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PubMed2001

Termination of resuscitative efforts: medical futility for the trauma patient.

Despite years of research on the resuscitation of the patient with critical traumatic injuries, controversy remains surrounding the criteria to waive initiation of resuscitation in the pre-hospital setting or to terminate such efforts in the emergency department. The decision to initiate or continue resuscitation on moribund trauma patients is associated with considerable costs. Ambulance transport using lights and sirens carries potential risk. Emergency department thoracotomy, with exposure to high risk bodily fluids, involvement of numerous staff, and usage precious blood products, is a procedure that has fewer and fewer indications. This review presents guidelines to help determine when to initiate resuscitation for the critically injured trauma patient and when to cease these efforts in the emergency department. Since there are economic, societal, and ethical implications, each system should establish their own criteria, using these guidelines as a basis.

Cardiopulmonary Resuscitation↗
PubMed1992

[Decision to withdraw cardiopulmonary resuscitation at Norwegian hospitals].

We present a survey on the use of do-not-resuscitate orders in Norwegian hospitals based on mailed questionnaires. 559 doctors, at least one from every somatic hospital in Norway responded. Do-not-resuscitate orders were issued by 92% of these doctors. There were large differences, however, as to who made the decision, who was involved in the decision-making, the consequences of a do-not-resuscitate order, and how the orders were documented. Formal rules for do-not-resuscitate orders are needed.

Cardiopulmonary Resuscitation↗
PubMed1992

Prearrest predictors of survival following in-hospital cardiopulmonary resuscitation: a meta-analysis.

BACKGROUND: The success rate of cardiopulmonary resuscitation (CPR) varies with the patient population studied. Prearrest variables have been used to identify groups of patients with a particularly low rate of survival following CPR. The purpose of this study was to use the technique of meta-analysis to identify prearrest variables associated with a decreased rate of survival to the time of discharge following CPR of hospitalized patients. METHODS: The MEDLINE database was searched using the following key words: resuscitation, survival, and 1980-1991. The bibliographies of studies identified in the computerized search as well as those of appropriate studies in the author's personal files were reviewed. The following inclusion criteria were used: study published since 1980 (data collected after 1975), in-hospital resuscitation, retrospective or prospective design, consecutive adult patients from both the general wards and intensive care units, an end-point of survival to hospital discharge, and data reported for at least one variable measured before cardiac arrest. Of the 22 studies initially identified, 14 met the above criteria. Data were taken directly from the published reports. In two cases where no specific survival data were reported but the studies met all other criteria for inclusion, the authors were contacted and agreed to supply the necessary information. Two-way variables were combined across studies using the Mantel-Haenszel statistic. RESULTS: The following prearrest variables were associated with a decreased rate of survival to discharge following CPR (P less than .005): age over 70 years, serum creatinine greater than 130 mumol/L, serum creatinine greater than 220 mumol/L, homebound lifestyle, presence of cancer or metastatic cancer, and a primary diagnosis of sepsis or pneumonia. A primary diagnosis of myocardial infarction was associated with an increased rate of survival to discharge following CPR (P = .005). Based on these results, modifications to the Pre-Arrest Morbidity Index initially devised by George and colleagues have been proposed. CONCLUSIONS: The identification of prearrest variables that are associated with decreased survival following CPR will assist clinicians when they counsel their patients regarding do-not-resuscitate (DNR) orders. In addition, the further refinement of a predictive tool such as the modified Pre-Arrest Morbidity Index can help clinicians to identify patients for whom CPR is futile. Such an instrument must be validated on an independent data set before it can be considered for clinical application.

Age Factors↗
PubMed1993

Management of cardiopulmonary and trauma resuscitation in the pediatric emergency department.

