The objective of this trial (Double Sequential External Defibrillation for Refractory Ventricular Fibrillation [DOSE VF]) was to evaluate Double Sequential External Defibrillation (DSED) and Vector Change (VC) defibrillation as compared with standard defibrillation in patients who remain in refractory ventricular fibrillation during out-of-hospital cardiac arrest.
1. Post resuscitation care involves not only return of spontaneous circulation but return to pre-arrest status through management of global ischemia, cardiovascular dysfunction, and persistent precipitant causes.
2. Immediate goals after ROSC include optimization of cardiovascular function and oxygen delivery, ventilation support, temperature management, etiology investigation, and interventions to prevent recurrence.
3. Prognostication is an essential component using markers like neurological exams, EEGs, imaging and biomarkers to predict outcomes in comatose post-cardiac arrest patients.
Post-Cardiac Arrest Syndrome:
Epidemiology, Pathophysiology, Treatment, and Prognostication
A Consensus Statement From the International Liaison Committee on Resuscitation
Circulation. 2008;118:2452-2483
This document provides guidelines for post-cardiac arrest care. It recommends:
1) Performing emergency coronary angiography for OHCA patients with suspected cardiac cause and ST elevation on ECG.
2) Maintaining blood pressure above 90 mmHg systolic or 65 mmHg mean and immediately correcting any hypotension.
3) Inducing therapeutic hypothermia between 32-36°C for at least 24 hours in comatose cardiac arrest patients to minimize brain injury.
This document provides an overview of arrhythmias that may present in the intensive care unit (ICU) with a focus on atrial fibrillation, wide complex tachycardia, bradycardia, and supraventricular tachycardia. It discusses approaches to determining whether arrhythmias require rate or rhythm control and outlines treatment strategies including pharmacological and electrical cardioversion. Guidelines for determining the need for anticoagulation based on a patient's CHADS2-VASc score are also reviewed.
Cardiac arrhythmias occur frequently in ICU patients, with the most common being sinus tachycardia. Arrhythmias are often seen in patients with structural heart disease and can be exacerbated by critical illness. Management involves treating any imbalances that may be triggering the arrhythmia as well as directed medical therapy. Arrhythmias in the ICU represent a major source of morbidity and increased length of stay.
1) Ambulatory blood pressure monitoring (ABPM) provides accurate blood pressure measurements over 24 hours and can detect differences between daytime and nighttime blood pressure that are important for diagnosing and treating hypertension.
2) ABPM was initially developed in the 1960s and has advantages over clinic blood pressure measurements in predicting health outcomes.
3) ABPM involves using an automated cuff to measure blood pressure at regular intervals over 24 hours while patients go about their daily activities. This provides definitions for diagnosing white coat, masked, and other types of hypertension.
Niklas Nielsen talks about the TTM trial as seen through a 2019 lens.
The video and references from the talk and all the rest of the goodness from The Big Sick 2019 in Zermatt is up at
https://scanfoam.org/
1. Post resuscitation care involves not only return of spontaneous circulation but return to pre-arrest status through management of global ischemia, cardiovascular dysfunction, and persistent precipitant causes.
2. Immediate goals after ROSC include optimization of cardiovascular function and oxygen delivery, ventilation support, temperature management, etiology investigation, and interventions to prevent recurrence.
3. Prognostication is an essential component using markers like neurological exams, EEGs, imaging and biomarkers to predict outcomes in comatose post-cardiac arrest patients.
Post-Cardiac Arrest Syndrome:
Epidemiology, Pathophysiology, Treatment, and Prognostication
A Consensus Statement From the International Liaison Committee on Resuscitation
Circulation. 2008;118:2452-2483
This document provides guidelines for post-cardiac arrest care. It recommends:
1) Performing emergency coronary angiography for OHCA patients with suspected cardiac cause and ST elevation on ECG.
2) Maintaining blood pressure above 90 mmHg systolic or 65 mmHg mean and immediately correcting any hypotension.
3) Inducing therapeutic hypothermia between 32-36°C for at least 24 hours in comatose cardiac arrest patients to minimize brain injury.
This document provides an overview of arrhythmias that may present in the intensive care unit (ICU) with a focus on atrial fibrillation, wide complex tachycardia, bradycardia, and supraventricular tachycardia. It discusses approaches to determining whether arrhythmias require rate or rhythm control and outlines treatment strategies including pharmacological and electrical cardioversion. Guidelines for determining the need for anticoagulation based on a patient's CHADS2-VASc score are also reviewed.
Cardiac arrhythmias occur frequently in ICU patients, with the most common being sinus tachycardia. Arrhythmias are often seen in patients with structural heart disease and can be exacerbated by critical illness. Management involves treating any imbalances that may be triggering the arrhythmia as well as directed medical therapy. Arrhythmias in the ICU represent a major source of morbidity and increased length of stay.
1) Ambulatory blood pressure monitoring (ABPM) provides accurate blood pressure measurements over 24 hours and can detect differences between daytime and nighttime blood pressure that are important for diagnosing and treating hypertension.
2) ABPM was initially developed in the 1960s and has advantages over clinic blood pressure measurements in predicting health outcomes.
