scholarly journals The use of induced hypothermia after cardiac arrest: a survey of Canadian emergency physicians

CJEM ◽  
2008 ◽  
Vol 10 (02) ◽  
pp. 125-130 ◽  
Author(s):  
Joel Kennedy ◽  
Robert S. Green ◽  
Robert Stenstrom ◽  
Keyword(s):  
Cardiac Arrest ◽  
Clinical Practice ◽  
Patient Outcomes ◽  
Odds Ratio ◽  
Mild Hypothermia ◽  
Induced Hypothermia ◽  
Emergency Physicians ◽  
Institutional Policies ◽  
Unadjusted Odds Ratio ◽  
Canadian Association

ABSTRACTObjective:Inducing mild hypothermia in survivors of cardiac arrest has been demonstrated to improve outcomes. Despite this, other studies have found that few resuscitation physicians have used hypothermia in clinical practice. The objective of this study was to characterize the use of induced hypothermia by Canadian emergency physicians.Methods:An internet-based survey was distributed to all members of the Canadian Association of Emergency Physicians (CAEP). Participants were asked about their experience with, methods for and barriers to inducing hypothermia.Results:Of the 1328 CAEP members surveyed, 247 (18.6%) responded, with the majority working in academic centres (60.3%). Ninety-five out of 202 respondents (47.0%, 95% confidence interval [CI] 40.8%–53.2%) indicated that they had induced hypothermia in clinical practice and 86 of 212 (40.6%, 95% CI 34.0%–47.2%) worked in a department that had a policy or protocol for the use of induced hypothermia. The presence of a departmental policy or protocol was strongly associated with the use of induced hypothermia (unadjusted odds ratio 10.5, 95% CI 5.3–20.8). Barriers against induced hypothermia cited by respondents included a lack of institutional policies and protocols (38.9%), and of resources (29.4%). Lack of support from consultants was relatively uncommon (8.7%) in Canadian practice.Conclusion:Only one-half of Canadian emergency physicians report that they have used therapeutic hypothermia in practice. Emergency departments should develop policies or protocols for inducing hypothermia in cardiac arrest survivors to optimize patient outcomes.

scholarly journals Hypothermic modulation of anoxic brain injury in adult survivors of cardiac arrest: a review of the literature and an algorithm for emergency physicians

CJEM ◽  
2005 ◽  
Vol 7 (01) ◽  
pp. 42-47 ◽  
Author(s):  
Robert S. Green ◽  
Daniel Howes
Keyword(s):  
Cardiac Arrest ◽  
Brain Injury ◽  
Treatment Algorithm ◽  
Adult Survivors ◽  
Induced Hypothermia ◽  
Emergency Physicians ◽  
Review Of The Literature ◽  
Anoxic Brain Injury ◽  
Neurological Outcomes ◽  
Canadian Association

ABSTRACT Anoxic brain injury is a common outcome after cardiac arrest. Despite substantial research into the pathophysiology and management of this injury, a beneficial treatment modality has not been previously identified. Recent studies show that induced hypothermia reduces mortality and improves neurological outcomes in patients resuscitated from ventricular fibrillation. This article reviews the literature on induced hypothermia for anoxic brain injury and summarizes a treatment algorithm proposed by the Canadian Association of Emergency Physicians Critical Care Committee for hypothermia induction in cardiac arrest survivors.

Abstract 168: Association Between Prehospital Advanced Airway Management for Pediatric Out-of-Hospital Cardiac Arrest and Survival

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Masashi Okubo ◽  
Sho Komukai ◽  
Junichi Izawa ◽  
Koichiro Gibo ◽  
Kosuke Kiyohara ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Propensity Score ◽  
Airway Management ◽  
Patient Outcomes ◽  
Odds Ratio ◽  
Pediatric Patients ◽  
Time Dependent ◽  
Advanced Airway ◽  
Hospital Cardiac Arrest ◽  
Favorable Functional Outcome

