Postconditioning in cardiopulmonary resuscitation: A better protocol for cardiopulmonary resuscitation

Although current cardiopulmonary resuscitation (CPR) performance can increase the rates of restoration of spontaneous circulation (ROSC) and survival to hospital admission, the discharge rates of patients remain disappointing. The high mortality rate is attributed to post-cardiac arrest brain injury. The discovery of the postconditioning phenomenon opens a door to endogenous neuroprotection. The protection mechanisms of postconditioning include attenuating mitochondrial calcium overload and reducing oxidative stress, recruiting the reperfusion injury salvage kinase (RISK) pathway, and preventing from the mitochondrial permeability transition pore (mPTP) opening at the time of reperfusion. An advantage of postconditioning lies in the potentially clinical application in the unexpected ischemic situation. Prior laboratory researches indicate that postconditioning may lessen the reperfusion/ischemia-induced injury in unexpected coronary occlusion, acute myocardial infarction and stroke. Because cardiac arrest, stroke and acute myocardial infarction have a similar pathophysiological process, we hypothesize that postconditioning could be used in the clinical practice of CPR to treat patients with post-cardiac arrest brain injury. We propose a novel protocol of “Postconditioning cardiocerebral resuscitation (Post-CCR)”. The Post-CCR includes applying three cycles of 18 s chest compression and 10 s interruption for ventilation first, and then executing chest compression only CPR until the patients return spontaneous circulation. Post-CCR can not only provide vital blood flow to the heart and brain but also activate endogenous protective mechanism to lessen post-cardiac arrest brain injury. We consider that it would become a feasible, safe and efficient cerebralprotective intervention in the prevention and alleviation of post-cardiac arrest brain injury, which would also improve the outcome after cardiac arrest.     

Shock Duration after Resuscitation Is Associated with Occurrence of Post-Cardiac Arrest Acute Kidney Injury

This retrospective observational study investigated the clinical course and predisposing factors of acute kidney injury (AKI) developed after cardiac arrest and resuscitation. Eighty-two patients aged over 18 yr who survived more than 24 hr after cardiac arrest were divided into AKI and non-AKI groups according to the diagnostic criteria of the Kidney Disease/Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for AKI. Among 82 patients resuscitated from cardiac arrest, AKI was developed in 66 (80.5%) patients (AKI group) leaving 16 (19.5%) patients in the non-AKI group. Nineteen (28.8%) patients of the AKI group had stage 3 AKI and 7 (10.6%) patients received renal replacement therapy during admission. The duration of shock developed within 24 hr after resuscitation was shorter in the non-AKI group than in the AKI group (OR 1.02, 95% CI 1.01-1.04, P < 0.05). On Multiple logistic regression analysis, the only predisposing factor of post-cardiac arrest AKI was the duration of shock. In conclusion, occurrence and severity of post-cardiac arrest AKI is associated with the duration of shock after resuscitation. Renal replacement therapy is required for patients with severe degree (stage 3) post-cardiac arrest AKI.     

Association of obstructive sleep apnea with severity of patients hospitalized for acute asthma

BackgroundStudies suggest that obstructive sleep apnea (OSA) is associated with suboptimal disease control and worse chronic severity of asthma. However, little is known about the relations of OSA with acute asthma severity in hospitalized patients.ObjectiveTo investigate the association of OSA with acute asthma severity.MethodsThis is a retrospective cohort study (2010-2013) using State Inpatient Databases from 8 geographically diverse states in the United States. The outcomes were markers of acute severity, including mechanical ventilation use, hospital length of stay, and in-hospital mortality. To determine the association of interest, we fit multivariable logistic regression models, adjusting for age, sex, race/ethnicity, primary insurance, household income, patient residence, comorbidities, hospital state, and hospitalization year. We repeated the analysis for children aged 6 to 17 years.ResultsAmong 73,408 adult patients hospitalized for acute asthma, 10.3% had OSA. Coexistent OSA was associated with a significantly higher risk of noninvasive positive pressure ventilation use (14.9% vs 3.1%; unadjusted odds ratio, 6.48; 95% CI, 5.88-7.13; adjusted odds ratio, 5.20; 95% CI, 4.65-5.80), whereas coexistent OSA was not significantly associated with the risk of invasive mechanical ventilation use. Patients with OSA had 37% longer hospital length of stay (unadjusted incidence rate ratio, 1.37; 95% CI, 1.33-1.40); this significant association persisted in the multivariable model (incidence rate ratio, 1.13; 95% CI, 1.10-1.17). The in-hospital mortality did not significantly differ between groups. These findings were consistent in both obesity and nonobesity groups and in 27,935 children.ConclusionAmong patients hospitalized for acute asthma, OSA was associated with a higher risk of noninvasive positive pressure ventilation use and longer length of stay compared with those without OSA.     

