-
Paediatric Anaesthesia Apr 2020Current pediatric resuscitation guidelines suggest that resuscitators using an advanced airway deliver 8-10 breaths per minute while carefully avoiding excessive...
BACKGROUND
Current pediatric resuscitation guidelines suggest that resuscitators using an advanced airway deliver 8-10 breaths per minute while carefully avoiding excessive ventilation. In the intraoperative setting, having a dedicated ventilation rescuer may be difficult because of limited personnel. Continuing pressure-controlled mechanical ventilation during resuscitation for intraoperative cardiac arrest reduces personnel needed and the risk of hyperventilation but might risk hypoventilation during chest compression delivery.
AIMS
To determine whether the use of pressure-controlled mechanical ventilation at prearrest settings provides normoxia and normocarbia during resuscitation from cardiac arrest.
METHODS
We retrospectively analyzed combined data from preclinical randomized controlled trials. Two-week-old swine (3-4 kg) underwent asphyxia-induced cardiac arrest. Animals were resuscitated with periods of basic and advanced life support. During resuscitation, pressure-controlled mechanical ventilation was delivered at the prearrest respiratory rate, peak inspiratory pressure, and positive end-expiratory pressure. Arterial blood gases were measured prearrest, at 11 minutes of asphyxia, and at 8 and 20 minutes of cardiopulmonary resuscitation.
RESULTS
Piglets (n = 154) received pressure-controlled mechanical ventilation before and during cardiopulmonary resuscitation with a peak inspiratory pressure of 14-15 cm H O, positive end-expiratory pressure of 4 cm H O, 20 breaths/minute, and an inspiratory:expiratory ratio of 1:2. During asphyxia, the arterial blood gas showed the expected severe hypercarbia and hypoxia. Continuing pressure-controlled mechanical ventilation using prearrest parameters and increasing the FiO to 1.0 returned the PaCO to prearrest levels and slightly increased the partial pressure of arterial oxygen at 8 and 20 minutes of cardiopulmonary resuscitation.
CONCLUSION
In this piglet model of resuscitation from asphyxial arrest, pressure-controlled mechanical ventilation during cardiopulmonary resuscitation at the prearrest ventilator settings with an FiO of 1.0 provides adequate oxygenation and restores normocarbia. Clinical investigation is warranted to determine the benefits of continuing pressure-controlled mechanical ventilation at prearrest parameters during pediatric cardiopulmonary resuscitation.
Topics: Animals; Disease Models, Animal; Heart Arrest; Intraoperative Complications; Pediatrics; Respiration, Artificial; Retrospective Studies; Swine; Treatment Outcome
PubMed: 31900987
DOI: 10.1111/pan.13820 -
The Israel Medical Association Journal... Mar 2007Cardiopulmonary resuscitation is an emotion-ridden issue that often leads to conflicts when crucial decisions have to be made. The purported benefits of this 40 year old... (Review)
Review
Cardiopulmonary resuscitation is an emotion-ridden issue that often leads to conflicts when crucial decisions have to be made. The purported benefits of this 40 year old procedure in the frail elderly have been scrutinized, establishing its lack of efficacy. A review of the medical, ethics and halakhic literature on the potential merits of CPR in the frail elderly revealed that in secular medical practice, CPR is often routinely provided to elderly frail individuals for whom its clinical benefit is questionable. For patients suffering from dementia, surrogates are usually responsible for decision making, which complicates the process. With such poor clinical outcomes, the halakhic interpretation of what steps should be taken, and currently are, may not be valid and CPR may be applied too frequently. When clinical ambiguity is combined with strong cultural and religious influences, an acceptable CPR/DNR (Do Not Resuscitate) approach to cardiac arrest can be daunting. A clinically responsible, ethically sound and religiously sensitive approach to CPR requires a deep understanding of the factors involved in decision making. It seems timely for the halakhic interpretation of the duty to provide CPR in the frail elderly to be reevaluated. Perhaps a more humane and halakhically sound approach might be reached by stringently limiting CPR to clinically unusual circumstances rather than the common practice of providing frail Jewish elders with CPR in the absence of a DNR order.
