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The IoT can lead to disruptive healthcare innovation. Research articles on IoT in healthcare and COVID-19 pandemics are thus researched in order to discover the potential of this technology. This literature-based research may help professionals to explore solutions to associated issues and battle the COVID-19 epidemic. Using a process diagram, IoT's significant accomplishments were briefly evaluated. Then seven critical IoT technologies that look useful in healthcare during the COVID-19 Pandemic are identified and illustrated. Finally, in the COVID-19 Pandemic, potential fundamental IoT applications were identified for the medical industry with a short explanation. The present predicament has opened up a fresh avenue to creativity in our everyday lives. The Internet of Things is an up-and-coming technology that enhances and gives better solutions in the medical area, such as appropriate medical record-keeping, sample, device integration, and cause of sickness. IoT's sensor-based technology gives a remarkable ability to lower the danger of intervention in challenging circumstances and is helpful for the pandemic type COVID-19. In the sphere of medicine, IoT's emphasis is on helping to treat diverse COVID-19 situations accurately. It facilitates the work of the surgeon by reducing risks and enhancing overall performance. Using this technology, physicians may readily identify changes in the COVID-19′s vital parameters. These information-based services provide new prospects for healthcare as they advance towards the ideal technique for an information system to adapt world-class outcomes by improving hospital treatment systems. Medical students may now be better taught and led in the future for the identification of sickness. Proper use of IoT may assist handle several medical difficulties such as speed, affordability, and complexity appropriately. It may simply be adapted to track patients' calorific intake and therapy with COVID-19 asthma, diabetes, and arthritis. In COVID-19 pandemic days, this digitally managed health management system may enhance the overall healthcare performance.

Three-dimensional (3D) right ventricular (RV) strain analysis is not routinely performed perioperatively. Although 3D RV strain adds incrementally to outcome prediction in various cardiac diseases, its role in the perioperative setting is not sufficiently understood. The aim of this study was to investigate the association between 3D RV strain measured on RV meshes created from 3D transesophageal echocardiographic data and short-term outcomes among patients undergoing cardiac surgery.A total of 496 patients undergoing cardiac surgery who underwent intraoperative 3D transesophageal echocardiography (under general anesthesia, before sternotomy) were retrospectively selected, and RV meshes were generated using commercially available speckle-tracking software. Custom-made software automatically quantified longitudinal and circumferential RV strains on the mesh surfaces. Echocardiographic and clinical parameters were entered into logistic regression models to determine their associations with the primary (in-hospital death or need for extracorporeal life support) and secondary (postoperative ventilation48 hours) end points.Mesh-derived RV strain analysis was feasible in 94% of patients and revealed distinct regional patterns with basal-apical gradients for both longitudinal and circumferential strain. Thirty-seven patients (7.6%) reached the primary end point, and 118 patients (23.8%) reached the secondary end point. In a multivariable logistic regression model, serum lactate (P .01), an emergency indication for surgery (P .01), tricuspid regurgitation (P .001), and mesh-derived RV global longitudinal strain (RV-GLS; P .01) were independently associated with the primary end point, while established measures of RV function (3D RV ejection fraction, fractional area change, tricuspid annular plane systolic excursion) and left ventricular (LV) function (3D-derived LV ejection fraction and LV-GLS) were not independently associated. Hematocrit (P .01), serum lactate (P .001), pulmonary hypertension (P = .04), tricuspid regurgitation (P .01), emergency procedures (P = .02), LV-GLS (P = .02), and RV-GLS (P .001) were associated with the secondary end point.RV-GLS measured on RV meshes derived from 3D transesophageal echocardiography was independently associated with short-term outcomes in patients undergoing cardiac surgery and might be helpful for identifying patients at risk for adverse postoperative events.

Accidental hypothermia (core temperature

Accidental hypothermia (AH) in Mediterranean countries often is underestimated. AH should be suspected in patients also in moderate climates throughout all seasons. Compared with other countries, the mortality rate due to AH in Spain is low, and hypothermia rarely is recognized and treated. The case of a patient who experienced cardiac arrest due to severe AH and was resuscitated for more than six hours using extracorporeal life support recently was published. Herein that case is reviewed, with the anesthetic management during cannulation detailed. In addition, the authors highlight how the application of extracorporeal cardiopulmonary resuscitation guidelines is different in AH patients, how in-hospital (HOPE score) triage criteria should be applied, and how the establishment of clear standard operating procedures and education strategies should be promoted.

Aim To evaluate missed nursing care (MNC) phenomenon on Neonatal Intensive Care Units (NICUs) infants. Design A cross-sectional study. Methods A sample of 113 eligible Registered Nurses (RNs) and Registered Midwives (RMs) were prospectively recruited at the Neonatal Intensive Care Units (NICUs). The study uses a self -designed authors questionnaire (ADQ) and the Neonatal Extent of Work Rationing Instrument (NEWRI). Results MNC evidence was the most significant in the parental support and teaching subscales (M = 2.21, SD = 0.87) and the least in life support and discharge planning (M = 1.19, SD = 0.9). MNC in the care coordination and discharge planning subscales significantly (p

The survival of completely buried victims in an avalanche mainly depends on burial duration. Knowledge is limited about survival probability after 60 min of complete burial. We aimed to study the survival probability and prehospital characteristics of avalanche victims with long burial durations. We retrospectively included all completely buried avalanche victims with a burial duration of ≥60 min between 1997 and 2018 in Switzerland. Data were extracted from the registry of the Swiss Institute for Snow and Avalanche Research and the prehospital medical records of the physician-staffed helicopter emergency medical services. Avalanche victims buried for ≥24 h or with an unknown survival status were excluded. Survival probability was estimated by using the non-parametric Ayer-Turnbull method and logistic regression. The primary outcome was survival probability. We identified 140 avalanche victims with a burial duration of ≥60 min, of whom 27 (19%) survived. Survival probability shows a slight decrease with increasing burial duration (23% after 60 min, to

