QuestionDoes sodium bicarbonate administered during in-hospital cardiac arrest improve return of spontaneous circulation?FindingsIn this randomized clinical trial that included 779 patients with in-hospital cardiac arrest in Denmark, the proportion of patients who achieved return of spontaneous circulation was 39% in the sodium bicarbonate group and 37% in the placebo group, a difference that was not statistically significant.MeaningThese findings do not support routine administration of sodium bicarbonate for patients with in-hospital cardiac arrest. ImportancePatients with in-hospital cardiac arrest have poor outcomes. Sodium bicarbonate is commonly administered during cardiac arrest, but the effects on clinical outcomes are unknown.ObjectiveTo determine whether administration of sodium bicarbonate during in-hospital cardiac arrest increases the proportion of patients with return of spontaneous circulation.Design, Setting, and ParticipantsRandomized, parallel-group, double-blind, placebo-controlled clinical trial conducted at 21 hospitals in Denmark. Participants were adults with in-hospital cardiac arrest, who received at least 1 dose of epinephrine. Patients were enrolled from February 6, 2023, to February 11, 2026, with the last 90-day follow-up conducted on May 4, 2026. Final statistical analysis was conducted on May 5, 2026.InterventionSodium bicarbonate (up to 100 mmol) or placebo intravenously.Main Outcomes and MeasuresThe primary outcome was sustained return of spontaneous circulation. Key secondary outcomes were survival at 30 days and survival at 30 days with a favorable neurologic outcome, defined by a score of 0 to 3 on the modified Rankin Scale (scores range from 0 to 6, with higher scores indicating greater disability).ResultsA total of 2913 patients with in-hospital cardiac arrest were screened; 913 patients were randomized, of which 779 were eligible for the primary analyses, with 372 randomized to receive sodium bicarbonate and 407 randomized to receive placebo. The median (IQR) age of patients was 73 (64-79) years and 502 were male (64%). Sustained return of spontaneous circulation occurred in 146 patients (39%) in the sodium bicarbonate group and 150 (37%) in the placebo group (risk ratio, 1.05 [95% CI, 0.88-1.24]; P = .62). At 30 days, 45 patients (12%) in the sodium bicarbonate group and 37 (9.1%) in the placebo group were alive (risk ratio, 1.25 [95% CI, 0.84-1.88]); a favorable neurologic outcome at 30 days occurred in 30 patients (8.1%) and 22 patients (5.4%), respectively (risk ratio, 1.39 [95% CI, 0.82-2.34]). Alkalosis and hypernatremia after cardiac arrest were more common in the sodium bicarbonate group.Conclusions and RelevanceThere was no significant difference in sustained return of spontaneous circulation between sodium bicarbonate and placebo in adults with in-hospital cardiac arrest. These findings do not support routine administration of sodium bicarbonate for patients with in-hospital cardiac arrest.Trial RegistrationClinicalTrials.gov Identifier: NCT05564130; ClinicalTrialsRegister.eu Identifier: 2022-501304-10-00 This randomized clinical trial examines whether administration of sodium bicarbonate during in-hospital cardiac arrest increases return of spontaneous circulation as well as survival and survival with a favorable neurologic outcome.

