Preoperative Risk and the Association between Hypotension and Postoperative Acute Kidney Injury.

BACKGROUND: Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk. METHODS: Major noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10 min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline). RESULTS: Among 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort. CONCLUSIONS: Adult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury.

Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study.

BACKGROUND: Continuous infusions of norepinephrine to treat perioperative hypotension are typically administered through a central venous line rather than a peripheral venous catheter to avoid the risk of localized tissue necrosis in case of drug extravasation. There is limited literature to estimate the risk of skin necrosis when peripheral norepinephrine is used to counteract anesthesia-associated hypotension in elective surgical cases. This study aimed to estimate the rate of occurrence of drug-related adverse effects, including skin necrosis requiring surgical management when norepinephrine peripheral extravasation occurs. METHODS: This retrospective cohort study used the perioperative databases of the University Hospitals in Amsterdam and Utrecht, the Netherlands, to identify surgical patients who received norepinephrine peripheral intravenous infusions (20 µg/mL) between 2012 and 2016. The risk of drug-related adverse effects, including skin necrosis, was estimated. Particular care was taken to identify patients who needed plastic surgical or medical attention secondary to extravasation of dilute, peripheral norepinephrine. RESULTS: A total of 14,385 patients who received norepinephrine peripheral continuous infusions were identified. Drug extravasation was observed in 5 patients (5/14,385 = 0.035%). The 95% confidence interval (CI) for infusion extravasation was 0.011%-0.081%, indicating an estimated risk of 1-8 events per every 10,000 patients. There were zero related complications requiring surgical or medical intervention, resulting in a 95% CI of 0%-0.021% and indicating a risk of approximately 0-2 events per 10,000 patients. CONCLUSIONS: In the current database analysis, no significant association was found between the use of peripheral intravenous norepinephrine infusions and adverse events.

Succinylcholine Use and Dantrolene Availability for Malignant Hyperthermia Treatment: Database Analyses and Systematic Review.

BACKGROUND: Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. METHODS: The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. RESULTS: Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. CONCLUSIONS: Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

Comparison of perioperative glucose regulation in patients with type 1 vs type 2 diabetes mellitus: A retrospective cross-sectional study.

BACKGROUND: Most perioperative diabetes mellitus (DM) guidelines do not distinguish between patients with type 1 (DM1) and type 2 (DM2). We hypothesised that similar treatment of DM1 and DM2 patients leads to differences in their perioperative glucose control. METHODS: We performed a retrospective cross-sectional study, of all DM patients undergoing surgery between May 2013 and November 2015 in a Dutch university hospital. We compared DM1 with DM2 patients, treated according to the same perioperative glucose protocol. Our primary outcome was the incidence of hyperglycaemia (glucose ≥10 mmol/L). Secondary outcomes were short-term glycaemic control (glucose before surgery and peak glucose perioperatively), long-term glycaemic control (HbA1c in 90 days before and after surgery) and the incidence of hypoglycaemia (glucose <4 mmol/L). RESULTS: We included 2259 patients with DM, 216 (10%) of which had DM1. The calculated incidences in our population were 7 out of 1000 patients with DM1 and 69 out of 1000 patients with DM2. Compared to those with DM2, patients with DM1 were younger, had a lower BMI, a higher glucose concentration before surgery, and a higher perioperative peak glucose concentration (11.0 [8.2-14.7] vs 9.4 [7.7-11.7], P < 0.001). The incidence of the primary endpoint, perioperative hyperglycaemia, was significantly higher in DM1 compared to DM2 patients (63% vs 43%, P < 0.001). Hypoglycaemia occurred more often in the DM1 population (7.1% vs 1.3%, P < 0.001). CONCLUSION: Providing similar perioperative treatment to patients with DM1 and DM2 is associated with poorer short-term and long-term glycaemic control in DM1 throughout the perioperative period as well as an increased risk of hypoglycaemia.

Long-term Effectiveness of the Airway Registry at Sydney Helicopter Emergency Medical Service.

OBJECTIVE: Prehospital rapid sequence intubation (RSI) is prone to suboptimal documentation. The Greater Sydney Area Helicopter Emergency Medical Service (GSA-HEMS) uses a dedicated Airway Registry (AR) to aid documentation. The AR was only evaluated shortly after its introduction. This first evaluation is followed up to assess the long-term effectiveness of the AR. The secondary objective was to compare the AR with templates in the literature. METHODS: A retrospective review of electronic records was undertaken to compare completeness of documentation between an immediate postintroduction and a long-term postintroduction cohort. Differences between the two cohorts were tested for significance. RESULTS: There was no significant difference in documentation for Cormack-Lehane laryngoscopy grade at the first intubation attempt (P = .552) and confirmation of end-tidal carbon dioxide (P = .258). A significant improvement in the documentation of laryngoscopy grade for the second attempt (P = 0) was found. The documentation of intubator details remained at 100% (165/165). The variables collected by GSA-HEMS corresponded well to the literature, but some definitions differ (eg, desaturation). CONCLUSION: There was no significant change in completeness of documentation for most key intubation variables eight years after the introduction of the AR. GSA-HEMS performs well in registering variables as proposed in the literature; however, variable definitions need to be synchronized.

