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Lascarrou JB, Le Gouge A, Dimet J, Lacherade JC, Martin-Lefèvre L, Fiancette M, Vinatier I, Lebert C, Bachoumas K, Yehia A, Lagarrigue MH, Colin G, Reignier J. Neuromuscular blockade during therapeutic hypothermia after cardiac arrest: Observational study of neurological and infectious outcomes. Resuscitation 2014; 85:1257-62. [DOI: 10.1016/j.resuscitation.2014.05.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 05/21/2014] [Accepted: 05/22/2014] [Indexed: 01/15/2023]
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Briot R, Maignan M, Debaty G. Hypothermie thérapeutique. Le contrôle thermique est aussi important que la baisse de température. ANNALES FRANCAISES DE MEDECINE D URGENCE 2014. [DOI: 10.1007/s13341-014-0453-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Donnino MW, Andersen LW, Giberson T, Gaieski D, Abella B, Peberdy MA, Rittenberger JC, Callaway CW, Ornato J, Clore J, Grossestreuer A, Salciccioli J, Cocchi M. Initial lactate and lactate change in post-cardiac arrest: a multicenter validation study. Crit Care Med 2014; 42:1804-11. [PMID: 24776606 PMCID: PMC4154535 DOI: 10.1097/ccm.0000000000000332] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Rate of lactate change is associated with in-hospital mortality in post-cardiac arrest patients. This association has not been validated in a prospective multicenter study. The objective of the current study was to determine the association between percent lactate change and outcomes in post-cardiac arrest patients. DESIGN Four-center prospective observational study conducted from June 2011 to March 2012. SETTING The National Post-Arrest Research Consortium is a clinical research network conducting research in post-cardiac arrest care. The network consists of four urban tertiary care teaching hospitals. PATIENTS Inclusion criteria consisted of adult out-of-hospital non-traumatic cardiac arrest patients who were comatose after return of spontaneous circulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was survival to hospital discharge, and secondary outcome was good neurologic outcome. We compared the absolute lactate levels and the differences in the percent lactate change over 24 hours between survivors and nonsurvivors and between subjects with good and bad neurologic outcomes. One hundred patients were analyzed. The median age was 63 years (interquartile range, 50-75) and 40% were female. Ninety-seven percent received therapeutic hypothermia, and overall survival was 46%. Survivors and patients with good neurologic outcome had lower lactate levels at 0, 12, and 24 hours (p< 0.01). In adjusted models, percent lactate decrease at 12 hours was greater in survivors (odds ratio, 2.2; 95% CI, 1.1-6.2) and in those with good neurologic outcome (odds ratio, 2.2; 95% CI, 1.1-4.4). CONCLUSION Lower lactate levels at 0, 12, and 24 hours and greater percent decrease in lactate over the first 12 hours post cardiac arrest are associated with survival and good neurologic outcome.
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Affiliation(s)
- Michael W. Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Medicine, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Lars W. Andersen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Research Center for Emergency Medicine, Aarhus University, Aarhus, Denmark
| | - Tyler Giberson
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - David Gaieski
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin Abella
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Anne Peberdy
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Jon C. Rittenberger
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Clifton W. Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph Ornato
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - John Clore
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Anne Grossestreuer
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Justin Salciccioli
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael Cocchi
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Anesthesia Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Karnatovskaia LV, Festic E, Freeman WD, Lee AS. Effect of therapeutic hypothermia on gas exchange and respiratory mechanics: a retrospective cohort study. Ther Hypothermia Temp Manag 2014; 4:88-95. [PMID: 24840620 DOI: 10.1089/ther.2014.0004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Targeted temperature management (TTM) may improve respiratory mechanics and lung inflammation in acute respiratory distress syndrome (ARDS) based on animal and limited human studies. We aimed to assess the pulmonary effects of TTM in patients with respiratory failure following cardiac arrest. Retrospective review of consecutive cardiac arrest cases occurring out of hospital or within 24 hours of hospital admission (2002-2012). Those receiving TTM (n=44) were compared with those who did not (n=42), but required mechanical ventilation (MV) for at least 4 days following the arrest. There were no between-group differences in age, gender, body mass index, APACHE II, or fluid balance during the study period. The TTM group had lower ejection fraction, Glasgow Coma Score, and more frequent use of paralytics. Matched data analyses (change at day 4 compared with baseline of the individual subject) showed favorable, but not statistically significant trends in respiratory mechanics endpoints (airway pressure, compliance, tidal volume, and PaO2/FiO2) in the TTM group. The PaCO2 decreased significantly more in the TTM group, as compared with controls (-12 vs. -5 mmHg, p=0.02). For clinical outcomes, the TTM group consistently, although not significantly, did better in survival (59% vs. 43%) and hospital length of stay (12 vs. 15 days). The MV duration and Cerebral Performance Category score on discharge were significantly lower in the TTM group (7.3 vs. 10.7 days, p=0.04 and 3.2 vs. 4, p=0.01). This small retrospective cohort suggests that the effect of TTM ranges from equivalent to favorable, compared with controls, for the specific respiratory and clinical outcomes in patients with respiratory failure following cardiac arrest.
