Propecia cost per pill

In an interview airing on 60 Minutes, President Joe Biden propecia after 3 months announced that the propecia is ending in the U.S propecia cost per pill. "We still have a problem with hair loss treatment," Biden said, "but the propecia is over."Though the comment seems somewhat contradictory, it captures the continuing struggle among specialists to determine where we stand with the current hair loss treatment propecia. In other words, scientists simply cannot agree whether the propecia was a problem of the past or whether continuing cases propecia cost per pill indicate that the propecia is far from over.The crux of the problem is that — despite what we want — diseases are tricky to eliminate, and propecias don't end decisively. They seldom culminate with a disease disappearing completely. Instead, they typically propecia cost per pill come to their close when a disease turns "endemic," transitioning into yet another stage of activity — albeit one with a steadier, more manageable rate of cases.

So what, exactly, does it mean when a propecia disease becomes endemic, and will hair loss treatment ever experience the change?. Differentiating Endemic, Epidemic and propecia DiseaseIt makes sense propecia cost per pill to begin with the basics. Scientists who study the development and the spread of diseases tend to describe ailments according to their circulation within particular populations. And, according to the Centers for Disease propecia cost per pill Control and Prevention (CDC), three of the top descriptors include the terms "endemic," "epidemic" and "propecia." To start, scientists apply the term "endemic" when a disease maintains a permanent presence in a specific area and appears at a relatively predictable rate. Though this is not necessarily the ideal or the desired occurrence of the disease — which may be no occurrence at all — this state is what scientists consider stable and manageable.

Essentially, endemic diseases are still active and still pose a threat to individual patients, but they rarely surge in surprising ways or cause significant disruptions in the day-to-day activities of a community.This is all true of two familiar endemic illnesses, the common cold and the seasonal influenza, which circulate propecia cost per pill according to predictable patterns and tend not to create medical crises in the U.S.Alternatively, specialists use the terms "epidemic" and "propecia" after sharp and sudden increases in a disease above what scientists would normally anticipate. While "epidemics" afflict a specific area, such as single state or country, "propecias" are much more widespread, stretching across populations and affecting several countries or continents all at once.The widespread impacts of hair loss treatment have sustained the propecia's propecia status since March 2020, but that does not mean that hair loss treatment will remain a propecia forever. In fact, propeciaes can cycle from state to state thanks to circumstances like propecia cost per pill the appearance of new variants or the development of new treatments. So, even if some illnesses can't be eradicated entirely, they can shift from the propecia stage to the endemic stage with the proper treatment.The trick, scientists say, is increasing immunity on a broad scale. This stabilizes the occurrence of a disease, pushing propecia cost per pill it toward endemic status.

In the case of hair loss treatment, increasing exposure to the propecia via variants like omicron and increasing use of treatments mean that more and more people are acquiring some amount of immunity to hair loss treatment in the U.S. With this propecia cost per pill immunity swelling, scientists predict that the propecia will spread in increasingly steady ways.When Will hair loss treatment Become Endemic?. So when, exactly, does a disease become endemic, and will hair loss treatment ever secure that status?. Because what scientists see as "stable" differs depending on the disease and the population that it afflicts, endemicity is best determined in propecia cost per pill the aftermath, once stabilization has already occurred. Put simply, there’s no clear scientific consensus for determining whether or not hair loss treatment is currently endemic.As such, some scientists assert that the propecia already lost its propecia label.

In an interview from April, for instance, Biden's Chief propecia cost per pill Medical Advisor Anthony Fauci said that the U.S. Was already transitioning "out of the propecia phase." Yet, others say the transformation will take a little longer, with a paper from July stating that the median time for the shift to occur sits at 1,437 days after the start of the propecia, which remains more than a year away.Though it's probably still too soon to tell, what matters most is the fact that the majority of experts think that hair loss treatment will swap its propecia status for endemic status eventually, becoming easier to prevent and to treat as a result of the trade.In fact, many specialists share relatively similar ideas about what hair loss treatment endemicity will look like. Once the propecia propecia cost per pill takes on endemic status, they say it will likely act like other common endemic conditions, transforming into a perennial or seasonal illness that’s much more of an inconvenience or an annoyance than an actual danger for the vast majority of sufferers. "People will still get infected," Fauci said in an interview last November. "People might still get hospitalized, but the level would be so low that we [wouldn't] think about it all the time, and it [wouldn't] influence what we do."Of course, continued caution will be necessary to prevent another hair loss treatment propecia from flaring up, and treatments propecia cost per pill and treatment boosters will remain of the utmost importance.

But, while the propecia won't be disappearing any time soon, the bottom line is that the disease will likely transition to a steadier, less disruptive state — that is, if it hasn’t transitioned already..

Propecia dosage

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No AbstractNo Buy renova online no prescription Reference information available - sign in for propecia dosage access. No Supplementary Data.No Article MediaNo MetricsDocument Type. EditorialAffiliations:Victorian Tuberculosis Program, Melbourne Health, Melbourne, VIC, Australia, Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for and Immunity, Parkville, VIC, AustraliaPublication date:01 May 2022More about this publication?. The International Journal of Tuberculosis and Lung Disease (IJTLD) is for clinical research and epidemiological studies on lung health, including articles on TB, TB-HIV and respiratory diseases such as hair loss treatment, asthma, COPD, child lung health and the hazards of tobacco and air pollution. Individuals and institutes can subscribe to the IJTLD online or in print – simply email us at propecia dosage [email protected] for details.

The IJTLD is dedicated to understanding lung disease and to the dissemination of knowledge leading to better lung health. To allow us to share scientific research as rapidly as possible, the IJTLD is fast-tracking the publication of certain articles as preprints prior to their publication. Read fast-track articles.Editorial BoardInformation for AuthorsSubscribe to this TitleInternational Journal of Tuberculosis and Lung DiseasePublic Health ActionIngenta Connect is not responsible for the content or availability of external websites.

No AbstractNo propecia cost per pill Reference information available - sign in for access http://dandgparts.com/buy-renova-online-no-prescription/. No Supplementary Data.No Article MediaNo MetricsDocument Type. EditorialAffiliations:Victorian Tuberculosis Program, Melbourne Health, Melbourne, VIC, Australia, Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for and Immunity, Parkville, VIC, AustraliaPublication date:01 May 2022More about this publication?. The International Journal of Tuberculosis and Lung Disease (IJTLD) is for clinical research and epidemiological studies on lung health, including articles on TB, TB-HIV and respiratory diseases such as hair loss treatment, asthma, COPD, child lung health and the hazards of tobacco and air pollution.

Individuals and institutes can subscribe to the IJTLD online or in print – simply email us at propecia cost per pill [email protected] for details. The IJTLD is dedicated to understanding lung disease and to the dissemination of knowledge leading to better lung health. To allow us to share scientific research as rapidly as possible, the IJTLD is fast-tracking the publication of certain articles as preprints prior to their publication. Read fast-track articles.Editorial BoardInformation for AuthorsSubscribe to this TitleInternational Journal of Tuberculosis and Lung DiseasePublic Health ActionIngenta Connect is not responsible for the content or availability of external websites.

What should I watch for while taking Propecia?

Do not donate blood until at least 6 months after your final dose of finasteride. This will prevent giving finasteride to a pregnant female through a blood transfusion.

Contact your prescriber or health care professional if there is no improvement in your symptoms. You may need to take finasteride for 6 to 12 months to get the best results.

Women who are pregnant or may get pregnant must not handle broken or crushed finasteride tablets; the active ingredient could harm the unborn baby. If a pregnant woman comes into contact with broken or crushed finasteride tablets she should check with her prescriber or health care professional. Exposure to whole tablets is not expected to cause harm as long as they are not swallowed.

Finasteride can interfere with PSA laboratory tests for prostate cancer. If you are scheduled to have a lab test for prostate cancer, tell your prescriber or health care professional that you are taking finasteride.

Biotin and propecia

AbstractOnce common, therapeutic privilege—the practice whereby a physician withholds diagnostic or prognostic information from a patient intending to protect the biotin and propecia patient—is now generally seen as unethical. However, instances of therapeutic privilege are common in some areas of clinical psychiatry. We describe therapeutic privilege in the context of borderline personality disorder, discuss the implications of diagnostic non-disclosure on integrated care and offer recommendations to promote diagnostic disclosure for this patient population.ethicspsychiatryapplied and professional ethicsclinical ethicsinformed consentData availability statementThere are no data in this work..

AbstractOnce common, therapeutic privilege—the practice whereby a physician withholds http://www.em-ernolsheim-bruche.ac-strasbourg.fr/?slideshow=travaux-rentree diagnostic or prognostic information from a patient intending to protect the patient—is propecia cost per pill now generally seen as unethical. However, instances of therapeutic privilege are common in some areas of clinical psychiatry. We describe therapeutic privilege in the context of borderline personality disorder, discuss the implications of diagnostic non-disclosure on integrated care and offer recommendations to promote diagnostic disclosure for this patient population.ethicspsychiatryapplied and professional ethicsclinical ethicsinformed consentData availability statementThere are no data in this work..

Propecia and fertility

New research from the Case Western Reserve University (CWRU) School of Medicine suggests that the children younger than age 5 who are infected with the hair loss treatment Omicron variant have less risk of severe health outcomes than those infected http://basey.com/reset-password/ with the Delta variant.The study, published Friday in JAMA Pediatrics, is the first large-scale research effort to compare the health outcomes of hair loss propecia and fertility from Omicron to Delta in children 4 and younger -- the age group not yet able to be vaccinated.The findings show that the Omicron variant is 6-8 times more infectious than the Delta variant. The severe clinical outcomes ranged from a 16% propecia and fertility lower risk for emergency room visits to 85% less risk for mechanical ventilation. And about 1.8% of children infected with Omicron were hospitalized, compared to 3.3% with Delta.The Case Western Reserve-led team analyzed the electronic health records of more than 651,640 children in the United States who had medical encounter with healthcare organizations between 9/2021-1/2022-including more than 22,772 children infected with Omicron in late December and late January -- to more than 66,000 children infected when Delta was prevalent in the fall.

The study also compared the records of more than 10,000 children immediately before the detection of Omicron in the U.S., but propecia and fertility when Delta was still predominant.Children younger than 5 are not yet eligible for hair loss treatments and have a low rate of previous hair loss s, which also limits their pre-existing immunity.The team examined clinical health outcomes for pediatric patients during a 14-day window following hair loss . Among the propecia and fertility factors they reviewed were. Emergency room visits, hospitalizations, ICU admissions and mechanical ventilation use.Further demographic data analysis found that children infected with Omicron were on average younger-1.5 years of age versus 1.7 years-and had fewer comorbidities."The major conclusion to our research was that many more children were infected with Omicron when compared to Delta, but the children who are infected are not impacted as severely as were children infected with the Delta variant," said Pamela Davis, the Arline H.

And Curtis F propecia and fertility. Garvin Research Professor at propecia and fertility the Case Western Reserve School of Medicine. "However, because there are so many more children infected, our hospitals were affected over the winter months by an influx of young children.""We saw the number of hospitalizations within this age group skyrocket in January of this year because the rate of Omicron is about 10 to 15 times compared to that of the Delta variant," said Rong Xu, professor of biomedical infomatics and director of the Center for AI in Drug Discovery at the School of Medicine.

"Omicron is less propecia and fertility severe than Delta, however, the reduction of the severity range in clinical outcomes is only 16 to 85%. Furthermore, since so many un-vaccinated children were infected, propecia and fertility the long-term effects of hair loss treatment s on the brain, heart, immune systems and other organs of children remains unknown and worrisome. "The CDC recommends those age 5 and older receive a hair loss treatment, and fully vaccinated people 12 and older receive a booster shot.

According to updated guidance by the CDC, Americans no longer need to mask indoors in counties with low or medium "hair loss treatment propecia and fertility Community Level." Story Source. Materials provided by http://akrai.org/apply/ Case Western Reserve University propecia and fertility. Note.

Content may be edited for style and length.A new study co-authored by a University of Rochester Medical Center (URMC) researcher has found that the survival rates of extremely pre-term babies has increased significantly in the past decade.The paper, "Mortality, In-Hospital Morbidity, Care Practices, and 2-Year Outcomes for Extremely Preterm Infants in the US, 2013-2018," examined the survival outcomes of 10,877 infants born at propecia and fertility 22-28 weeks' gestational age between January 1, 2013, and December 31, 2018, at 19 academic medical centers that form the NIH-funded Neonatal Research Network.Survival among actively treated infants was 30.0% (60/200) at 22 weeks and 55.8% (535/958) at 23 weeks. This is a considerably higher rate of survival than when the study when previously conducted between 2008-2012, in which survival to discharge was 7% (22/334) for live-born infants at 22 weeks and 32% (252/779) for live-born infants at 23 weeks.This improvement in outcomes for extremely pre-term infants can be attributed to multiple factors, including enhanced treatment protocols across participating medical centers, according to Carl D'Angio, M.D., co-author and Chief of the Division of Neonatology at URMC."Academic medical centers have been taking best-practices, applying them, propecia and fertility and disseminating them to a wider and wider group nationally," said D'Angio.Collective improvement in care in a variety of areas has contributed to the change in outcomes, according to D'Angio. "When we look at survival at almost any group of infants, it's a bundle of factors.

There are similarities and differences in the way they're treated at various centers, but there are elements where we've collectively moved forward, such as ventilation, nutrition and propecia and fertility hydration."When infants are born at 22 or 23 weeks, nearly every organ is immature, with the lungs and the brain being among the systems most at risk, according to D'Angio.In addition to studying survival outcomes, the paper assessed the health of severely pre-term infants after two years, including effects such as neurodevelopment, cerebral palsy, vision, hearing, rehospitalizations, and need for assistive devices. Slightly more than 8% had moderate to severe cerebral palsy, 1.5% had vision loss in both eyes, 2.5% needed hearing aids or cochlear implants, and 15% required mobility aids such as orthotics, braces, walkers, or wheelchairs.Nearly 49% had no or only mild neurodevelopmental impairment, about 29% had moderate neurodevelopmental impairment and roughly 21% had severe neurodevelopmental impairment.This study -- and overall improvement in outcomes -- can help clinicians provide clear information in discussions with families when babies are born extremely pre-term."We as clinicians support parents in a shared decision-making process when babies are born at the limits of viability," said propecia and fertility D'Angio. "The imminent delivery of an extremely premature infant is a major stressor for families.

An important part of helping parents cope is presenting the data we have and propecia and fertility letting parents know what to expect in the long-haul. This latest study is positive news for shaping those discussions and providing a more optimistic probability for propecia and fertility good outcomes." Story Source. Materials provided by University of Rochester Medical Center.

Original written by propecia and fertility Scott Hesel. Note. Content may be edited for style and length..

New research from the Case Western Reserve University (CWRU) School of Medicine suggests that the children younger than age 5 who are infected with the hair loss treatment Omicron variant have less http://nutritechsolutions.com/product/yeast-autolysate-agrimos/ risk of severe health outcomes than propecia cost per pill those infected with the Delta variant.The study, published Friday in JAMA Pediatrics, is the first large-scale research effort to compare the health outcomes of hair loss from Omicron to Delta in children 4 and younger -- the age group not yet able to be vaccinated.The findings show that the Omicron variant is 6-8 times more infectious than the Delta variant. The severe clinical outcomes ranged from a 16% lower risk for emergency room visits to propecia cost per pill 85% less risk for mechanical ventilation. And about 1.8% of children infected with Omicron were hospitalized, compared to 3.3% with Delta.The Case Western Reserve-led team analyzed the electronic health records of more than 651,640 children in the United States who had medical encounter with healthcare organizations between 9/2021-1/2022-including more than 22,772 children infected with Omicron in late December and late January -- to more than 66,000 children infected when Delta was prevalent in the fall. The study also compared the records of more than 10,000 children immediately before the detection of Omicron in the U.S., but when Delta was still predominant.Children younger than 5 are not yet eligible for hair loss treatments and have a low rate of previous hair loss s, which also limits their pre-existing immunity.The team examined clinical health outcomes propecia cost per pill for pediatric patients during a 14-day window following hair loss . Among the factors they reviewed propecia cost per pill were.

Emergency room visits, hospitalizations, ICU admissions and mechanical ventilation use.Further demographic data analysis found that children infected with Omicron were on average younger-1.5 years of age versus 1.7 years-and had fewer comorbidities."The major conclusion to our research was that many more children were infected with Omicron when compared to Delta, but the children who are infected are not impacted as severely as were children infected with the Delta variant," said Pamela Davis, the Arline H. And Curtis F propecia cost per pill. Garvin Research Professor at the Case propecia cost per pill Western Reserve School of Medicine. "However, because there are so many more children infected, our hospitals were affected over the winter months by an influx of young children.""We saw the number of hospitalizations within this age group skyrocket in January of this year because the rate of Omicron is about 10 to 15 times compared to that of the Delta variant," said Rong Xu, professor of biomedical infomatics and director of the Center for AI in Drug Discovery at the School of Medicine. "Omicron is less severe than Delta, however, the reduction of the severity range in clinical outcomes is only 16 propecia cost per pill to 85%.

Furthermore, since propecia cost per pill so many un-vaccinated children were infected, the long-term effects of hair loss treatment s on the brain, heart, immune systems and other organs of children remains unknown and worrisome. "The CDC recommends those age 5 and older receive a hair loss treatment, and fully vaccinated people 12 and older receive a booster shot. According to updated guidance by propecia cost per pill the CDC, Americans no longer need to mask indoors in counties with low or medium "hair loss treatment Community Level." Story Source. Materials provided by Case Western propecia cost per pill Reserve University. Note.

Content may be edited for style and length.A new study co-authored by a University of Rochester Medical Center (URMC) researcher has found that the survival propecia cost per pill rates of extremely pre-term babies has increased significantly in the past decade.The paper, "Mortality, In-Hospital Morbidity, Care Practices, and 2-Year Outcomes for Extremely Preterm Infants in the US, 2013-2018," examined the survival outcomes of 10,877 infants born at 22-28 weeks' gestational age between January 1, 2013, and December 31, 2018, at 19 academic medical centers that form the NIH-funded Neonatal Research Network.Survival among actively treated infants was 30.0% (60/200) at 22 weeks and 55.8% (535/958) at 23 weeks. This is a considerably propecia cost per pill higher rate of survival than when the study when previously conducted between 2008-2012, in which survival to discharge was 7% (22/334) for live-born infants at 22 weeks and 32% (252/779) for live-born infants at 23 weeks.This improvement in outcomes for extremely pre-term infants can be attributed to multiple factors, including enhanced treatment protocols across participating medical centers, according to Carl D'Angio, M.D., co-author and Chief of the Division of Neonatology at URMC."Academic medical centers have been taking best-practices, applying them, and disseminating them to a wider and wider group nationally," said D'Angio.Collective improvement in care in a variety of areas has contributed to the change in outcomes, according to D'Angio. "When we look at survival at almost any group of infants, it's a bundle of factors. There are similarities and differences in the way they're treated at various centers, but there are elements where we've collectively moved forward, such as ventilation, nutrition and hydration."When infants are born at 22 or 23 weeks, nearly every organ is immature, with the lungs and the brain being among the systems most at risk, according propecia cost per pill to D'Angio.In addition to studying survival outcomes, the paper assessed the health of severely pre-term infants after two years, including effects such as neurodevelopment, cerebral palsy, vision, hearing, rehospitalizations, and need for assistive devices. Slightly more than 8% had moderate to severe cerebral palsy, 1.5% had vision loss in both eyes, 2.5% needed hearing aids or cochlear implants, and propecia cost per pill 15% required mobility aids such as orthotics, braces, walkers, or wheelchairs.Nearly 49% had no or only mild neurodevelopmental impairment, about 29% had moderate neurodevelopmental impairment and roughly 21% had severe neurodevelopmental impairment.This study -- and overall improvement in outcomes -- can help clinicians provide clear information in discussions with families when babies are born extremely pre-term."We as clinicians support parents in a shared decision-making process when babies are born at the limits of viability," said D'Angio.

"The imminent delivery of an extremely premature infant is a major stressor for families. An important part of helping parents cope is propecia cost per pill presenting the data we have and letting parents know what to expect in the long-haul. This latest study is positive news for propecia cost per pill shaping those discussions and providing a more optimistic probability for good outcomes." Story Source. Materials provided by University of Rochester Medical Center. Original written propecia cost per pill by Scott Hesel.

Note. Content may be edited for style and length..

Propecia one year

Scope and methodsThis guideline covers adult patients undergoing any invasive procedure in the catheter laboratory, including coronary angiography, PCI, structural heart interventions including TAVI and mitral valve propecia one year procedures, pacemaker and ICD implantation, arrhythmia ablation, this hyperlink atrial appendage occlusion, and pacing system extraction. We did not consider patients who suffer a cardiac arrest and are then brought to the catheter laboratory as these patients have recently been considered in a position paper by the European Society of Cardiology (ESC).4The guideline was developed by a collaboration between nine stakeholder organisations. The British Cardiovascular Society (BCS), the British Cardiovascular Intervention Society (BCIS), the British Heart Rhythm Society (BHRS), the British Association for Nursing in Cardiovascular Care, the British Society of Echocardiography, the Association for Cardiothoracic Anaesthesia and Critical Care, the Cardiovascular Care Partnership UK, the Society for Cardiothoracic Surgery in Great Britain and Ireland, and the Resuscitation Council UK.These guidelines were developed in accordance with The Resuscitation Council UK 2021 guidelines development process.5 We used the ESC 2018 practice guidelines recommendations for grading the strength of recommendations and for assessing the levels of evidence in support of them.6 It should be acknowledged that the literature surrounding cardiac arrest comprises mostly of papers which reported the findings of studies after either in-hospital or out-of-hospital cardiac arrest rather than after cardiac arrest in the catheter laboratory and that their findings were extrapolated to the catheter laboratory environment.We undertook propecia one year a comprehensive review of the literature and a Delphi expert consensus process in order to identify all of the situations in the catheter laboratory that potentially lead to cardiac arrest and to provide team-based solutions to their management. We propose these guidelines as the standard of care in this specialist area.The International Liaison Committee on ResuscitationAccording to international guidelines, resuscitation is governed by The International Liaison Committee on Resuscitation (ILCOR) which is a collaborative of seven world resuscitation councils which was founded in 1992. The full range of all recommendations in propecia one year the area of resuscitation is reviewed and updated and a document of the ‘best evidence’ in resuscitation is created.

