Can a Physiologic Insight "Resuscitate" Research in Cardiopulmonary Resuscitation?
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SUBMITTER: Scales DC
PROVIDER: S-EPMC6423109 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ObjectiveVentricular unloading is associated with myocardial recovery. We sought to evaluate the association of extracorporeal cardiopulmonary resuscitation (ECPR) on myocardial function after cardiac arrest. We conducted a retrospective exploratory analysis, comparing ejection fraction (EF) after adult cardiac arrest, between ECPR and conventional CPR.ResultsAmong 1119 cases of cardiac arrest, 116 had an echocardiogram post-return of spontaneous circulation (ROSC) and were included. Thirty-eight patients had ≥ 2 echocardiograms. ECPR patients had differences in age, hypertension and chronic heart failure. ECPR patients had a lower EF post-ROSC (24% vs 45%; p < 0.01) and were more likely to undergo percutaneous coronary intervention (25% vs 3%; p < 0.01). In multivariate analysis, only ECPR use (β-coeff: 10.4 [95% CI 3.68-17.13]; p < 0.01) independently predicted improved myocardial function. In this exploratory study, EF after cardiac arrest may be more likely to improve among ECPR patients than CCPR patients. Our methodology should be replicated to confirm or refute the validity of our findings.
| S-EPMC7060522 | biostudies-literature
Project description:Extracorporeal cardiopulmonary resuscitation (ECPR) is a salvage procedure in which extracorporeal membrane oxygenation (ECMO) is initiated emergently on patients who have had cardiac arrest (CA) and on whom the conventional cardiopulmonary resuscitation (CCPR) has failed. Awareness and usage of ECPR are increasing all over the world. Significant advancements have taken place in the ECPR initiation techniques, in its device and in its post-procedure care. ECPR is a team work requiring multidisciplinary experts, highly skilled health care workers and adequate infrastructure with appropriate devices. Perfect coordination and communication among team members play a vital role in the outcome of the ECPR patients. Ethical, legal and financial issues need to be considered before initiation of ECPR and while withdrawing the support when the ECPR is futile. Numerous studies about ECPR are being published more frequently in the last few years. Hence, keeping updated about the ECPR is very important for proper selection of cases and its management. This article reviews various aspects of ECPR and relevant literature to date.
| S-EPMC7787697 | biostudies-literature
Project description:The hemodynamic effects of ventilation can be grouped into three concepts: 1) Spontaneous ventilation is exercise; 2) changes in lung volume alter autonomic tone and pulmonary vascular resistance and can compress the heart in the cardiac fossa; and 3) spontaneous inspiratory efforts decrease intrathoracic pressure, increasing venous return and impeding left ventricular ejection, whereas positive-pressure ventilation decreases venous return and unloads left ventricular ejection. Spontaneous inspiratory efforts may induce acute left ventricular failure and cardiogenic pulmonary edema. Reversing the associated negative intrathoracic pressure swings by using noninvasive continuous positive airway pressure rapidly reverses acute cardiogenic pulmonary edema and improves survival. Additionally, in congestive heart failure, states increasing intrathoracic pressure may augment left ventricular ejection and improve cardiac output. Using the obligatory changes in venous return induced by positive pressure breathing, one can quantify the magnitude of associated decreases in venous flow and left ventricular ejection using various parameters, including vena caval diameter changes, left ventricular stroke volume variation, and arterial pulse pressure variation. These parameters vary in proportion to the level of cardiac preload reserve present, thus accurately predicting which critically ill patients will increase their cardiac output in response to fluid infusions and which will not. Common parameters include arterial pulse pressure variation and left ventricular stroke volume variation. This functional hemodynamic monitoring approach reflects a practical clinical application of heart-lung interactions.