3) ABPM involves using an automated cuff to measure blood pressure at regular intervals over 24 hours while patients go about their daily activities. This provides definitions for diagnosing white coat, masked, and other types of hypertension.
Niklas Nielsen talks about the TTM trial as seen through a 2019 lens.
The video and references from the talk and all the rest of the goodness from The Big Sick 2019 in Zermatt is up at
https://scanfoam.org/
This document discusses post-resuscitation care after return of spontaneous circulation (ROSC) following cardiac arrest. The main goals are to ensure neurologically intact survival, treat the underlying cause, maintain adequate ventilation and oxygenation, achieve stable cardiac rhythm and hemodynamics, and perform targeted temperature management (TTM). Complications that can occur after ROSC include post-cardiac arrest brain injury, myocardial dysfunction, and systemic ischemia-reperfusion response. The document provides guidance on airway management, ventilation, oxygenation, hemodynamic support, TTM, and prognostication.
The document discusses right ventricular failure (RVF) after cardiac surgery. It begins by outlining risk factors and the dynamics that lead to RVF. It describes how to assess the severity of RVF using laboratory, hemodynamic, and echocardiographic data. The document concludes by discussing the management of RVF in postsurgical patients, which involves optimizing volume status, rhythm control, afterload reduction, RV perfusion, contractility, and the potential use of mechanical support devices if needed.
This document provides an overview of extracorporeal membrane oxygenation (ECMO), including its history, principles, components, indications, and complications. Some key points:
- ECMO is a form of extracorporeal life support that oxygenates blood and removes carbon dioxide outside of the body, then returns the blood to the patient. It has been used since the 1950s and is now standard treatment for some cardiac and respiratory conditions.
- The basic ECMO circuit includes a blood pump, membrane oxygenator, heat exchanger, cannulas, and tubing. There are various configurations depending on whether it is used for respiratory (VV ECMO) or cardiac (VA ECMO) support.
-
The document discusses the case of a 26-year-old female patient who is 36 weeks pregnant with mitral stenosis. She presents with palpitations, breathlessness, and fatigue. Her history and examination are consistent with mild mitral stenosis of rheumatic origin, as confirmed by echocardiogram findings of a mitral valve area of 2.0 cm2 and transvalvular pressure of 8 mm Hg. The discussion centers on the pathophysiology, diagnosis, and management of mitral stenosis, including the plan for regional anesthesia for her elective caesarean section.
This document discusses emergency department thoracotomy (ED thoracotomy). It describes the procedures as:
1) Releasing pericardial tamponade to improve cardiac output and control cardiac hemorrhaging.
2) Controlling intrathoracic vascular or cardiac hemorrhaging to improve cardiac output and myocardial perfusion.
3) Controlling massive air embolism or bronchopleural fistula to resolve myocardial ischemia and improve contractility and prevent neurological injury.
4) Performing open cardiac massage to improve resuscitative cardiac output and coronary perfusion, especially with limited ventricular filling pressures.
5) Occluding the descending aorta to redistribute limited blood volume to the myocardium and brain
Therapeutic hypothermia, or induced hypothermia, involves deliberately cooling cardiac arrest patients to between 32-34°C for 12-24 hours after return of spontaneous circulation (ROSC) to reduce reperfusion injury to organs like the brain, heart, liver and kidneys from hypoperfusion and ischemia during the cardiac arrest. It aims to improve outcomes by reducing the effects of post-cardiac arrest syndrome, which involves a complex pathophysiological cascade following ischemia. Current research shows benefits of inducing therapeutic hypothermia before or during the cardiac arrest event. Key aspects of care involve induction of hypothermia within 6 hours, preferably 2 hours, of ROSC, maintenance of target temperature for 12-24 hours,
This document discusses the management of atrial fibrillation. It provides information on the causes, consequences, classification, and epidemiology of AF. It describes the acute management of AF including assessing hemodynamic status, starting anticoagulation, and deciding between rate and rhythm control strategies. Methods for rhythm control include electrical cardioversion and pharmacological cardioversion with drugs like amiodarone, ibutilide, flecainide, and propafenone. Rate control strategies use drugs like digoxin, beta blockers, calcium channel blockers, and amiodarone. The document also discusses anticoagulation for thromboembolism prevention and newer oral anticoagulants.
The document outlines the importance of post resuscitation care to stabilize patients after return of spontaneous circulation, including supporting oxygenation and circulation, treating injuries from CPR, monitoring for recurrent cardiac arrest, and promptly transferring patients to intensive care units for specialized monitoring and treatment. Proper post resuscitation care is critical to optimize outcomes in the hours after resuscitation.
Intra Abdominal hypertension&Abdominal Compartment SyndromeAbdulgafoor MT
This document discusses intra-abdominal hypertension and abdominal compartment syndrome. It provides a brief history of discoveries related to measuring intra-abdominal pressure and defining abdominal compartment syndrome. Key points covered include definitions of intra-abdominal pressure, abdominal perfusion pressure, and grades of increased intra-abdominal hypertension. Causes, prevalence, incidence and physiological effects on multiple organ systems are summarized. Methods of measuring intra-abdominal pressure and treatments including decompressive laparotomy and temporary closure techniques are also mentioned.