Introduction: It is unclear whether prehospital advanced airway management (AAM: endotracheal intubation and supraglottic airway device placement) for pediatric patients with out-of-hospital cardiac arrest (OHCA) improves patient outcomes. Objective: To test the hypothesis that prehospital advanced airway management during pediatric OHCA is associated with patient outcomes. Methods: We conducted a secondary analysis of a nationwide, prospective, population-based OHCA registry in Japan. We included pediatric patients (<18 years) with OHCA in whom emergency medical services (EMS) personnel resuscitated and transported to medical institutions during 2014 and 2015. The primary outcome was one-month survival. Secondary outcome was one-month survival with favorable functional outcome, defined as cerebral performance category score 1 or 2. Patients who received AAM during cardiopulmonary resuscitation by EMS personnel at any given minute were sequentially matched with patients at risk of receiving AAM within the same minutes based on time-dependent propensity score calculated from a competing risk regression model in which we treated prehospital return of spontaneous circulation as a competing risk event. Results: We included 2,548 patients; 1,017 (39.9%) were infants (<1 year), 839 (32.9%) were children (1 year to 12 years), and 692 (27.2%) were adolescents. Of the 2,548, included patients, 336 (13.2%) underwent prehospital AAM during cardiac arrest. In the time-dependent propensity score matched cohort (n = 642), there were no significant differences in one-month survival (AAM: 32/321 [10.0%] vs. no AAM: 27/321 [8.4%]; odds ratio, 1.33 [95% CI, 0.80 to 2.21]) and one-month survival with favorable functional outcome (AAM: 6/321 [1.9%] vs. no AAM: 5/321 [1.6%]; odds ratio, 1.48 [95% CI, 0.41 to 5.40]). Conclusions: Among pediatric patients with OHCA, we found no associations between prehospital AAM and favorable patient outcomes.

Induced Moderate Hypothermia After Cardiac Arrest

2009 ◽  
Vol 20 (4) ◽  
pp. 343-355
Author(s):  
Staci McKean
Keyword(s):  
Cardiac Arrest ◽  
Best Practice ◽  
Mild Hypothermia ◽  
Head Injuries ◽  
Heart Association ◽  
Spontaneous Circulation ◽  
Moderate Hypothermia ◽  
Induced Hypothermia ◽  
Nursing Management ◽  
Hospital Cardiac Arrest

The use of induced hypothermia has been considered for treatment of head injuries since the 1900s. However, it was not until 2 landmark studies were published in 2002 that induced hypothermia was considered best practice for patients after cardiac arrest. In 2005, the American Heart Association included recommendations in the postresuscitation support guidelines recommending consideration of mild hypothermia for unconscious adult patients with return of spontaneous circulation following out-of-hospital cardiac arrest due to ventricular fibrillation. This article provides an overview on the history and supportive research for inducing mild hypothermia after cardiac arrest, the pathophysiology associated with cerebral ischemia occurring with hypothermia, nursing management for this patient population, and the development of a protocol for induced hypothermia after cardiac arrest.

scholarly journals P049: Post-intubation sedation in the emergency department: a survey of national practice patterns

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S80
Author(s):  
S. Freeman ◽  
M. Columbus ◽  
T. Nguyen ◽  
S. Mal ◽  
J. Yan
Keyword(s):  
Emergency Department ◽  
Cardiac Arrest ◽  
Respiratory Failure ◽  
Improve Patient Safety ◽  
Teaching Hospitals ◽  
Emergency Physicians ◽  
Cross Sectional ◽  
Canadian Association ◽  
Clinical Scenarios ◽  
Post Intubation

