RESUMO
PURPOSE: A systematic review and meta-analysis to evaluate the impact of extracorporeal carbon dioxide removal (ECCO2R) on gas exchange and respiratory settings in critically ill adults with respiratory failure. METHODS: We conducted a comprehensive database search, including observational studies and randomized controlled trials (RCTs) from January 2000 to March 2022, targeting adult ICU patients undergoing ECCO2R. Primary outcomes were changes in gas exchange and ventilator settings 24 h after ECCO2R initiation, estimated as mean of differences, or proportions for adverse events (AEs); with subgroup analyses for disease indication and technology. Across RCTs, we assessed mortality, length of stay, ventilation days, and AEs as mean differences or odds ratios. RESULTS: A total of 49 studies encompassing 1672 patients were included. ECCO2R was associated with a significant decrease in PaCO2, plateau pressure, and tidal volume and an increase in pH across all patient groups, at an overall 19% adverse event rate. In ARDS and lung transplant patients, the PaO2/FiO2 ratio increased significantly while ventilator settings were variable. "Higher extraction" systems reduced PaCO2 and respiratory rate more efficiently. The three available RCTs did not demonstrate an effect on mortality, but a significantly longer ICU and hospital stay associated with ECCO2R. CONCLUSIONS: ECCO2R effectively reduces PaCO2 and acidosis allowing for less invasive ventilation. "Higher extraction" systems may be more efficient to achieve this goal. However, as RCTs have not shown a mortality benefit but increase AEs, ECCO2R's effects on clinical outcome remain unclear. Future studies should target patient groups that may benefit from ECCO2R. PROSPERO Registration No: CRD 42020154110 (on January 24, 2021).
Assuntos
Dióxido de Carbono , Humanos , Dióxido de Carbono/análise , Dióxido de Carbono/sangue , Troca Gasosa Pulmonar/fisiologia , Respiração Artificial/métodos , Insuficiência Respiratória/terapiaRESUMO
OBJECTIVES: Telephone instructions are commonly used to improve cardiopulmonary resuscitation (CPR) by lay bystanders. This usually implies an audio but no visual connection between the provider and the emergency medical telecommunicator. We aimed to investigate whether video-guided feedback via a camera drone enhances the quality of CPR. METHODS: We conducted a randomized controlled simulation trial. Lay rescuers performed 8 min of CPR on an objective feedback manikin. Participants were randomized to receive telephone instructions with (intervention group) or without (control group) a drone providing a visual connection with the telecommunicator after a 2-min run-in phase. Performed work (total compression depth minus total lean depth) was the primary outcome. Secondary outcomes were the proportion of effective chest compressions, average compression depth, subjective physical strain measured every 2 min, and dexterity in the nine-hole peg test after the scenario. Outcomes were compared using the t- and Mann Whitney-U tests. A two-sided p-value of <0.05 was considered significant. RESULTS: We included 27 individuals (14 (52%) female, mean age 41 ± 14 years). Performed work was greater in the intervention than in the control group (41.3 ± 7.0 vs. 33.9 ± 10.9 m; absolute difference 7.5, 95% CI 1.4 to 14.8; p = 0.046), with higher average compression depth (49 ± 7 vs. 40 ± 13 mm; p = 0.041), and higher proportions of adequate chest compressions (43 (IQR 14-60) vs. 3 (0-29) %; p = 0.041). We did not find any significant differences regarding the remaining secondary outcomes. CONCLUSION: Video-guided feedback via drones might be a helpful tool to enhance the quality of telephone-assisted CPR in lay bystanders.