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105
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Hessel EA. Therapeutic hypothermia after in-hospital cardiac arrest: a critique. J Cardiothorac Vasc Anesth 2014; 28:789-99. [PMID: 24751488 DOI: 10.1053/j.jvca.2014.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Indexed: 02/08/2023]
Abstract
More than 210,000 in-hospital cardiac arrests occur annually in the United States. Use of moderate therapeutic hypothermia (TH) in comatose survivors after return of spontaneous circulation following out-of-hospital cardiac arrest (OOH-CA) caused by ventricular fibrillation or pulseless ventricular tachycardia is recommended strongly by many professional organizations and societies. The use of TH after cardiac arrest associated with nonshockable rhythms and after in-hospital cardiac arrest (IH-CA) is recommended to be considered by these same organizations and is being applied widely. The use in these latter circumstances is based on an extrapolation of the data supporting its use after out-of-hospital cardiac arrest associated with shockable rhythms. The purpose of this article is to review the limitations of existing data supporting these extended application of TH after cardiac arrest and to suggest approaches to this dilemma. The data supporting its use for OOH-CA appear to this author, and to some others, to be rather weak, and the data supporting the use of TH for IH-CA appear to be even weaker and to include no randomized controlled trials (RCTs) or supportive observational studies. The many reasons why TH might be expected to be less effective following IH-CA are reviewed. The degree of neurologic injury may be more severe in many of these cases and, thus, may not be responsive to TH as currently practiced following OOH-CA. The potential adverse consequences of the routine use of TH for IH-CA are listed and include complications associated with TH, interference with diagnostic and interventional therapy, and use of scarce personnel and financial resources. Most importantly, it inhibits the ability of researchers to conduct needed RCTs. The author believes that the proper method of providing TH in these cases needs to be better defined. Based on this analysis the author concludes that TH should not be used indiscriminantly following most cases of IH-CA, and instead clinicians should concentrate their efforts in conducting high-quality large RCTs or large-scale, well-designed prospective observation studies to determine its benefits and identify appropriate candidates.
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Affiliation(s)
- Eugene A Hessel
- Department of Anesthesiology, Surgery (Cardiothoracic), Neurosurgery, and Pediatrics, University of Kentucky College of Medicine, Lexington, KY.
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Lee BK, Lee SJ, Jeung KW, Lee HY, Heo T, Min YI. Outcome and adverse events with 72-hour cooling at 32°C as compared to 24-hour cooling at 33°C in comatose asphyxial arrest survivors. Am J Emerg Med 2014; 32:297-301. [DOI: 10.1016/j.ajem.2013.11.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 11/22/2013] [Accepted: 11/22/2013] [Indexed: 01/22/2023] Open
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Blood glucose level and outcome after cardiac arrest: insights from a large registry in the hypothermia era. Intensive Care Med 2014; 40:855-62. [PMID: 24664154 DOI: 10.1007/s00134-014-3269-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 03/13/2014] [Indexed: 01/04/2023]
Abstract
INTRODUCTION The influence of blood glucose (BG) level during the post-resuscitation period after out-of-hospital cardiac arrest (OHCA) is still debated. To evaluate the relationship between blood glucose level and outcome, we included the median glycemia and its maximal amplitude over the first 48 h following ICU admission in an analysis of outcome predictors. METHODS We conducted a database study in a cardiac arrest center in Paris, France. Between 2006 and 2010, we included 381 patients who were all resuscitated from an OHCA. A moderate glycemic control was applied in all patients. The median glycemia and the largest change over the first 48 h were included in a multivariate analysis that was performed to determine parameters associated with a favorable outcome. RESULTS Of the 381 patients, 136 (36 %) had a favorable outcome (CPC 1-2). Median BG level was 7.6 mmol/L (6.3-9.8) in patients with a favorable outcome compared to 9.0 mmol/L (IQR 7.1-10.6) for patients with an unfavorable outcome (p < 0.01). Median BG level variation was 7.1 (4.2-11) and 9.6 (5.9-13.6) mmol/L in patients with and without a favorable outcome, respectively (p < 0.01). In multivariate analysis, an increased median BG level over the first 48 h was found to be an independent predictor of poor issue [OR = 0.43; 95 % CI (0.24-0.78), p = 0.006]. Finally a progressive increase in median BG level was associated with a progressive increase in the proportion of patients with a poor outcome. CONCLUSION We observed a relationship between high blood glucose level and outcome after cardiac arrest. These results suggest the need to test a strategy combining both control of glycemia and minimization of glycemic variations for its ability to improve post-resuscitation care.
