Resus today autumn 2017 by Media Publishing Company

Volume 4 No. 3

Autumn 2017

Resuscitation Today A Resource for all involved in the Teaching and Practice of Resuscitation Supported by CPRO

Four things in one pack, one less thing to think about

In this issue Paediatric Cardiac Arrests Effect of Dextran Resuscitation Conference Programme www.i-gel.com

Quality, innovation and choice www.intersurgical.co.uk

medical

CONTENTS

CONTENTS 4

EDITORS COMMENT

EDUCATION

EVIDENCE

NEWS

COMPANY NEWS

COVER STORY The i-gel O2™ Resus Pack from Intersurgical In emergency medicine you need equipment that’s easy, rapid and reliable to use. The i-gel O2 Resus Pack contains everything you need to prepare, insert and secure the i-gel O2 quickly and efficiently: an i-gel O2 supraglottic airway, a sachet of lubricant, and an airway support strap. A suction tube is also included in the pack. The i-gel O2 has been designed to facilitate ventilation as part of standard resuscitation protocols, such as those designated by the European Resuscitation Council (ERC) and the American Heart Association (AHA). However, the i-gel O2 incorporates a supplementary oxygen port, so it can also be used for the delivery of passive oxygenation as part of an appropriate CardioCerebral Resuscitation (CCR) protocol. The i-gel O2 gets its name from the innovative soft, gel-like material from which it is made. It is the innovative application of this material that has enabled the development of a unique non-inflatable cuff. This means there is no need for cuff deflation prior to insertion and no cuff inflation after placement to secure a seal, shortening and simplifying the preparation and insertion procedure. The i-gel O2 is incredibly easy to use. Insertion is rapid and can normally be achieved in less than 5 seconds.

The i-gel O2 Resus Pack – everything you need to prepare, insert and secure the i-gel O2. For further information, please contact Intersurgical at: Intersurgical Crane House Molly Millars Lane Wokingham Berkshire RG41 2RZ England Tel: 0118 9656 300 Fax: 0118 9656 356 Email: info@intersurgical.co.uk Website: www.intersurgical.co.uk

This issue edited by: Lizzie Ryan c/o Media Publishing Company Media House 48 High Street SWANLEY, Kent BR8 8BQ ADVERTISING & CIRCULATION: Media Publishing Company Media House, 48 High Street SWANLEY, Kent, BR8 8BQ Tel: 01322 660434 Fax: 01322 666539 E: info@mediapublishingcompany.com www.MediaPublishingCompany.com PUBLISHED: Spring, Summer and Autumn COPYRIGHT: Media Publishing Company Media House 48 High Street SWANLEY, Kent, BR8 8BQ PUBLISHERS STATEMENT: The views and opinions expressed in this issue are not necessarily those of the Publisher, the Editors or Media Publishing Company. Next Issue Spring 2018 Subscription Information – Autumn 2017 Resuscitation Today is a tri-annual publication published in the months of March and September. The subscription rates are as follows:UK: Individuals - £12.00 inc. postage Commercial Organisations - £30.00 inc. postage Rest of the World: Individuals - £60.00 inc. postage Commercial Organisations - £72.00 inc. postage We are also able to process your subscriptions via most major credit cards. Please ask for details. Cheques should be made payable to MEDIA PUBLISHING. Designed in the UK by Hansell Design

RESUSCITATION TODAY - AUTUMN 2017

The pack includes a specially designed airway support strap for securing the i-gel O2 in position. This makes it ideal for use where adhesive tape is unsuitable.

Resuscitation Today

EDITORS COMMENT

RESUSCITATION TODAY - AUTUMN 2017

“We also look at the treatment sepsis, something that has been in the news a great deal recently with sepsis claiming 6 million lives a year worldwide (WHO); many of those lives could be saved with increased public awareness, education for healthcare professionals and other basic care provisions.”

EDITORS COMMENT In this issue we continue to report on a subject dear to my heart, simulation, looking at the development of ultra, realistic, next-generation synthetic bodies by Syn Daver Labs at a time when the universities that provide the next generation paramedics, doctors and nurses are struggling to gain access to real time patients for practice as they develop their skills. Schulman (2005) talked about signature pedagogy, where the teaching organises the fundamental ways that we teach our future practitioners about their new profession, and the critical aspects of the three fundamentals required – thinking, performing and acting with professional integrity. The new manikins, if we can call them that, provide a nearly identical and functional similarity to the human form and will be the way forward in teaching alongside virtual reality if we are to ensure our future workforce has the ability to practice their skills in a safe environment. This innovation is coupled, in this issue, with the CPR training system developed by Brayden to give real time feedback on CPR performance; something that will enhance CPR procedures in all healthcare environments and help to teach the correct procedures to leaners and practitioners. This issue continues to consider the educational setting and provides articles demonstrating the value of public health education, highlighting the benefits of the Trauma networks that we have in the UK. In addition, we see that the inclusion of the ability to provide relevant diagnosis and referral in training for those in pre-hospital care with the appropriate pre-alerts being used when in transit to hospital is key when assessing the possibility for resuscitation with extracorporeal re-warming. We also look at the treatment sepsis, something that has been in the news a great deal recently with sepsis claiming 6 million lives a year worldwide (WHO); many of those lives could be saved with increased public awareness, education for healthcare professionals and other basic care provisions (UK Sepsis Trust 2017). Until next time

Lizzie Ryan Editor

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EDUCATION

PAEDIATRIC CARDIAC ARRESTS IN THE NORTHERN EMIRATES, UNITED ARAB EMIRATES Alan M. Batt MSc(c)1-4 Ahmed S. Al-Hajeri BHSc1 Gerard Ward BSc1,5 Carmina S. Pilapil RN BScN1 Shannon Delport MTech1 Fergal H. Cummins MB BCh BAO1,6,7

Competing Interests Authors have no conflict of interests to declare, and the work was not

in the emirates of Al-Sharjah, Ras-al-Khaimah, Umm Al-Quwain, AlFujairah and Ajman (collectively referred to as the Northern Emirates) in the United Arab Emirates.

supported or funded by any drug company. Each author of this paper has completed the ICMJE conflict of interest statement.

Author Declarations The authors declare that this work has not been published elsewhere. Further, the authors declare that they are responsible and accountable for the accuracy and integrity of all aspects of this work.

Funding & Support No funding or support has been received for this manuscript or study from any manufacturer, pharmaceutical company, grant-awarding or commercial body.

Methods This study was a prospective cohort study of all OHCA incidents treated and/or transported by National Ambulance LLC ambulance crews between February 2014 and March 2015. A subgroup analysis was performed on all paediatric OHCA patients (defined as less than 18 years old) presenting during this period.

Results The subgroup comprised of 14 patients (3.6% of the overall cardiac arrest population). There were six male (43%) and eight female (57%) patients, with a median age of four years (IQR 0.63, 8.75). The majority of paediatric cardiac arrests occurred in patients from the Indian subcontinent (n=6, 43%) with UAE Nationals accounting for three

Author Contributions

cases (21%). Trauma induced cardiac arrest accounted for six cases (43%) with three of these (21%) as a result of traffic related incidents and two as a result of drowning (14%). The median response time was

AB was the principal investigator for the study, and principal author of

nine (9:00) minutes from receipt of emergency medical call to arrival of

the manuscript. AA, GW, CP, SD and FC assisted with study design,

crew at scene (IQR 7:45, 11:30). Bystander CPR was attempted in five

validated the dataset, and contributed to the final drafting and editing

cases (36%). Two patients (14%) presented in a shockable rhythm on

of the manuscript.

first analysis. An overall out-of-hospital (at scene or en-route) return-ofspontaneous-circulation (ROSC) rate of 14% (n=2) was observed in the

RESUSCITATION TODAY - AUTUMN 2017

paediatric population.

Acknowledgements The authors would like to acknowledge the PAROS steering committee and all National Ambulance staff for their engagement with the PAROS study.

Conclusion A low ROSC rate for paediatric cardiac arrest was identified in the population studied, in line with previous studies. This highlights the need for public education addressing prevention of paediatric cardiac arrest,

ABSTRACT Objectives

particularly prevention of trauma induced cardiac arrest. In addition, providing education to the public surrounding the early recognition of paediatric cardiac arrest and subsequent actions to be undertaken, including early EMS activation and provision of bystander CPR is an identified priority action arising from this study. Determining the

The objective of this study was to identify the incidence and clinical

baseline data presented in this study is essential in recommending and

characteristics of paediatric out-of-hospital cardiac arrest (OHCA) cases

implementing strategies to reduce mortality from paediatric OHCA.

National Ambulance LLC, Abu Dhabi, United Arab Emirates Fanshawe College, Paramedic Programs, London, ON, Canada 3 Centre for Paramedic Education and Research, Hamilton Health Sciences, ON, Canada

Centre for Prehospital Research, University of Limerick, Ireland Medical School, Royal College of Surgeons in Ireland, Dublin, Ireland Graduate Entry Medical School, University of Limerick, Ireland 7 Charles Sturt University, New South Wales, Australia 6

EDUCATION Keywords: paediatric; cardiac arrest; resuscitation; prehospital care;

EMTs who provided care for cardiac arrest patients completed PAROS

chain of survival; resuscitation; Middle East, UAE

data collection forms designed for the PAROS study, which were then reviewed by the PAROS coordinator in National Ambulance. Data requiring clarification such as dispatch and arrival times were cross-

Introduction

referenced with dispatch information before entry into PAROS database.