Electronically implemented clinical indicators based on a data warehouse in a tertiary hospital: Its clinical benefit and effectiveness

ObjectiveAssessing and monitoring care and service using clinical indicators (CIs) can allow the measurement of and lead to improvements in the quality of care. However, the management and maintenance of CI data has been shown to be difficult because the data are usually collected and provided manually. In this study, for the purpose of efficient managing quality indicators, a data warehouse (DW)-based CI monitoring system was developed. The clinical effectiveness and efficiency of a DW-based CI monitoring was investigated through several case studies of the system's operation at a tertiary hospital.MethodsThis study analyzed the CIs that have been developed over the past 8 years at a 1340-bed tertiary general university hospital in South Korea to improve and monitor the quality of care and patient safety. The hospital was opened as a fully digital hospital in 2003, and the CIs were computerized in 2005 by implementing a DW-based CI monitoring system. We classified the computerized CIs and evaluated the monitoring results for several representative CIs, such as the optimal prescribing of preventive antibiotics, the average length of stay, the mortality rate, and the rehospitalization rate.ResultsDuring the development of the system in 2005, 12 of 19 CIs were computerized, and this number gradually increased until 299 of 335 CIs were computerized by 2012. In addition, among the CIs built computationally through the CI task force team, focal CIs subject to monitoring were selected annually, and the results of this monitoring were shared with all of the staff or the related department and its staff. By providing some examples of our CI monitoring results, we showed the feasibility of improving the quality of care, and maintaining the optimum level of patient care with less labor.ConclusionsThe results of this study provide evidence regarding the clinical effectiveness and efficiency as well as the systems operation experience of a DW-based CI monitoring system. These findings may aid medical institutions that plan on computerizing CIs with respect to decision and policy making regarding their systems development and operations.     

Analysis of Tertiary Hospital Utilization in Pediatric Orthopaedics: a Study Using Nationwide Sample Data from Korea

BackgroundIn the Korean medical system, the severity classification for a specific disease depends primarily on its nationwide admission rate in tertiary hospitals. Inversely, one of the important designation criteria for a tertiary hospital is the hospital''s treatment ratio of patients classified as having a specific severe disease. Most diseases requiring pediatric orthopaedic surgery (POS) are not currently classified as high severity in terms of disease severity. We investigated the admission rates for the representative POS diseases in tertiary hospitals and compared these rates with those for adult orthopaedic surgery (AOS) diseases.MethodsSeven POS diagnoses and three AOS diagnoses were selected based on frequency of admission. Nationwide sample data were used to investigate the admission rates for these representative diagnoses from 2008 to 2017.ResultsSix of the seven frequent POS diagnoses presented high admission rates in tertiary hospitals (62.5–92.3%). In contrast, all frequent AOS diagnoses presented low admission rates in tertiary hospitals.ConclusionThe admission rates of frequent POS diagnoses in tertiary hospitals are high. Considering that these rates are the most important factors for the classification of disease severity, POS diseases seem to be underestimated in terms of severity. This may lead to a tendency for tertiary hospitals to intentionally reduce the admission of children with POS diseases. As a result, these children may not receive appropriate professional care. Therefore, for the disease severity, POS diseases should be classified differently from general AOS diseases by using different criteria reflecting the patient''s age.     

