Publications by authors named "Kjetil Sunde"

117 Publications

Complement activation is associated with poor outcome after out-of-hospital cardiac arrest.

Resuscitation 2021 Jun 11. Epub 2021 Jun 11.

Dept. of Immunology, University of Oslo and Oslo University Hospital, Oslo, Norway; Dept. of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Dept. of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway. Electronic address:

Background: Cardiopulmonary resuscitation after cardiac arrest initiates a whole-body ischemia-reperfusion injury, which may activate the innate immune system, including the complement system. We hypothesized that complement activation and subsequent release of soluble endothelial activation markers were associated with cerebral outcome including death.

Methods: Outcome was assessed at six months and defined by cerebral performance category scale (1-2; good outcome, 3-5; poor outcome including death) in 232 resuscitated out-of-hospital cardiac arrest patients. Plasma samples obtained at admission and day three were analysed for complement activation products C3bc, the soluble terminal complement complex (sC5b-9), and soluble CD14. Endothelial cell activation was measured by soluble markers syndecan-1, sE-selectin, thrombomodulin, and vascular cell adhesion molecule.

Results: Forty-nine percent of the patients had good outcome. C3bc and sC5b-9 were significantly higher at admission compared to day three (p < 0.001 for both) and in patients with poor compared to good outcome (p = 0.03 and p < 0.001, respectively). Unadjusted, higher sC5b-9 at admission was associated with poor outcome (odds ratio 1.08 (95% CI 1.01-1.14), p = 0.024). Adjusted, sC5b-9 was still associated with outcome, but the association became non-significant when time to return-of-spontaneous-circulation above 25 min was included as a covariate. Endothelial cell activation markers increased from admission to day three, but only sE-selectin and thrombomodulin were significantly higher in patients with poor versus good outcome (p = 0.004 and p = 0.03, respectively) and correlated to sCD14 and sC5b-9/C3bc, respectively.

Conclusion: Complement system activation, reflected by sC5b-9 at admission, leading to subsequent endothelial cell activation, was associated with poor outcome in out-of-hospital cardiac arrest patients.
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http://dx.doi.org/10.1016/j.resuscitation.2021.05.038DOI Listing
June 2021

Cost Analysis of Open Surgical Bedside Tracheostomy in Intensive Care Unit Patients.

Ear Nose Throat J 2021 May 19:1455613211018578. Epub 2021 May 19.

Division of Emergencies and Critical Care, Department of Anesthesiology, Oslo University Hospital Ullevål, Oslo, Norway.

Objectives: Open surgical tracheostomy (OST) is a common procedure performed on intensive care unit (ICU) patients. The procedure can be performed bedside in the ICU (bedside open surgical tracheostomy, BeOST) or in the operating room (operating room open surgical tracheostomy, OROST), with comparable safety and long-term complication rates. We aimed to perform a cost analysis and evaluate the use of human resources and the total time used for both BeOSTs and OROSTs.

Methods: All OSTs performed in 2017 at 5 different ICUs at Oslo University Hospital Ullevål were retrospectively evaluated. The salaries of the personnel involved in the 2 procedures were obtained from the hospital's finance department. The time taken and the number of procedures performed were extracted from annual reports and from the electronic patient record system, and the annual expenditures were calculated.

Results: Altogether, 142 OSTs were performed, of which 122 (86%) and 20 (14%) were BeOSTs and OROSTs, respectively. A BeOST cost 343 EUR (95% CI: 241.4-444.6) less than an OROST. Bedside open surgical tracheostomies resulted in an annual cost efficiency of 41.818 EUR. In addition, BeOSTs freed 279 hours of operating room occupancy during the study year. Choosing BeOST instead of OROST made 1 nurse, 2 surgical nurses, and 1 anesthetic nurse redundant.

Conclusion: Bedside open surgical tracheostomy appears to be cost-, time-, and resource-effective than OROST. In the absence of contraindications, BeOSTs should be performed in ICU patients whenever possible.
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http://dx.doi.org/10.1177/01455613211018578DOI Listing
May 2021

Outcome in refractory out-of-hospital cardiac arrest before and after implementation of an ECPR protocol.

Resuscitation 2021 May 10;162:35-42. Epub 2021 Feb 10.

Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Norway; Division of Prehospital Services, Oslo University Hospital and University of Oslo, Oslo, Norway.

Aim: To compare the outcomes in patients with refractory out-of-hospital cardiac arrest (OHCA) fulfilling the criteria for extracorporeal cardiopulmonary resuscitation (ECPR) before and after implementation of an ECPR protocol, whether the patient received ECPR or not.

Methods: We compared cardiac arrest registry data before (2014-2015) and after (2016-2019) implementation of the ECPR protocol. The ECPR criteria were presumed cardiac origin, witnessed arrest with ventricular fibrillation, bystander CPR, age 18-65, advanced life support (ALS) within 15 min and ALS > 10 min without return of spontaneous circulation (ROSC). The primary outcome was 30-day survival; the secondary outcomes were sustained ROSC, neurological outcome and the proportion of patients transported with ongoing ALS.

Results: There were 1086 and 3135 patients in the pre- and post-implementation sample; 48 (4%) and 100 (3%) met the ECPR criteria, respectively. Of these, 21 (44%) vs. 37 (37%) were alive after 30 days, p = 0.4, and 30 (63%) vs. 50 (50%) achieved sustained ROSC, p = 0.2. All survivors in the pre-implementation sample had cerebral performance category 1-2 vs. 30 (81%) in the post-implementation sample, p = 0.03. Of the patients fulfilling the ECPR criteria, 7 (15%) and 26 (26%), p = 0.1, were transported with ongoing ALS in the pre- and post-implementation sample, respectively.

Conclusions: There were no differences in 30-day survival or prehospital ROSC in patients with refractory OHCA before and after initiation of an ECPR protocol.
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http://dx.doi.org/10.1016/j.resuscitation.2021.01.038DOI Listing
May 2021

Health-related quality of life after out-of-hospital cardiac arrest - a five-year follow-up studyJūratė Šaltytė Benth.