Topics: Aged; Cardiopulmonary Resuscitation; Frail Elderly; Humans; Israel; Judaism; Religion and Medicine
PubMed: 17402332
DOI: No ID Found -
The Cochrane Database of Systematic... Mar 2018Providing effective positive pressure ventilation is considered to be the single most important component of successful neonatal resuscitation. Ventilation is frequently... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Providing effective positive pressure ventilation is considered to be the single most important component of successful neonatal resuscitation. Ventilation is frequently initiated manually with bag and face mask (BMV) followed by endotracheal intubation if respiratory depression continues. These techniques may be difficult to perform successfully resulting in prolonged resuscitation or neonatal asphyxia. The laryngeal mask airway (LMA) may achieve initial ventilation and successful resuscitation faster than a bag-mask device or endotracheal intubation.
OBJECTIVES
Among newborns requiring positive pressure ventilation for cardio-pulmonary resuscitation, is LMA more effective than BMV or endotracheal intubation for successful resuscitation? When BMV is either insufficient or ineffective, is effective positive pressure ventilation and successful resuscitation achieved faster with the LMA compared to endotracheal intubation?
SEARCH METHODS
We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1), MEDLINE via PubMed (1966 to 15 February 2017), Embase (1980 to 15 February 2017), and CINAHL (1982 to 15 February 2017). We also searched clinical trials registers, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.
SELECTION CRITERIA
We included randomised and quasi-randomised controlled trials that compared LMA for neonatal resuscitation with either BMV or endotracheal intubation and reported on any outcomes related to neonatal resuscitation specified in this review.
DATA COLLECTION AND ANALYSIS
Two review authors independently evaluated studies for risk of bias assessments, and extracted data using Cochrane Neonatal criteria. Categorical treatment effects were described as relative risks and continuous treatment effects were described as the mean difference, with 95% confidence intervals (95% CI) of estimates.
MAIN RESULTS
We included seven trials that involved a total of 794 infants. Five studies compared LMA with BMV and three studies compared LMA with endotracheal intubation. We added six new studies for this update (754 infants).LMA was associated with less need for endotracheal intubation than BMV (typical risk ratio (RR) 0.24, 95% CI 0.12 to 0.47 and typical risk difference (RD) -0.14, 95% CI -0.14 to -0.06; 5 studies, 661 infants; moderate-quality evidence) and shorter ventilation time (mean difference (MD) -18.90 seconds, 95% CI -24.35 to -13.44; 4 studies, 610 infants). Babies resuscitated with LMA were less likely to require admission to neonatal intensive care unit (NICU) (typical RR 0.60, 95% CI 0.40 to 0.90 and typical RD -0.18, 95% CI -0.31 to -0.04; 2 studies,191 infants; moderate-quality evidence). There was no difference in deaths or hypoxic ischaemic encephalopathy (HIE) events.Compared to endotracheal intubation, there were no clinically significant differences in insertion time or failure to correctly insert the device (typical RR 0.95, 95% CI 0.17 to 5.42; 3 studies, 158 infants; very low-quality evidence). There was no difference in deaths or HIE events.
AUTHORS' CONCLUSIONS
LMA can achieve effective ventilation during neonatal resuscitation in a time frame consistent with current neonatal resuscitation guidelines. Compared to BMV, LMA is more effective in terms of shorter resuscitation and ventilation times, and less need for endotracheal intubation (low- to moderate-quality evidence). However, in trials comparing LMA with BMV, over 80% of infants in both trial arms responded to the allocated intervention. In studies that allowed LMA rescue of infants failing with BMV, it was possible to avoid intubation in the majority. It is important that the clinical community resorts to the use of LMA more proactively to provide effective ventilation when newborn is not responding to BMV before attempting intubation or initiating chest compressions.LMA was found to offer comparable efficacy to endotracheal intubation (very low- to low-quality evidence). It therefore offers an alternate airway device when attempts at inserting endotracheal intubation are unsuccessful during resuscitation.Most studies enrolled infants with birth weight over 1500 g or 34 or more weeks' gestation. As such, there is lack of evidence to support LMA use in more premature infants.
Topics: Humans; Hypoxia, Brain; Infant, Newborn; Intensive Care Units, Neonatal; Intubation, Intratracheal; Laryngeal Masks; Masks; Positive-Pressure Respiration; Randomized Controlled Trials as Topic; Resuscitation
PubMed: 29542112
DOI: 10.1002/14651858.CD003314.pub3 -
Resuscitation Jan 2022T-piece resuscitators are commonly used for respiratory support during newborn resuscitation. This study aimed to describe delivered pressures and tidal volumes when... (Observational Study)
Observational Study
AIM
T-piece resuscitators are commonly used for respiratory support during newborn resuscitation. This study aimed to describe delivered pressures and tidal volumes when resuscitating term newborns immediately after birth, using the NeoPuff T-piece resuscitator.
