Background Identifying critically ill patients at risk of cardiac arrest is important because it offers the opportunity for early intervention and increased survival. The aim of this study was to develop a deep learning model to predict critical events, such as cardiopulmonary resuscitation or mortality. Methods: This retrospective observational study was conducted at a tertiary university hospital. All patients younger than 18 years who were admitted to the pediatric intensive care unit from January 2010 to May 2023 were included. The main outcome was prediction performance of the deep learning model at forecasting critical events. Long short-term memory was used as a deep learning algorithm. The five-fold cross validation method was employed for model learning and testing. Results: Among the vital sign measurements collected during the study period, 11,660 measurements were used to develop the model after preprocessing; 1,060 of these data points were measurements that corresponded to critical events. The prediction performance of the model was the area under the receiver operating characteristic curve (95% confidence interval) of 0.988 (0.9751.000), and the area under the precision-recall curve was 0.862 (0.700–1.000). Conclusions: The performance of the developed model at predicting critical events was excellent. However, follow-up research is needed for external validation.
Background Respiratory quotient (RQ) may be used as a tissue hypoxia marker in various clinical settings but its prognostic significance in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) is not known. Methods: Medical records of adult patients admitted to the intensive care units after ECPR in whom RQ could be calculated from May 2004 to April 2020 were retrospectively reviewed. Patients were divided into good neurologic outcome and poor neurologic outcome groups. Prognostic significance of RQ was compared to other clinical characteristics and markers of tissue hypoxia. Results: During the study period, 155 patients were eligible for analysis. Of them, 90 (58.1%) had a poor neurologic outcome. The group with poor neurologic outcome had a higher incidence of out-of-hospital cardiac arrest (25.6% vs. 9.2%, P=0.010) and longer cardiopulmonary resuscitation to pump-on time (33.0 vs. 25.2 minutes, P=0.001) than the group with good neurologic outcome. For tissue hypoxia markers, the group with poor neurologic outcome had higher RQ (2.2 vs. 1.7, P=0.021) and lactate levels (8.2 vs. 5.4 mmol/L, P=0.004) than the group with good neurologic outcome. On multivariable analysis, age, cardiopulmonary resuscitation to pump-on time, and lactate levels above 7.1 mmol/L were significant predictors for a poor neurologic outcome but not RQ. Conclusions: In patients who received ECPR, RQ was not independently associated with poor neurologic outcome.
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What factors are effective on the CPR duration of patients under extracorporeal cardiopulmonary resuscitation: a single-center retrospective study Amir Vahedian-Azimi, Ibrahim Fawzy Hassan, Farshid Rahimi-Bashar, Hussam Elmelliti, Anzila Akbar, Ahmed Labib Shehata, Abdulsalam Saif Ibrahim, Ali Ait Hssain International Journal of Emergency Medicine.2024;[Epub] CrossRef
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Background Anticipating the need for at-birth cardiopulmonary resuscitation (CPR) in neonates is very important and complex. Timely identification and rapid CPR for neonates in the delivery room significantly reduce mortality and other neurological disabilities. The aim of this study was to create a prediction system for identifying the need for at-birth CPR in neonates based on Machine Learning (ML) algorithms.
Methods In this study, 3,882 neonatal medical records were retrospectively reviewed. A total of 60 risk factors was extracted, and five ML algorithms of J48, Naïve Bayesian, multilayer perceptron, support vector machine (SVM), and random forest were compared to predict the need for at-birth CPR in neonates. Two types of resuscitation were considered: basic and advanced CPR. Using five feature selection algorithms, features were ranked based on importance, and important risk factors were identified using the ML algorithms.
Results To predict the need for at-birth CPR in neonates, SVM using all risk factors reached 88.43% accuracy and F-measure of 88.4%, while J48 using only the four first important features reached 90.89% accuracy and F-measure of 90.9%. The most important risk factors were gestational age, delivery type, presentation, and mother’s addiction.
Conclusions The proposed system can be useful in predicting the need for CPR in neonates in the delivery room.
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Background The Life-Sustaining Treatment (LST) Decisions Act allows withholding and withdrawal of LST, including cardiopulmonary resuscitation (CPR). In the present study, the incidence of CPR before and after implementation of the Act was compared.
Methods This was a retrospective review involving hospitalized patients who underwent CPR at a single center between February 2016 and January 2020 (pre-implementation period, February 2016 to January 2018; post-implementation period, February 2018 to January 2020). The primary outcome was monthly incidence of CPR per 1,000 admissions. The secondary outcomes were duration of CPR, return of spontaneous circulation (ROSC) rate, 24-hour survival rate, and survival-to-discharge rate. The study outcomes were compared before and after implementation of the Act.