The United Arab Emirates (UAE) is a country composed of a

All cases of paediatric out-of-hospital cardiac arrest (defined as

multinational population with diverse educational backgrounds, cultural practices, and religious beliefs. Only an estimated 15-20% of the total population are UAE nationals, with the remainder comprised of a large proportion of expatriate workers from the Indian subcontinent, the Philippines and neighbouring Arab countries. As part of its commitment to reducing morbidity and mortality from out-of-hospital cardiac arrest (OHCA) in the population in the UAE, National Ambulance is a contributing member to the Pan-Asian Resuscitation Outcomes Study

under 18 years old) treated by NA EMT crews were included in this study. Cardiac arrest was defined as cessation of cardiac mechanical activity that was confirmed by the absence of a palpable pulse, unresponsiveness, and absence of spontaneous respirations. NA clinical treatment protocols (based on the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care) during the period of this data collection mandated transport of all paediatric

(PAROS - cardiac arrest registry).

OHCA cases to hospital (unless obviously dead with rigor mortis,

Survival rates for OHCA in the Middle East and Asia are low compared

incompatible with life etc.). Do-not-resuscitate orders do not exist

to those in North America or Europe. Recent findings published from the United Arab Emirates and Saudi Arabia have confirmed these anecdotal reports of low survival rates for OHCA.(1â&#x20AC;&#x201C;3) Paediatric cardiac arrests generally have poorer survival rates associated with resuscitation, even

decapitation, dependant lividity, incineration, other injuries totally within the UAE. Excluded from this study were all patients who were not treated by EMTs, due to recognition of death at scene, and any patient over the age of 18 years. Results from post-mortem examinations were not utilised.

though historically many of these cardiac arrests occur in a home residence and are witnessed by family members. Survival is greater in witnessed

Statistical analysis was performed using Statistical Package for Social

events, and even greater in those who receive bystander CPR.(4)

Sciences (IBM SPSS Version 20, NY, USA). Descriptive analysis was performed to determine distribution and frequency and percentages

Health and healthcare delivery has improved dramatically in the UAE

were used to describe and report variables and patient characteristics.

over the past 40 years. Consequently, the infant mortality rate (<5 years) has reduced from 223 per 1000 live births in 1960, to seven per 1000 live births in 2009. In childhood years however, approximately 107 children per year die from trauma in the United Arab Emirates. Injury

Results

secondary to vehicular traffic incidents remains the leading cause of

A total of 14 patients were identified in the NA PAROS dataset,

death for children aged 0 to 14 years old (63%), followed by drowning

using a combination of date of birth and/or age data variables.

and falls (10% each).(5) Reasons for this include poor compliance with

This subgroup represents 3.6% of all OHCA cases in the full

traffic laws such as wearing of seatbelts and use of child seats, and

dataset (n=384). Patients ranged in age from less than one hour

inadequate safety measures applied to residential pools, beaches, and

old (new-born) to 17 years old. The median age was four years old

high-level windows and balconies.

(IQR 0.63, 8.75). Age and/or date of birth data was missing for 12

This prospective cohort study aimed to identify the incidence and clinical characteristics, including aetiology, of paediatric out-of-hospital cardiac arrest (OHCA) cases presenting to National Ambulance (NA) crews in the Northern Emirates (NE).

cases in the full dataset. There were six male and eight female patients (43% and 57% respectively). Five patients (28%) had previous chronic medical histories, which included diabetes mellitus, pulmonary hypertension, cardiac issues and cerebral palsy. Six patients (43%) were from the other Arab descent (21%).

A subgroup analysis of a prospective cohort study was applied

The most common locations for OHCA in this subgroup were at a

investigating all presentations of paediatric OHCA between February

home residence (n=5, 36%), street/highway (n=4, 28%) and healthcare

2014 and March 2015 in the NA Northern Emirates service area of the

facilities (n=3, 21%). The median response time was nine minutes

UAE.(2)

(09:00) from receipt of emergency medical call to arrival of crew at scene (IQR 07:45, 11:30). The most common aetiology (identified

This study complies with the Declaration of Helsinki and received

through a review of individual patient care records) was medical. Further

ethical approval from the Office of the Chief Medical Advisor, National

patient characteristics are outlined on a case-by case basis in Table 1.

Ambulance LLC. The implementation of the PAROS study has received

All patients were transported to hospital (n=14) by National Ambulance

various IRB approvals from the countries involved in the PAROS study to

crews. Data for paediatric OHCA cases presenting to Emergency

which National Ambulance LLC is a contributing member. The PAROS

Departments by means other than NA crews is unavailable for this study

network has a data sharing agreement that protects the confidentiality

period. Further patient demographics and OHCA characteristics are

of all patients enrolled in the study.

outlined in Table 2.

RESUSCITATION TODAY - AUTUMN 2017

Methods

Indian subcontinent, three (21%) were UAE nationals and three were of

EDUCATION

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RESUSCITATION TODAY - AUTUMN 2017

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EDUCATION

had a previous medical history. Both were documented as of Indian descent, and both presented in an unknown non-shockable rhythm on first analysis. These cases occurred at a healthcare facility, and both received some form of advanced airway management (one was orally intubated and one had a supraglottic device inserted) along with supplementary oxygen delivery. Both received epinephrine IV/IO from a healthcare provider at scene (physician or paramedic).

A total of nine incidents were witnessed by a bystander (63%) and one

Discussion

event was witnessed by NA EMTs (7%). There were four incidents that were not witnessed (28%). CPR advice was offered by NA Ambulance

Findings from this study support previous studies on the low survival

Communications Centre (NA-ACC) call-takers and dispatchers to all

rate for paediatric OHCA in the region.(6,7) The low rate of bystander

callers once a diagnosis of cardiac arrest was confirmed or suspected.

CPR may also be attributed to cultural norms, and a lack of knowledge

Telephone CPR (dispatcher assisted) had been attempted in five cases

surrounding first aid and CPR in general. Children with a chronic

(36%) of cases as confirmed by NA crews on arrival at scene. All of

medical illness were less likely to have bystander CPR performed on

these cases of bystander CPR were performed by a healthcare provider

them, and only one case with chronic illness received bystander CPR.

bystander. Two patients were in an unknown shockable rhythm at time

The overall bystander CPR rate for all cases was less than 40%, yet over

of first rhythm analysis (14%). Five patients presented in asystole (36%)

70% of these cases were witnessed, the majority by a family member.

and the remainder (n=7) were in an unknown non-shockable rhythm at time of first analysis.

The findings of this study highlight the need for education of public regarding paediatric chain of survival, in particular, reinforcement of the first link, namely prevention of cardiac arrest. This can be achieved

12 patients were transported with no record of return of spontaneous

through community-based and systemic efforts to raise awareness of

circulation (ROSC) at any stage in the pre-hospital setting. An overall

prevention, and increase capacity to respond in the unfortunate event

out-of-hospital (at scene or en-route) return-of-spontaneous-circulation

of a paediatric OHCA. Many of the witnessed paediatric OHCA cases in

(ROSC) rate of 14% (n=2) was observed in the paediatric population.

our study had a large delay in time before activation of the emergency

These two cases had sustained ROSC on arrival at ED. All patients were

response system. This is likely due to the fact that many members of the

transported to tertiary level centres. CPR quality data was not collected

public may have trouble identifying the patient who needs immediate

for the study period.

medical assistance, cultural norms, a lack of knowledge surrounding first aid and CPR in general, fear of litigation and uncertainty.

A total of two patients gained ROSC at some stage in the pre-hospital setting. Both were female and were six months and one year old

However, the issue of potential litigation was addressed in a fatwa

respectively. Both of these cases were bystander witnessed, were

issued by the Official Iftaa Centre, General Authority of Islamic Affairs

non-traumatic in nature and both had bystander CPR performed prior

and Endowments who have stated that first aid should be administered

to ambulance crew arrival. The mean time from ambulance dispatch

by all people in accordance with Sharia law, and this aid provision would

to arrival was eight minutes in both cases. Neither of these patients

not attract any criminal liability.(8)

RESUSCITATION TODAY - AUTUMN 2017

Of the 14 patients transported to the emergency department (ED),

EDUCATION years old in the United Arab Emirates.(5,9) The primary cause of these traumatic injuries is vehicular traffic, which is supported by our findings. Although the incidence of vehicular crashes is decreasing according to police data, the severity of crashes is increasing.(5,10) Three of the children represented in this study suffered severe head injuries as a result of vehicular trauma (vehicle versus pedestrian), and a fourth suffered a severe head injury as a result of a fall from a height. Drowning as a common cause of paediatric death in the UAE is also supported by our findings, and previous literature indicates that occurrences of drowning are vastly under-reported in the UAE.(5) Thus this study likely under represents the issue of paediatric drowning in the country. Of the two drowning cases in this cohort, one was in a pool in a hotel complex and the other was in a bathtub in a private residence. These six paediatric cardiac arrests (43%) occurred as a result of predictable, easily preventable trauma. The findings of this study highlight the continued need for OHCA system investment, public engagement and awareness campaigns for both the general public and healthcare professionals surrounding prevention of paediatric cardiac arrest. One of the key factors in the strategy to reduce paediatric mortality and morbidity from trauma is the establishment of a trauma network in the UAE, with dedicated trauma centres and an organised trauma system which includes a national registry. Numerous studies have shown that severely injured patients have a greater chance of survival when cared for in an inclusive trauma system (11â&#x20AC;&#x201C;14) and the treatment of paediatric cases at a dedicated paediatric trauma centre is associated with reduced mortality and morbidity.(15) National Ambulance LLC has recently been appointed the lead site for the United Arab Emirates for the Pan-Asian Trauma Outcomes Study (PATOS). PATOS is a collaborative research network that aims to inform trauma policies and practices within member states and in the Middle East-AsiaPacific region in general. This will further the future evidence-based management of trauma in the United Arab Emirates. This study was limited to data collected by National Ambulance crews in the prehospital setting utilising PAROS forms and patient care records. Limited data was obtained on other prehospital variables, such as time from arrest to hospital, cases which were transported by other means, and any performed interventions during these transports. The cause of arrest was not confirmed by post-mortem examination because of cultural standards. A significant number of paediatric OHCA cases might still arrive at a RESUSCITATION TODAY - AUTUMN 2017

hospital via private transport rather than by transport in an ambulance. This possibly resulted in incomplete enrolment of patients into our study. Our own data collection is incomplete for several variables, specifically 12 cases are missing age and/or date of birth data, and thus may have mistakenly been omitted from this subgroup analysis. This analysis may not be totally representative of the true paediatric cardiac arrest situation Utilisation of ambulance services for emergency medical conditions

in the Northern Emirates. Our inability to discuss findings beyond the

in general is low in the region (3) and anecdotally, many patients are

prehospital care phase, and the missing data on patient outcomes as

transported in private vehicles to emergency departments or medical

a result, is an obvious limitation of this study.

clinics by individuals with limited or no medical training. Based on this, the results of this study likely represent only a percentage of the true paediatric OHCA issue in the United Arab Emirates.

