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Sahu AK, Timilsina G, Mathew R, Jamshed N, Aggarwal P. "Six-dial Strategy"-Mechanical Ventilation during Cardiopulmonary Resuscitation. Indian J Crit Care Med 2020; 24:487-489. [PMID: 32863648 PMCID: PMC7435081 DOI: 10.5005/jp-journals-10071-23464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
As per current guidelines, whenever an advanced airway is in place during cardiopulmonary resuscitation, positive pressure ventilation should be provided without pausing for chest compression. Positive pressure ventilation can be provided through bag-valve resuscitator (BV) or mechanical ventilator (MV), which was found to be equally efficacious. In a busy emergency department, with less trained personnel use of MV is advantageous over BV in terms of reducing human errors and relieving the airway manager to focus on other resuscitation tasks. Currently, there are no guidelines specific to MV settings in cardiac arrest. We present a concept of "six-dial ventilator strategy during CPR" that encompasses the evidence-based settings appropriate during chest compression. We suggest use of volume control ventilation with the following settings: (1) positive end-expiratory pressure of 0 cm of water (to allow venous return), (2) tidal volume of 8 mL/kg with fraction of inspired oxygen at 100% (for adequate oxygenation), (3) respiratory rate of 10 per minute (for adequate ventilation), (4) maximum peak inspiratory pressure or P max alarm of 60 cm of water (to allow tidal volume delivery during chest compression), (5) switching OFF trigger (to avoid trigger by chest recoil), and (6) inspiratory to expiratory time ratio of 1:5 (to provide adequate inspiratory time of 1 second). How to cite this article: Sahu AK, Timilsina G, Mathew R, Jamshed N, Aggarwal P. "Six-dial Strategy"-Mechanical Ventilation during Cardiopulmonary Resuscitation. Indian J Crit Care Med 2020;24(6):487-489.
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Affiliation(s)
- Ankit Kumar Sahu
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ghanashyam Timilsina
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Roshan Mathew
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nayer Jamshed
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
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Sasannejad C, Ely EW, Lahiri S. Long-term cognitive impairment after acute respiratory distress syndrome: a review of clinical impact and pathophysiological mechanisms. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:352. [PMID: 31718695 PMCID: PMC6852966 DOI: 10.1186/s13054-019-2626-z] [Citation(s) in RCA: 196] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/27/2019] [Indexed: 02/06/2023]
Abstract
Acute respiratory distress syndrome (ARDS) survivors experience a high prevalence of cognitive impairment with concomitantly impaired functional status and quality of life, often persisting months after hospital discharge. In this review, we explore the pathophysiological mechanisms underlying cognitive impairment following ARDS, the interrelations between mechanisms and risk factors, and interventions that may mitigate the risk of cognitive impairment. Risk factors for cognitive decline following ARDS include pre-existing cognitive impairment, neurological injury, delirium, mechanical ventilation, prolonged exposure to sedating medications, sepsis, systemic inflammation, and environmental factors in the intensive care unit, which can co-occur synergistically in various combinations. Detection and characterization of pre-existing cognitive impairment imparts challenges in clinical management and longitudinal outcome study enrollment. Patients with brain injury who experience ARDS constitute a distinct population with a particular combination of risk factors and pathophysiological mechanisms: considerations raised by brain injury include neurogenic pulmonary edema, differences in sympathetic activation and cholinergic transmission, effects of positive end-expiratory pressure on cerebral microcirculation and intracranial pressure, and sensitivity to vasopressor use and volume status. The blood-brain barrier represents a physiological interface at which multiple mechanisms of cognitive impairment interact, as acute blood-brain barrier weakening from mechanical ventilation and systemic inflammation can compound existing chronic blood-brain barrier dysfunction from Alzheimer’s-type pathophysiology, rendering the brain vulnerable to both amyloid-beta accumulation and cytokine-mediated hippocampal damage. Although some contributory elements, such as the presenting brain injury or pre-existing cognitive impairment, may be irreversible, interventions such as minimizing mechanical ventilation tidal volume, minimizing duration of exposure to sedating medications, maintaining hemodynamic stability, optimizing fluid balance, and implementing bundles to enhance patient care help dramatically to reduce duration of delirium and may help prevent acquisition of long-term cognitive impairment.
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Affiliation(s)
- Cina Sasannejad
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, Survivorship (CIBS) Center, Department of Pulmonary and Critical Care Medicine, Veteran's Affairs Tennessee Valley Geriatric Research Education and Clinical Center (GRECC), Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Shouri Lahiri
- Division of Neurocritical Care, Department of Neurology, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, AHSP Building, Suite A6600, A8103, Los Angeles, CA, 90048, USA. .,Division of Neurocritical Care, Department of Neurosurgery, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, AHSP Building, Suite A6600, A8103, Los Angeles, CA, 90048, USA. .,Division of Neurocritical Care, Department of Biomedical Sciences, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, AHSP Building, Suite A6600, A8103, Los Angeles, CA, 90048, USA.
