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Treatment and Prognosis After Hypoxic-Ischemic Injury. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00682-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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202
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You YH, In YN, Park JS, Yoo I, Kim SW, Lee J, Ryu S, Min JH, Jeong WJ, Cho YC, Oh SK, Ahn HJ, Kang CS, Lee BK, Lee DH, Lee DH, Yu GG. Relationships between serum levels of lactate dehydrogenase and neurological outcomes of patients who underwent targeted temperature management after out-of-hospital cardiac arrest. Medicine (Baltimore) 2021; 100:e26260. [PMID: 34128855 PMCID: PMC8213304 DOI: 10.1097/md.0000000000026260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/20/2021] [Indexed: 01/04/2023] Open
Abstract
This study aimed to evaluate times for measuring serum lactate dehydrogenase levels (SLLs) to predict neurological prognosis among out-of-hospital cardiac arrest (OHCA) survivors.This retrospective study examined patients who experienced OHCA treated with targeted temperature management (TTM). The SLLs were evaluated at the return of spontaneous circulation (ROSC) and at 24, 48, and 72 hours later. Neurological outcomes after 3 months were evaluated for relationships with the SLL measurement times.A total of 95 comatose patients with OHCA were treated using TTM. Seventy three patients were considered eligible, including 31 patients (42%) who experienced good neurological outcomes. There were significant differences between the good and poor outcome groups at most time points (P < .001), except for ROSC (P = .06). The ROSC measurement had a lower area under the receiver operating characteristic curve (AUC: 0.631, 95% confidence interval [CI]: 0.502-0.761) than at 48 hours (AUC: 0.830, 95% CI: 0.736-0.924), at 24 hours (AUC: 0.786, 95% CI: 0.681-0.892), and at 72 hours (AUC: 0.821, 95% CI: 0.724-0.919).A higher SLL seemingly predicted poor neurological outcomes, with good prognostic values at 48 hours and 72 hours. Prospective studies should be conducted to confirm these results.
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Affiliation(s)
- Yeon Ho You
- Department of Emergency Medicine, Chungnam National University Hospital
| | - Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Jung-gu, Daejeon
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, Sejong
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Jung-gu, Daejeon
| | - Insool Yoo
- Department of Emergency Medicine, Chungnam National University Hospital
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Jung-gu, Daejeon
| | - Seung Whan Kim
- Department of Emergency Medicine, Chungnam National University Hospital
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Jung-gu, Daejeon
| | - Jinwoong Lee
- Department of Emergency Medicine, Chungnam National University Hospital
| | - Seung Ryu
- Department of Emergency Medicine, Chungnam National University Hospital
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Jung-gu, Daejeon
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, Sejong
| | - Won Joon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital
| | - Yong Chul Cho
- Department of Emergency Medicine, Chungnam National University Hospital
| | - Se Kwang Oh
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Jung-gu, Daejeon
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, Sejong
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Jung-gu, Daejeon
| | - Chang Shin Kang
- Department of Emergency Medicine, Chungnam National University Hospital
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University School of Medicine
- Department of Emergency Medicine, Chonnam National University Hospital, Dong-gu, Gwangju
| | - Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Dong-gu, Gwangju
| | - Dong Hoon Lee
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Dongjak-gu, Seoul
| | - Gyeong Gyu Yu
- Department of Emergency Medical Service, Seojeong University, Eunhyeon-myeon, Yangju-si, Gyeonggi-do, Republic of Korea
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203
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Qafiti FN, Rubay D, Shin R, Lottenberg L, Borrego R. Therapeutic Hypothermia With Progesterone Improves Neurologic Outcomes in Ventricular Fibrillation Cardiac Arrest After Electric Shock. Cureus 2021; 13:e15749. [PMID: 34290928 PMCID: PMC8289402 DOI: 10.7759/cureus.15749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2021] [Indexed: 11/24/2022] Open
Abstract
Trauma by electricity imposes mechanical, electrical, and thermal forces on the human body. Often, the delicate cardiac electrophysiology is disrupted causing dysrhythmia and subsequent cardiac arrest. Anoxic brain injury (ABI) is the most severe consequence and the main cause of mortality following cardiac arrest. Establishing a working protocol to treat patients who are at risk for ABI after suffering a cardiac arrest is of paramount importance. There has yet to be sufficient exploration of combination therapy of therapeutic hypothermia (TH) and progesterone as a neuroprotective strategy in patients who have suffered cardiac arrest after electric shock. The protocol required TH initiation upon transfer to the ICU with a target core body temperature of 33°C for 18 hours. This was achieved through a combination of cooling blankets, ice packs, chilled IV fluids, nasogastric lavage with iced saline, and intravascular cooling devices. Progesterone therapy at 80-100 mg intramuscularly every 12 hours for 72 hours was initiated shortly after admission to the ICU. We present a case series of three patients (mean age = 29.3 years, mean presenting Glasgow Coma Score = 3) who suffered ventricular fibrillation (VF) cardiac arrest from non-lightning electric shock, and who had considerably improved outcomes following the TH-progesterone combination therapy protocol. The average length of stay was 13.7 days. The cases presented suggest that there may be a role for neuroprotective combination therapy in post-resuscitation care of VF cardiac arrest. While TH is well documented as a neuroprotective measure, progesterone administration is a safe therapy with promising, albeit currently inconclusive, neuroprotective effect. Future protocols involving TH and progesterone combination therapy in these patients should be further explored.
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Affiliation(s)
- Fred N Qafiti
- General Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - David Rubay
- Trauma and Surgical Critical Care, University of Florida College of Medicine, Gainesville, USA
| | - Rebecca Shin
- Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - Lawrence Lottenberg
- Surgery, St. Mary's Medical Center, Florida Atlantic University, West Palm Beach, USA
| | - Robert Borrego
- Surgery, St. Mary's Medical Center, West Palm Beach, USA
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204
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Hou J, Zeng C, Zheng G, Liang L, Jiang L, Yang Z. LncRNAs Participate in Post-Resuscitation Myocardial Dysfunction Through the PI3K/Akt Signaling Pathway in a Rat Model of Cardiac Arrest and Cardiopulmonary Resuscitation. Front Physiol 2021; 12:689531. [PMID: 34194340 PMCID: PMC8238007 DOI: 10.3389/fphys.2021.689531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/10/2021] [Indexed: 12/18/2022] Open
Abstract
In this study, we aimed to explore the role of lncRNAs in post-resuscitation myocardial dysfunction in a rat model of CA-CPR. A rat model of CA-CPR was constructed using a VF method. Myocardial functions, including cardiac output (CO), ejection fraction (EF), and myocardial performance index (MPI), were evaluated at the baseline, and 1, 2, 3, 4, and 6 h after resuscitation. A high throughput sequencing method was used to screen the differentially expressed lncRNAs, miRNAs, and mRNAs, which were further analyzed with bioinformatics. In addition, relationships between the molecules involved in the PI3K/Akt signaling pathway were explored with ceRNA network. Compared with the sham group, EF was significantly reduced and MPI was increased at the five consecutive time points in the CA-CPR group. 68 lncRNAs were upregulated and 40 lncRNAs were downregulated in the CA-CPR group, while 30 miRNAs were downregulated and 19 miRNAs were upregulated. Moreover, mRNAs were also differentially expressed, with 676 upregulated and 588 downregulated. GO analysis suggested that genes associated with cell proliferation, cell death and programmed cell death were significantly enriched. KEGG analysis showed that the PI3K/Akt, MAPK and Ras signaling pathways were the three most-enriched pathways. Construction of a ceRNA regulatory network indicated that LOC102549506, LOC103689920, and LOC103690137 might play important roles in the regulation of the PI3K/Akt signaling pathway in the CA-CPR treated rat. Taken together, LncRNAs, including LOC102549506, LOC103689920 and LOC103690137, might participate in post-resuscitation myocardial dysfunction by functioning as ceRNAs and regulating the PI3K/Akt signaling pathway.
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Affiliation(s)
- Jingying Hou
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chaotao Zeng
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Guanghui Zheng
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lian Liang
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Longyuan Jiang
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhengfei Yang
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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205
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Zhang Z, Wang L, Liu Y, Luan Y, Zhu K, Tian Y, Liu Y, Zheng X. Activation of type 4 metabotropic glutamate receptor attenuates oxygen and glucose deprivation-induced apoptosis in human neural stem cells via inhibition of ASK1-p38 signaling pathway. Brain Res 2021; 1767:147561. [PMID: 34133989 DOI: 10.1016/j.brainres.2021.147561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/19/2021] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Abstract
Hypoxic ischemic brain injury (HIBI) has been one of the most severe central nervous system (CNS) diseases with high fatality and disability rate. Neural stem cells (NSCs) persist in the mammalian brain throughout life and NSCs-associated therapies might be a promising strategy for the HIBI treatment. In this study, we identified that type 4 metabotropic glutamate receptor (mGluR4) was expressed in cultured human NSCs (hNSCs) isolated from the human fetus cortex and further established the oxygen and glucose deprivation (OGD) model in hNSCs to study the role of mGluR4 in hypoxic and ischemic injury. The results indicated that mGluR4 activation by using VU0155041 (mGluR4-specific agonist) markedly attenuated the OGD-induced alterations in TUNEL staining, apoptosis rate, cleavages of pro-caspase-8, -9, -3, and Bcl-2/Bax expression balance. Furthermore, mGluR4 activation inhibited the ASK1/p38 signaling pathway. Asiatic acid, as a p38 MAPK activator, is capable of abolishing the neuroprotective effect of mGluR4, while both NQDI-1 (ASK-1 inhibitor) and SB203580 (p38 MAPK inhibitor) exerted similar effects to VU0155041 in the OGD-induced hNSC damage. In conclusion, this study indicates that mGluR4 activation protects hNSCs against the OGD-induced cell death via inhibiting the ASK1-p38 pathway. Activation of mGluR4 might be a promising strategy for enhancing NSCs survival in hypoxic and ischemic injury.
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Affiliation(s)
- Zhe Zhang
- Department of Stomatology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China; Institute of Neurobiology, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi 710061, China
| | - Li Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi 710077, China
| | - Yingfei Liu
- Institute of Neurobiology, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi 710061, China
| | - Yan Luan
- Institute of Neurobiology, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi 710061, China
| | - Kun Zhu
- Department of Neurology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710061, China
| | - Yumei Tian
- Department of Rehabilitation, Xi'an Mental Health Center, Xi'an, Shaanxi 710061, China
| | - Yong Liu
- Institute of Neurobiology, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi 710061, China.
| | - Xiaoyan Zheng
- Department of Hematology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China.