RESUMO
BACKGROUND: Acute coronary syndrome is a disease with high prevalence and high mortality. Exposure to heat or cold increases the risks of myocardial infarction significantly. Gender-specific effects of this have not yet been examined. Our goal was to determine whether extreme weather conditions, which become more and more frequent, are gender-specific risk factors for myocardial infarction, in order to help provide faster diagnosis and revascularization therapy for patients. METHODS: We analysed the incidence of ST-elevation myocardial infarction (STEMI) in a large urban area over a 65-months period in a cohort study. A day was the unit of analysis. Incidence rate ratios (IRR) with Poisson regression models were calculated. All patients with STEMI on Saturdays and Sundays were included. Gender, high or low perceived temperatures (PT), a function of temperature, wind speed and humidity, and meteorological cold and heat warnings by the Austrian Central Institute for Meteorology and Geodynamics (ZAMG) were considered as risk factors. RESULTS: During the 562 days of the study period, a total of 1109 patients with STEMI (803; 72% men, mean age 61;14 years) were included. The gender difference between men and women was much more pronounced on cold (0 °C) days (85% of patients male; 1.8 per day) than on hot (20 °C) days (71% male; 1.4 per day) or days without extreme temperatures (72% male; 1.4 per day). We found significant interaction between gender and cold days (IRR of the interaction term 2.3 (95% CI 1.2-4.6), p = 0.02). No gender-specific effect was observed on warm days (IRR for interaction 0.9 (95% CI 0.6-1.3), p = 0.3). CONCLUSION: Low perceived temperature pronouncedly increases the already elevated risk for STEMI in males. Whether this effect is based on gender alone, or on one of the cardiovascular risk factors which are more common in men, is up to further study.
Assuntos
Frio Extremo , Calor Extremo , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Áustria/epidemiologia , Estudos de Coortes , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Distribuição por SexoRESUMO
Background: Biomarkers of fibrinolysis are elevated during acute immunologic reactions (allergic reactions and angioedema), although it is unclear whether fibrinolysis is associated with disease severity. Objectives: We investigated a possible association between maximum lysis (ML) measured by thromboelastography and the severity of acute immunologic reactions. Methods: We recruited patients with acute immunologic reactions at a high-volume emergency department. Clinical disease severity at presentation and at the end of the emergency department stay was assessed using a 5-grade scale, ranging from local symptoms to cardiac arrest. We determined ML on admission by thromboelastography (ROTEM's extrinsic [EXTEM], and aprotinin [APTEM] tests), expressed as ML%. Hyperfibrinolysis was defined as an ML of >15% in EXTEM, which was reversed by adding aprotinin (APTEM). We used exact logistic regression to investigate an association between ML% and disease severity (grades 1 and 2 [mild] vs 3-5 [severe]) and between hyperfibrinolysis and disease severity. Results: We included 31 patients (71% female; median age, 52 [IQR, 35-58] years; 10 [32%] with a severe reaction). ML% was higher in patients with severe symptoms (21 [IQR, 12-100] vs 10 [IQR, 4-17]). Logistic regression found a significant association between ML% and symptom severity (odds ratio, 1.07; 95% CI, 1.01-1.21; P = .003). Hyperfibrinolysis was detected in 6 patients and found to be associated with severe symptoms (odds ratio, 17.59; 95% CI, 1.52-991.09; P = .02). D-dimer, tryptase, and immunoglobulin E concentrations increased with the severity of immunologic reactions. Conclusion: ML, quantified by thromboelastography, is associated with the severity of acute immunologic reactions.
RESUMO
Background: Socioeconomic factors and the COVID-19 pandemic influence children's physical and mental health. We aimed to investigate the association between a census tract's median household income [MHI in United States Dollars ($)] and pediatric intoxications in Rhode Island, the smallest state in the United States of America. Geographical hotspots, as well as interactions with the COVID-19 pandemic, should be identified. Methods: This study is a retrospective analysis of ambulance calls for pediatric (<18 years) intoxication in Rhode Island between March 1st, 2018, and February 28th, 2022. March 1st, 2020 was considered the beginning of the COVID-19 pandemic. Prehospital data were joined with information from the United States Census Bureau. The census tracts' case counts and MHI were examined using Poisson regression. Geographical clusters were identified with the Global Moran's I and local indicators of spatial association tests in ArcGIS Pro (Esri Corporation, Redlands, CA). Results: Inclusion criteria were met by 208 incidents (48% female, median age 16 (IQR 15 to 17) years). The regression model showed a 0.6% increase (IRR 1.006, 95% CI [1.002, 1.01], p = 0.003) in pediatric intoxications for every $ 1,000 increase in MHI. Interaction analysis showed that the effect of MHI was less pronounced during the pandemic (IRR 0.98, 95% CI [0.964, 0.997], p = 0.02). Thirty-four (14%) of the 244 census tracts contributed to geographical clusters, which changed after the onset of the pandemic. Conclusion: Higher median household income could be a risk factor for pediatric intoxications. Geographical hotspots changed with the pandemic.