METHOD
Observational study from June 2019 through March 2021 at Stavanger University Hospital, Norway, including term newborns ventilated with a T-piece resuscitator after birth, with consent to participate. Ventilation parameters of the first 100 inflations from each newborn were recorded by respiration monitors and divided into an early (inflation 1-20) and a late (inflation 21-100) phase.
RESULTS
Of the 7730 newborns born, 232 term newborns received positive pressure ventilation. Of these, 129 newborns were included. In the early and the late phase, the median (interquartile range) peak inflating pressure was 30 (28-31) and 30 (27-31) mbar, and tidal volume was 4.5 (1.6-7.8) and 5.7 (2.2-9.8) ml/kg, respectively. Increased inflation times were associated with an increase in volume before plateauing at an inflation time of 0.41 s in the early phase and 0.50 s in the late phase. Inflation rates exceeding 32 per minute in the early phase and 41 per minute in the late phase were associated with lower tidal volumes.
CONCLUSION
There was a substantial variation in tidal volumes despite a relatively stable peak inflating pressure. Delivered tidal volumes were at the lower end of the recommended range. Our results indicate that an inflation time of approximately 0.5 s and rates around 30-40 per minute are associated with the highest delivered tidal volumes.
Topics: Equipment Design; Humans; Infant, Newborn; Insufflation; Positive-Pressure Respiration; Respiration, Artificial; Resuscitation; Tidal Volume
PubMed: 34915085
DOI: 10.1016/j.resuscitation.2021.12.006 -
BioMed Research International 2016Background. Emergency airway management (AM) is a priority when resuscitating critically ill or severely injured patients. The goal of this study was to determine the... (Meta-Analysis)
Meta-Analysis Review
Background. Emergency airway management (AM) is a priority when resuscitating critically ill or severely injured patients. The goal of this study was to determine the success rates of LT insertion during AM. Methods. Studies that included LT first-pass insertion (FPI) and overall-pass insertion (OPI) success by emergency medical services and in-hospital providers performing AM for emergency situations as well as for scheduled surgery published until July 2014 were searched systematically in Medline. Results. Data of 36 studies (n = 1,897) reported a LT FPI success by physicians of 82.5% with an OPI success of 93.6% (p < 0.001). A cumulative analysis of all 53 studies (n = 3,600) led to FPI and OPI success of 80.1% and 92.6% (p < 0.001), respectively. The results of 26 studies (n = 2,159) comparing the LT with the laryngeal mask airway (LMA) demonstrated a FPI success of 77.0 versus 78.7% (p = 0.36) and an OPI success of 92.2 versus 97.7% (p < 0.001). Conclusion. LT insertion failed in the first attempt in one out of five patients, with an overall failure rate in one out of 14 patients. When compared with the LT, the LMA had a cumulative 5.5% better OPI success rate.
Topics: Emergency Medical Services; Humans; Larynx; Resuscitation
PubMed: 27642595
DOI: 10.1155/2016/3619159 -
Surgery Jun 2021Trauma patients may present with nonsurvivable injuries, which could be resuscitated for future organ transplantation. Trauma surgeons face an ethical dilemma of...
BACKGROUND
Trauma patients may present with nonsurvivable injuries, which could be resuscitated for future organ transplantation. Trauma surgeons face an ethical dilemma of deciding whether, when, and how to resuscitate a patient who will not directly benefit from it. As there are no established guidelines to follow, we aimed to describe resuscitation practices for organ transplantation; we hypothesized that resuscitation practices vary regionally.
METHOD
Over a 3-month period, we surveyed trauma surgeons practicing in Levels I and II trauma centers within a single state using an instrument to measure resuscitation attitudes and practices for organ preservation. Descriptive statistics were calculated for practice patterns.
RESULTS
The survey response rate was 51% (31/60). Many (81%) had experience with resuscitations where the primary goal was to preserve potential for organ transplantation. Many (90%) said they encountered this dilemma at least monthly. All respondents were willing to intubate; most were willing to start vasopressors (94%) and to transfuse blood (84%) (range, 1 unit to >10 units). Of respondents, 29% would resuscitate for ≥24 hours, and 6% would perform a resuscitative thoracotomy. Respect for patients' dying process and future organ quality were the factors most frequently considered very important or important when deciding to stop or forgo resuscitation, followed closely by concerns about excessive resource use.
