Raghu Seethala

Approaches to improving cardiac arrest resuscitation performance

Purpose of reviewThe survival rate from cardiac arrest remains poor despite advances in cardiopulmonary resuscitation (CPR) and postresuscitation therapies. Recent studies have documented many shortcomings during the performance of resuscitation care. We will review the various methods to improve the delivery of resuscitation care described in the current literature. Recent findingsDespite the fact that quality of CPR has been shown to correlate with improved patient outcomes, conventional training methods are often insufficient in enabling healthcare providers to deliver high-quality resuscitation care. Use of simulation methods during resuscitation training can increase subsequent resuscitation quality. Additionally, automated feedback during resuscitation has been shown to improve CPR performance. Focused debriefing after resuscitation can improve CPR quality and increase initial resuscitation success. Finally, minimizing pauses in chest compressions by adopting cardiocerebral resuscitation (CCR) protocols can lead to better patient survival. Implementing these measures on a more widespread basis can improve resuscitation care and ultimately decrease patient mortality. SummaryBy adopting techniques such as simulation, automated feedback, training refreshers, debriefing and CCR, the quality of resuscitation performance can be increased. Future work needs to demonstrate that improved resuscitation performance correlates with decreased mortality.

The Deyo-Charlson and Elixhauser-van Walraven Comorbidity Indices as predictors of mortality in critically ill patients

Objectives Our primary objective was to compare the utility of the Deyo-Charlson Comorbidity Index (DCCI) and Elixhauser-van Walraven Comorbidity Index (EVCI) to predict mortality in intensive care unit (ICU) patients. Setting Observational study of 2 tertiary academic centres located in Boston, Massachusetts. Participants The study cohort consisted of 59 816 patients from admitted to 12 ICUs between January 2007 and December 2012. Primary and secondary outcome For the primary analysis, receiver operator characteristic curves were constructed for mortality at 30, 90, 180, and 365 days using the DCCI as well as EVCI, and the areas under the curve (AUCs) were compared. Subgroup analyses were performed within different types of ICUs. Logistic regression was used to add age, race and sex into the model to determine if there was any improvement in discrimination. Results At 30 days, the AUC for DCCI versus EVCI was 0.65 (95% CI 0.65 to 0.67) vs 0.66 (95% CI 0.65 to 0.66), p=0.02. Discrimination improved at 365 days for both indices (AUC for DCCI 0.72 (95% CI 0.71 to 0.72) vs AUC for EVCI 0.72 (95% CI 0.72 to 0.72), p=0.46). The DCCI and EVCI performed similarly across ICUs at all time points, with the exception of the neurosciences ICU, where the DCCI was superior to EVCI at all time points (1-year mortality: AUC 0.73 (95% CI 0.72 to 0.74) vs 0.68 (95% CI 0.67 to 0.70), p=0.005). The addition of basic demographic information did not change the results at any of the assessed time points. Conclusions The DCCI and EVCI were comparable at predicting mortality in critically ill patients. The predictive ability of both indices increased when assessing long-term outcomes. Addition of demographic data to both indices did not affect the predictive utility of these indices. Further studies are needed to validate our findings and to determine the utility of these indices in clinical practice.

Providing Initial Transthoracic Echocardiography Training for Anesthesiologists: Simulator Training Is Not Inferior to Live Training

OBJECTIVE Transthoracic echocardiography (TTE) is finding increased use in anesthesia and critical care. Efficient options for training anesthesiologists should be explored. Simulator mannequins allow for training of manual acquisition and image recognition skills and may be suitable due to ease of scheduling. The authors tested the hypothesis that training with a simulator would not be inferior to training using a live volunteer. DESIGN Prospective, randomized trial. SETTING University hospital. PARTICIPANTS Forty-six anesthesia residents, fellows, and faculty. INTERVENTIONS After preparation with a written and video tutorial, study subjects received 80 minutes of TTE training using either a simulator or live volunteer. Practical and written tests were completed before and after training to assess improvement in manual image acquisition skills and theoretic knowledge. The written test was repeated 4 weeks later. MEASUREMENTS AND MAIN RESULTS Performance in the practical image-acquisition test improved significantly after training using both the live volunteer and the simulator, improving by 4.0 and 4.3 points out of 15, respectively. Simulator training was found not to be inferior to live training, with a mean difference of -0.30 points and 95% confidence intervals that did not cross the predefined non-inferiority margin. Performance in the written retention test also improved significantly immediately after training for both groups but declined similarly upon repeat testing 4 weeks later. CONCLUSIONS When providing initial TTE training to anesthesiologists, training using a simulator was not inferior to using live volunteers.

Health care utilization and charges following the enactment of the 2007 Graduated Drivers Licensing Law in Massachusetts

BACKGROUND Graduated Drivers Licensing (GDL) programs phase in driving privileges for teenagers. In 2007, Massachusetts implemented a stricter version of the 1998 GDL law, with increased fines and education. This study evaluated the impact of the law on motor vehicle crash (MVC)-related health care utilization and charges. METHODS Massachusetts government and US Census Bureau data were analyzed to compare the rates of MVC-related emergency department (ED) visits and hospital charges before (2002-2006) and after (2007-2011) the 2007 GDL law. Three driver age groups were studied: 16-17 (evaluating the law effect), 18-20 (evaluating the sustainability of the effect), and 25-29 years old (control group). RESULTS MVC-related ED visits per population decreased after the law for all three age groups (16-17: 2326 to 713; 18-20: 2110 to 1304; 25-29: 1694 to 1228; per 100,000, p<0.001), but the decrease was greater amongst teenagers (16-17: -69%; 18-20: -38%) compared to the control group (-27%); p<0.001. MVC-related hospital charges per population also decreased for teenagers but increased for the control group (16-17:

Age Legislation and Off-Road Vehicle Injuries in Children

2.70 m to

Extracorporeal life support in trauma: Worth the risks? A systematic review of published series

1.45 m; 18-20:

To ventilate or not to ventilate during cardiopulmonary resuscitation: that is the question

3.52 m to

The Association of Age With Short-Term and Long-Term Mortality in Adults Admitted to the Intensive Care Unit

2.26 m; 25-29:

1088: Effect Of The Use Of Theophylline And Sepsis Outcomes

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Association of pre-hospital theophylline use and mortality in chronic obstructive pulmonary disease patients with sepsis

1.92 m; per 100,000, p<0.001). CONCLUSIONS The 2007 GDL law in Massachusetts was associated with significant decreases in MVC-related health care utilization and hospital charges among teenage drivers.