Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery.

INTRODUCTION: Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines. MATERIAL AND METHODS: The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS: This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy. CONCLUSIONS: Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.

Does participation in the European Trauma Course lead to new behaviours and organisational change? A Portuguese experience.

BACKGROUND: Medical educational courses can be successful from an immediate feedback perspective but not lead to new behaviour or organisational changes in the workplace. The aim of this study was to assess the self-perceived impact of the European Trauma Course (ETC) on Reanima trainees' behaviour and organisational change. METHODS: A 40-item questionnaire based on Holton's evaluation model was used to evaluate the candidate's perceptions. The results were analysed with descriptive and inferential statistical analysis using nonparametric tests with α = 0.05. RESULTS: Out of 295 participants, 126 responded to the survey. Of these, 94% affirmed that the ETC modified their approach to trauma patients, and 71.4% described a change in their behaviour. Postcourse responders changed their behaviour in their initial approach to trauma care in the nontechnical skills of communication, prioritisation and teamwork. Being an ETC instructor strongly influenced the acquisition of new material, and this group was able to implement changes in attitudes. Individuals with no previous trauma course experience identified lack of self-efficacy as a significant obstacle to introducing new work-based learning. In contrast, responders with ATLS training noted a lack of ETC colleagues as the main impediment for moving from conceptualisation to experimentation in the workplace. CONCLUSIONS: Participation in the ETC led to behavioural changes in the workplace. However, the ability to influence others and bring about wider organisational changes was more difficult to achieve. Major factors were the status of the person, their experience and self-efficacy. National organisational impact was obtained, which went far beyond our aspirations in acknowledging change in individual daily practice. Future research studies will include the effect of implementing the ETC methodology on the outcome of trauma patients.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery.

INTRODUCTION: Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines. MATERIAL AND METHODS: The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS: This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy. CONCLUSION: Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.

Validating peer-led assessments of CPR performance.

BACKGROUND: A patient's survival from cardiac arrest is improved if they receive good quality chest compressions as soon as possible. During cardiopulmonary resuscitation (CPR) training subjective assessments of chest compression quality is still common. Recently manikins allowing objective assessment have demonstrated a degree of variance with Instructor assessment. The aim of this study was to compare peer-led subjective assessment of chest compressions in three groups of participants with objective data from a manikin. METHOD: This was a quantitative multi-center study using data from simulated CPR scenarios. Seventy-eight Instructors were recruited, from different backgrounds; lay persons, hospital staff and emergency services personnel. Each group consisted of 13 pairs and all performed 2 â€‹min of chest compressions contemporaneously by peers and manikin (Brayden PRO®). The primary hypothesis was subjective and objective assessment methods would produce different test outcomes. RESULTS: 13,227 chest compressions were assessed. The overall median score given by the manikin was 88.5% (interquartile range 71.75-95), versus 92% (interquartile range 86.75-98) by observers. There was poor correlation in scores between assessment methods (Kappa -0.051 - +0.07). Individual assessment of components within the manikin scores demonstrated good internal consistency (alpha â€‹= â€‹0.789) compared to observer scores (alpha â€‹= â€‹0.011). CONCLUSION: Observers from all backgrounds were consistently more generous in their assessment when compared to the manikin. Chest compressions quality influences outcome following cardiac arrest, the findings of this study support increased use of objective assessment at the earliest opportunity, irrespective of background.

Algorithms to guide ambulance clinicians in the management of emergencies in patients with implanted rotary left ventricular assist devices.

Advances in left ventricular assist device (LVAD) therapy have resulted in increasing numbers of adult LVAD recipients in the community. However, device failure, stroke, bleeding, LVAD thrombosis and systemic infection can be life-threatening emergencies. Currently, four LVAD systems are implanted in six UK transplant centres, each of which provides device-specific information to local emergency services. This has resulted in inconsistent availability and content of information with the risks of delayed or inappropriate decision-making. In order to improve patient safety, a consortium of UK healthcare professionals with expertise in LVADs developed universally applicable prehospital emergency algorithms. Guidance was framed as closely as possible on the standard ABCDE approach to the assessment of critically ill patients.

The use of trained volunteers in the response to out-of-hospital cardiac arrest - the GoodSAM experience.

