Intentional interruptions during compression only CPR: A scoping review.

Introduction: Out of hospital cardiac arrest (OHCA) remains one of the main causes of death among industrialized countries. The initiation of cardiopulmonary resuscitation (CPR) by laypeople before the arrival of emergency medical services improves survival. Mouth-to-mouth ventilation may constitute a hindering factor to start bystander CPR, while during continuous chest compressions (CCC) CPR quality decreases rapidly. The aim of this scoping review is to examine the existing literature on strategies that investigate the inclusion of intentional pauses during compression-only resuscitation (CO-CPR) to improve the performance in the context of single lay rescuer OHCA. Methods: The protocol of this Scoping review was prospectively registered in Open Science Framework (https://osf.io/rvn8j). A systematic search of PubMed, Scopus, EMBASE, CINAHL was performed. Results: Six articles were included. All studies were carried out on simulation manikins and involved a total of 1214 subjects. One study had a multicenter design. Three studies were randomized controlled simulation trials, the rest were prospective randomized crossover studies. The tested protocols were heterogeneous and compared CCC to CO-CPR with intentional interruptions of various length. The most common primary outcome was compressions depth. Compression rate, rescuers' perceived exertion and composite outcomes were also evaluated. Compressions depth and perceived exertion improved in most study groups while compression rate and chest compression fraction remained within guidelines indications. Conclusions: In simulation studies, the inclusion of intentional interruptions during CO-CPR within the specific scenario of single rescuer bystander CPR during OHCA may improve the rate of compressions with correct depth and lower rate of perceived exertion. Further high-quality research and feasibility and safety of protocols incorporating intentional interruptions during CO-CPR may be justified.

Hyperoxia in critically ill patients with sepsis and septic shock: a systematic review.

BACKGROUND: In septic patients, hyperoxia may help with its bactericidal effects, but it may cause systemic impairments. The role of hyperoxia and the appropriate oxygen target in these patients is unknown. The aim of this systematic review was to summarize the available literature. METHODS: We conducted a systematic search screening PubMed and Cochrane Library. Studies on adult patients with sepsis or septic shock and admitted to ICU addressing the topic of hyperoxia were included and described. RESULTS: We included 12 studies, for a total of 15.782 included patients. Five studies were randomized controlled trials (RCTs) or analyses from RCTs, three were prospective observational studies, and four were retrospective observational studies. The definition of hyperoxia was heterogeneous across the included studies. Mortality was the most frequent outcome: six studies showed an increased rate or risk of mortality with hyperoxia, three found no differences, and one a protective effect of hyperoxia. At the critical appraisal assessment stage, no major methodological flaws were detected, except for a single-center, pilot study, with a lack of adjustment for confounders and imbalance between the groups. CONCLUSION: The optimum range of oxygen level able to minimize risks and provide benefits in patients with sepsis or septic shock seems still unknown. Clinical equipoise between hyperoxia and normoxia is uncertain as conflicting evidence exists. Further studies should aim at identifying the best range of oxygenation and its optimal duration, investigating how effects of different levels of oxygen may vary according to identified pathogens, source of infection, and prescribed antibiotics in critically ill patients with sepsis and septic shock.

Association between night-time extubation and clinical outcomes in adult patients: A systematic review and meta-analysis.

BACKGROUND: Whether night-time extubation is associated with clinical outcomes is unclear. OBJECTIVE: The aim of this systematic review and meta-analysis was to evaluate the association between night-time extubation and the reintubation rate, mortality, ICU and in-hospital length of stay in adult patients, compared with daytime extubation. DESIGN: A systematic review and meta-analysis. DATA SOURCES: PubMed, EMBASE, CINAHL and Web of Science from inception to 2 January 2021 (PROSPERO registration - CRD42020222812). ELIGIBILITY CRITERIA: Randomised, quasi and cluster randomised, and nonrandomised studies describing associations between adult patients' outcomes and time of extubation (daytime/night-time) in intensive care or postanaesthesia care units. RESULTS: Seven retrospective studies were included in the systematic review and meta-analysis, for a total of 293 663 patients. All the studies were performed in United States (USA). All the studies were judged at moderate risk of bias for reintubation and mortality. The analyses were conducted with random effects models. The analyses from adjusted estimates demonstrated no association between night-time extubation and increased risk of either reintubation (OR 1.00; 95% CI 0.88 to 1.13; P = 1.00; I2 = 66%; low-certainty evidence) or all-cause mortality at the longest available follow-up (OR 1.11; 95% CI 0.87 to 1.42; P = 0.39; I2 = 79%; low-certainty evidence), in comparison with daytime extubation. Analyses from unadjusted data for reintubation, mortality and ICU or in-hospital length of stay showed no significant association with night-time extubation. Analyses based on type of admission, number of centres or duration of mechanical ventilation showed no significant subgroup effects. CONCLUSION: Night-time extubation of adult patients was not associated with higher adjusted risks for reintubation or death, in comparison with daytime extubation, but the certainty of the evidence was low.