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Thille AW, Mauri T, Talmor D. Update in Critical Care Medicine 2017. Am J Respir Crit Care Med 2019; 197:1382-1388. [PMID: 29554433 DOI: 10.1164/rccm.201801-0055up] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Arnaud W Thille
- 1 Réanimation Médicale, Centre Hospitalier Universitaire de Poitiers, Poitiers, France.,2 INSERM Centre d'Investigation Clinique 1402 ALIVE, Faculté de Médecine et Pharmacie, Université de Poitiers, Poitiers, France
| | - Tommaso Mauri
- 3 Department of Anesthesia, Critical Care and Emergency, Maggiore Policlinico Hospital, University of Milan, Milan, Italy; and
| | - Daniel Talmor
- 4 Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston Massachusetts
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Bilotta F, Giordano G, Sergi PG, Pugliese F. Harmful effects of mechanical ventilation on neurocognitive functions. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:273. [PMID: 31387627 PMCID: PMC6685219 DOI: 10.1186/s13054-019-2546-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/18/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Rome, Italy.
| | - Giovanni Giordano
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Rome, Italy
| | - Paola Giuseppina Sergi
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesco Pugliese
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Rome, Italy
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Wang CJ, Yang SH, Chen CH, Chung HP. Targeted Temperature Management for In-Hospital Cardiac Arrest: 6 Years of Experience. Ther Hypothermia Temp Manag 2019; 10:153-158. [PMID: 31314693 DOI: 10.1089/ther.2019.0019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Targeted temperature management (TTM) is widely used for postcardiac arrest management of patients with out-of-hospital cardiac arrest. However, the use of TTM for patients with in-hospital cardiac arrest (IHCA) is controversial. The aim of this study was to investigate the role of TTM in the management of patients with IHCA. The medical records of all IHCA patients who were resuscitated and returned to spontaneous circulation from January 2011 to December 2016 were reviewed. After excluding patients with new do not resuscitate orders and those who died within 24 hours, 262 patients were eligible for analysis. Thirty-five of the 262 patients (13.3%) received TTM after IHCA. Patients who received TTM and standard supportive care (SSC) had similar baseline epidemiological status. The TTM patients were older and had a longer cardiac pulmonary resuscitation duration; however, the differences were not statistically significant. The 28-day survival rate was not significantly different between groups (12/35 in the TTM group [34%] vs. 114/225 in the SSC group [50%], p = 0.079). In the patients with good neurological status before arrest (Glasgow-Pittsburgh cerebral performance category [GP-CPC] scores: 1-2), there was no significant difference in the 28-day survival between groups (11/26 in the TTM group [42.3%] vs. 81/154 [52.6%] in the SSC group; p = 0.332). In this subgroup, the TTM patients had poorer neurological outcomes at discharge (GP-CPC score 1-2) than the SSC patients (1/26 in the TTM group [3.8%] vs. 57/154 in the SSC group [37%]; p = 0.001). TTM was not associated with better 28-day survival than usual care among the patients with IHCA in this study, and the TTM patients had less favorable neurological outcomes at discharge. Randomized clinical trials are needed to assess the efficacy of TTM for IHCA patients.
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Affiliation(s)
- Chieh-Jen Wang
- Division of Pulmonary and Critical Care Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Sheng-Hsiung Yang
- Division of Pulmonary and Critical Care Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chao-Hsien Chen
- Division of Pulmonary and Critical Care Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Hsin-Pei Chung
- Division of Pulmonary and Critical Care Medicine, Mackay Memorial Hospital, Taipei, Taiwan
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Prekker ME, Donelan C, Ambur S, Driver BE, O'Brien-Lambert A, Hottinger DG, Adams AB. Adoption of low tidal volume ventilation in the emergency department: A quality improvement intervention. Am J Emerg Med 2019; 38:763-767. [PMID: 31235218 DOI: 10.1016/j.ajem.2019.06.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/07/2019] [Accepted: 06/14/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Ventilator tidal volumes of >8 mL/kg of predicted body weight (PBW) may increase the risk of lung injury. We sought to evaluate the impact of a quality improvement intervention among intubated Emergency Department (ED) patients to protocolize the prescription of low tidal volume ventilation. METHODS In this before-and-after study, the average tidal volume delivered to ED patients receiving volume assist-control ventilation was compared before (2007-2014) and after (2015-2016) implementation of a ventilator initiation protocol (the quality improvement intervention). The intervention emphasized 1) measurement of the patient's height to calculate PBW and therefore tailor the tidal volume to estimated lung size (<8 mL/kg PBW), and 2) focused education and reference materials for ED physicians and respiratory therapists. RESULTS Among ventilated ED patients meeting inclusion criteria in the before (N = 2185) and after (N = 774) cohorts, the mean (±SD) tidal volume decreased from 9.0 ± 1.4 mL/kg to 7.2 ± 0.9 mL/kg PBW following the intervention (absolute difference 1.8 mL/kg, 95% confidence interval 1.7 to 1.9 mL/kg, p < 0.001). The proportion of patients receiving low tidal volume ventilation increased after the intervention (72%), as compared to before (23%). Low tidal volume ventilation continued to be utilized at 24 h after ICU admission in patients who remained intubated in the cohort following the intervention (mean tidal volume 7.3 mL/kg PBW). CONCLUSIONS Pairing a ventilator initiation protocol with focused education and resources for emergency physicians and respiratory therapists was associated with a significant reduction in tidal volume delivered to ED patients.