Conclusion

Most child injuries are predictable and preventable, and as previously

A low prehospital return of spontaneous circulation rate for paediatric

identified, traumatic injuries are the main cause of death up to 19

cardiac arrest was identified in the population studied. This study

EDUCATION highlights the need for public education addressing prevention of paediatric cardiac arrest, in particular the prevention of trauma induced cardiac arrest. In addition, providing education to the public surrounding the early recognition of paediatric cardiac arrest and subsequent actions to be undertaken, including early EMS activation and bystander CPR provision is an identified priority arising from this study. Determining the baseline data presented in this study is essential in recommending and implementing strategies to reduce mortality from paediatric OHCA.

References 1. Ong MEH, Shin S Do, De Souza NNA, Tanaka H, Nishiuchi T, Song KJ, et al. Outcomes for out-of-hospital cardiac arrests across 7 countries in Asia: The Pan Asian Resuscitation Outcomes Study (PAROS). Resuscitation. 2015;96:100–8.

2. Batt A, Al-Hajeri A, Minton M, Haskins B, Cummins F. National Ambulance Northern Emirates PAROS Study Annual Report 2015. Abu Dhabi; 2015. 3. Bin Salleeh H, Gabralla K, Leggio W, Al Aseri Z. Out-of-hospital adult cardiac arrests in a university hospital in central Saudi Arabia. Saudi Med J. 2015;36(9):1071–5. 4. Tress E, Kochanek P, Saladino R, Manole M. Cardiac arrest in children. J Emergencies Trauma Shock [Internet]. 2010;3(3):267– 72. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4150140/?report=printable 5. Grivna M, Barss P, El-Sadig M. Epidemiology and Prevention of Child Injuries in the United Arab Emirates: A Report for SafeKids Worldwide. Al Ain; 2008. 6. Salleeh H Bin, Al Tom M, Ahmed Y, Leggio WJ, Abdulqader NF. Out of Hospital Pediatric Cardiac Arrest : Prospective Study from Riyadh , Saudi Arabia. Biosci Bioctechnology Res Asia. 2016;13(1):569–72. 7. Conroy KM, Jolin SW. Cardiac arrest in Saudi Arabia: A 7-year experience in Riyadh. J Emerg Med. 1999;17(4):617–23.

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8. Kelly R. “ Good Samaritan ” principles in the UAE : legal liabilities when administering first aid [Internet]. 2014 [cited 2015 Jun 14]. Available from: http://www.clydeco.com/insight/updates/view/goodsamaritan-principles-in-the-uae-legal-liabilities-when-administering-f 9. Thomsen J, Joubert D, Huang D. Monitoring the Burden of Injuries in Abu Dhabi Emirate : HAAD Fatal Injury Statistics. 2013. 10. Grivna M, Barss P, Stanculescu C, Eid HO, Abu-Zidan FM. Child and youth traffic-related injuries: use of a trauma registry to identify priorities for prevention in the United Arab Emirates. Traffic Inj Prev [Internet]. 2013;14(3):274–82. Available from: http://www.ncbi.nlm. nih.gov/pubmed/23441946

12. Chiara O, Cimbanassi S. Organized trauma care: does volume matter and do trauma centers save lives? Curr Opin Crit Care. 2003;9(6):510–4. 13. Lansink KWW, Leenen LPH. Do designated trauma systems improve outcome? Curr Opin Crit Care. 2007;13(6):686–90. 14. Twijnstra MJ, Moons KGM, Simmermacher RKJ, Leenen LPH. Regional trauma system reduces mortality and changes admission rates: a before and after study. Ann Surg. 2010;251(2):339–43. 15. Deasy C, Gabbe B, Palmer C, Babl FE, Bevan C, Crameri J, et al. Paediatric and adolescent trauma care within an integrated trauma system. Injury [Internet]. Netherlands; 2012;43(12):2006–11. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=r eference&D=medl&NEWS=N&AN=21978766

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11. Utter GH, Maier R V, Rivara FP, Mock CN, Jurkovich GJ, Nathens AB. Inclusive trauma systems: do they improve triage or outcomes of the severely injured? J Trauma. United States; 2006 Mar;60(3):529–37.

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EVIDENCE

EFFECT OF DEXTRAN-70 ON OUTCOME IN SEVERE SEPSIS; A PROPENSITYSCORE MATCHING STUDY Peter Bentzer1, 2, Marcus Broman2, 3 and Thomas Kander2, 3 Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine201725:65 https://doi.org/10.1186/s13049-017-0413-x © The Author(s). 2017 Received: 2 February 2017 Accepted: 28 June 2017 Published: 6 July 2017

Abstract

Conclusion

Background

No evidence to support a detrimental effect of dextran-70 on mortality or on organ failures in patients with severe sepsis or septic shock could be detected.

Albumin may be beneficial in patients with septic shock but availability is limited and cost is high. The objective of the present study was to investigate if the use of dextran-70 in addition to albumin and crystalloids influences organ failure or mortality in patients with severe sepsis or septic shock.

Methods Patients with severe sepsis or septic shock (n = 778) admitted to a university hospital intensive care unit (ICU) between 2007 and 2015 that received dextran-70 during resuscitation were propensity score matched to controls at a 1 to 1 ratio. Outcomes were highest acute kidney injury network (AKIN) score the first 10 days in the ICU, use of renal replacement therapy, days alive and free of organ support the first 28 days after admission to ICU, mortality and events of severe bleeding. Outcomes were assessed using paired hypothesis testing.

Results

Discussion There is a paucity of high quality data regarding effects of dextran solutions on outcome in sepsis. In the present study, propensity score matching was used in attempt to reduce bias.

Acute kidney injury Dextran Colloid Crystalloid Sepsis Resuscitation

Background The optimal fluid therapy for patients with severe sepsis and septic shock is debated [1, 2, 3]. Colloids have theoretical advantages compared to crystalloids because they are more efficacious plasma expanders than crystalloids and may minimize harmful effects of fluid overload [4, 5, 6, 7, 8, 9, 10, 11]. Some support for the use of albumin as an adjunct to the crystalloids may be inferred from the subgroup analyses of data from two large randomized trials showing improved outcomes in patients that received albumin compared to those treated only with saline [12, 13]. Moreover, the surviving sepsis guidelines support the use of albumin in patients requiring large amounts of fluid for hemodynamic stabilisation [14]. However, albumin is expensive, availability is limited and transfer of viruses remains a possibility in albumin products derived from human donors. Taken together, this provides a rational for the study of alternatives to albumin in patients with sepsis requiring large amounts of fluid. Given that the use of hydroxyletyl starches (HES) in septic patients is discouraged [15, 16, 17, 18] dextrans are a group of colloids that are of potential interest. Dextrans are branched glucose polysaccharides and dextran-70 is a more efficacious plasma volume expander than albumin [8, 19, 20]. In addition, dextrans possess antithrombotic and rheological effects [21]. Two small studies have suggested that the use of dextran-70 in sepsis may be associated with increased bleeding and increased risk of acute kidney injury thus raising safety concerns [22, 23]. In attempt to further investigate safety of dextran-70 as an alternative to albumin we propensity-score matched patients with severe sepsis or septic shock who received dextran-70 to those who did not receive dextran-70 in a cohort of patients treated in a single intensive care unit (ICU). Effects of dextran-70 on measures of organ failure, on incidence of severe bleeding and on mortality were then investigated.

Department of Anesthesia and Intensive Care Helsingborg Hospital, Helsingborgs lasarett, Charlotte Yhlens gata 10, 251 87 Helsingborg, Sweden. Department of Clinical Sciences Lund, Lund University, Box 157, 221 00 Lund, Sweden. Department of Intensive and Perioperative Care, Skåne University Hospital Lund, Getingevägen, 221 85 Lund, Sweden.

1 2

RESUSCITATION TODAY - AUTUMN 2014

Propensity score matching resulted in two groups of patients with 245 patients in each group. The dextran group received a median volume of 1483 ml (interquartile range, 1000–2000 ml) of dextran-70 during the ICU stay. Highest AKIN score did not differ between the control- and dextran groups (1 (0–3) versus 2 (0–3), p = 0.06). Incidence of renal replacement therapy in the control- and dextran groups was similar (19% versus 22%, p = 0.42, absolute risk reduction −2.9% [95% CI: −9.9 to 4.2]). Days alive and free of renal replacement, vasopressors and mechanical ventilation did not differ between the control- and dextran groups. The 180-day mortality was 50.2% in the control group and 41.6% in the dextran group (p = 0.046, absolute risk reduction 8.6% [−0.2 to 17.4]). Fraction of patients experiencing a severe bleeding in the first 10 days in the ICU did not differ between the control and dextran groups (14% versus 18%, p = 0.21).

