Problemy s traheostomičeskimi kanûlâmi u pacientov s COVID-19 - pričiny i sposoby rešeniâ

Patients with severe lung injury due to COVID-19 are often in need of mechanical ventilation. Due to the predicted length of invasive respiratory support, tracheostomy is commonly indicated to improve patient comfort, to reduce the need for sedation and to allow safer airway care [7] [8] [15]. In this article we report two clinical cases of patients with COVID-19, who suffered cardiac arrest due to problems with tracheostomy canula placement. The first case report is regarding a 74-year-old patient, who was transported to CT from the ICU. Problems first occurred in the elevator, where specialist were forced to switch to bag ventilation, when the oxygen supply ran out. As a result, an episode of desaturation to 80% was registered. Upon arriving in the ICU, the patient was connected to a mechanical ventilator, however ventilation was ineffective: peak pressure was more than 40 cmH2O and the tidal volume was less than 100 ml. Debridement of the trachea was performed, the position of the cannula was secured with no effect. While preparing for oropharyngeal intubation, the patient's saturation dropped to 70%, haemodynamics were unstable (BP 76/40), ECG showed bradycardia of 30 bpm, which quickly turned to asystole. Cardiopulmonary resuscitation was performed and the patient was intubated, mechanical ventilation was effective. The total time of cardiac arrest was around 2 minutes, when ROSC was achieved and sinus rhythm was registered on the ECG. In 6 hours after ROSC signs of acute coronary syndrome were registered, the patient received treatment accordingly. Despite the complications, the patient's condition improved and he was transferred to the therapeutics ward and later discharged home with no signs of neurological impairment. The second case presents a similar clinical situation with an alternate outcome. A 32-year-old patient with COVID-19 was transferred to ICU due to signs of respiratory distress. His condition worsened and the patient was intubated, and soon percutaneous dilatational tracheostomy was performed. On day 9 of treatment in ICU an episode of desaturation to 75% was registered. Debridement of the trachea was not possible due to a block in the cannula. Due to rapid demise in the patient's condition, the cannula was removed and the patient was intubated. After bronchoscopy, re-tracheostomy was performed. During the procedure, it was noted that the standard cannula was displaced at an angle to the posterior wall of the trachea. The cannula was replaced by an armored cannula. In the following hours, hypoxemia was observed, as well as subcutaneous emphysema of the patient's face and upper body. Applying a thoracic X-ray, a left-side pneumothorax was diagnosed, which was urgently drained. In the following days of intensive care the patient's condition gradually improved, mechanical ventilation was effective and signs of respiratory distress were fading. Neurologically the patient was responsive, able to perform simple tasks. Unfortunately, on the 15th day of ICU care the patient's condition worsened: his fever spiked to 39-40,2C, CRP was 149, and CT showed signs of ARDS progression and vasopressors were administered due to hemodynamic instability. An episode of desaturation to 88% was noted. It was assumed that the tracheostomy cannula had been displaced, which was not proven by bronchoscopy. Later that day, while turning the patient to the side, bradycardia was noted on the monitor with progression to asystole. Cardiopulmonary resuscitation was performed for 5 minutes until ROSC. The tracheostomy cannula was then removed, due to inadequate ventilation and the patient was intubated and ventilated through an IT tube. After ROSC the patient's neurological status was closely monitored. Without sedation the patient was unconscious (coma), non-responsive, hyporeflexive with little response to pain stimuli. In two weeks his neurological condition was regarded as a vegetative state (GCS -6).

