Recent discussions
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ILCOR Staff
And a noteworthy part, not explained, of the protocol is crucial; after declaring death, a balloon is inserted in the aorta and inflated (Fogarty catheter) to avoid reperfusion of both heart and brain that would restore flow after death declaration and theoretically (not only tough, as it has already happened) restore life to the individual. In addition, should be said that in the running protocols at Spain is said to prehospital EMS professionals to convey the individual ASAP to the center in which uDCD protocol is implemented, without giving any information about the target of this specific destination to the proxies unless they specifically ask for this sensible info. Where truthfulness and transparency in the clinical relationship remain at this point? How many pillars of both legal frame and ethical principles are underminned while doing this? It is understandable that uDCD outcomes have been decreased 36% in last two years at Madrid region, which was the more powerful international uDCD program for many decades... Health care providers and society begin to be uncomfortable with such a way to proceed. At the same time, starting ECPR programs for refractory OHCA show us that eligibility criteria to be enrolled as patient or as potential deceased donor are too much similar... Therefore, conflicts of interest are clear and EMS professionals' loyalty to life saving purposes is evident, so uDCD future is in really danger. While policy-makers on Deceased Donation will continue to maintain such an ambiguity and lack of transparency on their uDCD programs, the whole so-called Spanish Organ Donation model will be put in danger too. It's a pity, though. -
ILCOR Staff
May I suggest that an additional recommendation should focus on the PROSPECTIVE capture of treatment episodes in a multicenter and pre-defined way. This is still nowhere near a randomised trial but will identify confounders in a less biased fashion and could potentially give further evidence to answer questions 2,3,4 and 6. Currently knowledge is mostly drawn from single center observations and is hence prone to publication bias. ECPR is a complex intervention and its outcome is dependent on the right logistics, infrastructure, training and protocols. As with many complex intervention the best results will be achieved when the 'ifs', 'whens' and 'hows' are clear. -
ILCOR Staff
Typo, sorry! Neurological intact survival in hypothermic cardiac arrest treated with ECLS is NOW approaching 70% survival with neurological intact outcomes (My typo above says NOT apologies, Malin -
ILCOR Staff
To be fair, "the continuous evidence evaluation process for the production of the Consensus on Science with Treatment Recommendations (CoSTR)" actually did not started with a systematic review of ECPR (Holmberg 2018 91 – PROSPERO Registration CRD42018085404) as stated in this provided link, but with another one (2016 Ortega-Deballon I et al. Resuscitation. 2016;101:12-20. PROSPERO, CRD 42014015259). http://dx.doi.org/10.1016/j.resuscitation.2016.01.018. This PREVIOUS, and to our knowledge the first systematic review performed on ECPR topic until that moment, followed PICOTS question format, PRISMA format, explored both level of evidence (following the LOE scale tool proposed by ILCOR) and quality of guidelines (following AGREE II) from ECPR for refractory OHCA of cardiac origin in adults. In short, did pretty the same that Holmberg et al have been published. We do not understand, at first, why previous work is not referenced at any moment, why the research question, methodology and search strategy is close to duplicate and already did research and why if findings are pretty a duplication of our previous systematic review, the efforts were not focused on reducing knowledge gap while recognizing previous research work from colleagues instead. In any case, although, again, findings and results from the latter (2018 Holmberg et al) are practically identical to the former that we authorized (and conducted less than 2 years later) we are sure that running RCTs will help to really increase LOE and reduce knowledge gap in order to inform future research. At the same time, many other questions will remain despite of RCT publication, as such a methodology have also limitations when referred to Resuscitation Research environment. Finally, from a comprehensive approach to sudden cardiac arrest in the prehospital environment, we suggest that the option of Deceased Organ Donation (both after neurologic determination of death -NDD- and after circulatory determination of death -DCD-) should be explored between non eligible for/non survivors from "ECPR strategy", as also between patients with a very poor neurologic prognosis (CPC>3) despite of ROSC after ECPR strategy. This approach, has been already encouraged by ILCOR in 2015 Guidelines and should not be disregarded from a more effective, efficient and ethically sound point of view. Rowing together, both Resuscitationists/ECMOlogists community and Organ Donation & Transplant community, we really will do our best for both patients, their proxies, health providers confidence and thrutfulness of whole system from society according with best scientific evidence and ethical principles, taking into account the specific legal frame and cultural believes at each country. We really stress that this opportunity should not be lost again. We will continue working on it. The final goal, to increase survival from OHCA with QOL first and organ donation pool to reduce organ shortage for transplant when not possible, deserve to do so. -
ILCOR Staff
There are many variables in assessing dispatcher assisted CPR. This review does not take into account the nature of the advice vs the outcome i.e. ROSC, short term survival and survival to discharge i.e. compressions only (in the case of predominately cohorts of adult subjects or traditional compressions and ventilation CPR. Various studies have shown that compression-only CPR (as the primary scenario usually involves adults and is a SCA [>80%]) is as (or more) effective in producing favourable outcomes. Research in Sweden indicated compression-only instruction by Emergency Dispatchers/Calltakers resulted in a 75% increase in bystander willingness to commence resuscitation prior to ambulance arrival a factor not addressed in the review. In Australia (and no doubt other countries) ventilations are still part of dispatcher assisted CPR advice, despite no evidence that bystanders in an emergency (with or without training) can master both airway management and control of tidal volume to prevent aspiration. The is also significant barriers identified in research to the ability of non-clinical emergency calltakers to determine cardiac arrest i.e. an inability to correctly identify and recognise agonal respirations (in the absence of a response to pain) as indicative of SCA. This would further influence the accuracy of the outcomes