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206
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Chaban V, Nakstad ER, Stær-Jensen H, Schjalm C, Seljeflot I, Vaage J, Lundqvist C, Benth JŠ, Sunde K, Mollnes TE, Andersen GØ, Pischke SE. Complement activation is associated with poor outcome after out-of-hospital cardiac arrest. Resuscitation 2021; 166:129-136. [PMID: 34126135 DOI: 10.1016/j.resuscitation.2021.05.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/04/2021] [Accepted: 05/30/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Cardiopulmonary resuscitation after cardiac arrest initiates a whole-body ischemia-reperfusion injury, which may activate the innate immune system, including the complement system. We hypothesized that complement activation and subsequent release of soluble endothelial activation markers were associated with cerebral outcome including death. METHODS Outcome was assessed at six months and defined by cerebral performance category scale (1-2; good outcome, 3-5; poor outcome including death) in 232 resuscitated out-of-hospital cardiac arrest patients. Plasma samples obtained at admission and day three were analysed for complement activation products C3bc, the soluble terminal complement complex (sC5b-9), and soluble CD14. Endothelial cell activation was measured by soluble markers syndecan-1, sE-selectin, thrombomodulin, and vascular cell adhesion molecule. RESULTS Forty-nine percent of the patients had good outcome. C3bc and sC5b-9 were significantly higher at admission compared to day three (p < 0.001 for both) and in patients with poor compared to good outcome (p = 0.03 and p < 0.001, respectively). Unadjusted, higher sC5b-9 at admission was associated with poor outcome (odds ratio 1.08 (95% CI 1.01-1.14), p = 0.024). Adjusted, sC5b-9 was still associated with outcome, but the association became non-significant when time to return-of-spontaneous-circulation above 25 min was included as a covariate. Endothelial cell activation markers increased from admission to day three, but only sE-selectin and thrombomodulin were significantly higher in patients with poor versus good outcome (p = 0.004 and p = 0.03, respectively) and correlated to sCD14 and sC5b-9/C3bc, respectively. CONCLUSION Complement system activation, reflected by sC5b-9 at admission, leading to subsequent endothelial cell activation, was associated with poor outcome in out-of-hospital cardiac arrest patients.
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Affiliation(s)
- Viktoriia Chaban
- Dept. of Immunology, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Espen R Nakstad
- Dept. of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - Henrik Stær-Jensen
- Dept. of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Camilla Schjalm
- Dept. of Immunology, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Ingebjørg Seljeflot
- Dept. of Cardiology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jarle Vaage
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Dept. of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Section of Physiology, Dept. of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Christofer Lundqvist
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Dept. of Neurology, Akershus University Hospital, Oslo, Norway; Health Services Research Unit, Akershus University Hospital, Oslo, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Health Services Research Unit, Akershus University Hospital, Oslo, Norway
| | - Kjetil Sunde
- Dept. of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tom Eirik Mollnes
- Dept. of Immunology, University of Oslo and Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Research Laboratory, Nordland Hospital Bodø, and K.G. Jebsen TREC, University of Tromsø, Norway; Centre of Molecular Inflammation Research, Department of Clinical and Molecular Research, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Søren Erik Pischke
- Dept. of Immunology, University of Oslo and Oslo University Hospital, Oslo, Norway; Dept. of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Dept. of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.
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207
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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208
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Albrecht M, de Jonge RCJ, Nadkarni VM, de Hoog M, Hunfeld M, Kammeraad JAE, Moors XRJ, van Zellem L, Buysse CMP. Association between shockable rhythms and long-term outcome after pediatric out-of-hospital cardiac arrest in Rotterdam, the Netherlands: An 18-year observational study. Resuscitation 2021; 166:110-120. [PMID: 34082030 DOI: 10.1016/j.resuscitation.2021.05.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/06/2021] [Accepted: 05/23/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Shockable rhythm following pediatric out-of-hospital cardiac arrest (pOHCA) is consistently associated with hospital and short-term survival. Little is known about the relationship between shockable rhythm and long-term outcomes (>1 year) after pOHCA. The aim was to investigate the association between first documented rhythm and long-term outcomes in a pOHCA cohort over 18 years. METHODS All children aged 1 day-18 years who experienced non-traumatic pOHCA between 2002-2019 and were subsequently admitted to the emergency department (ED) or pediatric intensive care unit (PICU) of Erasmus MC-Sophia Children's Hospital were included. Data was abstracted retrospectively from patient files, (ground) ambulance and Helicopter Emergency Medical Service (HEMS) records, and follow-up clinics. Long-term outcome was determined using a Pediatric Cerebral Performance Category (PCPC) score at the longest available follow-up interval through august 2020. The primary outcome measure was survival with favorable neurologic outcome, defined as PCPC 1-2 or no difference between pre- and post-arrest PCPC. The association between first documented rhythm and the primary outcome was calculated in a multivariable regression model. RESULTS 369 children were admitted, nine children were lost to follow-up. Median age at arrest was age 3.4 (IQR 0.8-9.9) years, 63% were male and 14% had a shockable rhythm (66% non-shockable, 20% unknown or return of spontaneous circulation (ROSC) before emergency medical service (EMS) arrival). In adolescents (aged 12-18 years), 39% had shockable rhythm. 142 (39%) of children survived to hospital discharge. On median follow-up interval of 25 months (IQR 5.1-49.6), 115/142 (81%) of hospital survivors had favorable neurologic outcome. In multivariable analysis, shockable rhythm was associated with survival with favorable long-term neurologic outcome (OR 8.9 [95%CI 3.1-25.9]). CONCLUSION In children with pOHCA admitted to ED or PICU shockable rhythm had significantly higher odds of survival with long-term favorable neurologic outcome compared to non-shockable rhythm. Survival to hospital discharge after pOHCA was 39% over the 18-year study period. Of survivors to discharge, 81% had favorable long-term (median 25 months, IQR 5.1-49.6) neurologic outcome. Efforts for improving outcome of pOHCA should focus on early recognition and treatment of shockable pOHCA at scene.
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Affiliation(s)
- M Albrecht
- Pediatric Intensive Care Unit, Department of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - R C J de Jonge
- Pediatric Intensive Care Unit, Department of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - V M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - M de Hoog
- Pediatric Intensive Care Unit, Department of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - M Hunfeld
- Pediatric Intensive Care Unit, Department of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands; Department of Pediatric Neurology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - J A E Kammeraad
- Department of Pediatric Cardiology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - X R J Moors
- Department of Pediatric Anesthesiology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands; Helicopter Emergency Medical Services, Erasmus MC, Rotterdam, The Netherlands
| | - L van Zellem
- Department of Youth Health Care, Public Health Service (GGD), Amsterdam, The Netherlands
| | - C M P Buysse
- Pediatric Intensive Care Unit, Department of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.
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209
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Presciutti A, Shaffer J, Sumner JA, Elkind MSV, Roh DJ, Park S, Claassen J, Edmondson D, Agarwal S. Hyperarousal Symptoms in Survivors of Cardiac Arrest Are Associated With 13 Month Risk of Major Adverse Cardiovascular Events and All-Cause Mortality. Ann Behav Med 2021; 54:413-422. [PMID: 32043140 DOI: 10.1093/abm/kaz058] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Key dimensions of cardiac arrest-induced posttraumatic stress disorder (PTSD) symptoms include reexperiencing, avoidance, numbing, and hyperarousal. It remains unknown which dimensions are most predictive of outcome. PURPOSE To determine which dimensions of cardiac arrest-induced PTSD are predictive of clinical outcome within 13 months posthospital discharge. METHODS PTSD symptoms were assessed in survivors of cardiac arrest who were able to complete psychological screening measures at hospital discharge via the PTSD Checklist-Specific scale, which queries for 17 symptoms using five levels of severity. Responses on items for each symptom dimension of the four-factor numbing model (reexperiencing, avoidance, numbing, and hyperarousal) were converted to Z-scores and treated as continuous predictors. The combined primary endpoint was all-cause mortality (ACM) or major adverse cardiovascular events (MACE; hospitalization for myocardial infarction, unstable angina, heart failure, emergency coronary revascularization, or urgent defibrillator/pacemaker placements) within 13 months postdischarge. Four bivariate Cox proportional hazards survival models evaluated associations between individual symptom dimensions and ACM/MACE. A multivariable model then evaluated whether significant bivariate predictors remained independent predictors of the primary outcome after adjusting for age, sex, comorbidities, premorbid psychiatric diagnoses, and initial cardiac rhythm. RESULTS A total of 114 patients (59.6% men, 52.6% white, mean age: 54.6 ± 13 years) were included. In bivariate analyses, only hyperarousal was significantly associated with ACM/MACE. In a fully adjusted model, 1 standard deviation increase in hyperarousal symptoms corresponded to a two-times increased risk of experiencing ACM/MACE. CONCLUSIONS Greater level of hyperarousal symptoms was associated with a higher risk of ACM/MACE within 13 months postcardiac arrest. This initial evidence should be further investigated in a larger sample.
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Affiliation(s)
- Alex Presciutti
- Department of Psychology, University of Colorado Denver, Denver, CO, USA
| | - Jonathan Shaffer
- Department of Psychology, University of Colorado Denver, Denver, CO, USA
| | - Jennifer A Sumner
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.,Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - David J Roh
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Soojin Park
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Donald Edmondson
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
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210
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Levy LE, Kaczorowski DJ, Pasrija C, Boyajian G, Mazzeffi M, Krause E, Shah A, Madathil R, Deatrick KB, Herr D, Griffith BP, Gammie JS, Taylor BS, Ghoreishi M. Peripheral cannulation for extracorporeal membrane oxygenation yields superior neurologic outcomes in adult patients who experienced cardiac arrest following cardiac surgery. Perfusion 2021; 37:745-751. [PMID: 33998349 DOI: 10.1177/02676591211018129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest has improved mortality in post-cardiac surgery patients; however, loss of neurologic function remains one of the main and devastating complications. We reviewed our experience with ECPR and investigated the effect of cannulation strategy on neurologic outcome in adult patients who experienced cardiac arrest following cardiac surgery that was managed with ECPR. METHODS Patients were categorized by central versus percutaneous peripheral VA-extracorporeal membrane oxygenation (ECMO) cannulation strategy. We reviewed patient records and evaluated in-hospital mortality, cause of death, and neurologic status 72 hours after cannulation. RESULTS From January 2010 to September 2019, 44 patients underwent post-cardiac surgery ECPR for cardiac arrest. Twenty-six patients received central cannulation; 18 patients received peripheral cannulation. Mean post-operative day of the cardiac arrest was 3 and 9 days (p = 0.006), and mean time between initiation of CPR and ECMO was 40 ± 24 and 28 ± 22 minutes for central and peripheral cannulation, respectively. After 72 hours of VA-ECMO support, 30% of centrally cannulated patients versus 72% of peripherally cannulated patients attained cerebral performance status 1-2 (p = 0.01). Anoxic brain injury was the cause of death in 26.9% of centrally cannulated and 11.1% of peripherally cannulated patients. Survival to discharge was 31% and 39% for central and peripheral cannulation, respectively. CONCLUSIONS Peripheral VA-ECMO allows for continuous CPR and systemic perfusion while obtaining vascular access. Compared to central cannulation, a peripheral cannulation strategy is associated with improved neurologic outcomes and decreased likelihood of anoxic brain death.