The etiology and management of critical illness and injury in a pediatric emergency department were reviewed to survey the use of cardiopulmonary and trauma resuscitation and to compare these data with the educational content of Pediatric Advanced Life Support (PALS) courses. The emergency department records of 183 patients treated in the cardiopulmonary/trauma resuscitation room of a pediatric emergency department over a 17-month period were reviewed for data on diagnosis, morbidity, presence of apnea or pulselessness, and utilization of several resuscitation skills: intubation, cardioversion, tibial interosseous line placement, and other resuscitation techniques. Apneic and pulseless pediatric patients had poor survival (10.3%), but apneic patients had excellent survival (96.9%). Endotracheal intubation (57.9%), bag-valve-mask ventilation (63.9%), and medications for rapid-sequence induction of anesthesia prior to endotracheal intubation (25.7%) were used frequently. Inasmuch as asystole was the most common rhythm in pulseless patients, cardioversion and defibrillation were rarely used (2.2%). Specialized vascular access techniques, tibial interosseous lines (24.0%), and femoral intravenous lines (19.7%), were used frequently in pediatric patients. The frequent use of airway management skills and the excellent survival of apneic pediatric patients supports the current emphasis on airway management in PALS courses. Cardioversion/defibrillation should receive less emphasis in PALS courses. The frequent use of rapid-sequence induction of anesthesia prior to endotracheal intubation indicates that these techniques might warrant increased emphasis in the training of pediatric emergency department personnel and in PALS courses.

Apnea↗
PubMed1996

The impact of do-not-resuscitate and patient care category policies on CPR and ventilator support rates.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is automatically provided in the event of a cardiac or pulmonary arrest, unless an order not to resuscitate is written. When successful, CPR usually leads to mechanical ventilatory support. A patient care category (PCC) policy, which replaces a do-not-resuscitate (DNR) policy, assigns a category on admission describing care to be provided. This PCC policy is perceived to avoid more unnecessary or undesired medical care that includes CPR and subsequent mechanical ventilatory support than a DNR policy. OBJECTIVE: To compare total rates of CPR and days of mechanical ventilatory support before and after instituting DNR and PCC policies. METHODS: A 7-year (1984 through 1990) retrospective review of rates of CPR and days of mechanical ventilatory support (DVS) in a community-teaching hospital was conducted. Two years were considered the baseline in which an institutional order not-to-resuscitate policy was nonexistent. Two years were during which an institutional DNR policy existed. Three years were during which an institutional PCC policy replaced the DNR policy. RESULTS: Compared with baseline years, during the DNR years mortality increased (8%), and CPR (-17%) and DVS (-8%) per 1000 admissions and CPR per 100 deaths (-26%) decreased. Compared with baseline years, during the PCC years mortality was unchanged and CPR (-61%) and DVS (-46%) per 1000 admissions and CPR per 100 deaths (-60%) decreased. Compared with DNR years, during the PCC years mortality (-8%), CPR (-53%), and DVS (-42%) per 1000 admissions and CPR per 100 deaths (-46%) decreased. CONCLUSIONS: A DNR policy significantly decreases the rates of CPR and DVS, but only modestly. A PCC policy dramatically decreases the rates of CPR and DVS with no change in mortality.

Cardiopulmonary Resuscitation↗
PubMed1987

Cancer and resuscitation. Does the diagnosis affect the decision?

We asked if physicians are less likely to resuscitate patients with cancer because of the diagnostic label alone. We composed a questionnaire of nine patient vignettes with similar expected mortality rates, identical quality of life, and witnessed cardiopulmonary arrest. Internists and neurologists in a university training program were asked to decide, for each "patient," whether to administer cardiopulmonary resuscitation (CPR) before and after being informed of similar mortality rates. Decisions for CPR were less frequent for cancer vignettes than for vignettes of other chronic medical illnesses before and after mortality information was given. Analysis indicated that decisions varied among physicians according to their subspecialties. Overall, women favored resuscitation less often than did men. The diagnosis of cancer appears to have a negative impact on physicians' CPR decisions over and above that due to inaccurate prognostic assumptions about cancer. A physician's subspecialty and gender may also influence resuscitation decisions for patients in general.

Aged↗
PubMed1993

Results of cardiopulmonary resuscitation. Failure to predict survival in two community hospitals.

