First-Response ABCDE Management of Status Epilepticus: A Prospective High-Fidelity Simulation Study

Respiratory infections following status epilepticus (SE) are frequent, and associated with higher mortality, prolonged ICU stay, and higher rates of refractory SE. Lack of airway protection may contribute to respiratory infectious complications. This study investigates the order and frequency of physicians treating a simulated SE following a systematic Airways-Breathing-Circulation-Disability-Exposure (ABCDE) approach, identifies risk factors for non-adherence, and analyzes the compliance of an ABCDE guided approach to SE with current guidelines. We conducted a prospective single-blinded high-fidelity trial at a Swiss academic simulator training center. Physicians of different affiliations were confronted with a simulated SE. Physicians (; n; = 74) recognized SE and performed a median of four of the five ABCDE checks (interquartile range 3-4). Thereof, 5% performed a complete assessment. Airways were checked within the recommended timeframe in 46%, breathing in 66%, circulation in 92%, and disability in 96%. Head-to-toe (exposure) examination was performed in 15%. Airways were protected in a timely manner in 14%, oxygen supplied in 69%, and antiseizure drugs (ASDs) administered in 99%. Participants' neurologic affiliation was associated with performance of fewer checks (regression coefficient -0.49;; p; = 0.015). We conclude that adherence to the ABCDE approach in a simulated SE was infrequent, but, if followed, resulted in adherence to treatment steps and more frequent protection of airways

Predicting neurological outcome in adult patients with cardiac arrest: systematic review and meta-analysis of prediction model performance

This work aims to assess the performance of two post-arrest (out-of-hospital cardiac arrest, OHCA, and cardiac arrest hospital prognosis, CAHP) and one pre-arrest (good outcome following attempted resuscitation, GO-FAR) prediction model for the prognostication of neurological outcome after cardiac arrest in a systematic review and meta-analysis. A systematic search was conducted in Embase, Medline, and Web of Science Core Collection from November 2006 to December 2021, and by forward citation tracking of key score publications. The search identified 1'021 records, of which 25 studies with a total of 124'168 patients were included in the review. A random-effects meta-analysis of C-statistics and overall calibration (total observed vs. expected [O:E] ratio) was conducted. Discriminatory performance was good for the OHCA (summary C-statistic: 0.83 [95% CI 0.81-0.85], 16 cohorts) and CAHP score (summary C-statistic: 0.84 [95% CI 0.82-0.87], 14 cohorts) and acceptable for the GO-FAR score (summary C-statistic: 0.78 [95% CI 0.72-0.84], five cohorts). Overall calibration was good for the OHCA (total O:E ratio: 0.78 [95% CI 0.67-0.92], nine cohorts) and the CAHP score (total O:E ratio: 0.78 [95% CI 0.72-0.84], nine cohorts) with an overestimation of poor outcome. Overall calibration of the GO-FAR score was poor with an underestimation of good outcome (total O:E ratio: 1.62 [95% CI 1.28-2.04], five cohorts). Two post-arrest scores showed good prognostic accuracy for predicting neurological outcome after cardiac arrest and may support early discussions about goals-of-care and therapeutic planning on the intensive care unit. A pre-arrest score showed acceptable prognostic accuracy and may support code status discussions

Deceased organ donation activity and efficiency in Switzerland between 2008 and 2017: achievements and future challenges.

Various actions have been taken during the last decade to increase the number of organs from deceased donors available for transplantation in Switzerland. This study provides an overview on key figures of the Swiss deceased organ donation and transplant activity between 2008 and 2017. In addition, it puts the evolution of the Swiss donation program's efficiency in relation to the situation in the neighboring countries. This study is an analysis of prospective registry data, covering the period from 1 January 2008 to 31 December 2017. It includes all actual deceased organ donors (ADD) in Switzerland. Donor data were extracted from the Swiss Organ Allocation System. The "donor conversion index" (DCI) methodology and data was used for the comparison of donation program efficiency in Switzerland, Germany, Austria, Italy and France. During the study period there were 1116 ADD in Switzerland. The number of ADD per year increased from 91 in 2008 to 145 in 2017 (+ 59%). The reintroduction of the donation after cardiocirculatory death (DCD) program in 2011 resulted in the growth of annual percentages of DCD donors, reaching a maximum of 27% in 2017. The total number of organs transplanted from ADD was 3763 (3.4 ± 1.5 transplants per donor on average). Of these, 48% were kidneys (n = 1814), 24% livers (n = 903), 12% lungs (n = 445), 9% hearts (n = 352) and 7% pancreata or pancreatic islets (n = 249). The donation program efficiency assessment showed an increase of the Swiss DCI from 1.6% in 2008 to 2.7% in 2017 (+ 69%). The most prominent efficiency growth was observed between 2012 and 2017. Even though Swiss donation efficiency increased during the study period, it remained below the DCI of the French and Austrian donation programs. Swiss donation activity and efficiency grew during the last decade. The increased donation efficiency suggests that measures implemented so far were effective. The lower efficiency of the Swiss donation program, compared to the French and Austrian programs, may likely be explained by the lower consent rate in Switzerland. This issue should be addressed in order to achieve the goal of more organs available for transplantation