Acute Decompensated Heart Failure : What is New ?drucsamal
Prof. U. C. SAMAL is an expert in cardiology who has held leadership positions in several cardiological societies. The document discusses the management of acute decompensated heart failure and summarizes recent changes to guidelines. It provides an overview of pharmacological interventions for acute heart failure such as diuretics, vasodilators, and inotropes. Non-invasive ventilation and risk stratification scores are also mentioned. The document emphasizes the importance of both short-term stabilization and long-term management through multi-disciplinary programs to prevent readmissions.
Valvular heart disease, specifically mitral stenosis, places a hemodynamic burden on the heart over time. The disease results in a narrowed mitral valve opening that obstructs blood flow from the left atrium to the left ventricle. This obstruction can lead to elevated left atrial pressure and pulmonary hypertension. Symptoms include breathlessness and fatigue. Echocardiography is used to evaluate the severity based on mitral valve area and pressure gradients. Treatment involves managing symptoms medically or surgically replacing/repairing the valve. Anesthetic management focuses on maintaining preload, controlling heart rate, and avoiding pulmonary vasoconstriction.
The document provides an overview of the management of sepsis and septic shock. It discusses that early goal-directed therapy within the first 6 hours including antibiotics, fluids, vasopressors and inotropes if needed can significantly improve outcomes. Other key points covered include the definitions and diagnostic criteria for sepsis; appropriate antibiotic therapy and vasopressor use; importance of lung-protective ventilation; role for activated protein C, steroids, tight glucose control and renal replacement therapy. Prognosis depends on early recognition and treatment as mortality increases significantly with delayed or inadequate care.
This document discusses the current concepts of anaesthesia for off-pump coronary artery bypass grafting (OPCAB). It begins with definitions of OPCAB and discusses its historical aspects. It then compares OPCAB to on-pump coronary artery bypass grafting and lists the goals of anaesthetic management for OPCAB. The document outlines considerations for preoperative assessment, induction, intraoperative management including hemodynamics, myocardial protection and postoperative/ICU management. It also discusses fast-track anesthesia and postoperative pain management.
The document provides guidelines for perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. It was developed by an expert panel representing multiple medical societies. The guidelines include recommendations on preoperative risk assessment, management of valvular heart disease and pulmonary hypertension, use of cardiovascular implantable electronic devices, and approaches to predicting and reducing perioperative cardiac risk. A stepwise approach to preoperative cardiac assessment and management is presented based on urgency of surgery and estimated risk of major adverse cardiac events.
Antiplatelets and anticoagulants in noncardiac surgeriesHiralal Pawar
This document discusses cardiac issues related to non-cardiac surgery and the role of antiplatelet and anticoagulant medications in the perioperative period. It notes that the aging population has increased coronary artery disease prevalence and antiplatelet agents are widely prescribed afterwards. It also discusses factors that increase stent thrombosis risk and the importance of continuing dual antiplatelet therapy. The document covers preoperative risk assessment, medication management of antiplatelets and anticoagulants in the perioperative period, and postoperative management strategies to reduce cardiac complications of non-cardiac surgery.
Guidelines for dvt prophylaxis in surgical patientsLajpat Rai
This is presentation about guidelines for DVT prophylaxis in surgical patients. i have come accross all guidliens of different countries. all are bit same, only minor differences. i found Australian guidelines bit easy that why my presentation is based on australian guidelines
This document outlines the steps to calculate sodium correction for hypo- and hypernatremia. For hyponatremia, it describes how to determine: 1) the change in serum sodium per liter of infusate, 2) the volume required, 3) the time required for correction, and 4) the infusion rate. For hypernatremia, the same steps are followed to calculate water deficit and rate of correction using free water. An example for each is provided to demonstrate the full calculation.
Preop evaluation of cardiac patient postd=ed for non cardiac surgery Rajesh Munigial
This document discusses pre-operative evaluation and preparation of cardiac patients for non-cardiac surgeries. It outlines that patients with coronary artery disease undergoing non-cardiac surgery are at increased risk of complications. A thorough pre-operative evaluation including history, physical exam, diagnostic tests, and knowledge of the planned surgery is important to assess risk factors and develop a management plan. Tests like ECG, stress testing, echocardiogram and in some cases angiography help evaluate cardiac status. Medical optimization including management of angina, heart failure, diabetes, etc. can help reduce perioperative risk. Timing of surgery depends on the clinical status and risk of delay. Intraoperative management focuses on preventing ischemia.
The document discusses the approach to anesthesia for patients with cardiac disease undergoing non-cardiac surgery. It emphasizes the importance of preoperative evaluation and risk stratification to determine the safest anesthetic plan. During surgery, careful monitoring is recommended to detect any deterioration in cardiac function. The appropriate selection of anesthetic drugs and techniques can help minimize stress on the heart. Overall, the key is choosing an anesthetic that provides stability for the patient's cardiac condition.