European Resuscitation Council guidelines 2021: Adult advanced life support changes related to the guidelines 2015

Adult advanced life support guidelines 2021 provided by the European Resuscitation Council in its largest extent do not differ significantly from equivalent guidelines published six years ago. However, some important points were further emphasized, and some protocols show new additions and structural changes. According to the new guidelines, there is a greater recognition that patients with both in-hospital and out-of-hospital cardiac arrest have premonitory signs, and that many of these arrests may be preventable. High-quality chest compressions with minimal interruption, early defibrillation, and treatment of reversible causes remained high priority steps in resuscitation process. New guidelines also recommend that, if an advanced airway is required, rescuers with a high tracheal intubation success rate should use this technique. With regard to using diagnostic procedures, medications, and special methods of cardiopulmonary resuscitation, newest guidelines also made new suggestions. According to these guidelines, when adrenaline is used, it should be used as soon as possible when the cardiac arrest rhythm is non-shockable, and after three defibrillation attempts for a shockable cardiac arrest rhythm. The guidelines recognise the increasing role of point-of-care ultrasound in peri-arrest care for diagnosis, but emphasis that it requires a skilled operator, and the need to minimise interruptions during chest compression. Additionally, 2015 guidelines suggested use of point-of-care ultrasound in diagnosing several various conditions with potential of causing cardiac arrest. However, 2021 guidelines limited indications in diagnosing only cardiac causes, such as tamponade or pneumothorax. The guidelines also reflect the increasing evidence for extracorporeal cardiopulmonary resuscitation as a rescue therapy for selected patients with cardiac arrest when conventional advanced life support measures are failing or to facilitate specific interventions. Additionally, newest guidelines made significant changes in the order of steps used in the In/hospital resuscitation algorithm, as well as changes in several very important steps of treating tachycardias and high heart rate associated arrhythmias.

Evaluation of healthcare professionals' knowledge on Code Blue: A multi-centre survey study

Introduction: The Blue Code practice provides increase in survival rates and decrease in the rate of permanent sequelae after cardiac arrest. There are issues that healthcare workers should pay attention to in the Code Blue practice. Aim The primary purpose of this survey study is to determine the knowledge levels of physicians and nurses about the Code Blue and cardiopulmonary resuscitation in 6 centres. The secondary aim is to determine the solutions that can be made to eliminate these deficiencies. Methods After the approval of the Faculty Ethics Committee, Mersin University Faculty of Medicine, Adana Baskent Turgut Noyan Training and Research Hospital, Dokuz Eylül Univ. Faculty of Medicine, Hacettepe University Faculty of Medicine, Gulhane Training and Research Hospital, Manisa Celal Bayar Univ. Faculty of Medicine, except for the doctors and technicians of the Department of Anaesthesiology and Reanimation and the healthcare professionals working in the intensive care units, the doctors and nurses working in other departments were asked to answer the questions in the questionnaire via the internet with the questionnaire form stated in Appendix 1. Results A total of 415 participants responded the survey. Of them, 45.8% were nurses, 24.8% residents, 23.3% faculty members, 5.4% specialist doctors and 0.7% general practitioners. Totally 86.6% of the participants knew the Code Blue number. To the question "What is the Code Blue?", 92.7% of the participants gave the correct answer to his question. "Do you hesitate to intervene when you encounter a patient requiring emergency intervention?" 25.9% of the participants answered "Yes" to the question. "Is there a form about Code Blue in your clinic?" 41% answered "No" to the question. Conclusion According to the results of the survey we conducted, we are of the opinion that healthcare workers have insufficient knowledge about the Code Blue. In order to solve these problems, it would be appropriate to direct healthcare professionals to both in-hospital and external training programs.

Pediatric tape

Introduction Care and management of a life threatened child is a stressful event per se, further aggravated by the need for precise calculation of medication doses, the amount of fluids for volume replacement and choosing the rightsized equipment based on child's weight and age, which is often an information unavailable at the scene of the emergency event. Objective Our objective was to make a pediatric tape modeled by Broselow tape, but modified for medications and overall conditions present in our region. The original Broselow tape is not available in our country. Method and materials For tailoring this pediatric tape we used the original Broselow tape. The connection between length/height of a child and its body weight was used in the same way, and then doses of medications and sizes of medical equipment were calculated for the appropriate age/body weight. Discussion Our pediatric tape has two measuring parts: measuring tape with colored zones and cards that follow the appropriate color. Tape is divided into nine zones with calculated doses of medications, the amounts of fluids for volume replacement and sizes of equipment for each zone. Conclusion Hoping that this pediatric tape will find its place and use in our region, we hereby open a discussion of our professional community regarding this accessory and its future potential.