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Affiliation(s)
- Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America; Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Crystal Donelan
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Sum Ambur
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Alex O'Brien-Lambert
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Daniel G Hottinger
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Alexander B Adams
- Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, MN, United States of America; Respiratory Therapy Department, Hennepin County Medical Center, Minneapolis, MN, United States of America
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Chang MP, Lu Y, Leroux B, Aramendi Ecenarro E, Owens P, Wang HE, Idris AH. Association of ventilation with outcomes from out-of-hospital cardiac arrest. Resuscitation 2019; 141:174-181. [PMID: 31112744 DOI: 10.1016/j.resuscitation.2019.05.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/04/2019] [Accepted: 05/08/2019] [Indexed: 12/29/2022]
Abstract
AIM OF STUDY To determine the association between bioimpedence-detected ventilation and out-of-hospital cardiac arrest (OHCA) outcomes. METHODS This is a retrospective, observational study of 560 OHCA patients from the Dallas-Fort Worth site enrolled in the Resuscitation Outcomes Consortium Trial of Continuous or Interrupted Chest Compressions During CPR from 4/2012 to 7/2015. We measured bioimpedance ventilation (lung inflation) waveforms in the pause between chest compression segments (Physio-Control LIFEPAK 12 and 15, Redmond, WA) recorded through defibrillation pads. We included cases ≥18 years with presumed cardiac cause of arrest assigned to interrupted 30:2 chest compressions with bag-valve-mask ventilation and ≥2 min of recorded cardiopulmonary resuscitation. We compared outcomes in two a priori pre-specified groups: patients with ventilation waveforms in <50% of pauses (Group 1) versus those with waveforms in ≥50% of pauses (Group 2). RESULTS Mean duration of 30:2 CPR was 13 ± 7 min with a total of 7762 pauses in chest compressions. Group 1 (N = 424) had a median 11 pauses and 3 ventilations per patient vs. Group 2 (N = 136) with a median 12 pauses and 8 ventilations per patient, which was associated with improved return of spontaneous circulation (ROSC) at any time (35% vs. 23%, p < 0.005), prehospital ROSC (19.8% vs. 8.7%, p < 0.0009), emergency department ROSC (33% vs. 21%, p < 0.005), and survival to hospital discharge (10.3% vs. 4.0%, p = 0.008). CONCLUSIONS This novel study shows that ventilation with lung inflation occurs infrequently during 30:2 CPR. Ventilation in ≥50% of pauses was associated with significantly improved rates of ROSC and survival.
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Affiliation(s)
- Mary P Chang
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8579, United States
| | - Yuanzheng Lu
- Emergency and Disaster Medicine Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, China
| | - Brian Leroux
- Department of Biostatistics and Oral Health Sciences, University of Washington, Seattle, WA, United States
| | | | - Pamela Owens
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8579, United States
| | - Henry E Wang
- University of Texas Health Science Center at Houston, Department of Emergency Medicine, Houston, TX, United States
| | - Ahamed H Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8579, United States.
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58
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Walker AC, Johnson NJ. Targeted Temperature Management and Postcardiac arrest Care. Emerg Med Clin North Am 2019; 37:381-393. [PMID: 31262410 DOI: 10.1016/j.emc.2019.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite recent advances, care of the post-cardiac arrest patient remains a challenge. In this article, the authors discuss an approach to the initial care of post-cardiac arrest patients with particular focus on targeted temperature management (TTM). The article starts with history, physiologic rationale, and the major randomized controlled trials that have shaped guidelines for post-cardiac arrest care. It also reviews controversial topics, including TTM for nonshockable rhythms, TTM dose, and surface versus endovascular cooling. The article concludes with a brief review of other key aspects of post-arrest care: coronary angiography, hemodynamic optimization, ventilator management, and prognostication.
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Affiliation(s)
- Amy C Walker
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA.
