Between-centre differences in care for in-hospital cardiac arrest:a prospective cohort study

Abstract Background Survival after in-hospital cardiac arrest is poor, but current literature shows substantial heterogeneity in reported survival rates. This study aims to evaluate care for patients suffering in-hospital cardiac arrest (IHCA) in the Netherlands by assessing between-hospital heterogeneity in outcomes and to explain this heterogeneity stemming from differences in case-mix or differences in quality of care. Methods A prospective multicentre study was conducted comprising 14 centres. All IHCA patients were included. The adjusted variation in structure and process indicators of quality of care and outcomes (in-hospital mortality and cerebral performance category [CPC] scale) was assessed with mixed effects regression with centre as random intercept. Variation was quantified using the median odds ratio (MOR), representing the expected odds ratio for poor outcome between two randomly picked centres. Results After excluding centres with less than 10 inclusions (2 centres), 701 patients were included of whom, 218 (32%) survived to hospital discharge. The unadjusted and case-mix adjusted MOR for mortality was 1.19 and 1.05, respectively. The unadjusted and adjusted MOR for CPC score was 1.24 and 1.19, respectively. In hospitals where personnel received cardiopulmonary resuscitation (CPR) training twice per year, 183 (64.7%) versus 290 (71.4%) patients died or were in a vegetative state, and 59 (20.8%) versus 68 (16.7%) patients showed full recovery (p < 0.001). Conclusion In the Netherlands, survival after IHCA is relatively high and between-centre differences in outcomes are small. The existing differences in survival are mainly attributable to differences in case-mix. Variation in neurological outcome is less attributable to case-mix

A systematic review of biomarkers multivariately associated with acute respiratory distress syndrome development and mortality

Background: Heterogeneity of acute respiratory distress syndrome (ARDS) could be reduced by identification of biomarker-based phenotypes. The set of ARDS biomarkers to prospectively define these phenotypes remains to be established. Objective: To provide an overview of the biomarkers that were multivariately associated with ARDS development or mortality. Data sources: We performed a systematic search in Embase, MEDLINE, Web of Science, Cochrane CENTRAL, and Google Scholar from inception until 6 March 2020. Study selection: Studies assessing biomarkers for ARDS development in critically ill patients at risk for ARDS and mortality due to ARDS adjusted in multivariate analyses were included. Data extraction and synthesis: We included 35 studies for ARDS development (10,667 patients at risk for ARDS) and 53 for ARDS

Cardiopulmonary resuscitation practices in the Netherlands: results from a nationwide survey

Background: Survival rates after in-hospital cardiac arrest are low and vary across hospitals. The ERC guidelines state that more research is needed to explore factors that could influence survival. Research into the role of cardiopulmonary resuscitation (CPR) practices is scarce. The goal of this survey is to gain information about CPR practices among hospitals in the Netherlands. Methods: A survey was distributed to all Dutch hospital organizations (n = 77). Items investigated were general hospital characteristics, pre-, peri- and post-resuscitation care. Characteristics were stratified by hospital teaching status. Results: Out of 77 hospital organizations, 71 (92%) responded to the survey, representing 99 locations. Hospitals were divided into three categories: university hospitals (8%), teaching hospitals (64%) and non-teaching hospitals (28%). Of all locations, 96% used the most recent guidelines for Advanced Life Support and 91% reported the availability of a Rapid Response System. Training frequencies varied from twice a year in 41% and once a year in 53% of hospital locations. The role of CPR team leader and airway manager is most often fulfilled by (resident) anaesthetists in university hospitals (63%), by emergency department professionals in teaching hospitals (43%) and by intensive care professionals in non-teaching hospitals (72%). The role of airway manager is most often attributed to (resident) anaesthetists in university hospitals (100%), and to intensive care professionals in teaching (82%) and non-teaching hospitals (79%). Conclusion: The majority of Dutch hospitals follow the ERC guidelines but there are differences

Failure of target attainment of beta-lactam antibiotics in critically ill patients and associated risk factors: a two-center prospective study (EXPAT)

Background: Early and appropriate antibiotic dosing is associated with improved clinical outcomes in critically ill patients, yet target attainment remains a challenge. Traditional antibiotic dosing is not suitable in critically ill patients, since these patients undergo physiological alterations that strongly affect antibiotic exposure. For betalactam antibiotics, the unbound plasma concentrations above at least one to four times the minimal inhibitory concentration (MIC) for 100% of the dosing interval (100%ƒT>1–4×MIC) have been proposed as pharmacodynamic targets (PDTs) to maximize bacteriological and clinical responses. The objectives of this study are to describe the PDT attainment in critically ill patients and to identify risk factors for target non-attainment. Methods: This prospective observational study was performed in two ICUs in the Netherlands. We enrolled adult patients treated with the following beta-lactam antibiotics: amoxicillin (with or without clavulanic acid), cefotaxime, ceftazidime, ceftriaxone, cefuroxime, and meropenem. Based on five samples within a dosing interval at day 2 of therapy, the time unbound concentrations above the epidemiological cut-off (ƒT > MICECOFF and ƒT > 4×MICECOFF) were determined. Secondary endpoints were estimated multivariate binomial and binary logistic regression models, for examining the association of PDT attainment with patient characteristics and clinical outcomes. Results: A total of 147 patients were included, of whom 63.3% achieved PDT of 100%ƒT > MICECOFF and 36.7% achieved 100%ƒT > 4×MICECOFF. Regression analysis identified male gender, estimated glomerular filtration rate (eGFR) ≥ 90 mL/min/1.73 m2 , and high body mass index (BMI) as risk factors for target non-attainment. Use of continuous renal replacement therapy (CRRT) and high serum urea significantly increased the probability of target attainment. In addition, we found a significant association between the 100%ƒT > MICECOFF target attainment and ICU length of stay (LOS), but no significant correlation was found for the 30-day survival. Conclusions: Traditional beta-lactam dosing results in low target attainment in the majority of critically ill patients. Male gender, high BMI, and high eGFR were significant risk factors for target non-attainment. These predictors, together with therapeutic drug monitoring, may help ICU clinicians in optimizing beta-lactam dosing in critically ill patients