Cristina Granja

European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators.

Basic life support (BLS) refers to maintaining airway patency and supporting breathing and the circulation, without the use of equipment other than a protective device.(1) This section contains the guidelines for adult BLS by lay rescuers and for the use of an automated external defibrillator (AED). It also includes recognition of sudden cardiac arrest, the recovery position and management of choking (foreign-body airway obstruction). Guidelines for in-hospital BLS and the use of manual defibrillators may be found in Sections 3 and 4b.

Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomised, controlled trial

IntroductionPatients recovering from critical illness have been shown to be at risk of developing Post Traumatic Stress disorder (PTSD). This study was to evaluate whether a prospectively collected diary of a patients intensive care unit (ICU) stay when used during convalescence following critical illness will reduce the development of new onset PTSD.MethodsIntensive care patients with an ICU stay of more than 72 hours were recruited to a randomised controlled trial examining the effect of a diary outlining the details of the patients ICU stay on the development of acute PTSD. The intervention patients received their ICU diary at 1 month following critical care discharge and the final assessment of the development of acute PTSD was made at 3 months.Results352 patients were randomised to the study at 1 month. The incidence of new cases of PTSD was reduced in the intervention group compared to the control patients (5% versus 13%, P = 0.02).ConclusionsThe provision of an ICU diary is effective in aiding psychological recovery and reducing the incidence of new PTSD.Trial registrationNCT00912613.

Understanding posttraumatic stress disorder-related symptoms after critical care: the early illness amnesia hypothesis.

Objective:To assess the factual and delusional memories reported by intensive care unit survivors and its relationship with the development of Posttraumatic Stress Syndrome (PTSS). Design:Multicenter observational cohort study. Setting:Nine Portuguese intensive care units, as part of a multicenter study. Methods and Patients:Between January and June 2005, 1,174 patients were admitted across the nine intensive care units. Two hundred thirty-nine patients were excluded, 14 with <18 yrs old and 225 with a length of intensive care stay ≤48 hrs. Thus a total of 935 patients were included in the study. One hundred ninety (20%) patients died in the intensive care unit, 90 (12%) patients died on the ward (30% in-hospital mortality rate), and another 56 (9%) died in the next 6 months after intensive care unit discharge. Results:From the 599 survivors at 6 months, 313 patients answered the questionnaires (52% response rate). From the 313 respondents, 58% (n = 183) were men, median age was 59. The median Simplified Acute Physiology Score II was 37, median intensive care unit length of stay was 8 days, 57% (n = 177) of the patients were admitted for medical reasons. Forty percent (n = 116) of the respondents did not remember their admission to hospital, 48% (n = 142) did not remember the time in the hospital before intensive care unit admission, 73% (n = 220) had factual memories and 39% (n = 118) had delusional memories. Twenty-three percent (n = 66) stated that they had had intrusive memories. A higher number of “adverse” experiences were significantly associated with a higher PTSS-14 score. Eighteen percent (n = 54) of patients had a PTSS-14 score >49, indicating a higher risk of developing posttraumatic stress disorder. A PTSS-14 score >49 was significantly associated with not remembering the hospital stay before intensive care unit admission. Conclusion:Amnesia for the early period of critical illness (early amnesia) was positively associated with the level of posttraumatic stress disorder-related symptoms, which may be a proxy for severity of disease at the time of intensive care unit admission.

Immediate and long-term impact of medical emergency teams on cardiac arrest prevalence and mortality: A plea for periodic basic life-support training programs