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
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Abstract
IMPORTANCE In-hospital cardiac arrest is common and associated with a high mortality rate. Despite this, in-hospital cardiac arrest has received little attention compared with other high-risk cardiovascular conditions, such as stroke, myocardial infarction, and out-of-hospital cardiac arrest. OBSERVATIONS In-hospital cardiac arrest occurs in over 290 000 adults each year in the United States. Cohort data from the United States indicate that the mean age of patients with in-hospital cardiac arrest is 66 years, 58% are men, and the presenting rhythm is most often (81%) nonshockable (ie, asystole or pulseless electrical activity). The cause of the cardiac arrest is most often cardiac (50%-60%), followed by respiratory insufficiency (15%-40%). Efforts to prevent in-hospital cardiac arrest require both a system for identifying deteriorating patients and an appropriate interventional response (eg, rapid response teams). The key elements of treatment during cardiac arrest include chest compressions, ventilation, early defibrillation, when applicable, and immediate attention to potentially reversible causes, such as hyperkalemia or hypoxia. There is limited evidence to support more advanced treatments. Post-cardiac arrest care is focused on identification and treatment of the underlying cause, hemodynamic and respiratory support, and potentially employing neuroprotective strategies (eg, targeted temperature management). Although multiple individual factors are associated with outcomes (eg, age, initial rhythm, duration of the cardiac arrest), a multifaceted approach considering both potential for neurological recovery and ongoing multiorgan failure is warranted for prognostication and clinical decision-making in the post-cardiac arrest period. Withdrawal of care in the absence of definite prognostic signs both during and after cardiac arrest should be avoided. Hospitals are encouraged to participate in national quality-improvement initiatives. CONCLUSIONS AND RELEVANCE An estimated 290 000 in-hospital cardiac arrests occur each year in the United States. However, there is limited evidence to support clinical decision making. An increased awareness with regard to optimizing clinical care and new research might improve outcomes.
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Affiliation(s)
- Lars W Andersen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Intensive Care Medicine, Randers Regional Hospital, Randers, Denmark
| | - Mathias J Holmberg
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Katherine M Berg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael W Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Asger Granfeldt
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
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Johnson NJ, Caldwell E, Carlbom DJ, Gaieski DF, Prekker ME, Rea TD, Sayre M, Hough CL. The acute respiratory distress syndrome after out-of-hospital cardiac arrest: Incidence, risk factors, and outcomes. Resuscitation 2019; 135:37-44. [PMID: 30654012 DOI: 10.1016/j.resuscitation.2019.01.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/25/2018] [Accepted: 01/02/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To define the incidence of the acute respiratory distress syndrome (ARDS) following out-of-hospital cardiac arrest (OHCA) and characterize its impact on outcome. METHODS This was a retrospective cohort study conducted at two urban, tertiary, academic hospitals from 2007 to 2014. We included adults with non-traumatic OHCA and survived for ≥48 h. Patients who received mechanical ventilation for ≥24 h, had 2 consecutive arterial blood gases with a ratio of the partial pressure of oxygen to the fraction of inspired oxygen ≤300, and bilateral radiographic opacities within 48 h of hospital admission were defined as having ARDS. We examined the associations between ARDS and outcome using multivariable analyses and performed sensitivity analyses excluding patients with evidence of cardiac dysfunction. RESULTS Of 978 OHCA patients transported to the study hospitals, 600 were mechanically ventilated and survived ≥48 h. A total of 287 (48%, 95% CI 44-52%) met criteria for ARDS within 48 h of admission. There were no differences in demographics, OHCA etiology, or cardiac rhythm according to ARDS status. Patients with ARDS had higher hospital mortality, longer ICU stays, more ventilator days, and were less likely to survive with full neurologic recovery. Upon excluding patients with cardiac dysfunction, the incidence of ARDS was unchanged. CONCLUSION Nearly half of initial OHCA survivors develop ARDS within 48 h of hospital admission. ARDS was associated with poor outcome and increased resource utilization. OHCA should be considered among the traditional ARDS risk factors.
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Affiliation(s)
- Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States; Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States.
| | - Ellen Caldwell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - David J Carlbom
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Matthew E Prekker
- Department of Emergency Medicine & Division Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN, United States
| | - Thomas D Rea
- Division of General Internal Medicine, University of Washington, Seattle, WA, United States; King County Medic One, WA, United States
| | - Michael Sayre
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States; Seattle Medic One, WA, United States
| | - Catherine L Hough
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
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Randhawa VK, Grunau BE, Debicki DB, Zhou J, Hegazy AF, McPherson T, Nagpal AD. Cardiac Intensive Care Unit Management of Patients After Cardiac Arrest: Now the Real Work Begins. Can J Cardiol 2018; 34:156-167. [PMID: 29407008 DOI: 10.1016/j.cjca.2017.11.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 11/22/2017] [Accepted: 11/22/2017] [Indexed: 11/18/2022] Open
Abstract
Survival with a good quality of life after cardiac arrest continues to be abysmal. Coordinated resuscitative care does not end with the effective return of spontaneous circulation (ROSC)-in fact, quite the contrary is true. Along with identifying and appropriately treating the precipitating cause, various components of the post-cardiac arrest syndrome also require diligent observation and management, including post-cardiac arrest neurologic injury and myocardial dysfunction, systemic ischemia-reperfusion phenomenon with potential consequent multiorgan failure, and the various sequelae of critical illness. There is growing evidence that an early invasive approach to coronary reperfusion with percutaneous coronary intervention, together with active targeted temperature management and optimization of hemodynamic, ventilator, and metabolic parameters, may improve survival and neurologic outcomes in cardiac arrest survivors. Neuroprognostication is complex, as are survivorship issues and long-term rehabilitation. Our paramedics, emergency physicians, and resuscitation specialists are all to be congratulated for ever-increasing success with ROSC… but now the real work begins.
