Rebecca Sell

Perishock Pause An Independent Predictor of Survival From Out-of-Hospital Shockable Cardiac Arrest

Background— Perishock pauses are pauses in chest compressions before and after defibrillatory shock. We examined the relationship between perishock pauses and survival to hospital discharge. Methods and Results— We included out-of-hospital cardiac arrest patients in the Resuscitation Outcomes Consortium Epistry–Cardiac Arrest who suffered arrest between December 2005 and June 2007, presented with a shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia), and had cardiopulmonary resuscitation process data for at least 1 shock (n=815). We used multivariable logistic regression to determine the association between survival and perishock pauses. In an analysis adjusted for Utstein predictors of survival, the odds of survival were significantly lower for patients with preshock pause ≥20 seconds (odds ratio, 0.47; 95% confidence interval, 0.27 to 0.82) and perishock pause ≥40 seconds (odds ratio, 0.54; 95% confidence interval, 0.31 to 0.97) compared with patients with preshock pause <10 seconds and perishock pause <20 seconds. Postshock pause was not independently associated with a significant change in the odds of survival. Log-linear modeling depicted a decrease in survival to hospital discharge of 18% and 14% for every 5-second increase in both preshock and perishock pause interval (up to 40 and 50 seconds, respectively), with no significant association noted with changes in the postshock pause interval. Conclusions— In patients with cardiac arrest presenting in a shockable rhythm, longer perishock and preshock pauses were independently associated with a decrease in survival to hospital discharge. The impact of preshock pause on survival suggests that refinement of automatic defibrillator software and paramedic education to minimize preshock pause delays may have a significant impact on survival. # Clinical Perspective {#article-title-32}Background— Perishock pauses are pauses in chest compressions before and after defibrillatory shock. We examined the relationship between perishock pauses and survival to hospital discharge. Methods and Results— We included out-of-hospital cardiac arrest patients in the Resuscitation Outcomes Consortium Epistry–Cardiac Arrest who suffered arrest between December 2005 and June 2007, presented with a shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia), and had cardiopulmonary resuscitation process data for at least 1 shock (n=815). We used multivariable logistic regression to determine the association between survival and perishock pauses. In an analysis adjusted for Utstein predictors of survival, the odds of survival were significantly lower for patients with preshock pause ≥20 seconds (odds ratio, 0.47; 95% confidence interval, 0.27 to 0.82) and perishock pause ≥40 seconds (odds ratio, 0.54; 95% confidence interval, 0.31 to 0.97) compared with patients with preshock pause <10 seconds and perishock pause <20 seconds. Postshock pause was not independently associated with a significant change in the odds of survival. Log-linear modeling depicted a decrease in survival to hospital discharge of 18% and 14% for every 5-second increase in both preshock and perishock pause interval (up to 40 and 50 seconds, respectively), with no significant association noted with changes in the postshock pause interval. Conclusions— In patients with cardiac arrest presenting in a shockable rhythm, longer perishock and preshock pauses were independently associated with a decrease in survival to hospital discharge. The impact of preshock pause on survival suggests that refinement of automatic defibrillator software and paramedic education to minimize preshock pause delays may have a significant impact on survival.

The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial.

BACKGROUND Previous research has demonstrated significant relationships between peri-shock pause and survival to discharge from out-of-hospital shockable cardiac arrest (OHCA). OBJECTIVE To determine the impact of peri-shock pause on survival from OHCA during the ROC PRIMED randomized controlled trial. METHODS We included patients in the ROC PRIMED trial who suffered OHCA between June 2007 and November 2009, presented with a shockable rhythm and had CPR process data for at least one shock. We used multivariable logistic regression to determine the association between peri-shock pause duration and survival to hospital discharge. RESULTS Among 2006 patients studied, the median (IQR) shock pause duration was: pre-shock pause 15s (8, 22); post-shock pause 6s (4, 9); and peri-shock pause 22.0 s (14, 31). After adjusting for Utstein predictors of survival as well as CPR quality measures, the odds of survival to hospital discharge were significantly higher for patients with pre-shock pause <10s (OR: 1.52, 95% CI: 1.09, 2.11) and peri-shock pause <20s (OR: 1.82, 95% CI: 1.17, 2.85) when compared to patients with pre-shock pause ≥ 20s and peri-shock pause ≥ 40s. Post-shock pause was not significantly associated with survival to hospital discharge. Results for neurologically intact survival (Modified Rankin Score ≤ 3) were similar to our primary outcome. CONCLUSIONS In patients with cardiac arrest presenting in a shockable rhythm during the ROC PRIMED trial, shorter pre- and peri-shock pauses were significantly associated with higher odds of survival. Future cardiopulmonary education and technology should focus on minimizing all peri-shock pauses.

