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Qi Z, An L, Liu B, Zhang Q, Yin W, Yu H, Li C. Patients with out-of-hospital cardiac arrest show decreased human leucocyte antigen-DR expression on monocytes and B and T lymphocytes after return of spontaneous circulation. Scand J Immunol 2018; 88:e12707. [PMID: 30270439 DOI: 10.1111/sji.12707] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 07/15/2018] [Accepted: 08/14/2018] [Indexed: 12/19/2022]
Abstract
Immune disorders are an important feature of patients with out-of-hospital cardiac arrest (OHCA) after return of spontaneous circulation (ROSC). However, the precise immune alterations in patients with OHCA that occur immediately after ROSC are unclear. In this study, we investigated human leucocyte antigen-DR (HLA-DR) expression on circulatory monocytes and B and T lymphocytes. Sixty-eight consecutive patients with OHCA with ROSC >12 hours were enrolled. Clinical data and 28-day survival were recorded. Peripheral blood samples after ROSC days 1 and 3 were analysed to evaluate HLA-DR expression. Fifty healthy individuals were enrolled as controls. Compared with levels in healthy individuals, HLA-DR expression on monocytes and B lymphocytes, but not on T lymphocytes, decreased on days 1 and 3 after ROSC. No significant difference in HLA-DR expression was detected between survivors and non-survivors on day 1. For 41 patients with expression data for days 1 and 3, HLA-DR expression on monocytes and B lymphocytes in non-survivors was lower than that in survivors on day 3. In non-survivors, the mean fluorescence intensities of HLA-DR on B lymphocytes and percentages of HLA-DR+ T lymphocytes were lower on day 3 than on day 1. On days 1 and 3, there were significant correlations between HLA-DR expression on monocytes and B lymphocytes and clinical indicators, such as time to ROSC, adrenaline dose, acute physiology, chronic health evaluation II and the sequential organ failure assessment. The decreases in HLA-DR expression on circulatory monocytes and B and T lymphocytes after ROSC may be involved in the observed immunosuppression in patients with OHCA.
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Affiliation(s)
- Zhijiang Qi
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Le An
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Bo Liu
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qiang Zhang
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wenpeng Yin
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Han Yu
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Chunsheng Li
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Qi ZJ, Zhang Q, Liu B, Shao H, Li CS. Early Changes in Circulatory T Helper Type 1, 2, and 17 Cells of Patients with Out-of-Hospital Cardiac Arrest after Successful Cardiopulmonary Resuscitation. Chin Med J (Engl) 2018; 131:2071-2079. [PMID: 30127217 PMCID: PMC6111693 DOI: 10.4103/0366-6999.239300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Immune disorder is an important feature of patients with out-of-hospital cardiac arrest (OHCA) after the return of spontaneous circulation (ROSC). We investigated the expression of circulatory T helper type (Th) 1, Th2, and Th17 cells to explore the early immune alteration in OHCA patients after ROSC. Methods During July-September 2016 and March-September 2017, 65 consecutive OHCA patients with ROSC >12 h and 30 healthy individuals were enrolled in this study. Clinical and 28-day survival data were collected. Peripheral blood samples were analyzed to evaluate the expression of Th1/Th2/Th17 cells by flow cytometry from OHCA patients after ROSC on days 1 and 3 and from healthy individuals. Results Compared with healthy individuals, T lymphocyte counts and Th1 cell counts decreased on days 1 and 3 after ROSC (1464 [1198, 2152] vs. 779 [481, 1140] vs. 581 [324, 1118]/μl, χ2 = 30.342, P < 0.001; 154 [90, 246] vs. 39 [19, 78] vs. 24 [12, 53]/μl, χ2 = 42.880, P < 0.001), and Th2 and Th17 cell counts decreased on day 3 (17.0 [10.8, 24.0] vs. 9.0 [3.0, 15.5]/μl, Z = -3.228, P = 0.001; 4.7 [2.7, 9.1] vs. 2.7 [1.0, 6.5]/μl, Z = -2.294, P = 0.022). No change in CD4+/CD3+ lymphocyte ratio was seen on day 1 or day 3 (57.9 [49.4, 63.0] vs. 55.4 [46.5, 66.5] vs. 55.4 [50.2, 67.0]%, χ2 = 0.171, P = 0.918). Th1/CD4+ lymphocyte ratio decreased on days 1 and 3 (19.0 [14.0, 24.9] vs. 9.3 [4.6, 13.9] vs. 9.5 [4.9, 13.6]%, χ2 = 25.754, P < 0.001), and Th2/CD4+ lymphocyte ratio increased on day 1 and decreased on day 3 (1.9 [1.2, 2.5] vs. 2.5 [1.6, 4.0] vs. 1.9 [1.6, 3.8]%, χ2 = 6.913, P = 0.032). Th1/Th2 cell ratio also decreased on both days (9.4 [7.3, 13.5] vs. 3.1 [1.9, 5.6] vs. 4.2 [2.8, 5.9], χ2 = 44.262, P < 0.001). Despite an upward trend in the median of Th17/CD4+ lymphocyte ratio in OHCA patients, there was no significant difference compared with healthy individuals (0.9 [0.4, 1.2] vs. 0.7 [0.4, 1.2] vs. 0.6 [0.3, 1.0]%, χ2 = 2.620, P = 0.270). The dynamic expression of Th1/Th2/Th17 cells on days 1 and 3 were simultaneously analyzed in 28/53 OHCA patients who survived >3 days; patients were divided into survivors (n = 10) and nonsurvivors (n = 18) based on 28-day survival. No significant differences in Th1/Th2/Th17 cell counts, ratios in CD4+ lymphocytes, and Th1/Th2 cell ratio were seen between survivors and nonsurvivors on both days (all P > 0.05). There was no difference over time in both survivors and nonsurvivors (all P > 0.05). Conclusion Downregulated T lymphocyte counts, including Th1/Th2/Th17 subsets and Th1/Th2 cell ratio imbalance, occur in the early period after ROSC, that may be involved in immune dysfunction in OHCA patients.
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Affiliation(s)
- Zhi-Jiang Qi
- Department of Emergency, Beijing Chao-Yang Hospital; Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Qiang Zhang
- Department of Emergency, Beijing Chao-Yang Hospital; Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Bo Liu
- Department of Emergency, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Huan Shao
- Department of Emergency, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Chun-Sheng Li
- Department of Emergency, Beijing Chao-Yang Hospital; Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
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Mongardon N, Kohlhauer M, Lidouren F, Barretto M, Micheau P, Adam C, Dhonneur G, Ghaleh B, Tissier R. Targeted Temperature Management With Total Liquid Ventilation After Ischemic Spinal Cord Injury. Ann Thorac Surg 2018; 106:1797-1803. [PMID: 30120942 DOI: 10.1016/j.athoracsur.2018.06.073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/08/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Ischemic spinal cord injury is a devastating condition after aortic surgery. We determined whether ultrafast and short whole-body hypothermia provided by total liquid ventilation (TLV) attenuated lower limb paralysis after aortic cross-clamping with a targeted temperature management at 33°C versus 36°C. METHODS Anesthetized rabbits were submitted to infrarenal aortic cross-clamping during 15 min. A control group (n = 7) was maintained at normothermia (38°C to 38.5°C) with conventional mechanical ventilation. In TLV groups, TLV was started after reperfusion and maintained during 30 min with a target temperature at either 33°C or 36°C (TLV-33°C and TLV-36°C, respectively; n = 7 in each condition). After TLV, animals were resumed to conventional ventilation. Hypothermia was maintained during 120 min, before rewarming and awakening. Hind limb motor function was assessed with modified Tarlov score at day 2 and infarct size in the spinal cord was determined using triphenyltetrazolium chloride staining. RESULTS Target temperature was achieved within 20 minutes in the two TLV groups. At day 2, the modified Tarlov score was significantly lower in the control group, as compared with TLV-33°C and TLV-36°C groups (0.0 ± 0.0 versus 3.1 ± 0.7 and 2.6 ± 0.6, respectively). The infarct size of the spinal cord was also significantly higher in the control group compared with TLV-33°C and TLV-36°C groups (75% ± 10% versus 32% ± 7% and 28% ± 10%, respectively). Neither motor function nor infarct size differed significantly between TLV-33°C and TLV-36°C groups. CONCLUSIONS Ultrafast hypothermic TLV attenuates spinal cord injury when applied after ischemic insult. Neurological outcome was similar with targeted temperature management at either 33°C or 36°C.
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Affiliation(s)
- Nicolas Mongardon
- Inserm, U955, Equipe 3, Créteil, France; Université Paris Est, UMR_S955, UPEC, DHU A-TVB, Créteil, France; Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France; Service d'Anesthésie-Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique des Hôpitaux de Paris, Créteil, France
| | - Matthias Kohlhauer
- Inserm, U955, Equipe 3, Créteil, France; Université Paris Est, UMR_S955, UPEC, DHU A-TVB, Créteil, France; Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France
| | - Fanny Lidouren
- Inserm, U955, Equipe 3, Créteil, France; Université Paris Est, UMR_S955, UPEC, DHU A-TVB, Créteil, France; Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France
| | - Mariana Barretto
- Inserm, U955, Equipe 3, Créteil, France; Université Paris Est, UMR_S955, UPEC, DHU A-TVB, Créteil, France; Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France
| | | | - Clovis Adam
- Service d'Anatomo-pathologie, Hôpital Bicêtre, Assistance Publique des Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Gilles Dhonneur
- Service d'Anesthésie-Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique des Hôpitaux de Paris, Créteil, France
| | - Bijan Ghaleh
- Inserm, U955, Equipe 3, Créteil, France; Université Paris Est, UMR_S955, UPEC, DHU A-TVB, Créteil, France; Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France
| | - Renaud Tissier
- Inserm, U955, Equipe 3, Créteil, France; Université Paris Est, UMR_S955, UPEC, DHU A-TVB, Créteil, France; Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France.
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Qi Z, Liu Q, Zhang Q, Liu B, Li C. Overexpression of programmed cell death-1 and human leucocyte antigen-DR on circulatory regulatory T cells in out-of-hospital cardiac arrest patients in the early period after return of spontaneous circulation. Resuscitation 2018; 130:13-20. [PMID: 29940295 DOI: 10.1016/j.resuscitation.2018.06.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/12/2018] [Accepted: 06/21/2018] [Indexed: 02/07/2023]
Abstract
AIM Whether regulatory T cells (Tregs) are involved in immune disorders of out-of-hospital cardiac arrest (OHCA) patients after return of spontaneous circulation (ROSC) is still unknown. We aimed to observe the expression of circulatory Tregs in OHCA patients and investigate programmed cell death-1 (PD-1) and human leucocyte antigen-DR (HLA-DR) on Tregs to evaluate the induction and activity of Tregs. METHODS Sixty-seven consecutive OHCA patients who recovered from spontaneous circulation over 12 h were enrolled. Clinical and 28-day outcome data were collected. Peripheral blood samples collected on days 1 and 3 after ROSC were analysed to evaluate PD-1 and HLA-DR expression on Tregs. Fifty healthy individuals were enrolled as healthy controls. RESULTS Compared with those in healthy individuals, circulatory Treg counts significantly decreased without changes of Treg/cluster-of-differentiation (CD)4+ lymphocyte ratios on day 1 after ROSC, and the percentage of PD-1+ Tregs and HLA-DR+ Tregs significantly rose. On day 3, Treg/CD4+ lymphocyte ratios rose with persistently low Treg counts, and the expression of PD-1 and HLA-DR on Tregs was not different from that on day 1. On day 1, both circulatory Treg counts and Treg/CD4+ lymphocyte ratios in non-survivors were lower than those in survivors, and Treg/CD4+ lymphocyte ratios increased in non-survivors on day 3. No significant difference of PD-1 and HLA-DR expression on Tregs was found between survivors and non-survivors on day 1. CONCLUSIONS After ROSC, despite decreased circulatory Treg counts, a relative increase of Treg percentage and enhanced activity of Tregs are involved in early immune regulation of OHCA patients.