This randomized controlled trial evaluated the effectiveness of double sequential external defibrillation (DSED) and vector change defibrillation compared to standard care for patients with refractory ventricular fibrillation. The trial was stopped early due to staffing shortages from COVID-19. DSED and vector change defibrillation were both associated with improved survival to hospital discharge compared to standard care. However, the treatment effect sizes may be overestimated due to the small sample size and early trial termination. [/SUMMARY]
Classification and Regression Tree Analysis in Biomedical Research Salford Systems
This document discusses using classification and regression tree (CART) analysis to develop clinical decision rules for three clinical settings: 1) emergency department triage of HIV-infected patients, 2) survival prediction of patients with colon and rectal cancer, and 3) prediction of neurologic survival in patients following out-of-hospital cardiac arrest. For each setting, the document describes developing CART models using various clinical variables to classify patients into risk groups and reports validation results for predicting outcomes like medical urgency and survival.
This document discusses post-resuscitation care after return of spontaneous circulation (ROSC) following cardiac arrest. The main goals are to ensure neurologically intact survival, treat the underlying cause, maintain adequate ventilation and oxygenation, achieve stable cardiac rhythm and hemodynamics, and perform targeted temperature management (TTM). Complications that can occur after ROSC include post-cardiac arrest brain injury, myocardial dysfunction, and systemic ischemia-reperfusion response. The document provides guidance on airway management, ventilation, oxygenation, hemodynamic support, TTM, and prognostication.
The document discusses right ventricular failure (RVF) after cardiac surgery. It begins by outlining risk factors and the dynamics that lead to RVF. It describes how to assess the severity of RVF using laboratory, hemodynamic, and echocardiographic data. The document concludes by discussing the management of RVF in postsurgical patients, which involves optimizing volume status, rhythm control, afterload reduction, RV perfusion, contractility, and the potential use of mechanical support devices if needed.
This document provides an overview of extracorporeal membrane oxygenation (ECMO), including its history, principles, components, indications, and complications. Some key points:
- ECMO is a form of extracorporeal life support that oxygenates blood and removes carbon dioxide outside of the body, then returns the blood to the patient. It has been used since the 1950s and is now standard treatment for some cardiac and respiratory conditions.
- The basic ECMO circuit includes a blood pump, membrane oxygenator, heat exchanger, cannulas, and tubing. There are various configurations depending on whether it is used for respiratory (VV ECMO) or cardiac (VA ECMO) support.
-
The document discusses the case of a 26-year-old female patient who is 36 weeks pregnant with mitral stenosis. She presents with palpitations, breathlessness, and fatigue. Her history and examination are consistent with mild mitral stenosis of rheumatic origin, as confirmed by echocardiogram findings of a mitral valve area of 2.0 cm2 and transvalvular pressure of 8 mm Hg. The discussion centers on the pathophysiology, diagnosis, and management of mitral stenosis, including the plan for regional anesthesia for her elective caesarean section.
This document discusses emergency department thoracotomy (ED thoracotomy). It describes the procedures as:
1) Releasing pericardial tamponade to improve cardiac output and control cardiac hemorrhaging.
2) Controlling intrathoracic vascular or cardiac hemorrhaging to improve cardiac output and myocardial perfusion.
3) Controlling massive air embolism or bronchopleural fistula to resolve myocardial ischemia and improve contractility and prevent neurological injury.
4) Performing open cardiac massage to improve resuscitative cardiac output and coronary perfusion, especially with limited ventricular filling pressures.
5) Occluding the descending aorta to redistribute limited blood volume to the myocardium and brain
Therapeutic hypothermia, or induced hypothermia, involves deliberately cooling cardiac arrest patients to between 32-34°C for 12-24 hours after return of spontaneous circulation (ROSC) to reduce reperfusion injury to organs like the brain, heart, liver and kidneys from hypoperfusion and ischemia during the cardiac arrest. It aims to improve outcomes by reducing the effects of post-cardiac arrest syndrome, which involves a complex pathophysiological cascade following ischemia. Current research shows benefits of inducing therapeutic hypothermia before or during the cardiac arrest event. Key aspects of care involve induction of hypothermia within 6 hours, preferably 2 hours, of ROSC, maintenance of target temperature for 12-24 hours,
This document discusses the management of atrial fibrillation. It provides information on the causes, consequences, classification, and epidemiology of AF. It describes the acute management of AF including assessing hemodynamic status, starting anticoagulation, and deciding between rate and rhythm control strategies. Methods for rhythm control include electrical cardioversion and pharmacological cardioversion with drugs like amiodarone, ibutilide, flecainide, and propafenone. Rate control strategies use drugs like digoxin, beta blockers, calcium channel blockers, and amiodarone. The document also discusses anticoagulation for thromboembolism prevention and newer oral anticoagulants.
The document outlines the importance of post resuscitation care to stabilize patients after return of spontaneous circulation, including supporting oxygenation and circulation, treating injuries from CPR, monitoring for recurrent cardiac arrest, and promptly transferring patients to intensive care units for specialized monitoring and treatment. Proper post resuscitation care is critical to optimize outcomes in the hours after resuscitation.
