Effects of team leaders' position in cardiopulmonary resuscitation teams on leadership behavior and team performance: A prospective randomized interventional cross-over simulation-based trial.

BACKGROUND Leadership is an important performance factor in resuscitation teams. Medical guidelines for cardiopulmonary resuscitation (CPR) advise team leaders to keep hands off patients. There is little evidence for this recommendation that is based purely on observational data. Accordingly, the aim of this trial was to investigate the effect of leaders' position during CPR on leadership behavior and team performance. METHOD This is a prospective randomized interventional crossover simulation-based single center trial. Teams of 3 to 4 physicians each, representing a rapid response team, were confronted with a simulated cardiac arrest. Team leaders were randomly assigned and assigned team leaders were 1:1 randomized to 2 leadership positions: position at the patient's head; and hands-off position. Data analysis was performed from video-recordings. All utterances during the first 4 minutes of CPR were transcribed and coded based on a modified "Leadership Description Questionnaire." The primary endpoint was the number of leadership statements. Secondary outcomes included CPR related performance markers like hands-on time and chest compression rate, and the behavioral related endpoints Decision Making, Error Detection, and Situational Awareness. RESULTS Data from 40 teams (143 participants) was analyzed. Leaders in hands-off position made more leadership statements (28 ± 8 vs 23 ± 8; P <.01) and contributed more to their team's leadership (59 ± 13% vs 50 ± 17%; P = .01) than leaders in the head position. Leaders' position had no significant effect on their teams' CPR performance, Decision Making, and Error Detection. Increased numbers of leadership statements lead to improved hands-on time ( R = 0.28; 95% confidence interval 0.05-0.48; P = .02). CONCLUSIONS Team leaders in a hands-off position made more leadership statements and contributed more to their teams' leadership during CPR than team leaders actively involved in the head position. However, team leaders' position had no effect on their teams' CPR performance

Acute phase proteins and white blood cell levels for prediction of infectious complications in status epilepticus

ABSTRACT: INTRODUCTION: Infections in status epilepticus (SE) patients result in severe morbidity making early diagnosis crucial. As SE may lead to inflammatory reaction, the value of acute phase proteins and white blood cells (WBC) for diagnosis of infections during SE may be important. We examined the reliability of C-reactive protein (CRP), procalcitonin (PCT), and WBC for diagnosis of infections during SE. METHODS: All consecutive SE patients treated in the ICU from 2005 to 2009 were included. Clinical and microbiological records, measurements of CRP and WBC during SE were analyzed. Subgroup analysis was performed for additional PCT measurements in the first 48 hours of SE. RESULTS: 22.5% of 160 consecutive SE patients had infections during SE. Single levels of CRP and WBC had no association with the presence of infections. Their linear changes over the first three days after SE onset were significantly associated with the presence of infections (p=0.0012 for CRP, p=0.0137 for WBC). Levels of PCT were available for 31 patients and did not differ significantly in patients with and without infections. Sensitivity of PCT and CRP was high (94% and 83%) and the negative predictive value of CRP increased over the first three days to 97%. Specificity was low, without improvement for different cut-offs. CONCLUSIONS: Single levels of CRP and WBC are not reliable for diagnosis of infections during SE, while their linear changes over time significantly correlated with the presence of infections. In addition, low levels of CRP and PCT rule out hospital-acquired infections in SE patient

Cerebral perfusion in sepsis-associated delirium

INTRODUCTION: The pathophysiology of sepsis-associated delirium is not completely understood and the data on cerebral perfusion in sepsis are conflicting. We tested the hypothesis that cerebral perfusion and selected serum markers of inflammation and delirium differ in septic patients with and without sepsis-associated delirium. METHODS: We investigated 23 adult patients with sepsis, severe sepsis, or septic shock with an extracranial focus of infection and no history of intracranial pathology. Patients were investigated after stabilisation within 48 hours after admission to the intensive care unit. Sepsis-associated delirium was diagnosed using the confusion assessment method for the intensive care unit. Mean arterial pressure (MAP), blood flow velocity (FV) in the middle cerebral artery using transcranial Doppler, and cerebral tissue oxygenation using near-infrared spectroscopy were monitored for 1 hour. An index of cerebrovascular autoregulation was calculated from MAP and FV data. C-reactive protein (CRP), interleukin-6 (IL-6), S-100beta, and cortisol were measured during each data acquisition. RESULTS: Data from 16 patients, of whom 12 had sepsis-associated delirium, were analysed. There were no significant correlations or associations between MAP, cerebral blood FV, or tissue oxygenation and sepsis-associated delirium. However, we found a significant association between sepsis-associated delirium and disturbed autoregulation (P = 0.015). IL-6 did not differ between patients with and without sepsis-associated delirium, but we found a significant association between elevated CRP (P = 0.008), S-100beta (P = 0.029), and cortisol (P = 0.011) and sepsis-associated delirium. Elevated CRP was significantly correlated with disturbed autoregulation (Spearman rho = 0.62, P = 0.010). CONCLUSION: In this small group of patients, cerebral perfusion assessed with transcranial Doppler and near-infrared spectroscopy did not differ between patients with and without sepsis-associated delirium. However, the state of autoregulation differed between the two groups. This may be due to inflammation impeding cerebrovascular endothelial function. Further investigations defining the role of S-100beta and cortisol in the diagnosis of sepsis-associated delirium are warranted. TRIAL REGISTRATION: ClinicalTrials.gov NCT00410111