Keywords

EVIDENCE Methods

renal failure after day 10 is likely to be increasingly influenced by factors

Subjects

days alive and free of RRT, days alive and free of mechanical ventilation,

other than dextran administration. Other outcomes were use of RRT, days alive and free of vasopressor therapy during the first 28 days of the

The study was approved by the regional ethical vetting board in Lund (registration number 2014/916). Patients admitted to the general tertiary ICU at Lund University Hospital, Sweden between 1 of January 2007 and 9 of November 2015 with the diagnosis of severe sepsis (ICDcode R65.1) or septic shock (ICD-code R57.2) according to Sepsis-2 definition [24] were eligeble for inclusion. Patients <18 years of age and

ICU stay, and 28, 90 and 180-day mortality. Any patient that died during the 28-day observation period was assigned 0 days alive and free of any organ support. To assess potential effects of dextran on incidence of severe bleeding episodes patients that received more than 3 units of packed red blood cells at any day during the first 10 days in the ICU were defined as having experienced a severe bleeding episode.

patients who received hydroxyethyl starch or gelatin during resuscitation were excluded. To increase power to detect effects on renal function, patients receiving renal replacement therapy (RRT) prior to admission were excluded. The manuscript was prepared according to the STROBE

Statistical analyses

guidelines for observational studies [25].

Dextran- and non-dextran-treated patients were propensity score

Patients with severe sepsis and septic shock were identified using

with outcome. The propensity score was calculated with linear logistic

data from the Swedish Intensive Care registry (SIR). For patients with more than 1 admission with the diagnosis of severe sepsis or septic shock only the first admission was included in the analysis. Mortality data was imported from SIR. Physiological and laboratory data and pre-existing conditions (age, gender, chronic obstructive pulmonary disease (COPD), renal failure, diabetes), outcome variables (except mortality) and fluid administration data were collected from raw data, i.e. from the electronic master chart system of the hospital or from the

matched to adjust for differences in baseline variables associated regression using a one_to_many macro for SAS [27] with the covariates specified in Table 1. Physiological and laboratory variables used in the propensity score matching were collected within 90 min of admission to the intensive care unit. A greedy matching procedure matched treated to controls at a ratio of 1:1. In a first step a match was sought with a propensity score that was identical to 8 decimal places to the treated patient. If no match was found, a match would be sought at 7 decimal places and so on. If no match was found at 1 decimal place, the patient

patient data management system at the ICU. Patients were divided

receiving dextran-70 was excluded from the study. A control could only

into a dextran and a control group, based on whether they received

be used once. The standardized difference was used as a balance

dextran-70 or not the first 5 days of the ICU-stay. The control group

diagnostics as it is not confounded by sample size [28]. A standardized

was resuscitated with a combination of crystalloids and 5 and 20%

difference of ≤10% is suggested to indicate negligible differences in the

albumin. The use of dextran-70 (6% dextran solution with a mean

mean or prevalence of covariates between groups [29].

molecular weight of 70 kilodalton [kDa] dissolved in 0.9% sodium chloride, Macrodex®, Meda) during the resuscitation was not regulated

Sample size was based on the number of available patients during the

in local guidelines and was left to the discretion of the attending

study period. Variables were summarized using mean or median with

physician. Dextran-1 (Promiten , Meda) was given prior to dextran-70

standard deviation or range as distribution measurement. An independent

as a prophylaxis against anaphylaxis.

statistician performed propensity score matching using SAS version 9.4

(SAS Institute Inc., Cary, NC, USA) prior to any comparison between the

RESUSCITATION TODAY - AUTUMN 2017

A secondary sensitivity analysis in which effects of a higher dose of

groups. Kaplan-Meier survival analysis was performed and is presented

dextran-70 was investigated was planned a priori. In this analysis only

in graphs with corresponding stratified log-rank test. In accordance with

patients receiving >900 ml dextran-70 the first 5 days after admission

previous recommendations [30, 31] all comparisons between the groups

(n = 323) were available for propensity score matching in the dextran

after propensity score matching was performed using paired hypothesis

group. These patients were propensity score matched to the same non-

testing. Wilcoxon rang sum test was used for continuous variables and

dextran group (control group) as in the primary analysis. Patients treated

McNemar’s test for categorical variables by SPSS Statistics version 24

with ≤900 ml dextran-70 were excluded in this secondary analysis. The

(SPSS Inc., Chicago, Ill., USA). A two-sided P value of less than 0.05 was

rationale for choosing >900 ml as a cut off for this analysis was that we

considered to indicate statistical significance.

wanted include patients that received ≈ two 500 ml bags of dextran-70 or more and the priming of the pumps usually resulted in slightly less than 1000 ml of dextran being given. According to the Summary of Product Characteristics for Macrodex®, maximum daily dose is 2500 ml.

Results A Consort chart of patients is presented in Fig. 1. Of 6776 admissions,

Outcomes

932 (13.8%) were diagnosed with severe sepsis or septic shock and a total of 342 control patients and 436 dextran-70 treated patients were eligible for inclusion in the propensity score match. At total of 490 of

Maximum acute kidney injury score according to the Acute Kidney Injury

these patients were matched at a 1:1 ratio, i.e. 245 unique patients in

Network (AKIN) criteria [26] during the first 10 days of admission to

the control group and 245 unique patients in the dextran group. The

the ICU was used as an outcome reflecting renal effects of dextran-70.

median number of propensity score matched patients included each

The rationale for choosing this time frame was that dextran-70 is mainly

year was 24 (min-max range 14–48) in the control group and 28 (min-

administered during the first few days of admission to the ICU and that

max range 20–33) in the dextran group.

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EVIDENCE Table 1 Patient demographics before and after propensity matching Unmatched groups

Standardized difference

Control N = 342

Dextran N = 436

Age, mean (SDa)

61.4 (17)

66.0 (15)

0.29

Male gender, no (%)

140 (41)

198 (45)

0.09

58 (17.0)

20 (4.6)

P-value

Propensity-matched groups

Standardized difference

P-value

Control N = 245

Dextran N = 245

0.0001

63.6 (16)

63.7 (16)

0.009

0.92

0.21

102 (42)

103 (42)

0.08

0.93

0.41

0.0001

18 (7)

17 (17)

0.02

0.86

Pre-existing conditions

Blood malignancy , no (%) c

COPD , no (%)

39 (11)

51 (12)

0.0092

0.89

32 (13)

0.00

1.00

Chronic renal failure, no (%)

14 (4.1)

10 (2.3)

0.10

0.15

10 (4.1)

9 (3.7)

0.02

0.82

Cirrhosis, no (%)

15 (4.4)

11 (2.5)

0.10

0.15

10 (4.1)

0.00

1.00

Diabetes, no (%)

38 (11)

45 (10)

0.03

0.72

28 (11)

31 (13)

0.04

0.68

54 (16)

38 (8.7)

0.22

0.002

26 (10.6)

22 (9.0)

0.05

0.54

Malignancy , no (%)

46 (13)

62 (14)

0.02

0.76

32 (13)

0.00

1.00

Nosocomial infectionf, no (%)

44 (13)

31 (7)

0.19

0.007

21 (8.6)

23 (9.4)

0.03

0.75

Immunosuppression , no (%) e

Surgery , no (%)

71 (21)

92 (21)

0.008

0.91

51 (21)

0.00

1.00

GIh bleeding, no (%)

3 (0.9)

3 (0.7)

0.02

0.77

1 (0.4)

2 (0.8)

0.05

0.56

DICi, no (%)

39 (11)

35 (8)

0.11

20 (8)

0.00

1.00

I.C. volume effect, no (%)

5 (1.5)

0 (0)

0.17

0.01

0 (0)

0.00

1.00

Airway infection, no (%)

94 (28)

106 (24)

0.07

0.32

66 (27)

59 (24)

0.07

0.93

Physiological and laboratory variables at admission , mean (SD) Heart rate, mean (SD)

110 (24)

0.04

0.60

110 (24)

112 (25)

0.08

0.35

SBP , (mmHg)

111 (30)

103 (28)

0.04

0.60

108 (29)

0.006

0.95

Lactate (mmol/L)

4.0 (3.8)

2.9 (3.1)

0.06

0.42

3.8 (3.4)

3.8 (3.1)

0.03

0.76

Norepinephrine (μg/min)

3.7 (5.7)

5.4 (8.9)

0.24

0.002

4.0 (5.7)

3.8 (5.5)

0.03

0.76

Temperature (°Celcius)

37.3 (1.6)

37.4 (1.2)

0.07

0.30

37.3 (1.4)

37.3 (1.2)

0.008

0.93

Oxygenation pointsm

2.0 (1.1)

1.9 (1.1)

0.02

0.79

2.0 (1.1)

0.02

0.84

16.6 (39.3)

14.0 (18.7)

0.09

0.22

15.5 (23.6)

15.2 (23.6)

0.01

0.89

Platelets (× 10 /L)

151 (133)

184 (119)

0.26

0.0003

173 (138)

167 (106)

0.05

0.61

7.34 (0.14)

7.32 (0.12)

0.12

0.09

7.34 (0.13)

7.34 0.11)

0.01

0.91

Bilirubin (μmol/L)

31.0 (49.7)

20.8 (29.9)

0.25

0.0006

23.6 (26.3)

24.6 (37.8)

0.03

0.73

Creatinine (μmol/L)

173 (136)

174 (133)

