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Aim: In-hospital paediatric cardiopulmonary resuscitation (CPR) survival has been improving in high-income countries. This study aimed to analyse factors associated with survival and neurological outcome after paediatric CPR in a middle-income country. Methods: This observational study of in-hospital cardiac arrest using Utstein-style registry included patients <18 years old submitted to CPR between 2015 and 2020, at a high-complexity hospital. Outcomes were survival and neurological status assessed using Paediatric Cerebral Performance Categories score at prearrest, discharge, and after 180 days. Results: Of 323 patients who underwent CPR, 108 (33.4%) survived to discharge and 93 (28.8%) after 180 days. In multivariable analysis, lower survival at discharge was associated with liver disease (OR 0.060, CI 0.007-0.510, p = 0.010); vasoactive drug infusion before cardiac arrest (OR 0.145, CI 0.065-0.325, p < 0.001); shock as the immediate cause (OR 0.183, CI 0.069-0.486, p = 0.001); resuscitation > 30 min (OR 0.070, CI 0.014-0.344, p = 0.001); and bicarbonate administration during CPR (OR 0.318, CI 0.130-0.780, p = 0.01). The same factors remained associated with lower survival after 180 days. Neurological outcome was analysed in the 93 survivors after 180 days following CPR. Prearrest neurological dysfunction was observed in 31.4%, and neurological prognosis was favourable in 79.7% at discharge and similar after 180 days. Conclusion: In-hospital paediatric cardiac arrest patients with complex chronic conditions had lower survival associated with liver disease, shock as cause of cardiac arrest, vasoactive drug infusion before cardiac arrest, bicarbonate administration during CPR, and prolonged resuscitation. Most survivors had favourable neurological outcome.
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The data presented in this article are related to the research article, "The Use of End-Tidal Carbon Dioxide (ETCO2) Measurement to Guide Management of Cardiac Arrest: A Systematic Review" [1]. This article is a systematic review and meta-analysis of existing data on the subject of whether any level of end-tidal carbon dioxide (ETCO2) measured during cardiopulmonary resuscitation (CPR) correlates with return of spontaneous circulation (ROSC) or survival in adult patients experiencing cardiac arrest in any setting. These data are made publicly available to enable critical or extended analyses.
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AIMS: To identify whether any level of end-tidal carbon dioxide (ETCO2) measured during cardiopulmonary resuscitation (CPR) correlates with return of spontaneous circulation (ROSC) or survival in adults experiencing cardiac arrest in any setting. METHODS: Systematic review. We included randomized controlled trials, cohort studies, and case-control studies of adult cardiac arrest in any setting that reported specific (rather than pooled) ETCO2 values and attempted to correlate those values with prognosis. Full-text articles were searched on EmBASE, MEDLINE, and Cochrane Database. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) guidelines were followed, assigning levels of quality to all evidence used in the meta-analysis. RESULTS: Seventeen observational studies, describing a total of 6198 patients, were included in the qualitative synthesis, and five studies were included in the meta-analysis. The available studies provided consistent but low-quality evidence that ETCO2 measurements ≥10mmHg, obtained at various time points during CPR, are substantially related to ROSC. Additional cut-off values were also found. Initial ETCO2 or 20-min ETCO2>20mmHg appears to be a better predictor of ROSC than the 10mmHg cut off value. A ETCO2<10mmHg after 20min of CPR is associated with a 0.5% likelihood of ROSC. CONCLUSIONS: Based upon existing evidence, ETCO2 levels do seem to provide limited prognostic information for patients who have experienced cardiac arrest. Given the many potential confounders that can influence initial ETCO2 levels, extreme or trending values may be more useful than static mid-range levels. Additional well-designed studies are needed to define optimal timing for the measurement of ETCO2 for prognostic purposes.
