Life-prolonging treatment restrictions and outcomes in patients with cancer and COVID-19: an update from the Dutch Oncology COVID-19 Consortium.

AIM OF THE STUDY: The coronavirus disease 2019 (COVID-19) pandemic significantly impacted cancer care. In this study, clinical patient characteristics related to COVID-19 outcomes and advanced care planning, in terms of non-oncological treatment restrictions (e.g. do-not-resuscitate codes), were studied in patients with cancer and COVID-19. METHODS: The Dutch Oncology COVID-19 Consortium registry was launched in March 2020 in 45 hospitals in the Netherlands, primarily to identify risk factors of a severe COVID-19 outcome in patients with cancer. Here, an updated analysis of the registry was performed, and treatment restrictions (e.g. do-not-intubate codes) were studied in relation to COVID-19 outcomes in patients with cancer. Oncological treatment restrictions were not taken into account. RESULTS: Between 27th March 2020 and 4th February 2021, 1360 patients with cancer and COVID-19 were registered. Follow-up data of 830 patients could be validated for this analysis. Overall, 230 of 830 (27.7%) patients died of COVID-19, and 60% of the remaining 600 patients with resolved COVID-19 were admitted to the hospital. Patients with haematological malignancies or lung cancer had a higher risk of a fatal outcome than other solid tumours. No correlation between anticancer therapies and the risk of a fatal COVID-19 outcome was found. In terms of end-of-life communication, 50% of all patients had restrictions regarding life-prolonging treatment (e.g. do-not-intubate codes). Most identified patients with treatment restrictions had risk factors associated with fatal COVID-19 outcome. CONCLUSION: There was no evidence of a negative impact of anticancer therapies on COVID-19 outcomes. Timely end-of-life communication as part of advanced care planning could save patients from prolonged suffering and decrease burden in intensive care units. Early discussion of treatment restrictions should therefore be part of routine oncological care, especially during the COVID-19 pandemic.

The influence of POLST on treatment intensity at the end of life: A systematic review.

BACKGROUND: Despite its widespread implementation, it is unclear whether Physician Orders for Life-Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty. METHODS: We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy <1 year. Primary outcomes included place of death and receipt of high-intensity treatment (i.e., hospitalization in the last 30- and 90-days of life, ICU admission in the last 30-days of life, and number of care setting transitions in last week of life). RESULTS: Among 104,554 patients across 20 observational studies, 27,090 had POLST. No randomized controlled trials were identified. The mean age of POLST users was 78.7 years, 55.3% were female, and 93.0% were white. The majority of POLST users (55.3%) had orders for comfort measures only. Most studies showed that, compared to full treatment orders on POLST, treatment limitations were associated with decreased in-hospital death and receipt of high-intensity treatment, particularly in pre-hospital settings. However, in the acute care setting, a sizable number of patients likely received POLST-discordant care. The overall strength of evidence was moderate based on eight retrospective cohort studies of good quality that showed a consistent, similar direction of outcomes with moderate-to-large effect sizes. CONCLUSION: We found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness. However, the evidence base is limited and demonstrates potential unintended consequences of POLST. We identify several important knowledge gaps that should be addressed to help maximize benefits and minimize risks of POLST.

Theoretical knowledge and skill retention 3 and 6 months after a European Newborn Life Support provider course.

