High rates of prasugrel and ticagrelor non-responder in patients treated with therapeutic hypothermia after cardiac arrest

Introduction

After cardiac arrest due to acute coronary syndromes (ACS) therapeutic hypothermia (HT) is the standard care to reduce neurologic damage. Additionally, the concomitant medical treatment with aspirin and a P2Y12 receptor inhibitor like clopidogrel (Cl), prasugrel (Pr) or ticagrelor (Ti) is mandatory. The platelet inhibitory effect of these drugs under hypothermia remains unclear.

Methods

164 patients with ACS were prospectively enrolled in this study. 84 patients were treated with HT, 80 patients were under normothermia (NT). All patients were treated with aspirin and one of the P2Y12 receptor inhibitors Cl, Pr or Ti. 24 h after the initial loading dose the platelet reactivity index (PRI/VASP-index) was determined to achieve the platelet inhibitory effect.

Results

In the HT-group the PRI/VASP-index was significantly higher compared to the NT-group (54.86% ± 25.1 vs. 28.98% ± 22.8; p < 0.001). In patients under HT receiving Cl, the platelet inhibition was most markedly reduced (HT vs. NT: 66.39% ± 19.1 vs. 33.36% ± 22.1; p < 0.001) compared to Pr (HT vs. NT: 37.6% ± 25.0 vs. 27.04% ± 25.5; p = 0.143) and Ti (HT vs. NT: 41.5% ± 21.0 vs. 17.83% ± 14.5; p = 0.009). The rate of non-responder defined as PRI/VASP-index > 50% was increased in HT compared to NT (60.7% vs. 22.5%; p < 0.001) with the highest rates in the group receiving Cl (CL: 82% vs. 26%, p < 0.001; Pr: 32% vs. 23%; n.s.; Ti: 30% vs. 8%, n.s.).

Conclusion

The platelet inhibitory effect in patients treated with HT after cardiac arrest is significantly reduced. This effect was most marked with the use of Cl. The new P2Y12-inhibitors Pr and Ti improved platelet inhibition in HT, but could not completely prevent non-responsiveness.     

Outcomes of patients with trauma and intraoperative cardiac arrest

Background

Although the occurrence of intraoperative cardiac arrest is rare, it is a severe adverse event with a high mortality rate. Trauma patients have additional causes for intraoperative arrest, and we hypothesised that the survival of trauma patients who experienced intraoperative cardiac arrest would be worse than nontrauma patients who experienced intraoperative cardiac arrest.

Objectives

The aim of the present study was to compare the outcomes of trauma and nontrauma patients after intraoperative cardiac arrest.

Methods

In a tertiary university hospital and trauma centre, the intraoperative cardiac arrest cases were evaluated from January 2007 to December 2009, excluding patients submitted to cardiac surgery. Data were prospectively collected using the Utstein-style. Outcomes among the patients with trauma were compared to the patients without trauma.

Results

We collected data from 81 consecutive intraoperative cardiac arrest cases: 32 with trauma and 49 without trauma. Patients in the trauma group were younger than the patients in the nontrauma group (44 ± 23 vs. 63 ± 17, p < 0.001). Hypovolaemia (63% vs. 35%, p = 0.022) and metabolic/hydroelectrolytic disturbances (41% vs. 2%, p < 0.001) were more likely to cause the cardiac arrest in the trauma group. The first documented arrest rhythm did not differ between the groups, and pulseless electrical activity was the most prevalent rhythm (66% vs. 53%, p = 0.698). The return of spontaneous circulation (47% vs. 63%, p = 0.146) and survival to discharge with favourable neurological outcome (16% vs. 14%, p = 0.869) did not differ between the two groups.

Conclusions

The outcomes did not differ between patients with trauma and nontrauma intraoperative cardiac arrest.     

Myocardial infarction is a frequent cause of exercise-related resuscitated out-of-hospital cardiac arrest in a general non-athletic population

Background

Performing exercise is shown to prevent cardiovascular disease, but the risk of an out-of-hospital cardiac arrest (OHCA) is temporarily increased during strenuous activity. We examined the etiology and outcome after successfully resuscitated OHCA during exercise in a general non-athletic population.

Methods

Consecutive patients with OHCA were admitted with return of spontaneous circulation (ROSC) or on-going resuscitation at hospital arrival (2002–2011). Patient charts were reviewed for post-resuscitation data. Exercise was defined as moderate/vigorous physical activity.

