In-hospital cardiopulmonary resuscitation: organization, management and training in hospitals of different levels of care

BACKGROUND: : During recent years in-hospital cardiopulmonary resuscitation (CPR) management has received much attention. This can be attributed to the Utstein model for in-hospital CPR developed in 1997. The present status of in-hospital resuscitation management in Finnish hospitals is not known. Therefore, a study was designed to describe the organization of training and clinical management of CPR in Finnish hospitals of different levels of care. METHODS: : In the summer of 2000, we performed a cross-sectional mail survey throughout Finland, including all district, central and university hospitals. The questionnaire outlined in detail in-hospital resuscitation management and training. For analysis the hospitals were divided into primary, secondary and tertiary groups, depending on levels of care. RESULTS: : Most hospitals (72%) reported having a physician or a nurse in charge of resuscitation management and training. Training in advanced life support was more common among nurses (80%) than among physicians (53%). Surprisingly, a majority of respondents (75%) reported that they felt training in CPR was insufficient. On the general wards and on wards treating cardiac patients, defibrillation was in most cases performed by a physician (91% and 51%, respectively), and less often by a nurse (16% and 31%, respectively). In the secondary and tertiary hospitals cardiac arrest was managed by a cardiac arrest team (53% and 62%, respectively) and in the primary hospitals by the ward physician (56%), anesthesiologist or emergency physician on call (44%). Most hospitals used do-not-resuscitate orders (83%) but only 33% of the hospitals had a unified style of notation. Systematic data collection was practised in 55% of hospitals, predominantly by using a model of their own. Only a few hospitals (11%) used the in-hospital Utstein model. CONCLUSION: : Our study showed that more attention needs to be paid to CPR management in Finnish hospitals. At present, 25% of hospitals do not have an appointed physician or nurse in charge of organizing CPR management. The study also revealed a lack of regular organized training in resuscitation for physicians. Fifty-five per cent of hospitals practise systematic data collection, but only 11% according to the Utstein template; and without which further quality assurance is difficult.     

Resuscitation after prolonged cardiac arrest: effects of cardiopulmonary bypass and sodium–hydrogen exchange inhibition on myocardial and neurological recovery

Objective: To determine if cardiopulmonary bypass (CPB), together with inhibition of the sodium–hydrogen exchanger (NHE), limits myocardial and neurological injury and improves recovery after prolonged (unwitnessed) cardiac arrest (CA), as NHE inhibition improved recovery after deep hypothermic circulatory arrest. Methods: Twenty-seven pigs (31–39 kg) underwent 15 min of prolonged (no-flow) CA followed by 10 min of cardiopulmonary resuscitation-advanced life support (CPR-ALS). Subjects with restoration of spontaneous circulation (ROSC) during CPR-ALS received either no drug (n = 6) or an inhibitor of the NHE (HOE-642; n = 5). In the 16 unsuccessfully resuscitated animals, peripheral normothermic CPB was instituted, and either no drug (n = 9) or similar HOE-642 (n = 7) therapy started. Hemodynamic data, a species-specific neurological deficit score (0 = normal to 500 = brain death), and mortality were recorded at 24 h, and biochemical variables of organ injury measured. Results: CPR-ALS restored ROSC in 41% (11/27) of animals, but was unsuccessful in 59% (16/27) that required CPB. Without CPB, HOE-642 increased cardiac index and decreased vascular resistance; with CPB, HOE-642 caused higher pump flows (3.4 ± 0.6 l min⁻¹ m⁻² vs 2.5 ± 0.7 l min⁻¹ m⁻²; p < 0.001) and higher post-arrest cardiac index; but animals required more vasopressors (p = 0.019) from drug-induced vasodilation. No differences between biochemical markers of oxidative and organ injury and overall 24-h mortality (20%) were found between groups. Neurological score was improved at 24 h compared with 4 h only after HOE-642 treatment with (150 ± 34 vs 220 ± 43; p = 0.003) or without CPB (162 ± 39 vs 238 ± 48; p ≤ 0.001), but failed to reach statistical difference with respect to the untreated group. Conclusions: CPB is an effective resuscitative tool to treat prolonged CA but there is limited improvement of neurological function. NHE inhibition augments cardiac and neurological function, but its effect was less pronounced than in other studies.     