INTRODUCTION: The European Resuscitation Council Newborn Life Support Course (ERC- NLS) aims at training healthcare professionals, involved in perinatal care, in order to intervene efficiently and promptly to assist transition or resuscitate neonates who require help at birth. However, limited data exists for the retention of the theoretical knowledge and practical skills provided by the course. This study aims to evaluate the degree of knowledge and skill retention 3 and 6 months after the ERC-NLS provider course. METHODS: This is a prospective study. Theoretical knowledge was evaluated using the ERC-approved NLS written test (50 True/False questions). Evaluation of technical skills included performance, on an Advanced Life Support neonatal maniquin (LAERDAL), of airway management, ventilation and support of circulation (21 detailed skills). The effect of certain factors on theoretical skill retention was also evaluated. RESULTS: One hundred and sixteen (n = 116) participants were initially recruited in the study (12 males and 104 females). Theoretical knowledge was evaluated in 113 participants (3 participants missed follow-up appointments) and technical skills in 80 participants. The mean score for theoretical knowledge was 86.24% ± 5.3, 80.88% ± 7.43 and 80.04% ± 7.04 at baseline, at 3 and 6 months, respectively. This difference was significant among the three time points (baseline vs 3 months: p < 0.001; baseline vs 6 months: p < 0.001; 3 month's vs 6 months: p = 0.034). Although gender did not have an effect, doctors and participants of higher education yielded higher score of success. Regarding technical skills, 9 skills showed a continuous decline of performance from baseline to 6 months, while no difference existed for 12 skills. CONCLUSIONS: Healthcare professionals after the NLS provider course retain satisfactory levels of theoretical knowledge and technical skills even at 6 months post-training, although, there is a decline compared to baseline. Further research is needed in order to establish the proper time and type of refreshment course in order to improve outcomes.

Association Between Low T3 Syndrome and Poor Prognosis in Adult Patients With Acute Myocarditis.

Background: This study aims to investigate the role of free triiodothyronine (fT3) in predicting poor prognosis of adult patients with acute myocarditis. Methods: A total of 173 consecutive adult patients with acute myocarditis completed thyroid function evaluations. They were divided into two groups according to fT3 levels: low fT3 group (n = 54, fT3 < 3.54 pmol/liter) and normal fT3 group (n = 119, fT3 ≥ 3.54 pmol/liter). The primary endpoint was major adverse cardiac events (MACE). Results: During the 3.5 ± 2.8 years follow-up, the rate of MACE was 29.6% versus 3.5% in low fT3 group versus normal fT3 group, respectively (P < 0.0001). Long-term at 8 years MACE-free survival were lower in low fT3 group versus normal fT3 group (52.9% versus 92.3%, log-rank P < 0.0001), respectively. Univariate Cox analysis showed that left ventricular ejection fraction (LVEF) < 50% [hazard ratio (HR) 10.231, 95% confidence interval (CI): 3.418-30.624, P < 0.0001) and low fT3 level (HR 0.360, 95% CI: 0.223-0.582, P < 0.0001) were strongest two predictors of MACE. After adjustment for traditional risk predictors, the prognostic value of fT3 status was still significant (HR 0.540, 95% CI: 0.316-0.922, P = 0.024). Compared with normal fT3 group, those in low fT3 group were at a much higher risk of MACE (HR 5.074, 95% CI: 1.518-16.964, P = 0.008). Conclusions: Low T3 syndrome was a strong predictor of poor prognosis in adult patients with acute myocarditis. These findings suggest that fT3 level could serve as a biomarker for risk stratification in acute myocarditis patients.

Higher vs lower doses of dexamethasone in patients with COVID-19 and severe hypoxia (COVID STEROID 2) trial: Protocol and statistical analysis plan.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has resulted in millions of deaths and overburdened healthcare systems worldwide. Systemic low-dose corticosteroids have proven clinical benefit in patients with severe COVID-19. Higher doses of corticosteroids are used in other inflammatory lung diseases and may offer additional clinical benefits in COVID-19. At present, the balance between benefits and harms of higher vs. lower doses of corticosteroids for patients with COVID-19 is unclear. METHODS: The COVID STEROID 2 trial is an investigator-initiated, international, parallel-grouped, blinded, centrally randomised and stratified clinical trial assessing higher (12 mg) vs. lower (6 mg) doses of dexamethasone for adults with COVID-19 and severe hypoxia. We plan to enrol 1,000 patients in Denmark, Sweden, Switzerland and India. The primary outcome is days alive without life support (invasive mechanical ventilation, circulatory support or renal replacement therapy) at day 28. Secondary outcomes include serious adverse reactions at day 28; all-cause mortality at day 28, 90 and 180; days alive without life support at day 90; days alive and out of hospital at day 90; and health-related quality of life at day 180. The primary outcome will be analysed using the Kryger Jensen and Lange test adjusted for stratification variables and reported as adjusted mean differences and median differences. The full statistical analysis plan is outlined in this protocol. DISCUSSION: The COVID STEROID 2 trial will provide evidence on the optimal dosing of systemic corticosteroids for COVID-19 patients with severe hypoxia with important implications for patients, their relatives and society.