Community saves lives

The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher. The Systems Saving Lives chapter describes numerous and important factors that can globally improve the management of cardiac arrest patients not as a single intervention but as a system-level approach. The aim of this paper is to provide evidence-informed best practice guidance, about interventions which can be implemented by healthcare systems to improve outcomes of out-of-hospital and/or in-hospital cardiac arrest (OHCA and IHCA). The intended audience of the paper are governments, managers of health and education systems, healthcare professionals, teachers, students and laypeople.

Anaphylaxis in new European Resuscitation Council guidelines 2021

Anaphylaxis is a potentially life-threatening allergic reaction. New guideline for treatment of anaphylaxis is presented in European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. There are no major changes. This guideline is specific for the initial treatment of adult patients with anaphylaxis or suspected anaphylaxis by clinician. Adrenaline is the most important drug for the treatment of anaphylaxis and the first line of treatment. regarding this accessory and its future potential.

Press release the fairness of ethical decisions related to the allocation of medical resources within the COVID-19 pandemic

The fairness of ethical decisions related to the allocation of medical resources within the COVID-19 pandemic The Serbian Resuscitation Council discussed, considered, and adopted based on the National Course Director leaders opinion consensus in the field of resuscitation medicine about the basic principles of resource allocations, related to the application of resuscitation procedures and care of patients during the pandemics. The COVID-19 pandemic around the world has brought a lot of changes within all segments of life, we all are faced to everyday challenges, including ethics in medicine, which is a very sensitive area due to specifics that are unique and different in each country individually, with strong cultural, economic, religious, medical, legal, and other diversities. The challenges are enormous, given by the current lack of a specific therapy, by the limited resources available for diagnosis, intervention, and preventive measures. The pandemic also brought the need to create conditions for the application of "unusual" requirements, measures, and procedures of the healthcare system and medical care, which entails a certain reorganization of medical interventions and care systems, including mandatory personal protection measures, adherence to adequate social distance, and all hygienic procedures. General ethical principles, such as maximum benefit and equality of treatment, while giving priority to those with the most severe conditions, have created the need to create ethical recommendations related to the allocation of medical resources in the COVID-19 pandemic and Eziekel et al. published six principles related to the above in terms of maximizing benefits, giving an advantage to healthcare professionals, triage outside the framework of the "first arrival" basis, responding to findings, recognizing participation in research, and applying the same principles to COVID-19 and in non-COVID-19 patients. A fair allocation of these ethical values and principles requires adaptable ethical frameworks depending on the resources available and the organizational structure of the healthcare system.

Recommendations of the resuscitation Council of Serbia for the implementation of resuscitation measures during the COVID-19 pandemic

The COVID-19 pandemic is caused by a virus where we have lack of knowledge about. This new situation led to the need to provide high-quality resuscitation to all patients with COVID-19 infection, but also with highest-quality and most appropriate personal protection for all medical professionals with the risk from the infection. Within our program activities, the Serbian Resuscitation Council, as lead professional organization, made efforts focused in creating and implementing recommendations related to cardiopulmonary resuscitation (CPR) under the COVID-19 pandemic. These recommendations are applicable for treatments and procedures during CPR, ethical issues, and CPR training conduction at COVID-19 pandemic, in collaboration with the European Resuscitation Council and other partner organizations, which are part of the network of national councils for resuscitation medicine in Europe. In the forthcoming period of time, these recommendations might be a subject of modification to be inline with more deeper and wider knowledge, based on scientific researches, about the SARS-COV-2, and it will be reviewed and updated on regular base.