ABSTRACT
Introduction: Out of hospital cardiac arrest (OHCA) is a common problem. Rates of survival are low and a proportion of survivors are left with an unfavourable neurological outcome. Four models have been developed to predict risk of unfavourable outcome at the time of critical care admission - the Cardiac Arrest Hospital Prognosis (CAHP), MIRACLE2, Out of Hospital Cardiac Arrest (OHCA), and Targeted Temperature Management (TTM) models. This evaluation evaluates the performance of these four models in a United Kingdom population and provides comparison to performance of the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score. Methods: A retrospective evaluation of the performance of the models was conducted over a 43-month period in 414 adult, non-pregnant patients presenting consecutively following non-traumatic OHCA to the five units in our regional critical care network. Scores were generated for each model for where patients had complete data (CAHP = 347, MIRACLE2 = 375, OHCA = 356, TTM = 385). Cerebral Performance Category (CPC) outcome was calculated for each patient at last documented follow up and an unfavourable outcome defined as CPC ⩾ 3. Performance for discrimination of unfavourable outcome was tested by generating receiver operating characteristic (ROC) curves for each model and comparing the area under the curve (AUC). Results: Best performance for discrimination of unfavourable outcome was demonstrated by the high risk group of the CAHP score with an AUC of 0.87 [95% CI 0.83-0.91], specificity of 97.1% [95% CI 93.8-100] and positive predictive value (PPV) of 96.3% [95% CI 92.2-100]. The high risk group of the MIRACLE2 model, which is significantly easier to calculate, had an AUC of 0.81 [95% CI 0.76-0.86], specificity of 92.3% [95% CI 87.2-97.4] and PPV of 95.2% [95% CI 91.9-98.4]. Conclusion: The CAHP, MIRACLE2, OHCA and TTM scores all perform comparably in a UK population to the original development and validation cohorts. All four scores outperform APACHE-II in a population of patients resuscitated from OHCA. CAHP and TTM perform best but are more complex to calculate than MIRACLE2, which displays inferior performance.
ABSTRACT
PURPOSE OF REVIEW: This review appraises recent evidence and provides clinical guidance on optimal perioperative fluid therapy. RECENT FINDINGS: Choice of perioperative intravenous fluid continues to be the source of much debate. Not all crystalloids are equivalent, and there is growing evidence that balanced solutions are superior to 0.9% saline in many situations. Recent evidence from the critical care population has highlighted risks associated with synthetic colloids; this and the absence of demonstrable benefit in the surgical population make it difficult to recommend their use in the perioperative period. Giving the correct amount of fluid may be as important as the choice of the fluid used. There is increasing evidence that excessive positive fluid balance is harmful to patients but there have been no randomized trials comparing maintenance fluid strategy. A knowledge of the physiology and accurate estimation of fluid balance is important for water and electrolyte homeostasis until the patient is able to resume adequate enteral nutrition. SUMMARY: Balanced crystalloids are the fluid of choice for perioperative resuscitation and optimization in patients not requiring blood products. Avoidance of a grossly positive sodium and water balance during the maintenance phase is likely to be important, but has not been assessed in randomized trials.