The seven resuscitation councils then take this evidence and generate guidelines adapted to the needs of their own healthcare systems.The American Heart Association guidelinesThe 2015 American Heart Association (AHA) guidelines contain a two-page section entitled ‘Cardiac Arrest During Percutaneous Coronary Intervention’, although this was omitted from its 2020 guideline.7 In 2015 the AHA concentrated mainly on a discussion on the use of automated CPR devices over manual compressions and the use of extracorporeal CPR (ECPR) devices. It did not come to any firm conclusion but stated that mechanical CPR devices and ECPR devices propecia one year have been used as bridges to other interventions such as coronary artery bypass surgery, cardiac transplantation or longer-term mechanical devices. In the text of the guideline it is also noted by the authors that early defibrillation within a minute of cardiac arrest is associated with excellent outcomes. No other special considerations were discussed with regard to the management of cardiac arrest in the catheter laboratory.The European Resuscitation Council guidelinesThe European Resuscitation Council (ERC) published guidance regarding resuscitation in the catheter laboratory in 2021 in its document entitled ‘cardiac arrest in special circumstances’.8 It included a protocol diagram, and there was a strong emphasis on ensuring that catheter laboratory staff are adequately trained in resuscitation technical skills including team training, and specific protocols for the initiation of mechanical propecia one year CPR, temporary pacing and pericardiocentesis, with the use of on-site emergency drills. The ERC also recommended the availability of resuscitation equipment and the use of checklists.

Mechanical CPR was recommended due to the risk to staff from manual CPR during fluoroscopy, and the requirement to continue CPR during PCI.The Australian and New Zealand guidelinesThese guidelines discussed the use of mechanical CPR in cardiac arrest during PCI.9 They propecia one year also discussed cough CPR for which they found case reports regarding its use during electrophysiology (EP) procedures. They discussed treatment of cardiac tamponade during cardiac arrest by thoracotomy and pericardiotomy if pericardiocentesis fails with a class B recommendation. They noted that the interventionalist is heavily task burdened and, as such, is seldom in a good position to lead the resuscitation and that there propecia one year may be tension between the requirement to perform CPR and the ability of the interventionalist to continue with the procedure, thus acknowledging two of the particular challenges faced by the catheter laboratory team during a cardiac arrest.A novel protocol for the management of patients who suffer a cardiac arrest in the catheter laboratoryWe have developed a modified resuscitation protocol which is specifically designed for the specialist area of the catheter laboratory. Of note this does not apply to recovery areas but does apply to hybrid laboratories where TAVI or Mitraclip procedures are being undertaken. This protocol could also be used in hybrid propecia one year laboratories performing thoracoscopic endovascular aortic repair (TEVAR).

The full protocol is shown in figure 1 and the rationale for its development is discussed.Protocol for resuscitation of patients who suffer a cardiac arrest in the catheter laboratory. BCIS, British Cardiovascular Intervention Society. BHRS, British propecia one year Heart Rhythm Society. CPR, cardiopulmonary resuscitation. PCI, percutaneous propecia one year coronary intervention.

PE, pulmonary embolus. PEA, pulseless propecia one year electrical activity. ROSC, restoration of spontaneous circulation. TAVI, transcatheter aortic valve implantation propecia one year. VF, ventricular fibrillation.

VT, ventricular tachycardia." data-icon-position data-hide-link-title="0">Figure 1 propecia one year Protocol for resuscitation of patients who suffer a cardiac arrest in the catheter laboratory. BCIS, British Cardiovascular Intervention Society. BHRS, British Heart Rhythm Society propecia one year. CPR, cardiopulmonary resuscitation. PCI, percutaneous coronary propecia one year intervention.

PE, pulmonary embolus. PEA, pulseless electrical activity. ROSC, restoration propecia one year of spontaneous circulation. TAVI, transcatheter aortic valve implantation. VF, ventricular fibrillation propecia one year.

VT, ventricular tachycardia.How should cardiac arrest be identified, defined and categorised?. In a catheter laboratory a cardiac arrest is identified much more quickly than propecia one year other in-hospital arrest scenarios. Ventricular fibrillation (VF), pulseless ventricular tachycardia (VT) and asystole may be diagnosed immediately when a continuous intra-arterial blood pressure is displayed, without need for an added pulse check.It is important to define what constitutes a cardiac arrest in a catheter lab. In contrast to propecia one year the two pathways in the standard arrest algorithm we have separated the protocol into three pathways. VF or pulseless VT, asystole or extreme bradycardia, and pulseless electrical activity (PEA).In VF or pulseless VT, the pulse oximeter and arterial trace will confirm the absence of a cardiac output.

A cardiac arrest should be called and the operator should tell the team if they know the reason propecia one year for the arrest (eg, vessel dissection or occlusion in PCI, occluded left main stem in TAVI or irritation of the ventricle in a pacing procedure for example). VF or VT is occasionally deliberately induced in EP labs and this should not trigger the arrest protocol.Temporary asystole or extreme bradycardia (<30/min) may occur and can be anticipated during manipulation of ventricular pacing leads or EP catheters. A cardiac arrest should be called when the rhythm disturbance is unexpected and propecia one year or prolonged. The pulse oximetry and any arterial transduction will show non-pulsatile traces, and percussion pacing, external pacing or temporary wire pacing may be attempted prior to chest compressions.Many cases of PEA may be diagnosed by the absence of a pulsatile waveform on a continuous intra-arterial blood pressure display. Non-pulsatility or minimal pulsatility of the arterial trace propecia one year and pulse oximetry in the presence of continuing electrical activity confirms the diagnosis.

The operator should call it a cardiac arrest and inform the laboratory team of the likely cause.Pulseless VT can be mistaken for PEA. A regular rhythm above 140/min should be considered as pulseless VT if the arterial trace and pulse oximetry have minimal or absent pulsation and the patient has lost consciousness. Similarly extreme bradycardia may be mistaken for PEA if propecia one year the arterial trace is not being transduced. It may be necessary to feel the pulse for 10 s or alternatively (and optimally) to perform a rapid echocardiogram to identify a cardiac output.Occasional patients will deteriorate in the catheter laboratory with support devices in place such as left ventricular assist device (LVAD), extra corporeal membrane oxygenation (ECMO) or Impella (Abiomed), where non-pulsatility does not equate with an absent cardiac output.Should all members of the resuscitation team wear lead aprons?. All clinicians coming into an arrest in propecia one year the catheter laboratory should wear lead aprons.

Our protocol uses the members of the team present in the catheter laboratory in the initial stages of the arrest and, thus, it is strongly recommended that everyone entering the room should wear lead aprons as it is very likely that the cardiologist may need to perform fluoroscopy in many emergency situations.We recommend that catheter laboratory team members are regularly trained in basic airway management to ensure a patent airway and good oxygenation for all patients, to ensure that the anaesthetic team have adequate time to put on protective lead before entering the laboratory. We recommend that an individual in propecia one year the catheter laboratory team is allocated to manage the personnel coming into the arrest. They will be required to assist these personnel to put on lead, and as they do this, they will be able to brief these clinicians as to the arrest situation in the catheter lab.Catheter laboratories must also ensure that lead aprons in a range of sizes are immediately available for emergency team members.View this table:Should we defibrillate before external chest compressions?. In 2020 ILCOR published a literature review on this subject10 and it was identified as a propecia one year priority area for the Basic Life Support Taskforce. They found that in five randomised controlled trials (RCTs)11 ,12 ,13 ,14 ,15 there was no difference in outcomes with a specified period of chest compressions (typically 1.5–3 min) before shock delivery compared with shock delivery as soon as possible with interim brief CPR while the defibrillator was readied for use.

A meta-analysis of these studies (n=10 600 patients) also found no differences propecia one year. Only when the arrest time was more than 5 min did any studies show an improvement with CPR before defibrillation.16 ,17 The ERC 2021 guidelines8 do not recommend the routine delivery of a prespecified period of CPR before rhythm analysis and shock delivery, and recommend shock delivery as soon as it can be applied. Deferring chest compressions until after shock delivery has been recommended in the ERC 2021 guidelines8 in other highly monitored propecia one year areas such as after cardiac surgery and these now state. €˜If a patient has a monitored and witnessed cardiac arrest (eg, in the catheter laboratory, coronary care unit, or other monitored critical care setting in or out-of-hospital) and a manual defibrillator is rapidly available. Confirm cardiac arrest propecia one year and shout for help.

If the initial rhythm is VF/pVT, give up to three quick successive (stacked) shocks. Rapidly check for a rhythm change and, if appropriate, ROSC after each defibrillation attempt. Start chest compressions and continue CPR propecia one year for 2 min if the third shock is unsuccessful’.View this table:How many attempts at defibrillation should be performed prior to commencing external chest compressions?. Evidence was sought for the optimal number of attempts at external defibrillation for VF or pulseless VT prior to commencing external chest compressions. This has been subject to a literature review looking at the effectiveness of the numbers of defibrillation attempts in a range of scenarios including ICD insertions, electrophysiological studies, out-of-hospital arrests and animal studies.18 When the data from all 15 papers are combined, the average success rate of sequential shocks declines from 78% for the first shock to 35% for the second shock and 14% for the propecia one year third, and any subsequent shock will have less than a 10% chance of success.

Thus, the likelihood of successful cardioversion declines dramatically from first to second shock and declines further from second to third shock.Our guideline seeks to place a mechanical CPR device on the patient early in the pathway and it is important to consider how we modify the protocol to allow this. First, it may be possible to assess the rhythm while the mechanical propecia one year CPR is ongoing. Our patients often have multi-lead ECG monitoring, and sometimes intracardiac ECG monitoring, and thus where the team leader is satisfied that there has been no change from the shockable rhythm, there is no need to pause the CPR device every 2 min. If the team leader is uncertain then a pause should be performed propecia one year every 2 min for rhythm assessment. As there is no risk to a rescuer, charging and administration of a shock may be performed while mechanical CPR is ongoing.

Finally, if multiple shocks have failed to cardiovert the patient and it is clear that propecia one year a coronary occlusion is the cause of the arrhythmia, then mechanical CPR should continue uninterrupted until coronary flow is restored.View this table:Should we perform pacing in patients who undergo an asystolic arrest in the catheter laboratory prior to external chest compressions?. In an asystolic arrest in a catheter laboratory there is the potential to rapidly restore cardiac output with pacing and, as this is a witnessed arrest, if pacing is performed immediately then potentially there will be an immediate restoration of a spontaneous circulation. Furthermore, in propecia one year the literature review on the effectiveness of external chest compressions in the early stages of an arrest19 it was found that there was little evidence to suggest harm from delaying external chest compressions for a few minutes. Periods of asystole are not uncommon in pacing and electrophysiology (EP) laboratories and most cardiologists would use external, percussion or transvenous temporary wire pacing to address this as a routine part of their practice. We recommend that pacing should be attempted prior to propecia one year the initiation of external chest compressions.Percussion pacing may initially be attempted (see the section below for further details).

For external pacing the pacing pads should be applied, and the amplitude of the pacing quickly increased to regain an output. Only if capture is not obtained with maximum amplitude with the pads well applied propecia one year should external chest compressions be performed. If the cardiologist suspects that the arrest is due to an extreme bradycardia due to a conduction defect then transvenous pacing can be used if external pacing has been ineffective in achieving ventricular capture.View this table:Interventions to address PEAOur protocol using three categories aims to ensure that the greatest number of patients possible may benefit from either immediate defibrillation or pacing prior to the institution of external cardiac compressions. In patients presenting with PEA efforts should be directed towards identifying the underlying causes and treating them rapidly. There are a number of possibilities to consider that are relevant to the propecia one year catheter laboratory:Hypoxia.

There is an airway and breathing protocol with a person allocated to address these issues in an arrest.Hypovolaemia. Bleeding. Our recommendation ensures that the four most likely areas for bleeding in the catheter laboratory (haemothorax, retroperitoneal or vascular bleed, aortic dissection and tamponade) are investigated.Hypo/hyperkalaemia, H+ ion imbalance and electrolyte abnormalities are addressed by a recommendation to perform an early blood gas.Hypothermia is unusual in a catheter lab, other than following prolonged out of hospital arrestTension pneumothorax may arise during procedures requiring vascular access in the thorax. This is addressed in the airway and breathing protocol and by fluoroscopy.Tamponade. Where tamponade is a possibility immediate echocardiography should be performed.

The clinical sign most suggestive of tamponade in a cardiac arrest is the inability to generate a systolic blood pressure of 70 mm Hg with external cardiac massage.Toxins. One possible cause of a toxin-related arrest in a catheter laboratory is a drug error. We recommend that any syringe drivers or infusions should be stopped in the arrested patient to address this possibility. Careful consideration should also be given to contrast-induced or antibiotic-induced anaphylaxis. Look for supportive signs such as rash, wheeze or facial swelling.

Our protocol recommends epinephrine 0.5 mg intramuscular or otherwise 50 mcg intravenous.Thrombosis. Coronary or pulmonary. In the catheter laboratory this would most commonly relate to acute coronary occlusion, either due to an acute myocardial infarction or a complication of PCI which in both circumstances would be treated by reopening of the vessels by PCI. Pulmonary embolism causing an arrest is far less common. In an arrest situation it can be very difficult to diagnose but is suggested by disproportionate right ventricular distention.

If suspected, then thrombolysis or thrombectomy might be considered. This is considered in our protocol.How deeply should we perform chest compressions?. The universal algorithm recommends compressing the chest to between 5 cm and 6 cm over the lower half of the sternum.7 8 For those patients with an arterial trace being transduced, we recommend ‘titrating’ chest compressions to achieve a systolic pressure of 70 mm Hg. This allows more gentle external compressions to be performed, potentially reducing the chance of compression related injury, while still producing effective cerebral perfusion. Furthermore, the inability to generate an acceptable systolic pressure is suggestive of tamponade.View this table:Should we perform a precordial thump?.

The AHA guidelines20 state that ‘The precordial thump may be considered for termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb, level of evidence (LOE) B), but should not delay CPR and shock delivery’. ILCOR produced a worksheet on this subject in 2021.21 This documents that precordial thump is only effective in 2% of attempts and, in fact, rhythm deterioration is twice as common as successful cardioversion. Thus, our protocol does not recommend a precordial thump. A defibrillator should be immediately at hand in every catheter laboratory, and this is much more likely to successfully cardiovert the patient.View this table:Is cough CPR an effective alternative to external chest compressions in the catheter laboratory?. The AHA stated in 2010 that ‘cough’ CPR may be considered in settings such as the cardiac catheterisation laboratory for conscious, supine and monitored patients if the patient can be instructed and coached to cough forcefully every 1–3 s during the initial seconds of an arrhythmic cardiac arrest.

It should not delay definitive treatment (Class IIb, LOE C). The AHA made no modifications to this recommendation in 2020.7The longest documented case of a patient maintaining their own spontaneous circulation is 90 s and most reports were around 30 s, in both VF as well as asystole. These patients seem able to maintain consciousness in a manner similar to the mechanism proposed for external CPR, namely a compression of the pulmonary vascular bed increasing the pressure in the left atrium then ventricle and allowing blood to flow across the aortic valve.22 There are case reports of its use for short periods of time in the catheter laboratory,23 including prior to defibrillation24 25 but the most effective use seems to be in patients with severe bradycardia who are periarrest. ILCOR performed a systematic review in 2021.21 Their conclusion was as follows. €˜We suggest cough CPR may only be considered as a temporising measure in an exceptional circumstance in a witnessed, monitored, in-hospital setting (such as a cardiac catheterisation laboratory) if a non-perfusing rhythm is recognised promptly before loss of consciousness (weak recommendation, very-low-certainty evidence)’.If a bradycardic or asystolic cardiac arrest is very rapidly identified (while the patient is responsive), then it is reasonable to attempt to coach the patient to cough forcefully every 1–3 s if experienced clinicians choose to try this.

This should not delay the commencement of the cardiac arrest protocol including the application of pads and defibrillating or pacing if necessary. Staff should be ready to perform CPR if the patient stops following the command to cough, and the arterial trace should be observed to monitor the effectiveness of cough CPR.View this table:Percussion (fist) pacing as an alternative to CPR in the catheter laboratoryILCOR performed a systematic review on this subject in 2021.21 The total number of cases reported in the literature is around 170 patients and in the largest series of 100 patients, 69 of these maintained consciousness and 90 had percussion pacing as an alternative to CPR.26In a study performed in 197827 19 healthy volunteers and 31 patients with paused pacing had a right heart catheter and the authors found reliable electrical impulses could be reproduced for up to 6 min when the left lower sternum was struck with the clenched fist from about 20–30 cm height, by causing the right ventricular pressure to rise by around 20 mm Hg with this action.The ILCOR 2021 systematic review states that ‘We suggest fist pacing may only be considered as a temporising measure in an exceptional circumstance in a witnessed, monitored, in-hospital setting (such as a cardiac catheterisation laboratory) if a non-perfusing rhythm is recognised promptly before loss of consciousness’.The catheterisation laboratory is a highly monitored environment where bradycardia and asystole are common. There have been no studies comparing CPR to percussion pacing directly but percussion pacing has been shown to effectively induce cardiac contraction and maintain consciousness in patients immediately identified as having an asystolic arrest. Therefore, with close monitoring, we recommend that this could be a useful temporising method in the catheterisation laboratory, while preparations are made for external pacing or a temporary wire or the administration of chronotropic medications.View this table:Active pad compression for defibrillationIn atrial fibrillation there are papers including the Ottowa AF Cardioversion protocol28 and the 2014 AHA guidelines for the management of patients with atrial fibrillation29 that mention using paddles to provide manual compression over the defibrillator pads as a method of increasing the success of cardioversion. The original citation as evidence in favour of this intervention was by Kerber et al30 in 1981 looking at 44 cardioversion patients, although, interestingly, the only part of this paper that actually looked at active compression was a subreport of four dogs who were cardioverted with or without active compression.Sirna et al in 1988 reported a 13% reduction in impedance with active compression when uniphasic defibrillation was being performed in 28 patients31 and a similar result was found by Ramirez et al in 2016 with 11 participants where they concluded that 8 kg of pressure could reduce the impedance by about 10%.32Thus, there is limited evidence from animal studies and case series, as well as a trial of cardioversion in atrial fibrillation, that active compression of the defibrillation pads using disconnected defibrillation paddles reduces intrathoracic impedance and improves shock efficacy.

In the absence of any studies in ventricular arrhythmias in humans the routine use of active compression during defibrillation is not recommended. However, the use of disconnected defibrillation paddles to apply external compression to defibrillation pads may be considered in patients with arrhythmias refractory to cardioversion particularly where there is a risk of high intrathoracic impedance.View this table:Does epinephrine improve outcomes in resuscitation in the catheter laboratory?. ILCOR in 2015 reviewed the literature with regard to epinephrine including a large RCT by Olasveengen et al33 where ambulances were randomised to Group 1. CPR and defibrillation with iv cannulation and usual resuscitation medications versus Group 2. CPR and defibrillation alone.

This RCT showed reduced survival to hospital discharge in Group 1 and this was felt to be due to the ineffectiveness of the drugs and also the delay in CPR in order to cannulate and administer the drugs. This paper, and a more recent meta-analysis34 (demonstrating no benefit of epinephrine in cardiac arrest) led ILCOR to write. €˜despite the widespread use of epinephrine during resuscitation, and several studies involving vasopressin, there is no placebo controlled study that shows that the routine use of any vasopressor at any stage during human cardiac arrest increases survival to hospital discharge. Current evidence is insufficient to support or refute the routine use of any particular drug or sequence of drugs. Despite the lack of human data, the use of epinephrine is still recommended, based largely on animal data’.The PARAMEDIC-2 Study35 randomised 8014 patients in an arrest situation across five ambulance services in the UK to receive either 1 mg of epinephrine every 3–5 min, or identical syringes containing 0.9% saline.

The mean time for the ambulance to arrive was 6.6 min and the mean time to trial drug administration was 13 min after arrival. There was a large increase in the number of patients who had return of spontaneous circulation in the epinephrine arm (36% vs 11%), as well as the number who were transferred to hospital (50% vs 30%). The primary outcome measure was survival at 30 days and this was 3.2% in the epinephrine group and 2.4% in the placebo group which was significant, but the number of survivors with severe neurological impairment was 31% in the epinephrine group versus 18% in the control group, and thus the trial was negative in terms of survival with favourable neurological outcome (2.2% vs 1.9%). The triallists concluded that epinephrine significantly improved the chance of achieving the return of spontaneous circulation and the survival of the patient to hospital admission but that it led only to a greater proportion surviving with severe neurological disability.In the light of this important study, we suggest that the current recommendations of giving epinephrine every 3–5 min at a dose of 1 mg is supported on the basis that it is unlikely to harm the patient and may be beneficial. We recommend that intravenous epinephrine (1 mg) is given after the third cycle.