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Affiliation(s)
- Varinder K Randhawa
- Division of Cardiology, University of Toronto/University Health Network, Toronto, Ontario, Canada
| | - Brian E Grunau
- Department of Emergency Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Derek B Debicki
- Department of Clinical Neurologic Sciences, Western University/London Health Sciences Centre, London, Ontario, Canada
| | - Jian Zhou
- Department of Anesthesia and Perioperative Medicine, Western University/London Health Sciences Centre, London, Ontario, Canada
| | - Ahmed F Hegazy
- Critical Care Western, Western University/London Health Sciences Centre, London, Ontario, Canada; Department of Anesthesia and Perioperative Medicine, Western University/London Health Sciences Centre, London, Ontario, Canada
| | - Terry McPherson
- Division of Cardiology, Western University/London Health Sciences Centre, London, Ontario, Canada
| | - A Dave Nagpal
- Division of Cardiac Surgery, Western University/London Health Sciences Centre, London, Ontario, Canada; Critical Care Western, Western University/London Health Sciences Centre, London, Ontario, Canada.
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Hope Kilgannon J, Hunter BR, Puskarich MA, Shea L, Fuller BM, Jones C, Donnino M, Kline JA, Jones AE, Shapiro NI, Abella BS, Trzeciak S, Roberts BW. Partial pressure of arterial carbon dioxide after resuscitation from cardiac arrest and neurological outcome: A prospective multi-center protocol-directed cohort study. Resuscitation 2018; 135:212-220. [PMID: 30452939 DOI: 10.1016/j.resuscitation.2018.11.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/21/2018] [Accepted: 11/13/2018] [Indexed: 12/23/2022]
Abstract
AIMS Partial pressure of arterial carbon dioxide (PaCO2) is a regulator of cerebral blood flow after brain injury. We sought to test the association between PaCO2 after resuscitation from cardiac arrest and neurological outcome. METHODS A prospective protocol-directed cohort study across six hospitals. INCLUSION CRITERIA age ≥18, non-traumatic cardiac arrest, mechanically ventilated after return of spontaneous circulation (ROSC), and receipt of targeted temperature management. Per protocol, PaCO2 was measured by arterial blood gas analyses at one and six hours after ROSC. We determined the mean PaCO2 over this initial six hours after ROSC. The primary outcome was good neurological function at hospital discharge, defined a priori as a modified Rankin Scale ≤3. Multivariable Poisson regression analysis was used to test the association between PaCO2 and neurological outcome. RESULTS Of the 280 patients included, the median (interquartile range) PaCO2 was 44 (37-52) mmHg and 30% had good neurological function. We found mean PaCO2 had a quadratic (inverted "U" shaped) association with good neurological outcome, with a mean PaCO2 of 68 mmHg having the highest predictive probability of good neurological outcome, and worse neurological outcome at higher and lower PaCO2. Presence of metabolic acidosis attenuated the association between PaCO2 and good neurological outcome, with a PaCO2 of 51 mmHg having the highest predictive probability of good neurological outcome among patients with metabolic acidosis. CONCLUSION PaCO2 has a "U" shaped association with neurological outcome, with mild to moderate hypercapnia having the highest probability of good neurological outcome.
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Affiliation(s)
- J Hope Kilgannon
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Benton R Hunter
- The Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Michael A Puskarich
- The Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, United States
| | - Lisa Shea
- The Department of Medicine, Division of Critical Care Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Brian M Fuller
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Christopher Jones
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Michael Donnino
- The Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Jeffrey A Kline
- The Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Alan E Jones
- The Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, United States
| | - Nathan I Shapiro
- The Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Benjamin S Abella
- The Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Stephen Trzeciak
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States; The Department of Medicine, Division of Critical Care Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Brian W Roberts
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States.
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Abstract
The post-cardiac arrest syndrome is a highly inflammatory state characterized by organ dysfunction, systemic ischemia and reperfusion injury, and persistent precipitating pathology. Early critical care should focus on identifying and treating arrest etiology and minimizing further injury to the brain and other organs by optimizing perfusion, oxygenation, ventilation, and temperature. Patients should be treated with targeted temperature management, although the exact temperature goal is not clear. No earlier than 72 hours after rewarming, prognostication using a multimodal approach should inform discussions with families regarding likely neurologic outcome.