Results

A total of 1393 OHCA-patients were included with 91(7%) arrests occurring during exercise. Exercise-related OHCA-patients were younger (60 ± 13 vs. 65 ± 15, p < 0.001) and predominantly male (96% vs. 69%, p < 0.001). The arrest was more frequently witnessed (94% vs. 86%, p = 0.02), bystander CPR was more often performed (88% vs. 54%, p < 0.001), time to ROSC was shorter (12 min (IQR: 5–19) vs. 15 (9–22), p = 0.007) and the primary rhythm was more frequently shock-able (91% vs. 49%, p < 0.001) compared to non-exercise patients. Cardiac etiology was the predominant cause of OHCA in both exercise and non-exercise patients (97% vs. 80%, p < 0.001) and acute coronary syndrome was more frequent among exercise patients (59% vs. 38%, p < 0.001). One-year mortality was 25% vs. 65% (p < 0.001), and exercise was even after adjustment associated with a significantly lower mortality (HR = 0.40 (95%CI: 0.23–0.72), p = 0.002).

Conclusions

OHCA occurring during exercise was associated with a significantly lower mortality in successfully resuscitated patients even after adjusting for confounding factors. Acute coronary syndrome was more common among exercise-related cardiac arrest patients.     

Prodromal symptoms and health care consumption prior to out-of-hospital cardiac arrest in patients without previously known ischaemic heart disease

Aims

To describe prodromal symptoms and health care consumption prior to an out-of-hospital cardiac arrest (OHCA) in patients without previously known ischaemic heart disease (IHD).

Background

The most common lethal event of cardiovascular disease is sudden cardiac death, and the majority occur outside hospital. Little is known about prodromal symptoms and health care consumption associated with OHCAs.

Design

Case-crossover study.

Methods

Medical records of 403 OHCA cases without previously known IHD, age 25–74 years in the MONICA myocardial registry in Norrbotten County 2000–2008, were reviewed. Presenting symptoms and emergency visits at public primary care facilities and internal medicine clinics in Norrbotten County were analyzed from the week prior to the OHCA and from the same week one year previously, which served as a control week. Unlike most studies we included unwitnessed arrests and those where no cardiopulmonary resuscitation (CPR) was attempted.

Results

Emergency visits were more common during the week prior to the OHCA than during the control week, both for visits to primary care (29 vs. 6, p < 0.001) and to internal medicine clinics (16 vs. 0, p < 0.001). Symptoms were more prevalent during the week prior to the OHCA (36.7 vs. 6.7%, p < 0.001). The most prevalent symptoms were chest pain (14.6 vs. 0%, p < 0.001), gastrointestinal symptoms (7.7 vs. 1.2%, p < 0.001) and dyspnoea/peripheral oedema (6.9 vs. 0.2%, p < 0.001).

Conclusions

Patients who suffer an OHCA seek health care and present prodromal symptoms significantly more often the week prior to the event than the same week one year earlier.     

Effects of adenosine monophosphate on induction of therapeutic hypothermia and neuronal damage after cardiopulmonary resuscitation in rats

Background

Animal studies and pathophysiological considerations suggest that therapeutic hypothermia after cardiopulmonary resuscitation is the more effective the earlier it is induced. Therefore this study is sought to examine whether pharmacological facilitated hypothermia by administration of 5′-adenosine monophosphate (AMP) is neuroprotective in a rat model of cardiac arrest (CA) and resuscitation.

Methods

Sixty-one rats were subjected to CA. After 6 min of ventricular fibrillation advanced cardiac life support was started. After successful return of spontaneous circulation (ROSC, n = 40), animals were randomized either to placebo group (n = 14) or AMP group (800 mg/kg body weight, n = 14). Animals were kept at an ambient temperature of 18 °C for 12 h after ROSC and core body temperature was measured using a telemetry temperature probe. Neuronal damage was analyzed by counting Nissl-positive (i.e. viable) neurons and TUNEL-positive (i.e. apoptotic) cells in coronal brain sections 7 days after ROSC. Functional status evaluated on days 1, 3 and 7 after ROSC by a tape removal test.