It may be acceptable to administer smaller doses of epinephrine if a senior clinician feels that there may be reactive hypertension on ROSC.The guideline group also discussed the question of the administration of epinephrine in cases of a non-shockable rhythm. Current recommendations from the ERC are to give epinephrine at a dose of 1 mg as soon as possible but they do caveat this by saying that ‘exceptions may exist where a clear reversible cause can be rapidly addressed’. In PEA and asystole in the catheter laboratory there are reversible causes that should be addressed, and for this reason the group concluded that we should recommend administering epinephrine at the same time as in a shockable rhythm to allow time for reversible causes to be addressed.View this table:Waveform capnography in cardiac arrestWe recommend that waveform capnography is used for patients in established cardiac arrest. Not only does this prove that the airway is patent, and that there is reasonable air entry to allow the exchange of CO2, but more importantly the level of exhaled CO2 correlates with the cardiac output. Capnography can be used as a prognostic guide to the likely result of prolonged resuscitation.

An end-tidal CO2 more than 20 mm Hg (2.7 kPa) is a good prognostic indicator whereas an end-tidal CO2 of less than 10 mm Hg (1.3 kPa) indicates a poor prognosis and may be used to indicate that further treatment is likely to be futile or that modifications are required to the CPR to improve this figure.Goal-directed management during prolonged cardiac arrest in the catheter laboratoryA number of physiological parameters are associated with higher rates of ROSC. This has led to the hypothesis that higher rates of ROSC and better clinical outcomes might be achieved by goal-directed resuscitation techniques. This may be particularly relevant to the management of cardiac arrest in the catheter laboratory where resuscitation attempts may be prolonged and invasive monitoring is routine.36 ,37 ,38 Physiological parameters of interest based on our literature review on this topic are listed in table 1. This concept was investigated in a series of 10 patients who underwent mechanical CPR and PCI to treat prolonged cardiac arrest in the catheter laboratory.39 The average time of mechanical CPR was 43 min. Systolic blood pressures above 70 mm Hg and diastolic blood pressures above 40 mm Hg were targeted.

A pigtail catheter was inserted into the right atrium via the femoral vein at the interventionists discretion to monitor CVP and to administer vasoactive drugs. The investigators aimed to keep the CVP below 25 mm Hg. If this was not achieved, echocardiography was performed to exclude cardiac tamponade, the mechanical CPR device was repositioned, and inotropes or vasoconstrictors were initiated. End-tidal CO2 was measured following insertion of an endotracheal tube or a supraglottic airway with a target of >15 mm Hg (>2 kPa). The SpO2 was kept above 80%, and arterial blood gas measurement was used to guide ‘normo’ ventilation.

Cerebral oximetry was also monitored. Vasoconstrictor infusions were used in favour of epinephrine boluses. For patients in VF, attention was directed towards opening the acutely occluded coronary artery in favour of repeated attempts at defibrillation. The protocol was simulated in training prior to its institution. Early experience identified difficulties measuring all of the parameters every 2 min during ongoing cardiac arrest.

When the parameters were measured successfully, they regularly identified patients whose vital parameters were suboptimal.View this table:Table 1 Physiological parameters of interest.In the AHA ‘get with the guidelines registry’ of 3023 monitored cardiac arrests and 6064 unmonitored in-hospital cardiac arrests, those who had a monitored arrest had a significantly better chance of survival based mostly on blood pressure and end-tidal CO2 monitoring.40 The AHA recommended keeping the end-tidal CO2 above 20 mm Hg and the diastolic blood pressure above 25 mm Hg in their consensus statement on improving resuscitation outcomes.41A group in Greece wrote a discussion document proposing the ‘PERSEUS’ protocol in 2019 aimed at prolonged physiological monitoring of patients in cardiac arrest.42 They proposed mechanical CPR, and ventilating the patient with positive end expiratory pressure (PEEP) of zero, respiratory rate of 10 per min, tidal volume 6 mL//kg, 100% oxygen, inspiration:expiration ratio 1:2. In a previous observational study they had found higher airway pressure was associated with better outcomes, with a pressure of 40–45 mm Hg giving optimal outcome. They discuss the pitfalls of using end-tidal CO2 to estimate cardiac output and discuss how positive pressure ventilation may be used to augment cardiac output during chest compressions. They suggested placing a CVP line with the aim being to keep the CVP below 25 mm Hg and advocated that if the CVP was low, a straight leg raise should be performed to assess volume status and then fluid be given as indicated. They suggested using optimal positioning of the mechanical CPR device and epinephrine infusions to keep the diastolic blood pressure above 40 mm Hg and that severe acidosis be treated immediately to prevent vasodilation and decreased central perfusion pressure.Among over 1500 patients with out-of-hospital cardiac arrest in whom a venous blood gas was measured, adverse results were associated with a lower rate of survival.

In particular, patients without ROSC had a mean pH of 7.11, pCO2 of 9.7 kPa, base excess of −7 mmol/L, potassium of 4.5 mmol/L and a lactate of 7 mmol/L. Low pH, high pCO2 and high plasma potassium concentration were predictors of poor outcome.43A meta-analysis of goal-directed resuscitation identified mainly animal studies but did conclude that goal- directed CPR may be superior to standard CPR, especially when end-tidal CO2 and blood pressure management were targeted.44 It is important to emphasise that a low end-tidal CO2 may reflect inadequate ventilation rather than low cardiac output, especially when a supraglottic airway is used, because of the higher airway pressures required during chest compressions and steps should be taken in these cases to place an endotracheal tube as soon as it is safe to do so.Monitoring of the CVP allows an estimate of coronary perfusion pressure by subtracting the diastolic arterial pressure from the CVP. Ideally it should be kept above 20 mm Hg.The catheter laboratory is a unique environment in which physiological parameters can be accurately monitored during circulatory arrest. These parameters can be used to assess the effect of interventions such as the adjustment of cardiac massage technique, intravenous administration of vasoactive medications, correction of acidosis, electrolytes, and volume status, and less conventional treatments such as head-up CPR, while prolonged revascularisation attempts are ongoing or preparation is made for ECPR. Whether or not goal-directed resuscitation improves clinical outcomes, or even increases rates of ROSC, is not yet clear so firm recommendations for setting physiological parameter targets during cardiac arrest cannot be made.

Nevertheless, we recommend that teams consider recording physiological parameters during prolonged cardiac arrest (table 1). Green, amber and red indicate the potential impact of the physiological parameters achieved during cardiac arrest on ROSC and could be used to guide future research. Clinical decisions regarding cessation of resuscitation should not be based only on these parameters.View this table:Is amiodarone of use in a VF arrest in the catheter laboratory?. We sought evidence as to whether amiodarone or lidocaine may be useful for VF/pulseless VT. There is good evidence in support of Amiodarone in four large randomised trials,45–48 each demonstrating an improvement of the chance of successful cardioversion of about 10%.

It must be noted that these studies are all in the out-of-hospital setting and thus there is less certainty that the results might be equivalent in the in-hospital setting or indeed in a catheter laboratory.Amiodarone should be given as a bolus injection of 300 mg. A further dose of 150 mg may be given for recurrent or refractory VF/VT followed by an infusion of 900 mg over 24 hours. Lidocaine 1 mg/kg may be used as an alternative and may have a similar efficacy.49 There is less robust evidence regarding alternatives such as procainamide.View this table:The use of echocardiography during cardiac arrestEchocardiography can help to identify the cause for the arrest and should be performed rapidly as an integral part of the resuscitation. It is important to exclude tamponade early in the resuscitative process and also to repeat the echo in a prolonged arrest if the effectiveness of CPR diminishes abruptly as this may indicate tamponade secondary to external cardiac massage or delayed onset of tamponade. Echocardiography has also been shown to reduce the time taken for pulse checks50 by enabling visualisation of the presence or absence of organised contractions.In patients who already have a transoesophageal echo (TOE) probe in place this has advantages compared with transthoracic echocardiography51 in that it does not require interruptions of CPR, can be performed continuously with better images, can be used to identify ROSC quickly, to look for dissection of the ascending aorta and, if required, can aid placement of pacing wires or the initiation of ECPR.

It is also better at monitoring the effectiveness of prolonged mechanical CPR. In addition, there may be clinicians experienced in its use available in the catheter laboratory. Thus, if it is in place already it is preferred to transthoracic echocardiography, and if it is not in place then it should be considered, especially if prolonged arrest management is being planned, allowing for the risk of oesophageal damage in TOE placement of around 0.2%51View this table:Fluoroscopy in order to identify a pneumothorax in an arrest in the catheter laboratoryA literature review was performed in an attempt to find cases of pneumothorax identified by fluoroscopy in a catheter laboratory and to gain an understanding of the incidence of pneumothorax causing cardiac arrest, particularly after pacing procedures, or transaxillary, transcarotid or subclavian arterial approaches.Pneumothorax is not uncommon after attempted vessel puncture in the thorax, such as pacemaker and implantable defibrillator insertion, with an incidence of around 0.6%–1.0%.25 52If a pneumothorax is suspected it is straightforward to diagnose in the catheter laboratory by fluoroscopy, which has also been used to guide chest drainage in such situations.53In a cardiac arrest, one potential cause could be pneumothorax. Since there is immediate access to fluoroscopy, it is recommended that in a cardiac arrest with no clear cause identified, and especially if the patient is undergoing an intervention that is high risk such as pacemaker or ICD insertion, fluoroscopy is performed to exclude pneumothorax as a cause.View this table:How should the team balance chest compressions with attempts at percutaneous intervention in a cardiac arrest?. Interventions on the coronary arteries can be associated with occlusion, or reduced flow secondary to dissection or thrombus formation.

Other complications can include no reflow and perforation. In the majority of these circumstances, a key part of the ongoing resuscitation effort will involve a further intervention to treat or reverse the underlying cause. In order to preserve cerebral perfusion until a spontaneous circulation is restored, external cardiac massage is required. Manual cardiac massage cannot be achieved at the same time as fluoroscopy due to radiation exposure for the rescuer and therefore a balance must be struck between the interventionalist and those performing external chest compressions.The AHA, the ERC and the Australian Guidelines all address the issue of external cardiac massage in the catheter laboratory. The AHA recommend early transfer to automated CPR devices, the ERC recommend that external cardiac massage should not be interrupted for angiography and the Australian Guidelines discuss the tension between the rescuers performing external CPR and the interventionalist wanting to continue with angiography.

These statements have not translated into an agreed protocol that can be followed by the resuscitation team.We strongly recommend using only mechanical CPR devices to administer CPR while undergoing PCI during an arrest. It is reasonable to pause manual CPR in order to perform angiography to search for a cause for the arrest, but subsequent PCI should be performed with mechanical CPR.View this table:Mechanical CPR devicesThe use of mechanical CPR has been extensively investigated in at least nine randomised trials with over 12 000 patients in both out-of-hospital and in-hospital arrest.54–56 Several meta-analyses exist and support the use of mechanical CPR for in-hospital patients, although the evidence is less strong for use in out-of-hospital patients.56–60 ,61The AHA reviewed the feasibility of using mechanical CPR devices during PCI and identified papers where feasibility has been demonstrated in both animal62 and human63–66 studies. No comparative studies have examined the use of mechanical CPR devices compared with manual chest compressions during PCI procedures although, due to the inherent need to cease manual compressions during fluoroscopy, there is a clear benefit for mechanical CPR.A number of case reports62 63 and case series65–68 have reported the use of mechanical CPR devices to facilitate prolonged resuscitation in patients who have a cardiac arrest during PCI. One study demonstrated that the use of a mechanical CPR device for cardiac arrest during PCI was feasible. However, no patients survived to hospital discharge.65 Other studies have reported good patient outcomes, including ROSC and survival to discharge with good functional outcome.62 Of note the length of time required to perform PCI with a mechanical CPR device was around 30 min (ranging from 12 min to 90 min), which highlights further the importance of a protocol that allows prolonged CPR while PCI is ongoing.We are therefore strongly of the view that mechanical CPR devices are of major benefit to patients in the specialist environment of the catheter laboratory, for liberating rescuers from performing manual CPR and for the ability to perform uninterrupted CPR for at least 30 min while interventions are performed (Figure 2).

In addition, we strongly advocate the immediate availability of these devices in the catheter laboratory and regular team-based training in order to be able to place these devices with a pause of less than 15 s.69 70Fluoroscopic projections possible with the automatic external cardiac massage device in place. (A) Right posterior oblique. (B) Left anterior oblique. (C) Right anterior oblique. (D) Straight cranial.

(E) Straight caudal (with permission from Stryker Corporation)." data-icon-position data-hide-link-title="0">Figure 2 Fluoroscopic projections possible with the automatic external cardiac massage device in place. (A) Right posterior oblique. (B) Left anterior oblique. (C) Right anterior oblique. (D) Straight cranial.

(E) Straight caudal (with permission from Stryker Corporation).View this table:ECPR in the catheter laboratoryThe AHA and the ERC both recommend the use of ECMO to provide ECPR. The AHA state that ‘rapid initiation of eCPR or cardiopulmonary bypass is associated with good patient outcomes in patients with haemodynamic collapse and cardiac arrest in the catheter laboratory and also the use of eCPR is feasible and associated with good outcomes when used as a bridge to coronary artery bypass grafting’ (AHA Class IIb, LOE C). The ERC are more equivocal, stating that very low quality evidence suggests that the use of extracorporeal life support can be considered as a rescue strategy if the infrastructure is available, and this should probably be preferred to the use of intra-aortic balloon pump (IABP) in such situations. The First RCT in this area called the ARREST Trial was stopped early due to the highly significant effects in favour of ECMO in out of hospital cardiac arrest (OHCA). Thirty patients were randomised and there were six survivors in the ECMO group compared with only one in the standard care group.71 Furthermore, there are many case series reporting the efficacy of extracorporeal cardiopulmonary bypass72–80 in the context of catheter laboratory based cardiac arrests.

Bagai et al reported in 2011 on the use of extracorporeal cardiopulmonary bypass in 39 patients in a range of situations including cardiac arrest and cardiogenic shock in the catheter laboratory. The survival to discharge was 71%.76 Van den Brink in 201880 reported the use of extracorporeal cardiopulmonary bypass in 12 patients of whom 11 were in cardiac arrest with a survival to discharge of 67% and a 1-year survival of 42%. Nine had out-of-hospital arrest and a further two had in-hospital arrest.The Extracorporeal Life Support Organisation has published a position paper in 2018, advocating ECMO in arrests of longer than 15 min of duration, but centres offering ECMO are required to be looking after at least 30 patients a year and therefore will generally be located only in transplantation centres.81View this table:IABP insertion in the arrest situationThe evidence for the insertion of an IABP in an arrest situation was reviewed. Of note the AHA have also reviewed this evidence and concluded that while IABP counterpulsation increases coronary perfusion, decreases myocardial oxygen demand and improves haemodynamics in cardiogenic shock states, it is not associated with improved patient survival. They state that the role of IABP in patients who have a cardiac arrest in the catheterisation laboratory is not known.The IABP-SHOCK II Trial which randomised nearly 600 patients who were in shock from an acute myocardial infarction did not find an improvement in the 30-day survival after the intervention.82 This landmark study followed 13 RCTs together with meta-analyses and a Cochrane systematic review which were all unable to detect a significant improvement in 30-day survival although other small improvements were sometimes reported.83–90 It must be noted that although these studies were in patients with an acute myocardial infarction (rather than patients in cardiac arrest in a catheter laboratory) the IABP-SHOCK Trial has led to a significant reduction in the use of IABP in cardiogenic shock in catheter laboratories.A further small RCT looking at IABP versus control in patients who suffered a cardiac arrest with an acute coronary syndrome also found no benefit.91There are few studies looking at the insertion of IABPs in the arrest situation.92 93 Without a spontaneous circulation to trigger the IABP, counterpulsation would be unlikely to be successful.

Thus, it is concluded that there is no indication to place an IABP acutely in the cardiac arrest period in the catheter laboratory.View this table:Is an Impella pump useful in an arrest?. The ERC in 2015 stated in their section on cardiac arrest in the catheter laboratory that ‘There is no evidence to recommend circulatory support with the Impella pump only during cardiac arrest’ and in 2021 they changed this slightly to say that they may provide circulatory support while performing rescue procedures but require further evaluation. They provided a single reference to support this94 which was a case series of eight patients who had an Impella device in an arrest, of whom four survived to hospital discharge. We identified a further paper documenting use in 7 patients in arrest, although only 1 survived,95 and a multicentre study across four countries96 of 35 patients having Impella insertion while in cardiac arrest with a 45% survival.There have been case series and cohort studies of the use of the Impella in cardiogenic shock in adults and children97 and in high-risk PCI cases98–100 and there is an interesting ongoing RCT currently recruiting that aims to randomise 360 patients with shock post-myocardial infarction (MI) to standard therapy or Impella that will report in the coming years.101The 2021 joint ERC and European Society of Intensive Care medicine guidelines for postresuscitation care state that ‘the evidence about which type of mechanical device is superior appears inconclusive and thus their use should be decided on a case-by case basis’.95View this table:The identification and treatment of pericardial tamponadeSethi et al reported the findings of the US National Inpatient Sample database from 2009 to 2013 which covers around 90% of all patients in the USA. They document 64 000 pericardiocentesis procedures and 57% of these were in unstable patients, 17% were in PCI cases, 13% in EP procedures and 14% in structural heart procedures.

Thus, pericardiocentesis is performed in all types of catheter laboratory interventions.102 As this was a database study they were unable to comment on the procedural success rate, although the inpatient mortality in the database overall was around one in four.Tsang et al documented a 21-year experience with a thousand pericardiocentesis procedures at the Mayo clinic, including many patients with perforation in the catheter laboratory. They report a 97% procedural success for this procedure in all settings with only a 2% major complication rate. They also reported that they saw a significant increase in the rate that clinicians left a drain in situ during the period of the study from 25% to 75%.103Cho et al confirmed these findings in a report of nearly 300 echocardiographically guided pericardiocentesis procedures, with approximately 40 during PCI. They reported a 99% procedural success with a 1% complication rate.104A UK observational study of 270 329 PCI procedures in the context of acute coronary syndromes describes 1013 coronary perforations (0.37%).41 Importantly, the adjusted ORs for all clinical outcomes were adversely affected by coronary perforation. The conclusion was ‘Coronary perforation is an infrequent event during ACS-PCI but is closely associated with adverse clinical outcomes’.The ESC position statement on the urgent management of cardiac tamponade105 gives a class I indication for pericardiocentesis for tamponade, preferring echocardiographic guidance where possible although fluoroscopic guidance is an acceptable alternative.

If unsuccessful, surgical drainage is recommended. Of note these guidelines are mainly for non-iatrogenic causes of the tamponadeIt is extremely important that all catheter laboratories have immediate access to an echo machine in order to be able to confirm or exclude tamponade in an emergency. All cardiologists who perform interventional procedures should be trained in pericardiocentesis techniques, and all catheter labs should have a dedicated and easily accessible pericardiocentesis kit, which the team are familiar with. The emergency procedures for pericardiocentesis should be familiar to all catheter laboratory staff. The pericardiocentesis/perforation kit should be stored together and include drainage equipment, coils and covered stents.

There should be an agreed unit protocol as to the method of distal embolisation technique as a wide variety of options are available.In all cases of pericardial collection, repeat TTE should be performed within 2 hours of return to the ward and often again within the following few hours. This is particularly important in the case of distal wire perforations and any case in which a perforation has apparently sealed spontaneously.View this table:Treatment of pericardial tamponade if pericardiocentesis failsA BCIS analysis from 2006 to 2013 of the complete UK PCI database reported a 0.3% perforation rate with PCI.106 This comprised of 1762 patients of whom 14% developed tamponade (246 pts) and 3% required emergency surgery (52 patients). Thus, there are roughly 250 coronary perforations per year with around 35 associated episodes of tamponade and seven patients per year in the UK who require emergency surgery after coronary perforation.This number is likely to have increased since 2013. Furthermore, this database does not include pacing procedures, EP or structural heart procedures. Thirty-seven per cent of coronary perforations occurred in a unit without surgical cover (589 coronary perforations in units without on-site surgical cover compared with 997 in units with cover).

Coronary perforations can be classified using the Ellis Classification both in the arrest and the non-arrest situation according to the significance of the defect created in the artery.107With regard to the perforation of cardiac chambers from non-PCI interventions, the National Cardiovascular Data Registry in the USA108 documented 625 cardiac perforations in a 5-year period, which was one perforation for every 700 implantations of an ICD. The BHRS has provided detailed guidance in their 2016 document entitled ‘Standards for Interventional Electrophysiology and catheter ablation in adults’.109We recommend that for coronary perforations consideration be given to heparin and antiplatelet reversal, a decision that must be balanced against the risk of producing stent thrombosis. An activated clotting time could be used to guide this decision.We recommend there should be on-site availability and experience with covered stents, embolisation coils and the ability to perform distal embolisation. There should be an agreed unit protocol as to the method of distal embolisation technique as a wide variety of options are available.For perforation of cardiac chambers we also recommend consideration of reversal of heparin, calling for senior colleague assistance, where relevant withdrawal of the lead or wire from the perforation and echocardiographic monitoring for a tamponade.View this table:Surgical supportThere should be access to emergency cardiothoracic surgery for all patients who have suffered a tamponade in the catheter laboratory. In units without cardiac surgical cover, an agreed written protocol must be in place in order to ensure that timely relief of a tamponade is possible.