Although hybrid and parallel ECMO circuits may prove useful in managing certain patients, generally these strategies should not be used as the initial means of cannulation. Rather, patients should be supported with isolated VA or VV ECMO with the understanding that patient conditions are dynamic and they may require a modification to their modality of support during their course. This may require optimization of the existing circuit, changing cannulation site (eg, femoral artery to axillary artery), conversion from one modality to another, the employment of hybrid or parallel ECMO circuits, or even conversion to central cannulation, and de-escalation from there as the patients’ status changes. Further, cannula position should be optimized and medical management should be maximized. Patients who ultimately require a hybrid or parallel ECMO support represent a small fraction of total patients receiving ECMO, as illustrated by Extracorporeal Life Support Organization data. In general, survival is lower in these patients, with adult respiratory patients having a survival of 32% with V-AV support compared to 60% with VV support, and adult cardiac patients having a survival of 32% with V-AV support compared with 41% with VA support.7 There are currently no data that clearly establish a mortality benefit of the use of hybrid or parallel circuits. The high mortality associated with these strategies likely reflects the severity of illness of patients who require hybrid strategies compared with those who are supported with isolated VV or VA ECMO. Mechanical circulatory support is a complex landscape, and patients requiring support have dynamic disease processes. With the myriad of ECMO configurations and mechanical circulatory support devices that are available, each patient requires an individualized approach. The determination must be made of the appropriate cannulation strategy for ECMO and whether to use it in isolation or in concert with another circulatory support device to best fit each patient. Conflict of Interest Statement David J. Kaczorowski has a patent for devices for endovascular access through extracorporeal life support circuits. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Case Presentation A 57-year-old man who had been intubated and placed on venovenous extracorporeal membrane oxygenation for hypoxemic respiratory failure due to COVID-19 pneumonia was transferred to our facility. He underwent anticoagulation with IV heparin titrated to an anti-Factor Xa goal of 0.1 to 0.3 international unit/mL. Over extracorporeal membrane oxygenation days 13 to 17, his WBC count rose from 17,500 to 47,000 cells/μL. He simultaneously experienced the development of fluid-refractory shock that required multiple vasopressors and received stress-dose hydrocortisone when his WBC was 30,000 cells/μL. He remained afebrile and was started on broad-spectrum antimicrobials that included antifungal and anthelminthic therapy.

Background Initiation or withholding life support at birth on infants born prematurely near the limit of viability is not an easy decision, with wide variation in practice around the world. Our aim was to review the outcome of preterm infants born near the limit of viability at 23–25 weeks gestation in our institution, with regard to resuscitation decision, survival, and major outcome measures. Methods We included all live newborn infants born prematurely at 23–25 weeks gestation at King Faisal Specialist Hospital and Research Centre from January 2006 to December 2015. We collected data on resuscitation decisions, survival, and major neonatal morbidities such as severe brain injury, severe retinopathy of prematurity, and bronchopulmonary dysplasia. Results Between January 1, 2006 and December 31, 2015, 97 infants with a gestational age (GA) of 23–25 weeks gestation were admitted; 23, 42, and 32 infants were born at 23, 24, and 25 weeks gestation, respectively. At 23 weeks gestation, full support was initiated in 87% of patients and later on support was withheld in 17.4% of patients, finally 13% of patients survived to discharge. At 24 weeks, full support was initiated in 97.6% of patients, then withheld in 7.1% of patients, and ultimately 59.5% survived. At 25 weeks, full support was initiated in 93.8% of patients, then withheld in 15.6% of patients, and ultimately 62.5% survived. In terms of survival with and without the three major neonatal morbidities, at 23 weeks gestation, no infant survived without any morbidity as compared to 7.1% and 28.1% at 24 and 25 weeks, respectively. The incidence of survival with 1 major morbidity was 8.7%, 30.9%, and 34.4% at 23, 24, and 25 weeks, respectively, the incidence of survival with 2 major morbidities was 0%, 19%, and 0% at 23, 24, and 25 weeks, respectively, and the incidence of survival with 3 major morbidities was 4.3%, 2.4%, and 0% at 23, 24, and 25 weeks, respectively. Conclusion In our patient cohort, survival and survival without major neonatal morbidity were very low at 23 weeks gestation, but it improved gradually as gestational age advanced.

Background Current American Heart Association Pediatric Life Support (PLS) guidelines do not recommend the routine use of sodium bicarbonate (SB) during cardiac arrest in pediatric patients. However, SB administration during pediatric resuscitation is still common in clinical practice. The objective of this study was to assess the impact of SB on mortality and neurological outcomes in pediatric patients with in-hospital cardiac arrest. Methods We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to January 2021. We included studies of pediatric patients that had two treatment arms (treated with SB or not treated with SB) during in-hospital cardiac arrest (IHCA). Risk of bias was assessed using the Newcastle-Ottawa Scale and the certainty of evidence was assessed using GRADE system. Results We included 7 observational studies with a total of 4877 pediatric in-hospital cardiac arrest patients. Meta-analysis showed that SB administration during pediatric cardiac resuscitation was associated with a significantly decreased rate of survival to hospital discharge (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.25–0.63, p value = 0.0003). There were insufficient studies for 24-h survival and neurologic outcomes analysis. The subgroup analysis showed a significantly decreased rate of survival to hospital discharge in both the “before 2010” subgroup (OR 0.47; 95% CI 0.30–0.73; p value = 0.006) and the “after 2010” subgroup (OR 0.46; 95% CI 0.25–0.87; p value = 0.02). The certainty of evidence ranged from very low to low. Conclusions This meta-analysis of non-randomized studies supported current PLS guideline that routine administration of SB is not recommended in pediatric cardiac arrest except in special resuscitation situations. Trial registration The protocol was registered with PROSPERO on 8 August 2020 (registration number: CRD42020197837).