Perceived stress and team performance during a simulated resuscitation

Purpose: Barriers to optimal performance of cardiopulmonary resuscitation may partly relate to human factors, such as stress and specific emotions. The aim of this study was to investigate whether mental stress and different perceived emotions have a negative impact on the performance of rescuers. Methods: This prospective, observational study was conducted at the Simulator Center of the University Hospital Basel, Switzerland. A total of 120 medical students (70% female) participated in teams of three. They reported levels of perceived stress, feeling overwhelmed, motivation and specific emotions before, during, and after a simulated resuscitation. The association of stress/overload (index of stress and feeling overwhelmed), motivation, and specific emotions with resuscitation performance defined as hands-on time during the first 180s after cardiac arrest was investigated. Results: During resuscitation, levels of stress/overload, motivation, and negative emotions were significantly higher as compared to the periods before and after resuscitation. In contrast, positive emotions were highest before and after resuscitation and significantly lower during resuscitation. In general, females reported higher stress/overload and negative emotions, whereas males reported more positive emotions. A multivariate linear regression model showed negative associations of stress/overload (regression coefficient −18.12, 95% CI −30.73, −5.51, p=0.006) and positive associations of motivation (regression coefficient 13.45, 95% CI 0.95, 25.95, p=0.036) with resuscitation performance. Conclusion: A simulated cardiac arrest caused substantial perceived stress/overload and negative emotions, particularly in female students, which adversely impacted resuscitation performance. Further studies are required to expand our findings to more experienced medical professionals and investigate whether stress coping strategies improve resuscitation performanc

Incidence, risk factors, and outcome of aspiration pneumonitis in ICU overdose patients

Objective: To assess the incidence and outcome of clinically significant aspiration pneumonitis in intensive care unit (ICU) overdose patients and to identify its predisposing factors. Design: Retrospective cohort study. Setting: Medical ICU of an academic tertiary care hospital. Patients: Atotal of 273 consecutive overdose admissions. Measurements and results: Clinically significant aspiration pneumonitis was defined as the occurrence of respiratory dysfunction in apatient with alocalised infiltrate on chest X-ray within 72 h of admission. In our cohort we identified 47 patients (17%) with aspiration pneumonitis. Importantly, aspiration pneumonitis was associated with ahigher incidence of cardiac arrest (6.4 vs 0.9%; p = 0.037) and an increased duration of both ICU stay and overall hospital stay [respectively: median 1 (interquartile range 1-3) vs 1 (1-2), p = 0.025; and median 2 (1-7) vs 1 (1-3), p < 0.001]. In multivariate logistic regression analysis, Glasgow Coma Scale (GCS) score [odds ratio (OR) for each point of GCS 0.8; 95% confidence interval (CI) 0.7-0.9; p = 0.001], ingestion of opiates (OR 4.5; 95% CI 1.7-11.6; p = 0.002), and white blood cell count (WBC) (OR for each increase in WBC of 109/l 1.05; 95% CI 1.0-1.19; p = 0.049) were identified as independent risk factors. Conclusions: Clinically relevant aspiration pneumonitis is afrequent complication in overdose patients admitted to the ICU. Moreover, aspiration pneumonitis is associated with ahigher incidence of cardiac arrest and increased ICU and total in-hospital sta

Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: a prospective, randomized controlled trial

Succinylcholine and rocuronium are widely used to facilitate rapid sequence induction (RSI) intubation in intensive care. Concerns relate to the side effects of succinylcholine and to slower onset and inferior intubation conditions associated with rocuronium. So far, succinylcholine and rocuronium have not been compared in an adequately powered randomized trial in intensive care. Accordingly, the aim of the present study was to compare the incidence of hypoxemia after rocuronium or succinylcholine in critically ill patients requiring an emergent RSI

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