Rapid Response System Should Be Enhanced at Non-general Ward Locations: a Retrospective Multicenter Cohort Study in Korea

BackgroundA rapid response system (RRS) contributes to the safety of hospitalized patients. Clinical deterioration may occur in the general ward (GW) or in non-GW locations such as radiology or dialysis units. However, there are few studies regarding RRS activation in non-GW locations. This study aimed to compare the clinical characteristics and outcomes of patients with RRS activation in non-GW locations and in the GW.MethodsFrom January 2016 to December 2017, all patients requiring RRS activation in nine South Korean hospitals were retrospectively enrolled and classified according to RRS activation location: GW vs non-GW RRS activations.ResultsIn total, 12,793 patients were enrolled; 222 (1.7%) were non-GW RRS activations. There were more instances of shock (11.6% vs. 18.5%) and cardiac arrest (2.7% vs. 22.5%) in non-GW RRS activation patients. These patients also had a lower oxygen saturation (92.6% ± 8.6% vs. 88.7% ± 14.3%, P < 0.001) and a higher National Early Warning Score 2 (7.5 ± 3.4 vs. 8.9 ± 3.8, P < 0.001) than GW RRS activation patients. Although non-GW RRS activation patients received more intubation (odds ratio [OR], 3.135; P < 0.001), advanced cardiovascular life support (OR, 3.912; P < 0.001), and intensive care unit transfer (OR, 2.502; P < 0.001), their hospital mortality (hazard ratio, 0.630; P = 0.013) was lower than GW RRS activation patients upon multivariate analysis.ConclusionConsidering that there were more critically ill but recoverable cases in non-GW locations, active RRS involvement should be required in such locations.     

Survival and Neurologic Outcomes of Out-of-Hospital Cardiac Arrest Patients Who Were Transferred after Return of Spontaneous Circulation for Integrated Post-Cardiac Arrest Syndrome Care: The Another Feasibility of the Cardiac Arrest Center

It has been proven that safety and efficiency of out-of-hospital cardiac arrest (OHCA) patients is transported to specialized hospitals that have the capability of performing therapeutic hypothermia (TH). However, the outcome of the patients who have been transferred after return of spontaneous circulation (ROSC) has not been well evaluated. We conducted a retrospective observational study between January 2010 to March 2012. There were primary outcomes as good neurofunctional status at 1 month and the secondary outcomes as the survivals at 1 month between Samsung Medical Center (SMC) group and transferred group. A total of 91 patients were enrolled this study. There was no statistical difference between good neurologic outcomes between both groups (38% transferred group vs. 40.6% SMC group, P=0.908). There was no statistical difference in 1 month survival between the 2 groups (66% transferred group vs. 75.6% SMC group, P=0.318). In the univariate and multivariate models, the ROSC to induction time and the induction time had no association with good neurologic outcomes. The good neurologic outcome and survival at 1 month had no significant differences between the 2 groups. This finding suggests the possibility of integrated post-cardiac arrest care for OHCA patients who are transferred from other hospitals after ROSC in the cardiac arrest center.

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Association between antecedent statin use and severe disease outcomes in COVID-19: A retrospective study with propensity score matching

BackgroundStatins have been associated with a reduction in inflammatory markers and improved endothelial function. Whether statins offer any benefit in COVID-19 needs to be elucidated.ObjectiveTo determine the association between antecedent statin use and severe disease outcomes among COVID-19 patients.MethodsA retrospective cohort study on 1014 patients with confirmed COVID-19 diagnosis. Outcomes were mortality, need for mechanical ventilation, and intensive care admission. Patients were classified into statin-users vs statin non-users based on antecedent use of statins. Multivariable regression analysis was performed adjusting for confounders such as age, sex, race, BMI, smoking, insurance, and comorbidities. Propensity score matching was performed to achieve a 1:1 balanced cohort.ResultsA total of 1014 patients (Median age 65 (IQR 53–73); 530 (52.3%) males; 753 (74.3%) African Americans; median BMI 29.4 (IQR 25.1–35.9); 615 (60.7%) with Medicare insurance) were included in the study. About 454 patients (44.77%) were using statins as home medication. Antecedent statin use was associated with significant decrease in mortality in the total cohort (OR, 0.66; 95% CI, 0.46 – 0.95; p = 0.03). Among the propensity score matched (PSM) cohort of 466 patients (233 statin users and 233 statin non-users), all the baseline characteristics had similar distribution among the two groups. Statin users had significant reduction in mortality in the PSM cohort as well (OR, 0.56; 95% CI, 0.37 – 0.83; p = 0.004).ConclusionsStatin use was associated with significant reduction in mortality among COVID-19 patients. These findings support the pursuit of randomized clinical trials to explore the possible benefits of statins in COVID-19.     