Resuscitation 2021 May 8;162:372-380. Epub 2021 Feb 8.

Department of Acute Medicine, Oslo University Hospital, Ullevål, Norway.

Background: Health-related quality of life (HRQoL) is affected after out-of-hospital cardiac arrest (OHCA), but data several years after the arrest are lacking. We assessed long-term HRQoL in OHCA survivors and how known outcome predictors impact HRQoL.

Methods: In adult OHCA survivors, HRQoL was assessed five years post arrest using Short-form 36 (SF-36), EQ-5D-3 L (EQ-5D) and Hospital Anxiety and Depression Scale (HADS) among others. Results were compared to the next of kins' estimates and to a Norwegian reference population.

Results: Altogether 96 survivors were included mean 5.3 (range 3.6-7.2) years after OHCA. HRQoL compared well to the reference population, except for lower score for general health with 67.2 (95%CI (62.1; 72.3) vs. 72.9 (71.9; 74.0)), p = 0.03. Younger (≤58 years) vs. older survivors scored lower for general health with mean (SD) of 62.1 (27.5) vs. 73.0 (19.5), p = 0.03, vitality (55.2 (20.5) vs. 64.6 (17.3), p = 0.02, social functioning (75.3 (28.7) vs. 94.1 (13.5), p < 0.001 and mental component summary (49.0 (9.9) vs. 55.8 (6.7), p < 0.001. They scored higher for HADS-anxiety (4.8 (3.6 vs. 2.7 (2.5), p = 0.001, and had lower EQ-5D index (0.72 (0.34) vs. 0.84 (0.19), p = 0.04. Early vs. late awakeners had higher EQ-5D index (0.82 (0.23) vs. 0.71 (0.35), p = 0.04 and lower HADS-depression scores (2.5 (2.9) vs. 3.8 (2.3), p = 0.04. Next of kin estimated HRQoL similar to the survivors' own estimates.

Conclusions: HRQoL five years after OHCA was good and mainly comparable to a matched reference population. Stratified analyses revealed impaired HRQoL among younger survivors and those awakening late, mainly for mental domains.
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http://dx.doi.org/10.1016/j.resuscitation.2021.01.036DOI Listing
May 2021

Fever management in COVID-19 patients.

Minerva Anestesiol 2021 01 24;87(1):1-3. Epub 2020 Nov 24.

Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium.

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http://dx.doi.org/10.23736/S0375-9393.20.15195-2DOI Listing
January 2021

Utility of coagulation analyses to assess thromboprophylaxis with dalteparin in intensive care unit patients.

Acta Anaesthesiol Scand 2020 Nov 18. Epub 2020 Nov 18.

Renal Research Group Ullevål, Faculty of Medicine, University of Oslo, Oslo, Norway.

Background: The aim of this study was to evaluate the utility of coagulation analyses to assess thromboprophylaxis with dalteparin in intensive care unit (ICU) patients.

Methods: Prospective observational study of ICU patients receiving dalteparin prophylaxis at Oslo University Hospital in Norway. Trough and peak antithrombin, protein C, anti-factor Xa activity (aFXa), d-dimer, thromboelastography, calibrated automated thrombogram and microparticles were analysed. Levels were compared in patients with and without venous thromboembolism (VTE), major bleeding, acute kidney injury (AKI) with use of renal replacement therapy (RRT) and variable dalteparin dose.

Results: Among 50 included patients (76% male, mean age 62 years) five (10%) developed VTE and eight (16%) major bleeding. Median through aFXa level was 0.03 (0.02-0.05) IU/mL, and 48 (96%) of patients were within and two (4%) above target range. Peak aFXa level was 0.21 (0.13-0.29) IU/mL, the number of patients below, within and above prophylactic range were 21 (42%), 25 (50%) and four (8%). Peak aFXa levels were similar in patients with and without VTE (0.18 vs 0.21 IU/L, P = .72), major bleeding (0.22 vs 0.21 IU/mL, P = .38) and AKI with RRT (0.18 vs 0.24, P = .13), but lower in patients receiving dalteparin 5000 IU od compared to 7500 IU od (0.19 vs 0.30 IU/mL, P < .01).

Conclusions: Intensive care unit patients receiving dalteparin prophylaxis had half of patients within prophylactic peak aFXa target range. Peak aFXa levels was affected by administered dalteparin dose, but not presence of VTE, major bleeding or AKI with RRT.
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http://dx.doi.org/10.1111/aas.13748DOI Listing
November 2020

Effect of Nurse-Led Consultations on Post-Traumatic Stress and Sense of Coherence in Discharged ICU Patients With Clinically Relevant Post-Traumatic Stress Symptoms-A Randomized Controlled Trial.

Crit Care Med 2020 12;48(12):e1218-e1225

Division of Emergencies and Critical Care, Department of Postoperative and Intensive Care, Oslo University Hospital, Oslo, Norway.

Objectives: To investigate the effect of nurse-led consultations on reducing post-traumatic stress symptoms and increasing sense of coherence in discharged ICU patients with clinically relevant post-traumatic stress symptoms and to identify variables associated with symptoms 12 months later.

Design: A pragmatic nonblinded randomized controlled trial.

Settings: Five surgical and medical ICUs at Oslo University Hospital.

Patients: Adult patients treated in the ICU greater than or equal to 24 hours were screened with Post-Traumatic Stress Scale 10 intensive part B after ICU discharge. Those scoring greater than or equal to 25 were included in the study.

Intervention: Patients randomized to intervention group were offered three nurse-led consultations within 2 months, and patients in the control group received standard care.