Withholding or withdrawing life-sustaining treatment in extremely low gestational age neonates.

OBJECTIVE: To identify sociodemographic and clinical factors associated with withholding or withdrawing life-sustaining treatment (WWLST) for extremely low gestational age neonates. DESIGN: Observational study of prospectively collected registry data from 19 National Institute of Child Health and Human Development Neonatal Research Network centres on neonates born at 22-28 weeks gestation who died >12 hours through 120 days of age during 2011-2016. Sociodemographic and clinical factors were compared between infants who died following WWLST and without WWLST. RESULTS: Of 1168 deaths, 67.1% occurred following WWLST. Withdrawal of assisted ventilation (97.4%) was the primary modality. WWLST rates were inversely proportional to gestational age. Life-sustaining treatment was withheld or withdrawn more often for non-Hispanic white infants than for non-Hispanic black infants (72.7% vs 60.4%; 95% CI 1.00 to 1.92) or Hispanic infants (72.7% vs 67.2%; 95% CI 1.32 to 3.72). WWLST rates varied across centres (38.6-92.6%; p<0.001). The centre with the highest rate had adjusted odds 4.89 times greater than the average (95% CI 1.18 to 20.18). The adjusted odds of WWLST were higher for infants with necrotiing enterocolitis (OR 1.77, 95% CI 1.21 to 2.59) and severe brain injury (OR 1.98, 95% CI 1.44 to 2.74). CONCLUSIONS: Among infants who died, WWLST rates varied widely across centres and were associated with gestational age, race, ethnicity, necrotiing enterocolitis, and severe brain injury. Further exploration is needed into how race, centre, and approaches to care of infants with necrotiing enterocolitis and severe brain injury influence WWLST.

Outcomes After Extracorporeal Life Support Cannulation in Pediatric Patients With Trisomy 13 and Trisomy 18.

BACKGROUND: Indications for extracorporeal life support (ECLS) have evolved and expanded, yet its use in trisomy 13 (T13) and trisomy 18 (T18) patients remains controversial. We reviewed the experience of the Extracorporeal Life Support Organization with ECLS in these patients to inform practice at our institution. METHODS: The Extracorporeal Life Support Organization registry was queried for all patients younger than 18 y with an International Classification of Diseases, Ninth Edition/Tenth Edition code for T13 or T18 from 2000 to 2018. Basic demographics, ECLS details, and clinical outcomes were recorded. Descriptive statistics were performed. RESULTS: Twenty-eight patients were identified (15 with T13; 13 with T18), representing 0.06% (28 of 46,901) of pediatric ECLS cannulations. The median weight was 3.5 kg (range, 1.4-13), and age at cannulation was 52 d (range, 0 d-6.8 y). Time on ECLS ranged from 13 to 478 h (median, 114). Cardiac defects were diagnosed in 19 (68%) patients, of which 13 (46%) underwent surgical repair. Median oxygenation index pre-ECLS was 45. Venoarterial cannulations accounted for 82% of patients, whereas 14% underwent venovenous cannulation. Overall survival to hospital discharge was 46% with 86% of patients experiencing one or more complications. There were no survivors when cannulation continued past 12 d. CONCLUSIONS: Although complications are frequent, the mortality rate in patients with T13 and T18 remains within the reported range for the general pediatric population. T13 and T18 alone should not be viewed as absolute contraindications to ECLS within the pediatric population but rather considered during the evaluation of a patient's potential candidacy.

