Eyal Golan

Part 8: Post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care

The recommendations in this 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care are based on an extensive evidence review process that was begun by the International Liaison Committee on Resuscitation (ILCOR) after the publication of the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations 1,2 and was completed in February 2015.3,4 In this in-depth evidence review process, ILCOR examined topics and then generated a prioritized list of questions for systematic review. Questions were first formulated in PICO (population, intervention, comparator, outcome) format,5 and then search strategies and inclusion and exclusion criteria were defined and a search for relevant articles was performed. The evidence was evaluated by the ILCOR task forces by using the standardized methodological approach proposed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group.6 The quality of the evidence was categorized based on the study methodologies and the 5 core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and other considerations (including publication bias). Then, where possible, consensus-based treatment recommendations were created. To create this 2015 Guidelines Update, the AHA formed 15 writing groups, with careful attention to manage conflicts of interest, to assess the ILCOR treatment recommendations and to write AHA treatment recommendations by using the AHA Class of Recommendation (COR) and Level of Evidence (LOE) system. The recommendations made in the Guidelines are informed by the ILCOR recommendations and GRADE classification, in the context of the delivery of medical care in North America. The AHA writing group made new recommendations only on topics specifically reviewed by ILCOR in 2015. This chapter delineates instances where the AHA writing group developed recommendations that are significantly stronger or weaker than the ILCOR statements. In the online …

Part 4: Advanced life support

The International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support (ALS) Task Force performed detailed systematic reviews based on the recommendations of the Institute of Medicine of the National Academies1 and using the methodological approach proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group.2 Questions to be addressed (using the PICO [population, intervention, comparator, outcome] format)3 were prioritized by ALS Task Force members (by voting). Prioritization criteria included awareness of significant new data and new controversies or questions about practice. Questions about topics no longer relevant to contemporary practice or where little new research has occurred were given lower priority. The ALS Task Force prioritized 42 PICO questions for review. With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library). By using detailed inclusion and exclusion criteria, articles were screened for further evaluation. The reviewers for each question created a reconciled risk of bias assessment for each of the included studies, using state-of-the-art tools: Cochrane for randomized controlled trials (RCTs),4 Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 for studies of diagnostic accuracy,5 and GRADE for observational studies that inform both therapy and prognosis questions.6 GRADE evidence profile tables7 were then created to facilitate an evaluation of the evidence in support of each of the critical and important outcomes. The quality of the evidence (or confidence in the estimate of the effect) was categorized as high, moderate, low, or very low,8 based on the study methodologies and the 5 core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and other considerations (including publication bias).9 These evidence profile tables were then used to create a …

Association of early withdrawal of life-sustaining therapy for perceived neurological prognosis with mortality after cardiac arrest

BACKGROUND Withdrawing life-sustaining therapy because of perceived poor neurological prognosis (WLST-N) is a common cause of hospital death after out-of-hospital cardiac arrest (OHCA). Although current guidelines recommend against WLST-N before 72h (WLST-N<72), this practice is common and may increase mortality. We sought to quantify these effects. METHODS In a secondary analysis of a multicenter OHCA trial, we evaluated survival to hospital discharge and survival with favorable functional status (modified Rankin Score ≤3) in adults alive >1h after hospital admission. Propensity score modeling the probability of exposure to WLST-N<72 based on pre-exposure covariates was used to match unexposed subjects with those exposed to WLST-N<72. We determined the probability of survival and functionally favorable survival in the unexposed matched cohort, fit adjusted logistic regression models to predict outcomes in this group, and then used these models to predict outcomes in the exposed cohort. Combining these findings with current epidemiologic statistics we estimated mortality nationally that is associated with WLST-N<72. RESULTS Of 16,875 OHCA subjects, 4265 (25%) met inclusion criteria. WLST-N<72 occurred in one-third of subjects who died in-hospital. Adjusted analyses predicted that exposed subjects would have 26% survival and 16% functionally favorable survival if WLST-N<72 did not occur. Extrapolated nationally, WLST-N<72 may be associated with mortality in approximately 2300 Americans each year of whom nearly 1500 (64%) might have had functional recovery. CONCLUSIONS After OHCA, death following WLST-N<72 may be common and is potentially avoidable. Reducing WLST-N<72 has national public health implications and may afford an opportunity to decrease mortality after OHCA.

Predicting neurologic outcome after targeted temperature management for cardiac arrest: systematic review and meta-analysis.