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Abstract
OBJECTIVE Observational studies suggest that infections are a common complication of therapeutic hypothermia. We performed a systematic review and meta-analysis of randomized trials to examine the risk of infections in patients treated with hypothermia. DATA SOURCES PubMed, Embase, and the Cochrane Central Register of Controlled Trials were systematically searched for eligible studies up to October 1, 2012. STUDY SELECTION We included randomized controlled clinical trials of therapeutic hypothermia induced in adults for any indication, which reported the prevalence of infection in each treatment group. DATA EXTRACTION For each study, we collected information about the baseline characteristics of patients, cooling strategy, and infections. DATA SYNTHESIS Twenty-three studies were identified, which included 2,820 patients, of whom 1,398 (49.6%) were randomized to hypothermia. Data from another 31 randomized trials, involving 4,004 patients, could not be included because the occurrence of infection was not reported with sufficient detail or not at all. The risk of bias in the included studies was high because information on the method of randomization and definitions of infections lacked in most cases, and assessment of infections was not blinded. In patients treated with hypothermia, the prevalence of all infections was not increased (rate ratio, 1.21 [95% CI, 0.95-1.54]), but there was an increased risk of pneumonia and sepsis (risk ratios, 1.44 [95% CI, 1.10-1.90]; 1.80 [95% CI, 1.04-3.10], respectively). CONCLUSION The available evidence, subject to its limitations, strongly suggests an association between therapeutic hypothermia and the risk of pneumonia and sepsis, whereas no increase in the overall risk of infection was observed. All future randomized trials of hypothermia should report on this important complication.
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109
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Factors associated with pneumonia in post–cardiac arrest patients receiving therapeutic hypothermia. Am J Emerg Med 2014; 32:150-5. [DOI: 10.1016/j.ajem.2013.10.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 10/11/2013] [Accepted: 10/14/2013] [Indexed: 11/20/2022] Open
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Noyes AM, Lundbye JB. Managing the Complications of Mild Therapeutic Hypothermia in the Cardiac Arrest Patient. J Intensive Care Med 2013; 30:259-69. [PMID: 24371249 DOI: 10.1177/0885066613516416] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 09/27/2013] [Indexed: 12/11/2022]
Abstract
Mild therapeutic hypothermia (MTH) is used to lower the core body temperature of cardiac arrest (CA) patients to 32°C from 34°C to provide improved survival and neurologic outcomes after resuscitation from in-hospital or out-of-hospital CA. Despite the improved benefits of MTH, there are potentially unforeseen complications associated during management. Although the adverse effects are transient, the clinician should be aware of the associated complications when managing the patient receiving MTH. We aim to provide the medical community comprehensive information related to the potential complications of survivors of CA receiving MTH, as it is imperative for the clinician to understand the physiologic changes that take place in the patient receiving MTH and how to prepare for them and manage them if they do occur. We hope to provide information of how to manage these potential complications through both a review of the current literature and a reflection of our own experience.
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Affiliation(s)
- Adam M Noyes
- Department of Medicine, University of Connecticut Medical School, Farmington, CT, USA
| | - Justin B Lundbye
- Division of Cardiology, the Hospital of Central Connecticut, Chief of Cardiology, New Britain, CT, USA
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111
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Bělohlávek J, Springer D, Mlček M, Huptych M, Bouček T, Hodková G, Fichtl J, Mrázek V, Zima T, Linhart A, Kittnar O. Early vancomycin, amikacin and gentamicin concentrations in pulmonary artery and pulmonary tissue are not affected by VA ECMO (venoarterial extracorporeal membrane oxygenation) in a pig model of prolonged cardiac arrest. Pulm Pharmacol Ther 2013; 26:655-60. [DOI: 10.1016/j.pupt.2013.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 03/07/2013] [Accepted: 03/12/2013] [Indexed: 10/27/2022]
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MacLaren R, Gallagher J, Shin J, Varnado S, Nguyen L. Assessment of adverse events and predictors of neurological recovery after therapeutic hypothermia. Ann Pharmacother 2013; 48:17-25. [PMID: 24259643 DOI: 10.1177/1060028013511228] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia improves neurological recovery after witnessed cardiac arrest from ventricular fibrillation or tachycardia. Its application is expanding despite associated adverse events. OBJECTIVE To assess the occurrence of adverse events and predictors of good versus poor neurological recovery after therapeutic hypothermia. METHODS A single-center, retrospective review of medical records of 91 patients who received therapeutic hypothermia for ≥6 hours. Adverse events included laboratory abnormalities, shivering, acute kidney injury, or infection. Cerebral performance categories (CPC) scores delineated good (CPC of 1-3) or poor (CPC of 4 or 5) neurological outcomes. Groups were compared and parameters evaluated for effect on neurological recovery using backward logistic regression analysis. RESULTS Therapeutic hypothermia was used for several indications, and 42 patients (46.2%) had good neurological recovery. Demographic parameters were similar between groups. Common adverse events were hypoglycemia (98.9%), shivering (84.6%), bradycardia (58.2%), electrolyte abnormalities (26.4%-91.2%), acute kidney injury (52.8%), infection (48.4%), and coagulopathy (40.7%). Characteristics independently associated with neurological recovery included faster return of spontaneous circulation (ROSC), quicker initiation of cooling, and the occurrence of infections. Pulseless electrical activity, faster achievement of goal cooling temperature, seizure, and the administration of insulin or epinephrine were inversely related to neurological recovery. CONCLUSIONS Adverse events of therapeutic hypothermia were numerous and frequent, necessitating monitoring. Neurological recovery is primarily driven by the type of arrest, the rapidity of ROSC, the time needed to provide and achieve therapeutic hypothermia, the development of seizures or infection, and the use of insulin or epinephrine.