Results

Time until core body temperature dropped to <34.0 °C was 31 min [28; 45] in AMP-treated animals and 125 min [90; 180] in the control group (p = 0.003). Survival until 7 days after ROSC was comparable in both groups. Also number of Nissl-positive cells (AMP: 1 [1; 7] vs. placebo: 2 [1; 3] per 100 pixel; p = 0.66) and TUNEL-positive cells (AMP: 56 [44; 72] vs. placebo: 53 [41; 67] per 100 pixel; p = 0.70) did not differ. Neither did AMP affect functional neurological outcome up to 7 days after ROSC. Mean arterial pressure 20 min after ROSC was 49 [45; 55] mmHg in the AMP group in comparison to 91 [83; 95] mmHg in the control group (p < 0.001).

Conclusion

Although application of AMP reduced the time to reach a core body temperature of <34 °C neither survival was improved nor neuronal damage attenuated. Reason for this is probably induction of marked hypotension as an adverse reaction to AMP treatment.     

Effect of moderate hyperventilation and induced hypertension on cerebral tissue oxygenation after cardiac arrest and therapeutic hypothermia

Aim

Improving cerebral perfusion is an essential component of post-resuscitation care after cardiac arrest (CA), however precise recommendations in this setting are limited. We aimed to examine the effect of moderate hyperventilation (HV) and induced hypertension (IH) on non-invasive cerebral tissue oxygenation (SctO₂) in patients with coma after CA monitored with near-infrared spectroscopy (NIRS) during therapeutic hypothermia (TH).

Methods

Prospective pilot study including comatose patients successfully resuscitated from out-of-hospital CA treated with TH, monitored with NIRS. Dynamic changes of SctO₂ upon HV and IH were analyzed during the stable TH maintenance phase. HV was induced by decreasing PaCO₂ from ∼40 to ∼30 mmHg, at stable mean arterial blood pressure (MAP ∼ 70 mmHg). IH was obtained by increasing MAP from ∼70 to ∼90 mmHg with noradrenaline.

Results

Ten patients (mean age 69 years; mean time to ROSC 19 min) were studied. Following HV, a significant reduction of SctO₂ was observed (baseline 74.7 ± 4.3% vs. 69.0 ± 4.2% at the end of HV test, p < 0.001, paired t-test). In contrast, IH was not associated with changes in SctO₂ (baseline 73.6 ± 3.5% vs. 74.1 ± 3.8% at the end of IH test, p = 0.24).

Conclusions

Moderate hyperventilation was associated with a significant reduction in SctO₂, while increasing MAP to supra-normal levels with vasopressors had no effect on cerebral tissue oxygenation. Our study suggests that maintenance of strictly normal PaCO₂ levels and MAP targets of 70 mmHg may provide optimal cerebral perfusion during TH in comatose CA patients.     

Hemostasis in cardiac arrest patients treated with mild hypothermia initiated by cold fluids

Aim of the study

Application of mild hypothermia (32–33 °C) has been shown to improve neurological outcome in patients with cardiac arrest. However, hypothermia affects hemostasis, and even mild hypothermia is associated with bleeding and increased transfusion requirements in surgery patients. On the other hand, crystalloid hemodilution has been shown to induce a hypercoagulable state. The study aim was to elucidate in which way the induction of mild therapeutic hypothermia by a bolus infusion of cold crystalloids affects the coagulation system of patients with cardiac arrest.

Methods

This was a prospective pilot study in 18 patients with cardiac arrest and return of spontaneous circulation (ROSC). Mild hypothermia was initiated by a bolus infusion of cold 0.9% saline fluid (4 °C; 30 ml/kg/30 min) and maintained for 24 h. At 0 h (before hypothermia), 1, 6 and 24 h we assessed coagulation parameters (PT, APPT), platelet count and performed thrombelastography (ROTEM) after in vitro addition of heparinase.

Results

A total amount of 2528 (±528) ml of 0.9% saline fluid was given. Hematocrit (p < 0.01) and platelet count (−27%; p < 0.05) declined, whereas APTT increased (2.7-fold; p < 0.01) during the observation period. All ROTEM parameters besides clotting time (CT) after 1 h (−20%; p < 0.05) did not significantly change.

Conclusion

Mild hypothermia only slightly prolonged clotting time as measured by rotation thrombelastography. Therefore, therapeutic hypothermia initiated by cold crystalloid fluids has only minor overall effects on coagulation in patients with cardiac arrest.     

Arterial carbon dioxide tension and outcome in patients admitted to the intensive care unit after cardiac arrest

Background

Arterial carbon dioxide tension (PaCO₂) affects neuronal function and cerebral blood flow. However, its association with outcome in patients admitted to intensive care unit (ICU) after cardiac arrest (CA) has not been evaluated.