Introduction: Endotracheal intubation (ETI) is a lifesaving procedure commonly performed by emergency department (ED) physicians that may lead to patient discomfort or adverse events (e.g., unintended extubation) if sedation is inadequate. No ED-based sedation guidelines currently exist, so individual practice varies widely. This study's objective was to describe the self-reported post-ETI sedation practice of Canadian adult ED physicians. Methods: An anonymous, cross-sectional, web-based survey featuring 7 common ED scenarios requiring ETI was distributed to adult ED physician members of the Canadian Association of Emergency Physicians (CAEP). Scenarios included post-cardiac arrest, hypercapnic and hypoxic respiratory failure, status epilepticus, polytrauma, traumatic brain injury, and toxicology. Participants indicated first and second choice of sedative medication following ETI, as well as bolus vs. infusion administration in each scenario. Data was presented by descriptive statistics. Results: 207 (response rate 16.8%) ED physicians responded to the survey. Emergency medicine training of respondents included CCFP-EM (47.0%), FRCPC (35.8%), and CCFP (13.9%). 51.0% of respondents work primarily in academic/teaching hospitals and 40.4% work in community teaching hospitals. On average, responding physicians report providing care for 4.9 ± 6.8 (mean ± SD) intubated adult patients per month for varying durations (39.2% for 1–2 hours, 27.8% for 2–4 hours, and 22.7% for ≤1 hour). Combining all clinical scenarios, propofol was the most frequently used medication for post-ETI sedation (38.0% of all responses) and was the most frequently used agent except for the post-cardiac arrest, polytrauma, and hypercapnic respiratory failure scenarios. Ketamine was used second most frequently (28.2%), with midazolam being third most common (14.5%). Post-ETI sedation was provided by &gt; 98% of physicians in all situations except the post-cardiac arrest (26.1% indicating no sedation) and toxicology (15.5% indicating no sedation) scenarios. Sedation was provided by infusion in 74.6% of cases and bolus in 25.4%. Conclusion: Significant practice variability with respect to post-ETI sedation exists amongst Canadian emergency physicians. Future quality improvement studies should examine sedation provided in real clinical scenarios with a goal of establishing best sedation practices to improve patient safety and quality of care.

scholarly journals How is quality of cardiopulmonary resuscitation being assessed? A national survey of Canadian emergency medicine physicians

CJEM ◽  
2019 ◽  
Vol 21 (6) ◽  
pp. 744-748 ◽  
Author(s):  
Natasha Wright ◽  
Yiqun Lin ◽  
Adam Cheng
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Real Time ◽  
Health Care Providers ◽  
Visual Observation ◽  
Care Providers ◽  
Emergency Physicians ◽  
Canadian Association ◽  
Cpr Quality

ABSTRACTBackgroundHigh-quality cardiopulmonary resuscitation (CPR) is a fundamental intervention for cardiac arrest, yet health care providers rarely adhere to recommended guidelines. Real-time feedback improves CPR performance. It is currently unknown how Canadian emergency physicians assess CPR quality during cardiac arrest and if they use feedback devices. Our aim was to describe how emergency physicians assess CPR quality and to describe eventual barriers to implementation of feedback technology.MethodsThis was a cross-sectional survey that was distributed to attending and resident emergency physicians through the Canadian Association of Emergency Physicians. Responses were summarized and analyzed using descriptive statistics.ResultsThe response rate was 19% (323/1735). Visual observation was the most common method of assessing CPR quality (41.2%), with leaders standing at the foot of the bed (67.4%). This was followed by real-time pulse check (29.7%) and end-tidal CO2 values (21.7%). Only 12% of physicians utilized CPR feedback technology. The most common perceived barrier to utilization was unavailability, inexperience with devices and lack of guidelines/evidence for their use.ConclusionMost Canadian emergency physicians that responded to our survey, assess quality of CPR by standing at the foot of the bed and utilize visual observation and palpation methods which are known to be inaccurate. A minority utilize objective measurements such as ETCO2 or feedback devices, with the greatest barrier being lack of availability.

scholarly journals Induced Hypothermia: From Bench to Bedside in Systemic and Neurological Protection After Resuscitation From Cardiac Arrest

2021 ◽  
pp. 1-5
Author(s):  
Tania Leme da Rocha Martinez ◽  
Keyword(s):  
Cardiac Arrest ◽  
Mild Hypothermia ◽  
Medical Center ◽  
Survival Rates ◽  
Brain Inflammation ◽  
Induced Hypothermia ◽  
Neurologic Injury ◽  
Multiple Organs ◽  
Inflammatory Damage ◽  
Neurological Protection