| S-EPMC5822394 | biostudies-literature
Project description:Approximately, 10-20% of newborns require breathing assistance at birth, which remains the cornerstone of neonatal resuscitation. Fortunately, the need for chest compression (CC) or medications in the delivery room (DR) is rare. About 0.1% of term infants and up to 15% of preterm infants receive these interventions, this will result in approximately one million newborn deaths annually worldwide. In addition, CC or medications (epinephrine) are more frequent in the preterm population (~15%) due to birth asphyxia. A recent study reported that only 6 per 10,000 infants received epinephrine in the DR. Further, the study reported that infants receiving epinephrine during resuscitation had a high incidence of mortality (41%) and short-term neurologic morbidity (57% hypoxic-ischemic encephalopathy and seizures). A recent review of newborns who received prolonged CC and epinephrine but had no signs of life at 10?min following birth noted 83% mortality, with 93% of survivors suffering moderate-to-severe disability. The poor prognosis associated with receiving CC alone or with medications in the DR raises questions as to whether improved cardiopulmonary resuscitation methods specifically tailored to the newborn could improve outcomes.
| S-EPMC5816046 | biostudies-literature
Project description:Survival from out-of-hospital cardiac arrest (OHCA) has remained low despite advances in resuscitation science. Hospital-based extra-corporeal cardiopulmonary resuscitation (ECPR) is a novel use of an established technology that provides greater blood flow and oxygen delivery during cardiac arrest than closed chest compressions. Hospital-based ECPR is currently offered to selected OHCA patients in specialized centres. The interval between collapse and restoration of circulation is inversely associated with good clinical outcomes after ECPR. Pre-hospital delivery of ECPR concurrent with conventional resuscitation is one approach to shortening this interval and improving outcomes after OHCA. This article examines the background and rationale for pre-hospital ECPR; summarises the findings of a literature search for published evidence; and considers candidate selection, logistics, and complications for this complex intervention.
| S-EPMC5870373 | biostudies-literature
Project description:After cardiac arrest a combination of basic and advanced airway and ventilation techniques are used during cardiopulmonary resuscitation (CPR) and after a return of spontaneous circulation (ROSC). The optimal combination of airway techniques, oxygenation and ventilation is uncertain. Current guidelines are based predominantly on evidence from observational studies and expert consensus; recent and ongoing randomised controlled trials should provide further information. This narrative review describes the current evidence, including the relative roles of basic and advanced (supraglottic airways and tracheal intubation) airways, oxygenation and ventilation targets during CPR and after ROSC in adults. Current evidence supports a stepwise approach to airway management based on patient factors, rescuer skills and the stage of resuscitation. During CPR, rescuers should provide the maximum feasible inspired oxygen and use waveform capnography once an advanced airway is in place. After ROSC, rescuers should titrate inspired oxygen and ventilation to achieve normal oxygen and carbon dioxide targets.
| S-EPMC6092791 | biostudies-literature
Project description:ImportanceWhether the cardiopulmonary resuscitation (CPR) preferences of patients receiving dialysis align with their values and other aspects of end-of-life care is not known.ObjectiveTo describe the CPR preferences of patients receiving dialysis and how these preferences are associated with their responses to questions about other aspects of end-of-life care.Design, setting, and participantsCross-sectional survey study of a consecutive sample of patients receiving dialysis at 31 nonprofit dialysis facilities in 2 US metropolitan areas (Seattle, Washington, and Nashville, Tennessee) between April 22, 2015, and October 2, 2018. Analyses for this article were conducted between December 2018 and April 2020.ExposuresParticipants were asked to respond to the question "If you had to decide right now, would you want CPR if your heart were to stop beating?" Those who indicated they would probably or definitely want CPR were categorized as preferring CPR.Main outcomes and measuresThis study examined the association between preference for CPR and other treatment preferences, engagement in advance care planning, values, desired place of death, expectations about prognosis, symptoms, and palliative care needs.ResultsOf the 1434 individuals invited to complete the survey, 1009 agreed to participate, and 876 were included in the analytic cohort (61.1%). The final cohort had a mean (SD) age of 62.6 (14.0) years; 492 (56.2%) were men, and 528 (60.3%) were White individuals. Among 738 of 876 participants (84.2%) who indicated that they would definitely or probably want CPR (CPR group), 555 (75.2%) wanted mechanical ventilation vs 13 of 138 (9.4%) of those who did not want CPR (do not resuscitate [DNR] group) (P < .001). A total of 249 of 738 participants (33.7%) in the CPR group vs 84 of 138 (60.9%) in the DNR group had documented treatment preferences (P < .001). In terms of values about future care, 171 participants (23.2%) in the CPR group vs 5 of 138 (3.6%) in the DNR group valued life prolongation (P < .001); 320 in the CPR group (43.4%) vs 109 of 138 in the DNR group (79.0%) valued comfort (P < .001); and 247 participants (33.5%) in the CPR group vs 24 of 138 (17.4%) in the DNR group were unsure about their wishes for future care (P < .001). In the CPR group, 207 (28.0%) had thought about stopping dialysis vs 62 of 138 (44.9%) in the DNR group (P < .001), and 181 (24.5%) vs 58 of 138 (42.0%) had discussed stopping dialysis (P = .001). No statistically significant associations were observed between CPR preference and documentation of a surrogate decision maker, thoughts or discussion of hospice, preferred place of death, expectations about prognosis, reported symptoms, or palliative care needs.Conclusions and relevanceThe CPR preferences of patients receiving dialysis were associated with some, but not all, other aspects of end-of-life care. How participants responded to questions about these other aspects of end-of-life care were not always aligned with their CPR preference. More work is needed to integrate discussions about code status with bigger picture conversations about patients' values, goals, and preferences for end-of-life care.