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Affiliation(s)
- Robert MacLaren
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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113
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Mongardon N, Bouglé A, Geri G, Daviaud F, Morichau-Beauchant T, Tissier R, Dumas F, Cariou A. Syndrome post-arrêt cardiaque : aspects physiopathologiques, cliniques et thérapeutiques. ACTA ACUST UNITED AC 2013; 32:779-86. [DOI: 10.1016/j.annfar.2013.07.818] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Accepted: 07/27/2013] [Indexed: 12/12/2022]
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114
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Coba V, Jaehne AK, Suarez A, Dagher GA, Brown SC, Yang JJ, Manteuffel J, Rivers EP. The incidence and significance of bacteremia in out of hospital cardiac arrest. Resuscitation 2013; 85:196-202. [PMID: 24128800 DOI: 10.1016/j.resuscitation.2013.09.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 08/14/2013] [Accepted: 09/24/2013] [Indexed: 01/25/2023]
Abstract
BACKGROUND The most common etiology of cardiac arrest is presumed of myocardial origin. Recent retrospective studies indicate that preexisting pneumonia, a form of sepsis, is frequent in patients who decompensate with abrupt cardiac arrest without preceding signs of septic shock, respiratory failure or severe metabolic disorders shortly after hospitalization. The contribution of pre-existing infection on pre and post cardiac arrest events remains unknown and has not been studied in a prospective fashion. We sought to examine the incidence of pre-existing infection in out-of hospital cardiac arrest (OHCA) and assess characteristics associated with bacteremia, the goal standard for presence of infection. METHODS AND RESULTS We prospectively observed 250 OHCA adult patients who presented to the Emergency Department (ED) between 2007 and 2009 to an urban academic teaching institution. Bacteremia was defined as one positive blood culture with non-skin flora bacteria or two positive blood cultures with skin flora bacteria. 77 met pre-defined exclusion criteria. Of the 173 OHCA adults, 65 (38%) were found to be bacteremic with asystole and PEA as the most common presenting rhythms. Mortality in the ED was significantly higher in bacteremic OHCA (75.4%) compared to non-bacteremic OHCA (60.2%, p<0.05). After adjustment for potential confounders, predictive factors associated with bacteremic OHCA were lower initial arterial pH, higher lactate, WBC, BUN and creatinine. CONCLUSIONS Over one-third of OHCA adults were bacteremic upon presentation. These patients have greater hemodynamic instability and significantly increased short-term mortality. Further studies are warranted to address the epidemiology of infection as possible cause of cardiac arrest.
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Affiliation(s)
- Victor Coba
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States; Department of Surgery, Henry Ford Hospital, Detroit, MI, United States.
| | - Anja Kathrin Jaehne
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Arturo Suarez
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States; Department of Anesthesiology, Henry Ford Hospital, Detroit, MI, United States
| | - Gilbert Abou Dagher
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Samantha C Brown
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - James J Yang
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, United States
| | - Jacob Manteuffel
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Emanuel P Rivers
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States; Department of Surgery, Henry Ford Hospital, Detroit, MI, United States
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Fever after therapeutic hypothermia – Does rebound pyrexia matter? Resuscitation 2013; 84:1011-2. [DOI: 10.1016/j.resuscitation.2013.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 05/09/2013] [Indexed: 11/18/2022]
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116
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Aslami H, Pulskens WP, Kuipers MT, Bos AP, van Kuilenburg ABP, Wanders RJA, Roelofsen J, Roelofs JJTH, Kerindongo RP, Beurskens CJP, Schultz MJ, Kulik W, Weber NC, Juffermans NP. Hydrogen sulfide donor NaHS reduces organ injury in a rat model of pneumococcal pneumosepsis, associated with improved bio-energetic status. PLoS One 2013; 8:e63497. [PMID: 23717435 PMCID: PMC3662774 DOI: 10.1371/journal.pone.0063497] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 04/03/2013] [Indexed: 01/04/2023] Open
Abstract
Sepsis is characterized by a generalized inflammatory response and organ failure, associated with mitochondrial dysfunction. Hydrogen sulfide donor NaHS has anti-inflammatory properties, is able to reduce metabolism and can preserve mitochondrial morphology and function. Rats were challenged with live Streptococcus pneumonia or saline and infused with NaHS (36 µmol/kg/h) or vehicle. Lung and kidney injury markers were measured as well as mitochondrial function, viability and biogenesis. Infusion of NaHS reduced heart rate and body temperature, indicative of a hypo-metabolic state. NaHS infusion reduced sepsis-related lung and kidney injury, while host defense remained intact, as reflected by unchanged bacterial outgrowth. The reduction in organ injury was associated with a reversal of a fall in active oxidative phosphorylation with a concomitant decrease in ATP levels and ATP/ADP ratio. Preservation of mitochondrial respiration was associated with increased mitochondrial expression of α-tubulin and protein kinase C-ε, which acts as regulators of respiration. Mitochondrial damage was decreased by NaHS, as suggested by a reduction in mitochondrial DNA leakage in the lung. Also, NaHS treatment was associated with upregulation of peroxisome proliferator-activated receptor-γ coactivator 1α, with a subsequent increase in transcription of mitochondrial respiratory subunits. These findings indicate that NaHS reduces organ injury in pneumosepsis, possibly via preservation of oxidative phosphorylation and thereby ATP synthesis as well as by promoting mitochondrial biogenesis. Further studies on the involvement of mitochondria in sepsis are required.