Palliative Care Principles and Anesthesiology Clinical Practice: Current Perspectives.

BACKGROUND: Palliative care is a person-centered approach aiming to relieve patient's health-related suffering and it is often needed when caring for critically ill patients to manage symptoms and identify goals of care. AIM: To describe the integration of palliative care principles in anesthesiology clinical practice, within and outside the ICU and to analyze the additional challenges that COVID-19 pandemic is posing in this context. METHODS: For the purpose of this review, PubMed database was searched for studies concerning palliative care and end of life care, in contexts involving anesthesiologists and intensivists, published in the last 5 years. RESULTS: Anesthesiologists and intensivists integrate palliative care within their daily practice providing symptoms management as well as family counseling. High-quality communicational skills are fundamental for anesthesiologists and intensivists especially when interfacing with surrogate decision makers in the ICU or with patients in the preoperative setting while discussing goals of care. Coronavirus disease 2019 (COVID-19) pandemic has challenged many aspects of palliative care delivery: reduced family presence within the ICU, communication with families through phone calls or video calls, patient-physician relationship mediated by bulky personal protective equipment and healthcare workers physical and psychological distress due to the increased workload and limitations in resources are some of the most evident. CONCLUSION: Anesthesiologists and intensivists are increasingly facing challenging clinical situations where principles and practice of palliative care have to be applied. In this sense, increasing knowledge on palliative care and providing specific training would allow to deliver high-quality symptom management, family counseling and end of life guidance in critical care settings. COVID-19 pandemic sets additional difficulties to palliative care delivery.

Bloodstream Infections in Hospitalized Patients with COVID-19: A Systematic Review and Meta-Analysis.

BACKGROUND: Little is known about the occurrence of bloodstream infections in hospitalized patients with COVID-19 and the related clinical consequences. The aim of this systematic review and meta-analysis was to estimate the pooled occurrence of BSIs among hospitalized patients with COVID-19 and mortality of this patient population. METHODS: A systematic search was performed on PubMed, EMBASE, and Web of Science from inception to 19 April 2021. The primary outcome was the occurrence of BSIs among hospitalized patients with COVID-19. The secondary outcome was mortality at the longest available follow-up. RESULTS: Forty-six studies met the inclusion criteria, with a total of 42,694 patients evaluated. The estimated occurrence of BSIs was 7.3% (95% CI 4.7-1.1%) among hospitalized patients with COVID-19, with a mortality rate of 41% (95% CI 30%-52.8%). The subgroup analysis conducted on patients admitted to ICU provided an estimated occurrence of 29.6% (95% CI 21.7%-38.8%). A higher occurrence of BSI was observed in patients with COVID-19, in comparison with patients without COVID-19 (OR 2.77; 95% CI 1.53-5.02; p < 0.001). CONCLUSIONS: Our analysis estimated the occurrence of BSIs among hospitalized patients with COVID-19 at around 7%. A four-times higher occurrence was estimated among patients admitted to ICU.

Ventilator-Associated Pneumonia in Patients with COVID-19: A Systematic Review and Meta-Analysis.

The aim of this systematic review and meta-analysis was to estimate the pooled occurrence of ventilator-associated pneumonia (VAP) among patients admitted to an intensive care unit with COVID-19 and mortality of those who developed VAP. We performed a systematic search on PubMed, EMBASE and Web of Science from inception to 2nd March 2021 for nonrandomized studies specifically addressing VAP in adult patients with COVID-19 and reporting data on at least one primary outcome of interest. Random effect single-arm meta-analysis was performed for the occurrence of VAP and mortality (at the longest follow up) and ICU length of stay. Twenty studies were included in the systematic review and meta-analysis, for a total of 2611 patients with at least one episode of VAP. The pooled estimated occurrence of VAP was of 45.4% (95% C.I. 37.8-53.2%; 2611/5593 patients; I2 = 96%). The pooled estimated occurrence of mortality was 42.7% (95% C.I. 34-51.7%; 371/946 patients; I2 = 82%). The estimated summary estimated metric mean ICU LOS was 28.58 days (95% C.I. 21.4-35.8; I2 = 98%). Sensitivity analysis showed that patients with COVID-19 may have a higher risk of developing VAP than patients without COVID-19 (OR 3.24; 95% C.I. 2.2-4.7; P = 0.015; I2 = 67.7%; five studies with a comparison group).

Mortality after in-hospital cardiac arrest in patients with COVID-19: A systematic review and meta-analysis.