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Affiliation(s)
- Lauren E Levy
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David J Kaczorowski
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Chetan Pasrija
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gregory Boyajian
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eric Krause
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Aakash Shah
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ronson Madathil
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristopher B Deatrick
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel Herr
- Department of Shock Trauma Critical Care, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bartley P Griffith
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - James S Gammie
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bradley S Taylor
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mehrdad Ghoreishi
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Lourbopoulos A, Mourouzis I, Xinaris C, Zerva N, Filippakis K, Pavlopoulos A, Pantos C. Translational Block in Stroke: A Constructive and "Out-of-the-Box" Reappraisal. Front Neurosci 2021; 15:652403. [PMID: 34054413 PMCID: PMC8160233 DOI: 10.3389/fnins.2021.652403] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/06/2021] [Indexed: 12/13/2022] Open
Abstract
Why can we still not translate preclinical research to clinical treatments for acute strokes? Despite > 1000 successful preclinical studies, drugs, and concepts for acute stroke, only two have reached clinical translation. This is the translational block. Yet, we continue to routinely model strokes using almost the same concepts we have used for over 30 years. Methodological improvements and criteria from the last decade have shed some light but have not solved the problem. In this conceptual analysis, we review the current status and reappraise it by thinking "out-of-the-box" and over the edges. As such, we query why other scientific fields have also faced the same translational failures, to find common denominators. In parallel, we query how migraine, multiple sclerosis, and hypothermia in hypoxic encephalopathy have achieved significant translation successes. Should we view ischemic stroke as a "chronic, relapsing, vascular" disease, then secondary prevention strategies are also a successful translation. Finally, based on the lessons learned, we propose how stroke should be modeled, and how preclinical and clinical scientists, editors, grant reviewers, and industry should reconsider their routine way of conducting research. Translational success for stroke treatments may eventually require a bold change with solutions that are outside of the box.
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Affiliation(s)
- Athanasios Lourbopoulos
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurointensive Care Unit, Schoen Klinik Bad Aibling, Bad Aibling, Germany
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig Maximilian University, Munich, Germany
| | - Iordanis Mourouzis
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Christodoulos Xinaris
- IRCCS – Istituto di Ricerche Farmacologiche ‘Mario Negri’, Centro Anna Maria Astori, Bergamo, Italy
- University of Nicosia Medical School, Nicosia, Cyprus
| | - Nefeli Zerva
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Filippakis
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Angelos Pavlopoulos
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Pantos
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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212
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Badenes R, Bogossian EG, Chisbert V, Robba C, Oddo M, Taccone FS, Matta BF. The role of non-invasive brain oximetry in adult critically ill patients without primary brain injury. Minerva Anestesiol 2021; 87:1226-1238. [PMID: 33938677 DOI: 10.23736/s0375-9393.21.15333-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A primary objective in intensive care and perioperative settings is to promote an adequate supply and delivery of oxygen to tissues and organs, particularly to the brain. Cerebral near infrared spectroscopy (NIRS) is a non-invasive, continuous monitoring technique, that can be used to assess cerebral oxygenation. Using NIRS to monitor cerebral oximetry is not new, and has been in widespread use in neonates and cardiac surgery for decades. In addition, it has become common to see NIRS being used in adult and pediatric cardiac surgery, acute neurological diseases, neurosurgical procedures, vascular surgery, severe trauma and other acute medical diseases. Furthermore, recent evidence suggests a role for NIRS in the perioperative settings; detecting and preventing episodes of cerebral desaturation aiming to reduce the development of post-operative delirium. NIRS is not without its limitations; these include the risk of extra-cranial contamination, spatial limitations and skin blood flow/volume changes, as well being a measure of localized blood oxygenation underneath the sensor. However, NIRS is a non-invasive technique and can, therefore, be used in those patients without indications or justification for invasive brain monitoring; non-neurosurgical procedures such as liver transplantation, major orthopedic surgery and critically illness where the brain is at risk. The aim of this manuscript was to discuss the physical principles of NIRS and to report the current evidence regarding its use in critically ill patients without primary non-anoxic brain injury.
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Affiliation(s)
- Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain - .,Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain - .,INCLIVA Health Research Institute, Valencia, Spain -
| | - Elisa G Bogossian
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Vicente Chisbert
- INCLIVA Health Research Institute, Valencia, Spain.,Escuela de Doctorado, Universidad Católica de Valencia, Valencia, Spain
| | - Chiara Robba
- Anaesthesia and Intensive Care, IRCSS S. Martino Hospital, Genoa, Italy
| | - Mauro Oddo
- Department of Intensive Care Medicine, Faculty of Biology and Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital, Lausanne, Switzerland
| | - Fabio S Taccone
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Basil F Matta
- Trauma and NeuroCritical Care Unit, Cambridge University Hospital, Cambridge, UK
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213
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Cerebrovascular pressure reactivity and intracranial pressure are associated with neurologic outcome after hypoxic-ischemic brain injury. Resuscitation 2021; 164:114-121. [PMID: 33930501 DOI: 10.1016/j.resuscitation.2021.04.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 04/09/2021] [Accepted: 04/20/2021] [Indexed: 11/21/2022]
Abstract
AIM We evaluated the association of physiological parameters measured by intracranial multimodality neuromonitoring with neurologic outcome in a consecutive series of patients with hypoxic-ischemic brain injury (HIBI). METHODS We retrospectively identified all patients with HIBI who underwent combined invasive intracranial pressure (ICP) and brain tissue oxygen (PbtO2) monitoring over a 3 year period. Cerebrovascular pressure reactivity index (PRx) was calculated continuously as a surrogate of cerebral autoregulation. Favorable outcome was defined as recovery of consciousness (Glasgow Coma Scale motor score = 6). Differences in mean ICP, PRx and PbtO2 for the entire monitoring period across outcomes were measured. Logistic regression and area under receiver operating characteristic (AUROC) curve were used to assess the association of each monitoring parameter with neurologic outcome. RESULTS We analyzed data from 36 patients. Most (89%) had an antecedent sudden cardiac arrest. Favorable outcome occurred in 8 (22%) patients. ICP and PRx were higher in patients with unfavorable outcome (ICP: 26 ± 4.1 mmHg vs 7.5 ± 2 mmHg, p = 0.0002; PRx: 0.51 ± 0.05 vs 0.11 ± 0.05, p < 0.0001). There was no significant difference in PbtO2 between groups (unfavorable: 20 ± 2.4 mmHg vs favorable: 25 ± 1.5 mmHg, p = 0.12). Both ICP (AUROC 0.84, 95%CI 0.72-0.98, p = 0.003) and PRx (AUROC 0.94, 95%CI 0.85-1, p = 0.0002) discriminated between favorable and unfavorable outcome, in contrast to PbtO2, (AUROC 0.59, 95%CI 0.39-0.78, p = 0.52). ICP > 15 mmHg, PRx > 0.2, and PbtO2 < 18 mmHg had sensitivity/specificity of 68%/100%, 89%/88%, and 40%/100% respectively for discriminating outcomes. CONCLUSION Cerebrovascular pressure reactivity and intracranial pressure appear to be associated with neurologic outcome in patients with HIBI.
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Hansen ML, Hyttel-Sørensen S, Jakobsen JC, Gluud C, Kooi EMW, Mintzer J, de Boode WP, Fumagalli M, Alarcon A, Alderliesten T, Greisen G. The clinical effects of cerebral near-infrared spectroscopy monitoring (NIRS) versus no monitoring: a protocol for a systematic review with meta-analysis and trial sequential analysis. Syst Rev 2021; 10:111. [PMID: 33863369 PMCID: PMC8052775 DOI: 10.1186/s13643-021-01660-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 04/01/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Multiple clinical conditions are associated with cerebral hypoxia/ischaemia and thereby an increased risk of hypoxic-ischaemic brain injury. Cerebral near-infrared spectroscopy monitoring (NIRS) is a tool to monitor brain oxygenation and perfusion, and the clinical uptake of NIRS has expanded over recent years. Specifically, NIRS is used in the neonatal, paediatric, and adult perioperative and intensive care settings. However, the available literature suggests that clinical benefits and harms of cerebral NIRS monitoring are uncertain. As rates of clinically significant hypoxic-ischaemic brain injuries are typically low, it is difficult for randomised clinical trials to capture a sufficiently large number of events to evaluate the clinical effect of cerebral NIRS monitoring, when focusing on specific clinical settings. The aim of this systematic review will be to evaluate the benefits and harms of clinical care with access to cerebral NIRS monitoring versus clinical care without cerebral NIRS monitoring in children and adults across all clinical settings. METHODS We will conduct a systematic review with meta-analysis and trial sequential analysis. We will only include randomised clinical trials. The primary outcomes are all-cause mortality, moderate or severe persistent cognitive or neurological deficit, and proportion of participants with one or more serious adverse events. We will search CENTRAL, EMBASE, MEDLINE, and the Science Citation Index Expanded from their inception and onwards. Two reviewers will independently screen all citations, full-text articles, and extract data. The risk of bias will be appraised using the Cochrane risk of bias tool version 2.0. If feasible, we will conduct both random-effects meta-analysis and fixed-effect meta-analysis of outcome data. Additional analysis will be conducted to explore the potential sources of heterogeneity (e.g. risk of bias, clinical setting). DISCUSSION As we include trials across multiple clinical settings, there is an increased probability of reaching a sufficient information size. However, heterogeneity between the included trials may impair our ability to interpret results to specific clinical settings. In this situation, we may have to depend on subgroup analyses with inherent increased risks of type I and II errors. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020202986 . This systematic review protocol has been submitted for registration in the International Prospective Register of Systematic Reviews (PROSPERO) (http://www.crd.york.ac.uk/prospero) on the 12th of October 2020 and published on the 12th of November 2020 (registration ID CRD42020202986 ).
