Recent discussions
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Racire Silva
The use of the stethoscope is still the most used, but little by little we are becoming more accustomed to placing the electrodes when necessary. -
Racire Silva
In our service we never had access. -
ILCOR Staff
Kate Berg, ALS ILCOR Chair: Thank you for your comments, and we look forward to reading about your planned trial. Your recently published observational study was not included in the present review as there was no comparison group (patients who did not receive ECPR), so it did not meet inclusion criteria for this review, but we agree that such large cohort studies will continue to contribute valuable information to the field. Regarding temperature, we are not aware of evidence supporting temperature control with hypothermic temperatures being more beneficial in patients receiving ECPR than in comatose postarrest patients generally, and anticipate that treatment recommendations on temperature management will continue to evolve as more trials emerge. We agree that whether temperature management at hypothermic or subnormal temperatures is beneficial in patients receiving ECPR is a knowledge gap and will discuss adding this. -
Rossiclei de Souza Pinheiro
Hypothermia has been associated with increased mortality, we have no doubts, but what we can do to reduce the risks: I believe that all interventions are important but safety is necessary. The use of thermal mattress has not yet demonstrated quality work, mainlyin very low weight drinks. We will invest in low-cost and security interventions. -
Maria Ladjane Leite Soares
Mt bom ! -
ILCOR Staff
From ALS Chair Kate Berg:Response: Dr. Chapman, thank you very much for your comments. First, while we agree that the available data did not allow for statistical comparison of DSED and VC, it is also the case that DSED compared with SD showed statistically significant benefits for all outcomes, while this was not the case for VC compared with SD. This is why the TF came to the conclusions it did, after extensive discussion. We include some of this discussion in the evidence to decision section and have included it as a knowledge gap. We agree about the importance of the sample size being smaller than planned due to the trial stopping early, and that the effect size might be an overestimate, which is why the evidence was downgraded for imprecision. The lack of comparison between DSD and VC, however, was not as a result of stopping the study early. The study was never designed to compare DSD to VC. Second, we agree that none of the currently available defibrillators are designed for DSED. We have discussed the importance of pad placement for SD, possible concerns about defibrillator damage and the reasoning for recommending the approach (single operator activating the shock with one hand, sequentially) used in the trial as well, as we agree that these are important considerations. Third, we are happy to ask ILCOR leadership to extend the public comment period. -
ILCOR Staff
Response from ALS Chair Kate Berg: Thank you Dr. Cheskes for the comments regarding your trial. Risk of bias and certainty of evidence were discussed extensively with the task force, and decisions were not easy to come to. The task force opinion is that there is a potential risk of bias in unblinded studies (unavoidable in this case) because whether the study intervention or a different intervention is used may depend on the clinician’s opinion about the intervention or their opinion about the specific patient. There was a significant amount of crossover between the 3 study treatments, which was not evenly distributed. Exactly why this occurred or how it could have influenced the results is not entirely clear, but the task force felt that this may indicate a potential source of risk of bias. Thank you for clarifying how termination of VF/VT was determined. We can make that adjustment in the relevant GRADE tables. Regarding the assessment of imprecision, we think the optimal information size was appropriate to invoke. GRADE recommends the optimal information size (OIS) as a “second, necessary criterion to consider.” The concept of optimal information size is meant to prompt downgrading for imprecision when you do not think the sample size was adequate to be a true population estimate, based on a conventional sample size calculation. Since the goal is to detect when an effect size reported in a smaller trial may not reflect the true effect size, systematic reviewers are advised to calculate a sample size based on relative risk difference of 20-30%, not on the effect size observed in the trial in question (see GRADE handbook section on imprecision 5.2.4.1, #2 under “dichotomous outcomes,” and then see Example 3). We thought the original sample size calculation conducted by your group was reasonably close to the GRADE recommendation for that calculation so relied on that for the OIS. The fact that survival increased more than your group initially hypothesized is notable and may reflect the true effect, but there is risk of overestimation of treatment effect when trials are stopped early (Liu et al, Trials 23, 747, Sept 2022; Guyatt et al, BMJ ;344:e3863, 2012), so we think determining OIS based on a more conservative sample size calculation is prudent. Overall, the task force opinion is that a single trial of approximately 130 patients per study group almost by definition cannot provide higher certainty evidence for what is a considerable practice change, and we think GRADE methodology supports that determination. -
Janet Bray (BLS Task Force Chair)
Thank you for your interest in this review. -
Kris Arnold
This is an important, evolving topic. In my opinion, it is still at the scoping report level. Hopefully publication of this will serve as a milestone in the development of this trend. It is unfortunate that at least one website promoting the use of drone-delivered AEDs demonstrated a collapsed person, presumably in cardiac arrest, not receiving any CPR while the bystander communicates with the emergency services to arrange and then retrieve the delivered AED from outside a gymnasium-like building. This raises a practical question if there is only one responder who does, correctly, begin compressions needing, then, to also retrieve the drone. I relate this only to make the point that developing effective drone-AED programs will require both flexibility/variability in the drones and careful thought on the part of the agency's deploying a response system. I look forward to your next report on this in another 3-5 years. -
Syed Moied Ahmed
1. Drone AED will definitely reduce the time to defibrillate 2. It will reduce the requirement of manpower 3. However, it will be not get of other benefits or the additional of EMS, specially the presence of expert opinion and extra hands 4. There should be a RCT framed to resolve this question.