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Anaesthesia Dec 2022We conducted a narrative review in six areas of obstetric emergencies: category-1 caesarean section; difficult and failed airway; massive obstetric haemorrhage;... (Review)
Review
We conducted a narrative review in six areas of obstetric emergencies: category-1 caesarean section; difficult and failed airway; massive obstetric haemorrhage; hypertensive crisis; emergencies related to neuraxial anaesthesia; and maternal cardiac arrest. These areas represent significant research published within the last five years, with emphasis on large multicentre randomised trials, national or international practice guidelines and recommendations from major professional societies. Key topics discussed: prevention and management of failed neuraxial technique; role of high-flow nasal oxygenation and choice of neuromuscular drug in obstetric patients; prevention of accidental awareness during general anaesthesia; management of the difficult and failed obstetric airway; current perspectives on the use of tranexamic acid, fibrinogen concentrate and cell salvage; guidance on neuraxial placement in a thrombocytopenic obstetric patient; management of neuraxial drug errors, local anaesthetic systemic toxicity and unusually prolonged neuraxial block regression; and extracorporeal membrane oxygenation use in maternal cardiac arrest.
Topics: Humans; Pregnancy; Female; Anesthesia, Obstetrical; Cesarean Section; Emergencies; Anesthesia, General; Heart Arrest
PubMed: 36089883
DOI: 10.1111/anae.15839 -
Circulation Oct 2023In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory... (Review)
Review
2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
Topics: Humans; Adrenergic beta-Antagonists; American Heart Association; Benzodiazepines; Cardiopulmonary Resuscitation; Digoxin; Heart Arrest; United States
PubMed: 37721023
DOI: 10.1161/CIR.0000000000001161 -
Neurocritical Care Jun 2023Among cardiac arrest survivors, about half remain comatose 72 h following return of spontaneous circulation (ROSC). Prognostication of poor neurological outcome in this...
BACKGROUND
Among cardiac arrest survivors, about half remain comatose 72 h following return of spontaneous circulation (ROSC). Prognostication of poor neurological outcome in this population may result in withdrawal of life-sustaining therapy and death. The objective of this article is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling surrogates of comatose cardiac arrest survivors.
METHODS
A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, which included clinical variables and prediction models, were selected based on clinical relevance and the presence of an appropriate body of evidence. The Population, Intervention, Comparator, Outcome, Timing, Setting (PICOTS) question was framed as follows: "When counseling surrogates of comatose adult survivors of cardiac arrest, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of poor functional outcome assessed at 3 months or later?" Additional full-text screening criteria were used to exclude small and lower-quality studies. Following construction of the evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format.
RESULTS
Eleven candidate clinical variables and three prediction models were selected based on clinical relevance and the presence of an appropriate body of literature. A total of 72 articles met our eligibility criteria to guide recommendations. Good practice recommendations include waiting 72 h following ROSC/rewarming prior to neuroprognostication, avoiding sedation or other confounders, the use of multimodal assessment, and an extended period of observation for awakening in patients with an indeterminate prognosis, if consistent with goals of care. The bilateral absence of pupillary light response > 72 h from ROSC and the bilateral absence of N20 response on somatosensory evoked potential testing were identified as reliable predictors. Computed tomography or magnetic resonance imaging of the brain > 48 h from ROSC and electroencephalography > 72 h from ROSC were identified as moderately reliable predictors.
CONCLUSIONS
These guidelines provide recommendations on the reliability of predictors of poor outcome in the context of counseling surrogates of comatose survivors of cardiac arrest and suggest broad principles of neuroprognostication. Few predictors were considered reliable or moderately reliable based on the available body of evidence.