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Affiliation(s)
- Hamid Aslami
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands.
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Davies KJ, Walters JH, Kerslake IM, Greenwood R, Thomas MJ. Early antibiotics improve survival following out-of hospital cardiac arrest. Resuscitation 2013; 84:616-9. [DOI: 10.1016/j.resuscitation.2012.11.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 09/09/2012] [Accepted: 11/01/2012] [Indexed: 11/15/2022]
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118
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Winters SA, Wolf KH, Kettinger SA, Seif EK, Jones JS, Bacon-Baguley T. Assessment of risk factors for post-rewarming "rebound hyperthermia" in cardiac arrest patients undergoing therapeutic hypothermia. Resuscitation 2013; 84:1245-9. [PMID: 23567472 DOI: 10.1016/j.resuscitation.2013.03.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 03/21/2013] [Accepted: 03/22/2013] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The outcomes associated with therapeutic hypothermia (TH) after cardiac arrest, while overwhelmingly positive, may be associated with adverse events. The incidence of post-rewarming rebound hyperthermia (RH) has been relatively unstudied and may worsen survival and neurologic outcome. The purpose of this study was to determine the incidence and risk factors associated with RH as well as its relationship to mortality, neurologic morbidity, and hospital length of stay (LOS). METHODS A retrospective, observational study was performed of adult patients who underwent therapeutic hypothermia after an out-of-hospital cardiac arrest. Data describing 17 potential risk factors for RH were collected. The primary outcome was the incidence of RH while the secondary outcomes were mortality, discharge neurologic status, and LOS. RESULTS 141 patients were included. All 17 risk factors for RH were analyzed and no potential risk factors were found to be significant at a univariate level. 40.4% of patients without RH experienced any cause of death during the initial hospitalization compared to 64.3% patients who experienced RH (OR: 2.66; 95% CI: 1.26-5.61; p=0.011). The presence of RH is not associated with an increase in LOS (10.67 days vs. 9.45 days; absolute risk increase=-1.21 days, 95% CI: -1.84 to 4.27; p=0.434). RH is associated with increased neurologic morbidity (p=0.011). CONCLUSIONS While no potential risk factors for RH were identified, RH is a marker for increased mortality and worsened neurologic morbidity in cardiac arrest patients who have underwent TH.
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Affiliation(s)
- S A Winters
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
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Affiliation(s)
- Benjamin M Scirica
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
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Engel H, Ben Hamouda N, Portmann K, Delodder F, Suys T, Feihl F, Eggimann P, Rossetti AO, Oddo M. Serum procalcitonin as a marker of post-cardiac arrest syndrome and long-term neurological recovery, but not of early-onset infections, in comatose post-anoxic patients treated with therapeutic hypothermia. Resuscitation 2013; 84:776-81. [PMID: 23380286 DOI: 10.1016/j.resuscitation.2013.01.029] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 01/24/2013] [Accepted: 01/25/2013] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To examine the relationship of early serum procalcitonin (PCT) levels with the severity of post-cardiac arrest syndrome (PCAS), long-term neurological recovery and the risk of early-onset infections in patients with coma after cardiac arrest (CA) treated with therapeutic hypothermia (TH). METHODS A prospective cohort of adult comatose CA patients treated with TH (33°C, for 24h) admitted to the medical/surgical intensive care unit, Lausanne University Hospital, was studied. Serum PCT was measured early after CA, at two time-points (days 1 and 2). The SOFA score was used to quantify the severity of PCAS. Diagnosis of early-onset infections (within the first 7 days of ICU stay) was made after review of clinical, radiological and microbiological data. Neurological recovery at 3 months was assessed with Cerebral Performance Categories (CPC), and was dichotomized as favorable (CPC 1-2) vs. unfavorable (CPC 3-5). RESULTS From December 2009 to April 2012, 100 patients (median age 64 [interquartile range 55-73] years, median time from collapse to ROSC 20 [11-30]min) were studied. Peak PCT correlated with SOFA score at day 1 (Spearman's R=0.44, p<0.0001) and was associated with neurological recovery at 3 months (peak PCT 1.08 [0.35-4.45]ng/ml in patients with CPC 1-2 vs. 3.07 [0.89-9.99] ng/ml in those with CPC 3-5, p=0.01). Peak PCT did not differ significantly between patients with early-onset vs. no infections (2.14 [0.49-6.74] vs. 1.53 [0.46-5.38]ng/ml, p=0.49). CONCLUSIONS Early elevations of serum PCT levels correlate with the severity of PCAS and are associated with worse neurological recovery after CA and TH. In contrast, elevated serum PCT did not correlate with early-onset infections in this setting.