The time taken for a patient to sternotomy should be of a similar order to that possible with on-site surgical facilities where a surgical team is not on stand-by.Options to achieve this may include rapid transfer to the cardiothoracic centre with surgeons ready to receive the patient, or using experienced on-site surgeons trained in emergency thoracotomy to commence relief of a tamponade while a cardiac surgeon travels to the local centre. We recommend that these protocols be documented and tested regularly to ensure equitable availability of potentially life-saving interventions in both centres with and without on-site cardiac surgical cover.We furthermore recommend the notification of the on-call surgical team for all coronary perforations that cannot be sealed via percutaneous techniques, and all cardiac chamber perforations requiring a pericardiocentesis drain, even if they seem stable, so that the most appropriate management strategy can be agreed.View this table:The management of pulmonary embolusWe identified papers relevant to the management of either confirmed or suspected pulmonary embolus (PE) in cardiac arrest. In addition, the ESC have guidance on the treatment of PE110 and the AHA and ERC both give recommendations in this area.It may be difficult to determine PE as the cause of the cardiac arrest although in-hospital arrest teams have been able to identify PE up to 85% of the time.111 Teams may identify factors precipitating the cardiac arrest before the actual arrest which may include a high-risk history such as malignancy, previous PEs or recent surgery, they may identify symptoms such as dyspnoea, tachycardia and chest pain, and there maybe signs on ECG or a distended right ventricle on echocardiography prior to the arrest.Once the arrest has occurred, the arrest rhythm is more commonly PEA (63%) versus only 5% in VF.112 Echocardiography during the cardiac arrest may identify a distended right ventricle with a flattened interventricular septum in cases of PE large enough to precipitate arrest,113 although right ventricular dilatation in arrest should be interpreted with caution.114In terms of the treatment of the PE in the cardiac arrest Li et al published a meta-analysis in 2006115 of eight papers that demonstrated that thrombolytics administered during CPR did improve survival, although inevitably there was also an increase in bleeding complications. In an RCT of 1000 patients with out-of-hospital arrests randomised to thrombolytic therapy, no improvement in survival was seen but the percentage of patients who actually had PE may have been low in this study.116The ERC recommend the use of fibrinolytics for patients suspected of arresting secondary to a massive pulmonary embolus.8 They also recommend that CPR should then continue for 60–90 min and that a mechanical compression device may therefore be required for this. In addition, if there is return of spontaneous circulation then particular attention should be paid to identification of bleeding complications thereafter and in centres where this is available ECPR could be considered.117–122The AHA gives a class IIb indication for echocardiography during cardiac arrest stating that ‘if a qualified sonographer is present and use of uasound does not interfere with the standard cardiac arrest treatment protocol, then uasound may be considered as an adjunct to standard patient evaluation’.

The AHA recommend thrombolysis with a class IIb strength of recommendation in addition to systemic anticoagulation. The AHA also mention the possibility of percutaneous mechanical thrombectomy although many units would not have access to this as it requires specialist equipment. One case series reported a successful outcome of percutaneous mechanical thrombectomy during CPR in six out of seven patients.We also discussed whether in an arrest where PE is suspected in the catheter laboratory pulmonary angiography should be performed, but technically this was felt to be difficult to perform.123View this table:Return of spontaneous circulationOnce there has been a return of spontaneous circulation a full airway, breathing, circulation examination should be performed. Angiography and echocardiography should be considered where appropriate. If the patient has not neurologically recovered sufficiently or their gas exchange is unfavourable it is often safer to intubate and ventilate.

Appropriate vascular access with a central line and an arterial line will allow cardiac monitoring and vasoactive drug use as necessary. It is important that such patients are treated in an intensive care area environment if ventilated and at least a high care area otherwise. If there has been a prolonged period of arrest then targeted temperature management has been extensively investigated especially in out-of-hospital arrests124 and may help a patient who has had a prolonged arrest. However there have been no in-hospital studies to demonstrate benefit and the target temperature has not been established and therefore routine early cooling is not recommended.Perhaps more importantly the possible longer-term effects of arresting in the catheter laboratory should be considered. If the patient makes a good physical recovery, they should be fully counselled as to the events that occurred in the arrest and consideration of additional or prolonged follow-up should be given to make sure that they suffer no neurological or psychological sequelae.

The ERC and the European Society of Intensive Care Medicine have written detailed guidance in 2021 for postresuscitation care which addresses many of these issues125 and in addition to this there is excellent patient support at the website www.suddencardiacarrest.org.The optimal configuration for the cardiac arrest teamIn order to carry out emergency protocols efficiently, whether they be in an arrest situation or with a deteriorating patient, it is vital for all team members to know their roles and responsibilities. There may be a wide variety of staff numbers and skill mixes available in the catheter laboratory area depending on the size of the institution and also the time of day or night. Therefore, there will clearly also have to be some flexibility and also additional roles that might be allocated, but we propose these six key roles to allow a structure for people to work towards (Figure 3). In addition, it is optimal that the staff members will know in advance the role that they would be expected to take in an emergency, and that this could be documented on a communication board at the start of a shift.The six key roles. BCIS, British Cardiovascular Intervention Society.

BHRS, British Heart Rhythm Society. CPR, cardiopulmonary resuscitation." data-icon-position data-hide-link-title="0">Figure 3 The six key roles. BCIS, British Cardiovascular Intervention Society. BHRS, British Heart Rhythm Society. CPR, cardiopulmonary resuscitation.The operatorWhile the cardiologist takes the lead in the catheter lab, the main aim of our protocols is to free this person up of responsibility for resuscitation in the cardiac arrest or the emergency situation.

The cardiologist should stay scrubbed at the side of the patient. They are often the person to see the emergency first, and thus must declare this early to the team but thereafter an emergency team leader should be allocated.The cardiologist is best placed to perform the specialist interventions that may resolve the situation. They should concentrate on this aspect of the pathway and coordinate with the other staff addressing resuscitation via the team leader.Role 1. The emergency leaderWe recommend that someone other than the operating cardiologist organise the team to achieve the best outcome for the patient. We do not mandate who this person should be in terms of their discipline or qualifications, and in fact we are of the opinion that everyone who works in a catheter laboratory should be trained to be able to carry out each of the six key roles, although often in the day there might be another senior cardiologist who will be available to perform this role.The role is to coordinate the protocols highlighted above as the leader of the group addressing all the components of the arrest response.

The leader is encouraged to have the protocol to hand on a flip chart or on a poster.The emergency leader must make sure personnel are allocated to all required roles and will also allocate tasks to additional people, outside of the six key rolesRole 2. Airway and breathingIf there is any acute emergency and especially in an arrest, the scrubbed personnel will be dealing with the circulation, so another member of staff should go straight to the head of the patient to take responsibility for airway and ventilation. For a person who is not breathing they must immediately get a bag/valve/mask at 100% oxygen and place this on the patient’s face and attempt to ventilate the patient. If they are successful, then the chest will rise on both sides, and water vapour may be seen in the mask. If they are unsuccessful then an airway obstruction issue must be considered.

Attempt airway manoeuvres—jaw thrust, chin lift, Guedel airway and perhaps ask another person to help with squeezing the bag so you can use two hands to form a good seal around the patient’s nose and mouth. We do not recommend that staff who are not fully trained in the technique attempt intubation. In most instances simple airway manoeuvres and airway adjuncts will suffice. A supraglottic airway is a recommended alternative to intubation. Emergency call-out for anaesthetic support is mandatory in this situation.Once air entry is established in an arrest you must coordinate 30:2 with the person performing massage or the automated CPR device.

Your role also requires you to feel the trachea to see if it is central or displaced and then ask everyone to stop massage and bag forcefully while listening bilaterally to see if you can hear a difference in breath sounds.It is mandatory to perform these assessments in every critically ill catheter laboratory patient if you do not know the cause of their deterioration, and you must communicate that you have done this to the team leader. It is not always easy to, but if you are getting air entry from bagging but it is more difficult than you would expect, if the trachea is not central and if you bag vigorously but cannot hear breath sounds on one side then a pneumothorax or haemothorax should be suspected and this must be communicated to the team leader. We also recommend that fluoroscopy is performed for every arrested patient without an obvious cause for the arrest.If a tension pneumothorax is suspected, for example, oxygen saturations dropping and the patient complaining of being short of breath before becoming periarrest or arresting during a pacing procedure, then needle thoracocentesis should be performed followed by a drain or a thoracostomy.Role 3. Defibrillation and pacingWe recommend that a single person is always allocated to this role and stays beside the defibrillator at all times, even if the rhythm is not shockable. The person fulfilling role 3 should place pads on the patient wherever it is most convenient.

Often they will be draped and therefore access will be limited but this will have been practised in simulation so should not be an issue. Anterior-lateral position, an anterior-posterior position or apex-posterior positions are all acceptable.Where the rhythm is shockable we recommend immediate three-stacked shocks. Once the first shock has been delivered, external cardiac massage should not be recommenced, but the rhythm assessed while the defibrillator is being charged for the next shock. If there is no ROSC and the rhythm remains shockable, up to two further shocks should be delivered in rapid succession. The defibrillator operator is responsible for communicating to the team when the defibrillator is charging and before each shock.If the third shock fails then further shocks may be given at 2 min intervals as determined by the resuscitation leader and the operating cardiologist.

Most defibrillators when turned on, activate a timer, so the defibrillator operator is often the best person to time the CPR cycles.Role 3 is also important in the two other rhythm disturbances. In asystole or extreme bradycardia without a pulse, external pacing may rapidly resolve the situation. We recommend that percussion pacing is attempted while pads are placed on the patient, and it is also important that defibrillators cannot pace and sense from the same pads and thus it is mandatory that ECG leads are placed on the patient and connected to the defibrillator prior to attempting external pacing. We recommend that external cardiac massage is withheld until the pacing is attempted. When the pacing is activated on the defibrillator it usually defaults to the minimum amplitude, and therefore this will have to be increased to achieve capture.

If capture is not achieved at maximum amplitude then it is unlikely to work unless the pads are poorly placed and the attempt can cease. If it is felt likely that the asystole or extreme bradycardia could be resolved with pacing, and both percussion and external pacing were unsuccessful then the final option would be a temporary wire to be placed in an arrest situation by the cardiologist.Defibrillation is not required in PEA arrest but the defibrillator operator should ensure that underlying VF or asystole is not mistaken for PEA in patients with either a temporary or permanent pacemaker in place. We are aware of three cases when this occurred and although rare, if there is a temporary wire with pacing this can be paused to check, or if there is a permanent pacemaker then a relatively narrow QRS complex with a regular rate should raise this suspicion.Role 4. Manual chest compressionsOne person should be allocated to perform CPR. If there are very limited numbers of people in the room at night then either the cardiologist or the scrub nurse could do this but it is an important role and having an allocated person is preferable.CPR is withheld if the arrest is VF or asystole until shocks have been administered or the external pacing has been commenced, but if this has failed then CPR must be commenced.

The person performing CPR will most likely need to be on the opposite side of the table to the cardiologist, and if the table is fairly high they may need a step to stand on. Hands should be linked together and elbow straight and CPR is performed on the lower half of the sternum.View this table:The general algorithm recommends a depth of 5–6 cm and there are devices available to measure whether you are compressing adequately, but if your patient has an arterial line in place then in fact this can function as a direct measure of the quality of your CPR. In this situation you should compress the chest hard enough that you achieve a systolic pressure of 70 mm Hg. It is also important to note that if you have a well-functioning arterial line and you are compressing as hard as you can but you are unable to achieve a systolic pressure of 70 mm Hg this implies that there is a mechanical cause to the arrest such as a tamponade or a bleed, as it indicates either that the heart is compressed by tamponade and cannot fill with blood to eject, or that the heart is empty of blood due to blood loss. The inability to maintain a systolic pressure of above 70 mm Hg requires you to immediately notify the team leader and cardiologist.Role 5.

Mechanical CPR, drugs, timing and vascular accessSome smaller centres or primary PCI sites in the middle of the night will not have six people in the catheter laboratory, but in the day-time many busy catheter laboratories will have sufficient numbers of people immediately available. Therefore we considered protocols from four to eight allocated members and propose six roles here The role of having a person in charge of mechanical CPR, drug administration, vascular access and timing we would regard as highly desirable assuming there is adequate personnel available. This person’s first role would be to immediately obtain the mechanical CPR device, turn it on and prepare it for placement after the first cycle of CPR. Then this person can stand by the person allocated to airway and breathing and give mediations as per protocol.There are some key drugs that this person would need to have immediately available. Epinephrine in an arrest should be given at a dose of 1 mg every 3–5 min.

We mandate its administration after the third cycle in the protocol for all arrest rhythms. It should then be given every other cycle which is again in line with the general algorithm unless the arrest is likely to be prolonged in which case the team leader will determine whether an infusion or a vasoconstrictor may be better.If the arrest is due to a resolvable mechanical issue such as a tamponade that needs draining, it may be best to withhold the epinephrine to avoid its proarrhythmic effects and potential hypertension once the tamponade is removed which may risk further bleeding from the vessel that caused the tamponade in the first place.The second drug in VF arrest is amiodarone. It has been shown to have a 10% increased change of defibrillation being successful in several RCTs and is recommended in all algorithms after the third cycle.The third drug to mention in cardiac arrests is atropine. It was removed from the universal algorithm in 2015 due to lack of efficacy in the arrest situation and therefore it does not appear in our arrest algorithm. It is important to remember that it is still an important medication in bradycardia with a pulse when the patient has not arrested and it is recommended at a dose of 600 mcg, repeated up to 3 mg so long as the patient has a pulse.

This issue has caused some confusion in the past.Finally it is useful to mention that in cases of oversedation naloxone at a dose of 400 mcg repeated every 3 min up to 10 mg will immediately reverse the effects of morphine and fentanyl, and intravenous flumazenil at 200 mcg repeated every 30 s up to 3 mg will equally effect a rapid reversal of midazolam and other benzodiazepines and that in a prolonged arrest infusions and bicarbonate may be required.Role 6. Resource coordinatorThere are often many members of the team available to help in an emergency situation and on simulations and observations of real-world emergencies it is clear that there has to be a great deal of organisation behind the actual arrest or acute emergency. The emergency team leader needs to be by the patient and coordinating everything in the room but there have to be advanced lines of communication between the catheter lab, the coronary care unit (CCU), the arrest team, the ICU, echocardiographers and also other clinicians in the other catheter labs.Therefore we feel this line of communication is sufficiently important to have a specific allocated role. If other personnel arrive, such as anaesthetists and surgeons then the resource coordinator can hand them lead aprons (and remind them that they must be worn) and while they are being put on then they can brief the person as to the case and what the nature of the emergency is. They may also be able to direct them to look at the communication board and to go and see the emergency leader rather than going into the room and immediately talking to the cardiologist.It is possible that this role may fall to the radiographer who is a key member of the team and will most usually be at the foot of the table..

Scope and methodsThis guideline covers adult patients undergoing my site any invasive procedure in the catheter laboratory, including propecia cost per pill coronary angiography, PCI, structural heart interventions including TAVI and mitral valve procedures, pacemaker and ICD implantation, arrhythmia ablation, atrial appendage occlusion, and pacing system extraction. We did not consider patients who suffer a cardiac arrest and are then brought to the catheter laboratory as these patients have recently been considered in a position paper by the European Society of Cardiology (ESC).4The guideline was developed by a collaboration between nine stakeholder organisations. The British Cardiovascular Society (BCS), the British Cardiovascular Intervention Society (BCIS), the British Heart Rhythm Society (BHRS), the British Association for Nursing in Cardiovascular Care, the British Society of Echocardiography, the Association for Cardiothoracic Anaesthesia and Critical Care, the Cardiovascular Care Partnership UK, the Society for Cardiothoracic Surgery in Great Britain and Ireland, and the Resuscitation Council UK.These guidelines were developed in accordance with The Resuscitation Council UK 2021 guidelines development process.5 We used the ESC 2018 practice guidelines recommendations for grading the strength of recommendations and for assessing the levels of evidence in support of them.6 It should be acknowledged that the literature surrounding cardiac arrest comprises mostly of papers which reported the findings of studies after either in-hospital or out-of-hospital cardiac arrest rather than after cardiac arrest in the catheter laboratory and that their findings were extrapolated to the catheter laboratory environment.We undertook a comprehensive review of the literature and a Delphi expert consensus process in order to identify all of the situations in the catheter laboratory that potentially lead to cardiac propecia cost per pill arrest and to provide team-based solutions to their management.

We propose these guidelines as the standard of care in this specialist area.The International Liaison Committee on ResuscitationAccording to international guidelines, resuscitation is governed by The International Liaison Committee on Resuscitation (ILCOR) which is a collaborative of seven world resuscitation councils which was founded in 1992. The full range of all recommendations in the area of resuscitation is reviewed and updated and a propecia cost per pill document of the ‘best evidence’ in resuscitation is created. The seven resuscitation councils then take this evidence and generate guidelines adapted to the needs of their own healthcare systems.The American Heart Association guidelinesThe 2015 American Heart Association (AHA) guidelines contain a two-page section entitled ‘Cardiac Arrest During Percutaneous Coronary Intervention’, although this was omitted from its 2020 guideline.7 In 2015 the AHA concentrated mainly on a discussion on the use of automated CPR devices over manual compressions and the use of extracorporeal CPR (ECPR) devices.

It did not come to any firm conclusion but stated that mechanical CPR devices and ECPR devices have been used as bridges to other interventions such as coronary artery bypass surgery, propecia cost per pill cardiac transplantation or longer-term mechanical devices. In the text of the guideline it is also noted by the authors that early defibrillation within a minute of cardiac arrest is associated with excellent outcomes. No other special considerations were discussed with propecia cost per pill regard to the management of cardiac arrest in the catheter laboratory.The European Resuscitation Council guidelinesThe European Resuscitation Council (ERC) published guidance regarding resuscitation in the catheter laboratory in 2021 in its document entitled ‘cardiac arrest in special circumstances’.8 It included a protocol diagram, and there was a strong emphasis on ensuring that catheter laboratory staff are adequately trained in resuscitation technical skills including team training, and specific protocols for the initiation of mechanical CPR, temporary pacing and pericardiocentesis, with the use of on-site emergency drills.

The ERC also recommended the availability of resuscitation equipment and the use of checklists. Mechanical CPR was recommended due to the risk to staff from manual CPR during fluoroscopy, and the requirement to continue CPR during PCI.The Australian and New Zealand guidelinesThese guidelines discussed the use of mechanical CPR propecia cost per pill in cardiac arrest during PCI.9 They also discussed cough CPR for which they found case reports regarding its use during electrophysiology (EP) procedures. They discussed treatment of cardiac tamponade during cardiac arrest by thoracotomy and pericardiotomy if pericardiocentesis fails with a class B recommendation.

They noted that the interventionalist is heavily task burdened and, as such, is seldom in a good position to lead the resuscitation and that there may be tension between the requirement to perform CPR and the ability of the interventionalist to continue with the procedure, thus acknowledging two of the particular challenges faced by the catheter laboratory team during a cardiac arrest.A novel protocol for the management of patients who suffer a cardiac arrest in the catheter laboratoryWe have developed a modified resuscitation protocol which is propecia cost per pill specifically designed for the specialist area of the catheter laboratory. Of note this does not apply to recovery areas but does apply to hybrid laboratories where TAVI or Mitraclip procedures are being undertaken. This protocol could also be used in hybrid laboratories performing thoracoscopic endovascular aortic propecia cost per pill repair (TEVAR).

The full protocol is shown in figure 1 and the rationale for its development is discussed.Protocol for resuscitation of patients who suffer a cardiac arrest in the catheter laboratory. BCIS, British Cardiovascular Intervention Society. BHRS, British propecia cost per pill Heart Rhythm Society.

CPR, cardiopulmonary resuscitation. PCI, percutaneous propecia cost per pill coronary intervention. PE, pulmonary embolus.

PEA, pulseless electrical activity propecia cost per pill. ROSC, restoration of spontaneous circulation. TAVI, transcatheter propecia cost per pill aortic valve implantation.

VF, ventricular fibrillation. VT, ventricular tachycardia." data-icon-position data-hide-link-title="0">Figure 1 Protocol for resuscitation of patients who suffer a cardiac arrest in the catheter propecia cost per pill laboratory. BCIS, British Cardiovascular Intervention Society.

BHRS, British propecia cost per pill Heart Rhythm Society. CPR, cardiopulmonary resuscitation. PCI, percutaneous propecia cost per pill coronary intervention.

PE, pulmonary embolus. PEA, pulseless electrical activity. ROSC, restoration propecia cost per pill of spontaneous circulation.

TAVI, transcatheter aortic valve implantation. VF, ventricular propecia cost per pill fibrillation. VT, ventricular tachycardia.How should cardiac arrest be identified, defined and categorised?.

In a catheter propecia cost per pill laboratory a cardiac arrest is identified much more quickly than other in-hospital arrest scenarios. Ventricular fibrillation (VF), pulseless ventricular tachycardia (VT) and asystole may be diagnosed immediately when a continuous intra-arterial blood pressure is displayed, without need for an added pulse check.It is important to define what constitutes a cardiac arrest in a catheter lab. In contrast to propecia cost per pill the two pathways in the standard arrest algorithm we have separated the protocol into three pathways.

VF or pulseless VT, asystole or extreme bradycardia, and pulseless electrical activity (PEA).In VF or pulseless VT, the pulse oximeter and arterial trace will confirm the absence of a cardiac output. A cardiac arrest should propecia cost per pill be called and the operator should tell the team if they know the reason for the arrest (eg, vessel dissection or occlusion in PCI, occluded left main stem in TAVI or irritation of the ventricle in a pacing procedure for example). VF or VT is occasionally deliberately induced in EP labs and this should not trigger the arrest protocol.Temporary asystole or extreme bradycardia (<30/min) may occur and can be anticipated during manipulation of ventricular pacing leads or EP catheters.