Intra Abdominal hypertension&Abdominal Compartment SyndromeAbdulgafoor MT
This document discusses intra-abdominal hypertension and abdominal compartment syndrome. It provides a brief history of discoveries related to measuring intra-abdominal pressure and defining abdominal compartment syndrome. Key points covered include definitions of intra-abdominal pressure, abdominal perfusion pressure, and grades of increased intra-abdominal hypertension. Causes, prevalence, incidence and physiological effects on multiple organ systems are summarized. Methods of measuring intra-abdominal pressure and treatments including decompressive laparotomy and temporary closure techniques are also mentioned.
Acute Decompensated Heart Failure : What is New ?drucsamal
Prof. U. C. SAMAL is an expert in cardiology who has held leadership positions in several cardiological societies. The document discusses the management of acute decompensated heart failure and summarizes recent changes to guidelines. It provides an overview of pharmacological interventions for acute heart failure such as diuretics, vasodilators, and inotropes. Non-invasive ventilation and risk stratification scores are also mentioned. The document emphasizes the importance of both short-term stabilization and long-term management through multi-disciplinary programs to prevent readmissions.
Valvular heart disease, specifically mitral stenosis, places a hemodynamic burden on the heart over time. The disease results in a narrowed mitral valve opening that obstructs blood flow from the left atrium to the left ventricle. This obstruction can lead to elevated left atrial pressure and pulmonary hypertension. Symptoms include breathlessness and fatigue. Echocardiography is used to evaluate the severity based on mitral valve area and pressure gradients. Treatment involves managing symptoms medically or surgically replacing/repairing the valve. Anesthetic management focuses on maintaining preload, controlling heart rate, and avoiding pulmonary vasoconstriction.
The document provides an overview of the management of sepsis and septic shock. It discusses that early goal-directed therapy within the first 6 hours including antibiotics, fluids, vasopressors and inotropes if needed can significantly improve outcomes. Other key points covered include the definitions and diagnostic criteria for sepsis; appropriate antibiotic therapy and vasopressor use; importance of lung-protective ventilation; role for activated protein C, steroids, tight glucose control and renal replacement therapy. Prognosis depends on early recognition and treatment as mortality increases significantly with delayed or inadequate care.
This document discusses the current concepts of anaesthesia for off-pump coronary artery bypass grafting (OPCAB). It begins with definitions of OPCAB and discusses its historical aspects. It then compares OPCAB to on-pump coronary artery bypass grafting and lists the goals of anaesthetic management for OPCAB. The document outlines considerations for preoperative assessment, induction, intraoperative management including hemodynamics, myocardial protection and postoperative/ICU management. It also discusses fast-track anesthesia and postoperative pain management.
The document provides guidelines for perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. It was developed by an expert panel representing multiple medical societies. The guidelines include recommendations on preoperative risk assessment, management of valvular heart disease and pulmonary hypertension, use of cardiovascular implantable electronic devices, and approaches to predicting and reducing perioperative cardiac risk. A stepwise approach to preoperative cardiac assessment and management is presented based on urgency of surgery and estimated risk of major adverse cardiac events.
Antiplatelets and anticoagulants in noncardiac surgeriesHiralal Pawar
This document discusses cardiac issues related to non-cardiac surgery and the role of antiplatelet and anticoagulant medications in the perioperative period. It notes that the aging population has increased coronary artery disease prevalence and antiplatelet agents are widely prescribed afterwards. It also discusses factors that increase stent thrombosis risk and the importance of continuing dual antiplatelet therapy. The document covers preoperative risk assessment, medication management of antiplatelets and anticoagulants in the perioperative period, and postoperative management strategies to reduce cardiac complications of non-cardiac surgery.
Guidelines for dvt prophylaxis in surgical patientsLajpat Rai
This is presentation about guidelines for DVT prophylaxis in surgical patients. i have come accross all guidliens of different countries. all are bit same, only minor differences. i found Australian guidelines bit easy that why my presentation is based on australian guidelines
This document outlines the steps to calculate sodium correction for hypo- and hypernatremia. For hyponatremia, it describes how to determine: 1) the change in serum sodium per liter of infusate, 2) the volume required, 3) the time required for correction, and 4) the infusion rate. For hypernatremia, the same steps are followed to calculate water deficit and rate of correction using free water. An example for each is provided to demonstrate the full calculation.
Preop evaluation of cardiac patient postd=ed for non cardiac surgery Rajesh Munigial
This document discusses pre-operative evaluation and preparation of cardiac patients for non-cardiac surgeries. It outlines that patients with coronary artery disease undergoing non-cardiac surgery are at increased risk of complications. A thorough pre-operative evaluation including history, physical exam, diagnostic tests, and knowledge of the planned surgery is important to assess risk factors and develop a management plan. Tests like ECG, stress testing, echocardiogram and in some cases angiography help evaluate cardiac status. Medical optimization including management of angina, heart failure, diabetes, etc. can help reduce perioperative risk. Timing of surgery depends on the clinical status and risk of delay. Intraoperative management focuses on preventing ischemia.
The document discusses the approach to anesthesia for patients with cardiac disease undergoing non-cardiac surgery. It emphasizes the importance of preoperative evaluation and risk stratification to determine the safest anesthetic plan. During surgery, careful monitoring is recommended to detect any deterioration in cardiac function. The appropriate selection of anesthetic drugs and techniques can help minimize stress on the heart. Overall, the key is choosing an anesthetic that provides stability for the patient's cardiac condition.