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Affiliation(s)
- Amy C Walker
- Department of Emergency Medicine, University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359702, Seattle, WA 98104, USA
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359702, Seattle, WA 98104, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359702, Seattle, WA 98104, USA.
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65
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Abstract
Few data are available regarding hypoxic hepatitis (HH) and acute liver failure (ALF) in patients resuscitated from cardiac arrest (CA). The aim of this study was to describe the occurrence of these complications and their association with outcome. All adult patients admitted to the Department of Intensive Care following CA were considered for inclusion in this retrospective study. Exclusion criteria were early death (<24 hours) or missing biological data. We retrieved data concerning CA characteristics and markers of liver function. ALF was defined as a bilirubin >1.2 mg/dL and an international normalized ratio ≥1.5. HH was defined as an aminotransferase level >1000 IU/L. Neurological outcome was assessed at 3 months and an unfavourable neurological outcome was defined as a Cerebral Performance Categories (CPC) score of 3–5. A total of 374 patients (age 62 [52–74] years; 242 male) were included. ALF developed in 208 patients (56%) and HH in 27 (7%); 24 patients developed both conditions. Patients with HH had higher mortality (89% vs. 51% vs. 45%, respectively) and greater rates of unfavourable neurological outcome (93% vs. 60% vs. 59%, respectively) compared to those with ALF without HH (n = 184) and those without ALF or HH (n = 163; p = 0.03). Unwitnessed arrest, non-shockable initial rhythm, lack of bystander cardiopulmonary resuscitation, high adrenaline doses and the development of acute kidney injury were independent predictors of unfavourable neurological outcome; HH (OR: 16.276 [95% CIs: 2.625–81.345; p = 0.003), but not ALF, was also a significant risk-factor for unfavourable outcome. Although ALF occurs frequently after CA, HH is a rare complication. Only HH is significantly associated with poor neurological outcome in this setting.
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66
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Silva PL, Rocco PRM. The basics of respiratory mechanics: ventilator-derived parameters. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:376. [PMID: 30460250 DOI: 10.21037/atm.2018.06.06] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Mechanical ventilation is a life-support system used to maintain adequate lung function in patients who are critically ill or undergoing general anesthesia. The benefits and harms of mechanical ventilation depend not only on the operator's setting of the machine (input), but also on their interpretation of ventilator-derived parameters (outputs), which should guide ventilator strategies. Once the inputs-tidal volume (VT), positive end-expiratory pressure (PEEP), respiratory rate (RR), and inspiratory airflow (V')-have been adjusted, the following outputs should be measured: intrinsic PEEP, peak (Ppeak) and plateau (Pplat) pressures, driving pressure (ΔP), transpulmonary pressure (PL), mechanical energy, mechanical power, and intensity. During assisted mechanical ventilation, in addition to these parameters, the pressure generated 100 ms after onset of inspiratory effort (P0.1) and the pressure-time product per minute (PTP/min) should also be evaluated. The aforementioned parameters should be seen as a set of outputs, all of which need to be strictly monitored at bedside in order to develop a personalized, case-by-case approach to mechanical ventilation. Additionally, more clinical research to evaluate the safe thresholds of each parameter in injured and uninjured lungs is required.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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67
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Newell C, Grier S, Soar J. Airway and ventilation management during cardiopulmonary resuscitation and after successful resuscitation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:190. [PMID: 30111343 PMCID: PMC6092791 DOI: 10.1186/s13054-018-2121-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 07/04/2018] [Indexed: 12/28/2022]
Abstract
After cardiac arrest a combination of basic and advanced airway and ventilation techniques are used during cardiopulmonary resuscitation (CPR) and after a return of spontaneous circulation (ROSC). The optimal combination of airway techniques, oxygenation and ventilation is uncertain. Current guidelines are based predominantly on evidence from observational studies and expert consensus; recent and ongoing randomised controlled trials should provide further information. This narrative review describes the current evidence, including the relative roles of basic and advanced (supraglottic airways and tracheal intubation) airways, oxygenation and ventilation targets during CPR and after ROSC in adults. Current evidence supports a stepwise approach to airway management based on patient factors, rescuer skills and the stage of resuscitation. During CPR, rescuers should provide the maximum feasible inspired oxygen and use waveform capnography once an advanced airway is in place. After ROSC, rescuers should titrate inspired oxygen and ventilation to achieve normal oxygen and carbon dioxide targets.
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Affiliation(s)
- Christopher Newell
- Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Scott Grier
- Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Jasmeet Soar
- Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK.