Aneurysmal subarachnoid hemorrhage is a neurological emergency that requires prompt patient stabilization, diagnosis, and treatment. While the classic presentation of a severe headache is common, there are a wide range of presentations including mild pain and coma. Treatment advances have moved towards early endovascular coiling of the ruptured aneurysm in most cases, based on two randomized clinical trials. Following securing of the aneurysm, there is evidence that patients are best served at centers employing multidisciplinary teams with specialized training in neurocritical care. The critical care management of the SAH patient is essential for treatment and mitigation of complications, in particular a syndrome of delayed neurological decline. Further study is essential for optimizing the acute care and improving outcomes in patients with aneurysmal SAH.

Informed by a series of systematic reviews, scoping reviews and evidence updates from the International Liaison Committee on Resuscitation, the 2021 European Resuscitation Council Guidelines present the most up to date evidence-based guidelines for the practice of resuscitation across Europe. The guidelines cover the epidemiology of cardiac arrest; the role that systems play in saving lives, adult basic life support, adult advanced life support, resuscitation in special circumstances, post resuscitation care, first aid, neonatal life support, paediatric life support, ethics and education.

The purpose of this review is to provide ECMO outcome data for medical personnel who counsel families of patients with pulmonary hypoplasia (PH), often secondary to renal abnormalities. We report diagnoses and outcomes associated with PH in neonates that were treated with ECMO over the past 35 years.Retrospective cohort study using the ELSO database for neonates born between 1981 and 2016 with a primary or secondary diagnosis of PH. Five patient groups were created based on ICD-9 codes. Mortality rates were compared and trends over time were investigated.Thirty-three percent of the 1385 patients survived to discharge. Congenital diaphragmatic hernia (CDH) patients had significantly higher mortality than PH patients secondary to renal dysplasia (p 0.001). Mortality decreased significantly over time for all groups (p 0.001). The proportion of patients alive at discharge increased over time for CDH patients (p 0.001), whereas survival decreased for patients with PH secondary to renal dysplasia (p = 0.012).Neonates with PH that require ECMO have high mortality rates, which have generally decreased over the past 35 years; however, mortality for neonates with PH secondary to renal dysplasia continues to increase. We speculate that the apparent rise in mortality for these patients is because of changes in patient selection subsequent to improvements in non-ECMO ventilatory support.II.

Background Acute respiratory distress syndrome (ARDS) is a relatively common condition of varied aetiology associated with high morbidity and mortality. A range of therapies have been proven to be useful for patients with ARDS, including ventilatory and nonventilatory strategies. Prone positioning is one of the nonventilatory strategies and has been proven to be safe and is associated with significant mortality benefit in patients with moderate to severe ARDS. It is now included in several international guidelines as the standard of care for these cases. Objectives The aim of the study was to develop, implement, and evaluate a prone positioning program in two nonmetropolitan, nontertiary intensive care units in South East Queensland. Methods A Plan–Do–Study–Act quality improvement model was used to implement changes in clinical practice in relation to prone positioning of patients. Results A description of the methods used to promote a complex change strategy is provided in this article. Conclusions In this article, we demonstrate the feasibility of introducing a nonventilatory intervention of prone positioning in the management of patients with moderate to severe ARDS in regional intensive care in South East Queensland. This implementation strategy could be replicated and adopted in other similar intensive care units that do not have the ability to provide tertiary services such as extracorporeal life support.

Outcomes in neonates receiving extracorporeal membrane oxygenation (ECMO) for meconium aspiration syndrome (MAS) and/or persistent pulmonary hypertension (PPHN) are favorable. Infants with preserved perfusion are often offered venovenous (VV) support to spare morbidities of venoarterial (VA) ECMO. Worsening perfusion or circuit complications can prompt conversion from VV-to-VA support. We examined whether outcomes in infants requiring VA ECMO for MAS/PPHN differed if they underwent VA support initially versus converting to VA after a VV trial, and what factors predicted conversion.We reviewed the Extracorporeal Life Support Organization registry from 2007 to 2017 for neonates with primary diagnoses of MAS/PPHN. Propensity score analysis matched VA single-runs (controls) 4:1 against VV-to-VA conversions based on age, pre-ECMO pH, and precannulation arrests. Primary outcomes were complications and survival. Data were analyzed using Mann-Whitney U and Fisher's exact testing. Multivariate regression identified independent predictors of conversion for VV patients.3831 neonates underwent ECMO for MAS/PPHN, including 2129 (55%) initially requiring VA support. Of 1702 patients placed on VV ECMO, 98 (5.8%) required VV-to-VA conversion. Compared with 364 propensity-matched isolated VA controls, conversion runs were longer (190 vs. 127 h, P 0.001), were associated with more complications, and decreased survival to discharge (70% vs. 83%, P = 0.01). On multivariate regression, conversion was more likely if neonates on VV ECMO did not receive surfactant (OR = 1.7;95%CI = 1.1-2.7;P = 0.03) or required high-frequency ventilation (OR = 1.9;95%CI = 1.2-3.3;P = 0.01) before ECMO.Conversion from VV-to-VA ECMO in infants with MAS/PPHN conveys increased morbidity and mortality compared to similar patients placed initially onto VA ECMO. VV patients not receiving surfactant or requiring high-frequency ventilation before cannulation may have increased risk of conversion. While conversions remain rare, decisions to offer VV ECMO for MAS/PPHN must be informed by inferior outcomes observed should conversion be required.Level of evidence 3 Retrospective comparative study.

For almost 20 years, therapeutic hypothermia has been a cornerstone of modern post-cardiac arrest care lowering mortality, and improvin neurologic outcome compared to conventional therapy. This was challenged by the first TTM-trial in 2013, which did not show a benefit for hypothermia at 33°C compared to controlled normothermia at 36°C. Now, the TTM2 trial showed no benefit of hypothermia compared to fever prevention alone. While TTM1 and TTM2 suggest that hypothermia might not be helpful, a deep dive into the trials reveals that this conclusion does not hold true. Here, we focus on patient selection, suboptimal application of hypothermia, interaction of standard sedation with hypothermia, high incidence of post-arrest fever, and withdrawal of life support based on per-protocol neurologic prognostication in the TTM2-trial. Of particular interest, contemporary trials and registries using intravascular cooling in TTM-like patients repeatedly reported much lower mortality rates than those described in both TTM1 and TTM2.