Introduction: Cardiac arrest outside medical center is a major cause of death. The survival rates ranges from 5 percent to 35 percent. In patients who are initially resuscitated, anoxic neurologic injury is the prime cause of morbidity and mortality, besides hazards in multiple organs as the kidneys, for example. Induced hypothermia has proven to improve the prognosis after resuscitation from cardiac arrest. Objective: To demonstrate in experiments where induced mild hypothermia has been able to reduce ischemic and inflammatory damage in animal’s brains and consequently the multiplicity of the other organs. Methods: Experiments were carried out with rabbits and rats when mild hypothermia was induced in order to demonstrate its neuroprotective properties. Results: Induced mild hypothermia demonstrated to be able to reduce the deleterious effects caused by brain ischemia and brain inflammation. Conclusions: Hypothermia may be helpful in reducing the ischemic process as well as in reducing the inflammatory cascade caused by ischemia. We believe that induced hypothermia improves prognosis after resuscitation from cardiac arrest reinforcing the application of mild hypothermia in cases of cerebral ischemia mainly after cardiac arrest.

scholarly journals Systematic review of randomized controlled trials of therapeutic hypothermia as a neuroprotectant in post cardiac arrest patients

CJEM ◽  
2006 ◽  
Vol 8 (05) ◽  
pp. 329-337 ◽  
Author(s):  
Ka Wai Cheung ◽  
Robert S. Green ◽  
Kirk D. Magee
Keyword(s):  
Systematic Review ◽  
Cardiac Arrest ◽  
Side Effects ◽  
Randomized Controlled Trials ◽  
Mild Hypothermia ◽  
Neurologic Outcome ◽  
Controlled Trials ◽  
Induced Hypothermia ◽  
Inclusion Criteria ◽  
Randomized Controlled

ABSTRACTObjective:Several randomized controlled trials have suggested that mild induced hypothermia may improve neurologic outcome in comatose cardiac arrest survivors. This systematic review of randomized controlled trials was designed to determine if mild induced hypothermia improves neurologic outcome, decreases mortality, or is associated with an increased incidence of adverse events.Data sources:The following databases were reviewed: Cochrane Controlled Trials Register (Issue 4, 2005), MEDLINE (January 1966 to November 2005), EMBASE (1980 to November 2005), CINAHL (1982 to November 2005) and Web of Science (1989 to November 2005). For each included study, references were reviewed and the primary author contacted to identify any additional studies.Study selection:Studies that met inclusion criteria were randomized controlled trials of adult patients (&gt;18 years of age) with primary cardiac arrest who remained comatose after return of spontaneous circulation. Patients had to be randomized to mild induced hypothermia (32°C-34°C) or normothermia within 24 hours of presentation. Only studies reporting pre-determined outcomes including discharge neurologic outcome, mortality or significant treatment-related adverse events were included. There were no language or publication restrictions.Data synthesis:Four studies involving 436 patients, with 232 cooled to a core temperature of 32°C-34°C met inclusion criteria. Pooled data demonstrated that mild hypothermia decreased inhospital mortality (relative ratio [RR] 0.75; 95% confidence interval [CI], 0.62-0.92) and reduced the incidence of poor neurologic outcome (RR 0.74; 95% CI, 0.62-0.84). Numbers needed to treat were 7 patients to save 1 life, and 5 patients to improve neurologic outcome. There was no evidence of treatment-limiting side effects.Conclusions:Therapeutically induced mild hypothermia decreases in-hospital mortality and improves neurologic outcome in comatose cardiac arrest survivors. The possibility of treatment-limiting side effects cannot be excluded.

Has the time come to integrate genetic risk scores into clinical practice?