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Affiliation(s)
- Zhijiang Qi
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China; Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Qiang Liu
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Qiang Zhang
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China; Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Bo Liu
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Chunsheng Li
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China; Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China.
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55
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Moskowitz A, Holmberg MJ, Donnino MW, Berg KM. In-hospital cardiac arrest: are we overlooking a key distinction? Curr Opin Crit Care 2018; 24:151-157. [PMID: 29688939 PMCID: PMC6007985 DOI: 10.1097/mcc.0000000000000505] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW To review the epidemiology, peri-arrest management, and research priorities related to in-hospital cardiac arrest (IHCA) and explore key distinctions between IHCA and out-of-hospital cardiac arrest (OHCA) as they pertain to the clinician and resuscitation scientist. RECENT FINDINGS IHCA is a common and highly morbid event amongst hospitalized patients in the United States. As compared with patients who experience an OHCA, patients who experience an IHCA tend to have more medical comorbidities, have a witnessed arrest, and be attended to by professional first responders. Further, providers resuscitating patients from IHCA commonly have access to tools and information not readily available to the OHCA responders. Despite these differences, society guidelines for the peri-arrest management of patients with IHCA are often based on data extrapolated from the OHCA population. To advance the care of patients with IHCA, clinicians and investigators should recognize the many important distinctions between OHCA and IHCA. SUMMARY IHCA is a unique disease entity with an epidemiology and natural history that are distinct from OHCA. In both research and clinical practice, physicians should recognize these distinctions so as to advance the care of IHCA victims.
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Affiliation(s)
- Ari Moskowitz
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mathias J. Holmberg
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital, Denmark
| | - Michael W. Donnino
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Katherine M. Berg
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Rambaud J, Lidouren F, Sage M, Kohlhauer M, Nadeau M, Fortin-Pellerin É, Micheau P, Zilberstein L, Mongardon N, Ricard JD, Terada M, Bruneval P, Berdeaux A, Ghaleh B, Walti H, Tissier R. Hypothermic total liquid ventilation after experimental aspiration-associated acute respiratory distress syndrome. Ann Intensive Care 2018; 8:57. [PMID: 29721820 PMCID: PMC5931951 DOI: 10.1186/s13613-018-0404-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 04/23/2018] [Indexed: 12/20/2022] Open
Abstract
Background Ultrafast cooling by total liquid ventilation (TLV) provides potent cardio- and neuroprotection after experimental cardiac arrest. However, this was evaluated in animals with no initial lung injury, whereas out-of-hospital cardiac arrest is frequently associated with early-onset pneumonia, which may lead to acute respiratory distress syndrome (ARDS). Here, our objective was to determine whether hypothermic TLV could be safe or even beneficial in an aspiration-associated ARDS animal model. Methods ARDS was induced in anesthetized rabbits through a two-hits model including the intra-tracheal administration of a pH = 1 solution mimicking gastric content and subsequent gaseous non-protective ventilation during 90 min (tidal volume [Vt] = 10 ml/kg with positive end-expiration pressure [PEEP] = 0 cmH2O). After this initial period, animals either received lung protective gas ventilation (LPV; Vt = 8 ml/kg and PEEP = 5 cmH2O) under normothermic conditions, or hypothermic TLV (TLV; Vt = 8 ml/kg and end-expiratory volume = 15 ml/kg). Both strategies were applied for 120 min with a continuous monitoring of respiratory and cardiovascular parameters. Animals were then euthanized for pulmonary histological analyses. Results Eight rabbits were included in each group. Before randomization, all animals elicited ARDS with arterial oxygen partial pressure over inhaled oxygen fraction ratios (PaO2/FiO2) below 100 mmHg, as well as decreased lung compliance. After randomization, body temperature rapidly decreased in TLV versus LPV group (32.6 ± 0.6 vs. 38.2 ± 0.4 °C after 15 min). Static lung compliance and gas exchanges were not significantly different in the TLV versus LPV group (PaO2/FiO2 = 62 ± 4 vs. 52 ± 8 mmHg at the end of the procedure, respectively). Mean arterial pressure and arterial bicarbonates levels were significantly higher in TLV versus LPV. Histological analysis also showed significantly lower inflammation in TLV versus LPV group (median histological score = 3 vs. 4.5/5, respectively; p = 0.03). Conclusion Hypothermic TLV can be safely induced in rabbits during aspiration-associated ARDS. It modified neither gas exchanges nor respiratory mechanics but reduced lung inflammation and hemodynamic failure in comparison with LPV. Since hypothermic TLV was previously shown to provide neuro- and cardio protective effects after cardiac arrest, these findings suggest a possible use of TLV in the settings of cardiac arrest-associated ARDS.
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Affiliation(s)
- Jérôme Rambaud
- U955 - IMRB, Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, 7 avenue du Général de Gaulle, 94700, Maisons-Alfort, France.,Paediatric and Neonatal Intensive Care Unit, Armand-Trousseau Hospital, UPMC, APHP, Paris, France
| | - Fanny Lidouren
- U955 - IMRB, Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, 7 avenue du Général de Gaulle, 94700, Maisons-Alfort, France
| | - Michaël Sage
- Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Matthias Kohlhauer
- U955 - IMRB, Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, 7 avenue du Général de Gaulle, 94700, Maisons-Alfort, France
| | | | | | | | - Luca Zilberstein
- U955 - IMRB, Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, 7 avenue du Général de Gaulle, 94700, Maisons-Alfort, France
| | - Nicolas Mongardon
- U955 - IMRB, Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, 7 avenue du Général de Gaulle, 94700, Maisons-Alfort, France.,Service d'Anesthésie et des Réanimations Chirurgicales, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique des Hôpitaux de Paris, Créteil, France
| | - Jean-Damien Ricard
- UMR 1137, Inserm, Université Paris Diderot, Hôpital Louis Mourier, Réanimation Médico-chirurgicale, APHP, Colombes, France
| | - Megumi Terada
- UMR 970, Inserm, Paris Cardiovascular Research Center, Hôpital Européen Georges Pompidou, Paris, France
| | - Patrick Bruneval
- UMR 970, Inserm, Paris Cardiovascular Research Center, Hôpital Européen Georges Pompidou, Paris, France
| | - Alain Berdeaux
- U955 - IMRB, Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, 7 avenue du Général de Gaulle, 94700, Maisons-Alfort, France
| | - Bijan Ghaleh
- U955 - IMRB, Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, 7 avenue du Général de Gaulle, 94700, Maisons-Alfort, France
| | - Hervé Walti
- U955 - IMRB, Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, 7 avenue du Général de Gaulle, 94700, Maisons-Alfort, France
| | - Renaud Tissier
- U955 - IMRB, Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, 7 avenue du Général de Gaulle, 94700, Maisons-Alfort, France.
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Leong SHB, Chan E, Ho BCH, Yeo C, Lew S, Sewa DW, Lim SL, Lee CW, Chia PL, Lim TSE, Lee EK, Ong MEH. Therapeutic temperature management (TTM): post-resuscitation care for adult cardiac arrest, with recommendations from the National TTM Workgroup. Singapore Med J 2018; 58:408-410. [PMID: 28740998 DOI: 10.11622/smedj.2017067] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Therapeutic temperature management (TTM) was strongly recommended by the 2015 International Liaison Committee on Resuscitation as a component of post-resuscitation care. It has been known to be effective in improving the survival rate and neurologic functional outcome of patients after cardiac arrest. In an effort to increase local adoption of TTM as a standard of post-resuscitation care, this paper discusses and makes recommendations on the treatment for local providers.
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Affiliation(s)
| | - Enoch Chan
- Unit for Prehospital Emergency Care, Singapore General Hospital, Singapore
| | | | - Colin Yeo
- Cardiology Department, Changi General Hospital, Singapore
| | - Sennen Lew
- Medical Intensive Care Unit, Khoo Teck Puat Hospital, Singapore
| | - Duu Wen Sewa
- Medical Intensive Care Unit, Singapore General Hospital, Singapore
| | - Shir Lynn Lim
- Medical Intensive Care Unit, Singapore General Hospital, Singapore
| | - Chee Wan Lee
- Cardiology Department, Khoo Teck Puat Hospital, Singapore
| | - Pow Li Chia
- Cardiology Department, Tan Tock Seng Hospital, Singapore
| | | | - Eng Kiang Lee
- Medical Intensive Care Unit, Ng Teng Fong General Hospital, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore.,Health Services and Systems Research, Duke-NUS Medical School, Singapore
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Endovascular cooling versus standard femoral catheters and intravascular complications: A propensity-matched cohort study. Resuscitation 2018; 124:1-6. [DOI: 10.1016/j.resuscitation.2017.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 12/07/2017] [Accepted: 12/11/2017] [Indexed: 11/21/2022]
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59
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Contrôle cible de la température en réanimation (hors nouveau-nés). MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Boulila C, Ben Abdallah S, Marincamp A, Coic V, Lauverjat R, Ericher N, Bougouin W, Mira JP, Cariou A, Geri G. Use of Neuromuscular Blockers During Therapeutic Hypothermia After Cardiac Arrest: A Nursing Protocol. Crit Care Nurse 2018; 36:33-40. [PMID: 27908944 DOI: 10.4037/ccn2016387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Neuromuscular blockers used to prevent shivering during therapeutic hypothermia in comatose patients after out-of-hospital cardiac arrest are associated with adverse events. OBJECTIVE To assess the influence of a nurse-implemented protocol on use of neuromuscular blockers in patients treated with 24-hour therapeutic hypothermia after out-of-hospital cardiac arrest. METHODS A before and after study was done in a 24-bed cardiac arrest center. During the before period, paralysis was maintained by continuous infusion of vecuronium during therapeutic hypothermia. During the after period, a nurse-implemented protocol was used to strictly control use of neuromuscular blockers. The primary outcome measure was duration of infusion of neuromuscular blockers; secondary end points included rates of ventilator-associated pneumonia and intensive care unit mortality. RESULTS Among the 22 patients in the before group and the 23 patients in the after group, most were men (78%) with a median age of 66 years. Baseline characteristics were similar between the 2 groups. Median duration of sedation was 36 hours, shorter in the after group (34 hours) than in the before group (38 hours; P = .02). Median duration of infusion of neuromuscular blockers was significantly shorter in the after group (6 hours) than in the before group (33 hours; P < .001). Ventilator-associated pneumonia occurred more frequently in the before group (45%) than in the after group (13%; P = .02). Overall intensive care unit mortality rate was 58%, similar in both groups (P = .44). CONCLUSION Use of a nurse-implemented protocol to reduce use of neuromuscular blockers is feasible.
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Affiliation(s)
- Coraline Boulila
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Samia Ben Abdallah
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Aude Marincamp
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Vincent Coic
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Romuald Lauverjat
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Nicole Ericher
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Wulfran Bougouin
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Jean-Paul Mira
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Alain Cariou
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France. .,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France. .,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University. .,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research. .,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.
| | - Guillaume Geri
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
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Venet F, Cour M, Demaret J, Monneret G, Argaud L. Decreased Monocyte HLA-DR Expression in Patients After Non-Shockable out-of-Hospital Cardiac Arrest. Shock 2018; 46:33-6. [PMID: 26796574 DOI: 10.1097/shk.0000000000000561] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Out-of-hospital cardiac arrest (OHCA) constitutes a major health care problem with the development in immediate survivors of a post-cardiac arrest syndrome including systemic inflammatory response as observed in sepsis. As a decreased monocyte HLA-DR expression (mHLA-DR) has been repeatedly described in septic patients in association with an increased risk of death and nosocomial infections, we tested whether this immune alteration could also be observed after OHCA. Fifty-five non-shockable OHCA patients sampled at Day 0 (D0: within 4 h after OHCA), D1 (the next day), and D3: (after 2 additional days) were included. CD4+ lymphocyte count and mHLA-DR were evaluated by flow cytometry. We observed a marked decrease in mHLA-DR as early as D0 in patients compared with normal values. This decrease persisted till D3 and was associated with a moderate decrease in the number of circulating CD4+ lymphocytes. No correlations were identified between mHLA-DR and usual prognostic markers after OHCA. However, overtime evolution in mHLA-DR values appeared different between survivors and non-survivors with a quasisystematic decrease between D1 and D3 in non-survivors versus an increased expression in survivors. In conclusion, this preliminary pilot study describes the occurrence of OHCA-induced immune alterations as illustrated by a decreased mHLA-DR and CD4+ lymphopenia. Furthermore, we show for the first time the differential overtime evolution in mHLA-DR between survivors and non-survivors without association with usual prognostic markers and multiple organ failure. These initial results should now be confirmed in a larger cohort of OHCA patients.