The European Trauma Course: Transforming systems through training.

The European Trauma Course (ETC) exemplifies an innovative approach to multispecialty trauma education. This initiative was started as a collaborative effort among the European Society for Emergency Medicine, the European Society for Trauma and Emergency Surgery, and the European Society of Anaesthesiology under the auspices of the European Resuscitation Council. With the robust support of these societies, the project has evolved into the independent European Trauma Course Organisation. Over the past 15 years, the ETC has transcended traditional training by integrating team dynamics and non-technical skills into a scenario-based simulation course, helping to shape trauma care practice and education. A distinctive feature of the ETC is its training of doctors and allied healthcare professionals, fostering a collaborative and holistic approach to trauma care. The ETC stands out for its unique team-teaching approach, which has gained widespread recognition as the standard for in-hospital trauma care training not only in Europe but also beyond. Since its inception ETC has expanded geographically from Finland to Sudan and from Brazil to the Emirates, training nearly 20,000 healthcare professionals and shaping trauma care practice and education across 25 countries. Experiencing exponential growth, the ETC continues to evolve, reflecting its unmet demand in trauma team education. This review examines the evolution of the ETC, its innovative team-teaching methodology, national implementation strategies, current status, and future challenges. It highlights its impact on trauma care, team training, and the effect on other life support courses in various countries.

A shocking injury: A clinical review of lightning injuries highlighting pitfalls and a treatment protocol.

INTRODUCTION: Lightning strikes have high morbidity and mortality rates. Thousands of fatalities are estimated to be caused by lightning worldwide, with the number of injuries being 10 times greater. However, evidence of lightning injuries is restricted to case reports and series and nonsystematic reviews. In this clinical review, we systematically select, score, and present evidence regarding lightning injuries. MATERIAL AND METHODS: We performed a systematic search for reviews and guidelines in the PubMed, Embase (OvidSP), MEDLINE (OvidSP), and Web of Science databases. All publications were scored according to the Levels of Evidence 2 Table of the Oxford center for Evidence-Based Medicine. The reviews were also scored using the scale for the quality assessment of narrative review articles (SANRA) and guidelines from the Appraisal of Guidelines for Research & Evaluation (AGREE II). RESULTS: The search yielded 536 articles. Eventually, 56 articles were included, which consisted of 50 reviews, five guidelines and one overview. The available reviews and guidelines were graded as low to moderate evidence. Most damage from lightning injuries is cardiovascular and neurological, although an individual can experience complications with any of their vital functions. At the scene, initial treatment and resuscitation should focus on those who appear to be dead, which is called the reverse triage system. We proposed an evidence-based treatment protocol for lightning strike patients. CONCLUSION: It is vital that every lightning strike patient is treated according to standard trauma guidelines, with a specific focus on the possible sequelae of lighting injuries. All emergency healthcare professionals should acknowledge the risks and particularities of treating lighting strike injuries to optimize the care and outcomes of these patients. Our evidence-based treatment protocol should help prehospital and in-hospital emergency healthcare practitioners to prevent therapeutic mismanagement among these patients.

A pre-hospital risk score predicts critical illness in non-trauma patients transported by ambulance to a Dutch tertiary referral hospital.

BACKGROUND: Early pre-hospital identification of critically ill patients reduces morbidity and mortality. To identify critically ill non-traumatic and non-cardiac arrest patients, a pre-hospital risk stratification tool was previously developed in the United States. The aim of this study was to investigate the accuracy of this tool in a Dutch Emergency Department. METHODS: This retrospective study included all patients of 18 years and older transported by ambulance to the Emergency Department of a tertiary referral hospital between January 1st 2017 and December 31st 2017. Documentation of pre-hospital vital parameters had to be available. The tool included a full set of vital parameters, which were categorized by predetermined thresholds. Study outcome was the accuracy of the tool in predicting critical illness, defined as admittance to the Intensive Care Unit for delivery of vital organ support or death within 28 days. Accuracy of the risk stratification tool was measured with the Area Under the Receiver Operating Characteristics (AUROC) curve. RESULTS: Nearly 3000 patients were included in the study, of whom 356 patients (12.2%) developed critical illness. We observed moderate discrimination of the pre-hospital risk score with an AUROC of 0.74 (95%-CI 0.71-0.77). Using a threshold of 3 to identify critical illness, we observed a sensitivity of 45.0% (95%-CI 44.8-45.2) and a specificity of 86.0% (95%-CI 85.9-86.0). CONCLUSION: These data show that this pre-hospital risk stratification tool is a moderately effective tool to predict which patients are likely to become critically ill in a Dutch non-trauma and non-cardiac arrest population.