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Affiliation(s)
- Mathias Lühr Hansen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Simon Hyttel-Sørensen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, The Capital Region of Denmark, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, The Capital Region of Denmark, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Elisabeth M W Kooi
- Division of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jonathan Mintzer
- Department of Pediatrics, Division of Newborn Medicine, Mountainside Medical Center, Montclair, NJ, USA
| | - Willem P de Boode
- Division of Neonatology, Department of Pediatrics, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, Netherlands
| | - Monica Fumagalli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Via Francesc Sforza 35, 20122, Milano, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milano, Italy
| | - Ana Alarcon
- Department of Neonatology, Hospital Sant Joan de Deu, Passeig de Sant Joan de Deu 2, 08950 Esplugues de Llobregat, Barcelona, Spain
| | - Thomas Alderliesten
- Department of Neonatology, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, Netherlands
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
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215
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Kang C, Jeong W, Park JS, You Y, Min JH, Cho YC, Ahn HJ. Comparison of Prognostic Performance between Neuron-Specific Enolase and S100 Calcium-Binding Protein B Obtained from the Cerebrospinal Fluid of Out-of-Hospital Cardiac Arrest Survivors Who Underwent Targeted Temperature Management. J Clin Med 2021; 10:jcm10071531. [PMID: 33917473 PMCID: PMC8038742 DOI: 10.3390/jcm10071531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/27/2021] [Accepted: 04/05/2021] [Indexed: 12/11/2022] Open
Abstract
We compared the prognostic performances of serum neuron-specific enolase (sNSE), cerebrospinal fluid (CSF) NSE (cNSE), and CSF S100 calcium-binding protein B (cS100B) in out-of-hospital cardiac arrest (OHCA) survivors. This prospective observational study enrolled 45 patients. All samples were obtained immediately and at 24 h intervals until 72 h after the return of spontaneous circulation. The inter- and intragroup differences in biomarker levels, categorized by 3 month neurological outcome, were analyzed. The prognostic performances were evaluated with receiver operating characteristic curves. Twenty-two patients (48.9%) showed poor outcome. At all-time points, sNSE, cNSE, and cS100B were significantly higher in the poor outcome group than in the good outcome group. cNSE and cS100B significantly increased over time (baseline vs. 24, 48, and 72 h) in the poor outcome group than in the good outcome group. sNSE at 24, 48, and 72 h showed significantly lower sensitivity than cNSE or cS100B. The sensitivities associated with 0 false-positive rate (FPR) for cNSE and cS100B were 66.6% vs. 45.5% at baseline, 80.0% vs. 80.0% at 24 h, 84.2% vs. 94.7% at 48 h, and 88.2% (FPR, 5.0%) vs. 94.1% at 72 h. High cNSE and cS100B are strong predictors of poor neurological outcome in OHCA survivors. Multicenter prospective studies may determine the generalizability of these results.
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Affiliation(s)
- Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon 35015, Korea;
- Correspondence: ; Tel.: +82-42-280-6002
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon 35015, Korea;
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong 30099, Korea
| | - Yong Chul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon 35015, Korea;
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216
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Kumar KM. ECPR-extracorporeal cardiopulmonary resuscitation. Indian J Thorac Cardiovasc Surg 2021; 37:294-302. [PMID: 33432257 PMCID: PMC7787697 DOI: 10.1007/s12055-020-01072-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/27/2020] [Accepted: 09/29/2020] [Indexed: 11/25/2022] Open
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is a salvage procedure in which extracorporeal membrane oxygenation (ECMO) is initiated emergently on patients who have had cardiac arrest (CA) and on whom the conventional cardiopulmonary resuscitation (CCPR) has failed. Awareness and usage of ECPR are increasing all over the world. Significant advancements have taken place in the ECPR initiation techniques, in its device and in its post-procedure care. ECPR is a team work requiring multidisciplinary experts, highly skilled health care workers and adequate infrastructure with appropriate devices. Perfect coordination and communication among team members play a vital role in the outcome of the ECPR patients. Ethical, legal and financial issues need to be considered before initiation of ECPR and while withdrawing the support when the ECPR is futile. Numerous studies about ECPR are being published more frequently in the last few years. Hence, keeping updated about the ECPR is very important for proper selection of cases and its management. This article reviews various aspects of ECPR and relevant literature to date.
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Affiliation(s)
- Kuppuswamy Madhan Kumar
- Heart and Lung Transplant Centre, Heart Institute, Apollo Hospitals, Ground floor, Main Block 21, Greams Lane off, Greams Road, Chennai, 600006 India
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217
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Salamah A, Mehrez M, Faheem A, El Amrousy D. Efficacy of Citicoline as a Neuroprotector in children with post cardiac arrest: a randomized controlled clinical trial. Eur J Pediatr 2021; 180:1249-1255. [PMID: 33169240 DOI: 10.1007/s00431-020-03871-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/30/2020] [Accepted: 11/04/2020] [Indexed: 02/08/2023]
Abstract
Brain hypoxia after cardiac arrest leads to damage of the neuronal cell membrane. Citicoline is necessary for the synthesis of cell membrane. We planned to assess the neuroprotective effect of citicoline in children after cardiac arrest. This randomized controlled trial was carried out at pediatric intensive care units (PICU) and surgical ICU at Tanta university hospital on 80 consecutive children surviving in-hospital cardiac arrest who were subdivided into two groups. Group I (citicoline group) included 40 children with post-cardiac arrest who received citicoline 10 mg /kg /12 h IV for 6 weeks plus other supportive measures and group II (control group) included 40 children with post-cardiac arrest who were managed with only supportive measures. All patients were evaluated for Glasgow coma score (GCS), modified Rankin scale (mRS) for children, seizures frequency, type and duration, and serum neuron-specific enolase (NSE) before and 3 months after the treatment. GCS and mRS significantly improved in citicholine group compared to the control group. Seizure frequency and duration, mortality, PICU and hospital stay significantly decreased in citicholine group compared to the control group. Serum NSE levels significantly decreased in citicholine group only. No side effects were recorded.Conclusion: Citicoline is a promising neuroprotective drug in children with post-cardiac arrest.Trial Registration: The study was registered at Pan African Clinical Trials Registry (PACTR) www.pactr.samrc.ac.za with trial number PACTR201907742119058. What is known? • Post-resuscitation brain injury is one of the major complications that can lead to death or disability. • CDP-choline has been studied for acute ischemic stroke in several adult studies because of its reparative effect. What is new? • Our study was the first in pediatrics that assessed the neuroprotective effect of CDP-choline on the brain in children after cardiac arrest. • We found that Citicoline is a promising neuroprotective drug in children with post-cardiac arrest.
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Affiliation(s)
- Abeer Salamah
- Pediatric Department, Kafr Elsheikh University, Kafr Elsheikh, Egypt
| | | | - Amany Faheem
- Anesthesiology and Surgical ICU Department, Tanta University, Tanta, Egypt
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218
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 468] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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219
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Neuromonitoring After Cardiac Arrest: Can Twenty-First Century Medicine Personalize Post Cardiac Arrest Care? Neurol Clin 2021; 39:273-292. [PMID: 33896519 DOI: 10.1016/j.ncl.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cardiac arrest survivors comprise a heterogeneous population, in which the etiology of arrest, systemic and neurologic comorbidities, and sequelae of post-cardiac arrest syndrome influence the severity of secondary brain injury. The degree of secondary neurologic injury can be modifiable and is influenced by factors that alter cerebral physiology. Neuromonitoring techniques provide tools for evaluating the evolution of physiologic variables over time. This article reviews the pathophysiology of hypoxic-ischemic brain injury, provides an overview of the neuromonitoring tools available to identify risk profiles for secondary brain injury, and highlights the importance of an individualized approach to post cardiac arrest care.
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220
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 385] [Impact Index Per Article: 128.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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Mandigers L, den Uil CA, Bunge JJH, Gommers D, dos Reis Miranda D. Initial Arterial pCO 2 and Its Course in the First Hours of Extracorporeal Cardiopulmonary Resuscitation Show No Association with Recovery of Consciousness in Humans: A Single-Centre Retrospective Study. MEMBRANES 2021; 11:membranes11030208. [PMID: 33804283 PMCID: PMC8001427 DOI: 10.3390/membranes11030208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/22/2022]
Abstract
Background: Cardiac arrest is a severe condition with high mortality rates, especially in the case of prolonged low-flow durations resulting in severe ischaemia and reperfusion injury. Changes in partial carbon dioxide concentration (pCO2) may aggravate this injury. Extracorporeal cardiopulmonary resuscitation (ECPR) shortens the low-flow duration and enables close regulation of pCO2. We examined whether pCO2 is associated with recovery of consciousness. Methods: We retrospectively analysed ECPR patients ≥ 16 years old treated between 2010 and 2019. We evaluated initial arterial pCO2 and the course of pCO2 ≤ 6 h after initiation of ECPR. The primary outcome was the rate of recovery of consciousness, defined as Glasgow coma scale motor score of six. Results: Out of 99 ECPR patients, 84 patients were eligible for this study. The mean age was 47 years, 63% were male, 93% had a witnessed arrest, 45% had an out-of-hospital cardiac arrest, and 38% had a recovery of consciousness. Neither initial pCO2 (Odds Ratio (OR) 0.93, 95% confidence interval 95% (CI) 0.78–1.08) nor maximum decrease of pCO2 (OR 1.03, 95% CI 0.95–1.13) was associated with the recovery of consciousness. Conclusion: Initial arterial pCO2 and the course of pCO2 in the first six hours after initiation of ECPR were not associated with the recovery of consciousness.
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Affiliation(s)
- Loes Mandigers
- Department of Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands; (C.A.d.U.); (J.J.H.B.); (D.G.)
- Correspondence: (L.M.); (D.d.R.M.); Tel.: +31-010-703-5142 (D.d.R.M.)
| | - Corstiaan A. den Uil
- Department of Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands; (C.A.d.U.); (J.J.H.B.); (D.G.)
- Department of Cardiology, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Jeroen J. H. Bunge
- Department of Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands; (C.A.d.U.); (J.J.H.B.); (D.G.)
- Department of Cardiology, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands; (C.A.d.U.); (J.J.H.B.); (D.G.)
| | - Dinis dos Reis Miranda
- Department of Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands; (C.A.d.U.); (J.J.H.B.); (D.G.)
- Correspondence: (L.M.); (D.d.R.M.); Tel.: +31-010-703-5142 (D.d.R.M.)