Common agents described in ocular chemical and thermal injuries include cleaning agents, fertilizers, refrigerants, cement, preservatives, and fireworks. Visual prognosis is dependent on the concentration, quantity, and pH of the chemical involved as well as the timing and efficacy of treatment. Here we report a case of severe ocular alkali injury in effort to bring attention to the need for early recognition during the advanced burn life support evaluation. The patient is a 22-year-old factory worker who sustained 29.5% partial and full thickness burns while carrying a bucket of powdered magnesium. The magnesium contacted water and ignited onto his face, trunk, and arms. He was initially evaluated in a rural setting where he was immediately intubated and sedated prior to transfer to the regional burn center. Attention was paid to extremity and trunk injuries, however, ocular evaluation and irrigation was not performed until his arrival at the burn center, approximately 6 h later. At that point, he was found to have molten magnesium adhered to bilateral corneas. The patient unfortunately sustained irreversible ocular injury despite amniotic membrane grafts. Awareness of the importance of ocular evaluation during burn resuscitation must be raised in tertiary care centers, emergency medicine, and burn center communities.

Background The decision to implant durable mechanical circulatory systems (MCSs) in patients on extracorporeal life support (ECLS) is challenging due to expected poor outcomes in these patients. Objectives The aim of this study was to identify outcome predictors that may facilitate future patient selection and decision making. Methods The Durable MCS after ECLS registry is a multicenter retrospective study that gathered data on consecutive patients who underwent MCS implantation after ECLS between January 2010 and August 2018 in 11 high-volume European centers. Several perioperative parameters were collected. The primary endpoint was survival at 1 year after durable MCS implantation. Results A total of 531 durable MCSs after ECLS were implanted during this period. The average patient age was 53 ± 12 years old. ECLS cannulation was peripheral in 87% of patients and 33% of the patients had history of cardiopulmonary resuscitation before ECLS implantation. The 30-day, 1-year, and 3-year actuarial survival rates were 77%, 53%, and 43%, respectively. The following predictors for 1-year outcome have been observed: age, female sex, lactate value, Model of End-Stage Liver Disease XI score, history of atrial fibrillation, redo surgery, and body mass index >30 kg/m2. On the basis of this data, a risk score and an app to estimate 1-year mortality was created. Conclusions The outcome in patients receiving durable MCS after ECLS remains limited, yet preoperative factors may allow differentiating futile patients from those with significant survival benefit.

Objectives This study sought to determine the frequency, incidence rates over time, association with mortality, and potential risk factors for hemocompatibility-related adverse events (HRAEs) occurring during venoarterial-extracorporeal life support (VA-ECLS). Background HRAEs are common complications of VA-ECLS. Studies examining relevant clinical predictors and the association of HRAEs with survival are limited by small sample size and single-center setting. Methods We queried adult patients supported with VA-ECLS from 2010 to 2017 in the Extracorporeal Life Support Organization database to assess the impact of HRAEs on in-hospital mortality. Results Among 11,984 adults meeting study inclusion, 8,457 HRAEs occurred; 62.1% were bleeding events. The HRAE rate decreased significantly over the study period (p trend Conclusions Although decreasing, HRAEs remain common during VA-ECLS and have a cumulative association with survival. Bleeding events are twice as common as thrombotic events, with a hierarchy of HRAEs influencing survival. Differential risk factors for bleeding and thrombotic complications exist and raise the possibility of a tailored approach to ECLS management.

International audience; Purpose: Early and reliable prognostication after cardiac arrest (CA) remains crucial. We hypothesized that protein-S100B (PS100B) could predict more accurately outcome in the early phase of CA compared with other current biomarkers.Methods: This prospective single-center study included 330 adult comatose non-traumatic successfully resuscitated CA patients, treated with targeted temperature management but not extra-corporeal life support. Lactate, pH, creatinine, NSE, and PS100B were sampled in ICU early after return of spontaneous circulation (ROSC) corresponding to admission (Adm). Serial measurements were also performed at H24 and H48. PS100B was the sole biomarker blinded to physicians.Measurements and main results: The median delay between ROSC and first PS100B sampling was 220 min. At admission, all biomarkers were significantly associated with good outcome (CPC1-2; 109 patients) at 3-month follow-up (P ≤ 0.001, except for NSE: P = 0.03). PS100B-Adm showed the best AUC of ROC curves for outcome prediction at 3-month (AUC 0.83 [95%-CI: 0.78-0.88]), compared with other biomarkers (P < 0.0001), while AUC for lactate-Adm was higher than for NSE-Adm. AUC for PS100B-H24 was significantly higher than for other biomarkers except NSE-H24 (P ≤ 0.0001), while AUC for NSE-H24 was higher than for lactate-H24 and pH-H24. AUCs for PS100-H48 and NSE-H48 were significantly higher than for all other biomarkers (P < 0.001). Compared to patients with decreased PS100B values over time, an increasing PS100B value between admission and H24 was significantly associated with poor outcome at 3 months (P = 0.001). No-flow, initial non-shockable rhythm, PS100B-Adm, lactate-Adm, pH-Adm, clinical seizures, and absence of therapeutic hypothermia were independent predictors associated with poor outcome at 3-month in multivariate analysis. Net-Reclassification-Index was 70%, 64%, and 81% when PS100B-Adm was added to the clinical model, to clinical model with NSE-Adm, and to clinical model with standard biological parameters, respectively.Conclusions: Early PS100B compared with other biomarkers was independently correlated with outcome after CA, with an interesting added value.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.