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Affiliation(s)
- Fabienne Venet
- *Groupement Hospitalier Edouard Herriot, Cellular Immunology Laboratory †Université Claude Bernard Lyon I and Hospices Civils de Lyon, EAM 4174, Lyon, France ‡Medical Intensive Care Unit, Groupement Hospitalier Edouard Herriot, Hospices Civils de Lyon §INSERM UMR 1060, CarMeN, Team 5 "Cardioprotection", Lyon, France
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Kroupa J, Knot J, Ulman J, Bednar F, Dohnalova A, Motovska Z. Clinical and laboratory predictors of Infectious Complications in patients after Out-of-Hospital Cardiac Arrest. J Crit Care 2017; 42:85-91. [DOI: 10.1016/j.jcrc.2017.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 06/07/2017] [Accepted: 07/03/2017] [Indexed: 01/15/2023]
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Johnson NJ, Carlbom DJ, Gaieski DF. Ventilator Management and Respiratory Care After Cardiac Arrest: Oxygenation, Ventilation, Infection, and Injury. Chest 2017; 153:1466-1477. [PMID: 29175085 DOI: 10.1016/j.chest.2017.11.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/16/2017] [Accepted: 11/10/2017] [Indexed: 01/14/2023] Open
Abstract
Return of spontaneous circulation after cardiac arrest results in a systemic inflammatory state called the post-cardiac arrest syndrome, which is characterized by oxidative stress, coagulopathy, neuronal injury, and organ dysfunction. Perturbations in oxygenation and ventilation may exacerbate secondary injury after cardiac arrest and have been shown to be associated with poor outcome. Further, patients who experience cardiac arrest are at risk for a number of other pulmonary complications. Up to 70% of patients experience early infection after cardiac arrest, and the respiratory tract is the most common source. Vigilance for early-onset pneumonia, as well as aggressive diagnosis and early antimicrobial agent administration are important components of critical care in this population. Patients who experience cardiac arrest are at risk for the development of ARDS. Risk factors include aspiration, pulmonary contusions (from chest compressions), systemic inflammation, and reperfusion injury. Early evidence suggests that they may benefit from ventilation with low tidal volumes. Meticulous attention to mechanical ventilation, early assessment and optimization of respiratory gas exchange, and therapies targeted at potential pulmonary complications may improve outcomes after cardiac arrest.
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Affiliation(s)
- Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA.
| | - David J Carlbom
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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Úbeda-Iglesias A, Alonso-Romero L. Letter to the editor: Clinical and laboratory predictors of infectious complications in patients after out-of-hospital cardiac arrest. J Crit Care 2017; 41:311-312. [DOI: 10.1016/j.jcrc.2017.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 07/24/2017] [Indexed: 11/16/2022]
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Goury A, Poirson F, Chaput U, Voicu S, Garçon P, Beeken T, Malissin I, Kerdjana L, Chelly J, Vodovar D, Oueslati H, Ekherian JM, Marteau P, Vicaut E, Megarbane B, Deye N. Targeted temperature management using the "Esophageal Cooling Device" after cardiac arrest (the COOL study): A feasibility and safety study. Resuscitation 2017; 121:54-61. [PMID: 28951293 DOI: 10.1016/j.resuscitation.2017.09.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 09/18/2017] [Accepted: 09/22/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Targeted temperature management (TTM) between 32 and 36°C is recommended after out-of-hospital cardiac arrest (OHCA). We aimed to assess the feasibility and safety of the "Esophageal Cooling Device" (ECD) in performing TTM. PATIENTS AND METHODS This single-centre, prospective, interventional study included 17 comatose OHCA patients. Main exclusion criteria were: delay between OHCA and return of spontaneous circulation (ROSC)>60min, delay between sustained ROSC and inclusion >360min, known oesophageal disease. A TTM between 32 and 34°C was performed using the ECD (Advanced Cooling Therapy, USA) connected to a heat exchanger console (Meditherm III®, Gaymar, France), without cold fluids' use. Primary endpoint was feasibility of inducing, maintaining TTM, and rewarming using the ECD alone. Secondary endpoints were adverse events, focusing on potential digestive damages. Results were expressed as median (interquartiles 25-75). RESULTS Cooling rate to reach the Target Temperature (33°C-TT) was 0.26°C/h [0.19-0.36]. All patients reached the 32-34°C range with a time spent within the range of 26h [21-28] (3 patients did not reach 33°C). Temperature deviation outside the TT during TTM-maintenance was 0.10°C [0.03-0.20]. Time with deviation >1°C was 0h. Rewarming rate was 0.20°C/h [0.18-0.22]. Among the 16 gastrointestinal endoscopy procedures performed, 10 (62.5%) were normal. Minor oeso-gastric injuries (37.5% and 19%, respectively) were similar to usual orogastric tube injuries. One patient experienced severe oesophagitis mimicking peptic lesions, not cooling-related. No patient among the 9 alive at 3-month follow-up had gastrointestinal complains. CONCLUSION ECD seems an interesting, safe, accurate, semi-invasive cooling method in OHCA patients treated with 33°C-TTM, particularly during the maintenance phase.
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Affiliation(s)
- Antoine Goury
- Réanimation Médicale & Toxicologique, Hôpital Lariboisière, AP-HP, Paris Cedex 10, France
| | - Florent Poirson
- Réanimation Médicale & Toxicologique, Hôpital Lariboisière, AP-HP, Paris Cedex 10, France
| | - Ulriikka Chaput
- Hépato-gastro-entérologie, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Sebastian Voicu
- Réanimation Médicale & Toxicologique, Hôpital Lariboisière, AP-HP, Paris Cedex 10, France
| | - Pierre Garçon
- Réanimation Médicale & Toxicologique, Hôpital Lariboisière, AP-HP, Paris Cedex 10, France
| | - Thomas Beeken
- Réanimation Médicale & Toxicologique, Hôpital Lariboisière, AP-HP, Paris Cedex 10, France
| | - Isabelle Malissin
- Réanimation Médicale & Toxicologique, Hôpital Lariboisière, AP-HP, Paris Cedex 10, France
| | - Lamia Kerdjana
- Réanimation Médicale & Toxicologique, Hôpital Lariboisière, AP-HP, Paris Cedex 10, France
| | - Jonathan Chelly
- Réanimation Médicale & Toxicologique, Hôpital Lariboisière, AP-HP, Paris Cedex 10, France; Clinical Research Unit-Groupe Hospitalier Sud Île de France, 77000 Melun, France
| | - Dominique Vodovar
- Réanimation Médicale & Toxicologique, Hôpital Lariboisière, AP-HP, Paris Cedex 10, France
| | - Haikel Oueslati
- Réanimation Médicale & Toxicologique, Hôpital Lariboisière, AP-HP, Paris Cedex 10, France
| | - Jean Michel Ekherian
- Réanimation Médicale & Toxicologique, Hôpital Lariboisière, AP-HP, Paris Cedex 10, France
| | - Philippe Marteau
- Hépato-gastro-entérologie, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Eric Vicaut
- Unité de Recherche Clinique, Hôpital Fernand Widal, AP-HP, Paris Cedex 10, France
| | - Bruno Megarbane
- Réanimation Médicale & Toxicologique, Hôpital Lariboisière, AP-HP, Paris Cedex 10, France; INSERM UMRS-1144, Paris, France
| | - Nicolas Deye
- Réanimation Médicale & Toxicologique, Hôpital Lariboisière, AP-HP, Paris Cedex 10, France; INSERM U942, Hôpital Lariboisière, Paris, France.
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Postreanimationsbehandlung. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0331-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Targeted temperature management in the ICU: Guidelines from a French expert panel. Anaesth Crit Care Pain Med 2017; 37:481-491. [PMID: 28688998 DOI: 10.1016/j.accpm.2017.06.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Over the recent period, the use of induced hypothermia has gained an increasing interest for critically ill patients, in particular in brain-injured patients. The term "targeted temperature management" (TTM) has now emerged as the most appropriate when referring to interventions used to reach and maintain a specific level temperature for each individual. TTM may be used to prevent fever, to maintain normothermia, or to lower core temperature. This treatment is widely used in intensive care units, mostly as a primary neuroprotective method. Indications are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of TTM in adult and paediatric critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de réanimation de langue française [SRLF]) and the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie réanimation [SFAR]) with the participation of the French Emergency Medicine Association (Société française de médecine d'urgence [SFMU]), the French Group for Pediatric Intensive Care and Emergencies (Groupe francophone de réanimation et urgences pédiatriques [GFRUP]), the French National Association of Neuro-Anesthesiology and Critical Care (Association nationale de neuro-anesthésie réanimation française [ANARLF]), and the French Neurovascular Society (Société française neurovasculaire [SFNV]). Fifteen experts and two coordinators agreed to consider questions concerning TTM and its practical implementation in five clinical situations: cardiac arrest, traumatic brain injury, stroke, other brain injuries, and shock. This resulted in 30 recommendations: 3 recommendations were strong (Grade 1), 13 were weak (Grade 2), and 14 were experts' opinions. After two rounds of rating and various amendments, a strong agreement from voting participants was obtained for all 30 (100%) recommendations, which are exposed in the present article.
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Mongardon N, Kohlhauer M, Lidouren F, Hauet T, Giraud S, Hutin A, Costes B, Barau C, Bruneval P, Micheau P, Cariou A, Dhonneur G, Berdeaux A, Ghaleh B, Tissier R. A Brief Period of Hypothermia Induced by Total Liquid Ventilation Decreases End-Organ Damage and Multiorgan Failure Induced by Aortic Cross-Clamping. Anesth Analg 2017; 123:659-69. [PMID: 27482772 DOI: 10.1213/ane.0000000000001432] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In animal models, whole-body cooling reduces end-organ injury after cardiac arrest and other hypoperfusion states. The benefits of cooling in humans, however, are uncertain, possibly because detrimental effects of prolonged cooling may offset any potential benefit. Total liquid ventilation (TLV) provides both ultrafast cooling and rewarming. In previous reports, ultrafast cooling with TLV potently reduced neurological injury after experimental cardiac arrest in animals. We hypothesized that a brief period of rapid cooling and rewarming via TLV could also mitigate multiorgan failure (MOF) after ischemia-reperfusion induced by aortic cross-clamping. METHODS Anesthetized rabbits were submitted to 30 minutes of supraceliac aortic cross-clamping followed by 300 minutes of reperfusion. They were allocated either to a normothermic procedure with conventional ventilation (control group) or to hypothermic TLV (33°C) before, during, and after cross-clamping (pre-clamp, per-clamp, and post-clamp groups, respectively). In all TLV groups, hypothermia was maintained for 75 minutes and switched to a rewarming mode before resumption to conventional mechanical ventilation. End points included cardiovascular, renal, liver, and inflammatory parameters measured 300 minutes after reperfusion. RESULTS In the normothermic (control) group, ischemia-reperfusion injury produced evidence of MOF including severe vasoplegia, low cardiac output, acute kidney injury, and liver failure. In the TLV group, we observed gradual improvements in cardiac output in post-clamp, per-clamp, and pre-clamp groups versus control (53 ± 8, 64 ± 12, and 90 ± 24 vs 36 ± 23 mL/min/kg after 300 minutes of reperfusion, respectively). Liver biomarker levels were also lower in pre-clamp and per-clamp groups versus control. However, acute kidney injury was prevented in pre-clamp, and to a limited extent in per-clamp groups, but not in the post-clamp group. For instance, creatinine clearance was 4.8 ± 3.1 and 0.5 ± 0.6 mL/kg/min at the end of the follow-up in pre-clamp versus control animals (P = .0004). Histological examinations of the heart, kidney, liver, and jejunum in TLV and control groups also demonstrated reduced injury with TLV. CONCLUSIONS A brief period of ultrafast cooling with TLV followed by rapid rewarming attenuated biochemical and histological markers of MOF after aortic cross-clamping. Cardiovascular and liver dysfunctions were limited by a brief period of hypothermic TLV, even when started after reperfusion. Conversely, acute kidney injury was limited only when hypothermia was started before reperfusion. Further work is needed to determine the clinical significance of our results and to identify the optimal duration and timing of TLV-induced hypothermia for end-organ protection in hypoperfusion states.