Real-world evidence: Patient views on asthma in respiratory specialist clinics in America

BackgroundApproximately 30% to 50% of patients with moderate/severe asthma have inadequately controlled disease despite adherence to inhaled corticosteroid (ICS)/long-acting β₂-agonist (LABA) therapy. Data on prevalence and burden of uncontrolled asthma in specialty settings are lacking.ObjectiveTo evaluate the prevalence and burden of uncontrolled asthma in respiratory specialist clinics in the United States.MethodsAdults with physician-diagnosed asthma attending pulmonary and allergy clinics with self-reported ICS use in the previous 4 weeks completed an electronic questionnaire including the Asthma Control Test and St George’s Respiratory Questionnaire. Additional information was collected using an electronic case report form.ResultsOf 774 patients attending 12 pulmonary and 12 allergy clinics, 53% were not well controlled (mean [SD] Asthma Control Test, 14.3 [3.6] vs 22.4 [1.6] in well-controlled patients). Among ICS/LABA users, 56% were not well controlled, which increased with increasing ICS dose (low-dose 45.7%; high-dose 59.7%). The not well-controlled group reported more respiratory illnesses, more comorbidities, and poorer health-related quality of life (mean [SD] St George’s Respiratory Questionnaire, 46.1 [18.9] vs 19.8 [12.9] in the well-controlled group). These patients also had more asthma exacerbations (≥1 exacerbation, 68.9% vs 43.1%) and increased health care resource utilization (≥1 asthma-related hospitalization, 10.7% vs 2.7%); 27.3% were also receiving systemic corticosteroids. Approximately 40% of the population were eligible for step-up to ICS/LABA/long-acting muscarinic antagonist triple therapy, and 20% were eligible for biologic therapy.ConclusionSubstantial unmet needs exist among patients with inadequately controlled asthma managed in United States specialist settings, which may be addressed by improved patient and physician education, better guideline implementation, and improved adherence.     

Noninvasive ventilation: Are we overdoing it?

Background:

Use of noninvasive ventilation (NIV) outside guideline recommendations is common. We audited use of NIV in our tertiary care critical care unit (CCU) to evaluate appropriateness of use and patient outcomes when used outside level I recommendations.

Materials and Methods:

Prospective observational study of all patients requiring NIV. Clinical parameters and arterial blood gases were recorded at initiation of NIV and 2 h later (or earlier if clinically warranted). NIV titration and decision to intubate were left to the discretion of treating intensivist. Patients were categorized into two groups: Group 1: Those with level I indications for use of NIV and group 2: All other levels of indications. Patients were followed until hospital discharge.

Results:

From January 2010 to June 2010, 1120 patients were admitted to the CCU. Of these 106 patients required NIV support with 40.6% (n = 43/106) being in group 1 and 59.4% (n = 63/106) in group 2. Of these 35.8% patients (38/106) failed NIV and required endotracheal intubation. NIV failure rates (41.27% vs. 27.91%; P = 0.02) and mortality (30.6% vs. 18.6%; P = 0.03) were significantly higher in group 2 patients. In a logistic regression analysis Acute Physiology and Chronic Health Evaluation (APACHE) II score (P = 0.02), time on NIV before intubation (P = 0.001) and baseline PaCO₂ levels (P = 0.01) were strongly associated with mortality.

Conclusion:

Noninvasive ventilation failure and mortality rates were significantly higher when used outside level I recommendations. APACHE II score, baseline PaCO₂ and duration on NIV prior to intubation were predictors of increased mortality.     