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
F.V Moniz Mendonca ◽  
M.I Mendonca ◽  
A Pereira ◽  
J Monteiro ◽  
J Sousa ◽  
...  
Keyword(s):  
Risk Factors ◽  
Clinical Practice ◽  
Genetic Variants ◽  
Genetic Risk ◽  
Odds Ratio ◽  
Risk Scores ◽  
Cumulative Number ◽  
Genetic Risk Scores ◽  
Risk Alleles ◽  
Cad Risk

Abstract Background The risk for Coronary Artery Disease (CAD) is determined by both genetic and environmental factors, as well as by the interaction between them. It is estimated that genetic factors could account for 40% to 55% of the existing variability among the population (inheritability). Therefore, some authors have advised that it is time we integrated genetic risk scores into clinical practice. Aim The aim of this study was to evaluate the magnitude of the association between an additive genetic risk score (aGRS) and CAD based on the cumulative number of risk alleles in these variants, and to estimate whether their use is valuable in clinical practice. Methods A case-control study was performed in a Portuguese population. We enrolled 3120 participants, of whom 1687 were CAD patients and 1433 were normal controls. Controls were paired to cases with respect to gender and age. 33 genetic variants known to be associated with CAD were selected, and an aGRS was calculated for each individual. The aGRS was further subdivided into deciles groups, in order to estimate the CAD risk in each decile, defined by the number of risk alleles. The magnitude of the risk (odds ratio) was calculated for each group by multiple logistic regression using the 5th decile as the reference group (median). In order to evaluate the ability of the aGRS to discriminate susceptibility to CAD, two genetic models were performed, the first with traditional risk factors (TRF) and second with TRF plus aGRS. The AUC of the two ROC curves was calculated. Results A higher prevalence of cases over controls became apparent from the 6th decile of the aGRS, reflecting the higher number of risk alleles present (see figure). The difference in CAD risk was only significant from the 6th decile, increasing gradually until the 10th decile. The odds ratio (OR) for the last decile related to 5th decile (median) was 1.87 (95% CI:1.36–2.56; p&lt;0.0001). The first model yielded an AUC=0.738 (95% CI:0.720–0.755) and the second model was slightly more discriminative for CAD risk (AUC=0.748; 95% CI:0.730–0.765). The DeLong test was significant (p=0.0002). Conclusion Adding an aGRS to the non-genetic risk factors resulted in a modest improvement in the ability to discriminate the risk of CAD. Such improvement, even if statistically significant, does not appear to be of real value in clinical practice yet. We anticipate that with the development of further knowledge about different SNPs and their complex interactions, and with the inclusion of rare genetic variants, genetic risk scores will be better suited for use in a clinical setting. Funding Acknowledgement Type of funding source: None

scholarly journals Initial Experience of the Levodopa–Entacapone–Carbidopa Intestinal Gel in Clinical Practice

2021 ◽  
Vol 11 (4) ◽  
pp. 254
Author(s):  
Mezin Öthman ◽  
Erik Widman ◽  
Ingela Nygren ◽  
Dag Nyholm
Keyword(s):  
Cardiac Arrest ◽  
Clinical Practice ◽  
Observational Study ◽  
Prospective Studies ◽  
Infusion Rate ◽  
Treatment Duration ◽  
Initial Experience ◽  
Morning Dose ◽  
Efficacy And Safety ◽  
User Friendliness

Patients in fluctuating stages of Parkinson’s disease (PD) require device-aided treatments. Continuous infusion of levodopa–carbidopa intestinal gel (LCIG) is a well-proven option in clinical practice. We now report the first clinical experience of levodopa–entacapone–carbidopa intestinal gel (LECIG) therapy. An observational study of the first patients to start LECIG in our clinic was performed. Twenty-four patients (11 females, 13 males) were included. The median age was 71.5 years, and the median duration since PD diagnosis was 15.5 years. The median treatment duration was 305 days. Median doses were: 6.0 mL as morning dose, 2.5 mL/h as infusion rate, and 1.0 mL as extra dose. Half of the patients were switched directly from LCIG. These patients express improvements in the size and weight of the pump. Furthermore, most of them considered the new pump to be improved regarding user-friendliness. Six patients discontinued LECIG, three due to diarrhea, one due to hallucinations and two deceased (one cardiac arrest and one COVID-19). LECIG has shown to be possible to use in patients with PD, efficacy and safety as expected. Patients are generally happy with the size and usability of the pump, but some technical improvements of the software are warranted, as well as larger, prospective studies.

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