In England, fewer than 1 in 10 out-of-hospital cardiac arrest victims survive to hospital discharge. This could be substantially improved by increasing bystander cardiopulmonary resuscitation and Automated External Defibrillator use. GoodSAM is a mobile-phone, app-based system alerting trained individuals to nearby cardiac arrests. 'Responders' can be notified by bystanders using the GoodSAM 'Alerter' function. In London, when a 999 call-handler identifies cardiac arrest, in addition to dispatching the usual professional resources, London Ambulance Service automatically activates nearby GoodSAM responders. This article discusses the development of GoodSAM, its integration with London Ambulance Service, and the plans for future expansion.

Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study.

BACKGROUND: Internationally, hospital survival is lower for patients admitted at weekends and at night. Data from the UK National Cardiac Arrest Audit (NCAA) indicate that crude hospital survival was worse after in-hospital cardiac arrest (IHCA) at night versus day, and at weekends versus weekdays, despite similar frequency of events. OBJECTIVE: To describe IHCA demographics during three day/time periods-weekday daytime (Monday to Friday, 08:00 to 19:59), weekend daytime (Saturday and Sunday, 08:00 to 19:59) and night-time (Monday to Sunday, 20:00 to 07:59)-and to compare the associated rates of return of spontaneous circulation (ROSC) for >20 min (ROSC>20 min) and survival to hospital discharge, adjusted for risk using previously developed NCAA risk models. To consider whether any observed difference could be attributed to differences in the case mix of patients resident in hospital and/or the administered care. METHODS: We performed a prospectively defined analysis of NCAA data from 27 700 patients aged ≥16 years receiving chest compressions and/or defibrillation and attended by a hospital-based resuscitation team in response to a resuscitation (2222) call in 146 UK acute hospitals. RESULTS: Risk-adjusted outcomes (OR (95% CI)) were worse (p<0.001) for both weekend daytime (ROSC>20 min 0.88 (0.81 to 0.95); hospital survival 0.72 (0.64 to 0.80)), and night-time (ROSC>20 min 0.72 (0.68 to 0.76); hospital survival 0.58 (0.54 to 0.63)) compared with weekday daytime. The effects were stronger for non-shockable than shockable rhythms, but there was no significant interaction between day/time of arrest and age, or day/time of arrest and arrest location. While many daytime IHCAs involved procedures, restricting the analyses to IHCAs in medical admissions with an arrest location of ward produced results that are broadly in line with the primary analyses. CONCLUSIONS: IHCAs attended by the hospital-based resuscitation team during nights and weekends have substantially worse outcomes than during weekday daytimes. Organisational or care differences at night and weekends, rather than patient case mix, appear to be responsible.

Development and validation of risk models to predict outcomes following in-hospital cardiac arrest attended by a hospital-based resuscitation team.

AIM: The National Cardiac Arrest Audit (NCAA) is the UK national clinical audit for in-hospital cardiac arrest. To make fair comparisons among health care providers, clinical indicators require case mix adjustment using a validated risk model. The aim of this study was to develop and validate risk models to predict outcomes following in-hospital cardiac arrest attended by a hospital-based resuscitation team in UK hospitals. METHODS: Risk models for two outcomes-return of spontaneous circulation (ROSC) for greater than 20min and survival to hospital discharge-were developed and validated using data for in-hospital cardiac arrests between April 2011 and March 2013. For each outcome, a full model was fitted and then simplified by testing for non-linearity, combining categories and stepwise reduction. Finally, interactions between predictors were considered. Models were assessed for discrimination, calibration and accuracy. RESULTS: 22,479 in-hospital cardiac arrests in 143 hospitals were included (14,688 development, 7791 validation). The final risk model for ROSC>20min included: age (non-linear), sex, prior length of stay in hospital, reason for attendance, location of arrest, presenting rhythm, and interactions between presenting rhythm and location of arrest. The model for hospital survival included the same predictors, excluding sex. Both models had acceptable performance across the range of measures, although discrimination for hospital mortality exceeded that for ROSC>20min (c index 0.81 versus 0.72). CONCLUSIONS: Validated risk models for ROSC>20min and hospital survival following in-hospital cardiac arrest have been developed. These models will strengthen comparative reporting in NCAA and support local quality improvement.

Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit.

OBJECTIVE: To report the incidence, characteristics and outcome of adult in-hospital cardiac arrest in the United Kingdom (UK) National Cardiac Arrest Audit database. METHODS: A prospectively defined analysis of the UK National Cardiac Arrest Audit (NCAA) database. 144 acute hospitals contributed data relating to 22,628 patients aged 16 years or over receiving chest compressions and/or defibrillation and attended by a hospital-based resuscitation team in response to a 2222 call. The main outcome measures were incidence of adult in-hospital cardiac arrest and survival to hospital discharge. RESULTS: The overall incidence of adult in-hospital cardiac arrest was 1.6 per 1000 hospital admissions with a median across hospitals of 1.5 (interquartile range 1.2-2.2). Incidence varied seasonally, peaking in winter. Overall unadjusted survival to hospital discharge was 18.4%. The presenting rhythm was shockable (ventricular fibrillation or pulseless ventricular tachycardia) in 16.9% and non-shockable (asystole or pulseless electrical activity) in 72.3%; rates of survival to hospital discharge associated with these rhythms were 49.0% and 10.5%, respectively, but varied substantially across hospitals. CONCLUSIONS: These first results from the NCAA database describing the current incidence and outcome of adult in-hospital cardiac arrest in UK hospitals will serve as a benchmark from which to assess the future impact of changes in service delivery, organisation and treatment for in-hospital cardiac arrest.

A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, June 2008.

Paramedic tracheal intubation has been practised in the UK for more than 20 years and is currently a core skill for paramedics. Growing evidence suggests that tracheal intubation is not the optimal method of airway management by paramedics and may be detrimental to patient outcomes. There is also evidence that the current initial training of 25 intubations performed in-hospital is inadequate, and that the lack of ongoing intubation practice may compound this further. Supraglottic airway devices (eg, laryngeal mask airway), which were not available when extended training and paramedic intubation was first introduced, are now in use in many ambulance services and are a suitable alternative prehospital airway device for paramedics.

The European Trauma Course (ETC) and the team approach: past, present and future.

The European Trauma Course (ETC) was officially launched during the international conference of the European Resuscitation Council (ERC) in 2008. The ETC was developed on behalf of ESTES (European Society of Trauma and Emergency Surgery), EuSEM (European Society of Emergency Medicine), the ESA (European Society of Anaesthesiology) and the ERC. The objective of the ETC is to provide an internationally recognised and certified life support course, and to teach healthcare professionals the key principles of the initial care of severely injured patients. Its core elements, that differentiates it from other trauma courses, are a strong focus on team training and a novel modular design that is adaptable to the differing regional European requirements. This article describes the lessons learnt during the European Trauma Course development and provides an outline of the planned future development.

The European Trauma Course--from concept to course.

The Advanced Trauma Life Support (ATLS) course, developed by the American College of Surgeons, has revolutionised in-hospital management of major trauma patients and is now accepted as a standard of care in many countries worldwide. However, within Europe, there are significant differences in both the aetiology of trauma and the specialties involved in its initial management compared to the American model. Over the past 4 years, there have been a number of initiatives aimed at producing a trauma management course that was evidence based, practical and flexible enough to meet regional European needs and team oriented. Initial attempts tried to incorporate both pre- and in-hospital trauma care. This was eventually rationalised to the production of an in-hospital course and the first pilot course was run in Malta in November 2006. This article describes the evolution of the course, its current structure and plans for the future following the feedback received from candidates and instructors who participated in the first course.

Anaphylaxis to intrathecal diamorphine.

A 42-year-old male underwent a total hip arthroplasty under subarachnoid anaesthesia with intrathecal bupivacaine and diamorphine. Shortly after the start of surgery, he suffered an allergic reaction that, at first, was difficult to distinguish from the recognised side-effects of intrathecal diamorphine. Once the diagnosis was made, he was treated with adrenaline and made a full recovery. The serum concentration of mast cell tryptase approximately 1.5h after the onset of the adverse incident confirmed an anaphylactic reaction. Skin prick testing several weeks later identified diamorphine as the likely causative agent, a drug overlooked initially as a potential cause. We believe this is the first report of intrathecal diamorphine causing anaphylaxis.