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Affiliation(s)
- Nicolas Mongardon
- From the *Inserm, U955, Equipe 3, Créteil, France; †Université Paris Est, UMR_S 955, UPEC, DHU A-TVB, Créteil, France; ‡Université Paris Est, Ecole Nationale Vétérinaire Alfort, Maisons Alfort, France; §Service d' Anesthésie et des Réanimations Chirurgicales, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique - Hôpitaux de Paris, Créteil, France; ‖Inserm, U1082, Poitiers, France; ¶Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France; #CHU de Poitiers, Service de Biochimie, Poitiers, France; **Inserm, UMR 970, Paris Cardiovascular Research Center, Paris, France; ††Université de Sherbrooke, Sherbrooke, Canada; and ‡‡Service de Réanimation Médicale, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Paris, France
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Abstract
Over the recent period, the use of induced hypothermia has gained an increasing interest for critically ill patients, in particular in brain-injured patients. The term “targeted temperature management” (TTM) has now emerged as the most appropriate when referring to interventions used to reach and maintain a specific level temperature for each individual. TTM may be used to prevent fever, to maintain normothermia, or to lower core temperature. This treatment is widely used in intensive care units, mostly as a primary neuroprotective method. Indications are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of TTM in adult and paediatric critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de Réanimation de Langue Française [SRLF]) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d’Anesthésie Réanimation [SFAR]) with the participation of the French Emergency Medicine Association (Société Française de Médecine d’Urgence [SFMU]), the French Group for Pediatric Intensive Care and Emergencies (Groupe Francophone de Réanimation et Urgences Pédiatriques [GFRUP]), the French National Association of Neuro-Anesthesiology and Critical Care (Association Nationale de Neuro-Anesthésie Réanimation Française [ANARLF]), and the French Neurovascular Society (Société Française Neurovasculaire [SFNV]). Fifteen experts and two coordinators agreed to consider questions concerning TTM and its practical implementation in five clinical situations: cardiac arrest, traumatic brain injury, stroke, other brain injuries, and shock. This resulted in 30 recommendations: 3 recommendations were strong (Grade 1), 13 were weak (Grade 2), and 14 were experts’ opinions. After two rounds of rating and various amendments, a strong agreement from voting participants was obtained for all 30 (100%) recommendations, which are exposed in the present article.
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71
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Kim JC, Lee BK, Lee DH, Jung YH, Cho YS, Lee SM, Lee SJ, Park CH, Jeung KW. Association between lactate clearance during post-resuscitation care and neurologic outcome in cardiac arrest survivors treated with targeted temperature management. Clin Exp Emerg Med 2017; 4:10-18. [PMID: 28435897 PMCID: PMC5385509 DOI: 10.15441/ceem.16.149] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 12/30/2016] [Accepted: 01/04/2017] [Indexed: 12/31/2022] Open
Abstract
Objective We investigated the association between lactate clearance or serum lactate levels and neurologic outcomes or in-hospital mortality in cardiac arrest survivors who were treated with targeted temperature management (TTM). Methods A retrospective analysis of data from cardiac arrest survivors treated with TTM between 2012 and 2015 was conducted. Serum lactate levels were measured on admission and at 12, 24, and 48 hours following admission. Lactate clearance at 12, 24, and 48 hours was also calculated. The primary outcome was neurologic outcome at discharge. The secondary outcome was in-hospital mortality. Results The study included 282 patients; 184 (65.2%) were discharged with a poor neurologic outcome, and 62 (22.0%) died. Higher serum lactate levels at 12 hours (odds ratio [OR], 1.157; 95% confidence interval [CI], 1.006 to 1.331), 24 hours (OR, 1.320; 95% CI, 1.084 to 1.607), and 48 hours (OR, 2.474; 95% CI, 1.459 to 4.195) after admission were associated with a poor neurologic outcome. Furthermore, a higher serum lactate level at 48 hours (OR, 1.459; 95% CI, 1.181 to 1.803) following admission was associated with in-hospital mortality. Lactate clearance was not associated with neurologic outcome or in-hospital mortality at any time point after adjusting for confounders. Conclusion Increased serum lactate levels after admission are associated with a poor neurologic outcome at discharge and in-hospital mortality in cardiac arrest survivors treated with TTM. Conversely, lactate clearance is not a robust surrogate marker of neurologic outcome or in-hospital mortality.
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Affiliation(s)
- Jung Chang Kim
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yong Soo Cho
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Sung Min Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Seung Joon Lee
- Department of Emergency Medicine, Seonam University Myongji Hospital, Goyang, Korea
| | - Chi Ho Park
- Department of Emergency Medicine, Seonam University Myongji Hospital, Goyang, Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
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72
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Constant AL, Mongardon N, Morelot Q, Pichon N, Grimaldi D, Bordenave L, Soummer A, Sauneuf B, Merceron S, Ricome S, Misset B, Bruel C, Schnell D, Boisramé-Helms J, Dubuisson E, Brunet J, Lasocki S, Cronier P, Bouhemad B, Carreira S, Begot E, Vandenbunder B, Dhonneur G, Jullien P, Resche-Rigon M, Bedos JP, Montlahuc C, Legriel S. Targeted temperature management after intraoperative cardiac arrest: a multicenter retrospective study. Intensive Care Med 2017; 43:485-495. [PMID: 28220232 DOI: 10.1007/s00134-017-4709-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 01/31/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE Few outcome data are available about temperature management after intraoperative cardiac arrest (IOCA). We describe targeted temperature management (TTM) (32-34 °C) modalities, adverse events, and association with 1-year functional outcome in patients with IOCA. METHODS Patients admitted to 11 ICUs after IOCA in 2008-2013 were studied retrospectively. The main outcome measure was 1-year functional outcome. RESULTS Of the 101 patients [35 women and 66 men; median age, 62 years (interquartile range, 42-72)], 68 (67.3%) were ASA PS I to III and 57 (56.4%) had emergent surgery. First recorded rhythms were asystole in 44 (43.6%) patients, pulseless electrical activity in 36 (35.6%), and ventricular fibrillation/tachycardia in 20 (19.8%). Median times from collapse to cardiopulmonary resuscitation and return of spontaneous circulation (ROSC) were 0 min (0-0) and 10 min (4-20), respectively. The 30 (29.7%) patients who received TTM had an increased risk of infection (P = 0.005) but not of arrhythmia, bleeding, or metabolic/electrolyte disorders. By multivariate analysis, one or more defibrillation before ROSC was positively associated with a favorable functional outcome at 1-year (OR 3.06, 95% CI 1.05-8.95, P = 0.04) and emergency surgery was negatively associated with 1-year favorable functional outcome (OR 0.36; 95% CI 0.14-0.95, P = 0.038). TTM use was not independently associated with 1-year favorable outcome (OR 0.82; 95% CI 0.27-2.46, P = 0.72). CONCLUSIONS TTM was used in less than one-third of patients after IOCA. TTM was associated with infection but not with bleeding or coronary events in this setting. TTM did not independently predict 1-year favorable functional outcome after IOCA in this study.
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Affiliation(s)
- Anne-Laure Constant
- Medical-Surgical Intensive Care Unit, Intensive Care Department, Centre Hospitalier de Versailles-Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France.,Department of Anesthesiology and Critical Care Medicine, Hôpital Européen Georges Pompidou, 75015, Paris, France
| | - Nicolas Mongardon
- Department of Anesthesiology and Surgical Intensive Care Units, Hôpital Henri Mondor, Assistance Publique des Hôpitaux de Paris, 51 avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France.,Faculté de médecine, Université Paris Est, 8 avenue du général Sarrail, 94000, Créteil, France.,Inserm, U955, Equipe 3 "Stratégies pharmacologiques et thérapeutiques expérimentales des insuffisances cardiaques et coronaires", 8 avenue du général Sarrail, Créteil, France
| | - Quentin Morelot
- SBIM Biostatistics and Medical information, Hôpital Saint-Louis, APHP, 1, avenue Claude Vellefaux, Paris, France.,Université Paris Diderot, Paris, France.,ECSTRA Team (Epidémiologie Clinique et Statistiques pour la Recherche en Santé), UMR 1153 INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Nicolas Pichon
- Medical-Surgical Intensive Care Unit, Centre Hospitalier Universitaire de Limoges, 2, avenue Martin-Luther-King, 87042, Limoges, France
| | - David Grimaldi
- Medical-Surgical Intensive Care Unit, Intensive Care Department, Centre Hospitalier de Versailles-Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - Lauriane Bordenave
- Department of Anesthesiology, Institut Gustave Roussy, 39, rue Camille-Desmoulins, 94805, Villejuif Cedex, France
| | - Alexis Soummer
- Department of Intensive Care Medicine, Foch Hospital, 40 rue Worth, 92150, Suresnes, France
| | - Bertrand Sauneuf
- Pôle Anesthésie-Réanimation-SAMU, CHU de Caen, Avenue de la côte de Nacre, CS30001, 14033, Caen Cedex 9, France
| | - Sybille Merceron
- Medical-Surgical Intensive Care Unit, Intensive Care Department, Centre Hospitalier de Versailles-Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - Sylvie Ricome
- Department of Anesthesiology and Critical Care, Assistance Publique des Hôpitaux de Paris, 100 boulevard du Général-Leclerc, 92110, Clichy la Garenne, France
| | - Benoit Misset
- Medical-Surgical Intensive Care Unit, Groupe Hospitalier Saint Joseph, 185 rue Raymond Losserand, 75614, Paris Cedex, France.,Sorbonne Paris Cité-Medical School, Paris Descartes University, Paris, France
| | - Cedric Bruel
- Medical-Surgical Intensive Care Unit, Groupe Hospitalier Saint Joseph, 185 rue Raymond Losserand, 75614, Paris Cedex, France
| | - David Schnell
- Medical Intensive Care Unit, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Julie Boisramé-Helms
- Medical Intensive Care Unit, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,EA 7293, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de médecine, Université de Strasbourg, Strasbourg, France
| | - Etienne Dubuisson
- Department of Anesthesiology, Centre Hospitalier de Versailles-Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - Jennifer Brunet
- Pôle Anesthésie-Réanimation-SAMU, CHU de Caen, Avenue de la côte de Nacre, CS30001, 14033, Caen Cedex 9, France
| | - Sigismond Lasocki
- Pôle d'Anesthésie Réanimation, CHU d'Angers, 4 rue Larrey, 49933, Angers Cedex 9, Angers, France.,LUNAM Université, CHU d'Angers, 49933, Angers Cedex, France
| | - Pierrick Cronier
- Intensive Care Unit, Centre Hospitalier Sud-Francilien, 116 boulevard Jean Jaurès, 91106, Corbeil-Essonnes Cedex, France
| | - Belaid Bouhemad
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Saint Joseph, 185 rue Raymond Losserand, 75614, Paris Cedex, France
| | - Serge Carreira
- Department of Intensive Care Medicine, Hôpital Saint-Camill, 2 rue des Pères-Camiliens, 94360, Bry-sur-Marne, France
| | - Emmanuelle Begot
- Medical-Surgical Intensive Care Unit, Centre Hospitalier Universitaire de Limoges, 2, avenue Martin-Luther-King, 87042, Limoges, France
| | - Benoit Vandenbunder
- Department of Anesthesiology, Foch Hospital, 40 rue Worth, 92150, Suresnes, France
| | - Gilles Dhonneur
- Department of Anesthesiology and Surgical Intensive Care Units, Hôpital Henri Mondor, Assistance Publique des Hôpitaux de Paris, 51 avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France.,Faculté de médecine, Université Paris Est, 8 avenue du général Sarrail, 94000, Créteil, France
| | - Philippe Jullien
- Department of Anesthesiology, Centre Hospitalier de Versailles-Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - Matthieu Resche-Rigon
- SBIM Biostatistics and Medical information, Hôpital Saint-Louis, APHP, 1, avenue Claude Vellefaux, Paris, France.,Université Paris Diderot, Paris, France.,ECSTRA Team (Epidémiologie Clinique et Statistiques pour la Recherche en Santé), UMR 1153 INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Jean-Pierre Bedos
- Medical-Surgical Intensive Care Unit, Intensive Care Department, Centre Hospitalier de Versailles-Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - Claire Montlahuc
- SBIM Biostatistics and Medical information, Hôpital Saint-Louis, APHP, 1, avenue Claude Vellefaux, Paris, France.,Université Paris Diderot, Paris, France.,ECSTRA Team (Epidémiologie Clinique et Statistiques pour la Recherche en Santé), UMR 1153 INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Stephane Legriel
- Medical-Surgical Intensive Care Unit, Intensive Care Department, Centre Hospitalier de Versailles-Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France. .,Sorbonne Paris Cité-Medical School, Paris Descartes University, Paris, France. .,INSERM U970, Paris Cardiovascular Research Center, Paris, France.