Long-term follow-up of patients with culture-confirmed lyme disease

PURPOSE To determine the long-term outcome of patients with culture-confirmed Lyme disease. METHODS We analyzed data collected prospectively on adult patients from a highly endemic area in New York State who were diagnosed with early Lyme disease between 1991 and 1994. Patients with culture-confirmed erythema migrans were evaluated at baseline, 7 to 10 days, 21 to 28 days, 3 months, 6 months, 1 year, and annually thereafter. All patients were treated with antibiotics at the time of diagnosis. RESULTS We evaluated 96 cases on 709 separate occasions (median, eight evaluations per case). The erythema migrans rash resolved within 3 weeks in all of the 94 evaluable cases, none of whom developed an objective extracutaneous manifestation of Lyme disease. Of the 81 cases who were followed for >/=1 year, all but 8 (10%) were asymptomatic at their last visit, a mean (+/- SD) of 5.6 +/- 2.6 years into follow-up, and only 3 (4%) were symptomatic at every follow-up visit. Intercurrent tick bites were reported by 45 cases (47%), and 14 (15%) developed a second episode of erythema migrans. Four other cases who were asymptomatic seroconverted between years 2 and 5. CONCLUSION The long-term outcome of patients with erythema migrans after antibiotic therapy was excellent, but patients from a highly endemic area in New York State remained at high risk of re-exposure to ticks and reinfection. Subjective symptoms during follow-up evaluations tended to be mild to moderate, intermittent, and associated with more symptomatic illness at the time of initial diagnosis.

Favorable Neurocognitive Outcome with Low Tidal Volume Ventilation after Cardiac Arrest

Rationale: Neurocognitive outcome after out‐of‐hospital cardiac arrest (OHCA) is often poor, even when initial resuscitation succeeds. Lower tidal volumes (Vts) attenuate extrapulmonary organ injury in other disease states and are neuroprotective in preclinical models of critical illness. Objective: To evaluate the association between Vt and neurocognitive outcome after OHCA. Methods: We performed a propensity‐adjusted analysis of a two‐center retrospective cohort of patients experiencing OHCA who received mechanical ventilation for at least the first 48 hours of hospitalization. Vt was calculated as the time‐weighted average over the first 48 hours, in milliliters per kilogram of predicted body weight (PBW). The primary endpoint was favorable neurocognitive outcome (cerebral performance category of 1 or 2) at discharge. Measurements and Main Results: Of 256 included patients, 38% received time‐weighted average Vt greater than 8 ml/kg PBW during the first 48 hours. Lower Vt was independently associated with favorable neurocognitive outcome in propensity‐adjusted analysis (odds ratio, 1.61; 95% confidence interval [CI], 1.13‐2.28 per 1‐ml/kg PBW decrease in Vt; P = 0.008). This finding was robust to several sensitivity analyses. Lower Vt also was associated with more ventilator‐free days (&bgr; = 1.78; 95% CI, 0.39‐3.16 per 1‐ml/kg PBW decrease; P = 0.012) and shock‐free days (&bgr; = 1.31; 95% CI, 0.10‐2.51; P = 0.034). Vt was not associated with hypercapnia (P = 1.00). Although the propensity score incorporated several biologically relevant covariates, only height, weight, and admitting hospital were independent predictors of Vt less than or equal to 8 ml/kg PBW. Conclusions: Lower Vt after OHCA is independently associated with favorable neurocognitive outcome, more ventilator‐free days, and more shock‐free days. These findings suggest a role for low‐Vt ventilation after cardiac arrest.