Objectives:Targeted temperature management improves survival and neurologic outcomes for adult out-of-hospital cardiac arrest survivors but may alter the accuracy of tests for predicting neurologic outcome after cardiac arrest. Data Sources:We systematically searched Medline, Embase, CINAHL, and CENTRAL from database inception to September 2012. Study Selection:Citations were screened for studies that examined diagnostic tests to predict poor neurologic outcome or death following targeted temperature management in adult cardiac arrest survivors. Data Extraction:Data on study outcomes and quality were abstracted in duplicate. We constructed contingency tables for each diagnostic test and calculated sensitivity, specificity, and positive and negative likelihood ratios. Data Synthesis:Of 2,737 citations, 20 studies (n = 1,845) met inclusion criteria. Meta-analysis showed that three tests accurately predicted poor neurologic outcome with low false-positive rates: bilateral absence of pupillary reflexes more than 24 hours after a return of spontaneous circulation (false-positive rate, 0.02; 95% CI, 0.01–0.06; summary positive likelihood ratio, 10.45; 95% CI, 3.37–32.43), bilateral absence of corneal reflexes more than 24 hours (false-positive rate, 0.04; 95% CI, 0.01–0.09; positive likelihood ratio, 6.8; 95% CI, 2.52–18.38), and bilateral absence of somatosensory-evoked potentials between days 1 and 7 (false-positive rate, 0.03; 95% CI, 0.01–0.07; positive likelihood ratio, 12.79; 95% CI, 5.35–30.62). False-positive rates were higher for a Glasgow Coma Scale motor score showing extensor posturing or worse (false-positive rate, 0.09; 95% CI, 0.06–0.13; positive likelihood ratio, 7.11; 95% CI, 5.01–10.08), unfavorable electroencephalogram patterns (false-positive rate, 0.07; 95% CI, 0.04–0.12; positive likelihood ratio, 8.85; 95% CI, 4.87–16.08), myoclonic status epilepticus (false-positive rate, 0.05; 95% CI, 0.02–0.11; positive likelihood ratio, 5.58; 95% CI, 2.56–12.16), and elevated neuron-specific enolase (false-positive rate, 0.12; 95% CI, 0.06–0.23; positive likelihood ratio, 4.14; 95% CI, 1.82–9.42). The specificity of available tests improved when these were performed beyond 72 hours. Data on neuroimaging, biomarkers, or combination testing were limited and inconclusive. Conclusion:Simple bedside tests and somatosensory-evoked potentials predict poor neurologic outcome for survivors of cardiac arrest treated with targeted temperature management, and specificity improves when performed beyond 72 hours. Clinicians should use caution with these predictors as they carry the inherent risk of becoming self-fulfilling.

Safety and efficacy of noninvasive ventilation in patients with blunt chest trauma: a systematic review

IntroductionThis systematic review looks at the use of noninvasive ventilation (NIV), inclusive of noninvasive positive pressure ventilation (NPPV) and continuous positive pressure ventilation (CPAP), in patients with chest trauma to determine its safety and clinical efficacy in patients with blunt chest trauma who are at high risk of acute lung injury (ALI) and respiratory failure.MethodsWe searched the MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Pairs of reviewers abstracted relevant clinical data and assessed the methodological quality of randomized controlled trials (RCTs) using the Cochrane domain and observational studies using the Newcastle-Ottawa Scale.ResultsNine studies were included (three RCTs, two retrospective cohort studies and four observational studies without a comparison group). There was significant heterogeneity among the included studies regarding the severity of injuries, degree of hypoxemia and timing of enrollment. One RCT of moderate quality assessed the use of NPPV early in the disease process before the development of respiratory distress. All others evaluated the use of NPPV and CPAP in patients with blunt chest trauma after the development of respiratory distress. Overall, up to 18% of patients enrolled in the NIV group needed intubation. The duration of NIV use was highly variable, but NIV use itself was not associated with significant morbidity or mortality. Four low-quality observational studies compared NIV to invasive mechanical ventilation in patients with respiratory distress and showed decreased ICU stay (5.3 to 16 days vs 9.5 to 15 days), complications (0% to 18% vs 38% to 49%) and mortality (0% to 9% vs 6% to 50%) in the NIV group.ConclusionsEarly use of NIV in appropriately identified patients with chest trauma and without respiratory distress may prevent intubation and decrease complications and ICU length of stay. Use of NIV to prevent intubation in patients with chest trauma who have ALI associated with respiratory distress remains controversial because of the lack of good-quality data.

Prophylactic magnesium for improving neurologic outcome after aneurysmal subarachnoid hemorrhage: Systematic review and meta-analysis ☆,☆☆