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Jentzer JC, Clements CM, Murphy JG, Scott Wright R. Recent developments in the management of patients resuscitated from cardiac arrest. J Crit Care 2017; 39:97-107. [PMID: 28242531 DOI: 10.1016/j.jcrc.2017.02.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/18/2017] [Accepted: 02/01/2017] [Indexed: 01/31/2023]
Abstract
Cardiac arrest is the leading cause of death in Europe and the United States. Many patients who are initially resuscitated die in the hospital, and hospital survivors often have substantial neurologic dysfunction. Most cardiac arrests are caused by coronary artery disease; patients with coronary artery disease likely benefit from early coronary angiography and intervention. After resuscitation, cardiac arrest patients remain critically ill and frequently suffer cardiogenic shock and multiorgan failure. Early cardiopulmonary stabilization is important to prevent worsening organ injury. To achieve best patient outcomes, comprehensive critical care management is needed, with primary goals of stabilizing hemodynamics and preventing progressive brain injury. Targeted temperature management is frequently recommended for comatose survivors of cardiac arrest to mitigate the neurologic injury that drives outcomes. Accurate neurologic assessment is central to managing care of cardiac arrest survivors and should combine physical examination with objective neurologic testing, with the caveat that delaying neurologic prognosis is essential to avoid premature withdrawal of supportive care. A combination of clinical findings and diagnostic results should be used to estimate the likelihood of functional recovery. This review focuses on recent advances in care and specific cardiac intensive care strategies that may improve morbidity and mortality for patients after cardiac arrest.
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Affiliation(s)
- Jacob C Jentzer
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
| | | | - Joseph G Murphy
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - R Scott Wright
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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74
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Fernández A, Solís A, Cañete P, Del Castillo J, Urbano J, Carrillo A, López-Herce J. Incidence and prognosis of nosocomial infection after recovering of cardiac arrest in children. Resuscitation 2017; 113:87-89. [PMID: 28212839 DOI: 10.1016/j.resuscitation.2017.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/13/2017] [Accepted: 02/02/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE to analyze the incidence of infection in children who have suffered an in-hospital cardiac arrest (CA) and the association with mortality. METHODS A retrospective unicenter observational study on a prospective database with children between one month and 16 years old, who have suffered an in-hospital CA was performed. Clinical, analytical and monitorization data, treatment, mortality and cause of death were recorded. RESULTS 57 children were studied (57.6% males). Recovery of spontaneous circulation (ROSC) was achieved in 50 children (87.7%) and 32 (59.3%) survived. After ROSC, 28 patients (56% of those who achieved ROSC) were diagnosed of infection. There were not significant differences in mortality between patients infected (42.9%) and uninfected (27.3%) p=0.374. Only one died in consequence of a sepsis with multiorganic failure. CONCLUSIONS The frequency of infection in children after recovering of a cardiac arrest is high. There were no statistically significant differences in mortality between patients with and without infection after ROSC.
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Affiliation(s)
- Andrés Fernández
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón de Madrid, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Ana Solís
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón de Madrid, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Paloma Cañete
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón de Madrid, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Jimena Del Castillo
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón de Madrid, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Javier Urbano
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón de Madrid, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Angel Carrillo
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón de Madrid, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Jesús López-Herce
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón de Madrid, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón Facultad de Medicina, Universidad Complutense de Madrid, Spain.
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- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón de Madrid, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón Facultad de Medicina, Universidad Complutense de Madrid, Spain
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Dankiewicz J, Nielsen N, Linder A, Kuiper M, Wise MP, Cronberg T, Erlinge D, Gasche Y, Harmon MB, Hassager C, Horn J, Kjaergaard J, Pellis T, Stammet P, Undén J, Wanscher M, Wetterslev J, Åneman A, Ullén S, Juffermans NP, Friberg H. Infectious complications after out-of-hospital cardiac arrest-A comparison between two target temperatures. Resuscitation 2016; 113:70-76. [PMID: 27993631 DOI: 10.1016/j.resuscitation.2016.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 12/05/2016] [Accepted: 12/05/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND It has been suggested that target temperature management (TTM) increases the probability of infectious complications after cardiac arrest. We aimed to compare the incidence of pneumonia, severe sepsis and septic shock after out-of-hospital cardiac arrest (OHCA) in patients with two target temperatures and to describe changes in biomarkers and possible mortality associated with these infectious complications. METHODS Post-hoc analysis of the TTM-trial which randomized patients resuscitated from OHCA to a target temperature of 33°C or 36°C. Prospective data on infectious complications were recorded daily during the ICU-stay. Pneumonia, severe sepsis and septic shock were considered infectious complications. Procalcitonin (PCT) and C-reactive-protein (CRP) levels were measured at 24h, 48h and 72h after cardiac arrest. RESULTS There were 939 patients in the modified intention-to-treat population. Five-hundred patients (53%) developed pneumonia, severe sepsis or septic shock which was associated with mortality in multivariate analysis (Hazard ratio [HR] 1.39; 95%CI 1.13-1.70; p=0.001). There was no statistically significant difference in the incidence of infectious complications between temperature groups (sub-distribution hazard ratio [SHR] 0.88; 95%CI 0.75-1.03; p=0.12). PCT and CRP were significantly higher for patients with infections at all times (p<0.001), but there was considerable overlap. CONCLUSIONS Patients who develop pneumonia, severe sepsis or septic shock after OHCA might have an increased mortality. A target temperature of 33°C after OHCA was not associated with an increased risk of infectious complications compared to a target temperature of 36°C. PCT and CRP are of limited value for diagnosing infectious complications after cardiac arrest.
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Affiliation(s)
- Josef Dankiewicz
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Lund University, Getingevägen, 22185 Lund, Sweden.
| | - Niklas Nielsen
- Department of Clinical Sciences, Lund University, Getingevägen, 22185 Lund, Sweden; Department of Anaesthesiology and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Adam Linder
- Department of Clinical Sciences, Lund University, Getingevägen, 22185 Lund, Sweden; Division of Infection Medicine, Lund University Hospital, Lund, Sweden
| | - Michael Kuiper
- Department of Intensive Care, Leeuwarden Hospital, Leeuwarden, The Netherlands
| | - Matthew P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, United Kingdom
| | - Tobias Cronberg
- Department of Clinical Sciences, Lund University, Getingevägen, 22185 Lund, Sweden; Department of Neurology, Skåne University Hospital, Lund, Sweden
| | - David Erlinge
- Department of Clinical Sciences, Lund University, Getingevägen, 22185 Lund, Sweden; Department of Cardiology, Skåne University Hospital, Lund Sweden
| | - Yvan Gasche
- Department of Intensive Care, Geneva University Hospital, Geneva, Switzerland
| | | | - Christian Hassager
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jesper Kjaergaard
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Tommaso Pellis
- Department of Intensive Care, Santa Maria degli Ángeli, Pordenone, Italy
| | - Pascal Stammet
- Department of Anesthesiology and Intensive Care, Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg
| | - Johan Undén
- Department of Clinical Sciences, Lund University, Getingevägen, 22185 Lund, Sweden; Department of Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | - Michael Wanscher
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre of Clinical Intervention Research, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Anders Åneman
- Department of Intensive Care, Liverpool Hospital, Sydney, NSW, Australia
| | - Susann Ullén
- R&D Centre Skåne, Skåne University Hospital, Lund, Sweden
| | | | - Hans Friberg
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Lund University, Getingevägen, 22185 Lund, Sweden
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Ribaric SF, Turel M, Knafelj R, Gorjup V, Stanic R, Gradisek P, Cerovic O, Mirkovic T, Noc M. Prophylactic versus clinically-driven antibiotics in comatose survivors of out-of-hospital cardiac arrest-A randomized pilot study. Resuscitation 2016; 111:103-109. [PMID: 27987397 DOI: 10.1016/j.resuscitation.2016.11.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/12/2016] [Accepted: 11/29/2016] [Indexed: 01/24/2023]
Abstract
AIM To investigate benefits of prophylactic antibiotics in comatose survivors of out-of-hospital cardiac arrest (OHCA). METHODS Patients without evidence of tracheobronchial aspiration on admission bronchoscopy were randomized to prophylactic Amoxicillin-Clavulanic acid 1.2g every 8h (P) or clinically-driven antibiotics (C) administered if signs of infection developed during initial 7days of intensive care unit (ICU) stay. RESULTS Among 83 patients enrolled between September 2013 and February 2015, tracheobronchial aspiration was documented in 23 (28%). Accordingly, 60 patients were randomized. Percentage of patients on antibiotics between days 1-5 was significantly greater in P group. White blood count, C-reactive protein, procalcitonin (PCT) and CD 64 significantly increased during the postresuscitation phase. Except for lower CRP and PCT in group P on day 6 (p<0.05), there was no significant differences. Mini BAL on day 3 was less often positive in group P (7% vs. 42%; p<0.01). There was no significant difference in other microbiological samples and X-ray signs of pneumonia cumulatively documented in 50% in both groups. Use of vasopressors/inotropes (93% in both groups), duration of mechanical ventilation (5.4±3.7 vs. 5.2±3.1 days), tracheal intubation (6.5±4.6 vs. 5.9±4.3 days), ICU stay (7.7±5.2 vs. 6.9±4.5 days), survival (73% vs. 73%) and survival with good neurological outcome (50% vs. 40%) were also comparable between P and C groups. CONCLUSION Bronchoscopy on admission documented tracheobronchial aspiration in 28% of comatose survivors of OHCA. In the absence of aspiration, prophylactic antibiotics did not significantly alter systemic inflammatory response, postresuscitation pneumonia, ICU treatment and outcome (ClinicalTrials.gov Identifier: NCT02899507).