Perioperative approach of allergic patients.

Perioperative allergic reactions are rare, yet important complications of anesthesia. Severe, generalized allergic reactions called anaphylaxis are estimated to have a mortality of 3.5-4.8%. Adequate recognition and handling of a severe perioperative anaphylactic reaction result in better outcomes, including less hypoxic-ischemic encephalopathy and death. The diagnosis of a perioperative allergic reaction can be difficult as the list of possible culprits of a perioperative allergic reaction is extensive. Making an informed guess on the causative agent and avoiding this agent in future anesthesia procedures is undesirable and unsafe. Therefore, to ensure future patient safety, a thorough investigation following a perioperative allergic reaction is mandatory. A collaborate approach by allergists and anesthesiologists is advised. In this article, we discuss the basic approach of the allergic patient and of patients with a suspected allergy to perioperatively administered medication.

Optimizing airway management and ventilation during prehospital advanced life support in out-of-hospital cardiac arrest: A narrative review.

Airway management and ventilation are essential components of cardiopulmonary resuscitation to achieve oxygen delivery in order to prevent hypoxic injury and increase the chance of survival. Weighing the relative benefits and downsides, the best approach is a staged strategy; start with a focus on high-quality chest compressions and defibrillation, then optimize mask ventilation while preparing for advanced airway management with a supraglottic airway device. Endotracheal intubation can still be indicated, but has the largest downsides of all advanced airway techniques. Whichever stage of airway management, ventilation and chest compression quality should be closely monitored. Capnography has many advantages and should be used routinely. Optimizing ventilation strategies, harmonizing ventilation with mechanical chest compression devices, and implementation in complex and stressful environments are challenges we need to face through collaborative innovation, research, and implementation.

Assessment of Lung Reaeration at 2 Levels of Positive End-expiratory Pressure in Patients With Early and Late COVID-19-related Acute Respiratory Distress Syndrome.

PURPOSE: Patients with novel coronavirus disease (COVID-19) frequently develop acute respiratory distress syndrome (ARDS) and need invasive ventilation. The potential to reaerate consolidated lung tissue in COVID-19-related ARDS is heavily debated. This study assessed the potential to reaerate lung consolidations in patients with COVID-19-related ARDS under invasive ventilation. MATERIALS AND METHODS: This was a retrospective analysis of patients with COVID-19-related ARDS who underwent chest computed tomography (CT) at low positive end-expiratory pressure (PEEP) and after a recruitment maneuver at high PEEP of 20 cm H2O. Lung reaeration, volume, and weight were calculated using both CT scans. CT scans were performed after intubation and start of ventilation (early CT), or after several days of intensive care unit admission (late CT). RESULTS: Twenty-eight patients were analyzed. The median percentages of reaerated and nonaerated lung tissue were 19% [interquartile range, IQR: 10 to 33] and 11% [IQR: 4 to 15] for patients with early and late CT scans, respectively (P=0.049). End-expiratory lung volume showed a median increase of 663 mL [IQR: 483 to 865] and 574 mL [IQR: 292 to 670] after recruitment for patients with early and late CT scans, respectively (P=0.43). The median decrease in lung weight attributed to nonaerated lung tissue was 229 g [IQR: 165 to 376] and 171 g [IQR: 81 to 229] after recruitment for patients with early and late CT scans, respectively (P=0.16). CONCLUSIONS: The majority of patients with COVID-19-related ARDS undergoing invasive ventilation had substantial reaeration of lung consolidations after recruitment and ventilation at high PEEP. Higher PEEP can be considered in patients with reaerated lung consolidations when accompanied by improvement in compliance and gas exchange.

Automated reminders increase adherence to guidelines for administration of prophylaxis for postoperative nausea and vomiting.