Measurements And Main Results: Sense of Coherence Scale 13 and Post-Traumatic Stress Scale 10 intensive part B were completed after inclusion, and reevaluated after 3, 6, and 12 months. Linear mixed model for repeated measures and linear regression analyses were performed. Among 523 screened patients, 111 and 113 were randomized to intervention group and control group, respectively. Mean Post-Traumatic Stress Scale 10 intensive part B score was 37 (±10) before randomization. No differences in post-traumatic stress symptoms or sense of coherence were found between intervention group versus control group, with a mean Post-Traumatic Stress Scale 10 intensive part B score 39 (95% CI, 37-41) versus 37 (95% CI, 35-39), 32 (95% CI, 28-35) versus 32 (95% CI, 29-35), 31 (95% CI, 28-34) versus 30 (95% CI, 27-33), and 31 (95% CI, 28-34) versus 29 (95% CI, 26-33) at baseline, 3, 6, and 12 months, respectively. There was a significantly reduced Post-Traumatic Stress Scale 10 intensive part B score for both groups during the year (p = 0.001). Low sense of coherence, pain, and previous psychiatric problems were associated with increased level of post-traumatic stress symptoms at 12 months.

Conclusions: Nurse-led consultations did not reveal any significant effect on post-traumatic stress symptoms or sense of coherence after ICU discharge in patients with clinically relevant symptoms.
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http://dx.doi.org/10.1097/CCM.0000000000004628DOI Listing
December 2020

Ventilatory support for hypoxaemic intensive care patients with COVID-19.

Tidsskr Nor Laegeforen 2020 08 8;140(11). Epub 2020 Jul 8.

Background: COVID-19 pneumonia can result in severe hypoxaemic respiratory failure that requires intensive medical care. We wished to describe COVID-19 intensive care patients who were treated with and without invasive ventilatory support.

Material And Method: The material was retrieved from the local quality register and comprises data on patients with COVID-19 admitted to the intensive care department at Oslo University Hospital Ullevål from 5 March-28 May 2020. The patients were categorised in three groups on the basis of the treatment they received for respiratory failure (oxygen alone, supplemental non-invasive ventilation (NIV), and intubation/ventilator) and described using descriptive statistics.

Results: Of 165 hospitalised COVID-19 patients, a total of 26 (16 %) were treated in our intensive care department. Four of them had do-not-resuscitate-orders and were excluded. The 22 patients included in this study had an average age of 56 years (range 25 to 78 years); 17 (77 %) were men. Eleven patients received ventilator treatment, seven oxygen by mask, and four supplemental NIV. In the ventilator group, as of 28 May 2020 two had died, and the remainder had been discharged alive from the intensive care department, with one remaining hospitalised on a ward. All patients treated with oxygen and NIV were alive and had been discharged from hospital.

Interpretation: For many patients with COVID-19 respiratory failure and need for intensive care, increased oxygen and NIV are sufficient, but the need for intubation must be continuously assessed. More than 90 % of actively treated intensive care patients survived.
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http://dx.doi.org/10.4045/tidsskr.20.0445DOI Listing
August 2020

Late awakening, prognostic factors and long-term outcome in out-of-hospital cardiac arrest - results of the prospective Norwegian Cardio-Respiratory Arrest Study (NORCAST).

Resuscitation 2020 04 8;149:170-179. Epub 2020 Jan 8.

Department of Anaesthesiology, Oslo University Hospital, Ullevål, Postboks 4956 Nydalen, N-0424 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Institute of Clinical Medicine, PB 1171 Blindern, N-0318 Oslo, Norway.

Background: Outcome prediction after out-of-hospital cardiac arrest (OHCA) may lead to withdrawal of life-sustaining therapy if the prognosis is perceived negative. Single use of uncertain prognostic tools may lead to self-fulfilling prophecies and death. We evaluated prognostic tests, blinded to clinicians and without calls for hasty outcome prediction, in a prospective study.

Methods: Comatose, sedated TTM 33-treated OHCA patients of all causes were included. Clinical-neurological/-neurophysiological/-biochemical predictors were registered. Patients were dichotomized into good/poor outcome using cerebral performance category (CPC) six months and > four years post-arrest. Prognostic tools were evaluated using false positive rates (FPR).

Results: We included 259 patients; 49 % and 42 % had good outcome (CPC 1-2) after median six months and 5.1 years. Unwitnessed arrest, non-shockable rhythms, and no-bystander-CPR predicted poor outcome with FPR (CI) 0.05 (0.02-0.10), 0.13 (0.08-0.21), and 0.13 (0.07-0.20), respectively. Time to awakening was median 6 (0-25) days in good outcome patients. Among patients alive with sedation withdrawal >72 h, 49 % were unconscious, of whom 32 % still obtained good outcome. Only absence of pupillary light reflexes (PLR) -and N20-responses in somato-sensory evoked potentials (SSEP), as well as increased neuron-specific enolase (NSE) later than 24 h to >80 μg/L, had FPR 0. Malignant EEG (burst suppression/epileptic activity/flat) differentiated poor/good outcome with FPR 0.05 (0.01-0.15).

Conclusion: Time to awakening was over six days in good outcome patients. Most clinical parameters had too high FPRs for prognostication, except for absent PLR and SSEP-responses >72 h after sedation withdrawal, and increased NSE later than 24 h to >80 μg/L.
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http://dx.doi.org/10.1016/j.resuscitation.2019.12.031DOI Listing
April 2020

Esmolol for cardioprotection during resuscitation with adrenaline in an ischaemic porcine cardiac arrest model.

Intensive Care Med Exp 2019 Dec 4;7(1):65. Epub 2019 Dec 4.

Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway.

Background: The effectiveness of adrenaline during resuscitation continues to be debated despite being recommended in international guidelines. There is evidence that the β-adrenergic receptor (AR) effects of adrenaline are harmful due to increased myocardial oxygen consumption, post-defibrillation ventricular arrhythmias and increased severity of post-arrest myocardial dysfunction. Esmolol may counteract these unfavourable β-AR effects and thus preserve post-arrest myocardial function. We evaluated whether a single dose of esmolol administered prior to adrenaline preserves post-arrest cardiac output among successfully resuscitated animals in a novel, ischaemic cardiac arrest porcine model.