BACKGROUND: The use of closed chest cardiopulmonary resuscitation (CPR) has, since its initial description in 1960, expanded greatly. Recently, much energy has focused on identifying patients' probabilities of responding to CPR. The goal of this study was to determine the current rate of successful CPR in two community teaching hospitals and to identify patient characteristics associated with the likelihood of successful resuscitation. METHODS: A retrospective review of the medical records of all patients receiving CPR during 1988 and 1989 in two university-affiliated teaching hospitals. This review identified 300 patients who experienced in-hospital cardiopulmonary arrest during the study period. RESULTS: Survival of CPR and survival to hospital discharge were 53.9% and 23.3% in the combined populations. Likelihood of survival of CPR was increased when the initial rhythm was ventricular tachycardia or ventricular fibrillation and when the duration of CPR was less than 30 minutes. Survival to hospital discharge was associated with shorter duration of CPR. Combinations of variables did not allow improved prediction of resuscitation results but did aid in predicting survival to hospital discharge. Combinations of variables that were associated with survival in one hospital were not transferable to the other institution. CONCLUSION: Other than the length of resuscitation, easily accessible clinical variables provided limited predictive information about CPR results.

Aged↗
PubMed1999

Quality of survival after cardiopulmonary resuscitation.

BACKGROUND: Outcome of cardiopulmonary resuscitation (CPR) can be poor, in terms of life expectancy and quality of life. OBJECTIVES: To determine the impact of patient characteristics before, during, and after CPR on these outcomes, and to compare results of the quality-of-life assessment with published studies. METHODS: In a cohort study, we assessed by formal instruments the quality of life, cognitive functioning, depression, and level of dependence of survivors after inhospital CPR. Follow-up was at least 3 months after discharge from the hospital (tertiary care center). RESULTS: Of 827 resuscitated patients, 12% (n = 101) survived to follow-up. Of the survivors, 89% participated in the study. Most survivors were independent in daily life (75%), 17% were cognitively impaired, and 16% had depressive symptoms. Multivariate regression analysis showed that quality of life and cognitive function were determined by 2 factors known before CPR-the reason for admission and age. Factors during and after resuscitation, such as prolonged cardiac arrest and coma, did not significantly determine the quality of life or cognitive functioning of survivors. The quality of life of our CPR survivors was worse compared with a reference group of elderly individuals, but better than that of a reference group of patients with stroke. The quality of life did not importantly differ between the compared studies of CPR survivors. CONCLUSIONS: Cardiopulmonary resuscitation is frequently unsuccessful, but if survival is achieved, a relatively good quality of life can be expected. Quality of life after CPR is mostly determined by factors known before CPR. These findings may be helpful in informing patients about the outcomes of CPR.

Activities of Daily Living↗
PubMed1984

Cardiorespiratory arrest and resuscitation of children.

Ninety-one patients had cardiorespiratory arrest in a children's hospital emergency department over six years. Only five children survived, three with severe neurologic sequelae. The records of 40 other children in the same community resuscitated by paramedics, but taken to other hospitals, were reviewed and there were three survivors. The causes and outcomes of resuscitation of children are clearly different from those of adults. Cardiac disease and ventricular arrhythmias are uncommon. Neurologically intact survival was seen only in those children who received immediate resuscitation and responded promptly. Research in cerebral resuscitation at the cellular level is promising for the future. Prevention of some cardiorespiratory arrests through accident prevention and earlier recognition of serious infections is possible now.

Brain Diseases↗
PubMed1986

Longitudinal development in pediatric residents of attitudes toward neonatal resuscitation.

We used Guttman scaling procedures to devise a quantitative, reproducible measure among pediatric residents of attitude change concerning neonatal resuscitation. Preliminary cross-sectional testing of an incoming group of pediatric level 1 residents and graduating pediatric level 3 residents indicated that pediatric level 3 residents were more reluctant to resuscitate high-risk infants. This reluctance was not due to age differences. The pediatric level 1 residents were retested at the completion of each year of training. Residents showed significantly increased reluctance to resuscitate infants at the end of the first year of training and again at the end of the third year of training. These attitude changes were unrelated to gender, marital status, religious preference, or ethnic background. Data acquired both cross-sectionally and longitudinally indicated that attitudes toward neonatal resuscitation changed during residency training.

Attitude of Health Personnel↗
PubMed1998

Delayed fluid resuscitation of head injury and uncontrolled hemorrhagic shock.