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Affiliation(s)
- Harald Engel
- Department of Intensive Care Medicine, CHUV-Lausanne University Hospital, Faculty of Biology and Medicine, University of Lausanne, Switzerland
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121
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Hyperoxia is associated with increased mortality in patients treated with mild therapeutic hypothermia after sudden cardiac arrest. Crit Care Med 2013; 40:3135-9. [PMID: 22971589 DOI: 10.1097/ccm.0b013e3182656976] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine whether higher levels of PaO2 are associated with in-hospital mortality and poor neurological status at hospital discharge in patients treated with mild therapeutic hypothermia after sudden cardiac arrest. DESIGN Retrospective analysis of a prospective cohort. PATIENTS A total of 170 consecutive patients treated with therapeutic hypothermia in the cardiovascular care unit of an academic tertiary care hospital. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 170 patients, 77 (45.2%) survived to hospital discharge. Survivors had a significantly lower maximum PaO2 (198 mm Hg; interquartile range, 152.5-282) measured in the first 24 hrs following cardiac arrest compared to nonsurvivors (254 mm Hg; interquartile range, 172-363; p = .022). A multivariable analysis including age, time to return of spontaneous circulation, the presence of shock, bystander cardiopulmonary resuscitation, and initial rhythm revealed that higher levels of PaO2 were significantly associated with increased in-hospital mortality (odds ratio 1.439; 95% confidence interval 1.028-2.015; p = .034) and poor neurological status at hospital discharge (odds ratio 1.485; 95% confidence interval 1.032-2.136; p = .033). CONCLUSIONS Higher levels of the maximum measured PaO2 are associated with increased in-hospital mortality and poor neurological status on hospital discharge in patients treated with mild therapeutic hypothermia after sudden cardiac arrest.
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122
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Predictors of external cooling failure after cardiac arrest. Intensive Care Med 2013; 39:620-8. [DOI: 10.1007/s00134-012-2794-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Accepted: 10/18/2012] [Indexed: 10/27/2022]
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123
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Brain temperature: physiology and pathophysiology after brain injury. Anesthesiol Res Pract 2012; 2012:989487. [PMID: 23326261 PMCID: PMC3541556 DOI: 10.1155/2012/989487] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 11/09/2012] [Accepted: 12/12/2012] [Indexed: 12/02/2022] Open
Abstract
The regulation of brain temperature is largely dependent on the metabolic activity of brain tissue and remains complex. In intensive care clinical practice, the continuous monitoring of core temperature in patients with brain injury is currently highly recommended. After major brain injury, brain temperature is often higher than and can vary independently of systemic temperature. It has been shown that in cases of brain injury, the brain is extremely sensitive and vulnerable to small variations in temperature. The prevention of fever has been proposed as a therapeutic tool to limit neuronal injury. However, temperature control after traumatic brain injury, subarachnoid hemorrhage, or stroke can be challenging. Furthermore, fever may also have beneficial effects, especially in cases involving infections. While therapeutic hypothermia has shown beneficial effects in animal models, its use is still debated in clinical practice. This paper aims to describe the physiology and pathophysiology of changes in brain temperature after brain injury and to study the effects of controlling brain temperature after such injury.
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124
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Delhaye C, Lemesle G. [Therapeutic hypothermia and management of sudden death]. Ann Cardiol Angeiol (Paris) 2012; 61:440-446. [PMID: 23098610 DOI: 10.1016/j.ancard.2012.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Due to its protective effects on the brain and potentially the myocardium, cooling therapy is clearly part of the standard of care of any sudden death especially in the setting of myocardial infarction. Recent guidelines recommend cooling therapy (32 to 34 °C) for 12 to 24 hours in unconscious patients with spontaneous circulation after resuscitated sudden death. We provide here a review of clinical evidence, cooling techniques and potential adverse effects of cooling therapy.
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Affiliation(s)
- C Delhaye
- Unité des soins intensifs de cardiologie, centre hémodynamique, clinique de cardiologie, centre hospitalier régional et universitaire de Lille, boulevard du Pr-Jules-Leclercq, 59037 Lille cedex, France
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125
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Moreno J, Magaldi M, Fontanals J, Tió M, Carrero E, Tercero FJ. Respiratory complications in patients underwent mild hypothermia after cardiac arrest. Resuscitation 2012. [DOI: 10.1016/j.resuscitation.2012.08.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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126
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Corry JJ. Use of hypothermia in the intensive care unit. World J Crit Care Med 2012; 1:106-22. [PMID: 24701408 PMCID: PMC3953868 DOI: 10.5492/wjccm.v1.i4.106] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 06/25/2012] [Accepted: 07/12/2012] [Indexed: 02/06/2023] Open
Abstract
Used for over 3600 years, hypothermia, or targeted temperature management (TTM), remains an ill defined medical therapy. Currently, the strongest evidence for TTM in adults are for out-of-hospital ventricular tachycardia/ventricular fibrillation cardiac arrest, intracerebral pressure control, and normothermia in the neurocritical care population. Even in these disease processes, a number of questions exist. Data on disease specific therapeutic markers, therapeutic depth and duration, and prognostication are limited. Despite ample experimental data, clinical evidence for stroke, refractory status epilepticus, hepatic encephalopathy, and intensive care unit is only at the safety and proof-of-concept stage. This review explores the deleterious nature of fever, the theoretical role of TTM in the critically ill, and summarizes the clinical evidence for TTM in adults.