Methods: Myocardial infarction was induced in 20 anaesthetized pigs by inflating a percutaneous coronary intervention (PCI) balloon in the circumflex artery 15 min prior to induction of ventricular fibrillation. After 10 min of untreated VF, resuscitation with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated and the animals were randomized to receive an injection of either 1 mg/kg esmolol or 9 mg/ml NaCl, prior to adrenaline. Investigators were blinded to allocation. Successful defibrillation was followed by a 1-h high-flow VA-ECMO before weaning and an additional 1-h stabilization period. The PCI-balloon was deflated 40 min after inflation. Cardiac function pre- and post-arrest (including cardiac output) was assessed by magnetic resonance imaging (MRI) and invasive pressure measurements. Myocardial injury was estimated with MRI, triphenyl tetrazolium chloride (TTC) staining and serum concentrations of cardiac troponin T.

Results: Only seven esmolol and five placebo-treated pigs were successfully resuscitated and available for post-arrest measurements (p = 0.7). MRI revealed severe but similar reductions in post-arrest cardiac function with cardiac output 3.5 (3.3, 3.7) and 3.3 (3.2, 3.9) l/min for esmolol and control (placebo) groups, respectively (p = 0.7). The control group had larger left ventricular end-systolic and end-diastolic ventricular volumes compared to the esmolol group (75 (65, 100) vs. 62 (53, 70) ml, p = 0.03 and 103 (86, 124) vs. 87 (72, 91) ml, p = 0.03 for control and esmolol groups, respectively). There were no other significant differences in MRI characteristics, myocardial infarct size or other haemodynamic measurements between the two groups.

Conclusions: We observed similar post-arrest cardiac output with and without a single dose of esmolol prior to adrenaline administration during low-flow VA-ECMO in an ischaemic cardiac arrest pig model.
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http://dx.doi.org/10.1186/s40635-019-0279-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6892997PMC
December 2019

Systematic review and meta-analysis of intravascular temperature management vs. surface cooling in comatose patients resuscitated from cardiac arrest.

Resuscitation 2020 01 13;146:82-95. Epub 2019 Nov 13.

Department of Emergency Medicine, University of Washington, Seattle, WA, United States; Department of Internal Medicine, University of Washington, Seattle, WA, United States; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA, United States.

Objective: To systematically review the effectiveness and safety of intravascular temperature management (IVTM) vs. surface cooling methods (SCM) for induced hypothermia (IH).

Methods: Systematic review and meta-analysis. English-language PubMed, Embase and the Cochrane Database of Systematic Reviews were searched on May 27, 2019. The quality of included observational studies was graded using the Newcastle-Ottawa Quality Assessment tool. The quality of included randomized trials was evaluated using the Cochrane Collaboration's risk of bias tool. Random effects modeling was used to calculate risk differences for each outcome. Statistical heterogeneity and publication bias were assessed using standard methods.

Eligibility: Observational or randomized studies comparing survival and/or neurologic outcomes in adults aged 18 years or greater resuscitated from out-of-hospital cardiac arrest receiving IH via IVTM vs. SCM were eligible for inclusion.

Results: In total, 12 studies met inclusion criteria. These enrolled 1573 patients who received IVTM; and 4008 who received SCM. Survival was 55.0% in the IVTM group and 51.2% in the SCM group [pooled risk difference 2% (95% CI -1%, 5%)]. Good neurological outcome was achieved in 40.9% in the IVTM and 29.5% in the surface group [pooled risk difference 5% (95% CI 2%, 8%)]. There was a 6% (95% CI 11%, 2%) lower risk of arrhythmia with use of IVTM and 15% (95% CI 22%, 7%) decreased risk of overcooling with use of IVTM vs. SCM. There was no significant difference in other evaluated adverse events between groups.

Conclusions: IVTM was associated with improved neurological outcomes vs. SCM among survivors resuscitated following cardiac arrest. These results may have implications for care of patients in the emergency department and intensive care settings after resuscitation from cardiac arrest.
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http://dx.doi.org/10.1016/j.resuscitation.2019.10.035DOI Listing
January 2020

Post-traumatic stress symptoms and sense of coherence in proximity to intensive care unit discharge.

Nurs Crit Care 2020 03 16;25(2):117-125. Epub 2019 Aug 16.

Department of Postoperative and Intensive Care, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.

Background: Post-traumatic stress (PTS) symptoms following intensive care unit (ICU) treatment can lead to post-traumatic stress disorder and represent a severe health burden. In trauma patients, a strong sense of coherence (SOC) is associated with fewer PTS symptoms. However, this association has not been investigated in a general ICU sample.

Aims And Objectives: To examine the occurrence of PTS symptoms in general ICU patients early after ICU discharge and to assess possible associations between PTS symptoms and SOC, ICU memory, pain, and demographic and clinical characteristics.

Design: This was a cross-sectional study.

Methods: Adult patients aged ≥18 years admitted for ≥24 hours to five ICUs between 2014 and 2016 were recruited. PTS symptoms and SOC were measured at the ward within the first week after discharge from the ICU using the Posttraumatic Stress Scale-10 and Sense of Coherence Scale-13. Multiple linear regression analysis was used to identify associations between PTS symptoms and SOC and the selected independent variables.

Results: A total of 523 patients were included (17.8% trauma patients; median age 57 years [range 18-94]; 53.3% male). The prevalence of clinically significant PTS symptoms was 32%. After adjustments for gender and age, lower SOC (P < 0.001), more ICU delusional memories (P < 0.001), greater pain interference (P < 0.001), not being a trauma patient (P = 0.02), and younger age (P = 0.03) were significantly associated with more PTS symptoms.

Conclusions: One third of patients experienced clinically relevant PTS symptoms early after discharge from the ICU. In the present study, SOC, delusional memory, pain interference, younger age, and not being a trauma patient were factors associated with more PTS symptoms.