Assuntos
COVID-19 , Serviços Médicos de Emergência , Humanos , Criança , Feminino , Estados Unidos/epidemiologia , Adolescente , Masculino , Estudos Retrospectivos , Pandemias , Fatores de Risco , COVID-19/epidemiologiaRESUMO
Background: Prior literature suggests that mass gathering events pose challenges to an emergency medical services (EMS) system. We aimed to investigate whether events influence EMS call rates. Materials and methods: This study is a retrospective review of all primary response ambulance calls in Rhode Island (US) between January 1st, 2018 and August 31st, 2022. The number of EMS calls per day was taken from the state's EMS registry. Event data was collected using a Google (Google LLC, Mountain View, CA) search. We used separate Poisson regression models with the number of ambulance calls as the dependent and the social event categories sports, agricultural, music events, and public exhibitions as independent variables. All models controlled for the population at risk and the period of the COVID-19 pandemic. Results are presented as increases or decreases in calls per 100,000 inhabitants from the mean over the study period. Results: The mean number of daily EMS calls was 38 ± 4 per 100,000 inhabitants. EMS encountered significantly more missions on days with music events (+3, 95% CI [2; 3]) and public exhibitions (+2, 95% CI [1; 2]). In contrast, days with agricultural events were associated with fewer calls (-1, 95% CI [-1; 0]). We did not find any effect of sports events on call rates. Conclusion: Increased ambulance call volumes are observed on days with music events and public exhibitions. Days with agricultural events are associated with fewer EMS calls.
Assuntos
COVID-19 , Serviços Médicos de Emergência , Humanos , Estudos Retrospectivos , Serviços Médicos de Emergência/estatística & dados numéricos , COVID-19/epidemiologia , Rhode Island , Ambulâncias/estatística & dados numéricos , SARS-CoV-2 , Esportes/estatística & dados numéricosRESUMO
INTRODUCTION: Economic hardship is a major threat to children's health, implying that pediatric out-of-hospital cardiac arrest (pOHCA) might be promoted by lower incomes and child poverty. To target resources, it is helpful to identify geographical hotspots. Rhode Island is the smallest state by area in the United States of America. It has one million inhabitants and is comparable to many larger cities worldwide. We aimed to investigate the possible associations of pOHCA with economic factors and the coronavirus 2019 (COVID-19) pandemic. Our goal was to identify high-risk areas and evaluate whether the COVID-19 pandemic had an influence on delays in prehospital care. METHODS: We analyzed all pOHCA cases (patients <18 years of age) in Rhode Island between March 1, 2018-February 28, 2022. We performed Poisson regression with pOHCA as dependent and economic risk factors (median household income [MHI] and child poverty rate from the US Census Bureau) as well as the COVID-19 pandemic as independent variables. Hotspots were identified using local indicators of spatial association (LISA) statistics. We used linear regression to assess the association of emergency nedical services-related times with economic risk factors and COVID-19. RESULTS: A total of 51 cases met our inclusion criteria. Lower MHIs (incidence-rate ratio [IRR]) 0.99 per $1,000 MHI; P=0.01) and higher child poverty rates (IRR 1.02 per percent; P=0.02) were significantly associated with higher numbers of ambulance calls due to pOHCA. The pandemic did not have a significant influence (IRR 1.1; P=0.7). LISA identified 12 census tracts as hotspots (P<0.01). The pandemic was not associated with delays in prehospital care. CONCLUSION: Lower median household income and higher child poverty rate are associated with higher numbers of pediatric out-of-hospital cardiac arrest.