Commercial claims costs related to health care resource use associated with a diagnosis of peanut allergy

BackgroundPeanut allergy (PA) affects approximately 1.6 million US children. The current standard of care is strict avoidance and prompt reaction treatment. Peanut allergy health care costs and health care resource utilization (HCRU) are poorly understood.ObjectiveTo estimate PA health care costs and HCRU using a nationally representative commercial payer database.MethodsThe IBM MarketScan Commercial Claims and Encounters Database was examined for PA diagnosis/reaction codes between January 2010 and October 2016 in patients 64 years of age or younger, with age cohort–matched controls. Outcomes were measured 12 months before and after the first claim date. Health care costs and HCRU were compared using Student's t tests and χ² tests.ResultsPatients with a PA-related diagnostic code (n = 41,675) incurred almost double all-cause health care costs vs controls ($6436 vs $3493, P < .001), mainly from inpatient and outpatient medical costs ($5002 vs $2832, P < .001). More than one third of the PA group patients (36%) had a code indicative of an anaphylactic reaction during follow-up. Mean PA or reaction-related code costs per visit totaled $7921 for hospitalizations and $1115 for emergency department (ED) visits. Costs were 30% lower in patients with asthma codes without PA codes vs those with both codes ($5678 vs $8112, P < .001); all-cause ED costs were more than double in patients with atopic dermatitis codes with PA codes vs those without PA codes ($654 vs $308, P < .001).ConclusionNational commercial payer claims data indicate a significant health care burden associated with a PA-related code, including over $6400/patient in annual all-cause costs and increased health care utilization.     

Could a protocol based on early goal-directed therapy improve outcomes in patients with severe sepsis and septic shock in the Intensive Care Unit setting?

Context:

Sepsis is a disease with high incidence and mortality. Among the interventions of the resuscitation bundle, the early goal-directed therapy (EGDT) is recommended.

Aims:

The aim was to evaluate outcomes in patients with severe sepsis and septic shock using EGDT in real life compared with patients who did not undergo it in the Intensive Care Unit (ICU) setting.

Settings and Design:

retrospective and observational cohort study at tertiary hospital.

Subjects and Methods:

All the patients admitted to ICU were screened for severe sepsis or septic shock and included in a registry and followed. The patients were allocated in two groups according to submission or not to EGDT.

Results:

A total of 268 adult patients with severe sepsis or septic shock were included. EGDT was employed in 97/268 patients. The general mortality was higher in no early goal-directed therapy (no-EGDT) then in EGDT groups (49.7% vs. 37.1% [P = 0.04] in hospital and 40.4% vs. 29.9% [P = 0.08] in the ICU, respectively. The general length of stay [LOS] in the no-EGDT and EGDT groups was 45.0 ± 59.8 vs. 29.1 ± 30.1 days [P = 0.002] in hospital and 17.4 ± 19.4 vs. 9.1 ± 9.8 days [P < 0.001] in the ICU, respectively).

Conclusions:

Our study shows reduced mortality and LOS in patients submitted to EGDT in the ICU setting. A simplified EGDT without central venous oxygen saturation is an important tool for sepsis management.     

Characterisation of nosocomial and community-acquired influenza in a large university hospital during two consecutive influenza seasons

BackgroundNosocomial influenza is increasingly recognized as an important public health threat causing considerable morbidity and mortality each year. However, data on nosocomial influenza is usually collected during outbreaks only and clinical information of nosocomial influenza is sparsely available.ObjectivesTo systematically analyse the distribution of nosocomial and community-acquired influenza and epidemiological characteristics in a tertiary care unit in two consecutive seasons.Study designA retrospective observational study was conducted to identify and characterise cases of nosocomial and community-acquired influenza at Freiburg University hospital from 1 January 2013 to 30 April 2014. A validated multiplex RT-PCR to detect influenza virus and other respiratory pathogens was used throughout. Clinical information was retrieved from the hospital-based information system.ResultsOverall, 218 patients with laboratory-confirmed influenza were included (179 in the first, 39 patients in the second season). A rate of 20% of nosocomial influenza was observed throughout. A fatal outcome was recorded for 9% of nosocomial cases, which were mainly associated with influenza virus A(H1N1)pdm09. Nosocomial influenza occurred in all age groups, but fatalities were only observed in patients ≥18 years. Patients with nosocomial influenza were significantly older, underwent therapy for blood malignancies and immunosuppressive regimens more frequently, and received solid organ transplantation more often compared to community-acquired patients.ConclusionsDespite the different distribution of virus subtypes and epidemiological properties between both influenza seasons, the rate of nosocomial cases remained similar. Systematic detection and targeted prevention measures seem mandatory to minimize nosocomial influenza.     