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Fuller ZL, Faro JW, Callaway CW, Coppler PJ, Elmer J. Recovery among post-arrest patients with mild-to-moderate cerebral edema. Resuscitation 2021; 162:149-153. [PMID: 33662524 DOI: 10.1016/j.resuscitation.2021.02.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cerebral edema after cardiac arrest may be a modifiable cause of secondary brain injury. We aimed to identify processes of care associated with recovery in a cohort of patients with mild to moderate edema. METHODS We conducted a retrospective cohort study of adults resuscitated from out-of-hospital arrest (OHCA) at a single center from 2010 to 2018. We included those with cerebral edema ranging from mild to moderate (gray to white matter attenuation ratio (GWR) 1.2 to 1.3 on initial brain computerized tomography (CT). We used Pittsburgh Cardiac Arrest Category (PCAC) to adjust for illness severity and considered the following values in the first 24 h of admission as additional predictors: GWR, lab values affecting serum osmolality (sodium, glucose, blood urea nitrogen (BUN)), total osmolality, change in osmolality from 0 to 24 h, cardiac etiology of arrest, targeted temperature to 33 °C (vs 36 °C), time-weighted mean arterial pressure (MAP), partial pressures of arterial oxygen and carbon dioxide and select medications. Our primary outcome was discharge with cerebral performance category 1-3. We used unadjusted and adjusted logistic regression for analysis. RESULTS We included 214 patients for whom CT was performed median 3.8 [IQR 2.4-5.2] hours after collapse. Median age was 57 [IQR 48-67] years, 82 (38%) were female, and 68 (32%) arrested from ventricular tachycardia or fibrillation. In adjusted models, modifiable processes of care were not associated with outcome. CONCLUSIONS Illness severity, but not modifiable processes of care, were associated with recovery among post-arrest patients with mild-to-moderate cerebral edema.
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Affiliation(s)
- Zachary L Fuller
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John W Faro
- University of Cincinnati, Cincinnati College of Medicine, OH, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA.
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Lauridsen MD, Josiassen J, Schmidt M, Butt JH, Østergaard L, Schou M, Kjærgaard J, Møller JE, Hassager C, Torp-Pedersen C, Gislason G, Køber L, Fosbøl EL. Prognosis of myocardial infarction-related cardiogenic shock according to preadmission out-of-hospital cardiac arrest. Resuscitation 2021; 162:135-142. [PMID: 33662522 DOI: 10.1016/j.resuscitation.2021.02.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/03/2021] [Accepted: 02/20/2021] [Indexed: 11/26/2022]
Abstract
AIMS Out-of-hospital cardiac arrest (OHCA) is highly prevalent among patients with myocardial infarction and cardiogenic shock (MI-CS). We aimed to examine the prognostic importance of OHCA in patients with MI-CS. METHODS Using Danish nationwide registries, we identified first-time hospitalized MI-CS patients (2010-2015) by OHCA status. Cumulative incidence curves and adjusted Cox regression models were used to compare in-hospital mortality, and among hospital survivors we compared 5-year rates of heart failure hospitalization and mortality. RESULTS We identified 3107 MI-CS patients of whom 979 presented with OHCA (32%). OHCA patients were younger (median age: 65 vs. 74 years) and had less comorbidity. In-hospital mortality was 57% in those with OHCA compared with 67% in those without, but after adjustment the hazard ratio (HR) was 0.99 [95% CI: 0.87-1.11]. Hospital survivors consisted of 1375 MI-CS patients including 531 OHCA patients (39%). Five-year mortality was 22% for OHCA patients and 42% for patients without OHCA (adjusted HR: 0.90 [95% CI: 0.70-0.1.17]). The HR for five-year cardiovascular mortality was 0.80 [95% CI: 0.62-0.98]. Lastly, 5-year rate of heart failure hospitalization was 17% for patients with OHCA compared with 34% in those without (HR: 0.44 [95% CI: 0.34-0.57]). CONCLUSION Among patients hospitalized with MI-CS, OHCA did not influence all-cause in-hospital or long-term mortality but was a marker for reduced long-term rates of heart failure hospitalization and cardiovascular mortality. Future randomized studies are needed to improve prognosis of MI-CS, however, the importance of OHCA must be considered.
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Affiliation(s)
- Marie D Lauridsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Jakob Josiassen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Lauge Østergaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Hellerup, Denmark
| | - Jesper Kjærgaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jacob E Møller
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Research, Nordsjaellands Hospital, Hillerød and Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Hellerup, Denmark; The Danish Heart Foundation, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Coppler PJ, Elmer J. Mitochondrial resuscitation after cardiac arrest. Resuscitation 2021; 162:433-434. [PMID: 33662525 DOI: 10.1016/j.resuscitation.2021.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA.
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Lyden P, Gupta R, Sekhon M, Badjatia N. Temperature Management in Neurological and Neurosurgical Intensive Care Unit. Ther Hypothermia Temp Manag 2021; 11:7-9. [PMID: 33595371 DOI: 10.1089/ther.2021.29080.pjl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Patrick Lyden
- Department of Neurology, USC Keck School of Medicine, Los Angeles, California, USA
| | - Rishi Gupta
- Neurocritical Care, Cerebrovascular and Endovascular Neurosurgery, Wellstar Health System, Atlanta, Georgia, USA
| | - Mypinder Sekhon
- Division of Critical Care, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Non-invasive diffuse optical neuromonitoring during cardiopulmonary resuscitation predicts return of spontaneous circulation. Sci Rep 2021; 11:3828. [PMID: 33589662 PMCID: PMC7884428 DOI: 10.1038/s41598-021-83270-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 01/28/2021] [Indexed: 11/08/2022] Open
Abstract
Neurologic injury is a leading cause of morbidity and mortality following pediatric cardiac arrest. In this study, we assess the feasibility of quantitative, non-invasive, frequency-domain diffuse optical spectroscopy (FD-DOS) neuromonitoring during cardiopulmonary resuscitation (CPR), and its predictive utility for return of spontaneous circulation (ROSC) in an established pediatric swine model of cardiac arrest. Cerebral tissue optical properties, oxy- and deoxy-hemoglobin concentration ([HbO2], [Hb]), oxygen saturation (StO2) and total hemoglobin concentration (THC) were measured by a FD-DOS probe placed on the forehead in 1-month-old swine (8–11 kg; n = 52) during seven minutes of asphyxiation followed by twenty minutes of CPR. ROSC prediction and time-dependent performance of prediction throughout early CPR (< 10 min), were assessed by the weighted Youden index (Jw, w = 0.1) with tenfold cross-validation. FD-DOS CPR data was successfully acquired in 48/52 animals; 37/48 achieved ROSC. Changes in scattering coefficient (785 nm), [HbO2], StO2 and THC from baseline were significantly different in ROSC versus No-ROSC subjects (p < 0.01) after 10 min of CPR. Change in [HbO2] of + 1.3 µmol/L from 1-min of CPR achieved the highest weighted Youden index (0.96) for ROSC prediction. We demonstrate feasibility of quantitative, non-invasive FD-DOS neuromonitoring, and stable, specific, early ROSC prediction from the third minute of CPR.
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227
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Zhao Z, Liang JJ, Wang Z, Winans NJ, Morris M, Doyle S, Fry A, Fiore SM, Mofakham S, Mikell CB. Cardiac arrest after severe traumatic brain injury can be survivable with good outcomes. Trauma Surg Acute Care Open 2021; 6:e000638. [PMID: 33634211 PMCID: PMC7880094 DOI: 10.1136/tsaco-2020-000638] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/12/2020] [Accepted: 01/17/2021] [Indexed: 12/15/2022] Open
Abstract
Background Resuscitation for traumatic cardiac arrest (TCA) in patients with severe traumatic brain injury (sTBI) has historically been considered futile. There is little information on the characteristics and outcomes of these patients to guide intervention and prognosis. The purpose of the current study is to report the clinical characteristics, survival, and long-term neurological outcomes in patients who experienced TCA after sTBI and analyze the factors contributing to survival. Methods A retrospective review identified 42 patients with TCA from a total of 402 patients with sTBI (Glasgow Coma Scale (GCS) score ≤8) who were admitted to Stony Brook University Hospital, a level I trauma center, from January 2011 to December 2018. Patient demographics, clinical characteristics, survival, and neurological functioning during hospitalization and at follow-up visits were collected. Results Of the 42 patients, the average age was 45 years and 21.4% were female. Eight patients survived the injury (19.0%) to discharge and seven survived with good neurological function. Admission GCS score and bilateral pupil reactivity were found to be significant indicators of survival. The mean GCS score was 5.3 in survivors and 3.2 in non-survivors (p=0.020). Age, Injury Severity Score, or cardiac rhythm was not associated with survival. Frequent neuroimaging findings included subarachnoid hemorrhage, subdural hematoma, and diffuse axonal injury. Discussion TCA after sTBI is survivable and seven out of eight patients in our study recovered with good neurological function. GCS score and pupil reactivity are the best indicators of survival. Our results suggest that due to the possibility of recovery, resuscitation and neurosurgical care should not be withheld from this patient population. Level of evidence Level IV, therapeutic/care management.
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Affiliation(s)
- Zirun Zhao
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Justine J Liang
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Zhe Wang
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Nathan J Winans
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Matthew Morris
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Stephen Doyle
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Adam Fry
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Susan M Fiore
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Sima Mofakham
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Charles B Mikell
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
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Lee D, Cho Y, Ko Y, Heo NH, Kang HG, Han S. Neuron-specific enolase level as a predictor of neurological outcome in near-hanging patients: A retrospective multicenter study. PLoS One 2021; 16:e0246898. [PMID: 33566872 PMCID: PMC7875384 DOI: 10.1371/journal.pone.0246898] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 01/27/2021] [Indexed: 12/04/2022] Open
Abstract
Objectives Neuron-specific enolase (NSE) is frequently used to predict neurological outcomes in patients with hypoxic brain injury. Hanging can cause hypoxic brain damage, and survivors can suffer from neurological deficits that may impair daily activities. Here, we investigated the utility of the initial serum NSE level as a predictor of neurological outcomes in near-hanging patients with decreased consciousness. Methods This retrospective multicenter study was conducted in patients who visited the emergency department due to near-hanging injury from October 2013 to February 2019 at three university hospitals in Korea. They were divided into two groups according to the presence of out-of-hospital cardiac arrest. The neurological outcome was determined using the Cerebral Performance Category (CPC) measured at the time of discharge. Multivariate analysis was performed to determine whether initial serum NSE is an independent predictor of neurological outcome. Results Of the 70 patients included in the study, 44 showed a poor neurological outcome (CPC score = 3–5). Among the 52 patients with cardiac arrest, only 10 (19.2%) were discharged with good neurological outcome (CPC score = 1–2). In the whole cohort, a high serum NSE level was a significant predictor of poor neurological outcome (odds ratio [OR], 1.343; 95% confidence interval [CI], 1.003–1.800, p = 0.048). Among the patients with cardiac arrest, a high serum NSE level was a significant predictor of poor neurological outcome (OR, 1.138; 95% CI, 1.009–1.284, p = 0.036). Conclusions In near-hanging patients, a high initial serum NSE level is an independent predictor of poor neurological outcome.