reported. Although the presence or absence of “breathing” by a novice is extremely unlikely to be accurate nor to consider or recognise if the patient is “breathing normally”; the incorrect question (i.e. presence or absence of breathing) is still used by some emergency services (including Australia where there is a legacy and undying commitment to bystander ventilations despite evidence to the contrary in regard to efficacy). There is therefore doubt as to determining circumstances of an arrest as determined in reviewing the evidence and making assumptions. It is also a mistake in assuming bystanders are capable of effective ventilation and airway management and that will not result in gastric distension and aspiration (a significant cause of failure to survive to discharge due to aspiration pneumonia). This also applies to those trained in BLS, who must only be considered novices for the purposes of airway management and ventilation and not “trained individuals” as determined in other ILCOR documentation. Lastly it would be helpful to understand what formal consideration of public feedback is undertaken by the relevant ILCOR committees, prior to the release of treatment recommendations i.e. as to whether this input is just consultative or collaborative as in the past the drafts and final documents seem unchanged despite legitimate concerns about the utility and efficacy of the recommendations. -
ILCOR Staff
I strongly recommend that "in any setting" needs to be altered to "in a setting where the patient is normothermic" or "where the cause of cardiac arrest is not accidental hypothermia". The survival outcomes for Hypothermic Cardiac arrest is totally different from normothrmic cardiac arrest as is eloquently described in the article "Normothermic and hypothermic cardiac arrest—Beware of Jekyll and Hyde" Article in Resuscitation 129 · April 2018 DOI: 10.1016/j.resuscitation.2018.04.020 The survival data particularly form Dr Tomasz Darocha and his team in Krakow are not approaching 70% with neurological intact outcome. The overall European survival of hypothermic cardiac arrest treated with mechanical CPR and ECLS with intact neurological status is about 50% , thus way better than in normothermic cardiac arrest -
ILCOR Staff
*This is not a comment to add* One of my comments has been published duplicated. Is this one: IVAN ORTEGA-DEBALLON 2018.11.02 13:37:17 (modified: 2018.11.02 20:06:52) Thanks for removing THIS specifically. Best, Iván Ortega-Deballon -
ILCOR Staff
In the field first responders do not have the tools to determine if resuscitation is possible, but if during training the option of organ donation is discussed, it provides another reason to continue CPR - for the best outcome for whoever. Maintaining organ tissue allows the family more options. -
ILCOR Staff
I am a consumer/patient and I am interested in issues pertaining to end of life care and organ donation. I personally think that if I had a cardiac arrest and my heart could be of any use to help someone, in principal I do not have any problems with it being harvested. I have asked other consumers and some had the same opinion as me, but many people said that they would have to consult their priest or spiritual leader. I believe that would cause some delays in obtaining consent and therefore cause delays in harvesting the organ and transporting it to nearest hospital. I spoke with people of three different religious faiths, and they were adamant that they would consent only upon their religious leader approval. -
ILCOR Staff
uDCD remains an unusual activity in Europe and elsewhere despite some international organizations have called to considering this type of donation activity. For example, the 2015 European Resuscitation Council’s guidelines recommend that “After stopping cardiopulmonary resuscitation, the possibility of ongoing support of the circulation and transport to a dedicated center in perspective of organ donation should be considered”. The largest uDCD programs have been developed in Spain and France. The most important obstacles to the expansion of this type of donation is the absence of a legal framework supporting these programs, some ethical concerns well addressed in the outline provided, lack of organizational capability and technical expertise, and doubts about the quality of organs retrieved from uDCD donors. In fact, countries that have successfully implemented DCD programs have done so primarily by establishing a national ethical, professional and legal framework to address both public and professional concerns with all aspects of the DCD pathway. Therefore, identifying and addressing the aspects of the uDCD pathway that raise such professional and public concerns in the current project is pertinent and highly relevant. We take the opportunity of stressing how some of these aspects have been addressed in the Spanish regulatory framework and national guidelines that apply to uDCD: • The decisions to abandon CPR is always disconnected from any consideration of organ donation. The roles of each healthcare professional (HCP) involved in uDCD have been well defined. Thus each decision over the uDCD process is undertaken by a different HCP, to minimize any potential conflict of interests. o CPR is performed by the emergency medical service in according with the Guidelines of the Spanish Resuscitation Council, which are aligned with international standards on CPR. CPR is deemed unsuccessful and abandoned when resuscitation efforts have been exhausted according to existing protocols and best clinical expertise. Considering the option of donation whenever possible―based on the circumstances of the cardiac arrest and the inclusion criteria of the uDCD protocol―is considered a responsibility of any HPC. Once CPR is deemed unsuccessful by the attending team, if organ donation is possible, the candidate is referred to the Donor Coordinator (DC) who will evaluate the case and authorize the transfer to a hospital with an uDCD program. o During the transfer of the potential donor, cardiac compression and mechanical ventilation are maintained with the purpose of preserving potentially transplantable organs. Once in the emergency room of the receiving hospital, a physician independent of the out of hospital emergency team and the DC, must confirm that no further therapeutic efforts are indicated and declare the death of the individual after observing a period of 5 minutes of absence of spontaneous breathing and circulation. • The deceased person’s wishes regarding organ donation are ascertained by several methods, including donor registries, advanced directives, and after discussion with surrogates. The timing of the surrogate discussion varies according to pre-defined scenarios. Transparency is paramount during interactions with families, but disclosure of the critical information requires compassion and privacy, and consideration about their emotional capability to cope with the stressing news must drive the communication process.