Importance:Patients with in-hospital cardiac arrest have poor outcomes. Sodium bicarbonate is commonly administered during cardiac arrest, but the effects on clinical outcomes are unknown. Objective:To determine whether administration of sodium bicarbonate during in-hospital cardiac arrest increases the proportion of patients with return of spontaneous circulation. Design, Setting, and Participants:Randomized, parallel-group, double-blind, placebo-controlled clinical trial conducted at 21 hospitals in Denmark. Participants were adults with in-hospital cardiac arrest, who received at least 1 dose of epinephrine. Patients were enrolled from February 6, 2023, to February 11, 2026, with the last 90-day follow-up conducted on May 4, 2026. Final statistical analysis was conducted on May 5, 2026. Intervention:Sodium bicarbonate (up to 100 mmol) or placebo intravenously. Main Outcomes and Measures:The primary outcome was sustained return of spontaneous circulation. Key secondary outcomes were survival at 30 days and survival at 30 days with a favorable neurologic outcome, defined by a score of 0 to 3 on the modified Rankin Scale (scores range from 0 to 6, with higher scores indicating greater disability). Results:A total of 2913 patients with in-hospital cardiac arrest were screened; 913 patients were randomized, of which 779 were eligible for the primary analyses, with 372 randomized to receive sodium bicarbonate and 407 randomized to receive placebo. The median (IQR) age of patients was 73 (64-79) years and 502 were male (64%). Sustained return of spontaneous circulation occurred in 146 patients (39%) in the sodium bicarbonate group and 150 (37%) in the placebo group (risk ratio, 1.05 [95% CI, 0.88-1.24]; P = .62). At 30 days, 45 patients (12%) in the sodium bicarbonate group and 37 (9.1%) in the placebo group were alive (risk ratio, 1.25 [95% CI, 0.84-1.88]); a favorable neurologic outcome at 30 days occurred in 30 patients (8.1%) and 22 patients (5.4%), respectively (risk ratio, 1.39 [95% CI, 0.82-2.34]). Alkalosis and hypernatremia after cardiac arrest were more common in the sodium bicarbonate group. Conclusions and Relevance:There was no significant difference in sustained return of spontaneous circulation between sodium bicarbonate and placebo in adults with in-hospital cardiac arrest. These findings do not support routine administration of sodium bicarbonate for patients with in-hospital cardiac arrest. Trial Registration:ClinicalTrials.gov Identifier: NCT05564130; ClinicalTrialsRegister.eu Identifier: 2022-501304-10-00.

BACKGROUND:Meropenem and piperacillin/tazobactam are commonly used empirical antibiotics in critically ill adults with sepsis, but whether one is superior to the other is uncertain. METHODS:The Empirical Meropenem versus Piperacillin/Tazobactam for Adult Patients with Sepsis (EMPRESS) trial is an ongoing investigator-initiated, randomised, open-label, adaptive clinical trial with an integrated feasibility phase comparing empirical treatment with meropenem versus piperacillin/tazobactam in critically ill adults with sepsis. The integrated feasibility phase enrolled 200 participants across 10 intensive care units (ICUs) in Denmark between 28 June and 12 December 2025. Five pre-specified feasibility criteria were evaluated; if all feasibility criteria were met, the trial would proceed unaltered, whereas failure to meet one or more criteria would require intervention and re-evaluation. RESULTS:We randomised 200 of 284 screened patients (70.4%). The median age was 70 years (interquartile range (IQR): 60-77), 65.5% were males. At randomisation, 80.0% received vasopressors or inotropes, and 43.5% were on invasive mechanical ventilation. Four of five pre-specified feasibility criteria were met: time to completion of the feasibility phase (5.5 months vs. threshold < 12.0 months), recruitment proportion (70.4% vs. threshold ≥ 50.0%), proportion of participants without consent to the continued collection of data (2.5% vs. threshold < 5.0%) and protocol adherence (81.0% vs. threshold ≥ 75.0%). The proportion of participants with timely primary outcome data availability (30-day mortality) within 45 days was 85.5% and below the pre-specified threshold of ≥ 95.0%. The proportions were low in the first 3 months (33.3%, 22.2% and 30.8%, respectively), increasing to 95.8% in the last month of the feasibility phase. All-cause mortality at 30 days was 30.5%, and specific serious adverse reactions occurred in 4.0% of participants. CONCLUSIONS:In this integrated feasibility evaluation of the EMPRESS trial comparing empirical meropenem versus piperacillin/tazobactam in critically ill adults with sepsis, four of five pre-specified feasibility criteria were met. The unmet criterion, timely primary outcome data availability, improved substantially during the feasibility phase. We consider the trial feasible and will proceed without modifications. EDITORIAL COMMENT:This feasibility study assessed recruitment, randomised allocation and data collection for the multicentre EMPRESS trial. For adaptive trials on trial platforms, careful interim checking of trial design functions is an important and necessary process. TRIAL REGISTRATION:Clinical Trials Information System EUCT number: 2023-509703-33-00; ClinicalTrials.gov identifier: NCT06184659; Universal Trial Number: U1111-1301-6379.