OBJECTIVE: To evaluate the effects of delayed vs early fluid resuscitation on cerebral hemodynamics after severe head injury and uncontrolled hemorrhagic shock. DESIGN: Prospective, randomized, controlled experimental trial. SETTING: Surgical research laboratory. PARTICIPANTS: Immature swine (N=16) weighing 40 to 50 kg. INTERVENTIONS: Twelve swine were subjected to cryogenic brain lesion and hemorrhage to maintain a mean arterial pressure (MAP) of 50 mm Hg. Animals were randomized to receive 1 L of Ringer lactate solution in 20 minutes, starting 20 minutes after injury and hemorrhage, followed by 1 L of Ringer lactate solution in 30 minutes (ER group) (n=6), or no fluid resuscitation (DR group) (n=6). The 4 control animals underwent instrumentation only. The study ended 70 minutes after head injury and hemorrhage. MAIN OUTCOME MEASUREMENTS: Measurements of MAP, bilateral regional cerebral blood flow, serum hemoglobin level, systemic and regional cerebral oxygen delivery, and intracranial pressure performed at baseline and 20 (phase 1), 50 (phase 2), and 70 minutes (phase 3) after head injury and hemorrhage. Lesion size (percentage of ipsilateral cortex) was measured post mortem. RESULTS: All animals survived the experimental period. Systemic cerebral oxygen delivery in the DR group was significantly lower at phase 3 compared with that of the ER group (31.5% vs 53.1% at baseline) (P=.03). However, bilateral regional cerebral oxygen delivery was significantly greater in the DR group at phase 3 compared with that of the ER group (71.5% vs 47.0% at baseline in the injured side; 72.9% vs 48.4% at baseline in the noninjured side) (P=.02). Bilateral cerebral blood flow was similar in all groups at all times. The ER group showed a trend toward a greater intracranial pressure elevation (6.8 vs -0.25) (P=.07) and lesion size (37.0% vs 28.6%) (P=.07). Hemoglobin level became significantly lower in the ER group at phase 2 (7.0 vs 10.7) (P=.03) and remained lower at phase 3 (6.9 vs 11.7) (P=.01). CONCLUSIONS: Early fluid resuscitation with Ringer lactate solution following head injury and uncontrolled hemorrhagic shock worsens cerebral hemodynamics. Cerebral pressure autoregulation is sufficiently intact following head injury to maintain regional cerebral oxygen delivery without asanguineous fluid resuscitation.

Animals↗
PubMed1999

Relationship of systemic inflammatory response syndrome to organ dysfunction, length of stay, and mortality in critical surgical illness: effect of intensive care unit resuscitation.

BACKGROUND: A systemic proinflammatory response has been implicated in the pathogenesis of organ dysfunction. The effects of surgery, surgical stress, anesthesia, and subsequent intensive care unit (ICU) resuscitation may affect the components of the systemic inflammatory response syndrome (SIRS) score (temperature, heart rate, respiratory rate, and white blood cell count). Any SIRS scores calculated within 24 hours after surgery or at the onset of nonoperative resuscitation may overestimate the proinflammatory response itself, making quantitation of SIRS at that time potentially too sensitive. We hypothesized that SIRS attributable to ICU resuscitation can be quantitated, and that SIRS after the first day of therapy in the ICU correlates with several outcomes. METHODS: Prospective analysis of 2300 surgical ICU admissions during a 49-month period. Acute Physiology and Chronic Health Evaluation III (APACHE III) scores were recorded after 24 hours. Daily and cumulative multiple organ dysfunction scores (0-4 points for each of 6 organs, 24 points total) and SIRS scores (1 point for each parameter, 4 points total) were recorded. Defined end points were hospital mortality, days in the ICU, and organ dysfunction. RESULTS: On day 1, 49.4% of patients had SIRS (score > or =2), whereas 34.5% of patients who remained in the ICU had SIRS (score > or =2) on day 2 (P<.001). The SIRS score decreased by a mean of 0.8 points from day 1 to day 2, regardless of the type of admission. A SIRS score that decreased on day 2, in comparison with the score on day 1, resulted in less mortality than a unchanged or higher score on day 2 (11% vs. 18% vs. 22%, P<.001). Systemic inflammatory response scores were higher for nonsurvivors than survivors on each of the first 7 days in the ICU. The day 2 SIRS score correlated well with the admission APACHE III score (P<.001) and all defined end points (all P<.001). The day 2 SIRS score also correlated with the day 2 multiple organ dysfunction score (P<.001). By multiple logistic regression, APACHE III (P<.001), day 2 SIRS score (P<.01) (but not day 1 SIRS score, P = .99), and day 2 multiple organ dysfunction score (P<.001) (but not day 1 multiple organ dysfunction score, P = .81) predicted mortality. CONCLUSIONS: Systemic inflammatory response syndrome attributable to surgery or surgical stress can be quantitated. Twenty-four hours of ICU resuscitation results in a decline in the SIRS score. The magnitude of the proinflammatory response on the second ICU day may be a useful predictor of outcome in critical surgical illness.