| S-EPMC7445594 | biostudies-literature
Project description:BACKGROUND:The prognosis in refractory out-of-hospital cardiac arrest (OHCA) with ongoing cardiopulmonary resuscitation (CPR) at hospital arrival is often considered dismal. The use of extracorporeal cardiopulmonary resuscitation (eCPR) for perfusion enhancement during resuscitation has shown variable results. We aimed to investigate outcome in refractory OHCA patients managed conservatively without use of eCPR. METHODS:We included consecutive OHCA patients with refractory arrest or prehospital return of spontaneous circulation (ROSC) in the Copenhagen area in 2002-2011. RESULTS:A total of 3992 OHCA patients with resuscitation attempts were included; in 2599, treatment was terminated prehospital, and 1393 (35%) were brought to the hospital either with ROSC (n?=?1285, 92%) or with refractory OHCA (n?=?108, 8%). Of patients brought in with refractory OHCA, 56 (52%) achieved ROSC in the emergency department. There were no differences between patients with refractory OHCA or prehospital ROSC with regard to age, sex, comorbidities, or etiology of OHCA. Time to emergency medical services (EMS) arrival was similar, whereas time to ROSC (when ROSC was achieved) was longer in refractory OHCA patients (EMS, 6 (5-9] vs. 7 [5-10] min, p?=?0.8; ROSC, 15 [9-22] vs. 27 [20-41] min, p?<?0.001). Independent factors associated with transport with refractory OHCA instead of prehospital termination of therapy were OHCA in public (OR, 3.6 [95% CI, 2.2-5.8]; p?<?0.001), witnessed OHCA (OR, 3.7 [2.0-7.1]; p?<?0.001), shockable rhythm (OR, 3.0 [1.9-4.7]; p?<?0.001), younger age (OR, 1.2 [1.1-1.2]; p?<?0.001), and later calendar year (OR, 1.4 [1.2-1.6]; p?<?0.001). Thirty-day survival was 20% in patients with refractory OHCA compared with 42% in patients with prehospital ROSC (p?<?0.001). Four of 28 refractory OHCA patients with duration of resuscitation >?60 min achieved ROSC. No difference in favorable neurological outcome in patients surviving to discharge was found (prehospital ROSC 84% vs. refractory OHCA 86%; p?=?0.7). CONCLUSIONS:Survival after refractory OHCA with ongoing CPR at hospital arrival was significantly lower than among patients with prehospital ROSC. Despite a lower survival, the majority of survivors with both refractory OHCA and prehospital ROSC were discharged with a similar degree of favorable neurological outcome, indicating that continued efforts in spite of refractory OHCA are not in vain and may still lead to favorable outcome even without eCPR.