Background: Guidelines emphasise that reversible causes of cardiac arrest are identified to improve the chance of successful resuscitation and return of spontaneous circulation (ROSC). In this study, we investigated the effect of correct identification of in-hospital cardiac arrest (IHCA) aetiologies on the rate of ROSC in patients without obvious aetiology. Methods: This study was a post-hoc analysis of the WHY-IHCA study and leveraged data on presumed IHCA aetiologies and on expert panel-assessed IHCA aetiologies from this study. Correct identification of aetiology was defined as patients where the presumed aetiology was the same as the aetiology assessed by at least 3 of 4 experts. The effect of correct identification of IHCA aetiologies on the rate of ROSC was assessed using logistic regression with adjustment for age, witnessed status, monitored status, shockable status, and actual aetiology. Results: A total of 150 patients were included of which the aetiology was correctly identified in 80 (53%) patients. The rate of ROSC was 54% and 41% in those with and without correct identification of aetiology, respectively. After adjustment for confounders, correct aetiology identification resulted in a 1.88 (95% confidence interval: 0.77–4.57) times higher odds of ROSC. Results were similar in exploratory analyses of more stringent and more liberal definitions of correct aetiology identification. Conclusion: The rate of ROSC is higher in patients in whom the aetiology of IHCA is correctly recognised. After adjustment for confounders, correct identification of aetiologies resulted in a numerically higher, although not statistically significant, odds of ROSC.

BACKGROUND:Hyperkalaemia is a life-threatening electrolyte disturbance and also a potential cause of cardiac arrest. The objective was to assess the effects of acute pharmacological interventions for the treatment of hyperkalaemia in patients with and without cardiac arrest. METHODS:The review was reported according to PRISMA guidelines and registered on PROSPERO (CRD42023440553). We searched OVID Medline, EMBASE, and CENTRAL on September 9, 2024 for randomized trials, non-randomized trials, observational studies, and experimental animal studies. Two investigators performed abstract screening, full-text review, data extraction, and bias assessment. Outcomes included potassium levels, ECG findings, and clinical outcomes. Certainty of evidence was evaluated using GRADE. RESULTS:A total of 101 studies were included, with two studies including patients with cardiac arrest. In meta-analyses including adult patients without cardiac arrest, treated with insulin in combination with glucose, inhaled salbutamol, intravenous salbutamol dissolved in glucose, or a combination, the average reduction in potassium was between 0.7 and 1.2 mmol/l (very low to low certainty of evidence). The use of bicarbonate had no effect on potassium levels (very low certainty of evidence). In neonatal and paediatric populations, inhaled salbutamol and intravenous salbutamol reduced the average potassium between 0.9 and 1.0 mmol/l (very low to low certainty of evidence). There was no evidence to support a clinical beneficial effect of calcium for treatment of hyperkalemia. CONCLUSIONS:Evidence supports treatment with insulin in combination with glucose, inhaled or intravenous sal-butamol, or the combination. No evidence supporting a clinical effect of calcium or bicarbonate for hyperkalaemia was identified.

BACKGROUND:Adult intensive care unit (ICU) patients receive many interventions, but few are supported by high-certainty evidence. Randomised clinical trials (RCTs) are essential for trustworthy comparisons of intervention effects, but conventional RCTs are costly, cumbersome, inflexible, and often turn out inconclusive. Adaptive platform trials may mitigate these issues and have higher probabilities of obtaining conclusive results faster and at lower costs per participant. METHODS:The Intensive Care Platform Trial (INCEPT) is an investigator-initiated, pragmatic, randomised, embedded, multifactorial, international, adaptive platform trial including adults acutely admitted to ICUs. INCEPT will assess comparable groups of interventions (primarily commonly used interventions with clinical uncertainty and practice variation) nested in domains. Interventions may be either open-label or masked. New domains will continuously be added to the platform. INCEPT assesses multiple core outcomes selected following substantial stakeholder involvement: mortality, days alive without life support/out of hospital/free of delirium, health-related quality of life, cognitive function, and safety outcomes. Each domain will use one of these core outcomes as the primary outcome. INCEPT primarily uses Bayesian statistical methods with neutral, minimally informative or sceptical priors, adjustment for important prognostic baseline variables, and calculation of absolute and relative differences in the intention-to-treat populations. Domains and intervention arms may be stopped for superiority/inferiority, practical equivalence, or futility according to pre-specified adaptation rules evaluated using statistical simulation or at pre-specified maximum sample sizes. Domains may use response-adaptive randomisation, meaning that more participants will be allocated to interventions with higher probabilities of being superior. CONCLUSIONS:INCEPT provides an efficient, pragmatic, and flexible platform for comparing the effects of many interventions used in adult ICU patients. The adaptive design enables the trial to use accumulating data to improve the treatment of future participants. INCEPT will provide high-certainty, conclusive evidence for many interventions, directly inform clinical practice, and thus improve patient-important outcomes.

