[Education for resuscitation]. / Lehre in der Reanimation: Leitlinien des European Resuscitation Council 2021.

These European Resuscitation Council education guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidance to citizens and healthcare professionals with regard to teaching and learning the knowledge, skills and attitudes of resuscitation with the ultimate aim of improving patient survival after cardiac arrest.

Predictors of postoperative atrial fibrillation in patients with coronary artery disease undergoing cardiopulmonary bypass: a possible role for myocardial ischemia and atrial inflammation.

OBJECTIVE: To evaluate the preoperative presence of C-reactive protein (CRP) and troponin T(hs-TnT) in patients with coronary artery disease (CAD) undergoing cardiopulmonary bypass (CPB) in order to better clarify the role of atrial inflammation and/or myocardial ischemia in the development of postoperative atrial fibrillation (POAF). DESIGN: Prospective, nonrandomized study. SETTING: University hospital. PARTICIPANTS: Thirty-eight consecutive ischemic patients admitted to the authors' hospital for CAD undergoing elective on-pump coronary artery bypass grafting (CABG). INTERVENTION: Elective on-pump CABG. MEASUREMENTS AND MAIN RESULTS: Peripheral blood samples were collected from all patients before and 24 hours after CABG to assess high sensitive (hs)-CRP and troponin T (hs-TnT) levels. The patients' heart rhythm was monitored by continuous ECG telemetry. Biopsies from the right atrial appendage were obtained at the beginning of the CABG procedure in order to perform immunohistochemistry for CRP and reverse transcription polymerase chain reaction for CRP mRNA expression. Fourteen patients out of 38 (36%) developed POAF. Atrial CRP was found in 31 patients (82%), 10 with POAF and 21 with sinus rhythm (71% v 87% respectively, p = ns). None of the atrial samples was positive for CRP mRNA. Atrial CRP did not correlate with serum hs-CRP levels and with occurrence of POAF, but with the incidence of diabetes (p = 0.010). Postoperative hs-TnT levels, but not hs-CRP levels, were identified as the only predictor of POAF occurrence (p = 0.016). CONCLUSIONS: In patients undergoing CABG, neither peripheral nor tissue preoperative CRP levels, but only postoperative hs-TnT levels, correlated with POAF, suggesting the primary role of an ischemic trigger of atrial fibrillation.

Extracorporeal membrane oxygenation for resuscitation and cardiac arrest management.

This article reviews the potential application of extracorporeal membrane oxygenation (ECMO) technology to cardiopulmonary resuscitation for in and out-of-hospital cardiac arrest and discusses the current evidence on the subject. The possible strategies for organ protection during ECMO and the concept of ECMO networks are also reviewed.

Assessment of Cardiopulmonary Resuscitation Quality among Healthcare Providers: A Randomized Experimental Study of the Italian Resuscitation Council.

Background. The quality of cardiopulmonary resuscitation (CPR) is pivotal in improving the outcome of cardiac arrest. Nevertheless, there is evidence that even professional rescuers may deliver ineffective chest compressions (CCs). We sought to evaluate the impact of a CPR feedback device on the quality of CC performed by a supposedly highly trained and skilled population of attendees to the national annual congress of the Italian Resuscitation Council. Methods. A total of 202 congress attendees were enrolled to perform 2 min CC without feedback, followed by a 5 min rest and another 2 min interval of CC with feedback. Moreover, participants were randomly assigned to two study groups: "feedback later", in which the first 2 min CCs were delivered without the feedback, and "feedback first", in which the first 2 min CCs were aided by feedback. CPR quality has been analyzed in terms of the percentage of CC with adequate depth (CC, %), complete chest release (CR, %), and the CC rate (CC/min). Results. Approximately 60% of correct CCs were performed without feedback, which significantly increased to 79% with the use of feedback. In the "feedback later" group, the percentage of correctly performed CC and CR significantly increased during the second 2 min interval of CC with feedback (median value 51% vs. 86%, p < 0.0001 and 71% vs. 84%, p = 0.025, respectively). In the "feedback first" group, the percentage of correct CC remained stable during the two CC intervals (71% vs. 80%, p = 0.06), while CR was better without the help of the feedback (70% vs. 93%, p < 0.0001). CC/min was in the recommended range (100-120/min) in all the CC events. Conclusions. In this population of expected highly skilled CPR providers, the overall quality was inconsistent and, in many cases, did not reach guidelines recommendations. The use of a feedback device significantly improved the quality of CC. When the feedback device was used in the first CC attempt, it had a learning effect that was reflected in maintaining quality during the second CC series.

Flurbiprofen in the subglottic space to prevent postoperative sore throat after cardiac surgery: A randomized double-blind study.