Skill decay is a recognised problem in resuscitation training. Spaced learning has been proposed as an intervention to optimise resuscitation skill performance compared to traditional massed learning. A systematic review was performed to answer 'In learners taking resuscitation courses, does spaced learning compared to massed learning improve educational outcomes and clinical outcomes?' This systematic review followed the PRISMA guidelines. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 2 December 2019. Randomised controlled trials and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using RoB, ROBINS-I tool and GRADEpro respectively. Educational outcomes studied were skill retention and performance 1 year after completion of training; skill performance between completion of training and 1 year; and knowledge at course conclusion. Clinical outcomes were skill performance at actual resuscitation, patient survival to discharge with favourable neurological outcome. This systematic review was registered in PROSPERO (CRD42019150358). From 2,042 references, we included data from 17 studies (13 randomised studies, 4 cohort studies) in courses with manikins and simulation in the narrative synthesis. Eight studies reported results from basic life support training (with or without automatic external defibrillator); three studies reported from paediatric life support training; five were in neonatal resuscitation and one study reported results from a bespoke emergency medicine course which included resuscitation teaching. Fifteen out of seventeen studies reported improved performance with the use of spaced learning. The overall certainty of evidence was rated as very low for all outcomes primarily due to a very serious risk of bias. Heterogeneity across studies precluded any meta-analyses. There was a lack of data on the effectiveness of spaced learning on skill acquisition compared to maintaining skill performance and/or preventing skill decay. There was also insufficient data to examine the effectiveness of spaced learning on laypeople compared to healthcare providers. Despite the very low certainty of evidence this systematic review suggests that spaced learning can improve skill performance at 1 year post course conclusion and skill performance between course conclusion and 1 year. There is a lack of data from this educational intervention on skill performance in clinical resuscitation and patient survival at discharge with favourable neurological outcomes. [Abstract copyright: Copyright © 2020 Elsevier B.V. All rights reserved.]

Background Impella (Abiomed Inc, Danvers, MA) is a temporary mechanical support device positioned across the aortic valve, and can be used to support patient before LVAD implantation. There are no data on the incidence of aortic insufficiency (AI) in patients supported with Impella as a bridge to durable LVAD implantation. We sought to assess the incidence of AI in patients with Impella support as a bridge to durable left ventricular assist device (LVAD) implantation. Methods We reviewed all patients undergoing primary LVAD implantation at the University of Pennsylvania from January 2015 onward, comparing those supported with Impella as temporary mechanical support with those supported by either venoarterial extracorporeal life support or an intra-aortic balloon pump. We reviewed transthoracic echocardiography preoperatively, as well as at 1 week, 1, 3, 6, 9, and 12 months after LVAD implantation. Results A total of 215 echocardiograms were analyzed in 41 patients. Eleven patients were supported with Impella before LVAD implant—6 patients with Impella alone (5 with Impella CP, 1 with Impella 5.0) and 5 with Impella in conjunction with venoarterial extracorporeal life support (2 with Impella 2.5, 2 with Impella CP, and 1 with Impella 5.0). After LVAD implant, mild or moderate AI developed in 82% of patients supported with Impella (9 of 11) compared with 43% of those without Impella (13 of 30) (P = .038). Conclusions Patients supported by Impella as a bridge to durable LVAD have a higher risk of developing AI. Further studies are needed to assess this risk as the use of the Impella increases.

Objectives This study describes the largest North American single-institution experience with adult patients requiring multiple extracorporeal membrane oxygenation (ECMO) runs in the same admission and aims to describe outcomes of survival and complication rates in this patient population. Design A retrospective chart review–based study in a single quaternary care center of venoarterial (VA) ECMO patients cannulated multiple times on ECMO support to assess for outcomes and survival (both of ECMO therapy and survival to discharge). Setting Single quaternary academic center for ECMO. Participants All patients undergoing VA ECMO who were at least 18 years of age from 2011 to 2019, composed of a total of 14 patients requiring multiple cannulations. Interventions None, this was a retrospective chart review. Measurements and Main Results Of the 326 patients reviewed, 14 patients (4.3% of all patients in the database) had multiple ECMO therapies. The average patient age was 55.2 ± 10.99 years of age, and 57% were female; 4 of the 14 (28.6%) patients survived to hospital discharge. The top 2 indications for initial VA ECMO therapy were cardiogenic shock after myocardial infarction (35.7%) and after cardiotomy shock (35.7%). For repeated cannulation, the most common cause was hypoxia (64%, 9 patients), with 6 of these patients requiring a right ventricular assist device plus oxygenator. Other causes for repeated cannulation included post-cardiotomy shock (14%), recurrent ventricular tachycardia (14%), and cardiogenic shock (7%). All patients who required continuous venovenous hemofiltration during their first run of ECMO did not survive to discharge. Conclusions Fourteen of 326 patients in the authors’ VA ECMO database required additional ECMO therapy after decannulation; this represents at least 1 to 2 cases per year at higher-volume centers. Despite the small number of patients in this retrospective review, it seems that certain patients are reasonable candidates for additional ECMO therapy should their cardiopulmonary function again decline. The findings of renal replacement therapy and infection being more common during a second ECMO run are logical, but larger cohorts (ideally multicenter or from within the Extracorporeal Life Support Organization registry) are required to validate these preliminary findings.

Health systems confronting the coronavirus disease 2019 (COVID-19) pandemic must plan for surges in ICU demand and equitably distribute resources to maximize benefit for critically ill patients and the public during periods of resource scarcity. For example, morbidity and mortality could be mitigated by a proactive regional plan for the triage of mechanical ventilators. Extracorporeal membrane oxygenation (ECMO), a resource-intensive and potentially life-saving modality in severe respiratory failure, has generally not been included in proactive disaster preparedness until recently. This paper explores underlying assumptions and triage principles that could guide the integration of ECMO resources into existing disaster planning. Drawing from a collaborative framework developed by one US metropolitan area with multiple adult and pediatric extracorporeal life support centers, this paper aims to inform decision-making around ECMO use during a pandemic such as COVID-19. It also addresses the ethical and practical aspects of not continuing to offer ECMO during a disaster.