BACKGROUND:Piperacillin/tazobactam may be associated with less favourable outcomes than carbapenems in patients with severe bacterial infections, but the certainty of evidence is low. METHODS:The Empirical Meropenem versus Piperacillin/Tazobactam for Adult Patients with Sepsis (EMPRESS) trial is an investigator-initiated, international, parallel-group, randomised, open-label, adaptive clinical trial with an integrated feasibility phase. We will randomise adult, critically ill patients with sepsis to empirical treatment with meropenem or piperacillin/tazobactam for up to 30 days. The primary outcome is 30-day all-cause mortality. The secondary outcomes are serious adverse reactions within 30 days; isolation precautions due to resistant bacteria within 30 days; days alive without life support and days alive and out of hospital within 30 and 90 days; 90- and 180-day all-cause mortality and 180-day health-related quality of life. EMPRESS will use Bayesian statistical models with weak to somewhat sceptical neutral priors. Adaptive analyses will be conducted after follow-up of the primary outcome for the first 400 participants concludes and after every 300 subsequent participants, with adaptive stopping for superiority/inferiority and practical equivalence (absolute risk difference <2.5%-points) and response-adaptive randomisation. The expected sample sizes in scenarios with no, small or large differences are 5189, 5859 and 2570 participants, with maximum 14,000 participants and ≥99% probability of conclusiveness across all scenarios. CONCLUSIONS:EMPRESS will compare the effects of empirical meropenem against piperacillin/tazobactam in adult, critically ill patients with sepsis. Due to the pragmatic, adaptive design with high probability of conclusiveness, the trial results are expected to directly inform clinical practice.

BACKGROUND:General anesthesia is common, but concerns regarding post-operative complications and mortality remain. No study has described the Danish patient population undergoing general anesthesia on a national level. The aim of this study was to describe the characteristics and outcomes of patients undergoing general anesthesia in Denmark. METHODS:This study was a registry-based observational cohort study of adult patients (≥18 years) undergoing general anesthesia in Denmark during 2020 and 2021. Data from nationwide registries covering patient characteristics, anesthesia and procedure information, and patient outcomes were combined. Descriptive statistics were used to present findings, both overall and in subgroups based on the American Society of Anesthesiologists (ASA) classification. RESULTS:We identified 453,133 cases of general anesthesia in 328,951 unique patients. The median age was 57 years (quartiles: 41, 71), and 242,679 (54%) were females. Data on ASA classification were missing for less than 1% of the population, and ASA II was the most prevalent ASA classification (49%). Among cases of general anesthesia, 0.1% experienced a stroke, 0.2% had in-hospital cardiac arrest, and 3.9% had a stay in the intensive care unit within 30 days. Mortality at 30 days and 1 year were 1.8% and 6.3%, respectively, increasing with a higher ASA classification. CONCLUSION:This study offers the first comprehensive overview of adult patients undergoing general anesthesia in Denmark. Post-anesthesia complications were few and increased with ASA classification.

Background Intravenous fluids are often used in the treatment of sepsis. The better strategy regarding fluid volume is debated, but preliminary data in patients with septic shock or sepsis-related hypotension favor restrictive fluid administration. We describe the protocol and statistical analysis plan for the Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)—a multicenter, randomized clinical proof-of-concept trial. The aim of the REFACED Sepsis trial is to test if a restrictive intravenous fluid protocol in emergency department patients with sepsis without shock is feasible and decreases the intravenous fluid volume administered in comparison to standard care. Methods This is an investigator-initiated, multicenter, randomized, parallel-group, open-labeled, feasibility trial investigating volumes of crystalloid fluid within 24 h in 124 patients with sepsis without shock enrolled at three emergency departments in the Central Denmark Region. Patients are allocated to two different intravenous fluid regimens: a restrictive approach using four trigger criteria for fluid administration vs. standard care. The primary, feasibility outcome is total intravenous, crystalloid fluid volume within 24 h, and key secondary outcomes include protocol violations, total fluids (intravenous and oral) within 24 h, and serious adverse reactions and suspected unexpected serious adverse reactions. Status: The trial started in November 2021, and the last patient is anticipated to be included in January 2022. Discussion Sepsis is very common in emergency department patients and fluid administration is very frequently administered in these patients. However, the evidence to guide fluid administration is very sparse. This feasibility trial will be the foundation for a potential future large-scale trial investigating restrictive vs. standard fluid administration in patients with sepsis. Trial registration EudraCT number: 2021-000224-35 (date: 2021 May 03), ClinicalTrials.gov number: NCT05076435 (date: 2021 October 13), Committee on Health Research Ethics – Central Denmark Region: 1-10-72-163-21 (date: 2021 June 28).