Objective: To evaluate whether the introduction of a program including a medical emergency team responding to widened criteria together with the institution-wide training on basic life support of all hospital staff would decrease cardiac arrest prevalence and mortality in patients at risk, in the immediate and long-term periods after the program. Design: Before-after design. Setting: Urban general hospital with 470 beds. Patients: All patients admitted in the hospital between 2002 and 2006 were eligible. All patients with a medical emergency team activation were included. We compared cardiac arrest prevalence and mortality and in-hospital mortality before (2002), after (2003–2004), and long term after (2005–2006) the program implementation. Measurements and Main Results: There was a significant (p = .037) decrease of 27% (95% confidence interval, 2%–46%) in cardiac arrest occurrence, 33% decrease (p = .014) in cardiac arrest mortality (95% confidence interval, 8%–52%), and a nonsignificant (p = .152) decrease of 17% (95% confidence interval, −7%–36%) in in-hospital mortality associated with the program implementation. No significant differences were found for any of the outcome variables between before and long term after periods. The main factor associated with in-hospital mortality was cardiac arrest. Factors affecting cardiac arrest were age, comorbidities, measures started before medical emergency team arrival and the intervention/program. The effect in the prevention of cardiac arrest has an adjusted relative risk, 0.646 (95% confidence interval, 0.450–0.876) and an absolute risk reduction of adjusted relative risk, 18% (95% confidence interval, 6%–29%). The program prevented one cardiac arrest for every five medical emergency team activations. Conclusions: Widening criteria for hospital emergency calls together with an integrated training program may reduce cardiac arrest prevalence and mortality in at-risk patients. Program effectiveness was critically related to the staff education, awareness, and responsiveness to physiologic instability of the patients. Long-term effectiveness of the program may decrease in the absence of periodic and continued implementation of educational interventions.

Quality of life 6-months after cardiac arrest

BACKGROUND Evaluation of outcome after cardiac arrest focuses mainly on survival. Survivors of cardiac arrest end up in different states of health and survival alone may not be a sensitive measure for successful cardiopulmonary resuscitation (CPR). OBJECTIVES To evaluate health-related quality of life (HR-QOL) of cardiac arrest survivors with EQ-5D, a generic instrument developed by the EuroQol group. PATIENTS AND METHODS From April 1997 to December 2000, all cardiac arrest adult patients admitted to an eight-bed medical/surgical (ICU) of a tertiary care hospital were enrolled. At 6-months after ICU discharge survivors attended a follow-up interview and answered EQ-5D questionnaire. A match-control group was created choosing for each survivor of cardiac arrest two controls, with similar age range (+/-5 years) and similar Apache II (+/-3 Apache II units), that were randomly selected among other ICU patients. RESULTS From a total of 1106 patients, 97 (9%) patients were admitted after cardiac arrest. Forty-seven patients (48%) were discharged from ICU. Of these, 11 patients died in the ward. Thirty-six (37%) patients were discharged from hospital. Twelve patients died after hospital discharge but before 6-month evaluation. Five patients were not evaluated, three because they were living in distant locations and two for unknown reasons. Nineteen patients attended the follow-up consultation. Eight of these patients were actively working and six of them had managed to return to their previous activity. Eleven patients were retired and seven of these managed to return to their previous level of activity while four patients presented with anoxic encephalopathy: one with mild and one with moderate neurological dysfunction, two with severe anoxic neurological dysfunction. Although a higher percentage of cardiac arrest survivors reported more extreme problems in some dimensions than other ICU patients, no significant differences were found on HR-QOL, when evaluated by EQ-5D. CONCLUSIONS When evaluated with EQ-5D at 6-months after ICU discharge, survivors of cardiac arrest exhibit a HR-QOL similar to other ICU survivors. These results agree with previous reports stating that CPR is frequently unsuccessful but if survival is achieved a fairly good quality of life can be expected.

Cardiac arrest: long-term cognitive and imaging analysis

BACKGROUND Neurological and cognitive sequelae resulting from cardiac arrest (CA), despite their potential personal and social impact, are usually not considered as major outcome measures in long-term analysis of survivors. The aim of this study is to analyze the contribution of neuropsychological testing and cerebral imaging to the development of a long-term classification of neurological impairment. PATIENTS AND METHODS A total of 19 patients admitted over a 3 years period in an eight-bed intensive care unit of a tertiary care hospital with a diagnosis of CA were alive and attended a 6-month follow-up consultation. Eleven of these patients agreed to participate in this study carried out between 1 and 3 years after CA. Patients were classified using the Cerebral Performance Categories (CPC), neurological examination, detailed cognitive testing and computerized tomography (CT) scan with qualitative and quantitative imaging analysis. RESULTS Six of the 11 patients had good cerebral performance. Verbal and visuo-spatial short-term memory scores were associated with CPC. All patients with at least moderate cerebral disability had abnormal verbal memory test results compared with only one survivor with CPC 1; visuo-spatial short-term memory was abnormal in four moderately affected survivors and normal in those with CPC 1. The bicaudate ratio evaluated in the CT scan was correlated with the verbal memory score while the III ventricle diameter correlated with the executive functions score, suggesting involvement of different brain areas in these functions. CONCLUSIONS Neuropsychological and CT scan measurements are proxy measures of long-term impairment of CA survivors, providing a dichotomized global evaluation of CA survivors in close agreement with CPC.