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Dióxido de Carbono/análise , Reanimação Cardiopulmonar , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Parada Cardíaca Extra-Hospitalar/terapia , Adulto , Dióxido de Carbono/metabolismo , Estudos de Casos e Controles , Humanos , Estudos Observacionais como Assunto , Parada Cardíaca Extra-Hospitalar/mortalidade , Valor Preditivo dos Testes , Estudos Prospectivos , Análise de Sobrevida , Volume de Ventilação Pulmonar/fisiologiaRESUMO
The importance of thrombosis and anticoagulation in clinical practice is rooted firmly in several fundamental constructs that can be applied both broadly and globally. Awareness and the appropriate use of anticoagulant therapy remain the keys to prevention and treatment. However, to assure maximal efficacy and safety, the clinician must, according to the available evidence, choose the right drug, at the right dose, for the right patient, under the right indication, and for the right duration of time. The first International Symposium of Thrombosis and Anticoagulation in Internal Medicine was a scientific program developed by clinicians for clinicians. The primary objective of the meeting was to educate, motivate and inspire internists, cardiologists and hematologists by convening national and international visionaries, thought-leaders and dedicated clinician-scientists in Sao Paulo, Brazil. This article is a focused summary of the symposium proceedings.
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Anticoagulantes , Congressos como Assunto , Trombose , BrasilRESUMO
UNLABELLED: The risk for venous thromboembolism (VTE) in medical patients is high, but risk assessment is rarely performed because there is not yet a good method to identify candidates for prophylaxis. PURPOSE: To perform a systematic review about VTE risk factors (RFs) in hospitalized medical patients and generate recommendations (RECs) for prophylaxis that can be implemented into practice. DATA SOURCES: A multidisciplinary group of experts from 12 Brazilian Medical Societies searched MEDLINE, Cochrane, and LILACS. STUDY SELECTION: Two experts independently classified the evidence for each RF by its scientific quality in a standardized manner. A risk-assessment algorithm was created based on the results of the review. DATA SYNTHESIS: Several VTE RFs have enough evidence to support RECs for prophylaxis in hospitalized medical patients (eg, increasing age, heart failure, and stroke). Other factors are considered adjuncts of risk (eg, varices, obesity, and infections). According to the algorithm, hospitalized medical patients > or =40 years-old with decreased mobility, and > or =1 RFs should receive chemoprophylaxis with heparin, provided they don't have contraindications. High prophylactic doses of unfractionated heparin or low-molecular-weight-heparin must be administered and maintained for 6-14 days. CONCLUSIONS: A multidisciplinary group generated evidence-based RECs and an easy-to-use algorithm to facilitate VTE prophylaxis in medical patients.
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Algoritmos , Tromboembolia/prevenção & controle , Humanos , Medição de RiscoRESUMO
BACKGROUND: When efforts to resuscitate a child after cardiac arrest are unsuccessful despite the administration of an initial dose of epinephrine, it is unclear whether the next dose of epinephrine (i.e., the rescue dose) should be the same (standard) dose or a higher dose. METHODS: We performed a prospective, randomized, double-blind trial to compare high-dose epinephrine (0.1 mg per kilogram of body weight) with standard-dose epinephrine (0.01 mg per kilogram) as rescue therapy for in-hospital cardiac arrest in children after failure of an initial, standard dose of epinephrine. The trial included 68 children, and Utstein-style reporting guidelines were used. The primary outcome measure was survival 24 hours after the arrest. RESULTS: The rate of survival at 24 hours was lower in the group assigned to a high dose of epinephrine as rescue therapy than in the group assigned to a standard dose: 1 of the 34 patients in the high-dose group survived for 24 hours, as compared with 7 of the 34 patients in the standard-dose group (unadjusted odds ratio for death with the high dose, 8.6; 97.5 percent confidence interval, 1.0 to 397.0; P=0.05). After adjustment by multiple logistic-regression analysis for differences in the groups at the time of arrest, the high-dose group tended to have a lower 24-hour survival rate (odds ratio for death, 7.9; 97.5 percent confidence interval, 0.9 to 72.5; P=0.08). The two treatment groups did not differ significantly in terms of the rate of return of spontaneous circulation (which occurred in 20 patients in the high-dose group and 21 of those in the standard-dose group; odds ratio, 1.1; 97.5 percent confidence interval, 0.4 to 3.0). None of the patients in the high-dose group, as compared with four of those in the standard-dose group, survived to hospital discharge. Among the 30 patients whose cardiac arrest was precipitated by asphyxia, none of the 12 who were assigned to high-dose epinephrine were alive at 24 hours, as compared with 7 of the 18 who were assigned to a standard dose (P=0.02). CONCLUSIONS: We did not find any benefit of high-dose epinephrine rescue therapy for in-hospital cardiac arrest in children after failure of an initial standard dose of epinephrine. The data suggest that high-dose therapy may be worse than standard-dose therapy.