Editor—We read with great interest the article by Harper and colleagues1Harper N.J.N. Nolan J.P. Soar J. Cook T.M. Why chest compressions should start when systolic arterial blood pressure is below 50 mm Hg in the anaesthetised patient.Br J Anaesth. 2020; 124: 234-238Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar regarding when to start chest compressions in the setting of profound hypotension in the anaesthetised patient.1Harper N.J.N. Nolan J.P. Soar J. Cook T.M. Why chest compressions should start when systolic arterial blood pressure is below 50 mm Hg in the anaesthetised patient.Br J Anaesth. 2020; 124: 234-238Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar In line with previous publications, the authors support a threshold below 50 mm Hg to start chest compressions.2Garvey L.H. Dewachter P. Hepner D.L. et al.Management of suspected immediate perioperative allergic reactions: an international overview and consensus recommendations.Br J Anaesth. 2019; 123: e50-e64Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar,3Harper N.J.N. Cook T.M. Garcez T. et al.Anaesthesia, surgery, and life-threatening allergic reactions: management and outcomes in the 6th National Audit Project (NAP6).Br J Anaesth. 2018; 121: 172-188Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar Here, we provide additional reflections on when to start chest compressions in this situation, whilst acknowledging that there is limited evidence to support any specific recommendation. Setting a fixed threshold below 50 mm Hg will likely increase the number of anaesthetised patients receiving chest compressions, potentially at the cost of individualised patient care, and without lack of evidence that this approach will improve patient outcomes. First, it is important to clarify that this discussion is not relevant for patients with a shockable rhythm or asystole, in which chest compressions should be started immediately. In the setting of profound hypotension in the anaesthetised patient, the aim of chest compressions is to augment organ perfusion beyond was is provided by the heart itself. Originally chest compression was developed to provide some degree of circulation with a non-beating heart,4Kouwenhoven W.B. Jude J.R. Knickerbocker G.G. Closed-chest cardiac massage.JAMA. 1960; 173: 1064-1067Crossref PubMed Scopus (1337) Google Scholar but chest compressions provide only about 25% of normal cardiac output in animal models.5Lurie K.G. Nemergut E.C. Yannopoulos D. Sweeney M. The physiology of cardiopulmonary resuscitation.Anesth Analg. 2016; 122: 767-783Crossref PubMed Scopus (77) Google Scholar This may be even less if cardiac filling is reduced. Irrespective of cause, reduced perfusion as a result of inadequate filling of a normal beating heart will not improve with chest compressions. In a hypovolaemic pig cardiac arrest model, right ventricular diameter, a marker of ventricular filling, is markedly reduced if spontaneous circulation is still present, but increases when the heart stops beating.6Aagaard R. Granfeldt A. Botker M.T. Mygind-Klausen T. Kirkegaard H. Lofgren B. The right ventricle is dilated during resuscitation from cardiac arrest caused by hypovolaemia: a porcine ultrasound study.Crit Care Med. 2017; 45: e963-e970Crossref PubMed Scopus (33) Google Scholar This suggests that, in the presence of hypovolaemia and spontaneous circulation, the heart is inadequately filled for chest compressions to be effective until cardiac standstill results in increased ventricular filling. The authors mentioned that chest compression may not improve perfusion in haemorrhagic shock.7Jeffcoach D.R. Gallegos J.J. Jesty S.A. et al.Use of CPR in hemorrhagic shock, a dog model.J Trauma Acute Care Surg. 2016; 81: 27-33Crossref PubMed Scopus (11) Google Scholar,8Watts S. Smith J.E. Gwyther R. Kirkman E. Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest.Resuscitation. 2019; 140: 37-42Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar This may also apply to distributive shock, such as anaphylaxis and sepsis, in which a reduction in effective circulating blood volume and vasodilation result in reduced cardiac filling. This would also be valid for a low arterial pressure as a result of vasodilation after administration of anaesthetic agents. In contrast, if the low arterial pressure is attributable to low cardiac output (e.g. severe bradycardia), chest compressions could theoretically be beneficial. Harper and colleagues1Harper N.J.N. Nolan J.P. Soar J. Cook T.M. Why chest compressions should start when systolic arterial blood pressure is below 50 mm Hg in the anaesthetised patient.Br J Anaesth. 