AIM: To estimate the mortality rate, the rate of return of spontaneous circulation (ROSC) and survival with favorable neurological outcome in patients with COVID-19 after in-hospital cardiac arrest (IHCA) and attempted cardiopulmonary resuscitation (CPR). METHODS: PubMed, EMBASE, Web of Science, bioRxiv and medRxiv were surveyed up to 8th February 2021 for studies reporting data on mortality of patients with COVID-19 after IHCA. The primary outcome sought was mortality (in-hospital or at 30 days) after IHCA with attempted CPR. Additional outcomes were the overall rate of IHCA, the rate of non-shockable presenting rhythms, the rate of ROSC and the rate of survival with favorable neurological status. RESULTS: Ten articles were included in the systematic review and meta-analysis, for a total of 1179 COVID-19 patients after IHCA with attempted CPR. The estimated overall mortality rate (in-hospital or at 30 days) was 89.9% (95% Predicted Interval [P.I.] 83.1%-94.2%; 1060/1179 patients; I2 = 82%). The estimated rate of non-shockable presenting rhythms was 89% (95% P.I. 82.8%-93.1%; 1022/1205 patients; I2 = 85%), and the estimated rate of ROSC was 32.9% (95% P.I. 26%-40.6%; 365/1205 patients; I2 = 82%). The estimated overall rate of survival with favorable neurological status at 30 days was 6.3% (95% P.I. 4%-9.7%; 50/851 patients; I2 = 48%). Sensitivity analysis showed that COVID-19 patients had higher risk of death after IHCA than non COVID-19 patients (OR 2.34; 95% C.I. 1.37-3.99; number of studies = 3; 1215 patients). CONCLUSIONS: Although one of three COVID-19 patients undergoing IHCA may achieve ROSC, almost 90% may not survive at 30 days or to hospital discharge.

Personal protective equipment use by healthcare workers in intensive care unit during the early phase of COVID-19 pandemic in Italy: a secondary analysis of the PPE-SAFE survey.

BACKGROUND: Italy was the first Western country to be heavily affected by COVID-19. Healthcare workers (HCWs) were exposed to a high risk of occupational infection, partially due to insufficient personal protective equipment (PPE) supplies. This study aimed to describe the practices, availability, training, confidence in PPE use and the adverse effects due to extended PPE use, as reported by HCWs in Italy. We also aimed to provide a comparison between Italian data and those from other countries. METHODS: This study was a secondary analysis of a previously published international study, the PPE-SAFE Survey, conducted in April 2020. Data were analysed from the original study database. RESULTS: We analysed the responses from 380 healthcare workers based in Italy, out of the 2711 respondents to the international survey. Among the Italian respondents, FFP2 and FFP3 respirators or equivalent were the most used masks for routine tasks (respectively 188/380, 50%; and 163/380, 43%). The median time of wearing PPE without taking a break was 5 h [interquartile range (IQR) 4-6], with statistically significant difference from other countries [median 4 h (IQR 2-5) p < 0.0001]. In Italy, 249 out of 380 (65%) HCWs had never performed a formal fit test for a N95 mask or equivalent and 91/380 (24%) never had a partner for donning and doffing procedures. Most of the respondents (299/380, 79%) had received formal training in PPE use at any time. CONCLUSION: Most of the surveyed Italian HCWs reported working at above usual capacity, long shifts with PPE without breaks and routine use in intensive care unit of aerosol protection (e.g. FFP2/FFP3), hazmat suits and face shields/visors. The correct adherence to safety procedures (e.g. donning/doffing in pairs, performing fit test) has substantial scope for improvement in the future.

Prone positioning and convalescent plasma therapy in a critically ill pregnant woman with COVID-19.

Prone positioning is feasible in pregnancy and may have contributed to the positive outcome in this case. Doctors should not be reluctant to move a patient to a prone position just because they are pregnant.

Cardiopulmonary resuscitation in prone position: A scoping review.

INTRODUCTION: The ongoing pandemic of COVID-19 brought to the fore prone positioning as treatment for patients with acute respiratory failure. With the increasing number of patients in prone position, both spontaneously breathing and mechanically ventilated, cardiac arrest in this position is more likely to occur. This scoping review aimed to summarize the available evidence on cardiopulmonary resuscitation in prone position ('reverse CPR') and knowledge or research gaps to be further evaluated. The protocol of this scoping review was prospectively registered on 10th May 2020 in Open Science Framework (https://osf.io/nfuh9). METHODS: We searched PubMed, EMBASE, MEDLINE and pre-print repositories (bioRxiv and medRxiv) for simulation, pre-clinical and clinical studies on reverse CPR until 31st May 2020. RESULTS: We included 1 study on manikins, 31 case reports (29 during surgery requiring prone position) and 2 nonrandomized studies describing reverse CPR. No studies were found regarding reverse CPR in patients with COVID-19. CONCLUSIONS: Even if the algorithms provided by the guidelines on basic and advanced life support remain valid in cardiac arrest in prone position, differences exist in the methods of performing CPR. There is no clear evidence of superiority in terms of effectiveness of reverse compared to supine CPR in patients with cardiac arrest occurring in prone position. The quality of evidence is low and knowledge gaps (e.g. protocols, training of healthcare personnel, devices for skill acquisition) should be fulfilled by further research. Meanwhile, a case-by-case evaluation of patient and setting characteristics should guide the decision on how to start CPR in such cases.