特殊病理生理条件下的心肺复苏——-2015年美国心脏协会心肺复苏与心血管急救指南更新解读

背景 在临床工作中我们常常需要对一些处在特殊病理生理状态下的患者进行心肺复苏.目的 通过解读2015年美国心脏协会心肺复苏与心血管急救指南更新相关部分,提高对相关患者的心肺复苏能力.内容 妊娠状态下的心肺复苏注意体位,母体复苏失败时及时进行剖宫产术.肺栓塞引起的心搏骤停,疑似或确诊的病例都可以进行早期溶栓术,对于确诊的病例还可以经行手术取栓.阿片类药物过量导致心搏骤停,可以首先使用纳洛酮治疗,并同时开始心肺复苏术.局部麻醉药中毒引起心搏骤停,在心肺复苏同时可以使用脂肪乳剂配合抢救.冠状动脉介入治疗术中发生的心搏骤停,应及时进行体外心肺复苏.趋向 用手将子宫向左推移以减轻低血压产妇下腔静脉所受的妊娠子宫施加的压力,缺乏相关文献证实,且对产妇围死亡期剖宫产的时机选择也未有定论.疑似肺栓塞造成心搏骤停患者溶栓治疗是否纳入治疗的标准仍有争议.在某些情况下,静脉脂肪乳剂可以加强肾上腺素和垂体后叶素的疗效,得到了动物研究的证实,但缺乏人类实验数据支持.     

The incidence of potentially serious complications during non-obstetric anaesthetic practice in the United Kingdom: an analysis from the 7th National Audit Project (NAP7) activity survey

Complications and critical incidents arising during anaesthesia due to patient, surgical or anaesthetic factors, may cause harm themselves or progress to more severe events, including cardiac arrest or death. As part of the 7th National Audit Project of the Royal College of Anaesthetists, we studied a prospective national cohort of unselected patients. Anaesthetists recorded anonymous details of all cases undertaken over 4 days at their site through an online survey. Of 416 hospital sites invited to participate, 352 (85%) completed the survey. Among 24,172 cases, 1922 discrete potentially serious complications were reported during 1337 (6%) cases. Obstetric cases had a high reported major haemorrhage rate and were excluded from further analysis. Of 20,996 non-obstetric cases, 1705 complications were reported during 1150 (5%) cases. Circulatory events accounted for most complications (616, 36%), followed by airway (418, 25%), metabolic (264, 15%), breathing (259, 15%), and neurological (41, 2%) events. A single complication was reported in 851 (4%) cases, two complications in 166 (1%) cases and three or more complications in 133 (1%) cases. In non-obstetric elective surgery, all complications were ‘uncommon’ (10–100 per 10,000 cases). Emergency (urgent and immediate priority) surgery accounted for 3454 (16%) of non-obstetric cases but 714 (42%) of complications with severe hypotension, major haemorrhage, severe arrhythmias, septic shock, significant acidosis and electrolyte disturbances all being ‘common’ (100–1000 per 10,000 cases). Based on univariate analysis, complications were associated with: younger age; higher ASA physical status; male sex; increased frailty; urgency and extent of surgery; day of the week; and time of day. These data represent the rates of potentially serious complications during routine anaesthesia care and may be valuable for risk assessment and patient consent.     

Pediatric patients requiring extracorporeal membrane oxygenation in heart failure: 30‐day outcomes; mid‐ and long‐term survival. A single center experience