Methods and results

Observational cohort study using data from the Australian New Zealand (ANZ) Intensive Care Society Adult-Patient-Database (ANZICS-APD). Outcomes analyses were adjusted for illness severity, co-morbidities, hypothermia, treatment limitations, age, year of admission, glucose, source of admission, PaO₂ and propensity score.We studied 16,542 consecutive patients admitted to 125 ANZ ICUs after CA between 2000 and 2011. Using the APD-PaCO₂ (obtained within 24 h of ICU admission), 3010 (18.2%) were classified into the hypo- (PaCO₂ < 35 mmHg), 6705 (40.5%) into the normo- (35–45 mmHg) and 6827 (41.3%) into the hypercapnia (>45 mmHg) group. The hypocapnia group, compared with the normocapnia group, had a trend toward higher in-hospital mortality (OR 1.12 [95% CI 1.00–1.24, p = 0.04]), lower rate of discharge home (OR 0.81 [0.70–0.94, p < 0.01]) and higher likelihood of fulfilling composite adverse outcome of death and no discharge home (OR 1.23 [1.10–1.37, p < 0.001]). In contrast, the hypercapnia group had similar in-hospital mortality (OR 1.06 [0.97–1.15, p = 0.19]) but higher rate of discharge home among survivors (OR 1.16 [1.03–1.32, p = 0.01]) and similar likelihood of fulfilling the composite outcome (OR 0.97 [0.89–1.06, p = 0.52]). Cox-proportional hazards modelling supported these findings.

Conclusions

Hypo- and hypercapnia are common after ICU admission post-CA. Compared with normocapnia, hypocapnia was independently associated with worse clinical outcomes and hypercapnia a greater likelihood of discharge home among survivors.     

Post-resuscitation electrocardiograms,acute coronary findings and in-hospital prognosis of survivors of out-of-hospital cardiac arrest

Background

Identification of acute coronary lesions amenable to urgent intervention in survivors of out-of-hospital cardiac arrest is crucial. We aimed to compare the clinical and electrocardiographic characteristics to urgent coronary findings, and to analyze in-hospital prognosis of these patients.

Methods

From January 2005 to December 2012 we retrospectively identified consecutive patients resuscitated from out-of-hospital cardiac arrest, and analyzed the clinical characteristics, post-resuscitation electrocardiogram and coronary angiogram of those who underwent emergent angiography. Mortality and neurologic status at discharge were also assessed.

Results

Patients with ST-elevation more frequently had obstructive coronary artery disease (89% vs. 51%, p < 0.001) or acute coronary occlusions (83% vs. 8%, p < 0.001) than patients without ST-elevation. Independent predictors of an acute coronary occlusion were chest pain before arrest (OR 0.16, 95% CI 0.04–0.7, p = 0.01), a shockable initial rhythm (OR 0.16, 95% CI 0.03–0.9, p = 0.03), and ST-elevation on the post-resuscitation electrocardiogram (OR 0.02, 95% CI 0.004–0.13, p < 0.001). Survival with favorable neurologic recovery at discharge was 59%. Independent predictors of mortality or unfavorable neurological outcome at discharge were absence of basic life support (OR 0.2, 95% CI 0.06–0.9, p = 0.04), prolonged resuscitation time (OR 0.9, 95% CI 0.8–0.9, p = 0.01), and necessity of vasopressors (OR 14.8, 95% CI 3.3–65.4, p = 0.001).

Conclusions

Most patients with ST-elevation on the post-resuscitation electrocardiogram had an acute coronary occlusion, as opposed to patients without ST-elevation. Absence of basic life support, prolonged resuscitation time and use of vasopressors were independent predictors of worse in-hospital outcome.     

Association of serum lactate and survival outcomes in patients undergoing therapeutic hypothermia after cardiac arrest

Introduction

Recent studies have suggested that serum lactate may serve as a marker to predict mortality after resuscitation from cardiac arrest (CA). The relationship between serum lactate and CA outcomes requires further characterization, especially among patients treated with therapeutic hypothermia (TH) and aggressive post-arrest care.

Methods

A retrospective analysis of patients resuscitated from non-traumatic CA at three urban U.S. hospitals was performed using an established internet-based post-arrest registry. Adult (≥18 years) patients resuscitated from CA and receiving TH treatment were included. Logistic regression analysis was used to adjust for potential confounders to survival outcomes. Survival to discharge served as the primary endpoint.