A performance improvement-based resuscitation programme reduces arrest incidence and increases survival from in-hospital cardiac arrest

BACKGROUND Traditional resuscitation training models are inadequate to achieving and maintaining resuscitation competency. This analysis evaluates the effectiveness of a novel, performance improvement-based inpatient resuscitation programme. METHODS This was a prospective, before-and-after study conducted in an urban, university-affiliated hospital system. All inpatient adult cardiac arrest victims without an active Do Not Attempt Resuscitation order from July 2005 to June 2012 were included. The advanced resuscitation training (ART) programme was implemented in Spring 2007 and included a unique treatment algorithm constructed around the capabilities of our providers and resuscitation equipment, a training programme with flexible format and content including early recognition concepts, and a comprehensive approach to performance improvement feeding directly back into training. Our inpatient resuscitation registry and electronic patient care record were used to quantify arrest rates and survival-to-hospital discharge before and after ART programme implementation. Multiple logistic regression analysis was used to adjust for age, gender, location of arrest, initial rhythm, and time of day. RESULTS A total of 556 cardiac arrest victims were included (182 pre- and 374 post-ART). Arrest incidence decreased from 2.7 to 1.2 per 1000 patient discharges in non-ICU inpatient units, with no change in ICU arrest rate. An increase in survival-to-hospital discharge from 21 to 45% (p < 0.01) was observed following ART programme implementation. Adjusted odds ratios for survival-to-discharge (OR 2.2, 95% CI 1.4-3.4) and good neurological outcomes (OR 3.0, 95% CI 1.7-5.3) reflected similar improvements. Arrest-related deaths decreased from 2.1 to 0.5 deaths per 1000 patient discharges in non-ICU areas and from 1.5 to 1.3 deaths per 1000 patient discharges in ICU areas, and overall hospital mortality decreased from 2.2% to 1.8%. CONCLUSIONS Implementation of a novel, performance improvement-based inpatient resuscitation programme was associated with a decrease in the incidence of cardiac arrest and improved clinical outcomes.

Electrical and mechanical recovery of cardiac function following out-of-hospital cardiac arrest

BACKGROUND Compression pauses may be particularly harmful following the electrical recovery but prior to the mechanical recovery from cardiopulmonary arrest. METHODS AND RESULTS A convenience sample of patients with out-of-hospital cardiac arrest (OOHCA) were identified. Data were exported from defibrillators to define compression pauses, electrocardiogram rhythm, PetCO2, and the presence of palpable pulses. Pulse-check episodes were randomly assigned to a derivation set (one-third) and a validation set (two-thirds). Both an unweighted and a weighted receiver-operator curve (ROC) analysis were performed on the derivation set to identify optimal thresholds to predict ROSC using heart rate and PetCO2. A sequential decision guideline was generated to predict the presence of ROSC during compressions and confirm perfusion once compressions were stopped. The ability of this decision guideline to correctly identify pauses in which pulses were and were not palpated was then evaluated. A total of 145 patients with 349 compression pauses were included. The ROC analyses on the derivation set identified an optimal pre-pause heart rate threshold of >40 beats min(-1) and an optimal PetCO2 threshold of >20 mmHg to predict ROSC. A sequential decision guideline was developed using pre-pause heart rate and PetCO2 as well as the PetCO2 pattern during compression pauses to predict and rapidly confirm ROSC. This decision guideline demonstrated excellent predictive ability to identifying compression pauses with and without palpable pulses (positive predictive value 95%, negative predictive value 99%). The mean latency period between recovery of electrical and mechanical cardiac function was 78 s (95% CI 36-120 s). CONCLUSIONS Heart rate and PetCO2 can predict ROSC without stopping compressions, and the PetCO2 pattern during compression pauses can rapidly confirm ROSC. Use of a sequential decision guideline using heart rate and PetCO2 may reduce unnecessary compression pauses during critical moments during recovery from cardiopulmonary arrest.

A novel configuration of a traditional rapid response team decreases non–intensive care unit arrests and overall hospital mortality

BACKGROUND In-hospital cardiopulmonary arrest (CPA) accounts for substantial morbidity and mortality. Rapid response teams (RRTs) are designed to prevent non-intensive care unit (ICU) CPA through early detection and intervention. However, existing evidence has not consistently demonstrated a clear benefit. OBJECTIVE To explore the effectiveness of a novel RRT program design to decrease non-ICU CPA and overall hospital mortality. METHODS This study was conducted from the start of fiscal year 2005 to 2011. In November 2007, our hospitals implemented RRTs as part of a novel resuscitation program. Charge nurses from each inpatient unit underwent training as unit-specific RRT members. Additionally, all inpatient staff received annual training in RRT concepts including surveillance and recognition of deterioration. We compared the incidence of ICU and non-ICU CPA from first complete preimplementation year 2006 to postimplementation years 2007 to 2011. Overall hospital mortality was also reported. RESULTS The incidence of non-ICU CPA decreased, whereas the incidence of ICU CPA remained unchanged. Overall hospital mortality also decreased (2.12% to 1.74%, P < 0.001). The year-over-year change in RRT activations was inversely related to the change in Code Blue activations for each inpatient unit (r = -0.68, P < 0.001). CONCLUSION Our novel RRT program was associated with a decreased incidence of non-ICU CPA and improved hospital mortality.