CONCLUSION
Trauma surgeons' regional resuscitation practices vary widely for this patient population. This variation implies a lack of professional consensus regarding initiation and extent of resuscitations in this setting. These data suggest this is a common clinical challenge, which would benefit from further study to determine national variability, areas of equipoise, and features amenable to practice guidelines.
Topics: Adult; Female; Humans; Male; Middle Aged; Practice Patterns, Physicians'; Resuscitation; Surveys and Questionnaires; Tennessee; Tissue Donors; Transplantation; Trauma Centers; Traumatology; Wounds and Injuries
PubMed: 33436273
DOI: 10.1016/j.surg.2020.11.037 -
International Heart Journal Jul 2021The frequencies of autonomous bystander-initiated cardiopulmonary resuscitation (CPR) and public access defibrillation have not yet been clarified. We aimed to evaluate... (Comparative Study)
Comparative Study
The frequencies of autonomous bystander-initiated cardiopulmonary resuscitation (CPR) and public access defibrillation have not yet been clarified. We aimed to evaluate the frequency of autonomous actions by citizens not having a duty to act.This retrospective observational study included patients who suffered an out-of-hospital cardiac arrest (OHCA) in Tokyo between January 1, 2013 and December 31, 2017. The Delphi method with a panel of 11 experts classified the locations of OHCA resuscitations into 3 categories as follows; autonomous, non autonomous, and undetermined. The locations determined as autonomous were further divided into 2 groups; home and other locations. Bystander-initiated CPR and application of an automated external defibrillator (AED) pad were evaluated in 43,460 patients with OHCA.Group A (non autonomous), group B (autonomous, not home), and group C (home), consisted of 7,352, 3,193, and 32,915 patients, respectively. Compared with group A, group B and group C had significantly lower rates of bystander-initiated CPR (group A, B, C; 68.3% versus 38.6% versus 23.9%) and AED pad application (groups A, B, C; 26.8% versus 15.1% versus 0.6%). In addition, multivariate analysis demonstrated that an autonomous location of resuscitation was independently associated with the frequencies of bystander-initiated CPR and AED pad application, even after adjusting for age, sex, and witness status.Autonomous actions by citizens were unacceptably infrequent. Therefore, the education and training of citizens is necessary to further enhance autonomous CPR.
Topics: Aged; Aged, 80 and over; Cardiopulmonary Resuscitation; Defibrillators; Female; Humans; Male; Middle Aged; Out-of-Hospital Cardiac Arrest; Retrospective Studies; Tokyo
PubMed: 34276018
DOI: 10.1536/ihj.21-016 -
BMC Surgery Aug 2022To develop a perfused cadaveric model for trauma surgery simulation, and to evaluate its efficacy in trauma resuscitation advanced surgical skills training.
BACKGROUND
To develop a perfused cadaveric model for trauma surgery simulation, and to evaluate its efficacy in trauma resuscitation advanced surgical skills training.
METHODS
Fourteen fourth-year general surgery residents attended this workshop at Siriraj Hospital (Bangkok, Thailand). Inflow and outflow cannulae and a cardiopulmonary bypass pump were used to create the perfusion circuit. Inflow was achieved by cannulating the right common carotid artery, and outflow by cannulation of both the right common femoral artery and the internal jugular vein. Arterial line monitoring was used to monitor resuscitation response and to control perfusion pressure. The perfusion solution comprised saline solution mixed 1:1 with glycerol (50%) and water with red food dye added. Advanced surgical skills during life-threatening injuries and damage control resuscitation operations were practiced starting from the airway to the neck, chest, peripheral vessels, abdomen, and pelvis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) was also practiced. Post-workshop survey questions were grouped into three categories, including comparison with previous training methods; the realism of anatomical correlation and procedures; and, satisfaction, safety, and confidence. All questions and tasks were discussed among all members of the development team, and were agreed upon by at least 90% of experts from each participating medical specialty/subspecialty.
RESULTS
The results of the three main groups of post-workshop survey questions are, as follows: (1) How the training compared with previous surgical training methods-mean score: 4.26/5.00, high score: 4.73/5.00; (2) Realism of anatomical correlation and procedures-mean score: 4.03/5.00, high score: 4.60/5.00; and, (3) Satisfaction, safety, and confidence-mean score: 4.24/5.00, high score: 4.47/5.00.