Results A total of 867 patients who underwent CPR was included in the analysis. The incidence of CPR per 1,000 admissions showed no significant difference before and after implementation of the Act (3.02±0.68 vs. 2.81±0.75, P=0.255). The ROSC rate (67.20±0.11 vs. 70.99±0.12, P=0.008) and survival to discharge rate (20.24±0.09 vs. 22.40±0.12, P=0.029) were higher after implementation of the Act than before implementation.
Conclusions The incidence of CPR did not significantly change for 2 years after implementation of the Act. Further studies are needed to assess the changes in trends in the decisions of CPR and other LSTs in real-world practice.
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Background Although a rapid response system (RRS) can reduce the incidence of cardiopulmonary resuscitation (CPR) in general wards, avoidable CPR cases still occur. This study aimed to investigate the incidence and causes of avoidable CPR.
Methods We retrospectively reviewed the medical records of all adult patients who received CPR between April 2013 and March 2016 (35 months) at a tertiary teaching hospital where a part-time RRS was introduced in October 2012. Four experts reviewed all of the CPR cases and determined whether each event was avoidable.
Results A total of 192 CPR cases were identified, and the incidence of CPR was 0.190 per 1,000 patient admissions. Of these, 56 (29.2%) were considered potentially avoidable, with the most common cause being doctor error (n=32, 57.1%), followed by delayed do-not-resuscitate (DNR) placement (n=12, 21.4%) and procedural complications (n=5, 8.9%). The percentage of avoidable CPR was significantly lower in the RRS operating time group than in the RRS non-operating time group (20.7% vs. 35.5%; P=0.026). Among 44 avoidable CPR events (excluding cases related to DNR issues), the rapid response team intervened in only three cases (6.8%), and most of the avoidable CPR cases (65.9%) occurred during the non-operating time.
Conclusions A significant number of avoidable CPR events occurred with a well-functioning, part-time RRS in place. However, RRS operation does appear to lower the occurrence of avoidable CPR. Thus, it is necessary to extend RRS operation time and modify RRS activation criteria. Moreover, policy and cultural changes are needed prior to implementing a full-time RRS.
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Background Clinical deteriorations during hospitalization are often preventable with a rapid response system (RRS). We aimed to investigate the effectiveness of a daytime RRS for surgical hospitalized patients.
Methods A retrospective cohort study was conducted in 20 general surgical wards at a 1,779-bed University hospital from August 2013 to July 2017 (August 2013 to July 2015, pre-RRS-period; August 2015 to July 2017, post-RRS-period). The primary outcome was incidence of cardiopulmonary arrest (CPA) when the RRS was operating. The secondary outcomes were the incidence of total and preventable cardiopulmonary arrest, in-hospital mortality, the percentage of “do not resuscitate” orders, and the survival of discharged CPA patients.
Results The relative risk (RR) of CPA per 1,000 admissions during RRS operational hours (weekdays from 7 AM to 7 PM) in the post-RRS-period compared to the pre-RRS-period was 0.53 (95% confidence interval [CI], 0.25 to 1.13; P=0.099) and the RR of total CPA regardless of RRS operating hours was 0.76 (95% CI, 0.46 to 1.28; P=0.301). The preventable CPA after RRS implementation was significantly lower than that before RRS implementation (RR, 0.31; 95% CI, 0.11 to 0.88; P=0.028). There were no statistical differences in in-hospital mortality and the survival rate of patients with in-hospital cardiac arrest. Do-not-resuscitate decisions significantly increased during after RRS implementation periods compared to pre-RRS periods (RR, 1.91; 95% CI, 1.40 to 2.59; P<0.001).
Conclusions The day-time implementation of the RRS did not significantly reduce the rate of CPA whereas the system effectively reduced the rate of preventable CPA during periods when the system was operating.
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Background There are few studies on the effect of intensivist staffing in pediatric intensive care units (PICUs) in Korea. We aimed to evaluate the effect of pediatric intensivist staffing on treatment outcomes in a Korean hospital PICU.
Methods We analyzed two time periods according to pediatric intensivist staffing: period 1, between November 2015 to January 2017 (no intensivist staffing, n=97) and period 2, between February 2017 to February 2018 (intensivists staffing, n=135).