Results

A total of 199 post-CA patients treated with TH between 5/2005 and 11/2011 were included in this analysis. The mean age was 56.9 ± 16.5 years, 85/199 (42.7%) patients were female, and survival to discharge was attained in 84/199 (42.2%). While lower initial post-CA serum lactate levels were not associated with increased survival to discharge, subsequent lactate measurements were significantly associated with outcomes (24-h serum lactate levels in survivors vs. non-survivors, 2.7 ± 0.5 vs. 4.2 ± 0.4 mmol/L, p < 0.01). Multivariable logistic regression confirmed this relationship with survival to discharge (p < 0.01).

Conclusion

Lower serum lactate levels at 12 h and 24 h, but not initially following cardiac arrest, are associated with survival to hospital discharge after resuscitation from CA and TH treatment. Prospective investigation of serum lactate as a potential prognostic tool in CA is needed.     

The impact of therapeutic hypothermia on neurological function and quality of life after cardiac arrest

Aims

To assess the impact of therapeutic hypothermia on cognitive function and quality of life in comatose survivors of out of Hospital Cardiac arrest (OHCA).

Methods

We prospectively studied comatose survivors of OHCA consecutively admitted in a 4-year period. Therapeutic hypothermia was implemented in the last 2-year period, intervention period (n = 79), and this group was compared to patients admitted the 2 previous years, control period (n = 77). We assessed Cerebral Performance Category (CPC), survival, Mini Mental State Examination (MMSE) and self-rated quality of life (SF-36) 6 months after OHCA in the subgroup with VF/VT as initial rhythm.

Results

CPC in patients alive at hospital discharge was significantly better in the intervention period with a CPC of 1–2 in 97% vs. 71% in the control period, p = 0.003, corresponding to an adjusted odds ratio of a favourable cerebral outcome of 17, p = 0.01. No significant differences were found in long-term survival (57% vs. 56% alive at 30 months), MMSE, or SF-36. Therapeutic hypothermia (hazard ratio: 0.15, p = 0.007) and bystander CPR (hazard ratio 0.19, p = 0.002) were significantly related to survival in the intervention period.

Conclusion

CPC at discharge from hospital was significantly improved following implementation of therapeutic hypothermia in comatose patients resuscitated from OCHA with VF/VT. However, significant improvement in survival, cognitive status or quality of life could not be detected at long-term follow-up.     

Rapid response team calls to patients with a pre-existing not for resuscitation order

Objective

Compare and contrast rapid response team (RRT) calls to patients with, and those without, a pre-existing not for resuscitation (NFR) order.

Methods

Retrospective medical record and database review of adult inpatients with a hospital stay greater than 24 h.

Results

198 (15.7%) of 1258 patients with a RRT call, had a pre-existing NFR order. Patients with, compared to those without a pre-existing NFR, were older (median years, 81 vs 70, p < 0.01), similar gender (males, 56.6% vs 54.3%, p = 0.55), the trigger be the worried criterion (48.5% vs 33.9%, p < 0.01) and have had a prior RRT call (30.8% vs 18.0%, p < 0.01).At time of RRT attendance, NFR patients had a higher respiratory rate (24 vs 20, p < 0.01), lower SaO2 (93% vs 97%, p = 0.02) and just as likely to receive a critical care (24.2% vs 25.8%, p = 0.63) or ward type (88.9% vs 90.1%, p = 0.61) intervention. NFR patients were less likely to be admitted to an ICU (2.0% vs 9.4%, p < 0.01), more likely to be left on the ward (92.4% vs 80.3%, p < 0.01), and be documented not for further RRT calls (2.5% vs 0.9%, p = 0.06), but have a similar mortality (5.6% vs 3.5%, p = 0.16), at time of RRT call.

Conclusions

RRT calls to patients with pre-existing NFR orders are not uncommon. The worried criterion is more often the trigger, they have abnormal respiratory observations at time of call, a similar level of intervention, less likely to be admitted to the ICU and more likely to be documented not for further RRT calls.     

A multifaceted educational intervention to prevent delirium in older inpatients: A before and after study

Background

Systematically targeting modifiable risk factors for delirium may reduce its incidence. However, research interventions have not become part of routine clinical practice. Particular approaches to the education of clinical staff may improve their practice and patient outcomes.

Objectives

To evaluate the effectiveness of a multifaceted educational program in preventing delirium in hospitalised older patients and improving staff practice, knowledge and confidence.