Outcome of ICU survivors: a comprehensive review. The role of patient-reported outcome studies.

Problems survivors face after intensive care unit (ICU) discharge begin while they are still in the ward, where many of their specific problems may run unrecognized, but they assume a heavy weight when they arrive at their homes and face several kind of limitations, from being unable to climb stairs because of weight loss, asthenia, dyspnea or joint stiffness to anxiety, depression or post‐traumatic stress disorder.

The Predisposition, Infection, Response and Organ Failure (Piro) Sepsis Classification System: Results of Hospital Mortality Using a Novel Concept and Methodological Approach

Introduction PIRO is a conceptual classification system in which a number of demographic, clinical, biological and laboratory variables are used to stratify patients with sepsis in categories with different outcomes, including mortality rates. Objectives To identify variables to be included in each component of PIRO aiming to improve the hospital mortality prediction. Methods Patients were selected from the Portuguese ICU-admitted community-acquired sepsis study (SACiUCI). Variables concerning the R and O component included repeated measurements along the first five days in ICU stay. The trends of these variables were summarized as the initial value at day 1 (D1) and the slope of the tendency during the five days, using a linear mixed model. Logistic regression models were built to assess the best set of covariates that predicted hospital mortality. Results A total of 891 patients (age 60±17 years, 64% men, 38% hospital mortality) were studied. Factors significantly associated with mortality for P component were gender, age, chronic liver failure, chronic renal failure and metastatic cancer; for I component were positive blood cultures, guideline concordant antibiotic therapy and health-care associated sepsis; for R component were C-reactive protein slope, D1 heart rate, heart rate slope, D1 neutrophils and neutrophils slope; for O component were D1 serum lactate, serum lactate slope, D1 SOFA and SOFA slope. The relative weight of each component of PIRO was calculated. The combination of these four results into a single-value predictor of hospital mortality presented an AUC-ROC 0.84 (IC95%:0.81–0.87) and a test of goodness-of-fit (Hosmer and Lemeshow) of p = 0.368. Conclusions We identified specific variables associated with each of the four components of PIRO, including biomarkers and a dynamic view of the patient daily clinical course. This novel approach to PIRO concept and overall score can be a better predictor of mortality for patients with community-acquired sepsis admitted to ICUs.

Sepsis patients do not differ in health‐related quality of life compared with other ICU patients

The aim of the present multicentre study is to assess health‐related quality of life in patients with community‐acquired sepsis, severe sepsis, or septic shock (CAS) 6 months after discharge from the intensive care unit (ICU) and to compare the health‐related quality of life of the ICU survivors with CAS with ICU survivors with other ICU diagnoses.

Basismaßnahmen zur Wiederbelebung Erwachsener und Verwendung automatisierter externer Defibrillatoren

Die Basismasnahmen zur Wiederbelebung („basic life support“, BLS) beziehen sich auf das Freihalten der Atemwege sowie das Aufrechterhalten von Atmung und Kreislauf ohne Verwendung von Hilfsmitteln, abgesehen von einfachen Mitteln zum Eigenschutz [1]. Diese Sektion enthalt die Leitlinien zu den Basismasnahmen zur Wiederbelebung Erwachsener und zur Verwendung eines automatisierten externen Defibrillators (AED). Sie beinhaltet auch das Erkennen des plotzlichen Herztodes, die stabile Seitenlage und das Handeln bei Ersticken (Verlegung der Atemwege durch Fremdkorper). Leitlinien fur den Einsatz von manuellen Defibrillatoren und zur Einleitung von Wiederbelebungsmasnahmen im Krankenhaus finden sich in den Sektionen 3 und 4 [2, 3].