Extracorporeal membrane oxygenation is extracorporeal life support for life-threatening cardiopulmonary failure. Since its introduction, the use of extracorporeal membrane oxygenation has expanded to patients with more complex comorbidities without change in patient mortality rates. Although many patients survive, significant neurological complications like seizures, ischemic strokes, and intracranial hemorrhage can occur during extracorporeal membrane oxygenation care. The risks of these complications often add to the complexity of decision-making surrounding extracorporeal membrane oxygenation support. In this review, we discuss the pathophysiology and incidence of neurological complications in children supported on extracorporeal membrane oxygenation, factors influencing the incidence of these complications, commonly used neurological monitoring modalities, and outcomes for this complex patient population. We discuss the current literature on the use of electroencephalography for both seizure detection and monitoring of background electroencephalographic changes, in addition to the use of less commonly used imaging modalities like transcranial Doppler. We summarize the knowledge gaps and the lack of clinical consensus guidelines for managing these potentially life-changing neurological complications. Finally, we discuss future work to further understand the pathophysiology of extracorporeal membrane oxygenation-related neurological complications.

Background Early medication administration in cardiac arrest improves outcomes. The primary objective was to evaluate the association between epinephrine administration in in-hospital cardiac arrest (IHCA) patients with non-shockable rhythm and the patient outcomes. The secondary objective was to assess the compliance of epinephrine and amiodarone administration in accordance with the advanced cardiovascular life support (ACLS) guideline. Methods IHCA patients aged 18 years or above were identified from the resuscitation registry of 2016 of two public hospitals and categorized according to their initial rhythms. For patients with non-shockable rhythms, the associations between IHCA outcomes, return of spontaneous circulation (ROSC), and survival to discharge, and the time of epinephrine administration were analyzed by logistic regression. The compliance rate of epinephrine and amiodarone administration during resuscitation to ACLS guideline were reported. Results Among 349 patients with non-shockable rhythm, the median time to epinephrine administration was 3 min (interquartile range, 1−6 min). Early epinephrine administration ( 5 min), was significantly associated with the rate of ROSC (49.2% vs 34.9%; adjusted odds ratio, 1.630; 95% confidence interval 1.008–2.635, p = 0.046). The time to epinephrine administration (as continuous interval) was significantly associated with the rate of ROSC (p = 0.002) and survival to discharge (p = 0.029). In addition, the compliance rate of epinephrine and amiodarone administration during resuscitation were 83.6% and 33.3%, respectively. Conclusion Our study found that time of epinephrine administration was significantly associated with better results in ROSC and survival to discharge in IHCA patients with non-shockable rhythm. When we divided the IHCA patients with non-shockable rhythms into early and late administration group, early epinephrine administration was associated with significantly improved ROSC, but not survival to discharge after adjusting with potential confounding factors.

Aims: Data on the use of extracorporeal membrane oxygenation (ECMO) for cardiogenic shock in peripartumcardiomyopathy (PPCM) is limited. We queried the Extracorporeal Life Support Organization (ELSO) Registry for PPCMpatients treatedwith ECMO in order to characterize demographic and clinical features, complications, survival, and variables associated with mortality. Methods and results: This was a retrospective review of patients voluntarily entered into the ELSO Registry. Deidentified data was collected on patients with a diagnosis of PPCM based on ICD-9/ICD-10 coding who received ECMO between 2007 and 2019. Collected data included demographics, ECMOmode, cannulation strategies, preECMO ventilator, biochemical, and hemodynamic parameters, run duration, complications, and survival towean off ECMO and hospital discharge. Our primary outcome measure was survival to discharge. In the final analysis, 88 veno-arterial (VA) ECMO patients were included. Overall, 72% of patients were weaned off ECMO, including 10% who were weaned to ventricular assist device or heart transplantation, and 64% survived to hospital discharge. Extracorporeal cardiopulmonary resuscitation (ECPR) was performed in 11% of patients with 60% survival. Factors associated with decreased survival included neurologic complications (p = 0.03), specifically central nervous system hemorrhage (p= 0.01). Conclusion: Our review is the largest to date of PPCM patients supported with VA ECMO for cardiogenic shock. ECMO and ECPR are valuable forms of short-termmechanical circulatory support with acceptable mortality profiles for PPCMpatients who remain refractory to aggressive medicalmanagement. Complications should be meticulously avoided, especially neurologic complications. (c) 2020 Elsevier B.V. All rights reserved.

Purpose Various options of temporary mechanical circulatory support (tMCS) exist for the treatment of cardiogenic shock, however, all forms of tMCS carry a risk of complications. The aim of this study was to compare bleeding complications and thromboembolic events under extracorporeal life support + Impella 2.5/CP (ECMELLA) and isolated Impella 5.0 therapy in the same patient cohort. Material We retrospectively analyzed data of patients who underwent ECMELLA implantation and subsequent Impella 5.0 therapy. Implantation strategy and anticoagulation protocol were comparable in both groups. Results We included 15 patients (mean age 57.2 years; 80% of male patients) who were weaned from ECMELLA undergoing subsequent Impella 5.0 implantation. Mean duration of ECMELLA and Impella 5.0 therapy (10.5 vs. 11.2 days) did not differ significantly (p = .731). The average number of transfused packed red blood cells (PRBC) and thrombocyte concentrates (TC) was significantly decreased during Impella 5.0 treatment (PRBC: 30.3 vs 12.3, p = .001; TC: 5.9 vs 2.2, p = .045). Additionally, the transfusion rates per day were significantly reduced under Impella 5.0 support. Conclusions The need for transfusions is significantly lower in the phase of Impella 5.0 therapy compared to the initial phase on ECMELLA. Therefore, we recommend replacing ECMELLA by an Impella 5.0 device early, if possible.