BACKGROUND AND OBJECTIVE: Correct identification of patients at high risk for postoperative nausea and vomiting (PONV), prescription of PONV prophylaxis and correct administration of medication are all important for effective PONV prophylaxis. This has been acknowledged by development of guidelines throughout the world. We studied the effect of introducing patient-specific automated reminders on timely administration of PONV prophylaxis medication during general anaesthesia. METHODS: During the visit to the preoperative screening clinic, patients at high risk for PONV were identified and PONV prophylaxis was prescribed. To study the effect of patient-specific decision support [a pop-up window reminding the (nurse) anaesthetist that PONV prophylaxis had been prescribed for this particular patient] on the timely administration of PONV medication, we queried our database to extract data on all patients for three consecutive periods: 6 weeks before decision support (control), 12 weeks during decision support and 6 weeks after discontinuation of decision support (postdecision support) and studied how often PONV prophylaxis was administered correctly. RESULTS: Between November 2005 and May 2006, 1727, 2594 and 1331 patients presented for elective surgery in the control, decision support and postdecision support periods, respectively. In the control period, 236 patients receiving general anaesthesia were scheduled to receive PONV prophylaxis. Of these, 93 (39%) received both dexamethasone and granisetron in the correct timeframe. This increased to 464 (79%) out of 591 patients in the decision support period and decreased back to 99 (41%) out of 243 patients in the postdecision support period (P < 0.001). CONCLUSION: Decision support is effective in improving administration and timing of PONV prophylaxis medication. After withdrawal of decision support, adherence decreased to predecision support levels.

Prehospital ultrasound in the management of trauma patients: Systematic review of the literature.

INTRODUCTION: Emergency ultrasound methods such as Focused Assessment with Sonography in Trauma (FAST) are a widely used imaging method. This examination can be performed to examine the presence of several life-threatening injuries. Early diagnosis may lead to better outcome, but the effect of timely diagnosis in the prehospital setting is not yet clear. Therefore, the aim is to determine the diagnostic accuracy and the effect of prehospital ultrasound performed in (poly)trauma patients. METHODS: A literature search was performed in PubMed, Embase and Cochrane's Library. Articles were included if prehospital ultrasound was performed as a diagnostic intervention in patients with trauma. The main outcome measures included diagnostic accuracy, changes in prehospital diagnosis/treatment, changes in destination hospital and in-hospital response. Case reports and case series were excluded. RESULTS: After screening 3343 articles, nine studies met the inclusion criteria. These included three retrospective and six prospective observational studies, with a total number of 2,889 patients. Five studies report at least one change in polytrauma management, ranging from 6% to 48,9% of the cases. The diagnostic accuracy of prehospital ultrasound was adequate in eight (out of nine) articles. High sensitivity and high specificity were found on several endpoints (pneumothorax, free abdominal fluid, haemoperitoneum, both on site and during transport). CONCLUSION: Prehospital ultrasound led to a change in polytrauma management in all studies that included this as an outcome measure. The diagnostic accuracy was described in eight studies, high sensitivity and specificity were found. Overall, the studies seem to suggest a positive influence of performing ultrasound. However, additional research with homogenous accuracy endpoints and uniformly trained prehospital care providers is recommended.

Decision support increases guideline adherence for prescribing postoperative nausea and vomiting prophylaxis.

BACKGROUND: Guidelines for postoperative nausea and vomiting (PONV) prevention are implemented widely but their effectiveness may be limited by poor adherence. We hypothesized that the use of an electronic decision support (DS) system would significantly improve guideline adherence. METHODS: Medical information of all patients undergoing elective surgery in our regional teaching hospital is routinely entered in an anesthesia information management system at the preoperative screening clinic. Our departmental PONV prevention guidelines identifies patients as "high-risk" and thus eligible for PONV prophylaxis based on the presence of at least three of the following risk factors: female gender, history of PONV or motion sickness, nonsmoker status, and anticipated use of postoperative opioids. Using automated reminders, we studied the effect of DS on guidelines adherence using an off-on-off design. In these three study periods, we queried for all consecutive patients visiting the preoperative screening clinic who were eligible for PONV prophylaxis and studied how often it was prescribed correctly. RESULTS: Between November 2005 and June 2006, 1340, 2715, and 1035 patients were included in the control, DS and post-DS periods, respectively. As a result of mandatory data entry of risk factors, the percentage of high-risk PONV patients increased from 28% in the control period to 32% and 31% in the DS and post-DS periods, respectively. During the control period, 38% of all high-risk patients were prescribed PONV prophylaxis. This increased to 73% during the DS period and decreased to 37% in the post-DS period. CONCLUSION: Electronic DS increases guidelines adherence for the prescription of PONV prophylaxis in high-risk PONV patients.

The effect of requesting a reason for non-adherence to a guideline in a long running automated reminder system for PONV prophylaxis.