STUDY OBJECTIVE: Postoperative sore throat (POST) and hoarseness are common complications of tracheal intubation. This study aims to evaluate the efficacy of flurbiprofen administered through the subglottic port of tracheal tubes to prevent POST after cardiac surgery. DESIGN: Single-center, prospective, randomized, double-blind, placebo-controlled trial. SETTING: Tertiary Care Referral University Hospital (Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome). PATIENTS: Included 71 patients undergoing for elective cardiac surgery. Inclusion criteria were (a) age between 50 and 75 years, (b) NYHA class I or II, (c) surgery for myocardial revascularization or valve repair or replacement under cardiopulmonary bypass. INTERVENTION: Patients were double blind randomized to receive flurbiprofen or saline in the subglottic port of the endotracheal tube (groups F and P). The solution was injected ten minutes after tracheal tube placement, ten minutes after ICU admission and ten minutes before tracheal tube removal. MEASUREMENTS: The primary outcome was to assess the effect of topical flurbiprofen administered through the subglottic port of the tracheal tube to prevent post-operative sore throat (POST). The secondary outcomes were the presence of hoarseness safety and patient's subjective satisfaction with their recovery. We did not report any exploratory outcomes. MAIN RESULTS: We analyzed 68 patients, 34 patients in each group. In group F, two patients complained of POST and hoarseness (5.9%), while all controls did. The two groups significantly differed in the severity scores (VAS and TPS for sore throat and HOAR for hoarseness) at all time points. In group P, patients reported mild to moderate symptoms that significantly improved or disappeared 36 h after tracheal tube removal. According to the multivariable model, hoarseness affected women less than men, in the control group (p = 0.002). None of the patients in either group reported any adverse effects. CONCLUSIONS: Repeated administration of flurbiprofen through the subglottic port of tracheal tubes reduced the incidence of sore throat and hoarseness after cardiac surgery without evidence of complications.

The effect of the AED and AED programs on survival of individuals, groups and populations.

OBJECTIVE: The automated external defibrillator (AED) is a tool that contributes to survival with mixed outcomes. This review assesses the effectiveness of the AED, consistencies and variations among studies, and how varying outcomes can be resolved. METHODS: A worksheet for the International Liaison Committee on Resuscitation (ILCOR) 2010 science review focused on hospital survival in AED programs was the foundation of the articles reviewed. Articles identified in the search covering a broader range of topics were added. All articles were read by at least two authors; consensus discussions resolved differences. RESULTS: AED use developed sequentially. Use of AEDs by emergency medical technicians (EMTs) compared to manual defibrillators showed equal or superior survival. AED use was extended to trained responders likely to be near victims, such as fire/rescue, police, airline attendants, and casino security guards, with improvement in all venues but not all programs. Broad public access initiatives demonstrated increased survival despite low rates of AED use. Home AED programs have not improved survival; in-hospital trials have had mixed results. Successful programs have placed devices in high-risk sites, maintained the AEDs, recruited a team with a duty to respond, and conducted ongoing assessment of the program. CONCLUSION: The AED can affect survival among patients with sudden ventricular fibrillation (VF). Components of AED programs that affect outcome include the operator, location, the emergency response system, ongoing maintenance and evaluation. Comparing outcomes is complicated by variations in definitions of populations and variables. The effect of AEDs on individuals can be dramatic, but the effect on populations is limited.

Incidence, characteristics, and outcome of out-of-hospital cardiac arrest in Italy: A systematic review and meta-analysis.

Introduction: Data on out-of-hospital cardiac arrest (OHCA) is limited in Italy, and there has never been a comprehensive systematic appraisal of the available evidence. Therefore, this review aims to explore the incidence, characteristics, and outcome of OHCA in Italy. Methods: We systematically searched PubMed, Embase, Google Scholar, ResearchGate, and conference proceedings up to September 23, 2022. Studies investigating OHCA in Italy and reporting at least one outcome related to cardiac arrest were considered eligible. The primary outcome was survival at the longest follow-up available. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool. A random-effects model proportion meta-analysis was performed to calculate the pooled outcomes with 95% confidence interval (CI). Results: We included 42 studies (43,042 patients) from 13 of the 20 Italian regions published between 1995 and 2022. Only five studies were deemed to be at low risk of bias. The overall average incidences of OHCA attended by emergency medical services and with resuscitation attempted were 86 (range: 10-190) and 55 (range: 6-108) per 100,000 populations per year, respectively. Survival at the longest follow-up available was 9.0% (95% CI, 6.7-12%; 30 studies and 15,195 patients) in the overall population, 25% (95% CI, 21-30%; 16 studies and 2,863 patients) among patients with shockable rhythms, 28% (95% CI, 20-37%; 8 studies and 1,292 patients) among the Utstein comparator group. Favourable neurological outcome was 5.0% (95% CI, 3.6-6.6%; 16 studies and 9,675 patients). Return of spontaneous circulation was achieved in 19% (95% CI, 16-23%; 40 studies and 30,875 patients) of cases. Bystanders initiated cardiopulmonary resuscitation in 26% (95% CI, 21-32%; 33 studies and 23,491 patients) of cases but only in 3.2% (95% CI, 1.9-4.9%; 9 studies and 8,508 patients) with an automated external defibrillator. The mean response time was 10.2 (95% CI, 8.9-11.4; 25 studies and 23,997 patients) minutes. Conclusions: Survival after OHCA in Italy occurred in one of every ten patients. Bystanders initiated cardiopulmonary resuscitation in only one-third of cases, rarely with a defibrillator. Different areas of the country collected data, but an essential part of the population was not included. There was high heterogeneity and large variation in outcomes results and reporting, limiting the confidence in the estimates of incidence and outcome. Creating and maintaining a nationwide registry is a priority.