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Affiliation(s)
- Suada Filekovic Ribaric
- Center for Intensive Therapy, Department of Anesthesiology and Intensive therapy, University Medical Center, Zaloska 7, 1000 Ljubljana, Slovenia
| | - Matjaz Turel
- Department of Pulmonary Diseases and Allergy, University Medical Center, Zaloska 7, 1000 Ljubljana, Slovenia
| | - Rihard Knafelj
- Center for Intensive Internal Medicine, University Medical Center, Zaloska 7, 1000 Ljubljana, Slovenia
| | - Vojka Gorjup
- Center for Intensive Internal Medicine, University Medical Center, Zaloska 7, 1000 Ljubljana, Slovenia
| | - Rade Stanic
- Center for Intensive Therapy, Department of Anesthesiology and Intensive therapy, University Medical Center, Zaloska 7, 1000 Ljubljana, Slovenia
| | - Primoz Gradisek
- Center for Intensive Therapy, Department of Anesthesiology and Intensive therapy, University Medical Center, Zaloska 7, 1000 Ljubljana, Slovenia
| | - Ognjen Cerovic
- Center for Intensive Therapy, Department of Anesthesiology and Intensive therapy, University Medical Center, Zaloska 7, 1000 Ljubljana, Slovenia
| | - Tomislav Mirkovic
- Center for Intensive Therapy, Department of Anesthesiology and Intensive therapy, University Medical Center, Zaloska 7, 1000 Ljubljana, Slovenia
| | - Marko Noc
- Center for Intensive Internal Medicine, University Medical Center, Zaloska 7, 1000 Ljubljana, Slovenia.
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Roldán-Reina ÁJ, Corcia-Palomo Y, Martín-Bermúdez R. Empiric antibiotic therapy after cardiac arrest. Med Clin (Barc) 2016; 148:92-93. [PMID: 27823791 DOI: 10.1016/j.medcli.2016.09.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 09/17/2016] [Accepted: 09/22/2016] [Indexed: 11/25/2022]
Affiliation(s)
| | - Yael Corcia-Palomo
- Servicio de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Rafael Martín-Bermúdez
- Servicio de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, España
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Erath JW, Hodrius J, Bushoven P, Fichtlscherer S, Zeiher AM, Seeger FH, Honold J. [Early onset pneumonia after successful resuscitation : Incidence after mild invasive hypothermia therapy]. Med Klin Intensivmed Notfmed 2016; 112:519-526. [PMID: 27807612 DOI: 10.1007/s00063-016-0228-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/10/2016] [Accepted: 09/13/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND Targeted temperature management (TTM) represents an effective therapy to improve neurologic outcome in patients who survive an out-of-hospital cardiac arrest (OHCA). First publications about this therapy reported a higher incidence of infections in patients who underwent TTM induced by external cooling devices. Whether intravascular cooling devices are also associated with an increased infection rate has not been investigated so far. METHODS In a single center retrospective study, the incidence of early onset pneumonia (EOP) in OHCA patients with or without intravascular TTM at 33 °C target temperature for 24 h who survived at least 24 h after admission was analyzed. RESULTS A total of 68 OHCA survivors (mean age 65 ± 15 years) were included in this analysis. The most common causes of OHCA were myocardial infarction (35 %), primary ventricular fibrillation (24 %), asystole (15 %), and pulmonary embolism (7 %). Of those, 32 patients (48 %) received TTM. The overall incidence of EOP was 38 %. Incidence of EOP did not differ significantly between groups, was more frequent in the group without TTM (42 % vs. 34 %, p = 0.57) and had no impact on mortality (hazard ratio = 1.02; 95 % confidence interval 0.25-4.16; p = 0.97). CONCLUSION Intravascular TTM at 33 °C with a cooling catheter is not associated with more infective complications in OHCA patients. This finding underscores the safety of TTM.
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Affiliation(s)
- J W Erath
- Medizinische Klinik III, Kardiologie, Nephrologie, Angiologie, Universitätsklinikum der Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt a. M., Deutschland
| | - J Hodrius
- Medizinische Klinik III, Kardiologie, Nephrologie, Angiologie, Universitätsklinikum der Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt a. M., Deutschland
| | - P Bushoven
- Medizinische Klinik III, Kardiologie, Nephrologie, Angiologie, Universitätsklinikum der Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt a. M., Deutschland
| | - S Fichtlscherer
- Medizinische Klinik III, Kardiologie, Nephrologie, Angiologie, Universitätsklinikum der Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt a. M., Deutschland
| | - A M Zeiher
- Medizinische Klinik III, Kardiologie, Nephrologie, Angiologie, Universitätsklinikum der Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt a. M., Deutschland
| | - F H Seeger
- Medizinische Klinik III, Kardiologie, Nephrologie, Angiologie, Universitätsklinikum der Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt a. M., Deutschland
| | - J Honold
- Medizinische Klinik III, Kardiologie, Nephrologie, Angiologie, Universitätsklinikum der Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt a. M., Deutschland.
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79
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Tagami T, Matsui H, Kuno M, Moroe Y, Kaneko J, Unemoto K, Fushimi K, Yasunaga H. Early antibiotics administration during targeted temperature management after out-of-hospital cardiac arrest: a nationwide database study. BMC Anesthesiol 2016; 16:89. [PMID: 27717334 PMCID: PMC5055699 DOI: 10.1186/s12871-016-0257-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/28/2016] [Indexed: 12/12/2022] Open
Abstract
Background Patients resuscitated after cardiac arrest are reportedly at high risk for infection and sepsis, especially those treated with targeted temperature management (TTM). There is, however, limited evidence suggesting that early antibiotic use improves patient outcomes. We examined the hypothesis that early treatment with antibiotics reduces mortality in patients with cardiac arrest receiving TTM. Methods We identified 2803 patients with cardiogenic out-of-hospital cardiac arrest (OHCA) that were treated with TTM and were admitted to 371 hospitals that contribute to the Japanese Diagnosis Procedure Combination inpatient database between July 2007 and March 2013. Of these, 1272 received antibiotics within the first 2 days (antibiotics) and 1531 did not (control). We generated 802 propensity score-matched pairs. Results There was no significant difference in 30-day mortality between the groups (control vs. antibiotics; 33.0 % vs. 29.9 %; difference, 3.1 %; 95 % confidence interval [CI], −1.4 to 7.7 %, p = 0.18). Analysis using the hospital antibiotics prescribing rate as an instrumental variable showed that antibiotic use was not significantly associated with a reduction in 30-day mortality (6.6 %, CI 95 %, −0.5 to 13.7 %, p = 0.28). A subgroup analysis of patients who required extracorporeal membrane oxygenation (ECMO) indicated a significant difference in 30-day mortality between the 2 groups (62.9 % vs. 43.5 %; difference 19.3 %, CI 95 %, 5.9 to 32.7 %, p = 0.005). In the instrumental variable model, the estimated reduction in 30-day mortality associated with antibiotics was 18.2 % (CI 95 %, 21.3 to 34.4 %, p = 0.03) in ECMO patients. Conclusions Although there was no significant association between the use of antibiotics and mortality after overall cardiogenic OHCA treated with TTM, antibiotics may be beneficial in patients who require ECMO.
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Affiliation(s)
- Takashi Tagami
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1138555, Japan. .,Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo, 2068512, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1138555, Japan
| | | | - Yuuta Moroe
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo, 2068512, Japan
| | - Junya Kaneko
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo, 2068512, Japan
| | - Kyoko Unemoto
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo, 2068512, Japan
| | - Kiyohide Fushimi
- Department of Health Informatics and Policy, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyoku, Tokyo, 1138510, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1138555, Japan
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80
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Therapeutic hypothermia after cardiac arrest is not associated with favorable neurological outcome: a meta-analysis. J Clin Anesth 2016; 33:225-32. [DOI: 10.1016/j.jclinane.2016.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 03/07/2016] [Indexed: 11/24/2022]
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Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VRM, Deakin CD, Bottiger BW, Friberg H, Sunde K, Sandroni C. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2016; 95:202-22. [PMID: 26477702 DOI: 10.1016/j.resuscitation.2015.07.018] [Citation(s) in RCA: 745] [Impact Index Per Article: 93.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK.
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Alain Cariou
- Cochin University Hospital (APHP) and Paris Descartes University, Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden
| | - Véronique R M Moulaert
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care and NIHR Southampton Respiratory Biomedical Research Unit, University Hospital, Southampton, UK
| | - Bernd W Bottiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Hans Friberg
- Department of Clinical Sciences, Division of Anesthesia and Intensive Care Medicine, Lund University, Lund, Sweden
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
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Yannopoulos D, Bartos JA, Martin C, Raveendran G, Missov E, Conterato M, Frascone RJ, Trembley A, Sipprell K, John R, George S, Carlson K, Brunsvold ME, Garcia S, Aufderheide TP. Minnesota Resuscitation Consortium's Advanced Perfusion and Reperfusion Cardiac Life Support Strategy for Out-of-Hospital Refractory Ventricular Fibrillation. J Am Heart Assoc 2016; 5:JAHA.116.003732. [PMID: 27412906 PMCID: PMC4937292 DOI: 10.1161/jaha.116.003732] [Citation(s) in RCA: 161] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background In 2015, the Minnesota Resuscitation Consortium (MRC) implemented an advanced perfusion and reperfusion life support strategy designed to improve outcome for patients with out‐of‐hospital refractory ventricular fibrillation/ventricular tachycardia (VF/VT). We report the outcomes of the initial 3‐month period of operations. Methods and Results Three emergency medical services systems serving the Minneapolis–St. Paul metro area participated in the protocol. Inclusion criteria included age 18 to 75 years, body habitus accommodating automated Lund University Cardiac Arrest System (LUCAS) cardiopulmonary resuscitation (CPR), and estimated transfer time from the scene to the cardiac catheterization laboratory of ≤30 minutes. Exclusion criteria included known terminal illness, Do Not Resuscitate/Do Not Intubate status, traumatic arrest, and significant bleeding. Refractory VF/VT arrest was defined as failure to achieve sustained return of spontaneous circulation after treatment with 3 direct current shocks and administration of 300 mg of intravenous/intraosseous amiodarone. Patients were transported to the University of Minnesota, where emergent advanced perfusion strategies (extracorporeal membrane oxygenation; ECMO), followed by coronary angiography and primary coronary intervention (PCI), were performed, when appropriate. Over the first 3 months of the protocol, 27 patients were transported with ongoing mechanical CPR. Of these, 18 patients met the inclusion and exclusion criteria. ECMO was placed in 83%. Seventy‐eight percent of patients had significant coronary artery disease with a high degree of complexity and 67% received PCI. Seventy‐eight percent of patients survived to hospital admission and 55% (10 of 18) survived to hospital discharge, with 50% (9 of 18) achieving good neurological function (cerebral performance categories 1 and 2). No significant ECMO‐related complications were encountered. Conclusions The MRC refractory VF/VT protocol is feasible and led to a high functionally favorable survival rate with few complications.
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Affiliation(s)
- Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN
| | - Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN
| | - Cindy Martin
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN
| | - Ganesh Raveendran
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN
| | - Emil Missov
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN
| | - Marc Conterato
- Department of Emergency Medicine, North Memorial Medical Center, Robbinsdale, MN
| | - R J Frascone
- Department of Emergency Medicine, Regions Hospital, St. Paul, MN
| | - Alexander Trembley
- Department of Emergency Medicine, North Memorial Medical Center, Robbinsdale, MN
| | - Kevin Sipprell
- Department of Emergency Medicine, Ridgeview Medical Center, Waconia, MN
| | - Ranjit John
- Division of Cardiothoracic Surgery, University of Minnesota School of Medicine, Minneapolis, MN
| | - Stephen George
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN
| | - Kathleen Carlson
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN
| | - Melissa E Brunsvold
- Division of Surgical Critical Care, University of Minnesota School of Medicine, Minneapolis, MN
| | - Santiago Garcia
- Division of Cardiology, Department of Medicine, Minneapolis VA Healthcare System and University of Minnesota School of Medicine, Minneapolis, MN
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
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Abstract
Hypothermia, along with acidosis and coagulopathy, is part of the lethal triad that worsen the prognosis of severe trauma patients. While accidental hypothermia is easy to identify by a simple measurement, it is no less pernicious if it is not detected or treated in the initial phase of patient care. It is a multifactorial process and is a factor of mortality in severe trauma cases. The consequences of hypothermia are many: it modifies myocardial contractions and may induce arrhythmias; it contributes to trauma-induced coagulopathy; from an immunological point of view, it diminishes inflammatory response and increases the chance of pneumonia in the patient; it inhibits the elimination of anaesthetic drugs and can complicate the calculation of dosing requirements; and it leads to an over-estimation of coagulation factor activities. This review will detail the pathophysiological consequences of hypothermia, as well as the most recent principle recommendations in dealing with it.