Design

A before and after study.

Setting

A 22-bed general medical ward of a district hospital in Sydney, Australia.

Participants

Patients were aged 65 years and over and not delirious upon admission. Of 568 eligible patients, 129 were recruited pre-intervention (3 withdrew initial consent) and 129 patients post-intervention.

Methods

Prior to the intervention, in order to establish a baseline, patients were assessed early after admission and again at discharge. The intervention was a one-hour lecture on delirium focusing on prevention for medical and nursing staff followed by weekly interactive tutorials with delirium resource staff and ward modifications. Following the initial education session, data were gathered in a second group of medical ward patients at the same time-points to ascertain the effectiveness of the intervention. Pre and post-intervention data were analysed to determine change in staff objective knowledge and self-ratings of confidence and clinical practice in relation to delirium. The main outcome measures were incident delirium and change in staff practice, confidence and knowledge.

Results

The mean age of patients was 81. The pre and post-intervention groups were comparable, aside from greater co morbidity in the pre-intervention group (F(1, 253) = 9.20, p = 0.003). Post-intervention there was a significant reduction in incident delirium (19% vs. 10.1%, X² = 4.14, p = 0.042), and improved function on discharge (mean improvement 5.3 points, p < 0.001, SD 13.31, 95% CI −7.61 to −2.97). Staff objective knowledge of delirium improved post-intervention and their confidence assessing and managing delirious patients. Staff addressed more risk factors for delirium post-intervention (8.1 vs. 9.8, F(1, 253) = 73.44, p < 0.001).

Conclusions

A low-cost educational intervention reduced the incidence of delirium and improved function in older medical patients and staff knowledge and practice addressing risk factors for delirium. The program is readily transferable to other settings, but requires replication due to limitations of the before and after design.     

A 5-year experience with cardiopulmonary resuscitation using extracorporeal life support in non-postcardiotomy patients with cardiac arrest

Background

Cardiopulmonary resuscitation (CPR) using extracorporeal life support (ECLS) system has been successfully used to support patients with in- and out-of-hospital cardiac arrest (IHCA, OHCA) when conventional measures have failed. The purpose of the current study is to report on our experience with extracorporeal CPR in non-postcardiotomy patients.

Methods

We retrospectively analysed a total of 85 consecutive adult patients, who have been treated with ECLS between January 2007 and January 2012.

Results

The mean CPR duration was 40 min (20–70 min). The mean ECLS support duration was 49 h (12–92 h). Twenty-eight patients (33%) had ECLS related complications. Forty patients (47%) were successfully weaned and 29 patients (34%) survived to hospital discharge. Among survivors, 93% were without severe neurologic deficit. Duration of CPR was shorter for survivors than for non-survivors [(25: 20–50 min) vs. (50: 25–86 min); p = 0.003]. Immediately after ECLS start, the mean blood lactate level was lower (p = 0.003), and the mean pH value was higher in the survivors’ group (p < 0.0001) compared to the non-survivors’ group. The CPR duration for the IHCA group (25: 20–50 min) was shorter compared to the OHCA group (70: 55–110 min; p < 0.0001). The survival rate in this group was higher compared to the OHCA group (42% vs. 15%; p < 0.02).

Conclusions

CPR using modern miniaturized ECLS systems should be established in the treatment of prolonged cardiac arrest and unsuccessful conventional CPR in selected patients. CPR with ECLS for OHCA has worse outcomes compared to IHCA. Duration of CPR was independent risk factor for mortality after extracorporeal CPR.     

Intermittent versus indwelling urinary catheterisation in hip surgery patients: A randomised controlled trial with cost-effectiveness analysis

Background

Hip surgery is associated with the risk of postoperative urinary retention. To avoid urinary retention hip surgery patients undergo urinary catheterisation. Urinary catheterisation, however, is associated with increased risk for urinary tract infection (UTI). At present, there is limited evidence for whether intermittent or indwelling urinary catheterisation is the preferred choice for short-term bladder drainage in patients undergoing hip surgery.

Objectives

The aim of the study was to investigate differences between intermittent and indwelling urinary catheterisation in hip surgery patients in relation to nosocomial UTI and cost-effectiveness.

Design

Randomised controlled trial with cost-effectiveness analysis.

Setting

The study was carried out at an orthopaedic department at a Swedish University Hospital.