Relevance To Clinical Practice: Early individual follow up after ICU discharge focusing on pain relief and delusional memory may reduce PTS symptoms, with a potential of improving rehabilitation.
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http://dx.doi.org/10.1111/nicc.12466DOI Listing
March 2020

Use of social media for communicating about critical care topics: A Norwegian cross-sectional survey.

Acta Anaesthesiol Scand 2019 11 6;63(10):1398-1405. Epub 2019 Aug 6.

Department of Postoperative and Intensive Care, Oslo University Hospital, Oslo, Norway.

Background: Social media (SoMe) might be an alternative platform for communicating critical care topics to implement evidence-based practice in the intensive care unit (ICU). This survey aims to describe ICU nurses' and physicians' use of SoMe in general, and their perception of using closed Facebook-groups for receiving content on critical care topics.

Methods: A cross-sectional, web-based, anonymous survey was distributed to ICU physicians and nurses in four ICUs in autumn 2017 via an email-campaign. Descriptive statistics with rates, percentages and median numeric rating scale (NRS) scores, interquartile ranges are presented.

Results: The response-rate was 64% (253/ 394) including 210 nurses and 43 physicians. Overall, 93% had a SoMe-profile, and 77% had a profile on more than one network site. Facebook was the most used social network site, with 87% having a profile. Totally, 68% were daily users, but more nurses used Facebook daily vs physicians (81% vs 60%, respectively, P = 0.006). Nurses were also more positive toward being members of closed Facebook-groups aimed to exchange content on critical care topics (median NRS 9 (6-10) vs 6 (3-9), respectively, P = 0.014).

Conclusion: The majority of ICU nurses and physicians were active SoMe users, mainly for personal purposes, and Facebook was the most popular SoMe. Nurses used Facebook daily more frequent and were more positive toward content on critical care topics on Facebook than physicians. These findings might be relevant to customize future communication about critical care topics via SoMe.
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http://dx.doi.org/10.1111/aas.13449DOI Listing
November 2019

Urine -2-Microglobulin, Osteopontin, and Trefoil Factor 3 May Early Predict Acute Kidney Injury and Outcome after Cardiac Arrest.

Crit Care Res Pract 2019 7;2019:4384796. Epub 2019 May 7.

Institute of Clinical Medicine, University of Oslo, P.O.Box 1072 Blindern, 0316 Oslo, Norway.

Purpose: Acute kidney injury (AKI) is a common complication after out-of-hospital cardiac arrest (OHCA), leading to increased mortality and challenging prognostication. Our aim was to examine if urine biomarkers could early predict postarrest AKI and patient outcome.

Methods: A prospective observational study of resuscitated, comatose OHCA patients admitted to Oslo University Hospital in Norway. Urine samples were collected at admission and day three postarrest and analysed for -2-microglobulin (2M), osteopontin, and trefoil factor 3 (TFF3). Outcome variables were AKI within three days according to the Kidney Disease Improving Global Outcome criteria, in addition to six-month mortality and poor neurological outcome (PNO) (cerebral performance category 3-5).

Results: Among 195 included patients (85% males, mean age 60 years), 88 (45%) developed AKI, 88 (45%) died, and 96 (49%) had PNO. In univariate analyses, increased urine 2M, osteopontin, and TFF3 levels sampled at admission and day three were independent risk factors for AKI, mortality, and PNO. Exceptions were that 2M measured at day three did not predict any of the outcomes, and TFF3 at admission did not predict AKI. In multivariate analyses, combining clinical parameters and biomarker levels, the area under the receiver operating characteristics curves (95% CI) were 0.729 (0.658-0.800), 0.797 (0.733-0.861), and 0.812 (CI 0.750-0.874) for AKI, mortality, and PNO, respectively.

Conclusions: Urine levels of 2M, osteopontin, and TFF3 at admission and day three were associated with increased risk for AKI, mortality, and PNO in comatose OHCA patients. This trail is registered with NCT01239420.
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http://dx.doi.org/10.1155/2019/4384796DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6530154PMC
May 2019

Relationship between level of CPR training, self-reported skills, and actual manikin test performance-an observational study.

Int J Emerg Med 2019 Jan 10;12(1). Epub 2019 Jan 10.

Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, N-9037, Tromsø, Norway.

Background: Quality of bystander cardiopulmonary resuscitation (CPR) skills may influence out of hospital cardiac arrest (OHCA) outcomes. We analyzed how the level of CPR training related to indicators of good CPR quality and also the relationship between self-reported skills and actual CPR performance.

Methods: Two hundred thirty-seven persons trained in standardized BLS curricula were divided into three groups according to the level of training: group I (40 h basic first aid training), group II, and group III (96 h advanced first aid, group III had also some limited additional life support training courses). We recorded the participants' real-life CPR experience and self-reported CPR skills, and then assessed selected CPR quality indicators on a manikin. The data were analyzed with multivariate logistic regression. Differences between groups were analyzed with ANOVA/MANOVA.

Results: Out of 237 participants, 125 had basic training (group I), 84 reported advanced training (group II), and 28 advanced training plus additional courses (group III). Group II and III had shorter start-up time, better compression depth and hand positioning, higher fraction of effective rescue ventilations, shorter hands-off time, and thus a higher chest compression fraction. Chest compression rate did not differ between groups. The participants in group I assessed their own skills and preparedness significantly lower than groups II and III both before and after the test. In addition, group III reported higher confidence in examining the critically ill patient and preparedness in doing CPR before the manikin test than both groups I and II. However, the observed differences between groups II and III in self-reported skills and preparedness were not statistically significant after the test.

Conclusion: As expected, higher levels of BLS training correlated with better CPR quality. However, this study showed that ventilations and hands-on time were the components of CPR that were most affected by the level of training. Self-assessments of CPR ability correlated well to actual test performance and may have a role in probing CPR skills in students. The results may be important for BLS instructors and program developers.
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http://dx.doi.org/10.1186/s12245-018-0220-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6327595PMC
January 2019

Variability in functional outcome and treatment practices by treatment center after out-of-hospital cardiac arrest: analysis of International Cardiac Arrest Registry.