Initial end-tidal carbon dioxide as a prognostic indicator for inpatient PEA arrest

AIM Investigate the relationship of initial PetCO2 values of patients during inpatient pulseless electrical activity (PEA) cardiopulmonary arrest with return of spontaneous circulation (ROSC) and survival to discharge. METHODS This study was performed in two urban, academic inpatient hospitals. Patients were enrolled from July 2009 to July 2013. A comprehensive database of all inpatient resuscitative events is maintained at these institutions, including demographic, clinical, and outcomes data. Arrests are stratified by primary etiology of arrest using a priori criteria. Inpatients with PEA arrest for whom recorded PetCO2 was available were included in the analysis. Capnography data obtained after ROSC and/or more than 10 min after initiation of CPR were excluded. Multivariable logistic regression was used to explore the association between initial PetCO2 >20 mmHg and both ROSC and survival-to-discharge. RESULTS A total of 50 patients with PEA arrest and pre-ROSC capnography were analyzed. CPR continued an average of 11.8 min after initial PetCO2 was recorded confirming absence of ROSC at time of measurement. Initial PetCO2 was higher in patients with versus without eventual ROSC (25.3 ± 14.4 mmHg versus 13.4 ± 6.9 mmHg, P = 0.003). After adjusting for age, gender, and arrest location (ICU versus non-ICU), initial PetCO2 >20 mmHg was associated with increased likelihood of ROSC (adjusted OR 4.8, 95% CI 1.2-19.2, P = 0.028). Initial PetCO2 was not significantly associated with survival-to-discharge (P = 0.251). CONCLUSIONS Initial PetCO2 >20 mmHg during CPR was associated with ROSC but not survival-to-discharge among inpatient PEA arrest victims. This analysis is limited by relatively small sample size.

Ultrasound-guided Percutaneous Biopsy to Diagnose Indwelling Pleural Catheter Metastasis

Malignant pleural effusion is a common cause of morbidity and mortality in patients suffering from end-stage metastatic cancer. Malignant pleural effusion is associated with a shortened survival of 3 to 12 months after diagnosis, with 1- and 6-month mortality rates of 54% and 85%, respectively. Nearly all medical management in these patients is directed toward palliation of symptoms caused by pleural fluid accumulation. Options for treatment are repeated thoracentesis, use of chronic indwelling catheters, pleurodesis, and pleuroperitoneal shunts. Associated procedure risks include infection, bleeding, pneumothorax, and respiratory failure. Transthoracic ultrasound use is advocated to minimize procedural risks for thoracentesis and indwelling pleural catheter (IPC) placement. Most patients with advanced metastatic cancer and pleural effusion are not suitable candidates for pleuroscopy-delivered pleurodesis. Therefore, IPC is more commonly chosen to palliate respiratory symptoms related to pleural fluid accumulation from pleural tumor burden. Although pleural catheter complications are low, malignant seeding of the pleural tract can occur. Transthoracic ultrasound use to determine the presence of pleural tract seeding in conjunction with guided percutaneous biopsy has not been described. We report the use of ultrasound-guided percutaneous biopsy to diagnose metastatic seeding of an IPC.

Increased Risk of Death, in the Hospital and Outside the Intensive Care Unit, for Patients With Cirrhosis After Cardiac Arrest

Increased Risk of Death, in the Hospital and Outside the Intensive Care Unit, for Patients With Cirrhosis After Cardiac Arrest Megan E. Reinders,* Gabriel Wardi,* Ricki Bettencourt, Daniel Bouland,* Jessica Bazick,* Michel Mendler,k Irine Vodkin,k Denise Kalmaz,k Thomas Savides,k David Brenner,k Rebecca E. Sell, and Rohit Loomba§,k *Division of Internal Medicine, Division of Pulmonary and Critical Care, kDivision of Gastroenterology, Department of Medicine, Division of Epidemiology, Department of Family Medicine and Public Health, University of California at San Diego, La Jolla, California