preliminary estimates of the prevalence of bipolar disorder among a sample of emergency department (ED) patients. METHOD: For 1 week in November 2003, consecutive patients aged ≥ 18 years presenting to an urban ED between 8:00 a.m. and midnight were screened for bipolar disorder. We used the National Depression Screening Day protocol, which includes the Mood Disorder Questionnaire. Patients who were severely ill or who had altered mental status were excluded. Demographic factors, past mental health history, and medical history also were assessed. RESULTS: Of the 212 patients that were approached and eligible, 182 (86%) were enrolled. Our sample's point prevalence for positive screen for bipolar disorder was 6.6% (95% CI = 3.5% to 11.2%). CONCLUSION: Nearly 7% of ED patients screened positive for bipolar disorder, which is considerably higher than community estimates of 1.3%. Further prospective research on bipolar disorders among ED patients is needed to further define the scope of the problem and to inform the development of appropriate screening, assessment, and intervention programs.