Intensive Care Med 2019 05 8;45(5):637-646. Epub 2019 Mar 8.

Department of Neurology, Columbia-Presbyterian Medical Center, New York, NY, USA.

Purpose: Functional outcomes vary between centers after out-of-hospital cardiac arrest (OHCA) and are partially explained by pre-existing health status and arrest characteristics, while the effects of in-hospital treatments on functional outcome are less understood. We examined variation in functional outcomes by center after adjusting for patient- and arrest-specific characteristics and evaluated how in-hospital management differs between high- and low-performing centers.

Methods: Analysis of observational registry data within the International Cardiac Arrest Registry was used to perform a hierarchical model of center-specific risk standardized rates for good outcome, adjusted for demographics, pre-existing functional status, and arrest-related factors with treatment center as a random effect variable. We described the variability in treatments and diagnostic tests that may influence outcome at centers with adjusted rates significantly above and below registry average.

Results: A total of 3855 patients were admitted to an ICU following cardiac arrest with return of spontaneous circulation. The overall prevalence of good outcome was 11-63% among centers. After adjustment, center-specific risk standardized rates for good functional outcome ranged from 0.47 (0.37-0.58) to 0.20 (0.12-0.26). High-performing centers had faster time to goal temperature, were more likely to have goal temperature of 33 °C, more likely to perform unconscious cardiac catheterization and percutaneous coronary intervention, and had differing prognostication practices than low-performing centers.

Conclusions: Center-specific differences in outcomes after OHCA after adjusting for patient-specific factors exist. This variation could partially be explained by in-hospital management differences. Future research should address the contribution of these factors to the differences in outcomes after resuscitation.
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http://dx.doi.org/10.1007/s00134-019-05580-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6486427PMC
May 2019

Acute kidney injury in trauma patients admitted to the ICU: a systematic review and meta-analysis.

Intensive Care Med 2019 04 6;45(4):407-419. Epub 2019 Feb 6.

Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital Ullevål, Oslo, Norway.

Purpose: To perform a systematic review and meta-analysis of acute kidney injury (AKI) in trauma patients admitted to the intensive care unit (ICU).

Methods: We conducted a systematic literature search of studies on AKI according to RIFLE, AKIN, or KDIGO criteria in trauma patients admitted to the ICU (PROSPERO CRD42017060420). We searched PubMed, Cochrane Database of Systematic Reviews, UpToDate, and NICE through 3 December 2018. Data were collected on incidence of AKI, risk factors, renal replacement therapy (RRT), renal recovery, length of stay (LOS), and mortality. Pooled analyses with random effects models yielded mean differences, OR, and RR, with 95% CI.

Results: Twenty-four observational studies comprising 25,182 patients were included. Study quality (Newcastle-Ottawa scale) was moderate. Study heterogeneity was substantial. Incidence of post-traumatic AKI in the ICU was 24% (20-29), of which 13% (10-16) mild, 5% (3-7) moderate, and 4% (3-6) severe AKI. Risk factors for AKI were African American descent, high age, chronic hypertension, diabetes mellitus, high Injury Severity Score, abdominal injury, shock, low Glasgow Coma Scale (GCS) score, high APACHE II score, and sepsis. AKI patients had 6.0 (4.0-7.9) days longer ICU LOS and increased risk of death [RR 3.4 (2.1-5.7)] compared to non-AKI patients. In patients with AKI, RRT was used in 10% (6-15). Renal recovery occurred in 96% (78-100) of patients.

Conclusions: AKI occurred in 24% of trauma patients admitted to the ICU, with an RRT use among these of 10%. Presence of AKI was associated with increased LOS and mortality, but renal recovery in AKI survivors was good.
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http://dx.doi.org/10.1007/s00134-019-05535-yDOI Listing
April 2019

Venous thromboembolism in the critically ill: A prospective observational study of occurrence, risk factors and outcome.

Acta Anaesthesiol Scand 2019 05 8;63(5):630-638. Epub 2019 Jan 8.

Institute of Clinical Medicine, University of Oslo, Oslo, Norway.

Background: The aim of the study was to explore occurrence, risk factors and outcome of venous thromboembolism (VTE) in intensive care unit (ICU) patients.

Methods: Prospective observational study of ICU patients receiving thromboprophylaxis at Oslo University Hospital in Norway. Adult medical and surgical patients with ICU length of stay (LOS) longer than 48 hours were included. For detection of VTE, Doppler ultrasound screening of neck, upper and lower extremity veins was used, and computed tomography angiography when clinically indicated for any medical reason.

Results: Among 70 included patients, 79% were males and mean age was 62 (±12.1) years. All received thromboprophylaxis with dalteparin, and 44 (63%) used graduated compression stockings. VTE was found in 19 (27%) patients; deep vein thrombosis in 15 (21%) and pulmonary embolism in 4 (6%). Among the VTEs, 11 (58%) presented within the first 48 hours after admission, two (11%) were located in the lower limbs and five (26%) were symptomatic. Risk factors for VTE in multivariable analyses were malignancy, abdominal surgery and SAPS II score <41 with an AuROC (95% CI) of 0.72 (0.58-0.85, P = 0.01). Patients with and without VTE had comparable ICU LOS (13 vs 11 days, P = 0.27) and mortality (16% vs 20%, P = 0.72).

Conclusion: Venous thromboembolism was observed in 27% of ICU patients receiving thromboprophylaxis. Factors associated with increased risk of VTE were malignancy, abdominal surgery and SAPS II score <41. Presence of VTE did not impact on patient outcome.
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http://dx.doi.org/10.1111/aas.13316DOI Listing
May 2019

The present and future of cardiac arrest care: international experts reach out to caregivers and healthcare authorities.

Intensive Care Med 2018 06 2;44(6):823-832. Epub 2018 Jun 2.

Medical ICU, Cochin Hospital (AP-HP), Paris-Cardiovascular-Research-Centre, INSERM U970 (Sudden Death Expertize Centre), Paris, France.