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Affiliation(s)
- Fanny Vardon
- Équipe d'accueil « Modélisation de l'agression tissulaire et nociceptive », Toulouse University Teaching Hospital, Université Toulouse III Paul-Sabatier, Hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Dr-Baylac, 31059 Toulouse cedex 09, France
| | - Ségolène Mrozek
- Équipe d'accueil « Modélisation de l'agression tissulaire et nociceptive », Toulouse University Teaching Hospital, Université Toulouse III Paul-Sabatier, Hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Dr-Baylac, 31059 Toulouse cedex 09, France
| | - Thomas Geeraerts
- Équipe d'accueil « Modélisation de l'agression tissulaire et nociceptive », Toulouse University Teaching Hospital, Université Toulouse III Paul-Sabatier, Hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Dr-Baylac, 31059 Toulouse cedex 09, France.
| | - Olivier Fourcade
- Équipe d'accueil « Modélisation de l'agression tissulaire et nociceptive », Toulouse University Teaching Hospital, Université Toulouse III Paul-Sabatier, Hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Dr-Baylac, 31059 Toulouse cedex 09, France
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Abstract
OPINION STATEMENT Resuscitated cardiac arrest continues to carry a poor prognosis despite advances in medical care. One such advance, therapeutic hypothermia, is neuroprotective and has been demonstrated to improve clinical outcomes in patients who remain unresponsive despite return of spontaneous circulation after arrhythmogenic cardiac arrest. Two landmark randomized controlled trials, both reported in 2002, led to endorsements by major American and European guidelines for therapeutic hypothermia as a viable treatment option for the prevention of adverse outcomes related to anoxic encephalopathy. Since then, significant research has been conducted to better understand the optimum strategies to maximize the neuroprotective effects of hypothermia. However, dissemination of therapeutic hypothermia guideline recommendations into clinical practice has been slow and incomplete. In this review article, we discuss the historical background and physiologic rationale for therapeutic hypothermia, review the recent literature supporting this intervention, and outline practical considerations.
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85
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Timmermans K, Kox M, Gerretsen J, Peters E, Scheffer GJ, van der Hoeven JG, Pickkers P, Hoedemaekers CW. The Involvement of Danger-Associated Molecular Patterns in the Development of Immunoparalysis in Cardiac Arrest Patients. Crit Care Med 2016. [PMID: 26196352 DOI: 10.1097/ccm.0000000000001204] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES After cardiac arrest, patients are highly vulnerable toward infections, possibly due to a suppressed state of the immune system called "immunoparalysis." We investigated if immunoparalysis develops following cardiac arrest and whether the release of danger-associated molecular patterns could be involved. DESIGN Observational study. SETTING ICU of a university medical center. PATIENTS Fourteen post-cardiac arrest patients treated with mild therapeutic hypothermia for 24 hours and 11 control subjects. MEASUREMENTS AND MAIN RESULTS Plasma cytokines showed highest levels within 24 hours after cardiac arrest and decreased during the next 2 days. By contrast, ex vivo production of cytokines interleukin-6, tumor necrosis factor-α, and interleukin-10 by lipopolysaccharide-stimulated leukocytes was severely impaired compared with control subjects, with most profound effects observed at day 0, and only partially recovering afterward. Compared with incubation at 37°C, incubation at 32°C resulted in higher interleukin-6 and lower interleukin-10 production by lipopolysaccharide-stimulated leukocytes of control subjects, but not of patients. Plasma nuclear DNA, used as a marker for general danger-associated molecular pattern release, and the specific danger-associated molecular patterns (EN-RAGE and heat shock protein 70) were substantially higher in patients at days 0 and 1 compared with control subjects. Furthermore, plasma heat shock protein 70 levels were negatively correlated with ex vivo production of inflammatory mediators interleukin-6, tumor necrosis factor-α, and interleukin-10. Extracellular newly identified receptor for advanced glycation end products-binding protein levels only showed a significant negative correlation with ex vivo production of interleukin-6 and tumor necrosis factor-α and a borderline significant inverse correlation with interleukin-10. No significant correlations were observed between plasma nuclear DNA levels and ex vivo cytokine production. INTERVENTIONS None. CONCLUSIONS Release of danger-associated molecular patterns during the first days after cardiac arrest is associated with the development of immunoparalysis. This could explain the increased susceptibility toward infections in cardiac arrest patients.
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Affiliation(s)
- Kim Timmermans
- 1Department of Intensive Care Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands. 2Department of Anesthesiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands. 3Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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86
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Hellenkamp K, Onimischewski S, Kruppa J, Faßhauer M, Becker A, Eiffert H, Hünlich M, Hasenfuß G, Wachter R. Early pneumonia and timing of antibiotic therapy in patients after nontraumatic out-of-hospital cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:31. [PMID: 26831508 PMCID: PMC4736704 DOI: 10.1186/s13054-016-1191-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 01/13/2016] [Indexed: 11/10/2022]
Abstract
Background While early pneumonia is common in patients after out-of-hospital cardiac arrest (OHCA), little is known about the impact of pneumonia and the optimal timing of antibiotic therapy after OHCA. Methods We conducted a 5-year retrospective cohort study, including patients who suffered from OHCA and were treated with therapeutic hypothermia. ICU treatment was strictly standardized with defined treatment goals and procedures. Medical records, chest radiographic images and microbiological findings were reviewed. Results Within the study period, 442 patients were admitted to our medical ICU after successfully resuscitated cardiac arrest. Of those, 174 patients fulfilled all inclusion and no exclusion criteria and were included into final analysis. Pneumonia within the first week could be confirmed in 39 patients (22.4 %) and was confirmed or probable in 100 patients (57.5 %), without a difference between survivors and non-survivors (37.8 % vs. 23.1 % confirmed pneumonia, p = 0.125). In patients with confirmed pneumonia a tracheotomy was performed more frequently (28.2 vs. 12.6 %, p = 0.026) compared to patients without confirmed pneumonia. Importantly, patients with confirmed pneumonia had a longer ICU- (14.0 [8.5-20.0] vs. 8.0 [5.0-14.0] days, p < 0.001) and hospital stay (23.0 [11.5-29.0] vs. 15.0 [6.5-25.0] days, p = 0.016). A positive end expiratory pressure (PEEP) > =10.5 mbar on day 1 of the hospital stay was identified as early predictor of confirmed pneumonia (odds ratio 2.898, p = 0.006). No other reliable predictor could be identified. Median time to antibiotic therapy was 8.7 [5.4-22.8] hours, without a difference between patients with or without confirmed pneumonia (p = 0.381) and without a difference between survivors and non-survivors (p = 0.264). Patients receiving antibiotics within 12 hours after admission had a shorter ICU- (8.0 [4.0-14.0] vs. 10.5 [6.0-16.0] vs. 13.5 [8.0-20.0] days, p = 0.004) and hospital-stay (14.0 [6.0-25.0] vs. 16.5 [11.0-27.0] vs. 21.0 [17.0-28.0] days, p = 0.007) compared to patients receiving antibiotics after 12 to 36 or more than 36 hours, respectively. Conclusions Early pneumonia may extend length of ICU- and hospital-stay after OHCA and its occurrence is difficult to predict. A delayed initiation of antibiotic therapy in OHCA patients may increase the duration of the ICU- and hospital-stay. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1191-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kristian Hellenkamp
- Clinic for Cardiology & Pneumology/Heart Center, University Medical Center Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
| | - Sabrina Onimischewski
- Clinic for Cardiology & Pneumology/Heart Center, University Medical Center Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
| | - Jochen Kruppa
- Department of Medical Statistics, Georg-August-University Göttingen, Humboldtallee 32, Göttingen, 37073, Germany.
| | - Martin Faßhauer
- Institute for Diagnostic and Interventional Radiology, Georg-August-University Göttingen, Robert-Koch-Straße 40, Göttingen, 37075, Germany.
| | - Alexander Becker
- Clinic for Cardiology & Pneumology/Heart Center, University Medical Center Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
| | - Helmut Eiffert
- Institute for Medical Microbiology, Georg-August-University Göttingen, Kreuzbergring 57, Göttingen, 37075, Germany.
| | - Mark Hünlich
- Clinic for Cardiology & Pneumology/Heart Center, University Medical Center Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
| | - Gerd Hasenfuß
- Clinic for Cardiology & Pneumology/Heart Center, University Medical Center Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
| | - Rolf Wachter
- Clinic for Cardiology & Pneumology/Heart Center, University Medical Center Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
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87
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Kim D. Recent Trend in Therapeutic Hypothermia and Early-Onset Pneumonia in Cardiac Arrest. Korean J Crit Care Med 2016. [DOI: 10.4266/kjccm.2016.31.1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Deokkyu Kim
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Hospital, Jeonju, Korea
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88
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Kim SJ, Lee JK, Kim DK, Shin JH, Hong KJ, Heo EY. Effect of Antibiotic Prophylaxis on Early-Onset Pneumonia in Cardiac Arrest Patients Treated with Therapeutic Hypothermia. Korean J Crit Care Med 2016. [DOI: 10.4266/kjccm.2016.31.1.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Soo Jung Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Kyu Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Deog Kyeom Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Hwan Shin
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ki Jeong Hong
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Eun Young Heo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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89
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Lee BK, Song KH, Jung YH, Lee DH, Youn CS, Lee SM, Cho YS, Jeung KW. The influence of post-rewarming temperature management on post-rewarming fever development after cardiac arrest. Resuscitation 2015; 97:20-6. [DOI: 10.1016/j.resuscitation.2015.09.381] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 09/05/2015] [Accepted: 09/16/2015] [Indexed: 01/31/2023]
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91
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Fontanals M, Magaldi M, Fontanals J, Caballero Á, Ruíz A, Carretero MJ. Respiratory complications in post-cardiac arrest patients receiving therapeutic hypothermia. Resuscitation 2015. [DOI: 10.1016/j.resuscitation.2015.09.335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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92
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Hunter BR, Ellender TJ. Targeted temperature management in emergency medicine: current perspectives. Open Access Emerg Med 2015; 7:69-77. [PMID: 27147892 PMCID: PMC4806809 DOI: 10.2147/oaem.s71279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Landmark trials in 2002 showed that therapeutic hypothermia (TH) after out-of-hospital cardiac arrest due to ventricular tachycardia or ventricular fibrillation resulted in improved likelihood of good neurologic recovery compared to standard care without TH. Since that time, TH has been frequently instituted in a wide range of cardiac arrest patients regardless of initial heart rhythm. Recent evidence has evaluated how, when, and to what degree TH should be instituted in cardiac arrest victims. We outline early evidence, as well as recent trials, regarding the use of TH or targeted temperature management in these patients. We also provide evidence-based suggestions for the institution of targeted temperature management/TH in a variety of emergency medicine settings.
