ABSTRACT
BACKGROUND: The decision to initiate or continue advanced life support (ALS) in out-of-hospital cardiac arrest (OHCA) could be difficult due to the lack of information and contextual elements, especially in non-shockable rhythms. This study aims to explore factors associated with clinicians' decision to initiate or continue ALS and the conditions associated with higher variability in asystolic patients. METHODS: This retrospective observational study enrolled 2653 asystolic patients on whom either ALS was attempted or not by the emergency medical services (EMS) physician. A multivariable logistic regression analysis was performed to find the factors associated with the decision to access ALS. A subgroup analysis was performed on patients with a predicted probability of ALS between 35% and 65%. The single physician's behaviour was compared to that predicted by the model taking into account the entire agency. RESULTS: Age, location of event, bystander cardiopulmonary resuscitation and EMS-witnessed event were independent factors influencing physicians' choices about ALS. Non-medical OHCA, younger patients, less experienced physicians, presence of breath activity at the emergency call and a longer time for ALS arrival were more frequent among cases with an expected higher variability in behaviours with ALS. Significant variability was detected between physicians. CONCLUSIONS: Significant inter-physician variability in access to ALS could be present within the same EMS, especially among less experienced physicians, non-medical OHCA and in presence of signs of life during emergency call. This arbitrariness has been observed and should be properly addressed by EMS team members as it raises ethical issues regarding the disparity in treatment.
Subject(s)
Cardiopulmonary Resuscitation , Emergency Medical Services , Out-of-Hospital Cardiac Arrest , Physicians , Clinical Decision-Making , Humans , Out-of-Hospital Cardiac Arrest/therapyABSTRACT
Background: The return of spontaneous circulation (ROSC) after cardiac arrest (RACA) score was developed as a tool to predict ROSC probability (pROSC) based on easily available information and it could be useful to compare the performances of different EMS agencies or the effects of eventual interventions.We performed an external validation of the RACA score in a cohort of out of hospital cardiac arrest (OHCA) patients managed by the EMS of the metropolitan city of Bologna, Italy. Methods: We analyzed data from 2,310 OHCA events prospectively collected between January 2009 and June 2021. Discrimination was assessed with the area under the ROC curve (AUROC), while the calibration belts were used for the comparison of observed versus expected ROSC rates. The AUROCs from our cohort and other validation cohorts were compared using a studentized range test. Results: The AUROC for the study population was 0.691, comparable to that described by previous validation studies. Despite an acceptable overall calibration, we found a poor calibration for asystole and low pROSC ranges in PEA and shockable rhythms. The model showed a good calibration for patients aged over 80, while no differences in performance were found when evaluating events before and after the implementation of 2015 ERC guidelines. Conclusions: Despite AUROC values being similar in different validation studies for RACA score, we suggest separating the different rhythms when assessing ROSC probability with the RACA score, especially for asystole.
ABSTRACT
BACKGROUND: Several clinical studies have shown that hydroxyethyl starch (HES) may be as effective and safe as, but less expensive than, albumin when used for perioperative plasma volume replacement (PVR) in children. The new third generation HES 130/0.42 solution was designed to reduce adverse drug reactions (ADRs) and improve safety while maintaining efficacy. Therefore, the objective of this prospective multicenter observational postauthorization safety study (PASS) was to evaluate the perioperative use of HES 130/0.42 in 1000 children with a particular focus on possible ADRs. METHODS: Approximately 300 of 1000 pediatric patients aged up to 12 years with ASA risk scores of I-III receiving perioperative HES 130/0.42 (Venofundin 6%; Braun, Melsungen, Germany) should be enrolled for interims analysis in the first year. The statistical sample size calculation showed that this number of patients would be sufficient to detect a 1% incidence of ADRs. Following approval by local ethics committee, patient demographics, data relating to HES 130/0.42 use, the procedures performed, anesthesia, and ADRs were documented with a particular focus on cardiovascular stability, hemodilution, acid-base balance, renal function, blood coagulation, and hypersensitivity. RESULTS: Three hundred and sixteen children (ASA I-III, age 3 +/- 3.4 [range, day of birth-12 years], body weight 13 +/- 10.5 [range, 1.1-60 kg]) were studied at five centers in Germany, Austria, and Italy from May 2006 until August 2007. Forty-five percent of the patients underwent abdominal surgery, 12.4% urologic procedures, 11.4% thoracic surgery, 7.6% orthopedic procedures, and 7% cardiovascular surgery. The mean volume of infused HES 130/0.42 was 11 +/- 4.8 ml x kg(-1) (range, 5-42). Cardiovascular stability was maintained in all cases. After HES infusion, hemoglobin (11.5 vs 10.25 g x dl(-1)), base excess (-2 vs -2.7 mmol x l(-1)), anion gap (12.9 vs 11.2 mmol x l(-1)), and strong ion difference (34.3 vs 31.4 mmol x L(-1)) decreased, and chloride (105.7 vs 107.8 mmol x l(-1)) increased significantly (P < 0.05). No serious ADRs (i.e., anaphylactoid reaction, renal failure, clotting disorders) were observed. CONCLUSION: Moderate doses of HES 130/0.42 help to maintain cardiovascular stability and lead to only moderate changes in hemoglobin concentration and acid-base balance in children. The probability of serious ADRs is lower than 1%. Therefore, HES 130/0.42 for PVR seems to be safe and effective even in neonates and small infants with normal renal function and coagulation.