Results Median age at admission was 5.4 years (range, 0.7–10.3 years) in period 1 and 3.6 years (0.2–5.1 years) in period 2 (P=0.013). The bed occupancy rate decreased in period 2 (75%; 73%–88%) compared to period 1 (89%; 81%–94%; P=0.015). However, the monthly bed turnover rate increased in period 2 (2.2%; 1.9%–2.7%) compared to period 1 (1.5%, 1.1%– 1.7%; P=0.005). In both periods, patients with chronic neurologic illness were the most common. Patients with cardiovascular problems were more prevalent in period 2 than period 1 (P=0.008). Daytime admission occurred more frequently in period 2 than period 1 (63% vs. 39%, P<0.001). The length of PICU stay, parameters related with mechanical ventilation and tracheostomy, and pediatric Sequential Organ Failure Assessment score were not different between periods. Sudden cardiopulmonary resuscitations occurred in two cases during period 1, but no case occurred during period 2.
Conclusions Pediatric intensivist staffing in the PICU may affect efficient ICU operations.
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Acute Crit Care. 2019;34(4):246-254. Published online November 29, 2019
Background To determine the effects of implementing a rapid response system (RRS) on code rates and in-hospital mortality in medical wards.
Methods This retrospective study included adult patients admitted to medical wards at Seoul National University Hospital between July 12, 2016 and March 12, 2018; the sample comprised 4,224 patients admitted 10 months before RRS implementation and 4,168 patients admitted 10 months following RRS implementation. Our RRS only worked during the daytime (7 AM to 7 PM) on weekdays. We compared code rates and in-hospital mortality rates between the preintervention and postintervention groups.
Results There were 62.3 RRS activations per 1,000 admissions. The most common reasons for RRS activation were tachypnea or hypopnea (44%), hypoxia (31%), and tachycardia or bradycardia (21%). Code rates from medical wards during RRS operating times significantly decreased from 3.55 to 0.96 per 1,000 admissions (adjusted odds ratio [aOR], 0.29; 95% confidence interval [CI], 0.10 to 0.87; P=0.028) after RRS implementation. However, code rates from medical wards during RRS nonoperating times did not differ between the preintervention and postintervention groups (2.60 vs. 3.12 per 1,000 admissions; aOR, 1.23; 95% CI, 0.55 to 2.76; P=0.614). In-hospital mortality significantly decreased from 56.3 to 42.7 per 1,000 admissions after RRS implementation (aOR, 0.79; 95% CI, 0.64 to 0.97; P=0.024).
Conclusions Implementation of an RRS was associated with significant reductions in code rates during RRS operating times and in-hospital mortality in medical wards.
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Post-cardiac arrest syndrome is a complex and critical issue in resuscitated patients undergone cardiac arrest. Ischemic-reperfusion injury occurs in multiple organs due to the return of spontaneous circulation. Bundle of management practicies are required for post-cardiac arrest care. Early invasive coronary angiography should be considered to identify and treat coronary artery obstructive disease. Vasopressors such as norepinephrine and dobutamine are the first-line treatment for shock. Maintainance of oxyhemoglobin saturation greater than 94% but less than 100% is recommended to avoid fatality. Target temperature therapeutic hypothermia helps to resuscitated patients. Strict temperature control is required and is maintained with the help of cooling devices and monitoring the core temperature. Montorings include electrocardiogram, oxymetry, capnography, and electroencephalography (EEG) along with blood pressue, temprature, and vital signs. Seizure should be treated if EEG shows evidence of seizure or epileptiform activity. Clinical neurologic examination and magnetic resonance imaging are considered to predict neurological outcome. Glycemic control and metabolic management are favorable for a good neurological outcome. Recovery from acute kidney injury is essential for survival and a good neurological outcome.
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There has been no report about aortic dissection due to cardiopulmonary resuscitation (CPR). We present here a case of acute aortic dissection as a rare complication of CPR and propose the potential mechanism of injury on the basis of transesophageal echocardiographic observations. A 54-year-old man presented with cardiac arrest after choking and received 19 minutes of CPR in the emergency department. Transesophageal echocardiography (TEE) during CPR revealed a focal separation of the intimal layer at the descending thoracic aorta without evidence of aortic dissection. After restoration of spontaneous circulation, hemorrhagic cardiac tamponade developed. Follow-up TEE to investigate the cause of cardiac tamponade revealed aortic dissection of the descending thoracic aorta. Hemorrhagic cardiac tamponade was thought to be caused by myocardial hemorrhage from CPR.