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Affiliation(s)
- Dongwook Lee
- Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Yongil Cho
- Department of Emergency Medicine, Hanyang University Hospital, Seoul, Republic of Korea
| | - Yujin Ko
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Nam Hun Heo
- Department of Biostatistics, Clinical Trial Center, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Hyung Goo Kang
- Department of Emergency Medicine, Hanyang University Hospital, Seoul, Republic of Korea
| | - Sangsoo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
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Presciutti A, Newman MM, Grigsby J, Vranceanu AM, Shaffer JA, Perman SM. Associations between posttraumatic stress symptoms and quality of life in cardiac arrest survivors and informal caregivers: A pilot survey study. Resusc Plus 2021; 5:100085. [PMID: 34223351 PMCID: PMC8244463 DOI: 10.1016/j.resplu.2021.100085] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 01/20/2023] Open
Abstract
About 1 in 4 cardiac arrest survivors showed significant posttraumatic stress. Over 1 in 3 informal caregivers showed significant posttraumatic stress. Greater posttraumatic stress was associated with worse quality of life.
Aim To estimate the proportion of significant posttraumatic stress (PTS) in both cardiac survivors with good neurologic recovery and informal caregivers, and to pilot test the hypothesis that greater PTS are associated with worse quality of life (QoL) in both cardiac arrest survivors and informal caregivers of cardiac arrest survivors. Methods We distributed an online survey to survivor and caregiver members of the Sudden Cardiac Arrest Foundation. Participants provided demographic and cardiac arrest characteristics and completed the PTSD Checklist-5 (PCL-5), the Lawton Instrumental Activities of Daily Living scale, and the WHOQOL-BREF. We identified covariates through bivariate correlations or linear regressions as appropriate. Six multiple regression models (three each for survivors and caregivers) examined associations between PCL-5 scores with each QoL subscale, adjusted for covariates identified from the bivariate models. Results We included 169 survivors (mean months since arrest: 62.8, positive PTS screen: 24.9%) and 52 caregivers (mean months since arrest: 43.2, positive PTS screen: 34.6%). For survivors, the following showed significant bivariate associations with QoL: Lawton scores, daily memory problems, sex, months since arrest, age, and income; for caregivers, months since arrest, age, and income. In adjusted models, greater PCL-5 scores were associated with worse QoL (β: −0.35 to −0.53, p < .05). Conclusions Our pilot results suggest that PTS are prevalent years after the initial cardiac arrest and are associated with worse QoL in survivors and informal caregivers. Further study is needed to validate these findings in a larger, representative sample.
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Affiliation(s)
- Alex Presciutti
- University of Colorado Denver, Department of Psychology, United States.,University of Colorado School of Medicine, Department of Emergency Medicine, United States
| | | | - Jim Grigsby
- University of Colorado Denver, Department of Psychology, United States
| | | | | | - Sarah M Perman
- University of Colorado School of Medicine, Department of Emergency Medicine, United States
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Achieving Osmotic Stability in the Context of Critical Illness and Acute Kidney Injury During Continuous Renal Replacement Therapy. ASAIO J 2021; 66:e90-e93. [PMID: 31789653 DOI: 10.1097/mat.0000000000001100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The concept of osmotic stability during renal replacement therapy has received limited attention thus far. We report an illustrative case of a previously healthy 22 year old male presenting after prolonged ventricular fibrillation with 75 minutes of resuscitative efforts before regaining spontaneous perfusing rhythm. Central nervous system protecting hypothermia protocol and veno-arterious (VA) extracorporeal membrane oxygenator (ECMO) therapy were initiated at hospital admission due to refractory hypoxemia. Cardiovascular imaging procedures described global hypokinesis. Due to the combination of anuria, mixed acidosis and hemodynamic instability, we started continuous renal replacement therapy (CRRT) in continuous veno-venous hemodiafiltration functionality with added hypertonic saline solution (HTS) protocol, calculated to stabilize his serum sodium between 148 and 150 mEq/L. Serum osmolality also ranged between 321 and 317 mOsm/kg thereafter. Course was complicated by an acute right leg ischemia distal to VA ECMO cannula placement, requiring salvage therapy with cryoamputation. Vasoactive medication requirement and hemodynamics improved after the addition of intravenous (IV) hydrocortisone. Brain magnetic resonance imaging (MRI) 22 days post-arrest showed signals of limited hypoxic injury. He left the hospital in stable condition with limited neurologic sequelae. Therefore, the use of HTS during CRRT is a viable way to address potential or manifest cerebral edema and reduce the degree of cerebral injury.
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Olsen MH, Olesen ND, Karlsson M, Holmlöv T, Søndergaard L, Boutelle M, Mathiesen T, Møller K. Randomized blinded trial of automated REBOA during CPR in a porcine model of cardiac arrest. Resuscitation 2021; 160:39-48. [PMID: 33482264 DOI: 10.1016/j.resuscitation.2021.01.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/23/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) reportedly elevates arterial blood pressure (ABP) during non-traumatic cardiac arrest. OBJECTIVES This randomized, blinded trial of cardiac arrest in pigs evaluated the effect of automated REBOA two minutes after balloon inflation on ABP (primary endpoint) as well as arterial blood gas values and markers of cerebral haemodynamics and metabolism. METHODS Twenty anesthetized pigs were randomized to REBOA inflation or sham-inflation (n = 10 in each group) followed by insertion of invasive monitoring and a novel, automated REBOA catheter (NEURESCUE® Catheter & NEURESCUE® Assistant). Cardiac arrest was induced by ventricular pacing. Cardiopulmonary resuscitation was initiated three min after cardiac arrest, and the automated REBOA was inflated or sham-inflated (blinded to the investigators) five min after cardiac arrest. RESULTS In the inflation compared to the sham group, mean ABP above the REBOA balloon after inflation was higher (inflation: 54 (95%CI: 43-65) mmHg; sham: 44 (33-55) mmHg; P = 0.06), and diastolic ABP was higher (inflation: 38 (29-47) mmHg; sham: 26 (20-33) mmHg; P = 0.02), and the arterial to jugular oxygen content difference was lower (P = 0.04). After return of spontaneous circulation, mean ABP (inflation: 111 (95%CI: 94-128) mmHg; sham: 94 (95%CI: 65-123) mmHg; P = 0.04), diastolic ABP (inflation: 95 (95%CI: 78-113) mmHg; sham: 78 (95%CI: 50-105) mmHg; P = 0.02), CPP (P = 0.01), and brain tissue oxygen tension (inflation: 315 (95%CI: 139-491)% of baseline; sham: 204 (95%CI: 75-333)%; P = 0.04) were higher in the inflation compared to the sham group. CONCLUSION Inflation of REBOA in a porcine model of non-traumatic cardiac arrest improves central diastolic arterial pressure as a surrogate marker of coronary artery pressure, and cerebral perfusion. INSTITUTIONAL PROTOCOL NUMBER 2017-15-0201-01371.
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Affiliation(s)
- Markus Harboe Olsen
- Department of Neurointensive Care and Neuroanaesthesiology, Neuroscience Centre, Rigshospitalet, University of Copenhagen, Denmark.
| | - Niels D Olesen
- Department of Anesthesiology, Centre of Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Denmark
| | - Michael Karlsson
- Department of Neurosurgery, Neuroscience Centre, Rigshospitalet, University of Copenhagen, Denmark
| | - Theodore Holmlöv
- Department of Neurosurgery, Neuroscience Centre, Rigshospitalet, University of Copenhagen, Denmark; Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Lars Søndergaard
- Department of Cardiology, Centre of Cardiac, Vascular, Pulmonary and Infectious Diseases, Rigshospitalet, University of Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Martyn Boutelle
- Faculty of Engineering, Department of Bioengineering, Imperial College, London, United Kingdom
| | - Tiit Mathiesen
- Department of Neurosurgery, Neuroscience Centre, Rigshospitalet, University of Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Kirsten Møller
- Department of Neurointensive Care and Neuroanaesthesiology, Neuroscience Centre, Rigshospitalet, University of Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Abstract
Cardiac arrest is a catastrophic event with high morbidity and mortality. Despite advances over time in cardiac arrest management and postresuscitation care, the neurologic consequences of cardiac arrest are frequently devastating to patients and their families. Targeted temperature management is an intervention aimed at limiting postanoxic injury and improving neurologic outcomes following cardiac arrest. Recovery of neurologic function governs long-term outcome after cardiac arrest and prognosticating on the potential for recovery is a heavy burden for physicians. An early and accurate estimate of the potential for recovery can establish realistic expectations and avoid futile care in those destined for a poor outcome. This chapter reviews the epidemiology, pathophysiology, therapeutic interventions, prognostication, and neurologic sequelae of cardiac arrest.
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Affiliation(s)
- Rick Gill
- Department of Neurology, Loyola University Chicago, Chicago, Stritch School of Medicine, Maywood, IL, United States
| | - Michael Teitcher
- Department of Neurology, Loyola University Chicago, Chicago, Stritch School of Medicine, Maywood, IL, United States
| | - Sean Ruland
- Department of Neurology, Loyola University Chicago, Chicago, Stritch School of Medicine, Maywood, IL, United States.
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Wolters A, Reuther J, Gude P, Weber T, Theiss C, Vogelsang H, Matschke V. Teriflunomide provides protective properties after oxygen-glucose-deprivation in hippocampal and cerebellar slice cultures. Neural Regen Res 2021; 16:2243-2249. [PMID: 33818508 PMCID: PMC8354112 DOI: 10.4103/1673-5374.310689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
One of the major challenges in emergency medicine is out-of-hospital cardiac arrest (OHCA). Every year, about 53-62/100 000 people worldwide suffer an out-of-hospital cardiac arrest with serious consequences, whereas persistent brain injury is a major cause of morbidity and mortality of those surviving a cardiac arrest. Today, only few and insufficient strategies are known to limit neurological damage of ischemia and reperfusion injury. The aim of the present study was to investigate whether teriflunomide, an approved drug for treatment of relapsing-remitting-multiple-sclerosis, exerts a protective effect on brain cells in an in vitro model of ischemia. Therefore, organotypic slice cultures from rat hippocampus and cerebellum were exposed to oxygen-glucose-deprivation and subsequently treated with teriflunomide. The administration of teriflunomide in the reperfusion time on both hippocampal and cerebellar slice cultures significantly decreased the amount of detectable propidium iodide signal compared with an untreated culture, indicating that more cells survive after oxygen-glucose-deprivation. However, hippocampal slice cultures showed a higher vulnerability to ischemic conditions and a more sensitive response to teriflunomide compared with cerebellar slice cultures. Our study suggests that teriflunomide, applied as a post-treatment after an oxygen-glucose-deprivation, has a protective effect on hippocampal and cerebellar cells in organotypic slice cultures of rats. All procedures were conducted under established standards of the German federal state of North Rhine Westphalia, in accordance with the European Communities Council Directive 2010/63/EU on the protection of animals used for scientific purposes.