Topics: Adult; Humans; Coma; Heart Arrest; Hypothermia, Induced; Prognosis; Reproducibility of Results; Survivors
PubMed: 36949360
DOI: 10.1007/s12028-023-01688-3 -
Critical Care (London, England) Dec 2022In-hospital cardiac arrest (IHCA) is associated with a high risk of death, but mortality rates are decreasing. The latest epidemiological and outcome data from several... (Review)
Review
In-hospital cardiac arrest (IHCA) is associated with a high risk of death, but mortality rates are decreasing. The latest epidemiological and outcome data from several cardiac arrest registries are helping to shape our understanding of IHCA. The introduction of rapid response teams has been associated with a downward trend in hospital mortality. Technology and access to defibrillators continues to progress. The optimal method of airway management during IHCA remains uncertain, but there is a trend for decreasing use of tracheal intubation and increased use of supraglottic airway devices. The first randomised clinical trial of airway management during IHCA is ongoing in the UK. Retrospective and observational studies have shown that several pre-arrest factors are strongly associated with outcome after IHCA, but the risk of bias in such studies makes prognostication of individual cases potentially unreliable. Shared decision making and advanced care planning will increase application of appropriate DNACPR decisions and decrease rates of resuscitation attempts following IHCA.
Topics: Humans; Retrospective Studies; Heart Arrest; Hospitals
PubMed: 36474215
DOI: 10.1186/s13054-022-04247-y -
JAMA Pediatrics Mar 2021Pediatric in-hospital cardiac arrest (IHCA) occurs frequently and is associated with high morbidity and mortality. The objective of this narrative review is to summarize... (Review)
Review
IMPORTANCE
Pediatric in-hospital cardiac arrest (IHCA) occurs frequently and is associated with high morbidity and mortality. The objective of this narrative review is to summarize the current knowledge and recommendations regarding pediatric IHCA and cardiopulmonary resuscitation (CPR).
OBSERVATIONS
Each year, more than 15 000 children receive CPR for cardiac arrest during hospitalization in the United States. As many as 80% to 90% survive the event, but most patients do not survive to hospital discharge. Most IHCAs occur in intensive care units and other monitored settings and are associated with respiratory failure or shock. Bradycardia with poor perfusion is the initial rhythm in half of CPR events, and only about 10% of events have an initial shockable rhythm. Pre-cardiac arrest systems focus on identifying at-risk patients and ensuring that they are in monitored settings. Important components of CPR include high-quality chest compressions, timely defibrillation when indicated, appropriate ventilation and airway management, administration of epinephrine to increase coronary perfusion pressure, and treatment of the underlying cause of cardiac arrest. Extracorporeal CPR and measurement of physiological parameters are evolving areas in improving outcomes. Structured post-cardiac arrest care focused on targeted temperature management, optimization of hemodynamics, and careful intensive care unit management is associated with improved survival and neurological outcomes.
CONCLUSIONS AND RELEVANCE
Pediatric IHCA occurs frequently and has a high mortality rate. Early identification of risk, prevention, delivery of high-quality CPR, and post-cardiac arrest care can maximize the chances of achieving favorable outcomes. More research in this field is warranted.
Topics: Cardiopulmonary Resuscitation; Heart Arrest; Hospitalization; Humans; Pediatrics; United States
PubMed: 33226408
DOI: 10.1001/jamapediatrics.2020.5039 -
Circulation Aug 2019Successful resuscitation from cardiac arrest results in a post-cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The...
Successful resuscitation from cardiac arrest results in a post-cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post-cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post-cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post-cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post-cardiac arrest care.