Purpose: The purpose of this review is to describe the epidemiology of out-of-hospital cardiac arrest (OHCA), disparities in organisation and outcome, recent advances in treatment and ongoing controversies. We also outline the standard of care that should be provided by the critical care specialist and propose future directions for cardiac arrest research.

Methods: Narrative review with contributions from international resuscitation experts.

Results: Although it is recognised that survival rates from OHCA are increasing there is considerable scope for improvement and many countries have implemented national strategies in an attempt to achieve this goal. More resources are required to enable high-quality randomised trials in resuscitation.

Conclusions: Increasing international collaboration should facilitate resuscitation research and knowledge translation. The International Liaison Committee on Resuscitation (ILCOR) has adopted a continuous evidence review process, which facilitate the implementation of resuscitation interventions proven to improve patient outcomes.
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http://dx.doi.org/10.1007/s00134-018-5230-9DOI Listing
June 2018

Guidelines for post-resuscitation care should include management of acute kidney injury and use of renal replacement therapy.

Resuscitation 2018 05;126:e14

Institute of Clinical Medicine, University of Oslo, Post Box 1072, Blindern, N-0316, Oslo, Norway; Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Post Box 4956, Nydalen, N-0424, Oslo, Norway.

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http://dx.doi.org/10.1016/j.resuscitation.2018.02.013DOI Listing
May 2018

Comparison of three haemodynamic monitoring methods in comatose post cardiac arrest patients.

Scand Cardiovasc J 2018 06 16;52(3):141-148. Epub 2018 Mar 16.

d Department of Cardiology, Division of Medicine , Oslo University Hospital , Oslo , Norway.

Objectives: Haemodynamic monitoring during post arrest care is important to optimise treatment. We compared stroke volume measured by minimally-invasive monitoring devices with or without thermodilution calibration, and transthoracic echocardiography (TTE), and hypothesised that thermodilution calibration would give stroke volume index (SVI) more in agreement with TTE during targeted temperature management (TTM).

Design: Comatose out-of-hospital cardiac arrest survivors receiving TTM (33 °C for 24 hrs) underwent haemodynamic monitoring with arterial pulse contour analyses with (PiCCO2®) and without (FloTrac/Vigileo monitor) transpulmonary thermodilution calibration. Haemodynamic parameters were collected simultaneously every fourth hour during TTM (hypothermia) and (normothermia). SVI was measured with TTE during hypothermia and normothermia. Bland-Altman analyses were used for determination of SVI bias (±1SD).

Results: Twenty-six patients were included, of whom 77% had initial shockable rhythm and 52% discharged with good outcome. SVI (bias ±2SD) between PiCCO (after thermodilution calibration) vs FloTrac/Vigileo, TTE vs FloTrac/Vigileo and TTE vs PiCCO were 1.4 (±25.8), -1.9 (±19.8), 0.06 (±18.5) ml/m2 during hypothermia and 9.7 (±23.9), 1.0 (±17.4), -7.2 (±12.8) ml/m2 during normothermia. Continuous SVI measurements between PiCCO and FloTrac/Vigileo during hypothermia at reduced SVI (<35 ml/m2) revealed low bias and relatively narrow limits of agreement (0.5 ± 10.2 ml/m2).

Conclusion: We found low bias, but relatively wide limits of agreement in SV with PiCCO, FloTrac/Vigileo and TTE during TTM treatment. The methods are not interchangeable. Precision was not improved by transpulmonary thermodilution calibration during hypothermia.
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http://dx.doi.org/10.1080/14017431.2018.1450992DOI Listing
June 2018

Long-term survival in patients with acute myocardial infarction and out-of-hospital cardiac arrest: A prospective cohort study.

Resuscitation 2018 01 17;122:41-47. Epub 2017 Nov 17.

Department of Cardiology, Oslo University Hospital Ulleval, Postboks 4950 Nydalen, 0424 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, P.O. Box 1072 Blindern, 0316 Oslo, Norway.

Aim: To compare short- and long-term survival in patients admitted to hospital after acute myocardial infarction (AMI) with and without out-of-hospital cardiac arrest (OHCA).

Methods: Prospective cohort study of all AMI patients admitted to Oslo University Hospital Ulleval from September 1, 2005 to December 31, 2011. All-cause mortality was obtained from the Norwegian Cause of Death Registry with censoring date December 31, 2013. Cumulative survival was assessed with the Kaplan-Meier and the Life-table method. Logistic- and Cox regression were used for risk comparisons.

Results: We identified 404 AMI patients with OHCA and 9425 AMI patients without. AMI patients without OHCA were categorized as ST-elevation myocardial infarction (STEMI, n=4522) or non-STEMI (NSTEMI, n=4903). Mean age was 63.6±standard deviation (SD) 12.5, 63.8±13.1 and 69.7±13.6 years in OHCA, STEMI and NSTEMI, respectively. Coronary angiography with subsequent percutaneous coronary intervention if indicated, was performed in 87% of OHCA, 97% of STEMI and 80% of NSTEMI patients. Thirty-day survival was 63%, 94% and 94%, and 8-year survival was 49%, 74%, and 57%, respectively. Among patients surviving the first 30days, no significant difference in risk during long-term follow-up was found (adjusted Hazard Ratio (aHR) 1.15 [95% CI 0.82-1.60], aHR 0.89 [95% CI 0.64-1.24]).

Conclusions: Long-term survival after OHCA due to AMI was good, with 49% of admitted patients being alive after eight years. Although short-term mortality remained high, OHCA patients alive after 30days had similar long-term risk as AMI patients without OHCA.
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http://dx.doi.org/10.1016/j.resuscitation.2017.11.047DOI Listing
January 2018

Authors' response: overcautious adoption of extracorporeal cardiopulmonary resuscitation.

Emerg Med J 2017 08 13;34(8):558. Epub 2017 Jul 13.

Department of Anesthesiology, University of Oslo, Oslo, Norway.