Methods

One hundred and seventy hip surgery patients (patients with fractures or with osteoarthritis) were randomly allocated to either intermittent or indwelling urinary catheterisation. Data collection took place at four time points: during stay in hospital, at discharge and at 4 weeks and 4 months after discharge.

Results

Eighteen patients contracted nosocomial UTIs, 8 in the intermittent catheterisation group and 10 in the indwelling catheterisation group (absolute difference 2.4%, 95% CI −6.9–11.6%) The patients in the intermittent catheterisation group were more often catheterised (p < 0.001) and required more bladder scans (p < 0.001) but regained normal bladder function sooner than the patients in the indwelling catheterisation group (p < 0.001). Fourteen percent of the patients in the intermittent group did not need any catheterisation. Cost-effectiveness was similar between the indwelling and intermittent urinary catheterisation methods.

Conclusions

Both indwelling and intermittent methods could be appropriate in clinical practice. Both methods have advantages and disadvantages but by not using routine indwelling catheterisation, unnecessary catheterisations might be avoided in this patient group.     

Better sleep quality in chronic haemodialyzed patients is associated with morning-shift dialysis: A cross-sectional observational study

Objective

The aim of the study was to investigate the association between dialysis shift and subjective sleep quality in chronic haemodialyzed patients.

Design

A cross-sectional observational study.

Participants and methods

A total of 206 haemodialyzed patients aged from 22 to 71 participated in this study. Participants were grouped into the morning-shift and other-shifts groups. Subjective sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI). All participants also completed the Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI).

Results

Dialysis shift significantly predicted the PSQI score with patients receiving morning-shift haemodialysis having better sleep quality (β = 0.15, p = 0.01). Other independent predictors of the PSQI score included depression (β = 0.42, p < 0.001), anxiety (β = 0.38, p < 0.001), and tea drinking (β = 0.20, p 0.001). Together these factors explained 48.2% of the variance in the PSQI score.

Conclusion

Morning dialysis shift was significantly associated with better subjective sleep quality in chronic haemodialyzed patients after adjusting for other confounders.     

Serum S100B protein is associated with depressive symptoms in patients with end-stage renal disease

Objectives

Depression is associated with a poorer prognosis in patients with end-stage renal disease (ESRD). Increasing evidence indicates that glial pathology and blood–brain-barrier (BBB) dysfunction are involved in the pathophysiology of depression. S100B, a protein expressed in astro- and oligodendroglia in the human brain is considered a biomarker of depression. Our objective was to investigate the relationship between S100B and depressive symptoms in patients undergoing hemodialysis (HD).

Design and methods

Seventy-eight Korean patients undergoing chronic HD without significant neurological issues participated in a cross-sectional observation study. Depressive symptoms were assessed with the Beck Depression Inventory-II (BDI-II), and serum S100B levels were measured using blood samples obtained prior to a mid-week HD session.

Results

The mean age of patients was 59.0 years, and the mean dialysis duration was 51.7 months. About 45% of patients undergoing HD met criteria for depression (BDI-II ≥ 20). Serum S100B levels were significantly higher in patients with depression compared with patients without depression (115.1 ± 45.4 vs. 66.1 ± 35.3 pg/mL, p < 0.001). S100B (r = 0.556, p < 0.001) and high-sensitivity C-reactive protein (hs-CRP; r = 0.422, p < 0.001) and β2-microglobulin (r = 0.391, p < 0.001) levels were positively correlated with BDI-II scores. A multivariate regression analysis showed that both S100B and hs-CRP were significantly associated with BDI-II scores.

Conclusions

The results showed a close association between S100B and depressive symptoms in patients undergoing HD. However, the mechanisms underlying this relationship are currently unknown and warrant further investigation.     

The impact of severe acidemia on neurologic outcome of cardiac arrest survivors undergoing therapeutic hypothermia

Introduction

Therapeutic Hypothermia (TH) has become a standard of care in improving neurological outcomes in cardiac arrest (CA) survivors. Previous studies have defined severe acidemia as plasma pH < 7.20. We investigated the influence of severe acidemia at the time of initiation of TH on neurological outcome in CA survivors.

Methods

A retrospective analysis was performed on 196 consecutive CA survivors (out-of-hospital CA and in-hospital CA) who underwent TH with endovascular cooling between January 2007 and October 2012. Arterial blood gas drawn prior to initiation of TH was utilized to measure pH in all patients. Shockable and non-shockable CA patients were divided into two sub-groups based on pH (pH < 7.2 and pH ≥ 7.2). The primary end-point was measured using the Pittsburgh Cerebral Performance Category (CPC) scale prior to discharge from the hospital: good (CPC 1 and 2) and poor (CPC 3 to 5) neurologic outcome.