This randomized controlled trial evaluated the effectiveness of double sequential external defibrillation (DSED) and vector change defibrillation compared to standard care for patients with refractory ventricular fibrillation. The trial was stopped early due to staffing shortages from COVID-19. DSED and vector change defibrillation were both associated with improved survival to hospital discharge compared to standard care. However, the treatment effect sizes may be overestimated due to the small sample size and early trial termination. [/SUMMARY]
Classification and Regression Tree Analysis in Biomedical Research Salford Systems
This document discusses using classification and regression tree (CART) analysis to develop clinical decision rules for three clinical settings: 1) emergency department triage of HIV-infected patients, 2) survival prediction of patients with colon and rectal cancer, and 3) prediction of neurologic survival in patients following out-of-hospital cardiac arrest. For each setting, the document describes developing CART models using various clinical variables to classify patients into risk groups and reports validation results for predicting outcomes like medical urgency and survival.
The document summarizes information and recommendations regarding the Covid-19 pandemic from the perspective of intensive care and critical care specialists. It provides worldwide case statistics and outlines anticipated critical care bed needs for a hospital. It also discusses ventilation strategies, the use of ECMO, guidelines from medical societies, PPE recommendations, management of shock, antibiotics, experimental drug treatments and ongoing clinical trials. The overall focus is on evaluating and treating critically ill Covid-19 patients from an intensive care perspective.
The document summarizes information and recommendations regarding the Covid-19 pandemic from the perspective of intensive care and critical care specialists. It provides worldwide case statistics and projections for hospital bed and ventilator needs in California. Guidelines are presented on testing, diagnosis, treatment strategies including ventilation, use of sedatives, ECMO, and experimental drugs. Risk stratification, PPE guidance, and management of complications like shock are also addressed. Clinical trials and the potential use of convalescent plasma are discussed.
The document summarizes information and recommendations regarding the Covid-19 pandemic from the perspective of intensive care and critical care specialists. It provides worldwide case statistics and projections for hospital bed and ventilator needs in California. Guidelines are presented on testing, diagnosis, treatment strategies including ventilation, use of sedatives, ECMO, and experimental drugs. Risk stratification, PPE guidance, and management of complications like shock are also addressed. Clinical trials and the potential use of convalescent plasma are discussed.
Defibrillation strategies new techniques.pptxJoydeep Sarkar
The document discusses a cluster randomized control trial that compared standard defibrillation to double sequential external defibrillation (DSED) and vector-change defibrillation strategies for patients experiencing refractory ventricular fibrillation during out-of-hospital cardiac arrest, finding that survival rates to hospital discharge were higher in the DSED group compared to the other strategies. However, the trial was stopped early due to the COVID-19 pandemic and did not achieve its planned sample size.
This document discusses fast-track cardiac surgery protocols. It begins by defining fast-track surgery as rapidly progressing a patient from preoperative preparation through surgery and discharge from the hospital. It then mentions that fast-tracking requires a coordinated team approach. Several studies are referenced that show fast-tracking leads to shorter ICU and hospital stays without increasing complications when used for appropriately selected low-risk patients. Key elements of fast-tracking include enhanced patient education, same-day admissions, early extubation and mobilization, aggressive pulmonary care, and early discharge. Extubation in the operating room rather than ICU is associated with lower reintubation rates. The document concludes that fast-tracking cardiac surgery is safe and effective for reducing costs when applied to
This document outlines a proposal to implement a rapid response team (RRT) at an urban Magnet hospital to improve patient outcomes on medical and surgical units. The purpose is to determine if an RRT can reduce hospital stays, decrease transfers to higher levels of care, and increase patient functionality at discharge. The proposal describes the background on RRTs, significance to nursing practice, literature review on clinical outcomes, relevant nursing theories, and the Iowa Model framework. It provides details on the methodology, team development and training, communication systems, education, documentation, and implementation process including activation protocols and safety huddles. The goal is to activate the RRT for at-risk patients showing signs of respiratory distress, changes in mental status, abnormal
This document discusses using a SMART (Specific, Measurable, Achievable, Relevant, Time-bound) approach to control ventilator-associated pneumonia (VAP) through a bundled intervention strategy. It outlines that individual best practices for preventing VAP can have a greater effect when implemented together. Studies show educational interventions and emphasizing hand hygiene, positioning, oral intubation and drainage reduced VAP rates. The document recommends starting small tests in one ICU by measuring compliance and effects of 4-5 intervention measures. Choosing specific, achievable and time-bound objectives while engaging stakeholders is key to success.
The document provides information on Covid-19 cases worldwide and in the United States. It discusses planning for surges in critical care needs at UCSD Medical Center, including models for staffing ICU units with both ICU and non-ICU nurses. It also covers guidelines and strategies for diagnosis, treatment, and management of critically ill Covid-19 patients, including ventilation, use of sedatives, ECMO, and investigational therapies.
adult inpatient care and inpatient experience presentation - uhnd.pptAnanthakrishnanC2
This document summarizes an audit of inpatient care and experience for adults with ulcerative colitis in the UK. It discusses two parts of the audit: 1) Inpatient care, which assessed treatment for patients admitted to hospitals, collecting data on over 4,000 admissions. Key indicators like mortality, previous admissions, and medication use are presented. 2) Inpatient experience, which assessed patient care quality through nearly 1,700 post-discharge questionnaires. Key indicators like ratings of care, confidence in doctors, pain control, and cleanliness are presented. The document concludes with recommendations to improve inpatient care and experience based on the audit results.