A cardiac arrest should propecia cost per pill be called when the rhythm disturbance is unexpected and or prolonged. The pulse oximetry and any arterial transduction will show non-pulsatile traces, and percussion pacing, external pacing or temporary wire pacing may be attempted prior to chest compressions.Many cases of PEA may be diagnosed by the absence of a pulsatile waveform on a continuous intra-arterial blood pressure display. Non-pulsatility or minimal pulsatility of the arterial trace propecia cost per pill and pulse oximetry in the presence of continuing electrical activity confirms the diagnosis.

The operator should call it a cardiac arrest and inform the laboratory team of the likely cause.Pulseless VT can be mistaken for PEA. A regular rhythm above 140/min should be considered as pulseless VT if the arterial trace and pulse oximetry have minimal or absent pulsation and the patient has lost consciousness. Similarly extreme bradycardia may be mistaken for PEA if the arterial propecia cost per pill trace is not being transduced.

It may be necessary to feel the pulse for 10 s or alternatively (and optimally) to perform a rapid echocardiogram to identify a cardiac output.Occasional patients will deteriorate in the catheter laboratory with support devices in place such as left ventricular assist device (LVAD), extra corporeal membrane oxygenation (ECMO) or Impella (Abiomed), where non-pulsatility does not equate with an absent cardiac output.Should all members of the resuscitation team wear lead aprons?. All clinicians coming into an arrest in the catheter laboratory should wear lead propecia cost per pill aprons. Our protocol uses the members of the team present in the catheter laboratory in the initial stages of the arrest and, thus, it is strongly recommended that everyone entering the room should wear lead aprons as it is very likely that the cardiologist may need to perform fluoroscopy in many emergency situations.We recommend that catheter laboratory team members are regularly trained in basic airway management to ensure a patent airway and good oxygenation for all patients, to ensure that the anaesthetic team have adequate time to put on protective lead before entering the laboratory.

We recommend that an individual in the catheter laboratory team is allocated to manage the personnel coming into propecia cost per pill the arrest. They will be required to assist these personnel to put on lead, and as they do this, they will be able to brief these clinicians as to the arrest situation in the catheter lab.Catheter laboratories must also ensure that lead aprons in a range of sizes are immediately available for emergency team members.View this table:Should we defibrillate before external chest compressions?. In 2020 ILCOR published a literature review on this subject10 and it was identified as a priority area for the Basic Life propecia cost per pill Support Taskforce.

They found that in five randomised controlled trials (RCTs)11 ,12 ,13 ,14 ,15 there was no difference in outcomes with a specified period of chest compressions (typically 1.5–3 min) before shock delivery compared with shock delivery as soon as possible with interim brief CPR while the defibrillator was readied for use. A meta-analysis propecia cost per pill of these studies (n=10 600 patients) also found no differences. Only when the arrest time was more than 5 min did any studies show an improvement with CPR before defibrillation.16 ,17 The ERC 2021 guidelines8 do not recommend the routine delivery of a prespecified period of CPR before rhythm analysis and shock delivery, and recommend shock delivery as soon as it can be applied.

Deferring chest compressions until after shock delivery has been recommended in the ERC 2021 propecia cost per pill guidelines8 in other highly monitored areas such as after cardiac surgery and these now state. €˜If a patient has a monitored and witnessed cardiac arrest (eg, in the catheter laboratory, coronary care unit, or other monitored critical care setting in or out-of-hospital) and a manual defibrillator is rapidly available. Confirm cardiac arrest and shout for propecia cost per pill help.

If the initial rhythm is VF/pVT, give up to three quick successive (stacked) shocks. Rapidly check for a rhythm change and, if appropriate, ROSC after each defibrillation attempt. Start chest compressions and continue CPR for 2 min if the third shock is unsuccessful’.View this table:How many attempts at defibrillation should be propecia cost per pill performed prior to commencing external chest compressions?.

Evidence was sought for the optimal number of attempts at external defibrillation for VF or pulseless VT prior to commencing external chest compressions. This has been subject to a literature review looking at the effectiveness of the numbers of defibrillation attempts in a range of scenarios including ICD propecia cost per pill insertions, electrophysiological studies, out-of-hospital arrests and animal studies.18 When the data from all 15 papers are combined, the average success rate of sequential shocks declines from 78% for the first shock to 35% for the second shock and 14% for the third, and any subsequent shock will have less than a 10% chance of success. Thus, the likelihood of successful cardioversion declines dramatically from first to second shock and declines further from second to third shock.Our guideline seeks to place a mechanical CPR device on the patient early in the pathway and it is important to consider how we modify the protocol to allow this.

First, it may propecia cost per pill be possible to assess the rhythm while the mechanical CPR is ongoing. Our patients often have multi-lead ECG monitoring, and sometimes intracardiac ECG monitoring, and thus where the team leader is satisfied that there has been no change from the shockable rhythm, there is no need to pause the CPR device every 2 min. If the team leader is propecia cost per pill uncertain then a pause should be performed every 2 min for rhythm assessment.

As there is no risk to a rescuer, charging and administration of a shock may be performed while mechanical CPR is ongoing. Finally, if multiple shocks have propecia cost per pill failed to cardiovert the patient and it is clear that a coronary occlusion is the cause of the arrhythmia, then mechanical CPR should continue uninterrupted until coronary flow is restored.View this table:Should we perform pacing in patients who undergo an asystolic arrest in the catheter laboratory prior to external chest compressions?. In an asystolic arrest in a catheter laboratory there is the potential to rapidly restore cardiac output with pacing and, as this is a witnessed arrest, if pacing is performed immediately then potentially there will be an immediate restoration of a spontaneous circulation.

Furthermore, in the literature review on the effectiveness of external chest compressions in the early stages of an arrest19 it was found that there was propecia cost per pill little evidence to suggest harm from delaying external chest compressions for a few minutes. Periods of asystole are not uncommon in pacing and electrophysiology (EP) laboratories and most cardiologists would use external, percussion or transvenous temporary wire pacing to address this as a routine part of their practice. We recommend propecia cost per pill that pacing should be attempted prior to the initiation of external chest compressions.Percussion pacing may initially be attempted (see the section below for further details).

For external pacing the pacing pads should be applied, and the amplitude of the pacing quickly increased to regain an output. Only if capture is not obtained with maximum amplitude with the pads propecia cost per pill well applied should external chest compressions be performed. If the cardiologist suspects that the arrest is due to an extreme bradycardia due to a conduction defect then transvenous pacing can be used if external pacing has been ineffective in achieving ventricular capture.View this table:Interventions to address PEAOur protocol using three categories aims to ensure that the greatest number of patients possible may benefit from either immediate defibrillation or pacing prior to the institution of external cardiac compressions.

In patients presenting with PEA efforts should be directed towards identifying the underlying causes and treating them rapidly. There are a propecia cost per pill number of possibilities to consider that are relevant to the catheter laboratory:Hypoxia. There is an airway and breathing protocol with a person allocated to address these issues in an arrest.Hypovolaemia.

Bleeding. Our recommendation ensures that the four most likely areas for bleeding in the catheter laboratory (haemothorax, retroperitoneal or vascular bleed, aortic dissection and tamponade) are investigated.Hypo/hyperkalaemia, H+ ion imbalance and electrolyte abnormalities are addressed by a recommendation to perform an early blood gas.Hypothermia is unusual in a catheter lab, other than following prolonged out of hospital arrestTension pneumothorax may arise during procedures requiring vascular access in the thorax. This is addressed in the airway and breathing protocol and by fluoroscopy.Tamponade.

Where tamponade is a possibility immediate echocardiography should be performed. The clinical sign most suggestive of tamponade in a cardiac arrest is the inability to generate a systolic blood pressure of 70 mm Hg with external cardiac massage.Toxins. One possible cause of a toxin-related arrest in a catheter laboratory is a drug error.

We recommend that any syringe drivers or infusions should be stopped in the arrested patient to address this possibility. Careful consideration should also be given to contrast-induced or antibiotic-induced anaphylaxis. Look for supportive signs such as rash, wheeze or facial swelling.

Our protocol recommends epinephrine 0.5 mg intramuscular or otherwise 50 mcg intravenous.Thrombosis. Coronary or pulmonary. In the catheter laboratory this would most commonly relate to acute coronary occlusion, either due to an acute myocardial infarction or a complication of PCI which in both circumstances would be treated by reopening of the vessels by PCI.

Pulmonary embolism causing an arrest is far less common. In an arrest situation it can be very difficult to diagnose but is suggested by disproportionate right ventricular distention. If suspected, then thrombolysis or thrombectomy might be considered.

This is considered in our protocol.How deeply should we perform chest compressions?. The universal algorithm recommends compressing the chest to between 5 cm and 6 cm over the lower half of the sternum.7 8 For those patients with an arterial trace being transduced, we recommend ‘titrating’ chest compressions to achieve a systolic pressure of 70 mm Hg. This allows more gentle external compressions to be performed, potentially reducing the chance of compression related injury, while still producing effective cerebral perfusion.

Furthermore, the inability to generate an acceptable systolic pressure is suggestive of tamponade.View this table:Should we perform a precordial thump?. The AHA guidelines20 state that ‘The precordial thump may be considered for termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb, level of evidence (LOE) B), but should not delay CPR and shock delivery’. ILCOR produced a worksheet on this subject in 2021.21 This documents that precordial thump is only effective in 2% of attempts and, in fact, rhythm deterioration is twice as common as successful cardioversion.

Thus, our protocol does not recommend a precordial thump. A defibrillator should be immediately at hand in every catheter laboratory, and this is much more likely to successfully cardiovert the patient.View this table:Is cough CPR an effective alternative to external chest compressions in the catheter laboratory?. The AHA stated in 2010 that ‘cough’ CPR may be considered in settings such as the cardiac catheterisation laboratory for conscious, supine and monitored patients if the patient can be instructed and coached to cough forcefully every 1–3 s during the initial seconds of an arrhythmic cardiac arrest.

It should not delay definitive treatment (Class IIb, LOE C). The AHA made no modifications to this recommendation in 2020.7The longest documented case of a patient maintaining their own spontaneous circulation is 90 s and most reports were around 30 s, in both VF as well as asystole. These patients seem able to maintain consciousness in a manner similar to the mechanism proposed for external CPR, namely a compression of the pulmonary vascular bed increasing the pressure in the left atrium then ventricle and allowing blood to flow across the aortic valve.22 There are case reports of its use for short periods of time in the catheter laboratory,23 including prior to defibrillation24 25 but the most effective use seems to be in patients with severe bradycardia who are periarrest.

ILCOR performed a systematic review in 2021.21 Their conclusion was as follows. €˜We suggest cough CPR may only be considered as a temporising measure in an exceptional circumstance in a witnessed, monitored, in-hospital setting (such as a cardiac catheterisation laboratory) if a non-perfusing rhythm is recognised promptly before loss of consciousness (weak recommendation, very-low-certainty evidence)’.If a bradycardic or asystolic cardiac arrest is very rapidly identified (while the patient is responsive), then it is reasonable to attempt to coach the patient to cough forcefully every 1–3 s if experienced clinicians choose to try this. This should not delay the commencement of the cardiac arrest protocol including the application of pads and defibrillating or pacing if necessary.

Staff should be ready to perform CPR if the patient stops following the command to cough, and the arterial trace should be observed to monitor the effectiveness of cough CPR.View this table:Percussion (fist) pacing as an alternative to CPR in the catheter laboratoryILCOR performed a systematic review on this subject in 2021.21 The total number of cases reported in the literature is around 170 patients and in the largest series of 100 patients, 69 of these maintained consciousness and 90 had percussion pacing as an alternative to CPR.26In a study performed in 197827 19 healthy volunteers and 31 patients with paused pacing had a right heart catheter and the authors found reliable electrical impulses could be reproduced for up to 6 min when the left lower sternum was struck with the clenched fist from about 20–30 cm height, by causing the right ventricular pressure to rise by around 20 mm Hg with this action.The ILCOR 2021 systematic review states that ‘We suggest fist pacing may only be considered as a temporising measure in an exceptional circumstance in a witnessed, monitored, in-hospital setting (such as a cardiac catheterisation laboratory) if a non-perfusing rhythm is recognised promptly before loss of consciousness’.The catheterisation laboratory is a highly monitored environment where bradycardia and asystole are common. There have been no studies comparing CPR to percussion pacing directly but percussion pacing has been shown to effectively induce cardiac contraction and maintain consciousness in patients immediately identified as having an asystolic arrest. Therefore, with close monitoring, we recommend that this could be a useful temporising method in the catheterisation laboratory, while preparations are made for external pacing or a temporary wire or the administration of chronotropic medications.View this table:Active pad compression for defibrillationIn atrial fibrillation there are papers including the Ottowa AF Cardioversion protocol28 and the 2014 AHA guidelines for the management of patients with atrial fibrillation29 that mention using paddles to provide manual compression over the defibrillator pads as a method of increasing the success of cardioversion.

The original citation as evidence in favour of this intervention was by Kerber et al30 in 1981 looking at 44 cardioversion patients, although, interestingly, the only part of this paper that actually looked at active compression was a subreport of four dogs who were cardioverted with or without active compression.Sirna et al in 1988 reported a 13% reduction in impedance with active compression when uniphasic defibrillation was being performed in 28 patients31 and a similar result was found by Ramirez et al in 2016 with 11 participants where they concluded that 8 kg of pressure could reduce the impedance by about 10%.32Thus, there is limited evidence from animal studies and case series, as well as a trial of cardioversion in atrial fibrillation, that active compression of the defibrillation pads using disconnected defibrillation paddles reduces intrathoracic impedance and improves shock efficacy. In the absence of any studies in ventricular arrhythmias in humans the routine use of active compression during defibrillation is not recommended. However, the use of disconnected defibrillation paddles to apply external compression to defibrillation pads may be considered in patients with arrhythmias refractory to cardioversion particularly where there is a risk of high intrathoracic impedance.View this table:Does epinephrine improve outcomes in resuscitation in the catheter laboratory?.

ILCOR in 2015 reviewed the literature with regard to epinephrine including a large RCT by Olasveengen et al33 where ambulances were randomised to Group 1. CPR and defibrillation with iv cannulation and usual resuscitation medications versus Group 2. CPR and defibrillation alone.

This RCT showed reduced survival to hospital discharge in Group 1 and this was felt to be due to the ineffectiveness of the drugs and also the delay in CPR in order to cannulate and administer the drugs. This paper, and a more recent meta-analysis34 (demonstrating no benefit of epinephrine in cardiac arrest) led ILCOR to write. €˜despite the widespread use of epinephrine during resuscitation, and several studies involving vasopressin, there is no placebo controlled study that shows that the routine use of any vasopressor at any stage during human cardiac arrest increases survival to hospital discharge.

Current evidence is insufficient to support or refute the routine use of any particular drug or sequence of drugs. Despite the lack of human data, the use of epinephrine is still recommended, based largely on animal data’.The PARAMEDIC-2 Study35 randomised 8014 patients in an arrest situation across five ambulance services in the UK to receive either 1 mg of epinephrine every 3–5 min, or identical syringes containing 0.9% saline. The mean time for the ambulance to arrive was 6.6 min and the mean time to trial drug administration was 13 min after arrival.

There was a large increase in the number of patients who had return of spontaneous circulation in the epinephrine arm (36% vs 11%), as well as the number who were transferred to hospital (50% vs 30%). The primary outcome measure was survival at 30 days and this was 3.2% in the epinephrine group and 2.4% in the placebo group which was significant, but the number of survivors with severe neurological impairment was 31% in the epinephrine group versus 18% in the control group, and thus the trial was negative in terms of survival with favourable neurological outcome (2.2% vs 1.9%). The triallists concluded that epinephrine significantly improved the chance of achieving the return of spontaneous circulation and the survival of the patient to hospital admission but that it led only to a greater proportion surviving with severe neurological disability.In the light of this important study, we suggest that the current recommendations of giving epinephrine every 3–5 min at a dose of 1 mg is supported on the basis that it is unlikely to harm the patient and may be beneficial.

We recommend that intravenous epinephrine (1 mg) is given after the third cycle. It may be acceptable to administer smaller doses of epinephrine if a senior clinician feels that there may be reactive hypertension on ROSC.The guideline group also discussed the question of the administration of epinephrine in cases of a non-shockable rhythm. Current recommendations from the ERC are to give epinephrine at a dose of 1 mg as soon as possible but they do caveat this by saying that ‘exceptions may exist where a clear reversible cause can be rapidly addressed’.

In PEA and asystole in the catheter laboratory there are reversible causes that should be addressed, and for this reason the group concluded that we should recommend administering epinephrine at the same time as in a shockable rhythm to allow time for reversible causes to be addressed.View this table:Waveform capnography in cardiac arrestWe recommend that waveform capnography is used for patients in established cardiac arrest. Not only does this prove that the airway is patent, and that there is reasonable air entry to allow the exchange of CO2, but more importantly the level of exhaled CO2 correlates with the cardiac output. Capnography can be used as a prognostic guide to the likely result of prolonged resuscitation.

An end-tidal CO2 more than 20 mm Hg (2.7 kPa) is a good prognostic indicator whereas an end-tidal CO2 of less than 10 mm Hg (1.3 kPa) indicates a poor prognosis and may be used to indicate that further treatment is likely to be futile or that modifications are required to the CPR to improve this figure.Goal-directed management during prolonged cardiac arrest in the catheter laboratoryA number of physiological parameters are associated with higher rates of ROSC. This has led to the hypothesis that higher rates of ROSC and better clinical outcomes might be achieved by goal-directed resuscitation techniques. This may be particularly relevant to the management of cardiac arrest in the catheter laboratory where resuscitation attempts may be prolonged and invasive monitoring is routine.36 ,37 ,38 Physiological parameters of interest based on our literature review on this topic are listed in table 1.

This concept was investigated in a series of 10 patients who underwent mechanical CPR and PCI to treat prolonged cardiac arrest in the catheter laboratory.39 The average time of mechanical CPR was 43 min. Systolic blood pressures above 70 mm Hg and diastolic blood pressures above 40 mm Hg were targeted. A pigtail catheter was inserted into the right atrium via the femoral vein at the interventionists discretion to monitor CVP and to administer vasoactive drugs.

The investigators aimed to keep the CVP below 25 mm Hg. If this was not achieved, echocardiography was performed to exclude cardiac tamponade, the mechanical CPR device was repositioned, and inotropes or vasoconstrictors were initiated. End-tidal CO2 was measured following insertion of an endotracheal tube or a supraglottic airway with a target of >15 mm Hg (>2 kPa).

The SpO2 was kept above 80%, and arterial blood gas measurement was used to guide ‘normo’ ventilation. Cerebral oximetry was also monitored. Vasoconstrictor infusions were used in favour of epinephrine boluses.

For patients in VF, attention was directed towards opening the acutely occluded coronary artery in favour of repeated attempts at defibrillation. The protocol was simulated in training prior to its institution. Early experience identified difficulties measuring all of the parameters every 2 min during ongoing cardiac arrest.

When the parameters were measured successfully, they regularly identified patients whose vital parameters were suboptimal.View this table:Table 1 Physiological parameters of interest.In the AHA ‘get with the guidelines registry’ of 3023 monitored cardiac arrests and 6064 unmonitored in-hospital cardiac arrests, those who had a monitored arrest had a significantly better chance of survival based mostly on blood pressure and end-tidal CO2 monitoring.40 The AHA recommended keeping the end-tidal CO2 above 20 mm Hg and the diastolic blood pressure above 25 mm Hg in their consensus statement on improving resuscitation outcomes.41A group in Greece wrote a discussion document proposing the ‘PERSEUS’ protocol in 2019 aimed at prolonged physiological monitoring of patients in cardiac arrest.42 They proposed mechanical CPR, and ventilating the patient with positive end expiratory pressure (PEEP) of zero, respiratory rate of 10 per min, tidal volume 6 mL//kg, 100% oxygen, inspiration:expiration ratio 1:2. In a previous observational study they had found higher airway pressure was associated with better outcomes, with a pressure of 40–45 mm Hg giving optimal outcome. They discuss the pitfalls of using end-tidal CO2 to estimate cardiac output and discuss how positive pressure ventilation may be used to augment cardiac output during chest compressions.

They suggested placing a CVP line with the aim being to keep the CVP below 25 mm Hg and advocated that if the CVP was low, a straight leg raise should be performed to assess volume status and then fluid be given as indicated. They suggested using optimal positioning of the mechanical CPR device and epinephrine infusions to keep the diastolic blood pressure above 40 mm Hg and that severe acidosis be treated immediately to prevent vasodilation and decreased central perfusion pressure.Among over 1500 patients with out-of-hospital cardiac arrest in whom a venous blood gas was measured, adverse results were associated with a lower rate of survival. In particular, patients without ROSC had a mean pH of 7.11, pCO2 of 9.7 kPa, base excess recommended you read of −7 mmol/L, potassium of 4.5 mmol/L and a lactate of 7 mmol/L.