APACHE↗
PubMed1986

Effect of fresh-frozen plasma resuscitation on cardiopulmonary function and serum protein flux.

The adverse effects of albumin resuscitation on coagulation activity, cardiopulmonary function, and extravascular flux of nonalbumin protein have made fresh-frozen plasma (FFP) an attractive alternate volume expander for hemorrhagic shock. This study addresses the effects of FFP on cardiopulmonary hemodynamics and protein flux. Whole blood was collected three and six weeks before shock, separated into red blood cells (PRBCs) and FFP, and stored. In 24 conditioned splenectomized dogs, resuscitation from reservoir shock of two hours' duration consisted of autologous PRBCs and balanced electrolyte solution (BES) in control dogs and PRBCs, BES, and FFP in plasma-treated dogs. Hemorrhagic shock reduced serum albumin and IgG levels in both groups. Resuscitation with FFP led to a higher cardiac output, left ventricular stroke work (LVSW), and pulmonary capillary wedge pressure (PCWP). The PCWP/LVSW ratio was comparable for both groups. Postshock day 2 serum albumin and IgG levels and lymphatic albumin and IgG concentrations were increased in plasma dogs. Therefore, FFP supplement to PRBC and BES resuscitation does not derange the PCWP/LVSW ratio or reduce intravascular nonalbumin proteins.

Albumins↗
PubMed1992

Hypocalcemia during sepsis. Relationship to resuscitation and hemodynamics.

The ionized calcium (IC) and parathyroid hormone response to polymicrobial intra-abdominal sepsis and the relationship between IC and hemodynamic alterations with and without crystalloid resuscitation were investigated. Thirty swine underwent cecal ligation and incision (n = 19) or sham laparotomy (n = 11), with seven animals that had cecal ligation and incision administered Ringer's solution (50 mL/kg) after each set of measurements recorded on days 0, 1, 2, 4, and 8. An early decrease in mean arterial pressure and cardiac index in animals that had cecal ligation and incision reversed with resuscitation. The IC also fell early and parathyroid hormone level increased in both the unresuscitated and resuscitated septic groups. However, correlation coefficients of mean arterial pressure and cardiac index with IC ranged from .034 to .287 in the septic animals and were lower in the group that had sham laparotomy. We conclude that polymicrobial intra-abdominal sepsis results in decreased IC and an elevated parathyroid hormone level. Hemodynamics do not correlate with IC levels, and resuscitation can be achieved without calcium administration.

Animals↗
PubMed1997

Reduced resuscitation fluid volume for second-degree burns with delayed initiation of ascorbic acid therapy.