Assuntos
COVID-19 , Parada Cardíaca Extra-Hospitalar , Humanos , Criança , Estados Unidos/epidemiologia , Parada Cardíaca Extra-Hospitalar/epidemiologia , Parada Cardíaca Extra-Hospitalar/terapia , Parada Cardíaca Extra-Hospitalar/etiologia , Pandemias , COVID-19/epidemiologia , COVID-19/complicações , Fatores Socioeconômicos , Fatores de RiscoRESUMO
Critical illness polyneuropathy (CIP) is a frequent and underdiagnosed phenomenon among intensive care unit patients. The lipophilic nature of neuronal synapses may result in the association of low serum cholesterol levels with a higher rate of CIP development. We aimed to investigate this issue in critically ill patients. All cases diagnosed with CIP in our tertiary care hospital between 2013 and 2017 were 1:1 matched with controls without the condition by age, sex, and ICD diagnoses. The main risk factors examined were the differences in change between initial and minimum serum total cholesterol levels, and minimum serum total cholesterol levels between matched pairs. Other predictors were serum markers of acute inflammation. We included 67 cases and 67 controls (134 critically ill patients, 49% female, 46% medical). Serum total cholesterol levels decreased more profoundly in cases than controls (median: -74 (IQR -115 to -24) vs. -39 (IQR -82 to -4), median difference: -28, 95% CI [-51, -5]), mg/dl). Minimum serum total cholesterol levels were lower in the cases (median difference: -24, 95% CI [-39, -9], mg/dl). We found significant median differences across matched pairs in maximum serum C-reactive protein (8.9, 95% CI [4.6, 13.2], mg/dl), minimum albumin (-4.2, 95% CI [-6.7, -1.7], g/l), decrease in albumin (-3.9, 95% CI [-7.6, -0.2], g/l), and lowest cholinesterase levels (-0.72, 95% CI [-1.05, -0.39], U/l). Subsequently, more pronounced decreases in serum total cholesterol levels and lower minimum total cholesterol levels during critical care unit hospitalizations may be a risk factor for CIP.
Assuntos
Estado Terminal , Polineuropatias , Humanos , Feminino , Masculino , Estudos de Casos e Controles , Proteína C-Reativa , Colesterol , Polineuropatias/diagnóstico , Polineuropatias/etiologia , Fatores de RiscoRESUMO
BACKGROUND: Critical illness polyneuropathy (CIP) commonly occurs in critical care unit (CCU) patients, but timely diagnosis can be challenging. Therefore, new biomarkers, such as serum neurofilament light chain (sNfL), could help to improve early identification of patients with this condition. METHODS: CIP was diagnosed or excluded with neurological assessment and nerve conduction measurement in a prospective study of CCU patients. sNfL and secondary predictors for neuropathy (neuron-specific enolase (NSE), S100, folic acid, and vitamin B
Assuntos
Filamentos Intermediários , Polineuropatias , Humanos , Estudos Prospectivos , Biomarcadores , Polineuropatias/diagnóstico , Proteínas de NeurofilamentosRESUMO
BACKGROUND: Overcrowding decreases quality of care. Triage and patient administration are possible bottlenecks. We aimed to identify factors influencing door-to-triage- and triage-to-patient administration-time in a prospective observational study at a tertiary care center with 70,000 patients per year. METHODS: Measurement of aforementioned times at convenience-sampled time intervals on 16 days. Linear regression modelling with times as dependent variable, and demographic, medical and structural factors as covariables, testing for interactions with risk factor "weekend". RESULTS: We included 360 patients (183 female (51%)). Median door-to-triage-time was 6 (IQR 3-11) minutes, triage-to-patient administration-time was 5 (IQR 3-8) minutes. Overall door-to-triage-time was significantly shorter during weekends compared to weekdays (absolute difference 3 (IQR 1-7) minutes; 5 (IQR 3-8) vs. 8 (IQR 4-15) minutes, p < 0.01). Other influencing factors were closing hours of non-emergency department healthcare facilities (3.5 min more), number of ESI 2 patients seen during the interval (3 min more for each patient per hour), and ambulance activity (2 min more for each patient per hour brought by ambulance). CONCLUSIONS: Day of time and week as well as frequency of patients with urgent conditions and those brought by ambulance significantly increased door-to-triage times. This should be kept in mind when organizing ED workflow.
Assuntos
Serviço Hospitalar de Emergência , Triagem , Ambulâncias , Feminino , Humanos , Estudos Prospectivos , Centros de Atenção TerciáriaRESUMO
Background: Infectious diseases, including COVID-19, have a severe impact on child health globally. We investigated whether emergency medical service (EMS) calls are a bellwether for future COVID-19 caseloads. We elaborated on geographical hotspots and socioeconomic risk factors. Methods: All EMS calls for suspected infectious disease in the pediatric population (under 18 years of age) in Rhode Island between 1 March 2018 and 28 February 2022 were included in this quasi-experimental ecological study. The first of March 2020 was the beginning of the COVID-19 pandemic. We used the 2020 census tract and the most recent COVID-19 data. We investigated associations between pediatric EMS calls and positive COVID-19 tests with time series analysis and identified geographical clusters using local indicators of spatial association. Economic risk factors were examined using Poisson regression. Results: We included 980 pediatric ambulance calls. Calls during the omicron wave were significantly associated with increases in positive COVID-19 tests one week later (p < 0.001). Lower median household income (IRR 0.99, 95% CI [0.99, 0.99]; p < 0.001) and a higher child poverty rate (IRR 1.02, 95% CI [1.02, 1.02]; p < 0.001) were associated with increased EMS calls. Neighborhood hotspots changed over time. Conclusion: Ambulance calls might be a predictor for major surges of COVID-19 in children.