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Affiliation(s)
- Anna Wolters
- Institute of Anatomy, Department of Cytology, Medical Faculty, Ruhr University Bochum, Bochum, Germany
| | - Judith Reuther
- Institute of Anatomy, Department of Cytology, Medical Faculty, Ruhr University Bochum, Bochum, Germany
| | - Philipp Gude
- Department of Anaesthesiology and Intensive Care Medicine, Ruhr University Bochum, St. Josef Hospital, Bochum, Germany
| | - Thomas Weber
- Department of Anaesthesiology and Intensive Care Medicine, Ruhr University Bochum, St. Josef Hospital, Bochum, Germany
| | - Carsten Theiss
- Institute of Anatomy, Department of Cytology, Medical Faculty, Ruhr University Bochum, Bochum, Germany
| | - Heike Vogelsang
- Department of Anaesthesiology and Intensive Care Medicine, Ruhr University Bochum, St. Josef Hospital, Bochum, Germany
| | - Veronika Matschke
- Institute of Anatomy, Department of Cytology, Medical Faculty, Ruhr University Bochum, Bochum, Germany
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Ma Q, Feng L, Wang T, Li Y, Li Z, Zhao B, Qin X, Li Q, Wu S, Sun H, Yuan J, Chu L, Wu J, Gu Y, Pang P, Chen Z, Fan D. 2020 expert consensus statement on neuro-protection after cardiac arrest in China. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:175. [PMID: 33569477 PMCID: PMC7867902 DOI: 10.21037/atm-20-7853] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/29/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Qingbian Ma
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Liqun Feng
- Neurology Department, Anzhen Hospital, Capital Medical University, Beijing, China
| | - Tao Wang
- Neurosurgery Department, Peking University Third Hospital, Beijing, China
| | - Yongqiu Li
- Neurology Department, Tangshan Gongren Hospital, Tangshan, China
| | - Zhenzhong Li
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Bin Zhao
- Emergency Department, Beijing Jishuitan Hospital, Beijing, China
| | - Xiuchuan Qin
- Emergency Department, Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qingxi Li
- Neurosurgery Department, Dandong Central Hospital, Dandong, China
| | - Shizheng Wu
- Neurology Department, Qinghai Provincial People’s Hospital, Xining, China
| | - Hongbin Sun
- Neurology Department, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Jun Yuan
- Neurology Department, Inner Mongolia People’s Hospital, Hohhot, China
| | - Lan Chu
- Neurology Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jian Wu
- Neurology Department, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Yuxiang Gu
- Neurosurgery Department, Fudan University Huashan Hospital, Shanghai, China
| | - Peter Pang
- Accident and Emergency Department, Yan Chai Hospital, Hong Kong, China
| | - Zhi Chen
- Beijing Emergency Medical Center, Beijing, China
| | - Dongsheng Fan
- Neurology Department, Peking University Third Hospital, Beijing, China
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235
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Hassett CE, Cho SM, Suarez JI. Tachyarrhythmias and neurologic complications. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:151-162. [PMID: 33632434 DOI: 10.1016/b978-0-12-819814-8.00004-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Tachyarrhythmias are abnormal heart rhythms with a ventricular rate of 100 or more beats per minute. These rhythms are classified as either narrow or wide-complex tachycardia with further subdivision into regular or irregular rhythm. Patients are frequently symptomatic presenting with palpitations, diaphoresis, dyspnea, chest pain, dizziness, and syncope. Sudden cardiac death may occur with certain arrhythmias. Recognizing tachyarrhythmia and understanding its management is important as a wide spectrum of neurologic complications have been associated with such arrhythmias. The purpose of this chapter is to provide a comprehensive overview on the neurologic complications of tachyarrhythmias, neurologic adverse events of antiarrhythmic interventions, and neurologic conditions that can precipitate tachyarrhythmia.
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Affiliation(s)
- Catherine E Hassett
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Sung-Min Cho
- Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jose I Suarez
- Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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236
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Kang C, Lee IH, Park JS, You Y, Jeong W, Ahn HJ, Min JH. Measuring global impairment of cerebral perfusion using dynamic susceptibility contrast perfusion-weighted imaging in out-of-hospital cardiac arrest survivors: A prospective preliminary study. J Neuroradiol 2020; 48:379-384. [PMID: 33340642 DOI: 10.1016/j.neurad.2020.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/25/2020] [Accepted: 12/07/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE This study aimed to assess the global impairment and prognostic performance of cerebral perfusions (CP) measured by dynamic susceptibility contrast perfusion-weighted imaging (DSC-PWI) in out-of-hospital cardiac arrest (OHCA) patients after sustained restoration of spontaneous circulation (ROSC). MATERIALS AND METHODS This is a single-centre, prospective observational study. OHCA patients performed DSC-PWI within 8 h after ROSC were enrolled. We quantified the CP parameters, such as cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), time to peak (TTP), and time to maximum of the residue function (Tmax) either by normalization or arterial input function (AIF). The primary and secondary outcomes were survival to discharge and comparison of prognostic performance between CP parameters and serum neuron-specific enolase (NSE) using area under the receiver operating characteristic (AUROC) and sensitivity values. RESULTS Thirty-one patients were included in this study. CBV and TTP quantified by normalization, and MTT and Tmax quantified by AIF showed significantly higher CP values in the non-survival group (p = 0.02, 0.03, 0.02, and <0.01, respectively). Their AUROCs and 100% specific sensitivities were 0.74/25.0%, 0.60/33.3%, 0.75/56.3%, and 0.79/43.8%, respectively. MTT quantified by AIF showed sensitivity in predicting mortality at an early stage of PCA care, comparable with NSE. CONCLUSION Hyperaemia and delayed CP were generally observed in OHCA patients regardless of outcomes. MTT and Tmax quantified by AIF have prognostic performance in predicting mortality, comparable with NSE. Further prospective multicentre studies are required to confirm our results.
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Affiliation(s)
- Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - In Ho Lee
- Department of Radiology, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea.
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
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237
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Robba C, Siwicka-Gieroba D, Sikter A, Battaglini D, Dąbrowski W, Schultz MJ, de Jonge E, Grim C, Rocco PR, Pelosi P. Pathophysiology and clinical consequences of arterial blood gases and pH after cardiac arrest. Intensive Care Med Exp 2020; 8:19. [PMID: 33336311 PMCID: PMC7746422 DOI: 10.1186/s40635-020-00307-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022] Open
Abstract
Post cardiac arrest syndrome is associated with high morbidity and mortality, which is related not only to a poor neurological outcome but also to respiratory and cardiovascular dysfunctions. The control of gas exchange, and in particular oxygenation and carbon dioxide levels, is fundamental in mechanically ventilated patients after resuscitation, as arterial blood gases derangement might have important effects on the cerebral blood flow and systemic physiology. In particular, the pathophysiological role of carbon dioxide (CO2) levels is strongly underestimated, as its alterations quickly affect also the changes of intracellular pH, and consequently influence metabolic energy and oxygen demand. Hypo/hypercapnia, as well as mechanical ventilation during and after resuscitation, can affect CO2 levels and trigger a dangerous pathophysiological vicious circle related to the relationship between pH, cellular demand, and catecholamine levels. The developing hypocapnia can nullify the beneficial effects of the hypothermia. The aim of this review was to describe the pathophysiology and clinical consequences of arterial blood gases and pH after cardiac arrest. According to our findings, the optimal ventilator strategies in post cardiac arrest patients are not fully understood, and oxygen and carbon dioxide targets should take in consideration a complex pattern of pathophysiological factors. Further studies are warranted to define the optimal settings of mechanical ventilation in patients after cardiac arrest.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.
| | - Dorota Siwicka-Gieroba
- Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Andras Sikter
- Internal Medicine, Municipal Clinic of Szentendre, Szentendre, Hungary
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy
| | - Wojciech Dąbrowski
- Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Chloe Grim
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Patricia Rm Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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238
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Nagu P, Parashar A, Behl T, Mehta V. CNS implications of COVID-19: a comprehensive review. Rev Neurosci 2020; 32:219-234. [PMID: 33550782 DOI: 10.1515/revneuro-2020-0070] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/03/2020] [Indexed: 02/06/2023]
Abstract
COVID-19 was first reported in December 2019 in the Wuhan city of China, and since then it has spread worldwide taking a heavy toll on human life and economy. COVID-19 infection is commonly associated with symptoms like coughing, fever, and shortness of breath, besides, the reports of muscle pain, anosmia, hyposmia, and loss of taste are becoming evident. Recent reports suggest the pathogenic invasion of the SARS-CoV-2 into the CNS, that could thereby result in devastating long term complications, primarily because some of these complications may go unnoticed for a long time. Evidence suggest that the virus could enter the CNS through angiotensin-converting enzyme-2 (ACE-2) receptor, neuronal transport, haematogenous route, and nasal route via olfactory bulb, cribriform plate, and propagates through trans-synaptic signalling, and shows retrograde movement into the CNS along nerve fiber. COVID-19 induces CNS inflammation and neurological degenerative damage through a diverse mechanism which includes ACE-2 receptor damage, cytokine-associated injury or cytokine storm syndrome, secondary hypoxia, demyelination, blood-brain barrier disruption, neurodegeneration, and neuroinflammation. Viral invasion into the CNS has been reported to show association with complications like Parkinsonism, Alzheimer's disorder, meningitis, encephalopathy, anosmia, hyposmia, anxiety, depression, psychiatric symptoms, seizures, stroke, etc. This review provides a detailed discussion of the CNS pathogenesis of COVID-19. Authors conclude that the COVID-19 cannot just be considered as a disorder of the pulmonary or peripheral system, rather it has a significant CNS involvement. Therefore, CNS aspects of the COVID-19 should be monitored very closely to prevent long term CNS complications, even after the patient has recovered from COVID-19.
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Affiliation(s)
- Priyanka Nagu
- Department of Pharmaceutics, Government College of Pharmacy, Rohru, District Shimla, Himachal Pradesh, India
| | - Arun Parashar
- Faculty of Pharmaceutical Sciences, Shoolini University of Biotechnology and Management Sciences, Solan, District Shimla, Himachal Pradesh, India
| | - Tapan Behl
- Chitkara College of Pharmacy, Chitkara University, Rajpura, Punjab, India
| | - Vineet Mehta
- Department of Pharmacology, Government College of Pharmacy, Rohru 171207, District Shimla, Himachal Pradesh, India
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Dalby T, Wohl E, Dinsmore M, Unger Z, Chowdhury T, Venkatraghavan L. Pathophysiology of Cerebral Edema—A Comprehensive Review. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2020. [DOI: 10.1055/s-0040-1721165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
AbstractCerebral edema is a condition where an excess of cerebral water accumulates due to primary neurological or non-neurological causes. Cerebral edema complicates many brain pathologies causing additional injury often in excess of the original neurological insult. Classic descriptions divide cerebral edema into cytotoxic, vasogenic, interstitial, and osmotic subtypes. The interplay of different mechanisms is important in the clinical manifestations. Recent research has advanced our understanding of the molecular pathophysiology of cerebral edema, exposing the central role of aquaporins and specific ion channels. The aim of this review is to provide a comprehensive overview of the molecular pathophysiology of cerebral edema including unique disease specific mechanisms.