BACKGROUND: Oxygen radicals may play an important role in injury due to thermal burns. High-dose antioxidant ascorbic acid (vitamin C, Cenolete, Abbott Laboratory, Abbott Park, Ill) therapy reduces edema of burned and unburned tissue, lipid peroxidation, and subsequent resuscitation fluid volume requirement in experimental burn models. OBJECTIVE: To determine the hemodynamic effects of delayed initiation (2 hours after injury) of antioxidant therapy in patients with second-degree burns. DESIGN: Experimental study. MATERIALS AND INTERVENTION: Burns over 70% of body surface area were produced by subxiphoid immersion of 12 guinea pigs in 100 degrees C water for 3 seconds. The animals were resuscitated with Ringer's lactated solution according to the Parkland formula (4 mL/kg for 1% of burned body surface area during the first 24 hours) from 0.5 to 2 hours following injury, after which the resuscitation fluid volume was reduced to 25% of the Parkland formula. Animals received Ringer's lactated solution to which ascorbic acid (340 mg/kg during the first 24 hours) was added (vitamin C group [n = 6]) or Ringer's lactated solution only (control group [n = 6]). MEASUREMENTS: Heart rates, mean arterial blood pressure, cardiac output, hematocrit level, and water content in burned and unburned tissue were measured before injury and at intervals thereafter. RESULTS: There were no significant differences in heart rates (P = .29) and blood pressures (P = .53) between the 2 groups throughout the 24-hour study period. No animal died. The vitamin C group showed significantly lower hematocrit levels (P < .05) and significantly higher cardiac output values (P < .05) at 7 hours following burn injury and at intervals thereafter (P < .001). CONCLUSION: With delayed initiation of high-dose ascorbic acid therapy, the 24-hour fluid resuscitation volume was reduced to 32.5% of the Parkland formula, while maintaining adequate cardiac output values.

Animals↗
PubMed2006

Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial.

CONTEXT: High-quality cardiopulmonary resuscitation (CPR) may improve both cardiac and brain resuscitation following cardiac arrest. Compared with manual chest compression, an automated load-distributing band (LDB) chest compression device produces greater blood flow to vital organs and may improve resuscitation outcomes. OBJECTIVE: To compare resuscitation outcomes following out-of-hospital cardiac arrest when an automated LDB-CPR device was added to standard emergency medical services (EMS) care with manual CPR. DESIGN, SETTING, AND PATIENTS: Multicenter, randomized trial of patients experiencing out-of-hospital cardiac arrest in the United States and Canada. The a priori primary population was patients with cardiac arrest that was presumed to be of cardiac origin and that had occurred prior to the arrival of EMS personnel. Initial study enrollment varied by site, ranging from late July to mid November 2004; all sites halted study enrollment on March 31, 2005. INTERVENTION: Standard EMS care for cardiac arrest with an LDB-CPR device (n = 554) or manual CPR (n = 517). MAIN OUTCOME MEASURES: The primary end point was survival to 4 hours after the 911 call. Secondary end points were survival to hospital discharge and neurological status among survivors. RESULTS: Following the first planned interim monitoring conducted by an independent data and safety monitoring board, study enrollment was terminated. No difference existed in the primary end point of survival to 4 hours between the manual CPR group and the LDB-CPR group overall (N = 1071; 29.5% vs 28.5%; P = .74) or among the primary study population (n = 767; 24.7% vs 26.4%, respectively; P = .62). However, among the primary population, survival to hospital discharge was 9.9% in the manual CPR group and 5.8% in the LDB-CPR group (P = .06, adjusted for covariates and clustering). A cerebral performance category of 1 or 2 at hospital discharge was recorded in 7.5% of patients in the manual CPR group and in 3.1% of the LDB-CPR group (P = .006). CONCLUSIONS: Use of an automated LDB-CPR device as implemented in this study was associated with worse neurological outcomes and a trend toward worse survival than manual CPR. Device design or implementation strategies require further evaluation. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00120965.

Aged↗
PubMed2006

Use of an automated, load-distributing band chest compression device for out-of-hospital cardiac arrest resuscitation.