Nowadays, an increasing number of neonatal and pediatric patients with severe heart failure benefits from extracorporeal membrane oxygenation (ECMO) support. A total of 39 pediatric patients needed venoarterial ECMO (vaECMO) support in our department between January 2008 and December 2016. Patients were retrospectively divided in two groups: 30‐day survivor group (17 patients) and 30‐day nonsurvivor group (22 patients). Outcome and factors predictive for 30‐day mortality and mid‐ as well as long‐term survival up to 7‐year follow‐up were analyzed by univariate analysis and Kaplan‐Meier survival estimation. Basic demographics and preoperative characteristics did not differ between groups (P > 0.05). 67% of patients were successfully weaned off ECMO and 44% survived 30‐day after ECMO application. After 7‐year follow‐up 28% of pediatric patients were alive. Thirty‐day survivors were significantly more likely to undergo elective cardiac surgery (P = 0.001), whereas significantly more 30‐day nonsurvivors underwent urgent surgery (P = 0.004). Odds of incidence of catecholamine refractory circulatory failure, failed myocardial recovery, and cerebral edema was significantly higher in 30‐day nonsurvivor group (41.6‐fold, 16‐fold, and 2.5‐fold, respectively). Kaplan‐Meier survival estimation analysis revealed significant differences in terms of mid‐ and long‐term survival among neonates, infants, toddlers, and preadolescents (Breslow P = 0.037 and Log‐Rank P = 0.028, respectively). vaECMO provides an efficient therapy option for life‐threatening heart disorders in neonates and pediatric patients being at high risk for myocardial failure leading to circulatory arrest. Urgency of surgery effected on higher mortality, but there was no difference in terms of mortality in 30‐day survivor group in comparison to 30‐day nonsurvivor group among neonates, infants, toddlers, and preadolescents.     

Implementing advance care plans in the peri-operative period,including plans for cardiopulmonary resuscitation: Association of Anaesthetists clinical practice guideline

Contemporary guidance takes a patient-centred approach and recommends discussing and planning treatments that should be considered, not just those that should be withheld. Although some organisations and communities still use specific DNACPR (do not attempt cardiopulmonary resuscitation) forms to recommend that cardiopulmonary resuscitation is not attempted, this approach has been shown to have disadvantages and is no longer regarded as best practice. The following guidelines have been produced in response to this change. They are designed to help anaesthetists, as part of the wider healthcare team, to implement and respond to advance care planning documents before and during procedures. The guidelines apply to all procedures, however minor and low risk they are considered to be, and the same ethical and legal principles apply to procedures carried out under local or regional anaesthesia and/or conscious sedation, as well as to those under general anaesthesia.     

Cancer death from non‐muscle invasive bladder cancer: Report of the Japanese Urological Association of data from the 1999–2001 registry in Japan

Objectives: Our aim was to clarify the risk factors of cancer death in order to reduce mortality from T1 bladder cancer. Methods: The Japan registration database (1999–2001) was used for the analysis. Data were collected at least 3 years after the initial diagnosis. Cause‐specific survival using a Kaplan–Meier survival estimation with the log–rank method was evaluated. Univariate and multivariate analysis using the Cox proportional hazard model was also carried out. The 1997 TNM classification was used for pathological staging, and the 1973 WHO classification was used for pathological grading. Results: There were 76 cancer deaths among a total of 1919 clinical T1 cases. Regardless of the subsequent treatment strategies, non‐papillary tumor appearance, non‐peduncular tumor stalk, multiple tumors, a tumor size greater than 3 cm, positive urinary cytology and pathological grade 3 were found to be statistically significant in cancer death by univariate analysis. By multivariate analysis, non‐papillary tumor appearance, positive urinary cytology and a tumor size greater than 3 cm were confirmed as significant risk factors. Cancer death cases were found in 47.4% of worst‐grade 2 tumors, and in 67.1% of predominantly grade 1 or 2 tumors. Conclusion: Non‐papillary tumor appearance, positive urinary cytology and a tumor size greater than 3 cm should be included to enable the assessment of risk criteria in cancer death from T1 bladder cancer.     

Management of Deep Wound Complications With Vacuum‐Assisted Therapy After Berlin Heart EXCOR Ventricular Assist Device Placement in the Pediatric Population

Wound complications after ventricular assist device (VAD) placement remain a formidable challenge to surgeons. The Berlin Heart EXCOR VAD is a versatile pulsatile system that has been successful in pediatric patients of all ages and sizes. Prevention of device‐related complications such as infection, particularly in pediatric patients, remains an essential issue in minimizing patient morbidity and mortality. The introduction of vacuum‐assisted wound closure (VAC) therapy and its application in VAD‐related wound complications provide an efficient and effective method for wound healing. We report our experience in the management of deep wound complications in two pediatric patients after placement of the Berlin Heart EXCOR VAD. The wound VAC system proved to achieve complete wound healing without any infectious complications.     