Low pH, high pCO2 and high plasma potassium concentration were predictors of poor outcome.43A meta-analysis of goal-directed resuscitation identified mainly animal studies but did conclude that goal- directed CPR may be superior to standard CPR, especially when end-tidal CO2 and blood pressure management were targeted.44 It is important to emphasise that a low end-tidal CO2 may reflect inadequate ventilation rather than low cardiac output, especially when a supraglottic airway is used, because of the higher airway pressures required during chest compressions and steps should be taken in these cases to place an endotracheal tube as soon as it is safe to do so.Monitoring of the CVP allows an estimate of coronary perfusion pressure by subtracting the diastolic arterial pressure from the CVP. Ideally it should be kept above 20 mm Hg.The catheter laboratory is a unique environment in which physiological parameters can be accurately monitored during circulatory arrest. These parameters can be used to assess the effect of interventions such as the adjustment of cardiac massage technique, intravenous administration of vasoactive medications, correction of acidosis, electrolytes, and volume status, and less conventional treatments such as head-up CPR, while prolonged revascularisation attempts are ongoing or preparation is made for ECPR.

Whether or not goal-directed resuscitation improves clinical outcomes, or even increases rates of ROSC, is not yet clear so firm recommendations for setting physiological parameter targets during cardiac arrest cannot be made. Nevertheless, we recommend that teams consider recording physiological parameters during prolonged cardiac arrest (table 1). Green, amber and red indicate the potential impact of the physiological parameters achieved during cardiac arrest on ROSC and could be used to guide future research.

Clinical decisions regarding cessation of resuscitation should not be based only on these parameters.View this table:Is amiodarone of use in a VF arrest in the catheter laboratory?. We sought evidence as to whether amiodarone or lidocaine may be useful for VF/pulseless VT. There is good evidence in support of Amiodarone in four large randomised trials,45–48 each demonstrating an improvement of the chance of successful cardioversion of about 10%.

It must be noted that these studies are all in the out-of-hospital setting and thus there is less certainty that the results might be equivalent in the in-hospital setting or indeed in a catheter laboratory.Amiodarone should be given as a bolus injection of 300 mg. A further dose of 150 mg may be given for recurrent or refractory VF/VT followed by an infusion of 900 mg over 24 hours. Lidocaine 1 mg/kg may be used as an alternative and may have a similar efficacy.49 There is less robust evidence regarding alternatives such as procainamide.View this table:The use of echocardiography during cardiac arrestEchocardiography can help to identify the cause for the arrest and should be performed rapidly as an integral part of the resuscitation.

It is important to exclude tamponade early in the resuscitative process and also to repeat the echo in a prolonged arrest if the effectiveness of CPR diminishes abruptly as this may indicate tamponade secondary to external cardiac massage or delayed onset of tamponade. Echocardiography has also been shown to reduce the time taken for pulse checks50 by enabling visualisation of the presence or absence of organised contractions.In patients who already have a transoesophageal echo (TOE) probe in place this has advantages compared with transthoracic echocardiography51 in that it does not require interruptions of CPR, can be performed continuously with better images, can be used to identify ROSC quickly, to look for dissection of the ascending aorta and, if required, can aid placement of pacing wires or the initiation of ECPR. It is also better at monitoring the effectiveness of prolonged mechanical CPR.

In addition, there may be clinicians experienced in its use available in the catheter laboratory. Thus, if it is in place already it is preferred to transthoracic echocardiography, and if it is not in place then it should be considered, especially if prolonged arrest management is being planned, allowing for the risk of oesophageal damage in TOE placement of around 0.2%51View this table:Fluoroscopy in order to identify a pneumothorax in an arrest in the catheter laboratoryA literature review was performed in an attempt to find cases of pneumothorax identified by fluoroscopy in a catheter laboratory and to gain an understanding of the incidence of pneumothorax causing cardiac arrest, particularly after pacing procedures, or transaxillary, transcarotid or subclavian arterial approaches.Pneumothorax is not uncommon after attempted vessel puncture in the thorax, such as pacemaker and implantable defibrillator insertion, with an incidence of around 0.6%–1.0%.25 52If a pneumothorax is suspected it is straightforward to diagnose in the catheter laboratory by fluoroscopy, which has also been used to guide chest drainage in such situations.53In a cardiac arrest, one potential cause could be pneumothorax. Since there is immediate access to fluoroscopy, it is recommended that in a cardiac arrest with no clear cause identified, and especially if the patient is undergoing an intervention that is high risk such as pacemaker or ICD insertion, fluoroscopy is performed to exclude pneumothorax as a cause.View this table:How should the team balance chest compressions with attempts at percutaneous intervention in a cardiac arrest?.

Interventions on the coronary arteries can be associated with occlusion, or reduced flow secondary to dissection or thrombus formation. Other complications can include no reflow and perforation. In the majority of these circumstances, a key part of the ongoing resuscitation effort will involve a further intervention to treat or reverse the underlying cause.

In order to preserve cerebral perfusion until a spontaneous circulation is restored, external cardiac massage is required. Manual cardiac massage cannot be achieved at the same time as fluoroscopy due to radiation exposure for the rescuer and therefore a balance must be struck between the interventionalist and those performing external chest compressions.The AHA, the ERC and the Australian Guidelines all address the issue of external cardiac massage in the catheter laboratory. The AHA recommend early transfer to automated CPR devices, the ERC recommend that external cardiac massage should not be interrupted for angiography and the Australian Guidelines discuss the tension between the rescuers performing external CPR and the interventionalist wanting to continue with angiography.

These statements have not translated into an agreed protocol that can be followed by the resuscitation team.We strongly recommend using only mechanical CPR devices to administer CPR while undergoing PCI during an arrest. It is reasonable to pause manual CPR in order to perform angiography to search for a cause for the arrest, but subsequent PCI should be performed with mechanical CPR.View this table:Mechanical CPR devicesThe use of mechanical CPR has been extensively investigated in at least nine randomised trials with over 12 000 patients in both out-of-hospital and in-hospital arrest.54–56 Several meta-analyses exist and support the use of mechanical CPR for in-hospital patients, although the evidence is less strong for use in out-of-hospital patients.56–60 ,61The AHA reviewed the feasibility of using mechanical CPR devices during PCI and identified papers where feasibility has been demonstrated in both animal62 and human63–66 studies. No comparative studies have examined the use of mechanical CPR devices compared with manual chest compressions during PCI procedures although, due to the inherent need to cease manual compressions during fluoroscopy, there is a clear benefit for mechanical CPR.A number of case reports62 63 and case series65–68 have reported the use of mechanical CPR devices to facilitate prolonged resuscitation in patients who have a cardiac arrest during PCI.

One study demonstrated that the use of a mechanical CPR device for cardiac arrest during PCI was feasible. However, no patients survived to hospital discharge.65 Other studies have reported good patient outcomes, including ROSC and survival to discharge with good functional outcome.62 Of note the length of time required to perform PCI with a mechanical CPR device was around 30 min (ranging from 12 min to 90 min), which highlights further the importance of a protocol that allows prolonged CPR while PCI is ongoing.We are therefore strongly of the view that mechanical CPR devices are of major benefit to patients in the specialist environment of the catheter laboratory, for liberating rescuers from performing manual CPR and for the ability to perform uninterrupted CPR for at least 30 min while interventions are performed (Figure 2). In addition, we strongly advocate the immediate availability of these devices in the catheter laboratory and regular team-based training in order to be able to place these devices with a pause of less than 15 s.69 70Fluoroscopic projections possible with the automatic external cardiac massage device in place.

(A) Right posterior oblique. (B) Left anterior oblique. (C) Right anterior oblique.

(D) Straight cranial. (E) Straight caudal (with permission from Stryker Corporation)." data-icon-position data-hide-link-title="0">Figure 2 Fluoroscopic projections possible with the automatic external cardiac massage device in place. (A) Right posterior oblique.

(B) Left anterior oblique. (C) Right anterior oblique. (D) Straight cranial.

(E) Straight caudal (with permission from Stryker Corporation).View this table:ECPR in the catheter laboratoryThe AHA and the ERC both recommend the use of ECMO to provide ECPR. The AHA state that ‘rapid initiation of eCPR or cardiopulmonary bypass is associated with good patient outcomes in patients with haemodynamic collapse and cardiac arrest in the catheter laboratory and also the use of eCPR is feasible and associated with good outcomes when used as a bridge to coronary artery bypass grafting’ (AHA Class IIb, LOE C). The ERC are more equivocal, stating that very low quality evidence suggests that the use of extracorporeal life support can be considered as a rescue strategy if the infrastructure is available, and this should probably be preferred to the use of intra-aortic balloon pump (IABP) in such situations.

The First RCT in this area called the ARREST Trial was stopped early due to the highly significant effects in favour of ECMO in out of hospital cardiac arrest (OHCA). Thirty patients were randomised and there were six survivors in the ECMO group compared with only one in the standard care group.71 Furthermore, there are many case series reporting the efficacy of extracorporeal cardiopulmonary bypass72–80 in the context of catheter laboratory based cardiac arrests. Bagai et al reported in 2011 on the use of extracorporeal cardiopulmonary bypass in 39 patients in a range of situations including cardiac arrest and cardiogenic shock in the catheter laboratory.

The survival to discharge was 71%.76 Van den Brink in 201880 reported the use of extracorporeal cardiopulmonary bypass in 12 patients of whom 11 were in cardiac arrest with a survival to discharge of 67% and a 1-year survival of 42%. Nine had out-of-hospital arrest and a further two had in-hospital arrest.The Extracorporeal Life Support Organisation has published a position paper in 2018, advocating ECMO in arrests of longer than 15 min of duration, but centres offering ECMO are required to be looking after at least 30 patients a year and therefore will generally be located only in transplantation centres.81View this table:IABP insertion in the arrest situationThe evidence for the insertion of an IABP in an arrest situation was reviewed. Of note the AHA have also reviewed this evidence and concluded that while IABP counterpulsation increases coronary perfusion, decreases myocardial oxygen demand and improves haemodynamics in cardiogenic shock states, it is not associated with improved patient survival.

They state that the role of IABP in patients who have a cardiac arrest in the catheterisation laboratory is not known.The IABP-SHOCK II Trial which randomised nearly 600 patients who were in shock from an acute myocardial infarction did not find an improvement in the 30-day survival after the intervention.82 This landmark study followed 13 RCTs together with meta-analyses and a Cochrane systematic review which were all unable to detect a significant improvement in 30-day survival although other small improvements were sometimes reported.83–90 It must be noted that although these studies were in patients with an acute myocardial infarction (rather than patients in cardiac arrest in a catheter laboratory) the IABP-SHOCK Trial has led to a significant reduction in the use of IABP in cardiogenic shock in catheter laboratories.A further small RCT looking at IABP versus control in patients who suffered a cardiac arrest with an acute coronary syndrome also found no benefit.91There are few studies looking at the insertion of IABPs in the arrest situation.92 93 Without a spontaneous circulation to trigger the IABP, counterpulsation would be unlikely to be successful. Thus, it is concluded that there is no indication to place an IABP acutely in the cardiac arrest period in the catheter laboratory.View this table:Is an Impella pump useful in an arrest?. The ERC in 2015 stated in their section on cardiac arrest in the catheter laboratory that ‘There is no evidence to recommend circulatory support with the Impella pump only during cardiac arrest’ and in 2021 they changed this slightly to say that they may provide circulatory support while performing rescue procedures but require further evaluation.

They provided a single reference to support this94 which was a case series of eight patients who had an Impella device in an arrest, of whom four survived to hospital discharge. We identified a further paper documenting use in 7 patients in arrest, although only 1 survived,95 and a multicentre study across four countries96 of 35 patients having Impella insertion while in cardiac arrest with a 45% survival.There have been case series and cohort studies of the use of the Impella in cardiogenic shock in adults and children97 and in high-risk PCI cases98–100 and there is an interesting ongoing RCT currently recruiting that aims to randomise 360 patients with shock post-myocardial infarction (MI) to standard therapy or Impella that will report in the coming years.101The 2021 joint ERC and European Society of Intensive Care medicine guidelines for postresuscitation care state that ‘the evidence about which type of mechanical device is superior appears inconclusive and thus their use should be decided on a case-by case basis’.95View this table:The identification and treatment of pericardial tamponadeSethi et al reported the findings of the US National Inpatient Sample database from 2009 to 2013 which covers around 90% of all patients in the USA. They document 64 000 pericardiocentesis procedures and 57% of these were in unstable patients, 17% were in PCI cases, 13% in EP procedures and 14% in structural heart procedures.

Thus, pericardiocentesis is performed in all types of catheter laboratory interventions.102 As this was a database study they were unable to comment on the procedural success rate, although the inpatient mortality in the database overall was around one in four.Tsang et al documented a 21-year experience with a thousand pericardiocentesis procedures at the Mayo clinic, including many patients with perforation in the catheter laboratory. They report a 97% procedural success for this procedure in all settings with only a 2% major complication rate. They also reported that they saw a significant increase in the rate that clinicians left a drain in situ during the period of the study from 25% to 75%.103Cho et al confirmed these findings in a report of nearly 300 echocardiographically guided pericardiocentesis procedures, with approximately 40 during PCI.

They reported a 99% procedural success with a 1% complication rate.104A UK observational study of 270 329 PCI procedures in the context of acute coronary syndromes describes 1013 coronary perforations (0.37%).41 Importantly, the adjusted ORs for all clinical outcomes were adversely affected by coronary perforation. The conclusion was ‘Coronary perforation is an infrequent event during ACS-PCI but is closely associated with adverse clinical outcomes’.The ESC position statement on the urgent management of cardiac tamponade105 gives a class I indication for pericardiocentesis for tamponade, preferring echocardiographic guidance where possible although fluoroscopic guidance is an acceptable alternative. If unsuccessful, surgical drainage is recommended.

Of note these guidelines are mainly for non-iatrogenic causes of the tamponadeIt is extremely important that all catheter laboratories have immediate access to an echo machine in order to be able to confirm or exclude tamponade in an emergency. All cardiologists who perform interventional procedures should be trained in pericardiocentesis techniques, and all catheter labs should have a dedicated and easily accessible pericardiocentesis kit, which the team are familiar with. The emergency procedures for pericardiocentesis should be familiar to all catheter laboratory staff.

The pericardiocentesis/perforation kit should be stored together and include drainage equipment, coils and covered stents. There should be an agreed unit protocol as to the method of distal embolisation technique as a wide variety of options are available.In all cases of pericardial collection, repeat TTE should be performed within 2 hours of return to the ward and often again within the following few hours. This is particularly important in the case of distal wire perforations and any case in which a perforation has apparently sealed spontaneously.View this table:Treatment of pericardial tamponade if pericardiocentesis failsA BCIS analysis from 2006 to 2013 of the complete UK PCI database reported a 0.3% perforation rate with PCI.106 This comprised of 1762 patients of whom 14% developed tamponade (246 pts) and 3% required emergency surgery (52 patients).

Thus, there are roughly 250 coronary perforations per year with around 35 associated episodes of tamponade and seven patients per year in the UK who require emergency surgery after coronary perforation.This number is likely to have increased since 2013. Furthermore, this database does not include pacing procedures, EP or structural heart procedures. Thirty-seven per cent of coronary perforations occurred in a unit without surgical cover (589 coronary perforations in units without on-site surgical cover compared with 997 in units with cover).

Coronary perforations can be classified using the Ellis Classification both in the arrest and the non-arrest situation according to the significance of the defect created in the artery.107With regard to the perforation of cardiac chambers from non-PCI interventions, the National Cardiovascular Data Registry in the USA108 documented 625 cardiac perforations in a 5-year period, which was one perforation for every 700 implantations of an ICD. The BHRS has provided detailed guidance in their 2016 document entitled ‘Standards for Interventional Electrophysiology and catheter ablation in adults’.109We recommend that for coronary perforations consideration be given to heparin and antiplatelet reversal, a decision that must be balanced against the risk of producing stent thrombosis. An activated clotting time could be used to guide this decision.We recommend there should be on-site availability and experience with covered stents, embolisation coils and the ability to perform distal embolisation.

There should be an agreed unit protocol as to the method of distal embolisation technique as a wide variety of options are available.For perforation of cardiac chambers we also recommend consideration of reversal of heparin, calling for senior colleague assistance, where relevant withdrawal of the lead or wire from the perforation and echocardiographic monitoring for a tamponade.View this table:Surgical supportThere should be access to emergency cardiothoracic surgery for all patients who have suffered a tamponade in the catheter laboratory. In units without cardiac surgical cover, an agreed written protocol must be in place in order to ensure that timely relief of a tamponade is possible. The time taken for a patient to sternotomy should be of a similar order to that possible with on-site surgical facilities where a surgical team is not on stand-by.Options to achieve this may include rapid transfer to the cardiothoracic centre with surgeons ready to receive the patient, or using experienced on-site surgeons trained in emergency thoracotomy to commence relief of a tamponade while a cardiac surgeon travels to the local centre.

We recommend that these protocols be documented and tested regularly to ensure equitable availability of potentially life-saving interventions in both centres with and without on-site cardiac surgical cover.We furthermore recommend the notification of the on-call surgical team for all coronary perforations that cannot be sealed via percutaneous techniques, and all cardiac chamber perforations requiring a pericardiocentesis drain, even if they seem stable, so that the most appropriate management strategy can be agreed.View this table:The management of pulmonary embolusWe identified papers relevant to the management of either confirmed or suspected pulmonary embolus (PE) in cardiac arrest. In addition, the ESC have guidance on the treatment of PE110 and the AHA and ERC both give recommendations in this area.It may be difficult to determine PE as the cause of the cardiac arrest although in-hospital arrest teams have been able to identify PE up to 85% of the time.111 Teams may identify factors precipitating the cardiac arrest before the actual arrest which may include a high-risk history such as malignancy, previous PEs or recent surgery, they may identify symptoms such as dyspnoea, tachycardia and chest pain, and there maybe signs on ECG or a distended right ventricle on echocardiography prior to the arrest.Once the arrest has occurred, the arrest rhythm is more commonly PEA (63%) versus only 5% in VF.112 Echocardiography during the cardiac arrest may identify a distended right ventricle with a flattened interventricular septum in cases of PE large enough to precipitate arrest,113 although right ventricular dilatation in arrest should be interpreted with caution.114In terms of the treatment of the PE in the cardiac arrest Li et al published a meta-analysis in 2006115 of eight papers that demonstrated that thrombolytics administered during CPR did improve survival, although inevitably there was also an increase in bleeding complications. In an RCT of 1000 patients with out-of-hospital arrests randomised to thrombolytic therapy, no improvement in survival was seen but the percentage of patients who actually had PE may have been low in this study.116The ERC recommend the use of fibrinolytics for patients suspected of arresting secondary to a massive pulmonary embolus.8 They also recommend that CPR should then continue for 60–90 min and that a mechanical compression device may therefore be required for this.

In addition, if there is return of spontaneous circulation then particular attention should be paid to identification of bleeding complications thereafter and in centres where this is available ECPR could be considered.117–122The AHA gives a class IIb indication for echocardiography during cardiac arrest stating that ‘if a qualified sonographer is present and use of uasound does not interfere with the standard cardiac arrest treatment protocol, then uasound may be considered as an adjunct to standard patient evaluation’. The AHA recommend thrombolysis with a class IIb strength of recommendation in addition to systemic anticoagulation. The AHA also mention the possibility of percutaneous mechanical thrombectomy although many units would not have access to this as it requires specialist equipment.

One case series reported a successful outcome of percutaneous mechanical thrombectomy during CPR in six out of seven patients.We also discussed whether in an arrest where PE is suspected in the catheter laboratory pulmonary angiography should be performed, but technically this was felt to be difficult to perform.123View this table:Return of spontaneous circulationOnce there has been a return of spontaneous circulation a full airway, breathing, circulation examination should be performed. Angiography and echocardiography should be considered where appropriate. If the patient has not neurologically recovered sufficiently or their gas exchange is unfavourable it is often safer to intubate and ventilate.

Appropriate vascular access with a central line and an arterial line will allow cardiac monitoring and vasoactive drug use as necessary. It is important that such patients are treated in an intensive care area environment if ventilated and at least a high care area otherwise. If there has been a prolonged period of arrest then targeted temperature management has been extensively investigated especially in out-of-hospital arrests124 and may help a patient who has had a prolonged arrest.

However there have been no in-hospital studies to demonstrate benefit and the target temperature has not been established and therefore routine early cooling is not recommended.Perhaps more importantly the possible longer-term effects of arresting in the catheter laboratory should be considered. If the patient makes a good physical recovery, they should be fully counselled as to the events that occurred in the arrest and consideration of additional or prolonged follow-up should be given to make sure that they suffer no neurological or psychological sequelae. The ERC and the European Society of Intensive Care Medicine have written detailed guidance in 2021 for postresuscitation care which addresses many of these issues125 and in addition to this there is excellent patient support at the website www.suddencardiacarrest.org.The optimal configuration for the cardiac arrest teamIn order to carry out emergency protocols efficiently, whether they be in an arrest situation or with a deteriorating patient, it is vital for all team members to know their roles and responsibilities.

There may be a wide variety of staff numbers and skill mixes available in the catheter laboratory area depending on the size of the institution and also the time of day or night. Therefore, there will clearly also have to be some flexibility and also additional roles that might be allocated, but we propose these six key roles to allow a structure for people to work towards (Figure 3). In addition, it is optimal that the staff members will know in advance the role that they would be expected to take in an emergency, and that this could be documented on a communication board at the start of a shift.The six key roles.

BCIS, British Cardiovascular Intervention Society. BHRS, British Heart Rhythm Society. CPR, cardiopulmonary resuscitation." data-icon-position data-hide-link-title="0">Figure 3 The six key roles.

BCIS, British Cardiovascular Intervention Society. BHRS, British Heart Rhythm Society. CPR, cardiopulmonary resuscitation.The operatorWhile the cardiologist takes the lead in the catheter lab, the main aim of our protocols is to free this person up of responsibility for resuscitation in the cardiac arrest or the emergency situation.