2020; 124: 234-238Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar do not discuss how chest compressions should be applied in the presence of cardiac activity. Experimental animal studies suggest that synchronised chest compressions improve arterial blood pressure and coronary perfusion pressure compared with unsynchronised chest compression.9Paradis N.A. Halperin H.R. Zviman M. Barash D. Quan W. Freeman G. Coronary perfusion pressure during external chest compression in pseudo-EMD, comparison of systolic versus diastolic synchronization.Resuscitation. 2012; 83: 1287-1291Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar,10Marill K.A. Menegazzi J.J. Koller A.C. Sundermann M.L. Salcido D.D. Synchronized chest compressions for pseudo-PEA: proof of concept and a synching algorithm.Prehosp Emerg Care. 2019; : 1-9https://doi.org/10.1080/10903127.2019.1690605Crossref PubMed Scopus (2) Google Scholar Chest compression cannot improve systemic perfusion by compressing an unfilled heart, and may actually impair filling when performed unsynchronised. Chest compressions at the recommended rate of 100–120 min−1 will likely result in a high degree of unsynchronised chest compressions, and thereby potentially limited effects. In the lack of clear benefit, it is important to consider potential harm. The authors cited a study, in which chest compressions were performed by lay persons outside the hospital on patients who were not in cardiac arrest.11White L. Rogers J. Bloomingdale M. et al.Dispatcher-assisted cardiopulmonary resuscitation: risks for patients not in cardiac arrest.Circulation. 2010; 121: 91-97Crossref PubMed Scopus (135) Google Scholar A study by Koster and colleagues12Koster R.W. Beenen L.F. van der Boom E.B. et al.Safety of mechanical chest compression devices AutoPulse and LUCAS in cardiac arrest: a randomized clinical trial for non-inferiority.Eur Heart J. 2017; 38: 3006-3013Crossref PubMed Scopus (84) Google Scholar may provide a more realistic estimation of the prevalence of adverse events after chest compressions. In this study, designed specifically to address safety of chest compressions in patients with in-hospital cardiac arrest, 6.4% of patients had serious or life-threatening visceral resuscitation-related damage caused by manual chest compressions, whereas 41% had severe rib or sternum fractures. Similar numbers have been published by others.13Beom J.H. You J.S. Kim M.J. et al.Investigation of complications secondary to chest compressions before and after the 2010 cardiopulmonary resuscitation guideline changes by using multi-detector computed tomography: a retrospective study.Scand J Trauma Resusc Emerg Med. 2017; 25: 8Crossref PubMed Scopus (25) Google Scholar,14Seung M.K. You J.S. Lee H.S. Park Y.S. Chung S.P. Park I. Comparison of complications secondary to cardiopulmonary resuscitation between out-of-hospital cardiac arrest and in-hospital cardiac arrest.Resuscitation. 2016; 98: 64-72Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar In addition to the direct damage caused by applying chest compression, the decision to start chest compression may remove attention and resources from other resuscitative measures, such as administration of epinephrine, airway management, placement of i.v. access for administration of fluids/blood, and surgical management of potential bleeding. The decision to start chest compressions in the anaesthetised patient should not be simplified to a simple arterial pressure limit, but should be individualised to each patient dependent on the cause of the hypotension, the trajectory of the blood pressure, and other ongoing resuscitative actions. The authors declare that they have no conflicts of interest. Why chest compressions should start when systolic arterial blood pressure is below 50 mm Hg in the anaesthetised patientBritish Journal of AnaesthesiaVol. 