Community Initiatives to Promote Basic Life Support Implementation-A Scoping Review.

INTRODUCTION: Early intervention of bystanders (the first links of the chain of survival) have been shown to improve survival and good neurological outcomes of patients suffering out-of-hospital cardiac arrest (OHCA). Many initiatives have been implemented to increase the engagement of communities in early basic life support (BLS) and cardiopulmonary resuscitation (CPR), especially of lay people with no duty to respond. A better knowledge of the most effective initiatives might help improve survival and health system organization. Aim of the scoping review: To assess the impact of specific interventions involving lay communities on bystander BLS rates and other consistent clinical outcomes, and to identify relevant knowledge gaps. METHODS: This scoping review was part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR), and was performed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. We performed a literature search using the PubMed, EMBASE, and Cochrane databases until 1 February 2021. The screening process was conducted based on predefined inclusion/exclusion criteria, and for each included study, we performed data extraction focusing on the type of intervention implemented, and the impact of these interventions on the specific OHCAs outcomes. RESULTS: Our search strategy identified 19 eligible studies, originating mainly from the USA (47.4%) and Denmark (21%). The type of intervention included in 57.9% of cases was a community CPR training program, in 36.8% bundled interventions, and in 5.3% mass-media campaigns. The most commonly reported outcome for OHCAs was bystander CPR rate (94.7%), followed by survival to hospital discharge (36.8%), proportion of people trained (31.6%), survival to hospital discharge with good neurological outcome (21%), and Return of Spontaneous Circulation (10.5%). Community training programs and bundled interventions improved bystander CPR in most of the included studies. CONCLUSION: Based on the results of our scoping review, we identified the potential benefit of community initiatives, such as community training in BLS, even as part of bundled intervention, in order to improve bystander CPR rates and patient outcomes.

European Resuscitation Council Guidelines 2021: Education for resuscitation.

These European Resuscitation Council education guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidance to citizens and healthcare professionals with regard to teaching and learning the knowledge, skills and attitudes of resuscitation with the ultimate aim of improving patient survival after cardiac arrest.

European Resuscitation Council Guidelines 2021: Systems saving lives.

The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.

New Early Warning Score: EMS Off-Label Use in Out-of-Hospital Patients.

BACKGROUND: The National Early Warning Score (NEWS) is an assessment scale of in-hospital patients' conditions. The purpose of this study was to assess the appropriateness of a potential off-label use of NEWS by the emergency medical system (EMS) to facilitate the identification of critical patients and to trigger appropriate care in the pre-hospital setting. METHODS: A single centre, longitudinal, prospective study was carried out between July and August 2020 in the EMS service of Bologna. Home patients with age ≥ 18 years old were included in the study. The exclusion criterion was the impossibility to collect all the parameters needed to measure NEWS. RESULTS: A total of 654 patients were enrolled in the study. The recorded NEWS values increased along with the severity of dispatch priority code, the EMS return code, the emergency department triage code, and with patients' age (r = 0.135; p = 0.001). The aggregated value of NEWS was associated with an increased risk of hospitalization (OR = 1.30 (1.17; 1.34); p < 0.0001). CONCLUSION: This study showed that the use of NEWS in the urgent and emergency care services can help patient assessment while not affecting EMS crew operation and might assist decision making in terms of severity-code assignment and resources utilization.

Willingness to perform bystander cardiopulmonary resuscitation: A scoping review.