BACKGROUND: Automated reminders are employed frequently to improve guideline adherence, but limitations of automated reminders are becoming more apparent. We studied the reasons for non-adherence in the setting of automated reminders to test the hypothesis that a separate request for a reason in itself may further improve guideline adherence. METHODS: In a previously implemented automated reminder system on prophylaxis for postoperative nausea and vomiting (PONV), we included additional automated reminders requesting a reason for non-adherence. We recorded these reasons in the pre-operative screening clinic, the OR and the PACU. We compared adherence to our PONV guideline in two study groups with a historical control group. RESULTS: Guideline adherence on prescribing and administering PONV prophylaxis (dexamethasone and granisetron) all improved compared to the historical control group (89 vs. 82% (p< 0.0001), 96 vs 95% (not significant) and 90 vs 82% (p<0.0001)) while decreasing unwarranted prescription for PONV prophylaxis (10 vs. 13 %). In the pre-operative screening clinic, the main reason for not prescribing PONV prophylaxis was disagreement with the risk estimate by the decision support system. In the OR/PACU, the main reasons for not administering PONV prophylaxis were: 'unintended non-adherence' and 'failure to document'. CONCLUSIONS: In this study requesting a reason for non-adherence is associated with improved guideline adherence. The effect seems to depend on the underlying reason for non-adherence. It also illustrates the importance of human factors principles in the design of decision support. Some reasons for non-adherence may not be influenced by automated reminders.

Out of hospital thoracotomy for cardiac arrest after penetrating thoracic trauma.

INTRODUCTION: Emergency department thoracotomy is an established procedure for cardiac arrest in patients suffering from penetrating thoracic trauma and yields relatively high survival rates (up to 21%) in patients with cardiac tamponade. To minimize the delay between arrest and thoracotomy, some have advocated thoracotomy on the accident scene. The aim of this study was to determine the proportion of patients with return of spontaneous circulation and subsequent survival after out of hospital thoracotomy in the Netherlands. METHODS: A retrospective analysis of data collected on all out of hospital thoracotomies performed in the Netherlands after penetrating trauma between April 1st, 2011 and September 30th, 2016 was performed. Data on patient characteristics, trauma mechanism and outcome were collected and analyzed. Primary outcome measure was return of spontaneous circulation after the intervention. Survival to hospital discharge was the secondary outcome variable. RESULTS: Thirty-three prehospital emergency thoracotomies were performed. Ten patients (30%) had gunshot wounds and 23 patients (70%) had stab wounds. Nine patients (27%) had return of spontaneous circulation and were presented to the hospital. Of these, one patient survived until discharge without neurological damage. Five died in the emergency department or operating room and three died in ICU. CONCLUSION: Return of spontaneous circulation after out of hospital thoracotomy for cardiac arrest due to penetrating thoracic injury is achievable, but a substantial number of patients die during the in hospital resuscitation phase. However, neurologic intact survival can be achieved.

Training of police officers as first responders with an automated external defibrillator.

UNLABELLED: A short and effective training programme is an essential prerequisite for the use of automated external defibrillators (AED) by EMS providers and first responders. We evaluated a 3-h AED course based on the ERC requirements. METHODS: As part of a study evaluating the effectiveness of AEDs used by first responders (ARREST 4), we trained all police officers in the region of Amsterdam, the Netherlands. By means of a Basic Life Support (BLS) assessment at the beginning of the course and at the end, we evaluated whether BLS can be improved in a 3-h AED course. Through a combined BLS and AED assessment at the end of the course, we evaluated whether AED skills can be acquired sufficiently. BLS skills were measured with the Laerdal SkillMeter in evaluation mode. AED skills were assessed using 13 criteria. By means of logistic regression, we analysed the influence of student characteristics, such as age, gender, previous training, resuscitation experience and motivation for BLS and AED on BLS and AED skills acquisition. RESULTS: Between September 1999 and June 2000, 823 police officers were trained (76% male, mean age 36 (S.D. 9) years). BLS improved significantly (P < 0.001) in all criteria, except for hypoventilation (P < 0.001). After training, 89% of the students were able to use an AED safely and effectively. Self-confidence and motivation improved from 12 and 73% to 99 and 94% over the course (P < 0.001). Independent student characteristics influencing the success of the AED course were: previous BLS training, motivation before the course for an AED, and resuscitation experience that dated back for more than 12 months. CONCLUSION: The majority of police officers can be trained to use an AED safely and effectively within a 3-h AED course. During this course, they also improve on their BLS skills. Successful completion of the course depends in part on the student characteristics.