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Affiliation(s)
- Jesse J Corry
- Jesse J Corry, Department of Neurology, Marshfield Clinic, Marshfield, WI 54449-5777, United States
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127
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Affiliation(s)
- L A Urbano
- Department of Critical Care Medicine, Lausanne University Hospital and Faculty of Biology and Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, CH-1011 Lausanne, Switzerland.
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128
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Reply letter to: Drowning associated pneumonia. Resuscitation 2012. [DOI: 10.1016/j.resuscitation.2012.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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129
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Grimaldi D, Guivarch E, Neveux N, Fichet J, Pène F, Marx JS, Chiche JD, Cynober L, Mira JP, Cariou A. Markers of intestinal injury are associated with endotoxemia in successfully resuscitated patients. Resuscitation 2012; 84:60-5. [PMID: 22743354 DOI: 10.1016/j.resuscitation.2012.06.010] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 05/29/2012] [Accepted: 06/05/2012] [Indexed: 01/15/2023]
Abstract
AIMS Gut dysfunction is suspected to play a major role in the pathophysiology of post-resuscitation disease through an increase in intestinal permeability and endotoxin release. However this dysfunction often remains occult and is poorly investigated. The aim of this pilot study was to explore intestinal failure biomarkers in post-cardiac arrest patients and to correlate them with endotoxemia. METHODS Following resuscitation after cardiac arrest, 21 patients were prospectively studied. Urinary intestinal fatty acid-binding protein (IFABP), which marks intestinal permeability, plasma citrulline, which reflects the functional enterocyte mass, and whole blood endotoxin were measured at admission, days 1-3 and 6. We explored the kinetics of release and the relationship between IFABP, citrulline and endotoxin values. RESULTS IFABP was extremely high at admission and normalized at D3 (6668 pg/mL vs 39 pg/mL, p=0.01). Lowest median of citrulline (N=20-40 μmol/L) was attained at D2 (11 μmol/L at D2 vs 24 μmol/L at admission, p=0.01) and tended to normalize at D6 (21 μmol/L). During ICU stay, 86% of patients presented a detectable endotoxemia. Highest endotoxin level was positively correlated with highest IFABP level (R(2)=0.31, p=0.01) and was inversely correlated with lowest plasma citrulline levels (R(2)=0.55, p<0.001). Endotoxin levels increased between admission and D2 in patients with post-resuscitation shock, whereas it decreases in patients with no shock (median +0.33 EU vs -0.19 EU, p=0.03). Highest endotoxin level was positively correlated with D3 SOFA score (R(2)=0.45, p=0.004). CONCLUSION Biomarkers of intestinal injury are altered after cardiac arrest and are associated with endotoxemia. This could worsen post-resuscitation shock and organ failure.
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Affiliation(s)
- D Grimaldi
- Medical Intensive Care Unit, Groupe Hospitalier Broca Cochin Hotel-Dieu, AP-HP, 27 rue du Faubourg Saint Jacques, 75679 Paris Cedex 14, France
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130
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Broessner G, Fischer M, Lackner P, Pfausler B, Schmutzhard E. Complications of hypothermia: infections. Crit Care 2012. [PMCID: PMC3389479 DOI: 10.1186/cc11277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Bjelland TW, Dale O, Kaisen K, Haugen BO, Lydersen S, Strand K, Klepstad P. Propofol and remifentanil versus midazolam and fentanyl for sedation during therapeutic hypothermia after cardiac arrest: a randomised trial. Intensive Care Med 2012; 38:959-67. [DOI: 10.1007/s00134-012-2540-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 01/12/2012] [Indexed: 10/28/2022]
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Abstract
PURPOSE OF REVIEW To discuss recent data relating to survival rates after cardiac arrest and interventions that can be used to optimize outcome. RECENT FINDINGS A recent analysis of 70 studies indicates that following out-of-hospital cardiac arrest (OHCA), 7.6% of patients will survive to hospital discharge (95% confidence interval 6.7-8.4). Following in-hospital cardiac arrest, 18% of patients will survive to hospital discharge. Survival may be optimized by increasing the rate of bystander cardiopulmonary resuscitation (CPR), which can be achieved by improving recognition of cardiac arrest, simplifying CPR and training more of the community. Feedback systems improve the quality of CPR but this has yet to be translated into improved outcome. One study has shown improved survival following OHCA with active compression-decompression CPR combined with an impedance-threshold device. In those who have no obvious extracardiac cause of OHCA, 70% have at least one significant coronary lesion demonstrable by coronary angiography. Although generally reserved for those with ST-elevation myocardial infarction, primary percutaneous coronary intervention may also benefit OHCA survivors with ECG patterns other than ST elevation. The term 'mild therapeutic hypothermia' has been replaced by the term 'targeted temperature management'; its role in optimizing outcome after cardiac arrest continues to be defined. SUMMARY In several centres, survival rates following OHCA are increasing. All links in the chain of survival must be optimized if a good-quality neurological outcome is to be achieved.