0.006

0.94

180 (137)

180 (140)

0.003

0.97

Leucocytes (× 10 /L) 9

Standard deviation Lymphoma, acute leukaemia or myeloma Chronic obstructive pulmonary disease d Chronic steroid treatment correlative to ≥0.3 mg/kg prednisolone/day, radiation, or chemo therapy e Cancer spread beyond the regional lymph nodes f Infection that developed after ≥48 h in hospital or secondary to surgical or medical procedure g Before admission to intensive care h Gastro-intestinal i Disseminated intravascular coagulopathy j Intra-cranial k First value within 90 min after admission except for “Norepinephrine” which is the mean dose until the first day’s morning l Systolic blood pressure m In accordance with SAPS 3. 1 point: PaO2 ≥ 8 kPa and spontaneous breathing (SB). 2 points PaO2 ≤ 8 kPa and SB. 3 points PaO2/FiO2 ≥ 13.3 and mechanical ventilation (MV). 4 points PaO2/FiO2 ≤ 13.3 and MV b c

RESUSCITATION TODAY - AUTUMN 2017

Baseline demographics, pre-existing medical conditions, and clinical,

dextran-70 for the ICU stay was 1483 ml (interquartile range 1000–2000

physiologic, and laboratory data in the unmatched and matched study

ml), which corresponds to 17 ml/kg (interquartile range 12–27 ml/kg).

population are summarized in Table 1. Matching reduced standardized differences between the groups in baseline variables to ≤10% for all

There was a signal for a higher maximal AKIN score in the dextran group than

variables. The dose of dextran-70 in the dextran group the first day was

in the control group (p = 0.06) but this was not reflected in incidence of RRT

1000 ml (interquartile range 500–1000 ml) and for the first 5 days 399 ml/

or days alive and free of RRT (Table 2). Other measures of organ failure

day (interquartile range 200–656 ml/day) (Table 3). Cumulative dose of

and number of severe bleeding episodes were similar in the two groups.

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EVIDENCE The 180-day mortality was lower in the dextran group than in the control group whereas mortality at 28- and 90 days did not differ between the groups (Table 2 and Fig. 2). For details concerning fluid administration

6776 admissions were screened for severe sepsis or septic chock

and fluid balance please see Table 3. In summary the dextran group received less 5% and 20% albumin during the first 5 days in the ICU, the dextran group also received more crystalloids at day 1 in the ICU. The volume of packed red blood cells during the first five days in the ICU

5915 admissions without severe sepsis or septic chock

was higher than in the control group. Urinary output was lower and fluid balance more positive in the dextran group during the first days in the ICU compared to the control group. Number of patients in the dextran

932 admissions with severe sepsis or septic chock

778 unique patients in propensity score match

and control groups that experienced a bleeding episode did not differ between the groups (Table 2).

154 admissions 82 patients received hydroxythyl starch 67 multiple admissions same patient 4 missing data 1 patient in chronic dialysis

A pre-specified analysis was performed to investigate the interaction between dose of dextran-70 and outcome. In this analysis only patients receiving >900 ml dextran-70 the first 5 days after admission were included in the dextran group. The propensity score matching rendered 219 patients in the control group and 219 patients in the dextran group. The dose of dextran-70 in the dextran group the first day was 1000 ml (interquartile range 1000–1483 ml) and for the first 5 days in the treated patients was 413 ml/day (interquartile range 300–750 ml/day), and the cumulative dose for the ICU stay was 1500 ml (interquartile range 1000–

288 non-matched patents

2500 ml), which corresponds to 20 ml/kg (interquartile range 14–32 ml/ kg). Matching produced well-matched groups and reduced standardized differences in baseline variables to ≤10% for all variables but age

490 patients included in the analyses

245 patients in the control group

(Additional file 2). The differences between the groups in the secondary analyses were essentially unchanged compared to the primary analyses.

Discussion

245 patients in dextran group

Mortality at 180 days was lower in the dextran group whereas mortality at earlier time points did not differ. The use of dextran-70 was associated

Fig. 1 Consort scheme of the study patients

with more transfusions and a more positive fluid balance compared to patients that only received crystalloids and albumin. No effect of dextran on number of severe bleeding episodes could be detected.

Table 2 Main outcome variables Propensity-matched groups

Absolute risk reduction (95% CI)

Outcome

Control n = 245

Dextran n = 245

AKIN maxb median (Q1-Q3c)

1 (0–3)

2 (0–3)

0.06

28 (0–28)

0.52

DAF of vasopressors, median (Q1-Q3)

25 (0–27)

24 (0–26)

0.96

DAF of mechanical ventilation, median (Q1-Q3)

24 (0–28)

22 (0–27)

0.44

RESUSCITATION TODAY - AUTUMN 2017

Relative risk (95% CI)

DAF of RRT, median (Q1-Q3)

RRT , no (%)

46 (18.8)

53 (21.6)

1.15 (0.81 to 1.64)

−2.9% (−9.9 to 4.2%)

0.42

Bleeding episodesf, no (%)

35 (14)

45 (18)

1.29 (0.86 to 1.93)

−4.1% (−10.6 to 2.5%)

0.21

28-day mortality, no (%)

86 (35.1)

78 (31.8)

0.91 (0.71 to 1.17)

3.3% (−5.1 to 11.7%)

0.41

90-day mortality, no (%)

109 (44.5)

96 (39.2)

0.88 (0.71 to 1.08)

5.3% (−3.4 to 14.0%)

0.21

180-day mortality, no (%)

123 (50.2)

102 (41.6)

0.83 (0.68 to 1.01)

8.6% (−0.2 to 17.4%)

0.046

Wilcoxon rang sum or McNemar’s test Maximal Acute Kidney Injury Network classification score the first 10 days after admission Interquartile range d Days Alive and Free e Renal Replacement Therapy f Defined by patients that received more than 3 units of packed red blood cells at any day the first 10 days after admission b c

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RESUSCITATION TODAY - AUTUMN 2017

EVIDENCE

Fig. 2 Kaplanâ&#x20AC;&#x201C;Meier estimates of the probability of 180-day survival. P = 0.28 for the comparison between the control group (red line) and the dextran group (blue line). Difference between groups was tested using the stratified log-rank test

A signal for worsening of AKI was detected in the dextran group but other

Our finding that patients in the dextran group received more

measures of organ failure were similar in the dextran and control groups.

packed red blood cells during the 5 first days at the ICU, compared to patients in the control group is in line with the two previous

There is a paucity of high quality data regarding effects of dextran

studies investigating effects of dextran-70 in sepsis [22, 23].

solutions on outcomes despite the fact that dextrans have been used

However, in contrast to the above studies the present study could

clinically for more than 60 years. In the present study, propensity score

not demonstrate a difference in the number of episodes with

matching was used in attempt to reduce bias and to estimate treatment

severe bleedings between the dextran and control groups. Two

effects of dextran-70. The finding that standardized differences were

mechanisms could be responsible for the increased transfusions

below 10% for all covariates included in the main analysis indicates that

of packed red cells in the dextran group. Firstly dextran-70 is

matching was successful in reducing imbalances between the treatment

suggested to induce a von Willebrand-like syndrome and [34] and

groups [30]. However, as discussed in more detail below, it must be

to weaken fibrinogen polymerization [35, 36]. Weather these effects

stressed we cannot exclude that remaining imbalances in covariates,

of dextran-70 increases clinically significant bleeding is unclear.

that were not accounted for in the propensity score model, may have

Randomized trials were performed of dextran-70 versus crystalloids

influenced our results.

in the study of septic shock due to dengue in children [37] and a small study in shocked, adult trauma patients [38]. Neither of these

RESUSCITATION TODAY - AUTUMN 2017

There are conflicting data with regard to effects of dextran-70 on renal

trials reported increased bleeding with dextran-70. Nevertheless,

function in patients suffering from septic shock. Thus it was recently

increased bleeding incidence in the dextran group cannot be

reported that incidence of RRT in a cohort of patients with septic shock

ruled out as the cause for the need of more blood transfusions in

resuscitated with mainly Ringers acetate was lower than in historical

the present study. Secondly, dextran-70 is a more potent plasma

controls resuscitated with a combination isotonic saline, albumin and

expander than albumin and hemodilution will therefore occur to

dextran-70 (23% vs 48%) [23]. In contrast, a somewhat larger study

larger extent in dextran-70 resuscitated patients [7, 8, 37, 39].

using a similar design could not demonstrate a change in incidence of

Because hemoglobin level is controlled by the clinician, iatrogenic

RRT by dextran-70 [22]. The present result of a similar incidence of RRT

hemodilution is likely to contribute to the increased number of

of about 20% in both the control and dextran groups does not provide

transfusions in the dextran group.

support for adverse renal effects of dextran-70. It should be noted that the incidence of RRT in the present study is in the same range as that

The finding that use of dextran-70 was associated with decreased

reported in several recent randomized controlled trials investigating

use of albumin is in keeping with our hypothesis that dextran-70

effects of fluid therapy in sepsis and septic shock [12, 17, 18, 32]. In an

can be used to reduce use of albumin. However, the use of

attempt to increase sensitivity to detect changes in renal function that may

dextran-70 was also associated with a more positive fluid balance

be of importance for long-term mortality [33] we investigated maximum

during the first 5 days of admission. The positive balance could

AKIN score during the first 10 days after admission. There was a signal

mainly be referred to the use of dextran-70 in excess of the

for an increase in maximum AKIN score, which could indicate that dextran

relatively small reduction in volume of albumin and to a minor

may be injurious to kidneys even if patient important outcomes such as

extent to the increase in transfusion of packed red cells (Table 3).

events of RRT and days alive and free of organ failure were not affected.