Basic Life support is an emergency measure to make the airway, breathing without obstruction and helps maintain blood circulation without using tools. Student nurses perform nursing profession must have the skills to perform basic life support basic life support. Help in improving basic life skills student nursing profession in the implementation of basic life support in RSU Karsa Husada Batu. The study design was quasi (quasi-experimental designs) to design one group pre test and post test. Data collection tools with observation sheet with a sample of 30 respondents using random sampling techniques. The independent variable in this study is the simulation simulated basic life support and the dependent variable in this study is the student skills in performing simulated basic life support. Data were analyzed using the Wilcoxon statistical test-signed rank test with α = 0.05. Results showed before getting simulated basic life support skills of the respondents have enough skill as much as 46.7% (14 respondents) and after getting simulated basic life support skills of respondents, 76.73% (23 respondents). Based on Wilcoxon test signed rank test (Asym.p Sig. 2 tailed) earned value 0.000. Because the value of 0.000 is less than Students of the nursing profession who have obtained basic aid simulation have good skills increases due to learning their simulations to the knowledge and practice in performing basic life support.

Extracorporeal membrane oxygenation is an increasingly used mode of life support for patients with cardiac and/or respiratory failure refractory to conventional therapy. This review provides a synopsis of the evolution of extracorporeal life support in neonates, infants, and children and offers a framework for areas in need of research. Specific aspects addressed are the changing epidemiology; technologic advancements in extracorporeal membrane oxygenation circuitry; the current status and future direction of anticoagulation management; sedative and analgesic strategies; and outcomes, with special attention to the lessons learned from neonatal survivors.

Stingrays are found in open waters and are also kept in exhibits in many aquariums throughout the world. They are generally nonaggressive creatures by nature, but they can inflict injuries with their spines if provoked. We present a case of a 62-y-old diver who was pierced in the chest by the barb of a stingray while transferring the animal to another tank as part of his work in a public aquarium. He was rescued immediately from the tank but was found to be in cardiac arrest. Bystander cardiopulmonary resuscitation was promptly initiated by his colleagues. He was rapidly evacuated to the nearest emergency department, where he was noted to be in pulseless electrical activity. A single puncture wound was noted over the right second intercostal space, with the spine of the stingray still impaled in the chest. Trauma surgeons were activated promptly, and resuscitation was continued based on advanced cardiac and trauma life support guidelines, which included ongoing cardiopulmonary resuscitation, securing the airway, and emergency blood transfusion. An emergency department thoracotomy was performed, but despite aggressive resuscitation the thoracic injury was fatal. An autopsy revealed transection of the aorta by an impaled barb. We present a review of stingray injuries and suggest a general approach to management.

The role of extracorporeal membrane oxygenation in the adult patient population still is evolving. Technologic advancements have improved the ability to provide extracorporeal life support. The miniaturization and durability of these systems have made extracorporeal membrane oxygenation more convenient and mobile than ever. Because of these improvements, its use has increased steadily. The indications for use also have diversified. In this review, the authors provide a panoramic view of extracorporeal membrane oxygenation to provide a foundation of knowledge for anesthesiologists.

BACKGROUND: Difficulty weaning from cardiopulmonary bypass (CPB) or the need to return to CPB (collectively D-CPB) may occur after the Norwood procedure. We sought to evaluate the relationship between D-CBP and survival. METHODS: This was a retrospective chart review of all patients undergoing a Norwood procedure at our institution during the interval 2005-2017. Primary outcome was survival for the Norwood procedure. Secondary outcomes included various measures of morbidity. Successful wean from CBP (S-CPB) was defined as no need to return to full flow CPB during the initial definitive wean or after separation from CPB; otherwise the classification was difficulty with wean (D-CBP). Successful rescue in the D-CPB group was defined as not requiring extracorporeal life support (ECLS) either in the operating room or within the first three postoperative days. RESULTS: Of the 196 patients in the cohort, 49 were D-CPB. Survival for S-CPB was 92.5% (136/147) vs 71.4%% (35/49) for D-CPB (p = 0.001). Major morbidity occurred in 29.9% (44/147) in S-CPB vs 69.4 % (34/49) in D-CPB (p < 0.001). With multivariable analysis, D-CPB was significantly associated with mortality (OR=8.09; CI 2.72 – 24.05; p

Background The practice of “cutting-away” from venoarterial extracorporeal life support (ECLS) and leaving indwelling heparinized cannulas prior to decannulation is controversial. This study aims to determine the safety and efficacy of this strategy in patients with congenital diaphragmatic hernia (CDH) who require ECLS. Methods A single-center retrospective review of electronic health records was performed on all patients with CDH who underwent elective ECLS decannulation between January 2014 and September 2018. Descriptive statistics are presented as medians with interquartile range. Results Seventy-three percent (19/26) of patients who underwent venoarterial ECLS for CDH were electively decannulated. After a median ECLS run of 10.7 days [6.1–19.5], patients were “cut-away” for a median of 26 h [19.8–43] prior to decannulation. One patient required re-initiation at 36 h for a pulmonary hypertensive crisis (5%). There were no major bleeding or embolic events while “cut-away”, and four (21%) patients had clots removed from the cannulas without clinical sequelae. One patient was recannulated 16 days following initial decannulation. Conclusions Our data suggests that “cutting-away” from ECLS in patients with congenital diaphragmatic hernia is safe and allows a period of observation without significant complications. This strategy may be particularly helpful in patients at risk for recannulation, but better prognostic criteria are needed. Level of Evidence Level IV. Type of Study Treatment Study.

A narrative review is presented on the diagnosis, treatment and management of accidental hypothermia. Although all these processes form a continuum, for descriptive purposes in this manuscript the recommendations are organized into the prehospital and in-hospital settings. At prehospital level, it is advised to: a) perform high-quality cardiopulmonary resuscitation for cardiac arrest patients, regardless of body temperature; b) establish measures to minimize further cooling; c) initiate rewarming; d) prevent rescue collapse and continued cooling (afterdrop); and (e) select the appropriate hospital based on the clinical and hemodynamic situation of the patient. Extracorporeal life support has revolutionized rewarming of the hemodynamically unstable victim or patients suffering cardiac arrest, with survival rates of up to 100%. The new evidences indicate that the management of accidental hypothermia has evolved favorably, with substantial improvement of the final outcomes.

