Katherine Berg

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 …

Outcome Measures for Use with Home Care Clients

Prior to the past decade, much research examining outcomes of home care programs, including efforts at delaying institutional placement, maintaining function, and supporting independence, was atheoretical in character. Outcomes hoped for were often unobserved. New policy developments require comprehensive assessment of need and aggregation of this assessment information. As more and more patients leave hospitals with complex clinical problems and extensive rehabilitative goals there has been a corresponding explosion of home care services. Social care models, while they still exist, are becoming a smaller component of the overall home care market. In this changing environment, questions are now being asked concerning the appropriateness of the care programs in home care and other post-acute care settings. There are also concerns that need to be addressed about movement of clients between post-acute settings. In this paper, we describe a set of proposed functional, behavioural, and social outcome measures that are germane to evaluating the efficacy of programmatic efforts within the post-acute continuum. Data were collected with a standardized data collection instrument, the Resident Assessment Instrument for Home Care (RAI-HC). We provide data summarizing these proposed outcomes and evidence of known groups validity in a cross-national sample of home care clients. Data highlight the differing characteristics of clients across these agencies and provide evidence that this standardized data collection instrument can capture data that is reliable and valid for describing populations and evaluating program effectiveness.

Lack of an Association Between Insulin-like Growth Factor-I and Body Composition, Muscle Strength, Physical Performance or Self-Reported Mobility Among Older Persons with Functional Limitations

OBJECTIVE: The hypothesis that decreased growth hormone (GH) secretion contributes to the functional decline that occurs with aging is far from substantiated. There have been few studies addressing the distribution and correlates of IGF‐I, an indicator of GH activity, in nonclinical populations. As part of a growth hormone intervention trial, we examined the cross‐sectional relations between IGF‐I levels and multiple measures of physical function, body composition, and strength in a group of older men and women exhibiting mild to moderate reductions in measured physical performance.

Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest.

IMPORTANCE Delay in administration of the first epinephrine dose is associated with decreased survival among adults after in-hospital, nonshockable cardiac arrest. Whether this association is true in the pediatric in-hospital cardiac arrest population remains unknown. OBJECTIVE To determine whether time to first epinephrine dose is associated with outcomes in pediatric in-hospital cardiac arrest. DESIGN, SETTING AND PARTICIPANTS We performed an analysis of data from the Get With the Guidelines-Resuscitation registry. We included US pediatric patients (age <18 years) with an in-hospital cardiac arrest and an initial nonshockable rhythm who received at least 1 dose of epinephrine. A total of 1558 patients (median age, 9 months [interquartile range [IQR], 13 days-5 years]) were included in the final cohort. EXPOSURE Time to epinephrine, defined as time in minutes from recognition of loss of pulse to the first dose of epinephrine. MAIN OUTCOMES AND MEASURES The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC), survival at 24 hours, and neurological outcome. A favorable neurological outcome was defined as a score of 1 to 2 on the Pediatric Cerebral Performance Category scale. RESULTS Among the 1558 patients, 487 (31.3%) survived to hospital discharge. The median time to first epinephrine dose was 1 minute (IQR, 0-4; range, 0-20; mean [SD], 2.6 [3.4] minutes). Longer time to epinephrine administration was associated with lower risk of survival to discharge in multivariable analysis (multivariable-adjusted risk ratio [RR] per minute delay, 0.95 [95% CI, 0.93-0.98]). Longer time to epinephrine administration was also associated with decreased risk of ROSC (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.96-0.99]), decreased risk of survival at 24 hours (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.95-0.99]), and decreased risk of survival with favorable neurological outcome (multivariable-adjusted RR per minute delay, 0.95 [95% CI, 0.91-0.99]). Patients with time to epinephrine administration of longer than 5 minutes (233/1558) compared with those with time to epinephrine of 5 minutes or less (1325/1558) had lower risk of in-hospital survival to discharge (21.0% [49/233] vs 33.1% [438/1325]; multivariable-adjusted RR, 0.75 [95% CI, 0.60-0.93]; P = .01). CONCLUSIONS AND RELEVANCE Among children with in-hospital cardiac arrest with an initial nonshockable rhythm who received epinephrine, delay in administration of epinephrine was associated with decreased chance of survival to hospital discharge, ROSC, 24-hour survival, and survival to hospital discharge with a favorable neurological outcome.

Randomized, Double-Blind, Placebo-Controlled Trial of Thiamine as a Metabolic Resuscitator in Septic Shock: A Pilot Study.