Research interests and funding of members of the American Pediatric Surgical Association: report from 2010 American Pediatric Surgical Association Outcomes and Clinical Trials Committee

Objective

There is lack of data relating to the research interests and funding of pediatric surgeons within the United States and Canada. These data may be helpful in promoting basic and clinical research among pediatric surgeons.

Methods

The American Pediatric Surgical Association (APSA) Outcomes and Clinical Trials Committee developed and administered an online survey via e-mail to the APSA membership to help characterize research activities and funding. The survey was available for completion during December of 2009. The survey contained 10 items with a drop-down menu for multiple choice answers and required 5 to 10 minutes to complete. Results based on research interests as well as funding sources were compiled and analyzed.

Results

A total of 275 members, which comprises 27.4% of the APSA membership, completed the survey. Of the respondents, 177 (64%) described being in an academic practice, 44 (16%) in an academically associated private practice, 9 (3.3%) in a private solo practice, 17 (6.2%) in private group practice, and 3 (1%) in the military. A total of 189 (68.7%) respondents stated that they participated in formal research. Respondents also categorized their research interests, and the following were the most common subjects of study (decreasing order of frequency): appendicitis, trauma and critical care, outcomes, minimally invasive surgery, and congenital diaphragmatic hernia. Of those participating in research, 64.5% stated that they have no formal financial support. Of those supported through the National Institutes of Health, funding grants achieved were as follows: R01 (n = 29), K08 (n = 9), K23 (n = 2), and U01 (n = 8).

Conclusions

Research activities are common among APSA members and encompass a wide range of pediatric surgery topics. Strikingly, the overall financial support of these efforts is limited, predominantly supported by the surgeons themselves. Funded respondents attained grants through Public Health Service grants, departmental grants, or private institutions.     

Long‐term failure and function after restorative proctocolectomy – a multi‐centre study of patients from the UK national ileal pouch registry

Objective There is little information on the long‐term failure and function after restorative proctocolectomy (RPC). The results of data submitted to a national registry were analysed. Method The UK National Pouch Registry was established in 2004. By 2006, it comprised data collected from ten centres between 1976 and 2006. The long‐term failure and functional outcome were determined. Trends over time were assessed using the gamma statistic or the Kruskal–Wallis statistic wherever appropriate. Results In all, 2491 patients underwent primary RPC over a median of 54 months (range 1 month to 28.9 years). Of these, 127 (5.1%) underwent abdominal salvage surgery. The incidence of failure (excision or indefinite diversion) was 7.7% following primary and 27.5% following salvage RPC (P < 0.001). The median frequency of defaecation/24 h was five including one at night. Nocturnal seepage occurred in 8% at 1 year, rising to 15.4% at 20 years (P = 0.037). Urgency was experienced by 5.1% of patients at 1 year rising to 9.1% at 15 years (P = 0.022). Stool frequency and the need for antidiarrhoeal medication were greater following salvage RPC. Conclusion In patients retaining anal function after RPC, frequency of defaecation was stable over 20 years. Faecal urgency and minor incontinence worsened with time. Function after salvage RPC was significantly worse.     

Pediatric heart transplantation at adult‐specialty centers in the United States: A multicenter registry analysis

Recent Organ Procurement and Transplantation Network bylaw revisions mandate that US transplant programs have an “approved pediatric component” in order to perform heart transplantation (HT) in patients <18 years old. The impact of this change on adolescents, a group known to be at high risk for graft loss and nonadherence, is unknown. We studied all US primary pediatric (age <18 years) HT from 2000 to 2015 to compare graft survival between centers organized mainly for adult versus pediatric care. Centers were designated as pediatric‐ or adult‐specialty care according to the ratio of pediatric:adult HT performed and minimum age of HT (pediatric‐specialty defined as ratio>0.7; adult‐specialty ratio<0.05 and minimum age >8 years). In propensity score‐matched cohorts, we observed no difference in graft loss by center type (median survival: adult 12.4 years vs pediatric 9.2 years, P = .174). Compared to the matched pediatric cohort, adult‐specialty center recipients lived closer to their transplant center (31 vs 45 miles, P = .012), and trended toward fewer out‐of‐state transplants (15 vs 25%, P = .082). Our data suggest that select adolescents can achieve similar midterm graft survival at centers organized primarily for adult HT care. Regardless of post‐HT setting, the development of care models that demonstrably improve adherence may be of greatest benefit to improving survival of this high‐risk population.     