The authors report a case of intraoperative reversal of apixaban with andexanet alfa in a patient supported with venoarterial extracorporeal membrane oxygenation due to low- cardiac-output immediately after surgery for acute type A aortic dissection and massive intraoperative transfusion with administration of procoagulants. In this patient, andexanet alfa's off-label use was not associated with acute thrombotic complications despite being given during extracorporeal life support and after previous administration of prothrombin complex concentrates.

In the last 20 years there have been significant advances in extracorporeal support of the respiratory system. What once was a highly complex intervention, undertaken as a salvage procedure in a handful of patients, has become more wide spread, both in terms of availability and underlying indications. We review the principles of equipment; physiological control of oxygenation and decarboxylation; associated complications; and role in clinical practice. The evidence for extracorporeal life support in this rapidly evolving field of organ support is critiqued.

Purpose The risks of laparotomy during extracorporeal life support (ECLS) are poorly defined. We examined risk factors associated with bleeding and mortality after laparotomy on ECLS. Methods The Extracorporeal Life Support Organization (ELSO) database was queried for all pediatric patients [0–17 years] with a procedure code for laparotomy. Outcome data were analyzed to define factors contributing to laparotomy complications and mortality while on ECLS. Univariate and multivariate analyses were applied to determine independent risk factors. Results 196 patients who met inclusion criteria were identified. The mortality rate in the entire cohort was 67.3%. In both univariate and multivariate analyses, surgical site bleeding did not significantly increase the risk of mortality (OR 0.8; 95% CI 0.4–1.7). Logistic regression analysis revealed that lower gestational age, infectious complications and nonsurgical site hemorrhagic complications were independently increased mortality risk (all p Conclusion Mortality following laparotomy on ECLS is not independently associated with surgical site bleeding, but is associated with lower gestational age, infectious and nonsurgical site hemorrhagic complications. Type of study Retrospective comparative study. Level of evidence Level III.

Objective To determine factors related to limitations on life support within 48 h of intensive care unit (ICU) admission. Study design Prospective multicenter study. Setting Eleven ICUs. Patients All patients who died and/or had limitations on life support after ICU admission during a four-month period. Variables Patient characteristics, hospital characteristics, characteristics of limitations on life support. Time-to-first-limitation was classified as early ( Results 3335 patients were admitted; 326 (9.8%) had limitations on life support. A total of 344 patients died; 247 (71.8%) had limitations on life support (range among centers, 58.6%–84.2%). The median (p25–p75) time from admission to initial limitation was 2 (0–7) days. CHAID analysis found that the modified Rankin score was the variable most closely related with early limitations. Among patients with Rankin >2, early limitations were implemented in 71.7% (OR = 2.5; 95% CI: 1.5–4.4) and lung disease was the variable most strongly associated with early limitations (OR = 12.29; 95% CI: 1.63–255.91). Among patients with Rankin ≤2, 48.8% had early limitations; patients admitted after emergency surgery had the highest rate of early limitations (66.7%; OR = 2.4; 95% CI: 1.1–5.5). Conclusion Limitations on life support are common, but the practice varies. Quality of life has the greatest impact on decisions to limit life support within 48 h of admission.

Background Extracorporeal life support is used as a salvage procedure to treat refractory cardiopulmonary failure. There are limited data addressing discrepancies between pre- and postmortem findings in patients undergoing extracorporeal membrane oxygenation (ECMO). We investigated discrepancies between clinical and autopsy findings in patients placed on ECMO to assess in what proportion of patients were there significant cardiovascular or other pathologies present that were not clinically apparent prior to death. Methodology After institutional review board approval, a list of deceased ECMO patients who underwent autopsy examination from 2004 through 2015 was obtained from our institutional database. Retrospective analyses of findings on clinical investigations done while patients were on ECMO and findings on autopsy examination were compared and stratified according to modified Goldman Criteria, which classify discrepancies into four grades depending on their impact on patient's management and mortality. Results Of 19 patients, 18 patients had venoarterial ECMO (9 central + 5 peripheral + 4 conversions of ECMO type) and 1 patient received venovenous ECMO. Clinically unrecognized findings were found on autopsy in all patients. 56.6% of total discrepancies found were major [class I/II; e.g., myocardial infarction (MI), intracranial bleeding]. All patients had major discrepancies (class I/II) with an average of 4.21 class I discrepancies per patient. Class I discrepancies are findings which could have altered the course of treatment and survival of the patient if recognized premortem. The most common discrepancies were cardiovascular (MI 63.2%, marked cardiac remodeling 42.1%, severe coronary disease 31.6%) in nature across four classes of discrepancies. Conclusions We found major discrepancies between premortem and postmortem diagnoses in patients who underwent ECMO. Our findings underscore difficulties in clinically diagnosing events on ECMO as well as the need for enhanced surveillance and better diagnostic techniques in ECMO patients. Further prospective studies are necessary to understand effects of ECMO on major organs.

Significant burn injury in the setting of trauma poses a challenging clinical dilemma and can be a diversion to providers not familiar with such injuries. Approximately 5–7% of burn center admissions include patients with multiple traumatic injuries. A 44 year old male with poly-trauma due to a factory explosion presented with significant burns, and a pneumothorax, compartment syndromes of bilateral hands and forearms, and a missed axillary vein injury. In burn-trauma patient evaluations, thorough primary, secondary, and especially the tertiary surveys of the Advanced Trauma Life Support (ATLS®) and Advanced Burn Life Support (ABLS®) protocols must be performed and frequently reevaluated to avoid missed trauma injuries in the presence of thermal injury. This is especially important in blasts, explosions, assaults, and terror attacks at anytime and anywhere, when combined burn and trauma injuries are common. Early resuscitation of these patients mandates that frequent assessments uncover all other traumatic injuries, which may be less dramatic but more lethal than the burn. Keywords: Trauma, Burn, Missed injuries, ATLS, Axilla, Compartment syndrome