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Thoracic Aortic Rupture Post Cardiopulmonary Resuscitation in a Patient With Previous Thoracic Aneurysm Repair Aniekeme S Etuk, Olanrewaju F Adeniran , Bernard I Nkwocha, Nformbuh Asangmbeng, Mina Jacob Cureus.2023;[Epub] CrossRef
Cardiac Arrest as an Uncommon Manifestation of Late Type A Aortic Dissection Associated with Transcatheter Aortic Valve Replacement Jan Naar, Dagmar Vondrakova, Andreas Kruger, Marek Janotka, Iva Zemanova, Martin Syrucek, Petr Neuzil, Petr Ostadal Journal of Clinical Medicine.2023; 12(16): 5318. CrossRef
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Resuscitative endovascular occlusion of the aorta (REBOA) as a mechanical method for increasing the coronary perfusion pressure in non-traumatic out-of-hospital cardiac arrest patients Dong-Hyun Jang, Dong Keon Lee, You Hwan Jo, Seung Min Park, Young Taeck Oh, Chang Woo Im Resuscitation.2022; 179: 277. CrossRef
Blunt traumatic aortic dissection death by falling: an autopsy case report Gentaro Yamasaki, Marie Sugimoto, Takeshi Kondo, Motonori Takahashi, Mai Morichika, Azumi Kuse, Kanako Nakagawa, Yasuhiro Ueno, Migiwa Asano Forensic Science, Medicine and Pathology.2022; 19(3): 388. CrossRef
Intra-arrest transesophageal echocardiography during cardiopulmonary resuscitation Sung Oh Hwang, Woo Jin Jung, Young-Il Roh, Kyoung-Chul Cha Clinical and Experimental Emergency Medicine.2022; 9(4): 271. CrossRef
Intra-arrest transoesophageal echocardiographic findings and resuscitation outcomes Woo Jin Jung, Kyoung-Chul Cha, Yong Won Kim, Yoon Seop Kim, Young-Il Roh, Sun Ju Kim, Hye Sim Kim, Sung Oh Hwang Resuscitation.2020; 154: 31. CrossRef
Aortic Rupture as a Complication of Cardiopulmonary Resuscitation Prashanth Venkatesh, Edward J. Schenck JACC: Case Reports.2020; 2(8): 1150. CrossRef
Background This study aimed to present our 5-year experience of extracorporeal cardiopulmonary resuscitation (ECPR) performed by emergency physicians.
Methods We retrospectively analyzed 58 patients who underwent ECPR between January 2010 and December 2014. The primary parameter analyzed was survival to hospital discharge. The secondary parameters analyzed were neurologic outcome at hospital discharge, cannulation time, and ECPR-related complications.
Results Thirty-one patients (53.4%) were successfully weaned from extracorporeal membrane oxygenation, and 18 (31.0%) survived to hospital discharge. Twelve patients (20.7%) were discharged with good neurologic outcomes. The median cannulation time was 25.0 min (interquartile range 20.0-31.0 min). Nineteen patients (32.8%) had ECPR-related complications, the most frequent being distal limb ischemia. Regarding the initial presentation, 52 patients (83.9%) collapsed due to a cardiac etiology, and acute myocardial infarction (33/62, 53.2%) was the most common cause of cardiac arrest.
Conclusions The survival to hospital discharge rate for cardiac arrest patients who underwent ECPR conducted by an emergency physician was within the acceptable limits. The cannulation time and complications following ECPR were comparable to those found in previous studies.
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Extracorporeal cardiopulmonary resuscitation location, coronary angiography and survival in out-of-hospital cardiac arrest Yoonjic Kim, Jeong Ho Park, Sun Young Lee, Young Sun Ro, Ki Jeong Hong, Kyoung Jun Song, Sang Do Shin The American Journal of Emergency Medicine.2023; 64: 142. CrossRef
Extracorporeal cardiopulmonary resuscitation for adult out-of-hospital cardiac arrest patients: time-dependent propensity score-sequential matching analysis from a nationwide population-based registry Yeongho Choi, Jeong Ho Park, Joo Jeong, Yu Jin Kim, Kyoung Jun Song, Sang Do Shin Critical Care.2023;[Epub] CrossRef
Time from arrest to extracorporeal cardiopulmonary resuscitation and survival after out‐of‐hospital cardiac arrest Jeong Ho Park, Kyoung Jun Song, Sang Do Shin, Young Sun Ro, Ki Jeong Hong Emergency Medicine Australasia.2019; 31(6): 1073. CrossRef
Pre-hospital extra-corporeal cardiopulmonary resuscitation Ben Singer, Joshua C. Reynolds, David J. Lockey, Ben O’Brien Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine.2018;[Epub] CrossRef
We describe a case of traumatic aortic dissection associated with cardiac compression in a patient with anaphylactic cardiac arrest who underwent cardiopulmonary resuscitation (CPR). A 54-year-old man who was scheduled to undergo surgery for gastric cancer went into cardiac arrest caused by an anaphylactic reaction to prophylactic antibiotics in the operating room. Veno-arterial extracorporeal membrane oxygenation (ECMO) was performed. CPR, including chest compressions, was performed for 35 min, and the patient was transferred to the intensive care unit (ICU) after spontaneous circulation returned. The patient received ECMO for 9 hours until confirmation of normal cardiac function on transthoracic echocardiography (TTE). Twenty days after cardiac arrest, an aortic dissection and fractures in the left fourth and fifth ribs due to chest compression were detected by abdominal computed tomography. The DeBakey type III aortic dissection extended from the distal arch of the thoracic aorta to the proximal level of the renal artery, involving the celiac trunk. It was considered an uncomplicated type B aortic dissection with no sign of malperfusion of the major vessels. This case demonstrates the potential traumatic injuries that can occur after CPR and encourages proper management of mechanical complications in cardiac arrest survivors.