Conflicting Orders in Physician Orders for Life-Sustaining Treatment Forms.

BACKGROUND/OBJECTIVES: Many older persons with chronic illness use Physician Orders for Life-Sustaining Treatment (POLST) to document portable medical orders for emergency care. However, some POLSTs contain combinations of orders that do not translate into a cohesive care plan (eg, cardiopulmonary resuscitation [CPR] without intensive care, or intensive care without antibiotics). This study characterizes the prevalence and predictors of POLSTs with conflicting orders. DESIGN: Retrospective cohort study. SETTING: Large academic health system. PARTICIPANTS: A total of 3,123 POLST users with chronic life-limiting illness who died between 2010 and 2015 (mean age = 69.7 years). MEASUREMENTS: In a retrospective review of all POLSTs in participants' electronic health records, we describe the prevalence of POLSTs with conflicting orders for cardiac arrest and medical interventions, and use clustered logistic regression to evaluate potential predictors of conflicting orders. We also examine the prevalence of conflicts between POLST orders for antibiotics and artificial nutrition with orders for cardiac arrest or medical interventions. RESULTS: Among 3,924 complete POLSTs belonging to 3,123 decedents, 209 (5.3%) POLSTs contained orders to "attempt CPR" paired with orders for "limited interventions" or "comfort measures only"; 745/3169 (23.5%) POLSTs paired orders to restrict antibiotics with orders to deliver non-comfort-only care; and, 170/3098 (5.5%) POLSTs paired orders to withhold artificial nutrition with orders to deliver CPR or intensive care. Among POLSTs with orders to avoid intensive care, orders to attempt CPR were more likely to be present in POLSTs completed earlier in the patient's illness course (adjusted odds ratio = 1.27 per twofold increase in days from POLST to death; 95% confidence interval = 1.18-1.36; P < .001). CONCLUSION: Although most POLSTs are actionable by clinicians, 5% had conflicting orders for cardiac arrest and medical interventions, and 24% had one or more conflicts between orders for cardiac arrest, medical interventions, antibiotics, and artificial nutrition. These conflicting orders make implementation of POLST challenging for clinicians in acute care settings.

The impact of delirium on withdrawal of life-sustaining treatment after intracerebral hemorrhage.

OBJECTIVE: To determine the impact of delirium on withdrawal of life-sustaining treatment (WLST) after intracerebral hemorrhage (ICH) in the context of established predictors of poor outcome, using data from an institutional ICH registry. METHODS: We performed a single-center cohort study on consecutive patients with ICH admitted over 12 months. ICH features were prospectively adjudicated, and WLST and corresponding hospital day were recorded retrospectively. Patients were categorized using DSM-5 criteria as never delirious, ever delirious (either on admission or later during hospitalization), or persistently comatose. We determined the impact of delirium on WLST using Cox regression models adjusted for demographics and ICH predictors (including Glasgow Coma Scale score), then used logistic regression with receiver operating characteristic curve analysis to compare the accuracy of ICH score-based models with and without delirium category in predicting WLST. RESULTS: Of 311 patients (mean age 70.6 ± 15.6, median ICH score 1 [interquartile range 1-2]), 50% had delirium. WLST occurred in 26%, and median time to WLST was 1 day (0-6). WLST was more frequent in patients who developed delirium (adjusted hazard ratio 8.9 [95% confidence interval (CI) 2.1-37.6]), with high rates of WLST in both early (occurring ≤24 hours from admission) and later delirium groups. An ICH score-based model was strongly predictive of WLST (area under the curve [AUC] 0.902 [95% CI 0.863-0.941]), and the addition of delirium category further improved the model's accuracy (AUC 0.936 [95% CI 0.909-0.962], p = 0.004). CONCLUSION: Delirium is associated with WLST after ICH regardless of when it occurs. Further study on the impact of delirium on clinician and surrogate decision-making is warranted.