UK based multicentric trial involving 364 critically ill patients who were deemed difficult to wean, was conducted to prove shorter time to liberation from mechanical ventilation with non invasive weaning compared to invasive weaning.
Implementing American Heart Association Practice Standards for Inpatient ECG ...Allina Health
Implementing American Heart Association Practice Standards for Inpatient ECG Monitoring: An Interventional Study at Abbott Northwestern Hospital presented by Kristin Sandau, PhD, RN
STARSurg, Tripartite Colorectal Conference, July 2014STARSurg
Tripartite is an international colorectal meeting of surgeons from across Europe, Australasia and the Americas.
Here we presented the colorectal-specific findings of STARSurg's first national collaborative cohort study, assesing the safety profile of NSAIDs in colorectal resection.
ICN Victoria presents Dr Dashiell Gantner, research fellow at the Monash University in Melbourne. Here he talks about translating ICU research into clinical practice.
Importanza anestesista in oftalmologia 2013;role of the anesthesiologists in ...Claudio Melloni
Role of the anesthesiologist in ophthalmic surgery;cases,monitoring, challenges,screening of patients,complications,discussion from literature and more .dangers of Phenylephrine,accidents.
Heavy file,with documents not properly pictured,but useful for discussion.
Similar to Defibrillation strategy for refractory Ventricular fibrillation.pptx (20)
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Summer is a time for fun in the sun, but the heat and humidity can also wreak havoc on your skin. From itchy rashes to unwanted pigmentation, several skin conditions become more prevalent during these warmer months.
Lecture 6 -- Memory 2015.pptlearning occurs when a stimulus (unconditioned st...AyushGadhvi1
learning occurs when a stimulus (unconditioned stimulus) eliciting a response (unconditioned response) • is paired with another stimulus (conditioned stimulus)
Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
4. Background
• Out-of-hospital cardiac arrest accounts for more than 350,000 unexpected deaths each year in
North America
• Nearly 100,000 of these cardiac arrests are attributed to VF or pulseless VT
• Patients presenting with VF or pulseless VT have a higher survival rate than patients with other
rhythms
• However, despite advances in defibrillator technology, almost half these patients may remain in
refractory VF despite multiple defibrillation attempts
• In these patients, further defibrillation without modification of the defibrillation method is usually
unsuccessful.
5. Background
• Although antiarrhythmic medications such as amiodarone and lidocaine have been used to
prevent refibrillation, neither drug has been definitively shown to improve survival to hospital
discharge or neurologically intact survival
• Double sequential external defibrillation (DSED), the technique of providing rapid
sequential shocks from two defibrillators with defibrillation pads placed in two different planes
(anterior–lateral and anterior–posterior), has been studied for decades in the
electrophysiology laboratory for use in patients with refractory atrial or VF
• Vector-change (VC) defibrillation, the technique of switching defibrillation pads from the
anterior–lateral to the anterior–posterior position, offers the theoretical potential to defibrillate
a portion of the ventricle that may not be completely defibrillated by pads in the standard
anterior–lateral position.
6.
7. Background
• The use of DSED and VC defibrillation in settings outside the hospital has
been described in case reports, observational studies, and systematic
reviews
• These reports describe cases or series in which DSED was used as a last-
resort therapeutic option for patients who remained in refractory VF
• It has been suggested that early application of DSED may be associated
with higher rates of termination of VF and return of spontaneous circulation
than standard defibrillation.
8. Objective
• The objective of this trial (Double Sequential External Defibrillation
for Refractory Ventricular Fibrillation [DOSE VF]) was to evaluate
DSED and VC defibrillation as compared with standard
defibrillation in patients who remain in refractory ventricular
fibrillation during out-of-hospital cardiac arrest.
9. Methodology
• Three group cluster randomisation with cross-
over in six paramedic services (which include
approximately 4000 paramedics in total) from
March 2018 through May 2022.
• Each cluster crossed over every 6 months
• Randomisation performed at level of paramedic
service
• Prehospital medical care is provided by
advanced care paramedics (with standard ACLS
skills) and primary care paramedics (with BLS
skills, including the ability to perform manual
defibrillation).
10. Methodology
... continue
• Enrolment was paused on April 4, 2020, and
resumed on September 8, 2020, to allow the
paramedic services time to address
concerns about paramedic safety in
performing aerosol-generating procedures
during the coronavirus disease 2019
pandemic
• Random treatment sequences were
computer-generated
• Outcomes assessed until hospital discharge.
12. Methodology
Inclusion criteria
≥18 years
Out-of-hospital-VF arrest of presumed cardiac cause
Refractory VF
•Defined as initial presenting rhythm of VF/VT that was
still present after 3 consecutive rhythm checks and standard
defibrillations.
