Evolution of the use of intraosseous vascular access in prehospital advanced cardiopulmonary resuscitation: The IOVA-CPR study.

INTRODUCTION: Obtaining vascular access is crucial in critically ill patients. The EZ-IO® device is easy to use and has a high insertion success rate. Therefore, the use of intraosseous vascular access (IOVA) has gradually increased. AIM: We aim to determine how IOVA was integrated into management of vascular access during out-of-hospital cardiac arrest (OHCA) resuscitation. METHODS: Analysing the data from the OHCA French registry for events occurring between 1 January 2013 and 15 March 2021, we studied: demography, circumstances of occurrence and management including vascular access, delays and evolution. The primary outcome was the rate of IOVA implantation. RESULTS: Among the 7156 OHCA included in the registry, we analysed the 3964 (55%) who received cardiopulmonary resuscitation. The vascular access was peripheral in 3122 (79%) cases, intraosseous in 775 (20%) cases and central in 12 (<1%) cases. The use of IOVA has increased linearly (R2 = 0.61) during the 33 successive trimesters studied representing 7% of all vascular access in 2013 and 33% in 2021 (p = 0.001). It was significantly more frequent in traumatic cardiac arrest: 12% versus 5%; p < 0.0001. The first epinephrine bolus occurred significantly later in the IOVA group, at 6 (4-10) versus 5 (3-8) min; p < 0.0001. Survival rate in the IOVA group was significantly lower, at 1% versus 7%; p < 0.0001. CONCLUSION: The insertion rate of IOVA significantly increased over the studied period, to reach 30% of all vascular access in the management OHCA patients. The place of the intraosseous route in the strategy of venous access during the management of prehospital cardiac arrest has yet to be determined.

Digit preference and biased conclusions in cardiac arrest studies.

BACKGROUND: In cardiac arrest (CA), time is directly predictive of patients' prognosis. The increase in mortality resulting from delayed cardiopulmonary resuscitation has been quantified minute by minute. Times reported in CA management studies could reflect a timestamping bias referred to as "digit preference". This phenomenon leads to a preference for certain numerical values (such as 2, 5, or 10) over others (such as 13). Our objective was to investigate whether or not digit preference phenomenon could be observed in reported times of the day related to CA management, as noted in a national registry. METHODS: We analyzed data from the French National Electronic Registry of Cardiac Arrests. We analyzed twelve times-of-the-day corresponding to each of the main steps of CA management reported by the emergency physicians who managed the patients in prehospital settings. We postulated that if CA occurred at random times throughout the day, then we could expect to see events related to CA management occurring at a similar rate each minute of each hour of the day, at a fraction of 1/60. We compared the fraction of times reported as multiples of 15 (0, 15, 30, and 45 - on the hour, quarters, half hour) with the expected fraction of 4/60 (i.e. 4 × 1/60). MAIN RESULTS: A total of 47,211 times-of-the-day in relation to 6131 CA were analyzed. The most overrepresented numbers were: 0, with 3737 occurrences (8% vs 2% expected, p < 0.0001) and 30, with 2807 occurrences (6% vs 2% expected, p < 0.0001). Times-of-the-day as multiples of 15 were overrepresented (22% vs 7% expected, p < 0.0001). CONCLUSION: Prospectively collected times were considerably influenced by digit preference phenomenon. Studies that are not based on automatic time recordings and that have not evaluated and considered this bias should be interpretated with caution.

[Prevalence of advance directives and impact on the progress of cardiac arrest resuscitation in EHPAD]. / Prévalence des directives anticipées et impact sur le déroulement de la réanimation d'arrêts cardiaques en Ehpad.

Anticipated directives are of great value among patients living in residential care facilities for the elderly. Their prevalence in cases of cardiac arrest was studied. It was found that this issue is not systematically addressed. This results in the inappropriate use of resuscitation manoeuvres that could be avoided. This is an area that needs to be addressed in depth.

Prognostic value of prehospital quick sequential organ failure assessment score among patients with suspected infection.

OBJECTIVE: After the third international consensus on sepsis released its new definitions, the prognostic value of quick sequential organ failure assessment (qSOFA) score has been confirmed in the emergency department. However, its validity in the prehospital setting remains unknown. The objective of the study was to assess its accuracy for prehospital patients cared by emergency physician-staffed ambulances (services mobiles d'urgence et de réanimation SMUR). PATIENTS AND METHODS: This was a prospective observational multicenter cohort study (N = 6). All consecutive patients with prehospital clinical suspicion of infection by the emergency physician of the SMUR emergency medical service were included. Components of qSOFA were collected, and the patients were followed until hospital discharge. The primary end point was in-hospital mortality, censored at 28 days. Secondary end points included ICU admission longer than 72 h and a composite of 'death or ICU stay more than 72 h'. RESULTS: We screened 342 patients and included 332 in the analysis. Their mean age was 73 years, 159 (48%) were women, and the most common site of infection was respiratory (73% of cases). qSOFA was at least 2 in 133 (40%) patients. The overall in-hospital mortality was 27%: 41% in patients with qSOFA of at least 2 versus 18% for qSOFA less than 2 (absolute difference 23%; 95% confidence interval: 13-33%, P < 0.001). The overall discrimination for qSOFA was poor, with an area under the receiver operating characteristic curve of 0.69 (95% confidence interval: 0.62-0.74). CONCLUSION: In this large multicenter study, prehospital qSOFA presents a strong association with mortality in infected patient, though with poor prognostic performances in our severely ill sample.

Prevalence of advance directives and impact on advanced life support in out-of-hospital cardiac arrest victims.

AIM: To evaluate the prevalence of advance directives and their impact on the management of out-of-hospital cardiac arrest (OHCA) victims. METHODS: We analyzed data extracted from the French national registry of adult OHCA patients (RéAC). The data concerned the emergency medical services (EMS) of a Paris suburb over the period 01/01/2013 to 30/11/2015. The primary endpoint was the prevalence of advance directives. Secondary endpoints were the characteristics of the population, of cardiac arrest, and of basic life support as well as outcomes in patients with or without advance directives. RESULTS: Advance directives were available for 148/1985 (7.5%) of OHCA patients. Advanced life support was given to 35 patients with directives and 941 patients without (24% vs. 51%, p <0.0001) with no significant difference in the characteristics of the support provided. Spontaneous recovery of cardiac activity was observed in 5 patients with directives and in 217 patients without (14% vs. 23%, p=0.3). Among patients with advance directives, only one was admitted to hospital. He/she died within 24h of admission. CONCLUSION: Advance directives were accessed by EMS for 7.5% OHCA patients. Despite their availability, advanced life support was provided to 24% of patients.