Puesta al día y recomendaciones en la toma de decisiones de limitación de tratamientos de soporte vital / Update and recommendations in decision making referred to limitation of advanced life support treatment

El Grupo de Trabajo de Bioética de la SEMICYUC ha elaborado las recomendaciones en la toma de decisiones de limitación de tratamientos de soporte vital con la aspiración de disminuir la variabilidad en la práctica clínica observada y de contribuir a la mejora de los cuidados al final de la vida del paciente crítico. Además de abordar el marco conceptual de la limitación de tratamientos de soporte vital y de la futilidad, desarrolla las nuevas formas de limitación extendiéndola a la adecuación de otros tratamientos y métodos diagnósticos, además de planificar los posibles cursos evolutivos tras la decisión de limitación de tratamientos de soporte vital. Se enfatiza la importancia de la planificación compartida de la asistencia sanitaria en la toma de decisiones, se presentan los cuidados intensivos orientados a la donación y se promueve la integración de los cuidados paliativos en el tratamiento del paciente crítico en estadios del final de la vida en UCI

The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit

Impact of Urgent Chemotherapy in Critically Ill Patients.

OBJECTIVE: Compare the mortality between critically ill patients who received urgent chemotherapy for a cancer-related life-threatening complication with matched patients (controls) who did not received it. DESIGN: Propensity score-matched retrospective study. SETTING: Adult intensive care unit in an oncological hospital. PARTICIPANTS: All adults with solid tumor or hematological malignancies who received at least 1 day of urgent intravenous chemotherapy for a cancer-related life-threatening complication. Using the propensity score method adjusted for 10 variables, patients who received urgent chemotherapy were matched to patients who did not. INTERVENTIONS: None. MAIN OUTCOMES MEASURES: Intensive care unit and hospital mortality. RESULTS: Forty-seven patients (57% with solid tumors and 43% with hematological malignancies) who received urgent chemotherapy were matched to 94 controls. At intensive care unit admission, patients were similar except that those who received urgent chemotherapy were less likely to have received chemotherapy previously (36% vs 85%; P < .01). The intensive care unit (48.9% vs 23.4%; P < .01) and hospital (76.6% vs 46.8%; P < .01) mortality of the patients who received urgent chemotherapy was higher than the controls. The subgroup analysis showed that the higher mortality was limited to patients with solid tumor. CONCLUSION: The use of urgent chemotherapy is associated with an increase in the intensive care unit and hospital mortality of unselected critically ill patients with solid tumors but not in patients with hematological malignancies.

Using a National Representative Sample to Evaluate the Integrity of the 30-Day Surgical Mortality Metric.

The 30-day surgical mortality metric is endorsed by the National Quality Forum for value-based purchasing purposes. However, its integrity has been questioned, as there is documented evidence of hospital manipulation of this measure, by way of inappropriate palliative care designation and changes in patient selection. To determine if there is evidence of potential manipulation, we retrospectively analyzed 1,725,291 surgical admissions from 158 United States hospitals participating in the National Inpatient Sample from 2010 to 2011. As a way of evaluating unnecessary life-prolonging measures, we determined that a significant increase in mortality rate after post-operative day 30 (day 31-35) would indicate manipulation. We compared the post-operative mortality rates for each hospital between Post-Operative Day 26-30 and Post-Operative Day 31-35 using Wilcoxon signed-rank tests. After application of the Bonferroni correction, the results showed that none of the hospitals had a statistically significant increase in mortality after post-operative day 30. This analysis fails to impugn the integrity of this measure, as we did not identify any evidence of potential manipulation of the 30-day surgical mortality metric.

Prolongation of working life and its effect on mortality and health in older adults: Propensity score matching.