CONCLUSION
The developed perfused cadaveric model demonstrated potential advantages over previously employed conventional surgical training techniques for teaching vascular surgery at our center as evidenced by the improvement in the satisfaction scores from students attending perfused cadaveric training compared to the scores reported by students who attended earlier training sessions that employed other training techniques. Areas of improvement included 'a more realistic training experience' and 'improved facilitation of decision-making and damage control practice during trauma surgery'.
Topics: Balloon Occlusion; Cadaver; Endovascular Procedures; Humans; Resuscitation; Thailand
PubMed: 35941680
DOI: 10.1186/s12893-022-01754-1 -
Anesthesiology Mar 2016Automatic suspension of do-not-resuscitate (DNR) orders during general anesthesia does not sufficiently address a patient's right to self-determination and is a practice... (Meta-Analysis)
Meta-Analysis Review
Automatic suspension of do-not-resuscitate (DNR) orders during general anesthesia does not sufficiently address a patient's right to self-determination and is a practice still observed among anesthesiologists today. To provide an evidence base for ethical management of DNR orders during anesthesia and surgery, the authors performed a systematic review of the literature to quantify the survival after perioperative cardiopulmonary resuscitation (CPR). Results show that the probability of surviving perioperative CPR ranged from 32.0 to 55.7% when measured within the first 24 h after arrest with a neurologically favorable outcome expectancy between 45.3 and 66.8% at follow-up, which suggests a viable survival of approximately 25%. Because CPR generally proves successful in less than 15% of out-of-hospital cardiac arrests, the altered outcome probabilities that the conditions in the operating room bring on warrant reevaluation of DNR orders during the perioperative period. By preoperatively communicating the evidence to patients, they can make better informed decisions while reducing the level of moral distress that anesthesiologists may experience when certain patients decide to retain their DNR orders.
Topics: Cardiopulmonary Resuscitation; Disease Management; Evidence-Based Medicine; Humans; Resuscitation Orders; Survival Rate
PubMed: 26418698
DOI: 10.1097/ALN.0000000000000873 -
Acta Medica Portuguesa May 2024Data from previous studies have demonstrated inconsistency between current evidence and delivery room resuscitation practices in developed countries. The primary aim of...
INTRODUCTION
Data from previous studies have demonstrated inconsistency between current evidence and delivery room resuscitation practices in developed countries. The primary aim of this study was to assess the quality of newborn healthcare and resuscitation practices in Portuguese delivery rooms, comparing current practices with the 2021 European Resuscitation Council guidelines. The secondary aim was to compare the consistency of practices between tertiary and non-tertiary centers across Portugal.
METHODS
An 87-question survey concerning neonatal care was sent to all physicians registered with the Portuguese Neonatal Society via email. In order to compare practices between centers, participants were divided into two groups: Group A (level III and level IIb centers) and Group B (level IIa and I centers). A descriptive analysis of variables was performed in order to compare the two groups.
RESULTS
In total, 130 physicians responded to the survey. Group A included 91 (70%) and Group B 39 (30%) respondents. More than 80% of participants reported the presence of a healthcare professional with basic newborn resuscitation training in all deliveries, essential equipment in the delivery room, such as a resuscitator with a light and heat source, a pulse oximeter, and an O2 blender, and performing delayed cord clamping for all neonates born without complications. Less than 60% reported performing team briefing before deliveries, the presence of electrocardiogram sensors, end-tidal CO2 detector, and continuous positive airway pressure in the delivery room, and monitoring the neonate's temperature. Major differences between groups were found regarding staff attending deliveries, education, equipment, thermal control, umbilical cord management, vital signs monitoring, prophylactic surfactant administration, and the neonate's transportation out of the delivery room.
CONCLUSION
Overall, adherence to neonatal resuscitation international guidelines was high among Portuguese physicians. However, differences between guidelines and current practices, as well as between centers with different levels of care, were identified. Areas for improvement include team briefing, ethics, education, available equipment in delivery rooms, temperature control, and airway management. The authors emphasize the importance of continuous education to ensure compliance with the most recent guidelines and ultimately improve neonatal health outcomes.
Topics: Humans; Cross-Sectional Studies; Portugal; Infant, Newborn; Resuscitation; Delivery Rooms; Practice Patterns, Physicians'; Female; Male; Adult; Practice Guidelines as Topic
PubMed: 38744237
DOI: 10.20344/amp.20009