13. Methodology
Exclusion criteria
Non-VF/VT as presenting rhythm
Non-cardiac cause
Traumatic cardiac arrest, drowning, hypothermia, hanging,
or suspected drug overdose
DNAR order
Patients initially treated by non-participating fire or EMS
agencies
14. Randomization
and
intervention
procedure
All paramedics followed a provincial protocol consistent with
AHA guidelines for the treatment of patients in VF
Continuous chest compressions were performed before
application of the defibrillator Pads
Each rhythm analysis occurred at standard 2-minute intervals
VF was determined by manual defibrillator, rhythm analysis
performed by the paramedics
For all patients, the first three defibrillation attempts occurred
with defibrillation pads placed in the anterior–lateral position
(standard defibrillation).
15. Randomization and intervention procedure
Patients who remained in VF after three consecutive shocks
received one of three types of defibrillation according to the
random assignment for the cluster:
• 136 patients assigned to Standard defibrillation, in which all
subsequent defibrillation attempts occurred with the defibrillation
pads continuing in the original standard anterior–lateral
configuration
• 144 patients assigned to VC Defibrillation; All subsequent
defibrillations performed with Anterior-Posterior pad placement
• 125 patients assigned to DSED, All subsequent shocks performed
using DSED, 2nd defibrillator attached in AP position. Single
operator pressed shock button on anterior-lateral followed
immediately (<1sec) by anterior-posterior defibrillation.
16.
17. Data collection
• Pilot trial: March 2018 – September 2019 (n=152) – results also included
in this analysis
• Planned trial: September 2019 – May 2022 (n=253)
• Study paused April – September 2020 due to COVID pandemic
18. Statistical analysis
• Estimated 30-day survival of 28.7% among patients with out-of-hospital cardiac arrest
receiving 1 to 3 shocks, declining to 12.4% among those receiving 4 to 10 shocks and
4.9% among those receiving more than 10 shocks
• They assumed baseline survival of 12% and hypothesized that survival to hospital
discharge in the DSED and VC groups would be a minimum of 8 percentage points higher
than that in the standard group
• Both intervention strategies (DSED and VC defibrillation) shared a common control for
comparison (standard defibrillation)
• The trial design assumed at least two crossovers to allow the three treatment approaches
to be tested in each paramedic service. This approach was chosen to maximize efficiency,
allowing the evaluation of two new treatments in comparison with usual care in a single
three-group, randomized, controlled trial.
19. Statistical analysis
• The primary hypothesis was that each of these strategies would be better than usual care at a
P value of less than 0.05 and without correction for multiplicity, as has been recommended for
exploratory trials involving multiple treatment groups
• Outcomes are reported as adjusted relative risks with 95% confidence intervals, with standard
defibrillation as the reference group
• For analyses of all primary and secondary outcomes, generalized linear models used with log
link and binomial distribution, with a fixed effect for paramedic service and time since starting
the trial for each paramedic service used to account for clustering of patients within a
paramedic service
• A fragility index was calculated with the use of standard equations.All statistical analyses were
performed with SAS software.
20. Sample size calculation
■136 patients assigned to Standard defibrillation
■144 patients assigned to VC Defibrillation
■125 patients assigned to DSED
21. Trials Outcome
Primary outcome was
survival to hospital
discharge
Secondary outcomes
included :
Termination of VF, defined as the absence of VF on
subsequent rhythm analysis after defibrillation and a
2-minute interval of CPR
ROSC, defined as any change in rhythm to an organized
rhythm with a corresponding palpable pulse or blood
pressure documented by paramedics
Good neurologic outcome at hospital discharge, defined as
modified Rankin scale score of 2 or lower (scores range
from 0 [no symptoms] to 6 [death]).
28. Critical appraisal
• Is the basic study design valid
for a randomised controlled trial?
1. Did the study
address a clearly
focused
research question?
Yes No
Can’t tell
o o o
2. Was the
assignment of
participants to
interventions
randomised?
Yes No
Can’t tell
o o o
3. Were all
participants who
entered the study
accounted for at its
conclusion?
Yes No
Can’t tell
o o o
29. Was the study methodologically sound?
4.
Were the participants ‘blind’ to intervention they
were given?
Were the investigators ‘blind’ to the intervention they
were giving to participants?
Were the people assessing/analysing outcome/s
‘blinded’?
Yes No Can’t tell
o o o
5. Were the study groups similar at the start of the
randomised controlled trial?
Yes No Can’t tell
o o o
6. Apart from the experimental intervention, did each
study group receive the same level of care (that is, were
they treated equally)?
Yes No Can’t tell
o o o
30. What are the results?
7. Were the effects of intervention reported
comprehensively?
Yes No
Can’t tell
o o o
8. Was the precision of the estimate of the
intervention or treatment effect reported?
Yes No
Can’t tell
o o o
9. Do the benefits of the experimental
intervention outweigh the harms and costs?
Yes No
Can’t tell
o o o
31. Will the results help locally?
10. Can the results be applied to
your local population/in your
context?
Yes No
Can’t tell
o o o
11. Would the experimental
intervention provide greater value
to the people in your care than any
of the existing interventions?
Yes No
Can’t tell
o o o
32. References
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33. References … continue
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34. References … continue
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