Many countries are raising the age of pension eligibility because of increases in life expectancy. Given the social gradient in life expectancy and health, it is important to understand the potential late-life health effects of prolonging working life and whether any effects differ by socioeconomic position. We examined the effect of prolonging working life beyond age 65 on mortality and a series of indicators of late-life physical health (the ability to climb stairs without difficulty, self-rated health, ADL limitations, and musculoskeletal pain) in a representative sample of the Swedish population. In addition to average effects, we also examined heterogeneous effects, for instance by occupational social class. To do this, we use propensity score matching, a method suitable for addressing causality in observational data. The data came from two linked Swedish longitudinal surveys based on nationally representative samples with repeated follow-ups; The Swedish Level of Living Survey and the Swedish Panel Study of Living conditions of the Oldest Old, and from national income and mortality registries. The analytical sample for the mortality outcome included 1852 people, and for late-life physical health outcomes 1461 people. We found no significant average treatment effect on the treated (ATT) of working to age 66 or above on the outcomes, measured an average of 12 years after retirement: mortality (ATT -0.039), the ability to climb stairs (ATT -0.023), self-rated health (ATT -0.009), ADL limitations (ATT -0.023), or musculoskeletal pain (ATT -0.009) in late life. Analyses of whether the results varied by occupational social class or the propensity to prolong working life were inconclusive but suggest a positive effect of prolonging working life on health outcomes. Accordingly, more detailed knowledge about the precise mechanisms underlying these results are needed. In conclusion, working to age 66 or above did not have effect on mortality or late-life physical health.

Prognostication after cardiac arrest: Results of an international, multi-professional survey.

AIM: We explored preferences for prognostic test performance characteristics and error tolerance in decisions regarding withdrawal or continuation of life-sustaining therapy (LST) after cardiac arrest in a diverse cohort of medical providers. METHODOLOGY: We distributed a survey through professional societies and research networks. We asked demographic characteristics, preferences for prognostic test performance characteristics and views on acceptable false positive rates for decisions about LST after cardiac arrest. RESULTS: Overall, 640 respondents participated in our survey. Most respondents were attending physicians (74%) with >10 years of experience (59%) and practiced at academic centers (77%). Common specialties were neurology (22%), neuro- or general critical care (24%) and palliative care (31%). The majority (56%) felt an acceptable FPR for withdrawal of LST from patients who might otherwise have recovered was ≤0.1%. Acceptable FPRs for continuing LST in patients with unrecognized irrecoverable injury was higher, with 59% choosing a threshold ≤1%. Compared to providers with >10 years of experience, those with <5 years thought lower FPRs were acceptable (P < 0.001 for both). Palliative care providers accepted significantly higher FPRs for withdrawal of LST (P < 0.0001), and critical care providers accepted significantly higher FPRs for provision of long-term LST (P = 0.02). With regard to test performance characteristics, providers favored accuracy over timeliness, and prefer tests be optimized to predictrather than favorable outcomes. CONCLUSION: Medical providers are comfortable with low acceptable FPR for withdrawal (≤0.1%) and continuation (≤1%) of LST after cardiac arrest. These FPRs may be lower than can be achieved with current prognostic modalities.

Variations in Physician Orders for Life-Sustaining Treatment Program across the Nation: Environmental Scan.

Background: Physician Orders for Life-Sustaining Treatment (POLST) is an advance care planning tool that is designed to document end-of-life (EoL) care wishes of those living with limited life expectancies. Although positive impacts of POLST program has been studied, variations in state-specific POLST programs across the nation remain unknown. Objective: Identify state variations in POLST forms and determine if variations are associated with program maturity status. Design: Environmental scan. Measurements: Using the national POLST website, state-specific POLST program characteristics were examined. With available sample POLST forms, EoL care options were abstracted. Results: Of all 51 states (50 United States states and Washington, D.C examined), the majority (n = 48, 98%) were actively participating in POLST; 3 states (5.9%) had Mature status, 19 states and District of Columbia (39.2%) were Endorsed, 24 states were in the developing phase (47.1%), and 4 states (7.8%) were nonconforming. Forty-five states (88.2%) had forms available for review. Antibiotic and intravenous fluid options were identified in 32 (71.1%), and 33 (73.3%) POLST forms, respectively. Hospital transfer and use of oxygen were mentioned in all forms. Use of respiratory devices (i.e., continuous positive airway pressure and bi-level positive airway pressure) were mentioned on 27 (60%) forms, whereas ventilator or intubation use were mentioned in 36 POLST forms (80%). No associations were found between POLST maturity status and provision of treatment options. Conclusions: Variations in integration of infection and symptom management options were identified. Further research is needed to determine if there are regional factors associated with provision of treatment options on POLST forms and if there are differences in actual rates of infection or symptoms reported.