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Blunt traumatic aortic dissection death by falling: an autopsy case report Gentaro Yamasaki, Marie Sugimoto, Takeshi Kondo, Motonori Takahashi, Mai Morichika, Azumi Kuse, Kanako Nakagawa, Yasuhiro Ueno, Migiwa Asano Forensic Science, Medicine and Pathology.2022; 19(3): 388. CrossRef
A Case of an Aortic Dissection After Mechanical Chest Compression by LUCAS Karen Ho, David Kopriva, Payam Dehghani JACC: Case Reports.2020; 2(12): 1984. CrossRef
Cardiac arrest after topical application of lidocaine during microneedling procedure: A rare case Morteza Safi, Isa Khaheshi, Fatemeh Mottaghizadeh, Mohammadreza Tabary, Nasser Malekpour Alamdari Dermatologic Therapy.2020;[Epub] CrossRef
A 16-month-old girl with acute lymphoblastic leukemia expired during Hickman catheter insertion. She had undergone chemoport insertion of the left subclavian vein six months earlier and received five cycles of chemotherapy. Due to malfunction of the chemoport and the consideration of hematopoietic stem cell transplantation, insertion of a Hickmann catheter on the right side and removal of the malfunctioning chemoport were planned under general anesthesia. The surgery was uneventful during catheter insertion, but the patient experienced the sudden onset of pulseless electrical activity just after saline was flushed through the newly inserted catheter. Cardiopulmonary resuscitation was commenced aggressively, but the patient was refractory. Migration of a thrombus generated by the previous central catheter to the pulmonary circulation was suspected, resulting in a pulmonary embolism.
BACKGROUND We conducted this study to verify whether a mechanical ventilator is adequate for cardiopulmonary resuscitation (CPR).
Background: We conducted this study to verify whether a mechanical ventilator is adequate for cardiopulmonary resuscitation (CPR). Methods: A self-inflating bag resuscitator and a mechanical ventilator were used to test two experimental models: Model 1 (CPR manikin without chest compression) and Model 2 (CPR manikin with chest compression). Model 2 was divided into three subgroups according to ventilator pressure limits (Plimit). The self-inflating bag resuscitator was set with a ventilation rate of 10 breaths/min with the volume-marked bag-valve procedure. The mode of the mechanical ventilator was set as follows: volume-controlled mandatory ventilation of tidal volume (Vt) 600 mL, an inspiration time of 1.2 seconds, a constant flow pattern, a ventilation rate of 10 breaths/minute, a positive end expiratory pressure of 3 cmH2O and a maximum trigger limit. Peak airway pressure (Ppeak) and Vt were measured by a flow analyzer. Ventilation adequacy was determined at a Vt range of 400-600 mL with a Ppeak of ≤ 50 cmH2O. Results: In Model 1, Vt and Ppeak were in the appropriate range in the ventilation equipments. In Model 2, for the self-inflating bag resuscitator, the adequate Vt and Ppeak levels were 17%, and the Ppeak adequacy was 20% and the Vt was 65%. For the mechanical ventilator, the adequate Vt and Ppeak levels were 85%; the Ppeak adequacy was 85%; and the Vt adequacy was 100% at 60 cmH2O of Plimit. Conclusions: In a manikin model, a mechanical ventilator was superior to self-inflating bag resuscitator for maintaining adequate ventilation during chest compression.
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