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Affiliation(s)
- Benton R Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Timothy J Ellender
- Department of Emergency Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA; Department of Critical Care Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
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Kim YM, Youn CS, Kim SH, Lee BK, Cho IS, Cho GC, Jeung KW, Oh SH, Choi SP, Shin JH, Cha KC, Oh JS, Yim HW, Park KN. Adverse events associated with poor neurological outcome during targeted temperature management and advanced critical care after out-of-hospital cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015. [PMID: 26202789 PMCID: PMC4511983 DOI: 10.1186/s13054-015-0991-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Introduction The aim of this study was to investigate the association of adverse events (AEs) during targeted temperature management (TTM) and other AEs and concomitant treatments during the advanced critical care period with poor neurological outcome at hospital discharge in adult out-of-hospital cardiac arrest (OHCA) patients. Methods This was a retrospective study using Korean Hypothermia Network registry data of adult OHCA patients treated with TTM in 24 teaching hospitals throughout South Korea from 2007 to 2012. Demographic characteristics, resuscitation and post-resuscitation variables, AEs, and concomitant treatments during TTM and the advanced critical care were collected. The primary outcome was poor neurological outcome, defined as a cerebral performance category (CPC) score of 3–5 at hospital discharge. The AEs and concomitant treatments were individually entered into the best multivariable predictive model of poor neurological outcome to evaluate the associations between each variable and outcome. Results A total of 930 patients, including 704 for whom a complete dataset of AEs and covariates was available for multivariable modeling, were included in the analysis; 476 of these patients exhibited poor neurological outcome [CPC 3 = 50 (7.1 %), CPC 4 = 214 (30.4 %), and CPC 5 = 212 (30.1 %)]. Common AEs included hyperglycemia (45.6 %), hypokalemia (31.3 %), arrhythmia (21.3 %) and hypotension (29 %) during cooling, and hypotension (21.6 %) during rewarming. Bleeding (5 %) during TTM was a rare AE. Common AEs during the advanced critical care included pneumonia (39.6 %), myoclonus (21.9 %), seizures (21.7 %) and hypoglycemia within 72 hours (23 %). After adjusting for independent predictors of outcome, cooling- and rewarming-related AEs were not significantly associated with poor neurological outcome. However, sepsis, myoclonus, seizure, hypoglycemia within 72 hours and anticonvulsant use during the advanced critical care were associated with poor neurological outcome [adjusted odds ratios (95 % confidence intervals) of 3.12 (1.40–6.97), 3.72 (1.93–7.16), 4.02 (2.04–7.91), 2.03 (1.09–3.78), and 1.69 (1.03–2.77), respectively]. Alternatively, neuromuscular blocker use was inversely associated with poor neurological outcome (0.48 [0.28–0.84]). Conclusions Cooling- and rewarming-related AEs were not associated with poor neurological outcome at hospital discharge. Sepsis, myoclonus, seizure, hypoglycemia within 72 hours and anticonvulsant use during the advanced critical care period were associated with poor neurological outcome at hospital discharge in our study. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0991-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Young-Min Kim
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Chun Song Youn
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Soo Hyun Kim
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Byung Kook Lee
- Department of Emergency Medicine, College of Medicine, Chonnam National University, 160 Baekseo-ro, Dong-gu, Gwangju, 501-746, South Korea.
| | - In Soo Cho
- Department of Emergency Medicine, KEPCO Medical Center, 308 Uicheon-ro, Dobong-gu, Seoul, 132-703, South Korea.
| | - Gyu Chong Cho
- Department of Emergency Medicine, College of Medicine, Hallym University, Kangdong Sacread Heart Hospital 150 Seongan-ro, Gangdong-gu, Seoul, 134-701, South Korea.
| | - Kyung Woon Jeung
- Department of Emergency Medicine, College of Medicine, Chonnam National University, 160 Baekseo-ro, Dong-gu, Gwangju, 501-746, South Korea.
| | - Sang Hoon Oh
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Seung Pill Choi
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Jong Hwan Shin
- Department of Emergency Medicine, Boramae Medical Center, Seoul National University, 20 Boramae-ro, Dongjak-gu, Seoul, 156-707, South Korea.
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Wonju College of Medicine, Yonsei University, 20 Ilsan-ro, Wonju, Gangwon-do, 220-701, South Korea.
| | - Joo Suk Oh
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Hyeon Woo Yim
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Kyu Nam Park
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
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94
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Activity of antimicrobial drugs against bacterial pathogens under mild hypothermic conditions. Am J Emerg Med 2015; 33:1445-8. [PMID: 26231525 DOI: 10.1016/j.ajem.2015.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/03/2015] [Accepted: 07/03/2015] [Indexed: 11/23/2022] Open
Abstract
BACKROUND Infections are a common problem in cardiac arrest survivors. Antimicrobial drugs are often administered in routine care during treatment of patients with mild therapeutic hypothermia (MTH). Because there is to date no evidence for the pharmacodynamics of antimicrobial drugs under MTH conditions, we investigated the in vitro activity of common antimicrobials against clinically relevant bacterial pathogens. MATERIAL AND METHODS Activities of antimicrobial drugs against clinically relevant bacterial pathogens were assessed in vitro by disk diffusion and broth microdilution assays at normothermic (37°C) and hypothermic (32°C) conditions. RESULTS Seventy-three bacterial isolates were tested in disk diffusion and 15 in broth microdilution assays. Mean differences in zone diameters and minimal inhibitory concentration ratios were 0.6 mm (95% confidence interval, 0.3-0.9 mm) and 0.98 (95% confidence interval, 0.95-1.02), respectively, meeting predefined criteria for equivalence of in vitro antimicrobial activity. CONCLUSIONS The presented data provide reassuring evidence that the intrinsic activity of antimicrobials seems to be unaltered in MTH. However, further studies evaluating the pharmacokinetics including target site concentrations of the respective drugs and in vivo pharmacodynamics are necessary to complement our understanding of the appropriate use of antimicrobials in MTH.
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95
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Prophylactic antibiotic therapy for all out-of-hospital cardiac arrest survivors? Resuscitation 2015; 92:A4-5. [DOI: 10.1016/j.resuscitation.2015.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 03/11/2015] [Indexed: 12/11/2022]
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96
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Hypothermie thérapeutique après arrêt cardiaque et infections acquises en réanimation. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1045-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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97
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Champion S, Voicu S, Deye N. Conséquences cardiovasculaires de l’hypothermie. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1054-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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98
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Gagnon DJ, Nielsen N, Fraser GL, Riker RR, Dziodzio J, Sunde K, Hovdenes J, Stammet P, Friberg H, Rubertsson S, Wanscher M, Seder DB. Prophylactic antibiotics are associated with a lower incidence of pneumonia in cardiac arrest survivors treated with targeted temperature management. Resuscitation 2015; 92:154-9. [PMID: 25680823 DOI: 10.1016/j.resuscitation.2015.01.035] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/02/2014] [Accepted: 01/28/2015] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Prophylactic antibiotics (PRO) reduce the incidence of early-onset pneumonia in comatose patients with structural brain injury, but have not been examined in cardiac arrest survivors undergoing targeted temperature management (TTM). We investigated the effect of PRO on the development of pneumonia in that population. METHODS We conducted a retrospective cohort study comparing patients treated with PRO to those not receiving PRO (no-PRO) using Northern Hypothermia Network registry data. Cardiac arrest survivors ≥ 18 years of age with a GCS<8 at hospital admission and treated with TTM at 32-34 °C were enrolled in the registry. Differences were analyzed in univariate analyses and with logistic regression models to evaluate independent associations of clinical factors with incidence of pneumonia and good functional outcome. RESULTS 416 of 1240 patients (33.5%) received PRO. Groups were similar in age, gender, arrest location, initial rhythm, and time from collapse to return of spontaneous circulation. PRO patients had less pneumonia (12.6% vs. 54.9%, p < 0.001) and less sepsis (1.2 vs. 5.7%, p < 0.001) compared to no-PRO patients. ICU length of stay (98 vs. 100 h, p = 0.2) and incidence of a good functional outcome (41.1 vs. 36.6%, p = 0.19) were similar between groups. Backwards stepwise logistic regression demonstrated PRO were independently associated with a lower incidence of pneumonia (OR 0.09, 95% 0.06-0.14, p < 0.001) and a similar incidence of good functional outcome. CONCLUSIONS Prophylactic antibiotics were associated with a reduced incidence of pneumonia but a similar rate of good functional outcome.
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Affiliation(s)
- David J Gagnon
- Department of Pharmacy, Maine Medical Center, Portland, ME, USA.
| | - Niklas Nielsen
- Department of Anesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Gilles L Fraser
- Department of Pharmacy, Maine Medical Center, Portland, ME, USA; Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Richard R Riker
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA; Neuroscience Institute, Maine Medical Center, Portland, ME, USA; Division of Pulmonary Medicine, Maine Medical Center, Portland, ME, USA
| | - John Dziodzio
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Kjetil Sunde
- Oslo University Hospital Ulleval, Department of Anesthesiology, Division of Emergencies and Critical Care, Norway
| | - Jan Hovdenes
- Oslo University Hospital Rikshospitalet, Department of Anesthesiology, Division of Emergencies and Critical Care, Norway
| | - Pascal Stammet
- Department of Anesthesia and Intensive Care, Centre de Hospitalier de Luxembourg, Luxembourg
| | - Hans Friberg
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Sten Rubertsson
- Department of Anesthesiology and Intensive Care, Uppsala University, Uppsala Sweden
| | - Michael Wanscher
- Department of Cardiothoracic Anesthesia, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - David B Seder
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA; Neuroscience Institute, Maine Medical Center, Portland, ME, USA; Division of Pulmonary Medicine, Maine Medical Center, Portland, ME, USA
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99
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Kakavas S, Mongardon N, Cariou A, Gulati A, Xanthos T. Early-onset pneumonia after out-of-hospital cardiac arrest. J Infect 2015; 70:553-62. [PMID: 25644317 DOI: 10.1016/j.jinf.2015.01.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/09/2015] [Accepted: 01/24/2015] [Indexed: 12/20/2022]
Abstract
Early-onset pneumonia (EOP) is a common complication after successful cardiopulmonary resuscitation. Currently, EOP diagnosis is difficult because usual diagnostic tools are blunted by the features of post-cardiac arrest syndrome and therapeutic hypothermia itself. When the diagnosis of EOP is suspected, empiric antimicrobial therapy should be considered following bronchopulmonary sampling. The onset of EOP increases the length of mechanical ventilation duration and intensive care unit stay, but its influence on survival and neurological outcome seems marginal. Therapeutic hypothermia has been recognized as an independent risk factor for this infectious complication. All together, these observations underline the need for future prospective clinical trials to better delineate pathogens and risk factors associated with EOP. In addition, there is a need for diagnostic approaches serving the accurate diagnosis of EOP.
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Affiliation(s)
- S Kakavas
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece; Pulmonary Department, Evangelismos, General Hospital of Athens, Greece.
| | - N Mongardon
- Université Paris Est, Faculté de Médecine, Service d'Anesthésie et des Réanimations Chirurgicales, Hôpitaux Universitaires Henri Mondor, Assistance Publique des Hôpitaux de Paris, Créteil, France; Service d'Anesthésie et des Réanimations Chirurgicales, Hôpitaux Universitaires Henri Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris Est, Faculté de Médecine, INSERM U955, Equipe 3, physiopathologie et pharmacologie des insuffisances coronaires et cardiaques, Créteil, France.
| | - A Cariou
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Service de Réanimation Médicale, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France; Service de Réanimation Médicale, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine; INSERM U970, Paris Cardiovascular Research Centre (PARCC), European Georges Pompidou Hospital, Paris, France.
| | - A Gulati
- Midwestern University, Downers Grove, IL, USA.
| | - T Xanthos
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece; Midwestern University, Downers Grove, IL, USA.
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Magaldi M, Fontanals J, Moreno J, Ruiz A, Nicolás J, Bosch X. Supervivencia y pronóstico neurológico en paradas cardiorrespiratorias extrahospitalarias por ritmos desfibrilables tratadas con hipotermia terapéutica moderada. Med Intensiva 2014; 38:541-9. [DOI: 10.1016/j.medin.2014.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 02/11/2014] [Accepted: 03/02/2014] [Indexed: 11/16/2022]
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