A prospective cohort study evaluating the prognostic impact of clinical characteristics and comorbid conditions of hospitalized adult and pediatric cancer patients with candidemia

The purpose of this study was to describe the clinical aspects of the epidemiology of candidemia and compare the prognostic impact of potential risk factors and the microbiology data of adults and children with cancer. A prospective cohort study enrolling 99 adults and 130 children with candidemia at a tertiary oncology care center in Brazil was undertaken. A total of 229 episodes were analyzed. The overall mortality was higher among adults than in children (37.4% vs. 7.7%, respectively). Univariate analysis revealed significant differences in the risk factors associated with death between both groups. Mortality was similar following fungemia with Candida albicans and all C. non-albicans species. However, significant differences in the interspecies distribution and death rates were observed, mainly among C. glabrata, krusei, and tropicalis species. Multivariate analysis showed comorbidities and neutropenia to be independently associated with mortality in adults, while in children, only comorbidities negatively affected the outcome. Comorbidities were the most important independent prognostic factor in both groups. The inclusion of detailed information about pre-existent illnesses might have a real benefit in studies of candidemia outcome.     

Respiratory etiological surveillance among quarantined patients with suspected lower respiratory tract infection at a medical center in southern Taiwan during COVID-19 pandemic

BackgroundA comprehensive study of respiratory pathogens was conducted in an area with a low prevalence of COVID-19 among the adults quarantined at a tertiary hospital.MethodsFrom March to May 2020, 201 patients suspected lower respiratory tract infection (LRTI) were surveyed for etiologies by multiplex polymerase chain reaction (PCR: FilmArray TM Respiratory Panel) test combination with cultural method, viral antigen detection and serologic surveys.ResultsTotal 201 patients tested with FilmArray TM Respiratory Panel were enrolled, of which 68.2% had sputum bacterial culture, 86.1% had pneumococcus and Legionella urine antigen test. Their median age was 72.0 year-old with multiple comorbidities, and 11.4% were nursing home residents. Bacteria accounted for 59.7% of identified pathogens. Atypical pathogens were identified in 31.3% of total pathogens, of which viruses accounted for 23.9%. In comparison to patients with bacterial infection, patients with atypical pathogens were younger (median= 77.2 vs 67.1, years, P = 0.017) and had shorter length of hospital (8.0 vs 4.5, days, P = 0.007).ConclusionsPatients with LRTI caused by atypical pathogens was indistinguishable from those with bacterial pathogens by clinical manifestations or biomarkers. Multiplex PCR providing rapid diagnosis of atypical pathogens enhance patient care and decision making when rate of sputum culture sampling was low in quarantine ward during pandemic.     

Unsuccessful emergency medical resuscitation--are continued efforts in the emergency department justified?

BACKGROUND. The majority of attempts to resuscitate victims of prehospital cardiopulmonary arrest are unsuccessful, and patients are frequently transported to the emergency department for further resuscitation efforts. We evaluated the efficacy and costs of continued hospital resuscitation for patients in whom resuscitation efforts outside the hospital have failed. METHODS. We reviewed the records of 185 patients presenting to our emergency department after an initially unsuccessful, but ongoing, resuscitation for a prehospital arrest (cardiac, respiratory, or both) by an emergency medical team. Prehospital and hospital characteristics of treatment for the arrest were identified, and the patients' outcomes in the emergency room were ascertained. The hospital course and the hospital costs for the patients who were revived were determined. RESULTS. Over a 19-month period, only 16 of the 185 patients (9 percent) were successfully resuscitated in the emergency department and admitted to the hospital. A shorter duration of prehospital resuscitation was the only characteristic of the resuscitation associated with an improved outcome in the emergency department. No patient survived until hospital discharge, and all but one were comatose throughout hospitalization. The mean stay in the hospital was 12.6 days (range, 1 to 132), with an average of 2.3 days (range, 1 to 11) in an intensive care unit. The total hospital cost for the 16 patients admitted was $180,908 (range per patient, $1,984 to $95,144). CONCLUSIONS. In general, continued resuscitation efforts in the emergency department for victims of cardiopulmonary arrest in whom prehospital resuscitation has failed are not worthwhile, and they consume precious institutional and economic resources without gain.