Impact of prehospital mechanical ventilation: A retrospective matched cohort study of 911 calls in the United States.

Prehospital use of ventilators by emergency medical services (EMS) during 911 calls is increasing. This study described the impact of prehospital mechanical ventilation on prehospital time intervals and on mortality.This retrospective matched-cohort study used 4 consecutive public releases of the US National Emergency Medical Services Information System dataset (2011-2014). EMS activations with recorded ventilator use were randomly matched with activations without ventilator use (1 to 1) on age (range ±â€Š2 years), gender, provider's primary impression, urbanicity, and level of service.A total of 5740 EMS activations were included (2870 patients per group). Patients in the ventilator group had a mean age of 69.1 (±17.3) years with 49.4% males, similar to the non-ventilator group. Activations were mostly in urban settings (83.8%) with an advanced life support level of care (94.5%). Respiratory distress (77.8%) and cardiac arrest (6.8%) were the most common provider's primary impressions. Continuous positive airway pressure was the most common mode of ventilation used (79.2%).Mortality was higher at hospital discharge (29.0% vs 21.1%, P = .01) but not at emergency department (ED) discharge (8.4% vs 7.4%, P = .19) with prehospital ventilator use. Both total on-scene time and total prehospital time intervals increased with reported ventilator use (4.10 minutes (95% confidence interval [CI]: 2.71-5.49) and 3.59 minutes (95% CI: 3.04-4.14), respectively).Ventilator use by EMS agencies in 911 calls in the US is associated with higher prehospital time intervals without observed impact on survival to ED discharge. More EMS outcome research is needed to provide evidence-based prehospital care guidelines and targeted resource utilization.

Withdrawal of Life-Support in Neonatal Hypoxic-Ischemic Encephalopathy.

PURPOSE: We describe the frequency and timing of withdrawal of life-support (WLS) in moderate or severe hypoxic-ischemic encephalopathy (HIE) and examine its associations with medical and sociodemographic factors. PROCEDURES: We undertook a secondary data analysis of a prospective multicenter data registry of regional level IV Neonatal Intensive Care Units participating in the Children's Hospitals Neonatal Database. Infants ≥36 weeks gestational age with HIE admitted to a Children's Hospitals Neonatal Database Neonatal Intensive Care Unit between 2010 and 2016, who underwent therapeutic hypothermia were categorized as (1) infants who died following WLST and (2) survivors with severe HIE (requiring tube feedings at discharge). RESULTS: Death occurred in 267/1,925 (14%) infants with HIE, 87.6% following WLS. Compared to infants with WLS (n = 234), the survived severe group (n = 74) had more public insurance (73% vs 39.3%, P = 0.00001), lower household income ($37,020 vs $41,733, P = 0.006) and fewer [20.3% vs 35.0%, P = 0.0212] were from the South. Among infants with WLS, electroencephalogram was performed within 24 hours in 75% and was severely abnormal in 64% cases; corresponding rates for MRI were 43% and 17%, respectively. Private insurance was independently associated with WLS, after adjustment for HIE severity and center. CONCLUSIONS: In a multicenter cohort of infants with HIE, WLS occurred frequently and was associated with sociodemographic factors. The rationale for decision-making for WLS in HIE require further exploration.