PURPOSE Neurologic disability is common after aneurysmal subarachnoid hemorrhage (aSAH). Our objective was to systematically review the prophylactic use of magnesium to improve neurologic outcomes in these patients. METHODS We searched MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials to June 2012 for randomized and quasi-randomized controlled trials of intravenous magnesium in adults after aSAH, given before radiologic vasospasm or delayed cerebral ischemia (DCI) and compared with any control group. Two reviewers independently extracted data on study population, interventions, and outcomes (good neurologic outcome [primary outcome], cerebral infarction, DCI, radiographic vasospasm, mortality, adverse events). Analyses used random-effects models. RESULTS Of 702 citations, 13 trials (n = 2401) met the selection criteria. Meta-analyses showed that magnesium did not increase the probability of good neurologic outcome (risk ratio [RR], 1.02; 95% confidence interval [CI], 0.97-1.07; P = .49; 12 trials, n = 2345) or decrease the risks of cerebral infarction (RR, 0.69; 95% CI, 0.46-1.05; P = .08; 5 trials, n = 572), radiographic vasospasm (RR, 0.86; 95% CI, 0.71-1.04; P = .13; 7 trials, n = 438), or mortality (RR, 0.98; 95% CI, 0.80-1.20; P = .86; 11 trials, n = 2092). Magnesium did reduce the risk of DCI (RR, 0.73; 95% CI, 0.56-0.96; P = .02; 10 trials, n = 1095). Data on adverse events were generally sparse. CONCLUSIONS Despite decreasing the incidence of DCI in patients with aSAH, prophylactic intravenous magnesium does not improve neurologic outcome or decrease cerebral infarction, radiographic vasospasm, or mortality.

Nonbeneficial treatment Canada: definitions, causes, and potential solutions from the perspective of healthcare practitioners*.

Objective:Many healthcare workers are concerned about the provision of nonbeneficial treatment in the acute care setting. We sought to explore the perceptions of acute care practitioners to determine whether they perceived nonbeneficial treatment to be a problem, to generate an acceptable definition of nonbeneficial treatment, to learn about their perceptions of the impact and causes of nonbeneficial treatment, and the ways that they feel could reduce or resolve nonbeneficial treatment. Design:National, bilingual, cross-sectional survey of a convenience sample of nursing and medical staff who provide direct patient care in acute medical wards or ICUs in Canada. Main Results:We received 688 responses (response rate 61%) from 11 sites. Seventy-four percent of respondents were nurses. Eighty-two percent of respondents believe that our current means of resolving nonbeneficial treatment are inadequate. The most acceptable definitions of nonbeneficial treatment were “advanced curative/life-prolonging treatments that would almost certainly result in a quality of life that the patient has previously stated that he/she would not want” (88% agreement) and “advanced curative/life-prolonging treatments that are not consistent with the goals of care (as indicated by the patient)” (83% agreement). Respondents most commonly believed that nonbeneficial treatment was caused by substitute decision makers who do not understand the limitations of treatment, or who cannot accept a poor prognosis (90% agreement for each cause), and 52% believed that nonbeneficial treatment was “often” or “always” continued until the patient died or was discharged from hospital. Respondents believed that nonbeneficial treatment was a common problem with a negative impact on all stakeholders (> 80%) and perceived that improved advance care planning and communication training would be the most effective (92% and 88%, respectively) and morally acceptable (95% and 92%, respectively) means to resolve the problem of nonbeneficial treatment. Conclusions:Canadian nurses and physicians perceive that our current means of resolving nonbeneficial treatment are inadequate, and that we need to adopt new techniques of resolving nonbeneficial treatment. The most promising strategies to reduce nonbeneficial treatment are felt to be improved advance care planning and communication training for healthcare professionals.

Economic evaluation of decompressive craniectomy versus barbiturate coma for refractory intracranial hypertension following traumatic brain injury.

Objectives:Decompressive craniectomy and barbiturate coma are often used as second-tier strategies when intracranial hypertension following severe traumatic brain injury is refractory to first-line treatments. Uncertainty surrounds the decision to choose either treatment option. We investigated which strategy is more economically attractive in this context. Design:We performed a cost-utility analysis. A Markov Monte Carlo microsimulation model with a life-long time horizon was created to compare quality-adjusted survival and cost of the two treatment strategies, from the perspective of healthcare payer. Model parameters were estimated from the literature. Two-dimensional simulation was used to incorporate parameter uncertainty into the model. Value of information analysis was conducted to identify major drivers of decision uncertainty and focus future research. Setting:Trauma centers in the United States. Subjects:Base case was a population of patients (mean age = 25 yr) who developed refractory intracranial hypertension following traumatic brain injury. Interventions:We compared two treatment strategies: decompressive craniectomy and barbiturate coma. Measurements and Main Results:Decompressive craniectomy was associated with an average gain of 1.5 quality-adjusted life years relative to barbiturate coma, with an incremental cost-effectiveness ratio of

Beta-blockers and Traumatic Brain Injury: A Systematic Review, Meta-analysis, and Eastern Association for the Surgery of Trauma Guideline

9,565/quality-adjusted life year gained. Decompressive craniectomy resulted in a greater quality-adjusted life expectancy 86% of the time and was more cost-effective than barbiturate coma in 78% of cases if our willingness-to-pay threshold is

Choosing brain over lungs: Who wins?

50,000/quality-adjusted life year and 82% of cases at a threshold of