No abstract

Urban-Rural differences in Cardiac Arrest outcomes: a retrospective population-based cohort study, CJC Open (2022), doi: https://doi.org/10.1016/ j.cjco.2021.12.010. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Many adult critical care units (ACCU) use a standard feeding protocol to commence enteral nutrition (EN). This often involves measuring gastric residual volumes (GRV); if the volume is ‡ 200 ml the patient is considered to not be absorbing the feed (1) . Recently this protocol has been disputed as higher GRV can be present in the stomach than is measured and does not correlate well with increased aspiration risk (2) .A retrospective audit of GRV and delivery of EN was carried out for patients on the ACCU between October and December 2007. GRV were recorded for up to 14 days of ACCU stay. Other data collected included volume of feed delivered, volume prescribed, the use of prokinetics (metoclopramide°erythromycin) and other symptoms consistent with intolerance of EN (constipation, vomiting and high abdominal pressures/distension).During this period, 214 patients were admitted to the ACCU; of these, 53 patients met the inclusion criteria (excluded if on ACCU for < 48 h, or fed via a percutaneous tube, Parenteral Nutrition (PN) or case notes unavailable). Of these 53 patients, 28 (13 surgical and 15 medical) were fed via Nasogastric tube; the remaining patients were either eating and drinking or received no nutrition during this time.The EN was turned off in 67 % of patients (all surgical patients) between 2 and 8 times. The reason in 68 % of cases was due to feed intolerance, 43 % of patients received less than 50 % of feed volume prescribed and 11 % received less than 10 % of feed prescribed. Prokinetics were used in 49 %; 21 % being on dual therapy. Abdominal distension was present in nine patients (32 %) and GRV in this group varied: 55 % had total GRV of less than 1200 ml in 24 h. Thirty-two percent of patients showed an unusual pattern of GRV with minimal or nil aspirates, followed by aspirates of greater than 200 ml or vomiting. One patient aspirated while feeding during this period and the GRV of this patient was less than 600 ml daily; 3 patients (11 %) went on to PN.To conclude, using a 200 ml GRV as an indicator of feed tolerance appears to hinder the administration of EN. We believe that from our small audit a standard feeding protocol using 400 ml cut-off point for GRV as a marker of tolerance would lead to a greater delivery of EN. Forty-seven percent of patients would have benefited from this higher GRV cut-off point (2 patients potentially avoiding PN) and in the remaining 53 % patients this would have made no difference but would not have been detrimental.

Background Out of hospital cardiac arrest (OHCA) has an average global survival rate to discharge of 8%. Chain of survival factors are heavily time-dependant and optimization can increase survival. Regions with low population density encounter challeges in providing optimal OHCA care. Nova Scotia's average population density is 17.4 persons per square kilometer in compasiron to Toronto with 4334.4 person per square kilometer. OHCAs have been described well in large urban centers globally, however the characterization of OHCA chain of survival in low density populations is sparse. Purpose To describe chain of survival factors and identify characteristics of survivors and non-survivors among those treated by paramedics in a low average density provincial population. Methods This was a retrospective cohort study of OHCAs responded to by paramedics. All OHCA responses with a cardiac etiology in Nova Scotia, Canada were included. Exclusion criteria were non-cardiac cause arrests, those with “do not resuscitate” (DNR) directives and expected deaths. The paramedic electronic patient care record was reviewed for demographic, bystander, out of hospital treatment and operational characteristics. Primary outcome was survival to hospital discharge. Descriptive statistics were calculated to describe differences between survivorship using Prism 8.0 (San Diego, CA) with alpha=0.05 applying unpaired, Mann-Whitney tests. Results Of 1517 OHCA, 463 were excluded leaving 1054 OHCA. Of these, 478 (45.3%) were treated by paramedics and included in this analysis. Most were men (67.2%; n=274) with a mean age 66.8 (±16.4). A total of 7.1% (n=75) survived to discharge with 76% of survivors (n=58) discharged home. Survivors were more likely to present with ventricular fibrillation than non-survivors (42.7% vs. 19.6%). Survivors compared to non-survivors had significantly shorter paramedic response time (8.1 vs. 10.7 min, P&lt;0.001), paramedic time on scene (35.7 vs. 45.4 min, P=0.002), estimated time to paramedic defibrillation (13.2 vs 19.4 min, P&lt;0.001), and estimated time to return of spontaneous circulation (ROSC) (22.9 vs 31.9min, P&lt;0.001). Conclusion Links in the chain of survival are associated with survival from OHCA. OHCA survival is lower in the less densely populated province of Nova Scotia compared to studies in urban Canadian centers and worldwide. Our study is limited by the retrospective nature of data collection and lack of access to neurological outcomes. Even among survivors, EMS response is delayed compared to more densely populated centers. In Nova Scotia, longer paramedic response times are associated with decreased survival. Funding Acknowledgement Type of funding source: Other. Main funding source(s): Maritime Heart Center

Many adult critical care units (ACCU) use a standard protocol to commence enteral nutrition (EN). This often involves measuring gastric residual volumes (GRV); if GRV is ‡ 200 ml the patient is considered to not be absorbing EN (1) . Recently this protocol has been disputed as higher GRV can be present in the stomach than is measured and does not correlate well with increased aspiration risk (2) . We audited our practice (unpublished results) and concluded that using a GRV cut-off point of 200 ml was hindering the delivery of EN, as a result our unit trialled a GRV of 400 ml.After this change, a re-audit of GRV and EN delivery was carried out, between April and June 2008. GRV were recorded for up to 14 days of ACCU stay; other data collected included volume of EN delivered, volume prescribed, the use of prokinetics (metoclopramide°e rythromycin) and other symptoms consistent with intolerance of EN. During this period, 233 patients were admitted to the ACCU; of these, 47 patients met the inclusion criteria (excluded if on ACCU for < 48 h, fed via a percutaneous tube, Parenteral Nutrition (PN) or case notes unavailable). Of these 47 patients, 31 (10 surgical, 20 medical and 1 trauma) were fed via Nasogastric tube; of the remaining 16 patients, 12 were eating and drinking and 4 received no nutrition during this time.Average time to commence EN was 41 h, with a range of 0-116 h, with 40 % of patients exceeding the target time of 48 h. EN was stopped in 75 % of patients (on average 2.75 times per patient), accounting for an average loss of 20 % of feeding hours. Feed intolerance was the reason for stoppages in 37 % of patients, compared to 68 % in the previous audit. A high proportion of patients had EN stopped for other reasons: unplanned removal of NG (10 %), planned extubation (20%) procedures or surgery (12%) and for other unspecified reasons (36 %); these figures were notably higher than the previous audit. Prokinetics were used in 40 % of patients, 9 % being on dual therapy. Abdominal distension or high abdominal pressures were present in 15 % of patients. Unusual patterns of GRV (low or zero GRV followed by vomiting or large volumes were present in 56 % of patients; one of these patients aspirated. Three patients were deemed to have failed EN and went on to receive PN (9 %).To conclude, using a 400 ml GRV may improve EN delivery; EN was stopped less often due to a high GRV. When feed was not interrupted due to other reasons a higher volume was delivered -25 % of patients received more feed than would be expected if using a 200 ml GRV -Prokinetic use was reduced.There was no increase in aspiration. Due to a high number of other stoppages overall results did not improve, clearly the reasons for these stoppages need to be addressed. Other areas of our practice need to be reviewed: EN could have been commenced earlier in 21 % -earlier decisions for PN or naso-jejunal tube placement in 12.5 % and the use of a 24-h target volume instead of a target rate in 12 % (to account for feed being off for procedures).The high...