124Issue 3PreviewWe ask a deceptively simple question: when in the setting of profound hypotension, despite treatment, should chest compressions be started during general anaesthesia? The question arises out of discussions and recommendations in the 6th National Audit Project of the Royal College of Anaesthetists (NAP6), which studied perioperative anaphylaxis.1 The issues discussed apply to all causes of profound hypotension and pre-cardiac arrest low flow states with two exceptions: cardiac tamponade, in which the value of cardiac compressions has been questioned,2 and haemorrhagic shock with uncontrolled bleeding, in which chest compressions might accelerate blood loss and lead to worse outcomes. Full-Text PDF Open ArchiveWhy chest compressions should start when systolic blood pressure is below 50 mmHg in the anaesthetised patient. Reply to Br J Anaesth 2020; 124: e199–200British Journal of AnaesthesiaVol. 124Issue 4PreviewEditor—We thank Granfeldt and Andersen1 for their interest in our editorial. We agree that it is important to clarify that our comments were specific to patients with cardiac electrical activity compatible with perfusion. We implied this in our statement: ‘In ventricular fibrillation there is a clear need for immediate defibrillation and chest compressions and during asystole there is a clear need for chest compressions. What is less clear is the clinical criteria, particularly during isolated severe hypotension, which should prompt chest compressions in other situations?’ However, we agree that this could have been made clearer. Full-Text PDF Open Archive

Background: Cardiac arrests are often categorized into two separate groups depending on the location of the arrest: in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA). Despite this distinction, few studies have actually compared the two groups.

Purpose: Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest (VAM-IHCA) is a Danish randomised, placebo-controlled, multicentre trial testing the effect of the two medications on return of spontaneous circulation. Inter-hospital differences in the cardiac arrest team composition became evident during the trial and it is unknown how this affects the time from IHCA to administration of study drug. Here, we describe the time from cardiac arrest to the first dose of epinephrine and subsequently administration of VAM-IHCA medication in different hospitals in Denmark.

Introduction: Updates to PALS include modifications to recommendations and pictorial algorithms surrounding intra-arrest drug administration. These include: bicarbonate, which had been an option for prolonged arrests, was changed in 2010 to recommend against routine use; lidocaine was removed from the pictorial algorithm in 2010 and reintroduced in 2015, at which time the recommendation changed from it being 2 nd -line to being equivalent to amiodarone as 1 st line; and atropine for which text was added in 2010 stating there was insufficient evidence to support or refute routine use in pulseless cardiac arrest. Understanding the effects of these changes may be important in future guideline development. Hypotheses: We hypothesized that use of bicarbonate, lidocaine and atropine would decrease after 2010, and use of lidocaine would increase after 2015. Methods: Index pulseless IHCA in children ≤18 years of age in the GWTG-R pediatric database between 2001 and 2017 were included. We performed interrupted time series analyses using segmented linear regression with GEE for each medication. Atropine was analyzed post-hoc . Results: A total of 4,806 index cases (698 shockable, 4108 non-shockable) were included. After 2010, bicarbonate had no changes in the intercept (-3.1% (95% CI, -7.5, 1.3%; p = 0.17) or slope (0.7% (95% CI, -1.0, 2.3%; p = 0.41). For lidocaine in shockable arrests there was no change in the intercept (-7.7%, 95% CI, -21.6, 6.1%; p = 0.27) or slope (-2.7%, (95% CI, -7.2, 1.8%; p = 0.24) in 2010 nor in 2015 (intercept: -0.2%; 95% CI, -32.1, 31.8%; p = 0.99; slope: -3.6%; 95% CI; -7.8, 15.0%; p = 0.53). For atropine, there was a 9.3% downward step change in the intercept (95% CI, 3.3-15.2%; p < 0.01) for all arrests and 11.7% (95% CI, 5.3-18.2%; p < 0.001) for initial PEA/asystole. Conclusion: Recommendation changes in the PALS text correlated with decreased use of atropine but not bicarbonate. This is especially interesting considering atropine had not previously been part of the PALS cardiac arrest algorithm. However, this update coincides with the removal of atropine from the ACLS PEA/asystole algorithm in 2010, which may have influenced some providers. Lidocaine use was not affected by changes to the pictorial algorithm nor by changes in the text.