Recent discussions
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Janet Bray
Thanks for your comment. The BLS Task Force appreciates your feedback. We are currently reviewing all the drowning treatment recommendations together to ensure they make sense as a collective. Janet Bray (BLS TF Chair) -
Sheldon Cheskes
We thank the ILCOR task force for their careful review of our trial. We would like to provide some clarity regarding the trial methodology and respectfully challenge some of the rationale behind the downgrading of the quality of the evidence The task force rated down for Risk of Bias (RoB) and Imprecision. The explanation provided by the task force for rating down for RoB was that paramedics weren't blinded to the defibrillation strategy. In our opinion, this does not represent an important source of bias in the trial for the following reasons: (1) Paramedics did not choose to enroll individual patients; rather patients were enrolled if they met eligibility criteria and were allocated to a defibrillation strategy according to the cluster randomization; (2) all outcomes were objective and unlikely to be influenced by any subjective assessments; (3) our results showed that quality of CPR was excellent across groups, with no important differences in scene time, drug administration, or time to drug administration; if conscious or unconscious bias was a concern, one would expect these to be different (e.g., paramedics might spend less time on scene if standard care was thought to be inferior, or frequently crossover from standard to other interventions). The statement also notes that paramedics determined some secondary outcomes (VFT and ROSC). This is inaccurate: VFT was never determined by paramedics but was determined by blinded abstractors after review of each case; paramedics determined ROSC but this was according to standard practice and each case was independently reviewed and verified by the medical director or local site investigator. We do not believe these approaches to outcome assessment would have introduced important bias – and we would argue the task force should not have downgraded for Risk of Bias due to lack of blinding. The task force also downgraded for imprecision. We would argue the task force should not have downgraded for imprecision for the DSED vs standard comparison, but we are comfortable with the decision to downgrade for imprecision for the VC vs standard comparison. GRADE suggests an approach that relies on thresholds and CIs of the absolute effect (CI approach) as a primary criterion for imprecision rating, NOT the optimal information size approach. We therefore disagree with the stated rationale which currently says, "Optimal information size not met. Using the hypothesized survival rate with standard defibrillation in the original trial (12%) and the hypothesized absolute increase in survival of 8% for both DSED and VC, a sample size of 310 patients per study group was calculated by the authors. The actual sample size of 125 (DSED), 136 (SD) and 144 (VC) was well below this number, introducing the possibility of imprecision in the results". Note that the absolute increase in survival for DSED was actually 17% not 8%, suggesting the hypothesized effect size for DSED used in the sample size was likely an underestimate. In our opinion, the thresholds and CIs of the effect for DSED (aRR 2.21, 95% CI 1.33 to 3.67) were not close to 1 and do not suggest imprecision. We appreciate the opportunity to comment and welcome any feedback from the ILCOR task force. -
Talal Hagag
Thanks -
Toru Hifumi
I would like to add the following ILCOR stated that whether there are subsets of post–cardiac arrest patients who would benefit from hypothermic temperature control on previous Task Force Knowledge Gaps (2022 ILCOR CoSTR Summary). The effect of TTM is expected to be greater with ECMO (after ECPR) than without ECMO, because optimal target temperature control as well as hemodynamic stability can be obtained. Thus, we believe that TTM following ECPR needs to be added to the current knowledge gaps. -
Toru Hifumi
ILCOR performed systematic review and studies comparing ECPR with conventional CPR were included. According to the knowledge gaps, optimal techniques, cost, and post-cardiac arrest care strategy using ECPR remain unknown. Recently, we have published the largest cohort study (SAVE-J II study) including 1,644 patients with OHCA who received ECPR [Crit Care. 2022 May 9;26(1):129]. This large cohort dataset contains details of techniques to establish ECPR, ICU management (infection control, glucose control, sedation, and so on), cost, and socioeconomic status; therefore, a statistically confirmed study will provide robust conclusions and further hypotheses on ECPR. Thus, we hope ILCOR will focus on the results of these analyses in the future. Furthermore, although the effect of temperature control after ECPR was mentioned in the previous ILCOR statement as Task Force Knowledge Gaps (2022 ILCOR CoSTR Summary), it should be noted that there is no mention of it at all in the current knowledge gaps. We consider temperature control to be the principal component of optimal post-cardiac arrest care strategy. We are now planning to conduct the SAVE-J III study (A RCT study comparing target temperature of 34°C and 36°C in ECPR patients) to determine their efficacy. -
Alexis Topjian
In review of you CAB or ABC in drowning from January 2022 you recommend "a compression-first strategy (CAB) for lay persons providing resuscitation for adults and children in cardiac arrest due to drowning (Good practice statement)", however in this statement you seem to recommend CAB for adults which was previously covered in the CAB vs ABC COSTR. This is not paralleled in the peds bullet point starting with ventilations where you state rescue breathing should be used but do no comment on order. It would be clearer if the adult first bullet was a bit more in parallel to pediatrics with commenting on components not on commencing which has been addressed elsewhere -
Stacey Matthews
To whom it may concern, I am providing feedback on behalf of the National Heart Foundation of Australia, please see our comments and suggestions below: * Family presence during arrest should be based upon family and patients’ preferences and values. Suggest it should be discussed in advance with the patient and family as a part of advanced care planning if the situation occurred would they want to be present. *When implementing family presence procedures, they should incorporate cultural safety. *Consider mentioning there maybe some scenario that family presence is not appropriate, for example when family are obstructive to the health team in resuscitating the patient. *Could consider competencies to be completed to ensure that health professionals now how to conduct themselves and manage family distress during stressful resuscitation situations. *You could mention the potential impact on mental health for patients, families and health professionals with family presence during CPR. *Could mention structured debrief with family members and health care professionals involved post resuscitation. * Suggest mentioning when implementing this procedure, it should be reviewed within the hospital setting to see if appropriate and find out impacts on mental health and family reported outcomes especially from those of diverse backgrounds. Thank you for providing us with the opportunity to review. Please feel free to contact me if you would like to discuss the suggestions and comments. Kind regards, Stacey Matthews -
David Szpilman
I strongly disagree the use of bag-mask fro BLS. Even with best training (always in manikins, and no airway resistance) is usually a disaster. We have trained hundreds of full time lifeguards 30 years ago, and retraining every 6 month and did went very bad. For rescuer it seems to be great, they would think that they did not need to mouth contact but at the end for victim is far from the good. I would suggest to reconsider in order to not estimulante it use. -
William Montgomery
test by admin -
John Mouw
It may make for better understanding if the Intervention says, "Oxygen administration during pre-hospital resuscitation" and Comparison says, "No oxygen administration during pre-hospital resuscitation." Saying only "No oxygen administration before hospital arrival" does not imply during resuscitation attempts. These are two very different treatment considerations and comparisons.