Objective To determine the use of epinephrine (adrenaline) before defibrillation for treatment of in-hospital cardiac arrest due to a ventricular arrhythmia and examine its association with patient survival. Design Propensity matched analysis. Setting 2000-18 data from 497 hospitals participating in the American Heart Association’s Get With The Guidelines-Resuscitation registry. Participants Adults aged 18 and older with an index in-hospital cardiac arrest due to an initial shockable rhythm treated with defibrillation. Interventions Administration of epinephrine before first defibrillation. Main outcome measures Survival to discharge; favorable neurological survival, defined as survival to discharge with none, mild, or moderate neurological disability measured using cerebral performance category scores; and survival after acute resuscitation (that is, return of spontaneous circulation for >20 minutes). A time dependent, propensity matched analysis was performed to adjust for confounding due to indication and evaluate the independent association of epinephrine before defibrillation with study outcomes. Results Among 34 820 patients with an initial shockable rhythm, 9630 (27.6%) were treated with epinephrine before defibrillation, contrary to current guidelines. In comparison with participants treated with defibrillation first, participants receiving epinephrine first were less likely to have a history of myocardial infarction or heart failure, but more likely to have renal failure, sepsis, pneumonia, and receive mechanical ventilation before in-hospital cardiac arrest (P<0.0001 for all). Treatment with epinephrine before defibrillation was strongly associated with delayed defibrillation (median 3 minutes v 0 minutes). In propensity matched analysis (9011 matched pairs), epinephrine before defibrillation was associated with lower odds of survival to discharge (25.2% v 29.9%; adjusted odds ratio 0.81, 95% confidence interval 0.74 to 0.88; P<0.001), favorable neurological survival (18.6% v 21.4%; 0.85, 0.76 to 0.92; P<0.001), and survival after acute resuscitation (64.4% v 69.4%; 0.76, 0.70 to 0.83; P<0.001). The above findings were consistent in a range of sensitivity analyses, including matching according to defibrillation time. Conclusions Contrary to current guidelines that prioritize immediate defibrillation for in-hospital cardiac arrest due to a shockable rhythm, more than one in four patients are treated with epinephrine before defibrillation, which is associated with worse survival.
Background Mechanically ventilated patients have experienced greater periods of prolonged deep sedation during the coronavirus disease (COVID-19) pandemic. Multiple studies from the pre-COVID era demonstrate that early deep sedation is associated with worse outcome. Despite this, there is a lack of data on sedation depth and its impact on outcome for mechanically ventilated patients during the COVID-19 pandemic. We sought to characterize the emergency department (ED) and intensive care unit (ICU) sedation practices during the COVID-19 pandemic, and to determine if early deep sedation was associated with worse clinical outcomes. Study design and methods Dual-center, retrospective cohort study conducted over 6 months (March–August, 2020), involving consecutive, mechanically ventilated adults. All sedation-related data during the first 48 h were collected. Deep sedation was defined as Richmond Agitation-Sedation Scale of − 3 to − 5 or Riker Sedation-Agitation Scale of 1–3. To examine impact of early sedation depth on hospital mortality (primary outcome), we used a multivariable logistic regression model. Secondary outcomes included ventilator-, ICU-, and hospital-free days. Results 391 patients were studied, and 283 (72.4%) experienced early deep sedation. Deeply sedated patients received higher cumulative doses of fentanyl, propofol, midazolam, and ketamine when compared to light sedation. Deep sedation patients experienced fewer ventilator-, ICU-, and hospital-free days, and greater mortality (30.4% versus 11.1%) when compared to light sedation (p < 0.01 for all). After adjusting for confounders, early deep sedation remained significantly associated with higher mortality (adjusted OR 3.44; 95% CI 1.65–7.17; p < 0.01). These results were stable in the subgroup of patients with COVID-19. Conclusions The management of sedation for mechanically ventilated patients in the ICU has changed during the COVID pandemic. Early deep sedation is common and independently associated with worse clinical outcomes. A protocol-driven approach to sedation, targeting light sedation as early as possible, should continue to remain the default approach.
BackgroundOnly 14 states have laws or guidelines regarding the minimum age a child may be left home alone. These ages range from 6 to 14 years. Our objective was to identify factors that influence child neglect determination by experts with regards to parents leaving children home alone.MethodsAmerican Academy of Pediatrics Section on Child Abuse and Neglect members (N = 523) were surveyed from July–August, 2015. Respondents were asked whether scenarios involving a child of varying age knowingly left home alone for 4 h were neglect in the presence or absence of injury to the child and the legality of the situation. Comparisons were performed using the chi-square test.ResultsOne hundred ninety-three members responded (36.9%). In the scenario where there were no relevant laws and the child was uninjured, nearly 100% of the child experts determined this as being child neglect when the child was 6 years old. For 8, 10, 12, and 14 year olds, this was 88, 48, 4, and 1%, respectively. However, a significantly higher percentage of experts considered it child neglect for most ages when there was a law making the scenario illegal as compared when there was no law, and when the child was injured versus when they were not. The only demographic variable that showed a difference in child neglect determination was that females were more likely to consider higher aged children as having been neglected when there were no laws but the child was injured. The vast majority of experts (85%) stated that leaving a child home alone for 4 h should be illegal if the child is < 9 years old, and nearly one-half (44%) said it should be illegal for children < 11 years old.ConclusionsA number of factors affect how experts view children being left home alone as potential child neglect. Our data suggests that such cases may be evaluated differently due to variations in state laws, even though the risk to the child is the same. These results call for child safety law reform to provide greater uniformity in the evaluation of potential child neglect cases and better protect the safety of children.
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