This seems to be in disagreement with the experimental and clinical

Alternatively this signal represents a chance finding.

data discussed above suggesting that dextran-70 is a better

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EVIDENCE Table 3 Fluid therapy Propensity score matched groups Control, n = 245

Dextran, n = 245

Median

Q1 to Q3

Median

Q1 to Q3

Day 1

0 to 0

1000

500 to 1000

<0.001

Day 2

0 to 0

0 to 500

<0.001

Day 3

0 to 0

<0.001

Mean per daya

0 to 0

399

200 to 654

<0.001

Day 1

0 to 500

0.17

Day 2

0 to 0

0.0.66

Day 3

0 to 0

0.80

Mean per day

0 to 253

0 to 219

0.03

0 to 154

0 to 0

<0.001

Dextran-70, 60 mg/ml (ml)

Albumin 50 mg/ml (ml)

Albumin 200 mg/ml (ml) Day 1 Day 2

0 to 100

0 to 0

0.24

Day 3

0 to 100

0 to 81

0.71

Mean per day

0 to 121

0 to 80

<0.001

Day 1

2100

533 to 4000

3025

2000 to 4200

<0.001

Day 2

0 to 420

130

0 to 985

0.06

Day 3

0 to 200

0 to 300

0.09

Mean per day

1050

343 to 2104

1279

740 to 2162

0.13

Day 1

0 to 328

250

0 to 600

<0.001

Day 2

0 to 0

0 to 295

0.008

Crystalloidsb (ml)

Blood transfusion (ml)

Day 3

0 to 0

0 to 245

0.88

Mean per day

0 to 244

174

0 to 320

<0.001

Fluids in, totalc (ml) Day 1

4261

1942 to 6323

5700

3999 to 7475

<0.001

Day 2

2817

1852 to 3982

3699

2684 to 4645

<0.001

Day 3

2444

1253 to 3322

2924

2088 to 3964

0.006

Mean per day

3823

2413 to 4891

4544

3314 to 5600

<0.001

Day 1

1400

605 to 2545

1073

381 to 2076

0.009

Day 2

2243

1049 to 3622

1931

829 to 3211

0.04

Urine output (ml)

RESUSCITATION TODAY - AUTUMN 2017

Day 3

2640

1410 to 3850

2555

1025 to 3743

0.92

Mean per day

2010

376 to 3044

2078

327 to 3007

0.97

Day 1

1989

0 to 4528

3516

1703 to 5732

<0.001

Day 2

−627 to 1550

995

0 to 2617

<0.001

Day 3

−1

−1361 to 323

−38

−896 to 841

0.11

Mean per day

581

−82 to 2015

1022

204 to 2264

0.03

Total fluid balanced (ml)

The number of patients in the control group was: Day 1 = 245. Day 2 = 191. Day 3 = 138. Day 4 = 102. Day 5 = 79. The number of patients in the dextran group was: Day 1 = 245. Day 2 = 212. Day 3 = 175. Day 4 = 139. Day 5 = 124. The data were collected from the patient’s electronic charts. No missing values. The decreasing number of patients represents patients who died or were discharged from the ICU a Mean per day represents mean fluid administration per day up to 5 days after admission. For patients with ICU-stay <5 days the mean per day was calculated for the length of stay b Crystalloids represents the sum of NaCl 9 mg/ml and Ringer’s Acetate c Fluids in, total represents the sum of all enteral and parenteral administered fluids including blood products d Insensible perspiration not included

EVIDENCE plasma expander than crystalloids, [7, 8, 37, 39] which would be expected to lessen the need for other fluids in dextran-70 group. This result may have several explanations. As mentioned above a more pronounced hemodilution by dextran-70 is likely to have led to transfusions contributing to a more positive fluid balance in the dextran group. Also, although the groups we carefully matched

collected as raw data directly from the electronic charts and not from a secondary electronic case report form or register. Taken together this makes the data robust and reliable. In addition, optimization of the propensity score matching was performed by an independent statistician without knowledge of outcomes prior to any comparisons between the groups.

with regard physiological and laboratory parameters reflecting severity of illness, it is possible dextran-70 was more likely to be given to patients with more severe vascular leak and a higher need of fluid. Naturally it could be argued that a dextran-70 induced increase in vascular leak may have increased the volume requirements and contributed to the more positive fluid balance. However, dextrans are not known to influence on macromolecular permeability and have in fact been suggested to decease fluid permeability in experimental models [40, 41]. In attempt to evaluate if effects of dextran were dosedependent we performed a second propensity score matching in which only patients receiving >900 ml dextran-70 were available for matching. This sensitivity analysis did not provide evidence for a dose dependent negative or positive effect of dextran-70 administration. Our finding that the effect of dextran on 90-day and 180-day mortality appeared to be more marked, aligns with the results of the main analysis. However, this finding may also be due to a statistical type 1 error since we did not correct

for multiple testing and should be interpreted cautiously.

Strengths

PROVIDING PROFESSIONAL SERVICE AND SUPPORT OUR PRODUCTS SAVE LIVES

The strengths of the present study is that all physiological and laboratory variables and many pre-existing conditions were registered prospectively in electronic charts and

EVIDENCE Limitations

Declarations

Limitations include the single centre design and that the control group

Acknowledgments

may not reflect practice in other ICUs, which makes the external validity of the study uncertain. Although baseline characteristics and comorbidities were carefully adjusted for it cannot be excluded that factors of importance for outcomes were not included in the propensity

We thank Ann Svensson Gustafsson and Jan Karlsson for invaluable help with data extraction from the patient data management system.

score model. Also, it cannot be excluded that patients in the control group may have received dextran-70 prior to arrival in the intensive care unit.

Funding PB was supported by grants from Region SkĂĽne (ALF # 18401), the

Conclusions No evidence to support a detrimental effect of dextran-70 on kidney function or need for organ support or mortality in patients with severe

Anna and Edwin Berger Foundation.

Availability of data and materials

sepsis or septic shock could be detected. Treatment with dextran-70 was associated with increased transfusion of packed red cells and a

The data that support the findings of this study are available from the

more positive fluid balance in the first 5 days after admission but no

corresponding author upon reasonable request.

support for an increased incidence of severe bleeding episodes was found. A prospective large trial with low risk of bias is needed to further evaluate effects of dextran-70 before it can be recommended as an alternative to albumin in the resuscitation of septic patients.

Authorsâ&#x20AC;&#x2122; contribution PB was the originator of the study. PB and TK designed the study.

Abbreviations AKI: Acute kidney injury AKIN: Acute Kidney Injury Network COPD: Chronic obstructive pulmonary disease DAF: Days alive and free of

TK collected the data. An independent statistician performed the propensity score matching and TK performed the additional statistical analyses. PB, MB and TK contributed to the interpretation of the data and revised the manuscript critically. PB, MB and TK gave final approval of the version to be published. All authors agreed to be accountable for all aspects of the work.

HES: Hydroxylethyl starches ICU: Intensive care unit MV: Mechanical ventilation

Ethics approval and consent to participate

RRT: Renal replacement therapy

RESUSCITATION TODAY - AUTUMN 2017

SB: Spontaneous breathing

The study was approved by the regional ethical vetting board in Lund

SIR: Swedish intensive care registry

(registration number 2014/916).

Visit www.pulmolink.co.uk to choose your ideal Pulse Oximeter or Capnograph; rugged & reliable for emergency & outdoor use sales@pulmolink.co.uk 01233 713070

EVIDENCE References 1. Kumar G, Walker E, Stephens R. Intravenous fluid therapy. Trends in Anaesthesia and Critical Care. 2014;4:55–9.

21. Arfors KE, Buckley PB. Pharmacological characteristics of artificial colloids. Baillieres Clin Anaesthesiol. 1997;11:15–47.

2. Myburgh JA. Fluid resuscitation in acute medicine: what is the current situation? J Intern Med. 2015;277:58–68.

22. Hvidt LN, Perner A. High dosage of dextran 70 is associated with severe bleeding in patients admitted to the intensive care unit for septic shock. Dan Med J. 2012;59:A4531.

3. Rochwerg B, Alhazzani W, Sindi A, Heels-Ansdell D, Thabane L, Fox-Robichaud A, et al. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med. 2014;161:347– 55. 4. Acheampong A, Vincent JL. A positive fluid balance is an independent prognostic factor in patients with sepsis. Crit Care. 2015;19:251. 5. Arikan AA, Zappitelli M, Goldstein SL, Naipaul A, Jefferson LS, Loftis LL. Fluid overload is associated with impaired oxygenation and morbidity in critically ill children. Pediatr Crit Care Med. 2012;13:253–8. 6. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med. 2011;39:259–65. 7. Dubniks M, Persson J, Grände PO. Plasma volume expansion of 5% albumin, 4% gelatin, 6% HES 130/0.4, and normal saline under increased microvascular permeability in the rat. Intensive Care Med. 2007;33:293–9. 8. Dubniks M, Persson J, Grände PO. Comparison of the plasma volumeexpanding effects of 6% dextran 70, 5% albumin, and 6% HES 130/0.4 after hemorrhage in the guinea pig. Journal of Trauma - Injury Infection and Critical Care. 2009;67:1200–4. 9. Murphy CV, Schramm GE, Doherty JA, Reichley RM, Gajic O, Afessa B, et al. The importance of fluid management in acute lung injury secondary to septic shock. Chest. 2009;136:102–9. 10. Persson J, Grände PO. Plasma volume expansion and transcapillary fluid exchange in skeletal muscle of albumin, dextran, gelatin, hydroxyethyl starch, and saline after trauma in the cat. Crit Care Med. 2006;34:2456–62. 11. Prien T, Backhaus N, Pelster F, Pircher W, Bunte H, Lawin P. Effect of intraoperative fluid administration and colloid osmotic pressure on the formation of intestinal edema during gastrointestinal surgery. J Clin Anesth. 1990;2:317–23. 12. Caironi P, Tognoni G, Masson S, Fumagalli R, Pesenti A, Romero M, et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014;370:1412–21. 13. Finfer S, McEvoy S, Bellomo R, McArthur C, Myburgh J, Norton R. Impact of albumin compared to saline on organ function and mortality of patients with severe sepsis. Intensive Care Med. 2011;37:86–96. 14. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock. Intensive Care Med. 2016;2017:1–74.

16. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39:165–228.

24. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med. 2003;29:530–8. 25. Vandenbroucke JP, von Elm E, Altman DG, Gotzsche PC, Mulrow CD, Pocock SJ, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Epidemiology. 2007;18:805–35. 26. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, et al. Acute kidney injury network: Report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11:R31. 27. Parsons LS. Performing a 1:N Case–control Match on Propensity Score. 2004. http://www2.sas.com/proceedings/sugi29/165-29.pdf. Accessed 15 Dec 2016. 28. Austin PC. Assessing balance in measured baseline covariates when using many-to-one matching on the propensity-score. Pharmacoepidemiol Drug Saf. 2008;17:1218–25. 29. Normand SLT, Landrum MB, Guadagnoli E, Ayanian JZ, Ryan TJ, Cleary PD, et al. Validating recommendations for coronary angiography following acute myocardial infarction in the elderly: A matched analysis using propensity scores. J Clin Epidemiol. 2001;54:387–98. 30. Austin PC. An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies. Multivariate Behav Res. 2011;46:399–424. 31. Austin PC. Comparing paired vs non-paired statistical methods of analyses when making inferences about absolute risk reductions in propensity-score matched samples. Stat Med. 2011;30:1292–301. 32. Holst LB, Haase N, Wetterslev J, Wernerman J, Guttormsen AB, Karlsson S, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med. 2014;371:1381–91. 33. Linder A, Fjell C, Levin A, Walley KR, Russell JA, Boyd JH. Small acute increases in serum creatinine are associated with decreased long-term survival in the critically ill. Am J Respir Crit Care Med. 2014;189:1075–81. 34. Aberg M, Hedner U, Bergentz SE. Effect of dextran on factor VIII (antihemophilic factor) and platelet function. Ann Surg. 1979;189:243–7. 35. Carlin G, Karlstrom G, Modig J, Saldeen T. Effect of dextran on fibrinolysis inhibition activity in the blood after major surgery. Acta Anaesthesiol Scand. 1980;24:375–8. 36. Eriksson M, Saldeen T. Effect of dextran on plasma tissue plasminogen activator (t-PA) and plasminogen activator inhibitor-1 (PAI-1) during surgery. Acta Anaesthesiol Scand. 1995;39:163–6. 37. Wills BA, Dung NM, Loan HT, Tam DTH, Thuy TTN, Minh LTT, et al. Comparison of three fluid solutions for resuscitation in dengue shock syndrome. N Engl J Med. 2005;353:877–89.

17. Myburgh JA, Finfer S, Bellomo R, Billot L, Cass A, Gattas D, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med. 2012;367:1901–11.

38. Modig J. Effectiveness of dextran 70 versus Ringer’s acetate in traumatic shock and adult respiratory distress syndrome. Crit Care Med. 1986;14:454–7.

18. Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Aneman A, et al. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med. 2012;367:124–34.

39. Persson J. Physiological and clinical aspects of change in microvascular permeability. Acta Anaesthesiol Scand. 2006;50:628.

19. Lamke LO, Liljedahl SO. Plasma volume changes after infusion of various plasma expanders. Resuscitation. 1976;5:93–102.

40. Holbeck S, Bentzer P, Wikstrand C, Grände PO. Dextran, gelatin, and hydroxyethyl starch do not affect permeability for albumin in cat skeletal muscle. Crit Care Med. 2001;29:123–8.

20. Shoemaker WC. Comparison of the relative effectiveness of whole blood transfusions and various types of fluid therapy in resuscitation. Crit Care Med. 1976;4:71–8.

41. Holbeck S, Grände PO. Effects on capillary fluid permeability and fluid exchange of albumin, dextran, gelatin, and hydroxyethyl starch in cat skeletal muscle. Crit Care Med. 2000;28:1089–95.

RESUSCITATION TODAY - AUTUMN 2017

15. Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008;358:125–39.

23. Rasmussen AM, Jakobsen R, Strøm T, Carlsson M, DahlerEriksen B, Toft P. More complications in patients with septic shock treated with dextran compared with crystalloids. Dan Med J. 2015;62:A5018.

NEWS A breath of fresh air for patients with respiratory failure West Midlands Ambulance Service and the University of Sheffield have launched a trial which could save lives, reduce the time patients spend in hospital and save money. The ‘ACUTE’ trial is looking at patients who suffer from life threatening acute respiratory failure. The condition often results in patients spending long periods of time in hospital, frequently in intensive care. The condition happens when heart or lung disease suddenly develops or worsens and leads to patients being unable to maintain oxygen levels in the blood. As many as one in eight patients will die from the condition. Patients with conditions such as COPD (chronic obstructive pulmonary disease) and particularly serious cases of pneumonia are often victims of the condition, where they

Research paramedic, Josh Miller, said: “What

Jørgen, who splits his time between Manchester

we want to establish is whether using CPAP in

and his native Denmark, where he lives, said: “I

a pre-hospital setting will make a difference to

am looking forward to bringing my experience

a patient’s survival and reduce hospital stays

to the role and hopefully expanding the way we

at the same time. It has the potential to save

do trials in Greater Manchester.

many lives.” “I would like to see a more general, Consultant Paramedic, Matt Ward, said: “Patients

Manchester-wide approach which provides

who are to be recruited into the trial will receive

every talented health professional with the

a full briefing from the ambulance staff so that

opportunity to properly pursue research, even

they can make an informed choice. One of the

if their department has not previously had the

key issues is making sure ambulance staff can

critical mass to allow them to do so.

explain the trial in simple terms.” “It would be fantastic to have more Research Paramedic, Imogen Gunson, added:

investigator-led trials and I also believe we

“The mask and straps may not be pretty on

can make further progress with collaborations

the eye, but patients report that it can make a

between primary and secondary care.

big difference as to how they feel and also how

Wherever possible, I believe that research

easily they can breathe.”

should be done where the patients are based.”

45-minute training video is available for all staff

Jørgen, who is also the Respiratory Theme

and students at www.sheffield.ac.uk/acute

Lead for the NIHR Manchester Biomedical Research Centre (BRC), ranks the Salford

CRN GM welcomes worldleading respiratory professor as new specialty lead

Lung Study among the most important

Source: NIHR Professor Jørgen Vestbo is the new respiratory specialty lead for the Clinical Research Network, Greater Manchester.

questioned the traditional efficacy trial model

struggle to breathe. Ambulance staff currently provide oxygen delivered at normal pressure through a loose fitting mask. Under the trial, ambulance crews

The study, which has recruited more than 2,700 COPD patients from 75 GP practices, and promoted the merits of a study rooted in a real life, clinical environment. When asked to name other standout projects

will use a CPAP device (continuous positive airway pressure). It involves delivering oxygen

He works with the University Hospital South

he has helped lead, Jorgen cites Eclipse as

under increased pressure through a close-

Manchester NHS Foundation Trust’s (UHSM)

a study which was extremely productive in

fitting facemask effectively forcing oxygen into

Respiratory Medicine team in Wythenshawe,

the development of medical understanding of

the lungs. This allows the oxygen to be taken

where he is also an Honorary Consultant at

COPD.

into the blood stream and also allows carbon

UHSM’s North West Lung Centre. He was the chairman of the steering group

dioxide to be released.

RESUSCITATION TODAY - AUTUMN 2017

projects he has been involved with.

Regarded as a world-leading Professor of

for the ambitious three-year, multi-centre,

The ACUTE (Ambulance CPAP: Use,

Respiratory Medicine, Jørgen was recently

observational study, which you can read more

Treatment effect and Economics) trial, will

president of the European Respiratory Society,

about here - http://www.eclipse-copd.com/

involve ambulance crews in Staffordshire

one of the world’s leading organisations for

home.aspx

and Birmingham. Staffordshire historically

respiratory research, education and advocacy. Jørgen was based in Denmark during Eclipse,

has higher rates of respiratory disease. This pilot study will be used to see if a full trial of

He is also a Professor of Respiratory Medicine

but is now very much enjoying applying his

CPAP (Continuous Positive Airway Pressure) is

at the University of Manchester and an Honorary

expertise time in Greater Manchester.

feasible, acceptable and cost-effective.

Consultant at UHSM’s North West Lung Centre

WMAS Lead Research Paramedic, Andy Rosser,

and has remained an adjunct professor at the

He said: “I am fortunate to work with

University of Southern Denmark.

outstanding colleagues at UHSM, where we not only have a world-leading respiratory unit,

said: “We know that CPAP is used very effectively

but the most collegiate team in this field.

in hospitals. Small studies outside of the UK

His main research interests are epidemiology

suggest that using CPAP in an ambulance may

and clinical research in Chronic Obstructive

save more lives, particularly where the patient is

Pulmonary Disease (COPD). Epidemiology

“For me, research is a way of life and that is

in a more rural location and has further to travel

deals with populations rather than individuals

a culture shared by my colleagues and I look

to hospital. Where CPAP is used, the patient

and Jørgen stresses that it is highly useful for

forward to working even more collaboratively

would start to receive treatment sooner, rather

informing researchers about risk factors and

across the Clinical Research Network in this

than waiting until they arrive in hospital.”

disease trends over time.

new role.”