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68
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Anderson RJ, Jinadasa SP, Hsu L, Ghafouri TB, Tyagi S, Joshua J, Mueller A, Talmor D, Sell RE, Beitler JR. Shock subtypes by left ventricular ejection fraction following out-of-hospital cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:162. [PMID: 29907120 PMCID: PMC6003130 DOI: 10.1186/s13054-018-2078-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/21/2018] [Indexed: 12/14/2022]
Abstract
Background Post-resuscitation hemodynamic instability following out-of-hospital cardiac arrest (OHCA) may occur from myocardial dysfunction underlying cardiogenic shock and/or inflammation-mediated distributive shock. Distinguishing the predominant shock subtype with widely available clinical metrics may have prognostic and therapeutic value. Methods A two-hospital cohort was assembled of patients in shock following OHCA. Left ventricular ejection fraction (LVEF) was assessed via echocardiography or cardiac ventriculography within 1 day post arrest and used to delineate shock physiology. The study evaluated whether higher LVEF, indicating distributive-predominant shock physiology, was associated with neurocognitive outcome (primary endpoint), survival, and duration of multiple organ failures. The study also investigated whether volume resuscitation exhibited a subtype-specific association with outcome. Results Of 162 patients with post-resuscitation shock, 48% had normal LVEF (> 40%), consistent with distributive shock physiology. Higher LVEF was associated with less favorable neurocognitive outcome (OR 0.74, 95% CI 0.58–0.94 per 10% increase in LVEF; p = 0.01). Higher LVEF also was associated with worse survival (OR 0.81, 95% CI 0.67–0.97; p = 0.02) and fewer organ failure-free days (β = – 0.67, 95% CI – 1.28 to − 0.06; p = 0.03). Only 51% of patients received a volume challenge of at least 30 ml/kg body weight in the first 6 h post arrest, and the volume received did not differ by LVEF. Greater volume resuscitation in the first 6 h post arrest was associated with favorable neurocognitive outcome (OR 1.59, 95% CI 0.99–2.55 per liter; p = 0.03) and survival (OR 1.44, 95% CI 1.02–2.04; p = 0.02) among patients with normal LVEF but not low LVEF. Conclusions In post-resuscitation shock, higher LVEF—indicating distributive shock physiology—was associated with less favorable neurocognitive outcome, fewer days without organ failure, and higher mortality. Greater early volume resuscitation was associated with more favorable neurocognitive outcome and survival in patients with this shock subtype. Additional studies with repeated measures of complementary hemodynamic parameters are warranted to validate the clinical utility for subtyping post-resuscitation shock. Electronic supplementary material The online version of this article (10.1186/s13054-018-2078-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ryan J Anderson
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - Sayuri P Jinadasa
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Leeyen Hsu
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Tiffany Bita Ghafouri
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - Sanjeev Tyagi
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Jisha Joshua
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA
| | - Ariel Mueller
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Rebecca E Sell
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians & Surgeons, 622 W. 168th Street, 8E101, New York, NY, 10032, USA.
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69
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Nolan JP, Berg RA, Callaway CW, Morrison LJ, Nadkarni V, Perkins GD, Sandroni C, Skrifvars MB, Soar J, Sunde K, Cariou A. The present and future of cardiac arrest care: international experts reach out to caregivers and healthcare authorities. Intensive Care Med 2018; 44:823-832. [DOI: 10.1007/s00134-018-5230-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 05/12/2018] [Indexed: 12/24/2022]
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70
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Turon M, Fernández-Gonzalo S, de Haro C, Magrans R, López-Aguilar J, Blanch L. Mechanisms involved in brain dysfunction in mechanically ventilated critically ill patients: implications and therapeutics. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:30. [PMID: 29430447 DOI: 10.21037/atm.2017.12.10] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Critical illness may lead to significant long-term neurological morbidity and patients frequently develop neuropsychological disturbances including acute delirium or memory impairment after intensive care unit (ICU) discharge. Mechanical ventilation (MV) is a risk factor to the development of adverse neurocognitive outcomes. Patients undergoing MV for long periods present neurologic impairment with memory and cognitive alteration. Delirium is considered an acute form of brain dysfunction and its prevalence rises in mechanically ventilated patients. Delirium duration is an independent predictor of mortality, ventilation time, ICU length of stay and short- and long-term cognitive impairment in the ICU survivors. Although, neurocognitive sequelae tend to improve after hospital discharge, residual deficits persist even 6 years after ICU stay. ICU-related neurocognitive impairments occurred in many cognitive domains and are particularly pronounced with regard to memory, executive functions, attentional functions, and processing speed. These sequelae have an important impact on patients' lives and ICU survivors often require institutionalization and hospitalization. Experimental studies have served to explore the possible mechanisms or pathways involved in this lung to brain interaction. This communication can be mediated via a complex web of signaling events involving neural, inflammatory, immunologic and neuroendocrine pathways. MV can affect respiratory networks and the application of protective ventilation strategies is mandatory in order to prevent adverse effects. Therefore, strategies focused to minimize lung stretch may improve outcomes, avoiding failure of distal organ, including the brain. Long-term neurocognitive impairments experienced by critically ill survivors may be mitigated by early interventions, combining cognitive and physical therapies. Inpatient rehabilitation interventions in ICU promise to improve outcomes in critically ill patients. The cross-talk between lung and brain, involving specific pathways during critical illness deserves further efforts to evaluate, prevent and improve cognitive alterations after ICU admission, and highlights the crucial importance of tailoring MV to prevent adverse outcomes.