Acute Neurologic Complications During Extracorporeal Membrane Oxygenation-A Systematic Review

We determine the frequency, risk factors, and mortality of neurologic complications in adults on extracorporeal membrane oxygenation and propose an algorithm for preventive strategies.; PubMed, Embase, and Cochrane databases.; Screening was performed using predefined search terms to identify cohort studies reporting neurologic complications in adults during extracorporeal membrane oxygenation from 1990 to 2017.; The final reference list was generated on the basis of relevance to the discussed topics. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation classification of evidence scheme.; In 44 studies, the median frequency of acute neurologic complications is 13% (1-78%; 5% intracranial hemorrhages, 5% ischemic strokes, 2% seizures). Neurologic complications are reported more frequently with venoarterial extracorporeal membrane oxygenation compared with venovenous extracorporeal membrane oxygenation (14 vs eight studies) with a median proportion of complications of 15% (6-33%; 95% CI, 8-19) for venoarterial extracorporeal membrane oxygenation. Median in-hospital mortality is higher with neurologic complications (83%; interquartile range, 54-100% vs 42%; interquartile range, 24-55% without neurologic complications; p < 0.001). Median mortality is 96% for hemorrhages, 84% for ischemic strokes 84%, and 40% for seizures. Risk factors are age, preextracorporeal membrane oxygenation cardiac arrest, hypoglycemia, and administration of inotropes. Hemorrhages are associated with female gender, duration of ventilation and extracorporeal membrane oxygenation, decreased serum fibrinogen, heparin, serum creatinine greater than 2.6 mg/dL, hemodialysis, and thrombocytopenia. Increased odds for ischemic stroke is seen with a preextracorporeal membrane oxygenation serum lactate greater than 10 mmol/L. No studies report daily coagulation monitoring and neurologic assessments, and quality of evidence was low to very low.; Neurologic complications are reported frequently and with high occurrence rate, especially with venoarterial extracorporeal membrane oxygenation, and associated with high mortality calling for daily weaning from sedation and neuromuscular blockers for neurologic assessment and coagulation monitoring. The low quality of evidence indicates the need for higher quality studies in this context

What to exclude when brain death is suspected

With advances in critical care and organ donation, diagnosis of brain death is gaining importance. We aimed to assess potential brain death confounders from the literature, elucidating clinical presentation and diagnostic approaches in these cases.; PubMed and Embase were screened using 37 predefined search terms to identify suitable articles reporting cases, case series, or cohort studies in adults.; Out of 4769 articles, 40 case reports or case series describing 45 patients with 19 critical conditions were identified. Mortality was 11% and full recovery 33%. Intoxications (42%; mainly anti-seizure drugs and baclofen) and polyneuritis (37%) were most frequent. Brainstem reflex tests were reported in 96%, apnoea test in 16% and ancillary tests in all but one patient. Full recovery mainly occurred with intoxications. Quality of evidence regarding frequency of confounders is very low and risk of bias high.; Brain death confounders are infrequently reported and formal studies are lacking. Mainly younger patients with polyneuritis and intoxications are described. As outcome, especially in the latter, is often favourable, high awareness and strict adherence to guidelines is crucial. The importance of identifying pathologies compatible with extensive and irreversible brain damage before proceeding to diagnostic tests should be emphasized

Emergency response to out-of-hospital status epilepticus: A 10-year observational cohort study