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http://dx.doi.org/10.1136/emermed-2017-206917DOI Listing
August 2017

A survey on general and temperature management of post cardiac arrest patients in large teaching and university hospitals in 14 European countries-The SPAME trial results.

Resuscitation 2017 07 2;116:84-90. Epub 2017 Apr 2.

Dept. of Anaesthesiology and Intensive Care Medicine, St. Vincenz-Hospital, Limburg, Germany, Germany. Electronic address:

Introduction: International guidelines recommend a bundle of care, including targeted temperature management (TTM), in post cardiac arrest survivors. Aside from a few small surveys in different European countries, adherence to the European Resuscitation Council (ERC) and European Society of Intensive Care Medicine (ESICM) recommendations are unknown.

Methods: This international European telephone survey was conducted to provide an overview of current clinical practice of post cardiac arrest management with a main focus on TTM. We targeted large teaching and university hospitals within Europe as leading facilities and key opinion leaders in the field of post cardiac arrest care. Selected national principal investigators conducted the survey, which was based on a predefined questionnaire, between December 2014 and March 2015, before the publication of the ERC Guidelines 2015.

Results: The return rate was 94% from 268 participating intensive care units (ICU). The majority had a predefined standard operating procedure (SOP) protocol for post cardiac arrest patients. Altogether, 68% of the ICUs provided TTM at a target temperature of 32-34°C for 24h, and 33% had changed the target temperature to 36°C. The minority provided a written SOP for neurological prognostication, which was generally initiated 72h after return of spontaneous circulation (ROSC). Electroencephalography and somatosensory evoked potentials were used by most ICUs for early prognostication. Treating more than fifty patients a year was significantly associated with providing written SOPs for TTM and prognostication (p<0.01), as well as the use of a computer feedback device (p=0.03) for TTM.

Conclusion: This international European telephone survey revealed a high rate of implementation of TTM in post cardiac arrest patients in university and teaching hospitals. Most participants also provided a SOP, but only a minority had a SOP for neurological prognostication.
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http://dx.doi.org/10.1016/j.resuscitation.2017.03.038DOI Listing
July 2017

Intensive care medicine research agenda on cardiac arrest.

Intensive Care Med 2017 Sep 11;43(9):1282-1293. Epub 2017 Mar 11.

Medical ICU, Cochin Hospital (AP-HP), Paris-Cardiovascular-Research-Centre, INSERM U970 (Sudden Death Expertize Centre), Université Paris-Descartes-Sorbonne-Paris-Cité, Paris, France.

Over the last 15 years, treatment of comatose post-cardiac arrest patients has evolved to include therapeutic strategies such as urgent coronary angiography with percutaneous coronary intervention (PCI), targeted temperature management (TTM)-requiring mechanical ventilation and sedation-and more sophisticated and cautious prognostication. In 2015, collaboration between the European Resuscitation Council (ERC) and the European Society for Intensive Care Medicine (ESICM) resulted in the first European guidelines on post-resuscitation care. This review addresses the major recent advances in the treatment of cardiac arrest, recent trials that have challenged current practice and the remaining areas of uncertainty.
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http://dx.doi.org/10.1007/s00134-017-4739-7DOI Listing
September 2017

Extracorporeal cardiopulmonary resuscitation probably good, but adoption should not be too fast and furious!

Emerg Med J 2017 May 4;34(5):275-276. Epub 2017 Mar 4.

Department of Anesthesiology, Division of Emergencies and Critical Care, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.

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http://dx.doi.org/10.1136/emermed-2016-206442DOI Listing
May 2017

Targeted simulation and education to improve cardiac arrest recognition and telephone assisted CPR in an emergency medical communication centre.

Resuscitation 2017 05 21;114:21-26. Epub 2017 Feb 21.

Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS), Oslo University Hospital, P.O. Box 4956 Nydalen, N-0424 Oslo, Norway; Department of Anaesthesiology, Oslo University Hospital and University of Oslo, P.O. Box 4956 Nydalen, N-0424 Oslo, Norway.

Aim: Recognition of cardiac arrest and prompt activation time by emergency medical dispatch are key process measures that have been associated with improved survival after out-of-hospital cardiac arrest (OHCA). The aim of this study is to improve recognition of OHCA and time to initiation of telephone assisted chest compressions in an emergency medical communication centre (EMCC).

Methods: A prospective, interventional study implementing targeted interventions in an EMCC. Interventions included: (1) lectures focusing on agonal breathing and interrogation strategy (2) simulation training (3) structured dispatcher feedback (4) web-based telephone assisted CPR training program. All ambulance-confirmed OHCA calls in the study period were assessed and relevant process and result measures were recorded pre- and post-intervention. Cardiac arrest was reported as (1) recognised, (2) not recognised or (3) delayed recognition.

Results: We included 331 and 230 calls pre- and post-intervention, respectively. Recognition of cardiac arrest improved significantly after intervention (89 vs. 95%, p=0.024). Delayed recognition was significantly reduced (21 vs. 6%, p>0.001), as was misinterpretation of agonal breathing (25 vs. 10%, p<0.001). Telephone assisted compressions increased (71% vs. 83%, p=0.002) whereas bystander performed ventilations decreased after intervention (23% vs. 15%, p=0.016). Time intervals for initiation of chest compression instructions (2.6 vs. 2.3min, p=0.042) and delivery of telephone assisted chest compressions (3.3 vs. 2.8min, p=0.015) were significantly shortened after intervention.

Conclusion: Targeted simulation, education and feedback significantly improved recognition of OHCA and reduced time to first chest compression. Continuous measurement of key quality metrics can facilitate development of targeted education and training.
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http://dx.doi.org/10.1016/j.resuscitation.2017.02.013DOI Listing
May 2017

Intensive care medicine in 2050: managing cardiac arrest.

Intensive Care Med 2017 07 9;43(7):1041-1043. Epub 2017 Jan 9.

Division of Emergencies and Critical Care, Department of Anaesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.

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http://dx.doi.org/10.1007/s00134-016-4658-zDOI Listing
July 2017