The supply of renal physicians: an analysis of data from the American Medical Association Physician Masterfile

This study uses data from the American Medical Association (AMA) Physician Masterfile to describe current demographic trends among physicians specializing in adult and pediatric nephrology. The analysis shows that renal physicians are younger than the physician population as a whole. Compared with other specialty groups, renal physicians are less likely to be in patient-care activities and are more likely to be in research. In recent years, the population of renal physicians has grown at a much faster rate than the rest of the physician population. A projection analysis indicates that the adult nephrologist population will more than double in size between 1987 and 2010. Among adult nephrologists, the number of women is expected to grow much faster than the number of men. Rapid growth is expected in the older age categories, whereas the number of adult nephrologists 35 years of age and younger is expected to decrease slightly.     

Intra‐operative cardiac arrests during liver transplantation – a retrospective review of the first 15 yr in Asian population

Although many report intra‐operative cardiac arrests (ICAs) in liver transplantation (LT), the incidence, major causes, and outcome remain unclear. We aimed to investigate retrospectively, the incidence, nature, and outcome of ICA in Asian population and to identify risk factors for ICA. Consecutive 1071 LTs in an institution during 1996–2011 (adult 920, pediatric 151/living donor liver transplantation, LDLT 841, deceased donor liver transplantation, DDLT 230) were reviewed. ICA occurred in 14 adult LTs (1.5%), but none in pediatrics. ICA occurred 1.0% and 3.3% in LDLT and DDLT, respectively. Stages of ICA incidence were three at pre‐anhepatic, one at anhepatic, and 10 at neohepatic stage. Post‐reperfusion syndrome (PRS) with hyperkalemia and bleeding were the major causes of ICA. While LDLT showed miscellaneous causes for ICA at various stages, DDLT incurred ICAs at neohepatic stage only. Interestingly, we did not find pulmonary thromboembolism (PTE) to incur ICA. Risk factor analysis showed no association of pre‐operative patient condition, donor types, and intra‐operative parameters. In this review, the incidence of ICA was low in Asian population with LDLT predominance, and while PTE was not the cause of ICA, the neohepatic stage with PRS and bleeding was the most vulnerable period to anticipate ICA.     

Organisation of UK hospitals and anaesthetic departments in the treatment of peri-operative cardiac arrest: an analysis from the 7th National Audit Project (NAP7) local co-ordinator baseline survey

We report the results of the Royal College of Anaesthetists' 7th National Audit Project organisational baseline survey sent to every NHS anaesthetic department in the UK to assess preparedness for treating peri-operative cardiac arrest. We received 199 responses from 277 UK anaesthetic departments, representing a 72% response rate. Adult and paediatric anaesthetic care was provided by 188 (95%) and 165 (84%) hospitals, respectively. There was no paediatric intensive care unit on-site in 144 (87%) hospitals caring for children, meaning transfer of critically ill children is required. Remote site anaesthesia is provided in 182 (92%) departments. There was a departmental resuscitation lead in 113 (58%) departments, wellbeing lead in 106 (54%) and departmental staff wellbeing policy in 81 (42%). A defibrillator was present in every operating theatre suite and in all paediatric anaesthesia locations in 193 (99%) and 149 (97%) departments, respectively. Advanced airway equipment was not available in: every theatre suite in 13 (7%) departments; all remote locations in 103 (57%) departments; and all paediatric anaesthesia locations in 23 (15%) departments. Anaesthetic rooms were the default location for induction of anaesthesia in adults and children in 148 (79%) and 121 (79%) departments, respectively. Annual updates in chest compressions and in defibrillation were available in 149 (76%) and 130 (67%) departments, respectively. Following a peri-operative cardiac arrest, debriefing and peer support programmes were available in 154 (79%) and 57 (29%) departments, respectively. While it is likely many UK hospitals are very well prepared to treat anaesthetic emergencies including cardiac arrest, the survey suggests this is not universal.