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Schortgen F, Clabault K, Katsahian S, Devaquet J, Mercat A, Deye N, Dellamonica J, Bouadma L, Cook F, Beji O, Brun-Buisson C, Lemaire F, Brochard L. Fever control using external cooling in septic shock: a randomized controlled trial. Am J Respir Crit Care Med 2012; 185:1088-95. [PMID: 22366046 DOI: 10.1164/rccm.201110-1820oc] [Citation(s) in RCA: 175] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
RATIONALE Fever control may improve vascular tone and decrease oxygen consumption, but fever may contribute to combat infection. OBJECTIVES To determine whether fever control by external cooling diminishes vasopressor requirements in septic shock. METHODS In a multicenter randomized controlled trial, febrile patients with septic shock requiring vasopressors, mechanical ventilation, and sedation were allocated to external cooling (n = 101) to achieve normothermia (36.5-37°C) for 48 hours or no external cooling (n = 99). Vasopressors were tapered to maintain the same blood pressure target in the two groups. The primary endpoint was the number of patients with a 50% decrease in baseline vasopressor dose after 48 hours. MEASUREMENTS AND MAIN RESULTS Body temperature was significantly lower in the cooling group after 2 hours of treatment (36.8 ± 0.7 vs. 38.4 ± 1.1°C; P < 0.01). A 50% vasopressor dose decrease was significantly more common with external cooling from 12 hours of treatment (54 vs. 20%; absolute difference, 34%; 95% confidence interval [95% CI], -46 to -21; P < 0.001) but not at 48 hours (72 vs. 61%; absolute difference, 11%; 95% CI, -23 to 2). Shock reversal during the intensive care unit stay was significantly more common with cooling (86 vs. 73%; absolute difference, 13%; 95% CI, 2 to 25; P = 0.021). Day-14 mortality was significantly lower in the cooling group (19 vs. 34%; absolute difference, -16%; 95% CI, -28 to -4; P = 0.013). CONCLUSIONS In this study, fever control using external cooling was safe and decreased vasopressor requirements and early mortality in septic shock.
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134
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Delhaye C, Mahmoudi M, Waksman R. Hypothermia Therapy. J Am Coll Cardiol 2012; 59:197-210. [DOI: 10.1016/j.jacc.2011.06.077] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 06/20/2011] [Accepted: 06/27/2011] [Indexed: 10/14/2022]
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Mongardon N, Dumas F, Ricome S, Grimaldi D, Hissem T, Pène F, Cariou A. Postcardiac arrest syndrome: from immediate resuscitation to long-term outcome. Ann Intensive Care 2011; 1:45. [PMID: 22053891 PMCID: PMC3223497 DOI: 10.1186/2110-5820-1-45] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 11/03/2011] [Indexed: 11/15/2022] Open
Abstract
The prognosis for postcardiac arrest patients remains very bleak, not only because of anoxic-ischemic neurological damage, but also because of the "postcardiac arrest syndrome," a phenomenon often severe enough to cause death before any neurological evaluation. This syndrome includes all clinical and biological manifestations related to the phenomenon of global ischemia-reperfusion triggered by cardiac arrest and return of spontaneous circulation. The main component of the postcardiac arrest syndrome is an early but severe cardiocirculatory dysfunction that may lead to multiple organ failure and death. Cardiovascular support relies on conventional medical and mechanical treatment of circulatory failure. Hemodynamic stabilization is a major objective to limit secondary brain insult. When the cause of cardiac arrest is related to myocardial infarction, percutaneous coronary revascularization is associated with improved prognosis; early angiographic exploration should then be discussed when there is no obvious extracardiac cause. Therapeutic hypothermia is now the cornerstone of postanoxic cerebral protection. Its widespread use is clearly recommended, with a favorable risk-benefit ratio in selected population. Neuroprotection also is based on the prevention of secondary cerebral damages, pending the results of ongoing therapeutic evaluations regarding the potential efficiency of new therapeutic drugs.
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Affiliation(s)
- Nicolas Mongardon
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Universtitaire Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France.
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Combes A. Early-Onset Pneumonia after Cardiac Arrest: An Unintended Consequence of Therapeutic Hypothermia? Am J Respir Crit Care Med 2011; 184:993-4. [DOI: 10.1164/rccm.201108-1399ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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138
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Perbet S, Mongardon N, Dumas F, Bruel C, Lemiale V, Mourvillier B, Carli P, Varenne O, Mira JP, Wolff M, Cariou A. Early-Onset Pneumonia after Cardiac Arrest. Am J Respir Crit Care Med 2011; 184:1048-54. [DOI: 10.1164/rccm.201102-0331oc] [Citation(s) in RCA: 169] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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