Topics: Acute Kidney Injury; Adrenal Insufficiency; Anticonvulsants; Brain Damage, Chronic; Cardiomyopathies; Cardiopulmonary Resuscitation; Cardiovascular Agents; Child; Combined Modality Therapy; Fluid Therapy; Glucose Metabolism Disorders; Heart Arrest; Humans; Hypnotics and Sedatives; Hypothermia, Induced; Hypoxia-Ischemia, Brain; Infections; Inflammation; Monitoring, Physiologic; Multiple Organ Failure; Neuromuscular Blocking Agents; Oxygen Inhalation Therapy; Prognosis; Reperfusion Injury; Respiratory Therapy; Time Factors
PubMed: 31242751
DOI: 10.1161/CIR.0000000000000697 -
Critical Care (London, England) Nov 2022Most of the patients who die after cardiac arrest do so because of hypoxic-ischemic brain injury (HIBI). Experimental evidence shows that temperature control targeted at... (Review)
Review
Most of the patients who die after cardiac arrest do so because of hypoxic-ischemic brain injury (HIBI). Experimental evidence shows that temperature control targeted at hypothermia mitigates HIBI. In 2002, one randomized trial and one quasi-randomized trial showed that temperature control targeted at 32-34 °C improved neurological outcome and mortality in patients who are comatose after cardiac arrest. However, following the publication of these trials, other studies have questioned the neuroprotective effects of hypothermia. In 2021, the largest study conducted so far on temperature control (the TTM-2 trial) including 1900 adults comatose after resuscitation showed no effect of temperature control targeted at 33 °C compared with normothermia or fever control. A systematic review of 32 trials published between 2001 and 2021 concluded that temperature control with a target of 32-34 °C compared with fever prevention did not result in an improvement in survival (RR 1.08; 95% CI 0.89-1.30) or favorable functional outcome (RR 1.21; 95% CI 0.91-1.61) at 90-180 days after resuscitation. There was substantial heterogeneity across the trials, and the certainty of the evidence was low. Based on these results, the International Liaison Committee on Resuscitation currently recommends monitoring core temperature and actively preventing fever (37.7 °C) for at least 72 h in patients who are comatose after resuscitation from cardiac arrest. Future studies are needed to identify potential patient subgroups who may benefit from temperature control aimed at hypothermia. There are no trials comparing normothermia or fever control with no temperature control after cardiac arrest.
Topics: Adult; Humans; Hypothermia, Induced; Coma; Hypothermia; Heart Arrest; Cardiopulmonary Resuscitation; Fever
PubMed: 36434649
DOI: 10.1186/s13054-022-04238-z -
Circulation Jan 2024Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve... (Review)
Review
2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve outcomes. This "2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support" summarizes the most recent published evidence for and recommendations on the use of medications, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation, and seizure management in this population. We discuss the lack of data in recent cardiac arrest literature that limits our ability to evaluate diversity, equity, and inclusion in this population. Last, we consider how the cardiac arrest population may make up an important pool of organ donors for those awaiting organ transplantation.
Topics: Humans; United States; American Heart Association; Cardiopulmonary Resuscitation; Emergency Medical Services; Heart Arrest; Emergency Treatment
PubMed: 38108133
DOI: 10.1161/CIR.0000000000001194 -
Schweizer Archiv Fur Tierheilkunde Dec 2020Cardiopulmonary arrest (CPA) is the acute cessation of systemic perfusion and ventilation. It leads to a lack of tissue oxygen delivery and, if not addressed quickly,... (Review)
Review
Cardiopulmonary arrest (CPA) is the acute cessation of systemic perfusion and ventilation. It leads to a lack of tissue oxygen delivery and, if not addressed quickly, will inevitably cause death. Cardiopulmonary resuscitation (CPR) is the only available treatment for CPA and several opportunities exist to improve the veterinary team's resuscitation approach and optimize small animal CPR patient outcomes. In 2012, the Reassessment Campaign on Veterinary Resuscitation (RECOVER) initiative generated evidence-based clinical guidelines to form the basis for training and practice of CPR in dogs and cats. When employing an evidence-based, standardized approach to small animal CPR, return of spontaneous circulation can be achieved in up to 58% of patients and up to 7% of dogs and 19% of cats can be discharged from the veterinary hospital alive. Survival for dogs and cats that suffer CPA is best in patients that suffer a peri-anesthetic arrest, so high quality CPR in the anesthesia patient population is of utmost importance and expected to be the most rewarding. To ensure the best possible outcomes for any patient suffering from CPA and undergoing CPR, a comprehensive resuscitation strategy is necessary, that includes preventive and preparedness measures, basic life support (chest compressions and ventilation), advanced life support (optimization of the patient status by targeted drug therapy, cardiac rhythm monitoring, and defibrillation), and post-cardiac arrest critical care. This article summarizes the most important RECOVER CPR guidelines for the small animal practitioner.
Topics: Animals; Cardiopulmonary Resuscitation; Cats; Dogs; Heart Arrest; Hospitals, Animal
PubMed: 33263542
DOI: 10.17236/sat00280 -
Circulation Jan 2024The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence.... (Review)
Review
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
Topics: Humans; Cardiopulmonary Resuscitation; American Heart Association; Heart Arrest; Emergency Medical Services; Critical Care
PubMed: 38014539
DOI: 10.1161/CIR.0000000000001163