Results

Sixty-two percent of shockable CA patients with pH ≥ 7.20 had good neurological outcome as compared to 34% patients with pH < 7.20. Shockable CA patients with pH ≥ 7.20 were 3.3 times more likely to have better neurological outcome when compared to those with pH <7.20 [p = 0.013, OR 3.3, 95% CI (1.28–8.45)]. In comparison, non-shockable CA patients with p ≥ 7.20 did not have a significantly different neurological outcome as compared to those with pH < 7.20 [p = 0.97, OR 1.02, 95% CI (0.31–3.3)].

Conclusion

Presence of severe acidemia at initiation of TH in shockable CA survivors is significantly associated with poor neurological outcomes. This effect was not observed in the non-shockable CA survivors.     

Motion detection technology as a tool for cardiopulmonary resuscitation (CPR) quality training: A randomised crossover mannequin pilot study

Introduction

Outcome after cardiac arrest is dependent on the quality of chest compressions (CC). A great number of devices have been developed to provide guidance during CPR. The present study evaluates a new CPR feedback system (Mini-VREM: Mini-Virtual Reality Enhanced Mannequin) designed to improve CC during training.

Methods

Mini-VREM system consists of a Kinect^® (Microsoft, Redmond, WA, USA) motion sensing device and specifically developed software to provide audio–visual feedback. Mini-VREM was connected to a commercially available mannequin (Laerdal Medical, Stavanger, Norway). Eighty trainees (healthcare professionals and lay people) volunteered in this randomised crossover pilot study. All subjects performed a 2 min CC trial, 1 h pause and a second 2 min CC trial. The first group (FB/NFB, n = 40) performed CC with Mini-VREM feedback (FB) followed by CC without feedback (NFB). The second group (NFB/FB, n = 40) performed vice versa. Primary endpoints: adequate compression (compression rate between 100 and 120 min⁻¹ and compression depth between 50 and 60 mm); compressions rate within 100–120 min⁻¹; compressions depth within 50–60 mm.

Results

When compared to the performance without feedback, with Mini-VREM feedback compressions were more adequate (FB 35.78% vs. NFB 7.27%, p < 0.001) and more compressions achieved target rate (FB 72.04% vs. 31.42%, p < 0.001) and target depth (FB 47.34% vs. 24.87%, p = 0.002). The participants perceived the system to be easy to use with effective feedback.

Conclusions

The Mini-VREM system was able to improve significantly the CC performance by healthcare professionals and by lay people in a simulated CA scenario, in terms of compression rate and depth.     

Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest

Introduction

We sought to compare characteristics of emergency medical services-treated out-of-hospital cardiac arrests resulting from suspected drug overdose with non-overdose cases and test the relationship between suspected overdose and survival to hospital discharge.

Methods

Data from emergency medical services-treated, non-traumatic out-of-hospital cardiac arrests from 2006 to 2008 and late 2009 to 2011 were obtained from four EMS agencies in the Pittsburgh, Pennsylvania metropolitan area. Case definition for suspected drug overdose was naloxone administration, indication on the patient care report and/or indication by a review of hospital records. Resuscitation parameters included chest compression fraction, rate, and depth and the administration of resuscitation drugs. Demographic and outcome variables compared by suspected overdose status included age, sex, and survival to hospital discharge.

Results

From 2342 treated out-of-hospital cardiac arrests, 180 were suspected overdose cases (7.7%) and were compared to 2162 non-overdose cases. Suspected overdose cases were significantly younger (45 vs. 65, p < 0.001), less likely to be witnessed by a bystander (29% vs. 41%, p < 0.005), and had a higher rate of survival to hospital discharge (19% vs. 12%, p = 0.014) than non-overdoses. Suspected overdose cases had a higher overall chest compression fraction (0.69 vs. 0.67, p = 0.018) and higher probability of adrenaline, sodium bicarbonate, and atropine administration (p < 0.001). Suspected overdose status was predictive of survival to hospital discharge when controlling for other variables (p < 0.001).

Conclusion

Patients with suspected overdose-related out-of-hospital cardiac arrest were younger, received different resuscitative care, and survived more often than non-overdose cases.