CONTEXT: Only 1% to 8% of adults with out-of-hospital cardiac arrest survive to hospital discharge. OBJECTIVE: To compare resuscitation outcomes before and after an urban emergency medical services (EMS) system switched from manual cardiopulmonary resuscitation (CPR) to load-distributing band (LDB) CPR. DESIGN, SETTING, AND PATIENTS: A phased, observational cohort evaluation with intention-to-treat analysis of 783 adults with out-of-hospital, nontraumatic cardiac arrest. A total of 499 patients were included in the manual CPR phase (January 1, 2001, to March 31, 2003) and 284 patients in the LDB-CPR phase (December 20, 2003, to March 31, 2005); of these patients, the LDB device was applied in 210 patients. INTERVENTION: Urban EMS system change from manual CPR to LDB-CPR. MAIN OUTCOME MEASURES: Return of spontaneous circulation (ROSC), with secondary outcome measures of survival to hospital admission and hospital discharge, and neurological outcome at discharge. RESULTS: Patients in the manual CPR and LDB-CPR phases were comparable except for a faster response time interval (mean difference, 26 seconds) and more EMS-witnessed arrests (18.7% vs 12.6%) with LDB. Rates for ROSC and survival were increased with LDB-CPR compared with manual CPR (for ROSC, 34.5%; 95% confidence interval [CI], 29.2%-40.3% vs 20.2%; 95% CI, 16.9%-24.0%; adjusted odds ratio [OR], 1.94; 95% CI, 1.38-2.72; for survival to hospital admission, 20.9%; 95% CI, 16.6%-26.1% vs 11.1%; 95% CI, 8.6%-14.2%; adjusted OR, 1.88; 95% CI, 1.23-2.86; and for survival to hospital discharge, 9.7%; 95% CI, 6.7%-13.8% vs 2.9%; 95% CI, 1.7%-4.8%; adjusted OR, 2.27; 95% CI, 1.11-4.77). In secondary analysis of the 210 patients in whom the LDB device was applied, 38 patients (18.1%) survived to hospital admission (95% CI, 13.4%-23.9%) and 12 patients (5.7%) survived to hospital discharge (95% CI, 3.0%-9.3%). Among patients in the manual CPR and LDB-CPR groups who survived to hospital discharge, there was no significant difference between groups in Cerebral Performance Category (P = .36) or Overall Performance Category (P = .40). The number needed to treat for the adjusted outcome survival to discharge was 15 (95% CI, 9-33). CONCLUSION: Compared with resuscitation using manual CPR, a resuscitation strategy using LDB-CPR on EMS ambulances is associated with improved survival to hospital discharge in adults with out-of-hospital nontraumatic cardiac arrest.

Aged↗
PubMed2004

Colloids versus crystalloids for fluid resuscitation in critically ill patients.

BACKGROUND: Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids. OBJECTIVES: To assess the effects on mortality of colloids compared to crystalloids for fluid resuscitation in critically ill patients. SEARCH STRATEGY: We searched the Injuries Group specialised register, Cochrane Controlled Trials Register, MEDLINE, EMBASE and BIDS Index to Scientific and Technical Proceedings, and checked reference lists of trials and review articles. SELECTION CRITERIA: All randomised and quasi-randomised trials of colloids compared to crystalloids, in patients requiring volume replacement. Cross-over trials and trials in pregnant women and neonates were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and rated quality of allocation concealment. Trials with a 'double-intervention', such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, were analysed separately. The analysis was stratified according to colloid type and quality of allocation concealment. MAIN RESULTS: Colloids compared to crystalloidsAlbumin or plasma protein fraction. Nineteen trials reported data on mortality, including a total of 7576 patients. The pooled relative risk (RR) from these trials was 1.02 (95% confidence interval [95% CI] 0.93 to 1.11). When the trial with poor quality allocation concealment was excluded, pooled RR was 1.01 (95% CI 0.92 to 1.10). Hydroxyethyl starch. Ten trials compared hydroxyethyl starch with crystalloids, including a total of 374 randomised participants. The pooled RR was 1.16 (95% CI 0.68 to 1.96). Modified gelatin. Seven trials compared modified gelatin with crystalloid, including a total of 346 randomised participants. The pooled RR was 0.54 (95% CI 0.16 to 1.85). Dextran. Nine trials compared dextran with a crystalloid, including a total of 834 randomised participants. The pooled relative risk was RR 1.24 (95% CI 0.94 to 1.65). Colloids in hypertonic crystalloid compared to isotonic crystalloidEight trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1283 randomised participants. Pooled RR was 0.88 (95% CI 0.74 to 1.05). REVIEWERS' CONCLUSIONS: There is no evidence from randomised controlled trials that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of randomised controlled trials.

Colloids↗