NEWS Study settles debate over giving stroke patients routine oxygen A national trial involving more than 8,000 patients has revealed that giving oxygen to stroke victims makes no difference to their recovery or chances of survival. The study was led by Keele University’s stroke specialist Professor Christine Roffe, along with North Staffordshire Combined Healthcare NHS Trust and researchers from the University of Oxford and the University of Birmingham, and was funded by the National Institute for Health Research. Every year 152,000 people in the UK suffer a stroke. It is the fourthlargest cause of death in the UK, and half of all stroke survivors have a disability. During and after a stroke, blood supply to part of the brain is reduced, leading to a lack of oxygen. The Stoke Oxygen Study looked at whether or not giving patients oxygen soon after their stroke could prevent further brain damage and reduce the risk of disability or even death. Professor Roffe commented: “When a stroke happens either due to a blood clot or a brain haemorrhage, part of the brain dies because it’s being starved of oxygen, and other parts of the brain are unstable and vulnerable to low oxygen levels. Patients with stroke often have breathing problems leading to low oxygen levels. Our study provided low-dose oxygen to keep the patient’s oxygen levels within the normal range to test whether this would help to maintain brain function and help recovery, but we found that this intervention did not make a real difference. “At present, it is common when a stroke patient first receives care that they are given an oxygen mask, but our results provide clear and unambiguous evidence that patients admitted to hospital with a stroke do not need routine prophylactic oxygen treatment. “It remains important to monitor oxygen levels but it is not necessary to give patients oxygen routinely after a stroke - it did not improve patients’ brain function, level of disability, quality of life or chances of survival.” During the nine-year study three treatments were used, including providing continuous oxygen (day and night) for three days, overnight oxygen supply only for three nights, and no routine oxygen supply for three nights (unless required). The results found that providing routine oxygen did not improve functional outcome in any patients, and there was still no difference in results after 90 days.

Professor Roffe added: “While we have shown that giving oxygen routinely to all stroke patients makes no difference, we also know that stroke patients whose oxygen levels fall below normal levels recover less well. Low oxygen levels are caused by underlying airway, lung and heart problems, with the most common cause being pneumonia, therefore we now believe that it may be more important to address the underlying cause rather than just to treat the hypoxia by administering oxygen.” Professor Roffe and her team are now focusing their research efforts on ways to prevent pneumonia.

A series of Practical-heavy ½ day CPD sessions on Essential skills for all levels of responder. Delivered by the team from @phccinfo who are one of the largest providers of Trauma and Airway CPD training to PreHospital providers across Europe and beyond.

Morning Session 10am - 1pm Basic to Advanced Trauma Skills: Intro and closing short presentation plus a number of 30 Minute Practical skills stations to include: • Trauma Patient Assessment. • Catastrophic Bleeding. • Considerations for IV/IO access and Fluids in Trauma. • Splintage skills(Pelvic and Traction) • Considerations for modern immobilisation.

Afternoon Session 2pm - 5pm Basic to Advanced Airway Skills: Intro and closing short presentation plus a number of 30 Minute Practical skills stations to include: • Positioning, BVM and basic adjuncts done well! • Extraglottic devices. • Direct and Video Laryngoscopy (including assistant role) • Emergency Surgical Airway. • ETCO2 the essentials. Both workshops form part of our Life Connections events taking place in Harrogate (15th March), Bristol (21st June), Aylesbury (6th September) and Stoke on Trent (25th October). Only 12 places are available on each workshop at a cost of £40 per person. If however you are attending any of the morning / afternoon conferences that are taking place this cost will be reduced to just £25 per person. To secure your delegate place please call the organisers on 01322 660434 or visit www.lifeconnections.uk.com.

RESUSCITATION TODAY - AUTUMN 2017

The research is one of the largest stroke studies conducted in the UK and over half of all hospitals admitting stroke patients in England took part. The findings will now help clinicians to better understand how stroke patients should be treated when they first present at hospital.

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RESUSCITATION TODAY - AUTUMN 2017

“The Bluetooth link between the impressive Brayden PRO manikin and the app on an android tablet greatly enhances the training value of this system. It gives not only an immediate guide to the quality of compressions, but also offers trends and a permanent record of what is being achieved.”

COMPANY NEWS from silicone, are available for each stage of

World-leading “human” manufacturers put heads together for new partnership

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TAMPA, Fla. – SynDaver Labs, an advanced biotechnology company specialising in the creation of sophisticated synthetic humans and animals, announced the formation of a new international strategic partnership with medical manikin manufacturer Lifecast Body Simulation.

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Future human and animal models engineered by the two companies will combine the fullyfunctioning anatomy and life-like tissues of SynDaver surgical humans with the movieready realistic visual appearance pioneered by Lifecast Body Simulation.

About SynDaver Labs Headquartered in Tampa, Florida, SynDaver Labs is the world’s leading manufacturer of hyper-realistic, synthetic human and animal

The synthetic models developed as a result

surgical trainers. SynDaver’s synthetic bodies

of this partnership will be nearly identical and

simulate fully-functioning live organisms and

function similarly to living human and animal

are primarily used for training in schools,

bodies. The models can be used for medical

hospitals and military installations. SynDaver

testing, surgical training and engineering

has the world’s largest database of live-tissue

research, eliminating the need for testing with

properties and all SynDaver tissues are made

live animals or human cadavers. Other uses

from water, salts and fibers. The company

can include automobile crash testing, ballistic

currently has 10 patents on these materials,

testing and more.

processes and related products. Currently, SynDaver Labs employs more than 100

“We have always designed our products

people at their Tampa facility and is planning

with the goal of creating a suspension

additional facilities in the U.S., China, Europe

of disbelief. When it counts, you need to

and Latin America.

work with models that are realistic in both

RESUSCITATION TODAY - AUTUMN 2017

appearance and feel. We’re excited about

SynDaver products have been lauded by

this partnership with Lifecast Body Simulation

industry experts and earned a cult following

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after appearances on ABC’s Shark Tank,

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finale of CSI. The company’s models are also

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expected to feature prominently in multiple

Christopher Sakezles, founder of SynDaver

episodes of the upcoming MythBusters 2.0.

Labs. “By joining with Lifecast Body Simulation we will be able to take the synthetic human concept to an entirely new level.” Headquartered in Elstree Studios, London, Lifecast Body simulation supplies universities, hospitals, helicopter emergency medical

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London, Lifecast Body Simulation specializes

Lifecast Body Simulation models are made

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“We have always designed our products with the goal of creating a suspension of disbelief. When it counts, you need to work with models that are realistic in both appearance and feel. We’re excited about this partnership with Lifecast Body Simulation because it dramatically elevates our current capabilities and will lead to the development of unbelievably realistic products that can be used in a wide variety of industries”

COMPANY NEWS

Resuscitation Today Conference Programme Thursday 15th March 2018

The Pavilions of Harrogate, HG2 8NZ

Only 50 delegate places are available on this Harrogate Conference at a rate of £30 (inc VAT) to include lunch/tea/coffee and free parking.

Time

Presentation Registration

12.30 – 13.45

Lunch/Tea/Coffee/Exhibition

13.45 – 14.15

T.B.A.

14.15 – 14.45

Local Anaesthetic Toxicity (Recognition & Treatment)

14.45 – 15.15

Social Media & Continuing Professional Development… Challenging Learners

15.15 – 16.00

Tea/Coffee/Exhibition

16.00 – 16.30

Futile Resuscitation

16.30 - 17.00

T.B.A.

17.00 - 17.30

Simulation: Challenging Reality

Position

Prof. Sir Keith Porter

Professor of Traumatology

Giles Farrington

Senior Operating Dept. Practitioner

Mike Davis

Keele University

Matthew House

Doctor (PrD) NWAS

T.B.A.

Mike Davis

Keele Univeristy

Topics & Speakers correct at the time of press but may be subject to change. During the course of 2018 further Resuscitation Conferences are planned for Bristol (June 21), Aylesbury (September 6) and Stoke-on-Trent (October 25).

RESUSCITATION TODAY - AUTUMN 2017

12.00 – 12.30

Speaker

To view each individual Conference Programme or to Register please visit: www.lifeconnections.uk.com or call the Organisers on: 01322 660434

when every breath counts EVE Critical Care Ventilator

Designed for hospital Intensive care & Emergency transfer/transport use FAST ‘Safe-start’ Neonate > Child > Adult modes ready to ventilate in ‘< 70 seconds’ Invasive & Non-Invasive ventilation modes: CPAP, nCPAP, DUOPAP, nDUOPAP, PRVC, VC-CMV VC-SIMV, PSV, PC-CMV, PC-SIMV, PC-ACV, PC-ACV+, PC-APRV, nPC-ACV, nPC-ACV+, nPC-CMV, nPC-SIMV

All Patient use

Capnography & Sp02

Battery Optimisation

Fully Adjustable Oxygen

Adult, Paediatric, Neonate 0.5kg > >200+ kg {Vt 2 > 2000ml}

Waveform EtC02 Options: Sp02 ,SpCO, SpHB

6 hours continuous use + ‘hot swap’ battery pack

Adjustable 02 mixing 21 to 100%

Robust & Lightweight

8.4 inch Touch Screen

Independent Air Supply

Patient Data Transfer

Rugged design, compact & portable ~5 kg

Conﬁgurable display, loops alarms, curves & trends

Integrated air turbine

Transfer capability for patient data, events

Ventilation Innovation since 1974

02392 469737 info@medacx.co.uk www.medacx.co.uk