Assuntos
COVID-19 , Serviços Médicos de Emergência , Humanos , Criança , Adolescente , Pandemias , COVID-19/epidemiologia , Ambulâncias , Características de ResidênciaRESUMO
BACKGROUND: The COVID-19 pandemic led to widespread use of personal protection equipment (PPE), including filtering face piece (FFP) masks, throughout the world. PPE. Previous studies indicate that PPE impairs neurocognitive performance in healthcare workers. Concerns for personnel safety have led to special recommendations regarding basic life support (BLS) in patients with a potential SARS-CoV-2 infection, including the use of PPE. Established instruments are available to assess attention and dexterity in BLS settings, respectively. We aimed to evaluate the influence of PPE with different types of FFP masks on these two neuropsychological components of EMS personnel during BLS. METHODS: This was a randomized controlled non-inferiority triple-crossover study. Teams of paramedics completed three 12-min long BLS scenarios on a manikin after having climbed three flights of stairs with equipment, each in three experimental conditions: (a) without pandemic PPE, (b) with PPE including a FFP2 mask with an expiration valve and (c) with PPE including an FFP2 mask without an expiration valve. The teams and intervention sequences were randomized. We measured the shift in concentration performance using the d2 test and dexterity using the nine-hole peg test (NHPT). We compared results between the three conditions. For the primary outcome, the non-inferiority margin was set at 20 points. RESULTS: Forty-eight paramedics participated. Concentration performance was significantly better after each scenario, with no differences noted between groups: d2 shift control versus with valve - 8.3 (95% CI - 19.4 to 2.7) points; control versus without valve - 8.5 (- 19.7 to 2.7) points; with valve versus without valve 0.1 (- 11.1 to 11.3) points. Similar results were found for the NHPT: + 0.3 (- 0.7 to 1.4), - 0.4 (- 1.4 to 0.7), 0.7 (- 0.4 to 1.8) s respectively. CONCLUSION: Attention increases when performing BLS. Attention and dexterity are not inferior when wearing PPE, including FFP2 masks. PPE should be used on a low-threshold basis.
Assuntos
COVID-19 , Equipamento de Proteção Individual , Pessoal Técnico de Saúde , Atenção , Estudos Cross-Over , Humanos , Pandemias , Estudos Prospectivos , SARS-CoV-2RESUMO
AIM: Prior studies suggest that the use of personal protective equipment might impair the quality of critical care. We investigated the influence of personal protective equipment on out-of-hospital cardiopulmonary resuscitation. METHODS: Randomised controlled non-inferiority triple-crossover study. Forty-eight emergency medical service providers, randomized into teams of two, performed 12â¯min of basic life support (BLS) on a manikin after climbing 3 flights of stairs. Three scenarios were completed in a randomised order: Without personal protective equipment, with personal protective equipment including a filtering face piece (FFP) 2 mask with valve, and with personal protective equipment including an FFP2 mask without valve. The primary outcome was mean depth of chest compressions with a pre-defined non-inferiority margin of 3.5â¯mm. Secondary outcomes included other measurements of CPR quality, providers' subjective exhaustion levels, and providers' vital signs, including end-tidal CO2. RESULTS: Differences regarding the primary outcome were well below the pre-defined non-inferiority margins for both control vs. personal protective equipment without valve (absolute difference 1â¯mm, 95% CI [-1, 2]) and control vs. personal protective equipment with valve (absolute difference 1â¯mm, [-0.2, 2]). This was also true for secondary outcomes regarding quality of chest compressions and providers' vital signs including etCO2. Subjective physical strain after BLS was higher in the personal protective equipment groups (Borg 4 (SD 3) without valve, 4 (SD 2) with valve) than in the control group (Borg 3 (SD 2)). CONCLUSION: PPE including masks with and without expiration valve is safe for use without concerns regarding the impairment of CPR quality.