The cardiologist should stay scrubbed at the side of the patient. They are often the person to see the emergency first, and thus must declare this early to the team but thereafter an emergency team leader should be allocated.The cardiologist is best placed to perform the specialist interventions that may resolve the situation. They should concentrate on this aspect of the pathway and coordinate with the other staff addressing resuscitation via the team leader.Role 1.

The emergency leaderWe recommend that someone other than the operating cardiologist organise the team to achieve the best outcome for the patient. We do not mandate who this person should be in terms of their discipline or qualifications, and in fact we are of the opinion that everyone who works in a catheter laboratory should be trained to be able to carry out each of the six key roles, although often in the day there might be another senior cardiologist who will be available to perform this role.The role is to coordinate the protocols highlighted above as the leader of the group addressing all the components of the arrest response. The leader is encouraged to have the protocol to hand on a flip chart or on a poster.The emergency leader must make sure personnel are allocated to all required roles and will also allocate tasks to additional people, outside of the six key rolesRole 2.

Airway and breathingIf there is any acute emergency and especially in an arrest, the scrubbed personnel will be dealing with the circulation, so another member of staff should go straight to the head of the patient to take responsibility for airway and ventilation. For a person who is not breathing they must immediately get a bag/valve/mask at 100% oxygen and place this on the patient’s face and attempt to ventilate the patient. If they are successful, then the chest will rise on both sides, and water vapour may be seen in the mask.

If they are unsuccessful then an airway obstruction issue must be considered. Attempt airway manoeuvres—jaw thrust, chin lift, Guedel airway and perhaps ask another person to help with squeezing the bag so you can use two hands to form a good seal around the patient’s nose and mouth. We do not recommend that staff who are not fully trained in the technique attempt intubation.

In most instances simple airway manoeuvres and airway adjuncts will suffice. A supraglottic airway is a recommended alternative to intubation. Emergency call-out for anaesthetic support is mandatory in this situation.Once air entry is established in an arrest you must coordinate 30:2 with the person performing massage or the automated CPR device.

Your role also requires you to feel the trachea to see if it is central or displaced and then ask everyone to stop massage and bag forcefully while listening bilaterally to see if you can hear a difference in breath sounds.It is mandatory to perform these assessments in every critically ill catheter laboratory patient if you do not know the cause of their deterioration, and you must communicate that you have done this to the team leader. It is not always easy to, but if you are getting air entry from bagging but it is more difficult than you would expect, if the trachea is not central and if you bag vigorously but cannot hear breath sounds on one side then a pneumothorax or haemothorax should be suspected and this must be communicated to the team leader. We also recommend that fluoroscopy is performed for every arrested patient without an obvious cause for the arrest.If a tension pneumothorax is suspected, for example, oxygen saturations dropping and the patient complaining of being short of breath before becoming periarrest or arresting during a pacing procedure, then needle thoracocentesis should be performed followed by a drain or a thoracostomy.Role 3.

Defibrillation and pacingWe recommend that a single person is always allocated to this role and stays beside the defibrillator at all times, even if the rhythm is not shockable. The person fulfilling role 3 should place pads on the patient wherever it is most convenient. Often they will be draped and therefore access will be limited but this will have been practised in simulation so should not be an issue.

Anterior-lateral position, an anterior-posterior position or apex-posterior positions are all acceptable.Where the rhythm is shockable we recommend immediate three-stacked shocks. Once the first shock has been delivered, external cardiac massage should not be recommenced, but the rhythm assessed while the defibrillator is being charged for the next shock. If there is no ROSC and the rhythm remains shockable, up to two further shocks should be delivered in rapid succession.

The defibrillator operator is responsible for communicating to the team when the defibrillator is charging and before each shock.If the third shock fails then further shocks may be given at 2 min intervals as determined by the resuscitation leader and the operating cardiologist. Most defibrillators when turned on, activate a timer, so the defibrillator operator is often the best person to time the CPR cycles.Role 3 is also important in the two other rhythm disturbances. In asystole or extreme bradycardia without a pulse, external pacing may rapidly resolve the situation.

We recommend that percussion pacing is attempted while pads are placed on the patient, and it is also important that defibrillators cannot pace and sense from the same pads and thus it is mandatory that ECG leads are placed on the patient and connected to the defibrillator prior to attempting external pacing. We recommend that external cardiac massage is withheld until the pacing is attempted. When the pacing is activated on the defibrillator it usually defaults to the minimum amplitude, and therefore this will have to be increased to achieve capture.

If capture is not achieved at maximum amplitude then it is unlikely to work unless the pads are poorly placed and the attempt can cease. If it is felt likely that the asystole or extreme bradycardia could be resolved with pacing, and both percussion and external pacing were unsuccessful then the final option would be a temporary wire to be placed in an arrest situation by the cardiologist.Defibrillation is not required in PEA arrest but the defibrillator operator should ensure that underlying VF or asystole is not mistaken for PEA in patients with either a temporary or permanent pacemaker in place. We are aware of three cases when this occurred and although rare, if there is a temporary wire with pacing this can be paused to check, or if there is a permanent pacemaker then a relatively narrow QRS complex with a regular rate should raise this suspicion.Role 4.

Manual chest compressionsOne person should be allocated to perform CPR. If there are very limited numbers of people in the room at night then either the cardiologist or the scrub nurse could do this but it is an important role and having an allocated person is preferable.CPR is withheld if the arrest is VF or asystole until shocks have been administered or the external pacing has been commenced, but if this has failed then CPR must be commenced. The person performing CPR will most likely need to be on the opposite side of the table to the cardiologist, and if the table is fairly high they may need a step to stand on.

Hands should be linked together and elbow straight and CPR is performed on the lower half of the sternum.View this table:The general algorithm recommends a depth of 5–6 cm and there are devices available to measure whether you are compressing adequately, but if your patient has an arterial line in place then in fact this can function as a direct measure of the quality of your CPR. In this situation you should compress the chest hard enough that you achieve a systolic pressure of 70 mm Hg. It is also important to note that if you have a well-functioning arterial line and you are compressing as hard as you can but you are unable to achieve a systolic pressure of 70 mm Hg this implies that there is a mechanical cause to the arrest such as a tamponade or a bleed, as it indicates either that the heart is compressed by tamponade and cannot fill with blood to eject, or that the heart is empty of blood due to blood loss.

The inability to maintain a systolic pressure of above 70 mm Hg requires you to immediately notify the team leader and cardiologist.Role 5. Mechanical CPR, drugs, timing and vascular accessSome smaller centres or primary PCI sites in the middle of the night will not have six people in the catheter laboratory, but in the day-time many busy catheter laboratories will have sufficient numbers of people immediately available. Therefore we considered protocols from four to eight allocated members and propose six roles here The role of having a person in charge of mechanical CPR, drug administration, vascular access and timing we would regard as highly desirable assuming there is adequate personnel available.

This person’s first role would be to immediately obtain the mechanical CPR device, turn it on and prepare it for placement after the first cycle of CPR. Then this person can stand by the person allocated to airway and breathing and give mediations as per protocol.There are some key drugs that this person would need to have immediately available. Epinephrine in an arrest should be given at a dose of 1 mg every 3–5 min.

We mandate its administration after the third cycle in the protocol for all arrest rhythms. It should then be given every other cycle which is again in line with the general algorithm unless the arrest is likely to be prolonged in which case the team leader will determine whether an infusion or a vasoconstrictor may be better.If the arrest is due to a resolvable mechanical issue such as a tamponade that needs draining, it may be best to withhold the epinephrine to avoid its proarrhythmic effects and potential hypertension once the tamponade is removed which may risk further bleeding from the vessel that caused the tamponade in the first place.The second drug in VF arrest is amiodarone. It has been shown to have a 10% increased change of defibrillation being successful in several RCTs and is recommended in all algorithms after the third cycle.The third drug to mention in cardiac arrests is atropine.

It was removed from the universal algorithm in 2015 due to lack of efficacy in the arrest situation and therefore it does not appear in our arrest algorithm. It is important to remember that it is still an important medication in bradycardia with a pulse when the patient has not arrested and it is recommended at a dose of 600 mcg, repeated up to 3 mg so long as the patient has a pulse. This issue has caused some confusion in the past.Finally it is useful to mention that in cases of oversedation naloxone at a dose of 400 mcg repeated every 3 min up to 10 mg will immediately reverse the effects of morphine and fentanyl, and intravenous flumazenil at 200 mcg repeated every 30 s up to 3 mg will equally effect a rapid reversal of midazolam and other benzodiazepines and that in a prolonged arrest infusions and bicarbonate may be required.Role 6.

Resource coordinatorThere are often many members of the team available to help in an emergency situation and on simulations and observations of real-world emergencies it is clear that there has to be a great deal of organisation behind the actual arrest or acute emergency. The emergency team leader needs to be by the patient and coordinating everything in the room but there have to be advanced lines of communication between the catheter lab, the coronary care unit (CCU), the arrest team, the ICU, echocardiographers and also other clinicians in the other catheter labs.Therefore we feel this line of communication is sufficiently important to have a specific allocated role. If other personnel arrive, such as anaesthetists and surgeons then the resource coordinator can hand them lead aprons (and remind them that they must be worn) and while they are being put on then they can brief the person as to the case and what the nature of the emergency is.

They may also be able to direct them to look at the communication board and to go and see the emergency leader rather than going into the room and immediately talking to the cardiologist.It is possible that this role may fall to the radiographer who is a key member of the team and will most usually be at the foot of the table..

Is propecia safe long term

Start Preamble Agency for Healthcare Research and Quality, is propecia safe long term HHS. Notice. This notice announces the intention of the Agency for Healthcare is propecia safe long term Research and Quality (AHRQ) to request that the Office of Management and Budget (OMB) approve the revised information collection project “The AHRQ Safety Program for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention.” This proposed information collection was previously published in the Federal Register on July 21, 2022 and allowed 60 days for public comment. AHRQ did not receive substantive comments during public review period. The purpose is propecia safe long term of this notice is to allow an additional 30 days for public comment.

Comments on this notice must be received by November 10, 2022. Written is propecia safe long term comments and recommendations for the proposed information collection should be sent within 30 days of publication of this notice to www.reginfo.gov/​public/​do/​PRAMain. Find this particular information collection by selecting “Currently under 30-day Review—Open for Public Comments” or by using the search function. Start Further Info is propecia safe long term Doris Lefkowitz, AHRQ Reports Clearance Officer, (301) 427-1477, or by email at [email protected]. End Further Info End Preamble Start Supplemental Information Proposed Project AHRQ Safety Program for Methicillin-Resistant Staphylococcus Aureus (MRSA) Prevention The Agency for Healthcare Research and Quality (AHRQ) requests to revise the currently approved AHRQ Safety Program for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention.

The AHRQ Safety Program for MRSA Prevention's purpose is to reduce the incidence is propecia safe long term and prevalence of s caused by MRSA in a variety of settings. The AHRQ Safety Program for MRSA Prevention was last approved by OMB on August 31, 2021 and will expire on August 31, 2024. The OMB control number for the AHRQ Safety Program for MRSA Prevention is 0935-0260 is propecia safe long term. All of the supporting documents for the current AHRQ Safety Program for MRSA Prevention can be downloaded from OMB's website at https://www.reginfo.gov/​public/​do/​PRAViewICR?. €‹ref_​nbr=​202107-0935-003.

The revision for the AHRQ Safety Program for MRSA Prevention includes the following modifications. 1. ICU/Non-ICU cohort. The optional point prevalence data will be collected at baseline (pre-intervention) and every six months throughout the 18-month implementation period rather than only at baseline. Thus, it will be collected a total of four times.

The clinical outcomes measures for the ICU/Non-ICU cohort have been updated from the version included in the original OMB review. In addition to the change in the frequency of collection of point prevalence data, the program will accept hospital data collected using the new Version 2.0 of the AHRQ Hospital Survey on Patient Safety Culture (HSOPS) as an alternative to the original HSOPS Version 1.0. HSOPS Version 2.0 is a shorter instrument with a total of 40 survey items compared with 51 survey items in the HSOPS Version 1.0. 2. Surgical Services cohort.

After a discussion with the program's Technical Expert Panel (TEP), it was decided to collect surgical site (SSI) outcome data on a different subset of surgical procedures performed within the cardiac surgery, orthopedic surgery, and neurosurgery specialty areas. The clinical outcomes measures for the Surgical Services cohort have been updated from the version included in the original OMB review to reflect the changes in surgical types. For all three surgical specialties, hospitals will have the opportunity to confer rights to the program to their SSI data submitted via National Healthcare Safety Network (NHSN). Hospitals confer rights to their NHSN data by giving the program permission to access their data directly from NHSN. In addition, hospitals with cardiac surgery teams enrolled in the program will be asked to provide data elements that are regularly collected and submitted to the Society of Thoracic Surgeons (STS).

STS data elements for cardiac surgeries will include procedures that involve sternotomy and hospital readmission due to Endocarditis, (conduit harvest site), (deep sternum/mediastinitis), Pneumonia, Sepsis, or wound (drainage, cellulitis). We estimate that 50% of 300 enrolled units (n=150) will be orthopedic and neurosurgical specialties that will confer NHSN data rights to the program. These hospitals will not need to submit any data directly to the program. The remaining 50% of 300 enrolled units (n=150) are estimated to be either cardiac surgical specialties that need to submit STS data or orthopedic or neurosurgical specialties that do not confer NHSN data rights to the program. These hospitals are assumed to have some burden for either pulling and submitting STS data extracts for cardiac surgical specialties or pulling and submitting NHSN data elements for orthopedic or neurosurgical specialties that do not confer rights to NHSN.

We assume 1 hour for the initial data pull and 30 minutes for each subsequent quarterly data pull. In addition to the changes in clinical outcomes described above, the program will use the new HSOPS Version 2.0 instead of the original HSOPS Version 1.0 to assess patient safety culture within enrolled surgical services teams. 3. Long-Term Care (LTC) cohort. The LTC cohort will now also submit the Minimum Data Set (MDS) 3.0 M Skin Conditions data elements.

These elements are currently collected by CMS-certified LTC facilities to remain compliant. Since the MDS 3.0 data is already being collected for CMS, LTC facilities would be asked to submit the same data to the program after transmittal to CMS. As a result, there is a minimal change in burden ( i.e. From five hours to six hours for the initial data pull and from 30 minutes to 45 minutes for additional pulls). The clinical outcomes measures for the LTC cohort have been updated from the version included in the original OMB review.

The project is being conducted by AHRQ through its contractor, Johns Hopkins University (JHU) and JHU's subcontractor, NORC at the University of Chicago. The project is being undertaken pursuant to AHRQ's mission to enhance the quality, appropriateness, and effectiveness of health services, and access to such services, through the establishment of a broad base of scientific research and through the promotion of improvements in clinical and health systems practices, including Start Printed Page 61324 the prevention of diseases and other health conditions (42 U.S.C. 299). Method of Collection The data collection will include both primary and secondary data sources. The primary data collection includes the following.

(1) Unit-level clinical outcome change data. The program will use a secure online portal to collect clinical outcomes measures extracted from site electronic health record (EHR) systems for the 12 month period prior to the start of the implementation, as well as for the 18 month implementation period. These data will be used to evaluate the effectiveness of the AHRQ Safety Program for MRSA Prevention. The clinical outcomes measures for the ICU/non-ICU and Surgical Services and Long-Term Care cohorts have been updated from the version included in the original OMB review. For the ICU and non-ICU cohorts, the clinical outcomes data will be collected quarterly and will include.

Hospital onset MRSA invasive (MRSA bacteremia LabID Day 3 or after of admission). Community onset MRSA invasive (MRSA bacteremia LabID prior to Day 3 after admission). Patient days. Central Line-Associated Blood Stream s with causative organism(s). Central Line Days.

Hospital onset bacteremia (Day 3 or after of admission) with causative organisms, including MSSA. MRSA-positive clinical cultures. In addition, hospitals that are already conducting MRSA point prevalence surveys in participating ICU and non-ICU units will be asked to submit this optional data via the secure online portal. Hospitals will be asked to submit baseline data at the start of the program and then submit data once every six months for the duration of the 18-month implementation period. Thus, it will be collected a total of four times.

For the surgical services cohort, the clinical outcomes data will be collected quarterly and will include. Surgical site (SSI) events and causative organisms. Number of surgical procedures performed, by type of surgical procedure. Hospital readmissions. For the LTC cohort, the clinical outcomes data will be collected monthly via the secure online portal, or via fax submission, and will include.

Transfer of facility resident(s) to an acute care hospital, with reason of suspected or confirmed . Transfer of facility resident(s) to an acute care hospital, with reason other than . All-cause bacteremia with causative organisms. Resident days. MDS 3.0 Section M Skin Conditions data elements.

(2) Survey of Patient Safety. The program will administer AHRQ Surveys of Patient Safety Culture to all eligible AHRQ Safety Program for MRSA Prevention staff at the participating units or facilities at the beginning (month 1) and end (month 18) of the implementation. We will administer the Hospital Survey of Patient Safety Culture (HSOPS) in the ICU, non-ICU, and surgical cohorts, and the Nursing Home Survey on Patient Safety (NHSOPS) in the LTC cohort. We will accept either HSOPS Version 1.0 or Version 2.0 for the ICU and non-ICU cohort and will accept HSOPS Version 2.0 for the surgical services cohort. These surveys ask questions about patient safety issues, medical errors, and event reporting in the respective setting.

The program will request that all staff on the unit or facility that is implementing the AHRQ Safety Program for MRSA Prevention complete the survey. As unit and facility size vary, we estimate the average number of respondents to be 25 for each unit. (3) Infrastructure Assessment Tool- Gap Analysis. The program will administer the Gap Analysis at month 1 and month 18 of the implementation to an Preventionist and one of the unit's team leaders (most likely a nurse). Information on current practices in MRSA prevention on the unit will be collected.

The Gap Analysis for the surgical services cohort has been updated from the version included in the original OMB review. (4) Implementation Assessments- Team Checkup Tool. The implementation assessments will be conducted to monitor the program's progress and determine what the participating sites have learned through participating in the program. The Team Checkup Tool will be requested monthly, and we anticipate participation from approximately 1 frontline staff (most commonly a nurse) per unit. The program will use the Team Checkup Tool to monitor key actions of staff.

The Tool asks about use of safety guidelines, tools, and resources throughout three different phases. Assessment. Planning, Training, and Implementation. And Sustainment. The Team Checkup Tools for the LTC and Surgical Services cohorts have been updated from the versions included in the original OMB review.

The secondary data collection strategy includes use of NHSN data from hospitals that confer rights to the AHRQ Safety Program for MRSA Prevention to use their NHSN data for the evaluation. NHSN data will serve as secondary data sources for clinical outcomes in ICU, non-ICU, and surgical services units. Clinical outcome measures in LTC settings are not available in NHSN. For hospitals that confer NHSN rights to the program for the ICU and non-ICU cohorts, the secondary data will include the five out of seven clinical outcome measures that are available via NHSN. Hospital onset MRSA invasive (MRSA bacteremia LabID Day 3 or after of admission).

Community onset MRSA invasive (MRSA bacteremia LabID prior to Day 3 after admission). Patient days. Central Line-Associated Blood Stream s with causative organism(s). Central Line Days. For hospitals that confer NHSN rights to the program for the surgical services cohort, the secondary data will include the two clinical outcome measures that are available via NHSN.

Surgical site (SSI) events and causative organisms. Number of surgical procedures performed, by type of surgical procedure. Estimated Annual Respondent Burden Exhibit 1 shows the total estimated annualized burden hours for the data collection efforts. All data collection activities are expected to occur within the three-year clearance period. The total estimated annualized burden is 12,052 hours.