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Affiliation(s)
- Marc Turon
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Sol Fernández-Gonzalo
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
| | - Candelaria de Haro
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Rudys Magrans
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Josefina López-Aguilar
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Lluís Blanch
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
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71
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The association between tidal volume and neurological outcome following in-hospital cardiac arrest. Resuscitation 2017; 124:106-111. [PMID: 29292026 DOI: 10.1016/j.resuscitation.2017.12.031] [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: 10/17/2017] [Revised: 12/13/2017] [Accepted: 12/28/2017] [Indexed: 12/24/2022]
Abstract
AIMS Prior investigation has found that mechanical ventilation with lower tidal volumes (Vt) following out-of-hospital cardiac arrest is associated with better neurologic outcomes. The relationship between Vt and neurologic outcome following in-hospital cardiac arrest (IHCA) has not previously been explored. In the present study, we investigate the association between Vt and neurologic outcome following IHCA. METHODS This was an observational study using a prospectively collected database of IHCA patients at a tertiary care hospital in the United States. The relationship between time-weighted average Vt per predicted body weight (PBW) over the first 6- and 48 h after cardiac arrest and neurologic outcome were assessed using propensity-score adjusted logistic regression. MEASUREMENTS AND MAIN RESULTS Of 185 IHCA patients who received invasive mechanical ventilation within 6 h of return of spontaneous circulation (ROSC), the average Vt over the first 6 h was 7.7 ± 2.0 ml/kg and 68 (36.8%) patients received an average Vt > 8.0 ml/kg. Of 121 patients who received mechanical ventilation for at least 48 h post-ROSC, the average Vt was 7.6 ± 1.5 ml/kg and 46 (38.0%) patients received an average Vt > 8.0 ml/kg. There was no relationship between Vt/PBW over the first 6- or 48 h post-ROSC and neurologic outcome (OR 0.99; 95%CI 0.84-1.16; p = 0.89; OR 1.03; 95%CI 0.78-1.37; p = 0.83 respectively). CONCLUSIONS This study did not identify a relationship between Vt and neurologic outcome following IHCA. This contrasts with results in OHCA, where higher Vt has been associated with worse neurologic outcome. Additional investigation is needed with respect to other potential benefits of low-Vt post IHCA.
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72
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Dezfulian C, Trzeciak S, Girard TD. Lung-Brain Interaction after Cardiac Arrest? Am J Respir Crit Care Med 2017; 195:1127-1128. [PMID: 28459318 DOI: 10.1164/rccm.201703-0611ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Cameron Dezfulian
- 1 Department of Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania and
| | | | - Timothy D Girard
- 1 Department of Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania and
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73
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Alencar R, D'Angelo V, Carmona R, Schultz MJ, Serpa Neto A. Patients with uninjured lungs may also benefit from lung-protective ventilator settings. F1000Res 2017; 6:2040. [PMID: 29250319 PMCID: PMC5701436 DOI: 10.12688/f1000research.12225.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2017] [Indexed: 12/21/2022] Open
Abstract
Although mechanical ventilation is a life-saving strategy in critically ill patients and an indispensable tool in patients under general anesthesia for surgery, it also acts as a double-edged sword. Indeed, ventilation is increasingly recognized as a potentially dangerous intrusion that has the potential to harm lungs, in a condition known as ‘ventilator-induced lung injury’ (VILI). So-called ‘lung-protective’ ventilator settings aiming at prevention of VILI have been shown to improve outcomes in patients with acute respiratory distress syndrome (ARDS), and, over the last few years, there has been increasing interest in possible benefit of lung-protective ventilation in patients under ventilation for reasons other than ARDS. Patients without ARDS could benefit from tidal volume reduction during mechanical ventilation. However, it is uncertain whether higher levels of positive end-expiratory pressure could benefit these patients as well. Finally, recent evidence suggests that patients without ARDS should receive low driving pressures during ventilation.
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Affiliation(s)
- Roger Alencar
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Vittorio D'Angelo
- School of Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Rachel Carmona
- School of Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcus J Schultz
- Deptartment of Intensive Care, Academic Medical Center, Amsterdam, Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok , Thailand
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Deptartment of Intensive Care, Academic Medical Center, Amsterdam, Netherlands
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74
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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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