OBJECTIVE: To determine the implications of first responses of emergency medical services (EMS) to out-of-hospital status epilepticus (SE) on outcome. METHODS: From 2005 to 2014, prehospital and in-hospital data were assessed in consecutive adults admitted to an academic medical center with out-of-hospital SE. Logistic regression was performed to identify variables with a robust association between missed epileptic events by the EMS and no recovery to functional baseline in survivors. RESULTS: Among 213 SE patients, 150 were admitted via EMS. While nonconvulsive SE (NCSE) was missed by the EMS in 63.7%, convulsive SE (CSE) was not missed except in 4 patients with transformation into subtle SE. Missed NCSE was more likely with older age (odds ratio [OR]per year 1.06, 95% confidence interval [CI] 1.02-1.10, p = 0.003) and no seizure history (OR 6.64, 95% CI 2.43-18.1, p < 0.001). The area under the receiver operating characteristic curve for prediction of missed NCSE by these variables was 0.839. Independent predictors for not receiving benzodiazepines were increasing age (ORper year 1.05, 95% CI 1.01-1.08, p = 0.008) and higher Glasgow Coma Scale score (ORper increasing unit 1.21, 95% CI 1.09-1.36, p = 0.001). Missed NCSE was independently associated with increased odds for no return to functional baseline in survivors (OR 3.83, 95% CI 1.22-11.98, p = 0.021). CONCLUSIONS: Among patients admitted with out-of-hospital SE, CSE is mostly recognized while NCSE is frequently missed especially in patients with increasing age and no seizure history. This calls for heightened awareness for out-of-hospital NCSE in such patients, as missed NCSE is associated with lack of treatment and less recovery to functional baseline in survivors independent of established outcome predictors

Procedures of brain death diagnosis and organ explantation in a tertiary medical centre – a retrospective eight-year cohort study

AIMS OF THE STUDY: To assess the frequency and variables associated with the need for ancillary tests to confirm suspected brain death in adult patients, and to assess the time from brain death to organ explantation in donors. We further sought to identify modifiable factors influencing the time between brain death and start of surgery. METHODS: Medical records and the Swiss organ allocation system registry were screened for all consecutive adult patients diagnosed with brain death at an intensive care unit of a Swiss tertiary medical centre from 2013 to 2020. The frequency and variables associated with the performance of ancillary tests (i.e., transcranial doppler, digital subtraction angiography, and computed tomography angiography) to confirm brain death were primary outcomes; the time from death to organ explantation as well as modifying factors were defined as secondary outcomes. RESULTS: Among 91 patients with a diagnosis of brain death, 15 were not explanted and did not undergo further ancillary tests. Of the remaining 76 patients, who became organ donors after brain death, ancillary tests were performed in 24%, most frequently in patients with hypoxic-ischaemic encephalopathy. The leading presumed causes of death (not mutually exclusive) were haemorrhagic strokes (49%), hypoxic-ischaemic encephalopathies (33%) and severe traumatic brain injuries (22%). Surgery for organ explantation was started within a median of 16 hours (interquartile range [IQR] 13–18) after death with delay increasing over time (nonparametric test for trend p = 0.05), mainly due to organ allocation procedures. Patients with brain death confirmed during night shifts were explanted earlier (during night shifts 14.3 hours, IQR 11.8–16.8 vs 16.3 hours, IQR 13.5–18.5 during day shifts; p = 0.05). CONCLUSIONS: Ancillary tests to confirm brain death are frequently performed, mainly in resuscitated patients. The delay to surgery for organ explantation after confirmed brain death was longer during day shifts, increased over time and was mainly determined by organ allocation procedures. The trial was registered on clinical trials.gov (identifier: NCT03984981

Diagnostic Errors Induced by a Wrong a Priori Diagnosis: A Prospective Randomized Simulator-Based Trial

Preventive strategies against diagnostic errors require the knowledge of underlying mechanisms. We examined the effects of a wrong a priori diagnosis on diagnostic accuracy of a focussed assessment in an acute myocardial infarction scenario. One-hundred-and-fifty-six medical students (cohort 1) were randomized to three study arms differing in the a priori diagnosis revealed: no diagnosis (control group), myocardial infarction (correct diagnosis group), and pulmonary embolism (wrong diagnosis group). Forty-four physicians (cohort 2) were randomized to the control group and the wrong diagnosis group. Primary endpoint was the participants’ final presumptive diagnosis. Among students, the correct diagnosis of an acute myocardial infarction was made by 48/52 (92%) in the control group, 49/52 (94%) in the correct diagnosis group, and 14/52 (27%) in the wrong diagnosis group (p p = 0.023). In the wrong diagnosis group, 31/52 (60%) students and 6/23 (19%) physicians indicated their initially given wrong a priori diagnosis pulmonary embolism as final diagnosis. A wrong a priori diagnosis significantly increases the likelihood of a diagnostic error during a subsequent patient encounter