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Reanimação Cardiopulmonar , Epinefrina/administração & dosagem , Parada Cardíaca/tratamento farmacológico , Simpatomiméticos/administração & dosagem , Asfixia/complicações , Asfixia/mortalidade , Criança , Pré-Escolar , Relação Dose-Resposta a Droga , Método Duplo-Cego , Epinefrina/efeitos adversos , Feminino , Parada Cardíaca/etiologia , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Mortalidade Hospitalar , Humanos , Lactente , Masculino , Estudos Prospectivos , Terapia de Salvação , Choque/complicações , Choque/mortalidade , Taxa de Sobrevida , Simpatomiméticos/efeitos adversosRESUMO
OBJECTIVE: Amiodarone has been shown to be superior to both placebo and lidocaine in improving survival to hospital admission for victims of out-of-hospital refractory ventricular fibrillation. Concern had been expressed about the known vasodilatatory effects of amiodarone if given without precedent vasoconstrictive medications. The haemodynamic effects of intravenous amiodarone administered during ongoing CPR have not been systemically investigated. Our intention was to verify if amiodarone alone produced significantly lower resuscitation haemodynamics than did either adrenaline (epinephrine) alone or the combination of amiodarone and adrenaline. DESIGN: Prospective, randomized, comparative study. SETTING: Research laboratory of a medical school. SUBJECTS: Thirty mongrel dogs. INTERVENTIONS: After 8 min of untreated VF, defibrillation was attempted once at 3 J/kg and external chest compressions and ventilation started. Those animals resistant to the defibrillation attempt were randomized, ten to an adrenaline (0.02 mg/kg) group, ten to an amiodarone (5 mg/kg) group, and ten to a group receiving a combination of both drugs. MEASUREMENTS AND MAIN RESULTS: Aortic systolic and diastolic, and coronary perfusion pressures were all significantly lower in the group receiving amiodarone alone than in the other two groups. Amiodarone combined with adrenaline produced pressures during CPR similar to adrenaline alone. CONCLUSION: Amiodarone can be safely administered simultaneously in combination with adrenaline and such a combination results in similar haemodynamic support as adrenaline alone. Amiodarone administered alone produces significantly lower coronary perfusion pressure than when combined with adrenaline.
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Amiodarona/farmacologia , Reanimação Cardiopulmonar , Hemodinâmica/efeitos dos fármacos , Vasodilatadores/farmacologia , Fibrilação Ventricular/terapia , Amiodarona/administração & dosagem , Animais , Cães , Quimioterapia Combinada , Cardioversão Elétrica , Epinefrina/farmacologia , Parada Cardíaca/etiologia , Parada Cardíaca/terapia , Injeções Intravenosas , Distribuição Aleatória , Vasodilatadores/administração & dosagem , Fibrilação Ventricular/complicaçõesRESUMO
O conhecimento atualizado das taquiarritmias é fundamental no seu diagnóstico e fator decisivo para abordagem precisa na sala de emergência. Neste artigo, procuramos agrupar didaticamente, por meio de algoritmos, as taquiarritmias supraventriculares e ventriculares de forma a facilitar ao emergencista o diagnóstico e seus respectivos tratamentos. Devemos priorizar a importância da abordagem clínica e sempre tentar correlacionar quando a taquiarritmia em questäo está produzindo sinais e sintomas. Por fim, enfatizamos de forma prática a açäo dos antiarritmicos e os possíveis riscos e benefícios de cada um deles.