Objective:To determine if intravenous thiamine would reduce lactate in patients with septic shock. Design:Randomized, double-blind, placebo-controlled trial. Setting:Two US hospitals. Patients:Adult patients with septic shock and elevated (> 3 mmol/L) lactate between 2010 and 2014. Interventions:Thiamine 200 mg or matching placebo twice daily for 7 days or until hospital discharge. Measurements and Main Results:The primary outcome was lactate levels 24 hours after the first study dose. Of 715 patients meeting the inclusion criteria, 88 patients were enrolled and received study drug. There was no difference in the primary outcome of lactate levels at 24 hours after study start between the thiamine and placebo groups (median: 2.5 mmol/L [1.5, 3.4] vs. 2.6 mmol/L [1.6, 5.1], p = 0.40). There was no difference in secondary outcomes including time to shock reversal, severity of illness and mortality. 35% of the patients were thiamine deficient at baseline. In this predefined subgroup, those in the thiamine treatment group had statistically significantly lower lactate levels at 24 hours (median 2.1 mmol/L [1.4, 2.5] vs. 3.1 [1.9, 8.3], p = 0.03). There was a statistically significant decrease in mortality over time in those receiving thiamine in this subgroup (p = 0.047). Conclusion:Administration of thiamine did not improve lactate levels or other outcomes in the overall group of patients with septic shock and elevated lactate. In those with baseline thiamine deficiency, patients in the thiamine group had significantly lower lactate levels at 24 hours and a possible decrease in mortality over time.

Benefits of home health care after inpatient rehabilitation for hip fracture: Health service use by medicare beneficiaries, 1987–1992

OBJECTIVE To examine the added benefit of home health services for elderly patients with hip fracture discharged home after inpatient rehabilitation. DATA Medicare claims from 1% of 1986 beneficiaries followed until 1992. STUDY POPULATION Persons hospitalized with hip fracture at 70 years or older who had no major Medicare claims during the year before hospitalization and who were discharged home after inpatient rehabilitation. OUTCOMES Rehospitalization and any nonskilled nursing facility (non-SNF) nursing home admission during the 12 months after hospital discharge. RESULTS Patients who received additional home health services (27.2%) were less likely to be hospitalized than those who received rehabilitation only (31.1%); they were also less likely to have a non-SNF nursing home admission (11.3% vs 23.3%), and more likely to survive the year with no subsequent Medicare claims (65.6% vs 55%). Propensity scores were used to adjust for nonrandom treatment selection in a Cox proportional hazards analysis showing that home health was associated with a significantly lower risk of nursing home admission (adjusted odds ratio = .42, 95% confidence interval .21-.84), and hospitalization (adjusted odds ratio = .65, 95% confidence interval .26-1.00). CONCLUSIONS Studies of the relative effectiveness of post-acute services and postdischarge evaluations of inpatient rehabilitation should consider additional home care as a postacute service and examine optimal postacute treatment to minimize additional service use.

Temperature Management After Cardiac Arrest

For more than a decade, mild induced hypothermia (32 °C-34 °C) has been standard of care for patients remaining comatose after resuscitation from out-of-hospital cardiac arrest with an initial shockable rhythm, and this has been extrapolated to survivors of cardiac arrest with initially nonshockable rhythms and to patients with in-hospital cardiac arrest. Two randomized trials published in 2002 reported a survival and neurological benefit with mild induced hypothermia. One recent randomized trial reported similar outcomes in patients treated with targeted temperature management at either 33 °C or 36 °C. In response to these new data, the International Liaison Committee on Resuscitation Advanced Life Support Task Force performed a systematic review to evaluate 3 key questions: (1) Should mild induced hypothermia (or some form of targeted temperature management) be used in comatose post-cardiac arrest patients? (2) If used, what is the ideal timing of the intervention? (3) If used, what is the ideal duration of the intervention? The task force used Grading of Recommendations Assessment, Development and Evaluation methodology to assess and summarize the evidence and to provide a consensus on science statement and treatment recommendations. The task force recommends targeted temperature management for adults with out-of-hospital cardiac arrest with an initial shockable rhythm at a constant temperature between 32 °C and 36 °C for at least 24 hours. Similar suggestions are made for out-of-hospital cardiac arrest with a nonshockable rhythm and in-hospital cardiac arrest. The task force recommends against prehospital cooling with rapid infusion of large volumes of cold intravenous fluid. Additional and specific recommendations are provided in the document.