Start Printed Page 61325 Exhibit 1 Estimated Annualized Burden HoursForm nameNumber of respondents +Number of responses per respondentHours per responseTotal burden hoursSurvey of Patient Safety CultureHSOPS Version 1.0 (25 respondents per unit, pre- and post-implementation for ICU and non-ICU)666720.253334HSOPS Version 2.0 (25 respondents per unit, pre- and post-implementation for ICU and non-ICU)250020.211050NHSOPS (25 respondents per facility, one response per pre- and post-implementation for LTC cohort, 300 facilities total)2,50020.251,250Infrastructure AssessmentGap Analysis (1 assessment per unit or facility, pre and post-implementation for all four cohorts, 1,400 sites total)46721934Implementation AssessmentsTeam Checkup Tool (1 checklist conducted monthly during the 18 months of implementation for ICU, non-ICU, and Surgical cohorts, 1,100 units total)367180.171,123Team Checkup Tool (1 checklist conducted monthly per facility during the 18 month implementation period for LTC cohort, 300 facilities total)100180.17306Electronic Health Record (EHR) ExtractsInitial data pull for 10% of hospitals that do not confer rights to their NHSN data—( once at baseline for ICU and non-ICU cohorts, 800 units total)2715135Initial data pull for hospital onset bacteremia (including MSSA) and MRSA-positive clinical cultures (not available in NHSN) ( once at baseline for ICU and non-ICU cohorts, 800 units total)26713.5935Initial data pull for 10% of units that submit point prevalence survey data ( once at baseline for ICU and non-ICU cohorts, 800 units tota l)2710.514Subsequent data pull for 10% of units that submit point prevalence data ( every six months during 18 months of implementation for ICU and non-ICU cohorts, 800 units total)2730.2520Initial data pull for 50% of surgical units that do not confer rights to NHSN data—( once at baseline for Surgical cohort, 300 settings total)501150Initial data pull—( once at baseline for LTC cohort, 300 facilities total)10016600Quarterly data collection of monthly data— (quarterly during 18 months of implementation for ICU and non-ICU, cohorts, 800 units total)26760.5801Quarterly data collection of monthly data for 50% of hospitals that do not confer rights to their NHSN data ( quarterly during 18 months of implementation for surgical cohorts, 300 units total)5060.5150Monthly data— (monthly per facility during 18 months of implementation for LTC cohort, 300 facilities total)100180.751350Total13,51612,052+ The number of respondents per data collection effort is calculated by multiplying the number of respondents per unit by the total number of units. The result is divided by three to capture an annualized number. Exhibit 2 shows the estimated annualized cost burden based on the respondents' time to complete the data collection activities. The total annualized cost burden is estimated to be $554,699.76. Exhibit 2 Estimated Annualized Cost BurdenForm nameNumber of respondentsTotal burden hoursAverage hourly wage rateTotal cost burdenSurvey of Patient Safety CultureHSOPS Version 1.0 (25 respondents per unit, pre- and post-implementation for ICU and non-ICU cohorts)6,6673,334* $51.53$171,801.02HSOPS Version 2.0 (25 respondents per unit, pre- and post- implementation surgical cohort)2,5001,050* 51.5354,106.50NHSOPS (25 respondents per facility, one response per pre- and post-implementation for LTC cohort, 300 facilities total)2,5001,250* 51.5364,412.50Start Printed Page 61326Infrastructure AssessmentGap Analysis (1 assessment per unit or facility, pre- and post-implementation for all four cohorts, 1,400 sites total)467934* 51.5348,129.02Implementation AssessmentsTeam Checkup Tool (1 checklist conducted monthly during 3 months of ramp-up and 15 months of implementation periods for ICU, non-ICU, and Surgical cohorts, 1,100 units total)3671,123* 51.5357,868.19Team Checkup Tool (1 checklist conducted monthly per facility during 18 months of implementation for LTC cohort, 300 facilities total)100306* 51.5315,768.18Electronic Health Record (EHR) ExtractsInitial data pull for 10% of hospitals that do not confer rights to their NHSN data— (once at baseline for ICU and non-ICU cohorts, 800 units total)27135^ 35.174,747.95Initial data pull for hospital onset bacteremia (including MSSA) and MRSA-positive clinical cultures (not available in NHSN) (once at baseline for ICU and non-ICU cohorts, 800 units total)267935^ 35.1732,883.95Initial data pull for 10% of units that submit point prevalence survey data (once at baseline for ICU and non-ICU cohorts, 800 units total)2714^ 35.17492.38Subsequent data pull for 10% of units that submit point prevalence data (every six months during 18 months of implementation for ICU and non-ICU cohorts, 800 units total)2720^ 35.17703.40Initial data pull for 50% of surgical settings that do not confer rights to NHSN data— (once at baseline for Surgical cohort, 300 settings total)5050^ 35.171,758.50Initial data pull— (once at baseline for LTC cohort, 300 facilities total)100600^ 35.1721,102.00Quarterly data— (quarterly during 18 months of implementation for ICU and non-ICU cohorts, 1,100 units total)267801^ 35.1728,171.17Quarterly data collection of monthly data for 50% of hospitals that do not confer rights to their NHSN data (quarterly during 18 months of implementation for surgical cohorts, 300 units total)50150^ 35.175,275.50Monthly data— (monthly per facility during 18 months of implementation for LTC cohort, 100 facilities total)1001,350^ 35.1747,479.50Total13,51612,052554,699.76* This is an average of the average hourly wage rate for physician, nurse, nurse practitioner, physician's assistant, and nurse's aide from the May 2019 National Occupational Employment and Wage Estimates, United States, U.S.

Bureau of Labor Statistics (https://www.bls.gov/​oes/​current/​oes_​nat.htm#00-0000).^ This is an average of the average hourly wage rate for nurse and IT specialist from the May 2019 National Occupational Employment and Wage Estimates, United States, U.S. Bureau of Labor Statistics (https://www.bls.gov/​oes/​current/​oes_​nat.htm#00-0000). Request for Comments In accordance with the Paperwork Reduction Act, 44 U.S.C. 3501-3520, comments on AHRQ's information collection are requested with regard to any of the following. (a) whether the proposed collection of information is necessary for the proper performance of AHRQ's health care research and health care information dissemination functions, including whether the information will have practical utility.

(b) the accuracy of AHRQ's estimate of burden (including hours and costs) of the proposed collection(s) of information. (c) ways to enhance the quality, utility and clarity of the information to be collected. And (d) ways to minimize the burden of the collection of information upon the respondents, including the use of automated collection techniques or other forms of information technology. Comments submitted in response to this notice will be summarized and included in the Agency's subsequent request for OMB approval of the proposed information collection. All comments will become a matter of public record.

Start Signature Dated. October 4, 2022. Marquita Cullom, Associate Director. End Signature End Supplemental Information.

Start Preamble buy propecia no prescription Agency propecia cost per pill for Healthcare Research and Quality, HHS. Notice. This notice announces the intention of the Agency for Healthcare Research and Quality (AHRQ) to request that the Office of Management and Budget (OMB) approve the revised information collection project “The AHRQ Safety Program for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention.” This proposed information collection was previously published in the Federal propecia cost per pill Register on July 21, 2022 and allowed 60 days for public comment. AHRQ did not receive substantive comments during public review period. The purpose of this notice is to allow an additional 30 days for public propecia cost per pill comment.

Comments on this notice must be received by November 10, 2022. Written comments and recommendations for the proposed information collection should be sent propecia cost per pill within 30 days of publication of this notice to www.reginfo.gov/​public/​do/​PRAMain. Find this particular information collection by selecting “Currently under 30-day Review—Open for Public Comments” or by using the search function. Start Further Info Doris Lefkowitz, AHRQ Reports propecia cost per pill Clearance Officer, (301) 427-1477, or by email at [email protected]. End Further Info End Preamble Start Supplemental Information Proposed Project AHRQ Safety Program for Methicillin-Resistant Staphylococcus Aureus (MRSA) Prevention The Agency for Healthcare Research and Quality (AHRQ) requests to revise the currently approved AHRQ Safety Program for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention.

The AHRQ Safety Program for MRSA Prevention's purpose is to reduce the incidence propecia cost per pill and prevalence of s caused by MRSA in a variety of settings. The AHRQ Safety Program for MRSA Prevention was last approved by OMB on August 31, 2021 and will expire on August 31, 2024. The OMB control number for the AHRQ Safety Program for MRSA propecia cost per pill Prevention is 0935-0260. All of the supporting documents for the current AHRQ Safety Program for MRSA Prevention can be downloaded from OMB's website at https://www.reginfo.gov/​public/​do/​PRAViewICR?. €‹ref_​nbr=​202107-0935-003.

The revision for the AHRQ Safety Program for MRSA Prevention includes the following modifications. 1. ICU/Non-ICU cohort. The optional point prevalence data will be collected at baseline (pre-intervention) and every six months throughout the 18-month implementation period rather than only at baseline. Thus, it will be collected a total of four times.

The clinical outcomes measures for the ICU/Non-ICU cohort have been updated from the version included in the original OMB review. In addition to the change in the frequency of collection of point prevalence data, the program will accept hospital data collected using the new Version 2.0 of the AHRQ Hospital Survey on Patient Safety Culture (HSOPS) as an alternative to the original HSOPS Version 1.0. HSOPS Version 2.0 is a shorter instrument with a total of 40 survey items compared with 51 survey items in the HSOPS Version 1.0. 2. Surgical Services cohort.

After a discussion with the program's Technical Expert Panel (TEP), it was decided to collect surgical site (SSI) outcome data on a different subset of surgical procedures performed within the cardiac surgery, orthopedic surgery, and neurosurgery specialty areas. The clinical outcomes measures for the Surgical Services cohort have been updated from the version included in the original OMB review to reflect the changes in surgical types. For all three surgical specialties, hospitals will have the opportunity to confer rights to the program to their SSI data submitted via National Healthcare Safety Network (NHSN). Hospitals confer rights to their NHSN data by giving the program permission to access their data directly from NHSN. In addition, hospitals with cardiac surgery teams enrolled in the program will be asked to provide data elements that are regularly collected and submitted to the Society of Thoracic Surgeons (STS).

STS data elements for cardiac surgeries will include procedures that involve sternotomy and hospital readmission due to Endocarditis, (conduit harvest site), (deep sternum/mediastinitis), Pneumonia, Sepsis, or wound (drainage, cellulitis). We estimate that 50% of 300 enrolled units (n=150) will be orthopedic and neurosurgical specialties that will confer NHSN data rights to the program. These hospitals will not need to submit any data directly to the program. The remaining 50% of 300 enrolled units (n=150) are estimated to be either cardiac surgical specialties that need to submit STS data or orthopedic or neurosurgical specialties that do not confer NHSN data rights to the program. These hospitals are assumed to have some burden for either pulling and submitting STS data extracts for cardiac surgical specialties or pulling and submitting NHSN data elements for orthopedic or neurosurgical specialties that do not confer rights to NHSN.

We assume 1 hour for the initial data pull and 30 minutes for each subsequent quarterly data pull. In addition to the changes in clinical outcomes described above, the program will use the new HSOPS Version 2.0 instead of the original HSOPS Version 1.0 to assess patient safety culture within enrolled surgical services teams. 3. Long-Term Care (LTC) cohort. The LTC cohort will now also submit the Minimum Data Set (MDS) 3.0 M Skin Conditions data elements.

These elements are currently collected by CMS-certified LTC facilities to remain compliant. Since the MDS 3.0 data is already being collected for CMS, LTC facilities would be asked to submit the same data to the program after transmittal to CMS. As a result, there is a minimal change in burden ( i.e. From five hours to six hours for the initial data pull and from 30 minutes to 45 minutes for additional pulls). The clinical outcomes measures for the LTC cohort have been updated from the version included in the original OMB review.

The project is being conducted by AHRQ through its contractor, Johns Hopkins University (JHU) and JHU's subcontractor, NORC at the University of Chicago. The project is being undertaken pursuant to AHRQ's mission to enhance the quality, appropriateness, and effectiveness of health services, and access to such services, through the establishment of a broad base of scientific research and through the promotion of improvements in clinical and health systems practices, including Start Printed Page 61324 the prevention of diseases and other health conditions (42 U.S.C. 299). Method of Collection The data collection will include both primary and secondary data sources. The primary data collection includes the following.

(1) Unit-level clinical outcome change data. The program will use a secure online portal to collect clinical outcomes measures extracted from site electronic health record (EHR) systems for the 12 month period prior to the start of the implementation, as well as for the 18 month implementation period. These data will be used to evaluate the effectiveness of the AHRQ Safety Program for MRSA Prevention. The clinical outcomes measures for the ICU/non-ICU and Surgical Services and Long-Term Care cohorts have been updated from the version included in the original OMB review. For the ICU and non-ICU cohorts, the clinical outcomes data will be collected quarterly and will include.

Hospital onset MRSA invasive (MRSA bacteremia LabID Day 3 or after of admission). Community onset MRSA invasive (MRSA bacteremia LabID prior to Day 3 after admission). Patient days. Central Line-Associated Blood Stream s with causative organism(s). Central Line Days.

Hospital onset bacteremia (Day 3 or after of admission) with causative organisms, including MSSA. MRSA-positive clinical cultures. In addition, hospitals that are already conducting MRSA point prevalence surveys in participating ICU and non-ICU units will be asked to submit this optional data via the secure online portal. Hospitals will be asked to submit baseline data at the start of the program and then submit data once every six months for the duration of the 18-month implementation period. Thus, it will be collected a total of four times.

For the surgical services cohort, the clinical outcomes data will be collected quarterly and will include. Surgical site (SSI) events and causative organisms. Number of surgical procedures performed, by type of surgical procedure. Hospital readmissions. For the LTC cohort, the clinical outcomes data will be collected monthly via the secure online portal, or via fax submission, and will include.

Transfer of facility resident(s) to an acute care hospital, with reason of suspected or confirmed . Transfer of facility resident(s) to an acute care hospital, with reason other than . All-cause bacteremia with causative organisms. Resident days. MDS 3.0 Section M Skin Conditions data elements.

(2) Survey of Patient Safety. The program will administer AHRQ Surveys of Patient Safety Culture to all eligible AHRQ Safety Program for MRSA Prevention staff at the participating units or facilities at the beginning (month 1) and end (month 18) of the implementation. We will administer the Hospital Survey of Patient Safety Culture (HSOPS) in the ICU, non-ICU, and surgical cohorts, and the Nursing Home Survey on Patient Safety (NHSOPS) in the LTC cohort. We will accept either HSOPS Version 1.0 or Version 2.0 for the ICU and non-ICU cohort and will accept HSOPS Version 2.0 for the surgical services cohort. These surveys ask questions about patient safety issues, medical errors, and event reporting in the respective setting.

The program will request that all staff on the unit or facility that is implementing the AHRQ Safety Program for MRSA Prevention complete the survey. As unit and facility size vary, we estimate the average number of respondents to be 25 for each unit. (3) Infrastructure Assessment Tool- Gap Analysis. The program will administer the Gap Analysis at month 1 and month 18 of the implementation to an Preventionist and one of the unit's team leaders (most likely a nurse). Information on current practices in MRSA prevention on the unit will be collected.

The Gap Analysis for the surgical services cohort has been updated from the version included in the original OMB review. (4) Implementation Assessments- Team Checkup Tool. The implementation assessments will be conducted to monitor the program's progress and determine what the participating sites have learned through participating in the program. The Team Checkup Tool will be requested monthly, and we anticipate participation from approximately 1 frontline staff (most commonly a nurse) per unit. The program will use the Team Checkup Tool to monitor key actions of staff.

The Tool asks about use of safety guidelines, tools, and resources throughout three different phases. Assessment. Planning, Training, and Implementation. And Sustainment. The Team Checkup Tools for the LTC and Surgical Services cohorts have been updated from the versions included in the original OMB review.

The secondary data collection strategy includes use of NHSN data from hospitals that confer rights to the AHRQ Safety Program for MRSA Prevention to use their NHSN data for the evaluation. NHSN data will serve as secondary data sources for clinical outcomes in ICU, non-ICU, and surgical services units. Clinical outcome measures in LTC settings are not available in NHSN. For hospitals that confer NHSN rights to the program for the ICU and non-ICU cohorts, the secondary data will include the five out of seven clinical outcome measures that are available via NHSN. Hospital onset MRSA invasive (MRSA bacteremia LabID Day 3 or after of admission).

Community onset MRSA invasive (MRSA bacteremia LabID prior to Day 3 after admission). Patient days. Central Line-Associated Blood Stream s with causative organism(s). Central Line Days. For hospitals that confer NHSN rights to the program for the surgical services cohort, the secondary data will include the two clinical outcome measures that are available via NHSN.

Surgical site (SSI) events and causative organisms. Number of surgical procedures performed, by type of surgical procedure. Estimated Annual Respondent Burden Exhibit 1 shows the total estimated annualized burden hours for the data collection efforts. All data collection activities are expected to occur within the three-year clearance period. The total estimated annualized burden is 12,052 hours.

Start Printed Page 61325 Exhibit 1 Estimated Annualized Burden HoursForm nameNumber of respondents +Number of responses per respondentHours per responseTotal burden hoursSurvey of Patient Safety CultureHSOPS Version 1.0 (25 respondents per unit, pre- and post-implementation for ICU and non-ICU)666720.253334HSOPS Version 2.0 (25 respondents per unit, pre- and post-implementation for ICU and non-ICU)250020.211050NHSOPS (25 respondents per facility, one response per pre- and post-implementation for LTC cohort, 300 facilities total)2,50020.251,250Infrastructure AssessmentGap Analysis (1 assessment per unit or facility, pre and post-implementation for all four cohorts, 1,400 sites total)46721934Implementation AssessmentsTeam Checkup Tool (1 checklist conducted monthly during the 18 months of implementation for ICU, non-ICU, and Surgical cohorts, 1,100 units total)367180.171,123Team Checkup Tool (1 checklist conducted monthly per facility during the 18 month implementation period for LTC cohort, 300 facilities total)100180.17306Electronic Health Record (EHR) ExtractsInitial data pull for 10% of hospitals that do not confer rights to their NHSN data—( once at baseline for ICU and non-ICU cohorts, 800 units total)2715135Initial data pull for hospital onset bacteremia (including MSSA) and MRSA-positive clinical cultures (not available in NHSN) ( once at baseline for ICU and non-ICU cohorts, 800 units total)26713.5935Initial data pull for 10% of units that submit point prevalence survey data ( once at baseline for ICU and non-ICU cohorts, 800 units tota l)2710.514Subsequent data pull for 10% of units that submit point prevalence data ( every six months during 18 months of implementation for ICU and non-ICU cohorts, 800 units total)2730.2520Initial data pull for 50% of surgical units that do not confer rights to NHSN data—( once at baseline for Surgical cohort, 300 settings total)501150Initial data pull—( once at baseline for LTC cohort, 300 facilities total)10016600Quarterly data collection of monthly data— (quarterly during 18 months of implementation for ICU and non-ICU, cohorts, 800 units total)26760.5801Quarterly data collection of monthly data for 50% of hospitals that do not confer rights to their NHSN data ( quarterly during 18 months of implementation for surgical cohorts, 300 units total)5060.5150Monthly data— (monthly per facility during 18 months of implementation for LTC cohort, 300 facilities total)100180.751350Total13,51612,052+ The number of respondents per data collection effort is calculated by multiplying the number of respondents per unit by the total number of units. The result is divided by three to capture an annualized number. Exhibit 2 shows the estimated annualized cost burden based on the respondents' time to complete the data collection activities. The total annualized cost burden is estimated to be $554,699.76. Exhibit 2 Estimated Annualized Cost BurdenForm nameNumber of respondentsTotal burden hoursAverage hourly wage rateTotal cost burdenSurvey of Patient Safety CultureHSOPS Version 1.0 (25 respondents per unit, pre- and post-implementation for ICU and non-ICU cohorts)6,6673,334* $51.53$171,801.02HSOPS Version 2.0 (25 respondents per unit, pre- and post- implementation surgical cohort)2,5001,050* 51.5354,106.50NHSOPS (25 respondents per facility, one response per pre- and post-implementation for LTC cohort, 300 facilities total)2,5001,250* 51.5364,412.50Start Printed Page 61326Infrastructure AssessmentGap Analysis (1 assessment per unit or facility, pre- and post-implementation for all four cohorts, 1,400 sites total)467934* 51.5348,129.02Implementation AssessmentsTeam Checkup Tool (1 checklist conducted monthly during 3 months of ramp-up and 15 months of implementation periods for ICU, non-ICU, and Surgical cohorts, 1,100 units total)3671,123* 51.5357,868.19Team Checkup Tool (1 checklist conducted monthly per facility during 18 months of implementation for LTC cohort, 300 facilities total)100306* 51.5315,768.18Electronic Health Record (EHR) ExtractsInitial data pull for 10% of hospitals that do not confer rights to their NHSN data— (once at baseline for ICU and non-ICU cohorts, 800 units total)27135^ 35.174,747.95Initial data pull for hospital onset bacteremia (including MSSA) and MRSA-positive clinical cultures (not available in NHSN) (once at baseline for ICU and non-ICU cohorts, 800 units total)267935^ 35.1732,883.95Initial data pull for 10% of units that submit point prevalence survey data (once at baseline for ICU and non-ICU cohorts, 800 units total)2714^ 35.17492.38Subsequent data pull for 10% of units that submit point prevalence data (every six months during 18 months of implementation for ICU and non-ICU cohorts, 800 units total)2720^ 35.17703.40Initial data pull for 50% of surgical settings that do not confer rights to NHSN data— (once at baseline for Surgical cohort, 300 settings total)5050^ 35.171,758.50Initial data pull— (once at baseline for LTC cohort, 300 facilities total)100600^ 35.1721,102.00Quarterly data— (quarterly during 18 months of implementation for ICU and non-ICU cohorts, 1,100 units total)267801^ 35.1728,171.17Quarterly data collection of monthly data for 50% of hospitals that do not confer rights to their NHSN data (quarterly during 18 months of implementation for surgical cohorts, 300 units total)50150^ 35.175,275.50Monthly data— (monthly per facility during 18 months of implementation for LTC cohort, 100 facilities total)1001,350^ 35.1747,479.50Total13,51612,052554,699.76* This is an average of the average hourly wage rate for physician, nurse, nurse practitioner, physician's assistant, and nurse's aide from the May 2019 National Occupational Employment and Wage Estimates, United States, U.S.

Bureau of Labor Statistics (https://www.bls.gov/​oes/​current/​oes_​nat.htm#00-0000).^ This is an average of the average hourly wage rate for nurse and IT specialist from the May 2019 National Occupational Employment and Wage Estimates, United States, U.S. Bureau of Labor Statistics (https://www.bls.gov/​oes/​current/​oes_​nat.htm#00-0000). Request for Comments In accordance with the Paperwork Reduction Act, 44 U.S.C. 3501-3520, comments on AHRQ's information collection are requested with regard to any of the following. (a) whether the proposed collection of information is necessary for the proper performance of AHRQ's health care research and health care information dissemination functions, including whether the information will have practical utility.

(b) the accuracy of AHRQ's estimate of burden (including hours and costs) of the proposed collection(s) of information. (c) ways to enhance the quality, utility and clarity of the information to be collected. And (d) ways to minimize the burden of the collection of information upon the respondents, including the use of automated collection techniques or other forms of information technology. Comments submitted in response to this notice will be summarized and included in the Agency's subsequent request for OMB approval of the proposed information collection. All comments will become a matter of public record.

Start Signature Dated. October 4, 2022. Marquita Cullom, Associate Director. End Signature End Supplemental Information.

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