BACKGROUND: Despite the proven effectiveness of rapid initiation of cardiopulmonary resuscitation (CPR) for patients with out-of-hospital cardiac arrest (OHCA) by bystanders, fewer than half of the victims actually receive bystander CPR. We aimed to review the evidence of the barriers and facilitators for bystanders to perform CPR. METHODS: This scoping review was conducted as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR), and followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. This review included studies assessing barriers or facilitators for the lay rescuers to perform CPR in actual emergency settings and excluded studies that overlapped with other ILCOR systematic reviews/scoping reviews (e.g. dispatcher instructed CPR etc). The key findings were classified into three kinds of factors: personal factors; CPR knowledge; and procedural issues. RESULTS: We identified 18 eligible studies. Of these studies addressing the reduced willingness to respond to cardiac arrest, 14 related to "personal factors", 3 to "CPR knowledge", and 2 to "procedural issues". On the other hand, we identified 5 articles assessing factors increasing bystanders' willingness to perform CPR. However, we observed significant heterogeneity among study populations, methodologies, factors definitions, outcome measures utilized and outcomes reported. CONCLUSIONS: We found that a number of factors were present in actual settings which either inhibit or facilitate lay rescuers' performance of CPR. Interventional strategies to improve CPR performance of lay rescuers in the actual settings should be established, taking these factors into consideration.

Healthcare professionals' knowledge on cardiopulmonary resuscitation correlated with return of spontaneous circulation rates after in-hospital cardiac arrests: A multicentric study between university hospitals in 12 European countries.

BACKGROUND: In-hospital cardiac arrest is a major cause of death in European countries, and survival of patients remains low ranging from 20% to 25%. AIMS: The purpose of this study was to assess healthcare professionals' knowledge on cardiopulmonary resuscitation among university hospitals in 12 European countries and correlate it with the return of spontaneous circulation rates of their patients after in-hospital cardiac arrest. METHODS AND RESULTS: A total of 570 healthcare professionals from cardiology, anaesthesiology and intensive care medicine departments of European university hospitals in Italy, Poland, Hungary, Belgium, Spain, Slovakia, Germany, Finland, The Netherlands, Switzerland, France and Greece completed a questionnaire. The questionnaire consisted of 12 questions based on epidemiology data and cardiopulmonary resuscitation training and 26 multiple choice questions on cardiopulmonary resuscitation knowledge. Hospitals in Switzerland scored highest on basic life support (P=0.005) while Belgium hospitals scored highest on advanced life support (P<0.001) and total score in cardiopulmonary resuscitation knowledge (P=0.01). The Swiss hospitals scored highest in cardiopulmonary resuscitation training (P<0.001). Correlation between cardiopulmonary resuscitation knowledge and return of spontaneous circulation rates of patients with in-hospital cardiac arrest demonstrated that each additional correct answer on the advanced life support score results in a further increase in return of spontaneous circulation rates (odds ratio 3.94; 95% confidence interval 2.78 to 5.57; P<0.001). CONCLUSION: Differences in knowledge about resuscitation and course attendance were found between university hospitals in 12 European countries. Education in cardiopulmonary resuscitation is considered to be vital for patients' return of spontaneous circulation rates after in-hospital cardiac arrest. A higher level of knowledge in advanced life support results in higher return of spontaneous circulation rates.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

A modified intracavitary electrocardiographic method for detecting the location of the tip of central venous catheters in atrial fibrillation patients.

INTRODUCTION: The intracavitary electrocardiographic method is recommended for assessing the location of the tip of central venous catheter when there is an identifiable P wave. Previous reports suggested that intracavitary electrocardiographic method might also be applied to patients with atrial fibrillation, considering the so-called f waves as a surrogate of the P wave. METHODS: We studied 18 atrial fibrillation patients requiring simultaneously a central venous catheter and a trans-esophageal echocardiography. An intracavitary electrocardiographic trace was recorded with the catheter tip in three different positions defined by trans-esophageal echocardiography imaging: in the superior vena cava, 2 cm above the cavo-atrial junction; at the cavo-atrial junction; and in the right atrium, 2 cm below the cavo-atrial junction. Three different criteria of measurement of the f wave pattern in the TQ tract were used: the mean height of f waves (method A); the height of the highest f wave (method B); the difference between the highest positive peak and the lowest negative peak (method C). RESULTS: There were no complications. With the tip placed at the cavo-atrial junction, the mean value of the f waves was significantly higher than in the other two positions. All three methods were effective in discriminating the tip position at the cavo-atrial junction, though method B proved to be the most accurate. CONCLUSION: A modified intracavitary electrocardiographic technique can be safely used for detecting the location of the tip of central venous catheters in atrial fibrillation patients: the highest activity of the f waves is an accurate indicator of the location of the tip at the cavo-atrial junction.