Postacute Care Following Stroke or Hip Fracture Single Services and Combinations Used by Medicare Beneficiaries (1987-1992)

Objective: To describe the use of postacute services alone or in combination following a hospitalization for a hip fracture or stroke by Medicare beneficiaries who were relatively well and living in the community prior to the index event. Methods: Healthservice use histories were constructed using Medicare claims. Patients in the study represented all subjects from a 1% sample of Medicare beneficiaries who were age 70 years or older at the time of the index hospitalization. Results: From 1987 to 1992, the proportion of patients receiving any postacute care and those receiving combinations of care increased. For example, therewas a doubling of the proportion of patients with either condition using sequences of rehabilitation with home health or SNF and home health. Within 1 year of the hospitalization, 42.6% of patients with stroke and 35.0% post-hip fracture had been rehospitalized. Discussion: Resource use and assessment of patient outcomes should be examined across the continuum of postacute care and in the months beyond to examine the relative effectiveness of different combinations of care.

The Rapid Shallow Breathing Index as a Predictor of Failure of Noninvasive Ventilation for Patients With Acute Respiratory Failure

BACKGROUND: Noninvasive ventilation (NIV) may reduce the need for intubation in acute respiratory failure (ARF). However, there is no standard method to predict success or failure with NIV. The rapid shallow breathing index (RSBI) is a validated tool for predicting readiness for extubation. We evaluated the ability of the RSBI to predict failure of NIV and mortality in ARF. METHODS: Prospective, observational trial of patients with ARF treated with NIV. NIV was initiated at the discretion of the clinicians, and an RSBI was recorded on the initial level of support (designated as assisted RSBI [aRSBI]). Patients were categorized by initial aRSBI value as either high (aRSBI > 105) or low (aRSBI ≤ 105). The primary end point was need for intubation, and the secondary end point was in-hospital mortality. Patients in the low and high aRSBI groups were compared using univariate analysis, followed by multivariable logistic regression to determine the association between aRSBI groups and outcome. RESULTS: A total of 101 patients were included. The majority of patients had an inspiratory pressure of 5–10 cm H2O in addition to an expiratory pressure of 5–8 cm H2O. Of 83 patients with an aRSBI ≤ 105, 26 (31%) required intubation, compared to 10/18 (55%) with an aRSBI > 105 (multivariate odds ratio 3.70, 95% CI 1.14–11.99, P = .03). When comparing mortality, 7/83 patients (8.4%) with an aRSBI ≤ 105 died, compared to 6/18 (33%) patients in the group with an aRSBI > 105 (multivariate odds ratio 4.51, 95% CI 1.19–17.11, P = .03). CONCLUSIONS: An aRSBI of > 105 is associated with need for intubation and increased in-hospital mortality. Whether patients with an elevated aRSBI could also have benefitted from an increase in NIV settings remains unclear. Validation of this concept in a larger patient population is warranted.

Neurologic outcome in comatose patients resuscitated from out-of-hospital cardiac arrest with prolonged downtime and treated with therapeutic hypothermia

BACKGROUND Previous reports have shown that prolonged duration of resuscitation efforts in out-of-hospital cardiac arrest (OHCA) is associated with poor neurologic outcome. This concept has recently been questioned with advancements in post-cardiac arrest care including the use of therapeutic hypothermia (TH). The aim of this study was to determine the rate of good neurologic outcome based on the duration of resuscitation efforts in OHCA patients treated with TH. METHODS This prospective, observational, study was conducted between January 2008 and September 2012. Inclusion criteria consisted of adult non-traumatic OHCA patients who were comatose after return of spontaneous circulation (ROSC) and received TH. The primary endpoint was good neurologic outcome defined as a cerebral performance category score of 1 or 2. Downtime was calculated as the length of time between the patient being recognized as pulseless and ROSC. RESULTS 105 patients were treated with TH and 19 were excluded due to unknown downtime, leaving 86 patients for analysis. The median downtime was 18.5 (10.0-32.3)min and 33 patients (38.0%) had a good neurologic outcome. When downtime was divided into four groups (≤10min, 11-20min, 21-30min, >30min), good neurologic outcomes were 62.5%, 37%, 25%, and 21.7%, respectively (p=0.02). However, even with downtime >20min, 22.9% had a good neurologic outcome, and this percentage increased to 37.5% in patients with an initial shockable rhythm. CONCLUSIONS Although longer downtime is associated with worse outcome in OHCA patients, we found that comatose patients who have been successfully resuscitated and treated with TH have neurologically intact survival rates of 23% even with downtime >20min.