Recent discussions
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Виктория Антонова
Thanks for your insight, we agree fully with your wish for high stake multicenter trials. -
Виктория Антонова
Thanks for your comment about possible impact of no TOR rules on hospital transport of futile patients. That was the reason why we added a paragraph about that in the Justification chapter of this CoSTR. EIT will consider your suggestion for the gap of knowledge. -
Виктория Антонова
Thank you for your comment. We did not identify any human studies that directly compared the rate of drug infusion between humeral IO vs IV during cardiac arrest. As such, there is insufficient evidence for making any conclusions on this topic. -
Виктория Антонова
Thank you for your insightful comments. They underscore the lack of a standard uniform definition of cardiac activity. If the definition from Gaspari, et al. is considered the most user-friendly definition, then we encourage stakeholders and guideline organization to promulgate this definition so it can be uniformly used across investigations. This specific PICOST questions pertains to using POCUS for prognostication of clinical outcome during cardiac arrest. It is agnostic to POCUS as a diagnostic test for specific etiologies of cardiac arrest or POCUS as a means to assess hemodynamic response to therapy. Huis, et al. and Clattenburg, et al. are cited as a means to simply caution clinicians to not introduce additional interruptions in chest compressions with POCUS. We acknowledge the existence of several strategies to minimize interruptions in chest compressions. In response to this comment, we are adding additional language to the penultimate Evidence-to-Decision bullet point: Clinicians should be cautious about introducing additional interruptions in chest compressions with a transthoracic approach to point-of-care echocardiography during cardiac arrest. (Huis In’t Veld 2017 95, Clattenburg 2018 65). Several strategies to minimize these interruptions have been proposed. Additionally, we are adding additional clarifying language to the final print version of this CoSTR (pending publication in October, 2020). “Finally, in 2015 the question of whether the use of cardiac ultrasound during CPR changed outcomes was reviewed {Soar 2015 e71, Callaway 2015 s84}. This topic was not prioritized for an evidence update in 2020. The 2015 treatment recommendation currently remains pending further review: We suggest that if cardiac ultrasound can be performed without interfering with standard ACLS protocols, it may be considered as an additional diagnostic tool to identify potentially reversible causes (weak recommendation, very-low-quality evidence).” -
Виктория Антонова
Thank you for your comments. As mentioned in the response to Comment #1 above, this specific PICOST questions pertains to using POCUS for prognostication of clinical outcome during cardiac arrest. It is agnostic to POCUS as a diagnostic test for specific etiologies of cardiac arrest or POCUS as a means to assess hemodynamic response to therapy. Additionally, we are adding additional clarifying language to the final print version of this CoSTR (pending publication in October, 2020). “Finally, in 2015 the question of whether the use of cardiac ultrasound during CPR changed outcomes was reviewed {Soar 2015 e71, Callaway 2015 s84}. This topic was not prioritized for an evidence update in 2020. The 2015 treatment recommendation currently remains pending further review: We suggest that if cardiac ultrasound can be performed without interfering with standard ACLS protocols, it may be considered as an additional diagnostic tool to identify potentially reversible causes (weak recommendation, very-low-quality evidence).” -
Виктория Антонова
Thank you for your comment. We agree completely! We will be communicating this suggestion to the respective regional resuscitation councils in charge of developing algorithms. -
Виктория Антонова
Dear colleagues, I wonder why the study of Grunau et al. Resuscitation 2019 vol. 135 51 - 56 validating the Bokutoh criteria in North-America is not included in the analysis, this study was published within your time frame. My general comment is that there will always be unmeasured variability, 100% prediction is impossible and we need to accept the fact that uncertainty is inherent to medicine. As such we have to look at the number needed to treat (which is huge for some subpopulations, when for instance looking at the Bokutoh criteria (284 in their validation cohort) ) and allow and validate the clinical insight of the team to decide on an individual patient whether to proceed with resuscitation or whether to start at all. Especially since an estimated 13 - 20% of the cardiac arrests occur in dismal conditions (non-witnessed, non-shockable, old) the collateral damage we are causing needs to be stressed more, the extremely bad outcomes in non-shockable non-witnessed arrests in older people should not be treated by default but only in exceptional circumstances based on the clinical insight of the team or within a randomized controlled trial. I have a problem with the sentence: 'inclusion of a TOR within a termination guideline has the potential to reduce variation in practice associated with clinician judgment and improve termination decisions more generally." This variability can be justified and needs to be accepted due to the differences between patients. -
Виктория Антонова
I believe it is important to keep in mind the history of this topic. The 2-min post-shock CC protocol was instituted in 2005 not primarily to provide circulation for pulselessness after successful shocks; rather, it was clearly adopted to mitigate the harm of the lengthy “hands-off” periods for repeated rhythm analysis required by automated external defibrillators (AEDs). There is evidence that this strategy does improve survival when AEDs are used. However, its appropriateness for resuscitative attempts using manual defibrillators is highly questionable. If defibrillation results in the quick return of a perfusing rhythm, 2 additional min of CCs poses a risk of harm to the victim. Based on prior evidence for the efficacy of "stacked" shocks, a 2-min delay in giving a second shock for continuing VF could significantly decrease the likelihood of success. Claims of long intervals of pulselessness after successful shocks are dubious: one study found that delays of 2 min for return of a palpable pulse were common--if the first pulse check did not occur until the two-minute mark! The blanket recommendation for 2 min (or indeed any interval) of CCs before rhythm analysis and pulse check obscures a relative disadvantage of AEDs; it stands as a case of undue influence of the medical device industry over guidelines development. -
Виктория Антонова
EIT would like to thank for the comment. EIT is aware that that all the regional resuscitation councils have a teaching program exactly addressing that and offer a variety of teaching courses from BLS over neonatal, pediatric and adult courses. -
Виктория Антонова
Thanks for their insight and we consider including these limitations of the scoping review in future reviews and we will define better what is meant by “bundles of care”. Furthermore, this review was not intended to assess teaching methods, therefore no statement about blended learning was made - ILCOR EIT assessed that in other PICOSTs.