| S-EPMC6162879 | biostudies-other
Project description:We aimed to investigate the impact of mechanical cardiopulmonary resuscitation devices over manual cardiopulmonary resuscitation on outcomes from inhospital cardiac arrests. Design:Restrospective review. Setting:Single academic medical center. Participants:Data were collected on all patients who suffered cardiac arrest from December 2015 to November 2019. Main Outcomes and Measures:Primary end point was return of spontaneous circulation. Secondary end points included survival to discharge and survival to discharge with favorable neurologic outcomes. Results:About 104 patients were included in the study: 59 patients received mechanical cardiopulmonary resuscitation and 45 patients received manual cardiopulmonary resuscitation during the enrollment period. Return of spontaneous circulation rate was 83% in the mechanical cardiopulmonary resuscitation group versus 48.8% in the manual group (p = 0.009). Survival-to-discharge rate was 32.2% in the mechanical cardiopulmonary resuscitation group versus 11.1% in those who received manual cardiopulmonary resuscitation (p = 0.02). Of the patients who survived to discharge and received mechanical cardiopulmonary resuscitation, 100% (n = 19) had a favorable neurologic outcome versus 40% (two out of five) of patients who survived and received manual cardiopulmonary resuscitation (p = 0.005). Conclusions:Our findings demonstrate a significant association of improved outcomes with mechanical cardiopulmonary resuscitation over manual cardiopulmonary resuscitation during inhospital cardiac arrests. Mechanical cardiopulmonary resuscitation may improve rates of return of spontaneous circulation, survival to discharge, and favorable neurologic outcomes.
| S-EPMC7671880 | biostudies-literature
Project description:ImportanceApproximately 40% of children who experience an in-hospital cardiac arrest survive to hospital discharge. Achieving threshold intra-arrest diastolic blood pressure (BP) targets during cardiopulmonary resuscitation (CPR) and systolic BP targets after the return of circulation may be associated with improved outcomes.ObjectiveTo evaluate the effectiveness of a bundled intervention comprising physiologically focused CPR training at the point of care and structured clinical event debriefings.Design, setting, and participantsA parallel, hybrid stepped-wedge, cluster randomized trial (Improving Outcomes from Pediatric Cardiac Arrest-the ICU-Resuscitation Project [ICU-RESUS]) involving 18 pediatric intensive care units (ICUs) from 10 clinical sites in the US. In this hybrid trial, 2 clinical sites were randomized to remain in the intervention group and 2 in the control group for the duration of the study, and 6 were randomized to transition from the control condition to the intervention in a stepped-wedge fashion. The index (first) CPR events of 1129 pediatric ICU patients were included between October 1, 2016, and March 31, 2021, and were followed up to hospital discharge (final follow-up was April 30, 2021).InterventionDuring the intervention period (n = 526 patients), a 2-part ICU resuscitation quality improvement bundle was implemented, consisting of CPR training at the point of care on a manikin (48 trainings/unit per month) and structured physiologically focused debriefings of cardiac arrest events (1 debriefing/unit per month). The control period (n = 548 patients) consisted of usual pediatric ICU management of cardiac arrest.Main outcomes and measuresThe primary outcome was survival to hospital discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1 to 3 or no change from baseline (score range, 1 [normal] to 6 [brain death or death]). The secondary outcome was survival to hospital discharge.ResultsAmong 1389 cardiac arrests experienced by 1276 patients, 1129 index CPR events (median patient age, 0.6 [IQR, 0.2-3.8] years; 499 girls [44%]) were included and 1074 were analyzed in the primary analysis. There was no significant difference in the primary outcome of survival to hospital discharge with favorable neurologic outcomes in the intervention group (53.8%) vs control (52.4%); risk difference (RD), 3.2% (95% CI, -4.6% to 11.4%); adjusted OR, 1.08 (95% CI, 0.76 to 1.53). There was also no significant difference in survival to hospital discharge in the intervention group (58.0%) vs control group (56.8%); RD, 1.6% (95% CI, -6.2% to 9.7%); adjusted OR, 1.03 (95% CI, 0.73 to 1.47).Conclusions and relevanceIn this randomized clinical trial conducted in 18 pediatric intensive care units, a bundled intervention of cardiopulmonary resuscitation training at the point of care and physiologically focused structured debriefing, compared with usual care, did not significantly improve patient survival to hospital discharge with favorable neurologic outcome among pediatric patients who experienced cardiac arrest in the ICU.Trial registrationClinicalTrials.gov Identifier: NCT02837497.
| S-EPMC8905390 | biostudies-literature