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Affiliation(s)
- Tara Dalby
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Elyana Wohl
- Department of Anesthesia, Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Michael Dinsmore
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Zoe Unger
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Tumul Chowdhury
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Lakshmikumar Venkatraghavan
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
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240
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Kirschen MP, Morgan RW, Majmudar T, Landis WP, Ko T, Balu R, Balasubramanian S, Topjian A, Sutton RM, Berg RA, Kilbaugh TJ. The association between early impairment in cerebral autoregulation and outcome in a pediatric swine model of cardiac arrest. Resusc Plus 2020; 4:100051. [PMID: 34223325 PMCID: PMC8244245 DOI: 10.1016/j.resplu.2020.100051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/03/2020] [Accepted: 11/08/2020] [Indexed: 12/26/2022] Open
Abstract
AIMS Evaluate cerebral autoregulation (CAR) by intracranial pressure reactivity index (PRx) and cerebral blood flow reactivity index (CBFx) during the first four hours following return of spontaneous circulation (ROSC) in a porcine model of pediatric cardiac arrest. Determine whether impaired CAR is associated with neurologic outcome. METHODS Four-week-old swine underwent seven minutes of asphyxia followed by ventricular fibrillation induction and hemodynamic-directed CPR. Those achieving ROSC had arterial blood pressure, intracranial pressure (ICP), and microvascular cerebral blood flow (CBF) monitored for 4 h. Animals were assigned an 8 -h post-ROSC swine cerebral performance category score (1 = normal; 2-4=abnormal neurologic function). In this secondary analytic study, we calculated PRx and CBFx using a continuous, moving correlation coefficient between mean arterial pressure (MAP) and ICP, and between MAP and CBF, respectively. Burden of impaired CAR was the area under the PRx or CBFx curve using a threshold of 0.3 and normalized as percentage of monitoring duration. RESULTS Among 23 animals, median PRx was 0.14 [0.06,0.25] and CBFx was 0.36 [0.05,0.44]. Median burden of impaired CAR was 21% [18,27] with PRx and 30% [17,40] with CBFx. Neurologically abnormal animals (n = 10) did not differ from normal animals (n = 13) in post-ROSC MAP (63 vs. 61 mmHg, p = 0.74), ICP (15 vs. 14 mmHg, p = 0.78) or CBF (274 vs. 397 Perfusion Units, p = 0.12). CBFx burden was greater among abnormal than normal animals (45% vs. 24%, p = 0.001), but PRx burden was not (25% vs. 20%, p = 0.38). CONCLUSION CAR is impaired early after ROSC. A greater burden of CAR impairment measured by CBFx was associated with abnormal neurologic outcome.CHOP Institutional Animal Care and Use Committee protocol 19-001327.
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Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, USA
| | - Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
| | - Tanmay Majmudar
- School of Biomedical Engineering, Science and Health Systems, Drexel University, USA
| | - William P. Landis
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
| | - Tiffany Ko
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
| | - Ramani Balu
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, USA
| | | | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
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241
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Mckenzie N, Finn J, Dobb G, Bailey P, Arendts G, Celenza A, Fatovich D, Jenkins I, Ball S, Bray J, Ho KM. Non-linear association between arterial oxygen tension and survival after out-of-hospital cardiac arrest: A multicentre observational study. Resuscitation 2020; 158:130-138. [PMID: 33232752 DOI: 10.1016/j.resuscitation.2020.11.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 10/25/2020] [Accepted: 11/06/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Studies to identify safe oxygenation targets after out-of-hospital cardiac arrest (OHCA) have often assumed a linear relationship between arterial oxygen tension (PaO2) and survival, or have dichotomised PaO2 at a supra-physiological level. We hypothesised that abnormalities in mean PaO2 (both high and low) would be associated with decreased survival after OHCA. METHODS We conducted a retrospective multicentre cohort study of adult OHCA patients who received mechanical ventilation on admission to the intensive care unit (ICU). The potential non-linear relationship between the mean PaO2 within the first 24 -hs of ICU admission and survival to hospital discharge (STHD) was assessed by a four-knot restricted cubic spline function with adjustment for potential confounders. RESULTS 3764 arterial blood gas results were available for 491 patients in the first 24-hs of ICU admission. The relationship between mean PaO2 over the first 24-hs and STHD was an inverted U-shape, with highest survival for those with a mean PaO2 between 100 and 180 mmHg (reference category) compared to a mean PaO2 of <100 mmHg (adjusted odds ratio [aOR] 0.50 95% confidence interval [CI] 0.30, 0.84), or >180 mmHg (aOR 0.41, 95% CI 0.18, 0.92). Mean PaO2 within 24 -hs was the third most important predictor and explained 9.1% of the variability in STHD. CONCLUSION The mean PaO2 within the first 24-hs after admission for OHCA has a non-linear association with the highest STHD seen between 100 and 180 mmHg. Randomised controlled trials are now needed to validate the optimal oxygenation targets in mechanically ventilated OHCA patients.
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Affiliation(s)
- Nicole Mckenzie
- Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), Curtin University, Bentley, WA, Australia; Intensive Care Unit, Royal Perth Hospital, Perth, WA, Australia.
| | - Judith Finn
- Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), Curtin University, Bentley, WA, Australia; St John Western Australia, Belmont, WA, Australia; School of Medicine (Emergency Medicine), University of Western Australia, Crawley, WA, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Geoffrey Dobb
- Intensive Care Unit, Royal Perth Hospital, Perth, WA, Australia; Faculty of Health and Medical Sciences, University of Western Australia, Crawley, WA, Australia
| | - Paul Bailey
- Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), Curtin University, Bentley, WA, Australia; St John Western Australia, Belmont, WA, Australia
| | - Glenn Arendts
- Faculty of Health and Medical Sciences, University of Western Australia, Crawley, WA, Australia; Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Antonio Celenza
- School of Medicine (Emergency Medicine), University of Western Australia, Crawley, WA, Australia; Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Daniel Fatovich
- Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), Curtin University, Bentley, WA, Australia; School of Medicine (Emergency Medicine), University of Western Australia, Crawley, WA, Australia; Emergency Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - Ian Jenkins
- Fremantle Hospital, Fremantle, WA, Australia
| | - Stephen Ball
- Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), Curtin University, Bentley, WA, Australia; St John Western Australia, Belmont, WA, Australia
| | - Janet Bray
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Kwok M Ho
- Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), Curtin University, Bentley, WA, Australia; Intensive Care Unit, Royal Perth Hospital, Perth, WA, Australia; Medical School, University of Western Australia, Crawley, WA, Australia; School of Veterinary and Life Sciences, Murdoch University, Perth, WA, Australia
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242
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Polat İ, Yiş U, Ayanoğlu M, Okur D, Edem P, Paketçi C, Bayram E, Hız Kurul S. Risk Factors of Post-Stroke Epilepsy in Children; Experience from a Tertiary Center and a Brief Review of the Literature. J Stroke Cerebrovasc Dis 2020; 30:105438. [PMID: 33197802 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 10/02/2020] [Accepted: 10/29/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Acute seizures and post-stroke epilepsy have been reported more frequently in patients with pediatric stroke than adults. Acute seizures in the first days of a stroke may deteriorate stroke and ischemia-related neurodegeneration and contribute to the development of post-stroke epilepsy. In this study, we aimed to investigate risk factors for the development of post-stroke epilepsy in children with arterial ischemic stroke. MATERIALS AND METHODS We recruited 86 children with arterial ischemic stroke. We analyzed variables, including age at admission, gender, complaints at presentation, focal or diffuse neurologic signs, neurologic examination findings, laboratory investigations that were conducted at admission with stroke (complete blood cell count, biochemical-infectious-metabolic-immunological investigations, vitamin B12 levels, vitamin D levels), neuroimaging results, etiologies, time of the first seizure, time of remote seizures, and development of neurologic deficit retrospectively. Seizures during the first six hours after stroke onset were defined as 'very early seizures'. 'Early seizures' were referred to seizures during the first 48 h. Patients who experienced two or more seizures that occurred after the acute phase of seizures were classified as 'epileptic.' A binary logistic regression analysis was used to estimate risk factors. RESULTS An acute seizure was detected in 59% and post-stroke epilepsy developed in 41% of our cohort. Binary logistic regression analysis demonstrated that 'very early seizures' increased epilepsy risk six-fold. Epilepsy was 16 times higher in patients with 'early seizures'. Low vitamin D levels were defined as a risk factor for post-stroke epilepsy. CONCLUSION Seizures in the very early period (within the first six hours) are the most significant risk factors for the development of post-stroke epilepsy Further studies regarding seizure prevention and neuroprotective therapies are needed because post-stroke epilepsy will affect long term prognosis in patients with pediatric stroke.
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Affiliation(s)
- İpek Polat
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Uluç Yiş
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Müge Ayanoğlu
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Derya Okur
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Pınar Edem
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Cem Paketçi
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Erhan Bayram
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Semra Hız Kurul
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
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243
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Dibué M, Spoor JKH, Dremmen M, von Saß CF, Hänggi D, Steiger HJ, Ryvlin P, Kamp MA. Sudden death in epilepsy: There is room for intracranial pressure. Brain Behav 2020; 10:e01838. [PMID: 32949224 PMCID: PMC7667321 DOI: 10.1002/brb3.1838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/18/2020] [Accepted: 08/26/2020] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Sudden unexpected death in patients with epilepsy (SUDEP) remains a poorly understood entity, and it is unclear whether the same pathomechanisms underlie all sudden deaths occurring in patients with epilepsy. One aspect not included in current models of SUDEP is the role of increased intracranial pressure (ICP) which can be observed immediately upon seizure activity in neurosurgical practice. METHODS We conducted a systematic review of the occurrence of edema in patients with epilepsy reported to have died of sudden death who underwent brain autopsy or postmortem brain imaging and discuss how increased ICP may contribute to clinical features of SUDEP. RESULTS 19 eligible studies comprising a total of 623 patients were identified. Edema-mostly mild or moderate-was reported in 17% of cases and 74% of studies. 1% (n = 6) of the overall cases were clearly identified as having Dravet syndrome or an SCN1A mutation. In these patients, edema was found in 4 (67%) of cases. CONCLUSION Edema is regularly found in patients with epilepsy classified to have died from SUDEP. We argue that seizures preceding SUDEP may in certain cases elicit acute edema which may represent an additional contributing factor in the cascade of events leading to sudden death of patients with epilepsy. Furthermore, we hypothesize that mild edema may especially progress to severe edema in patients with sodium channel mutations which may represent an important mechanism to investigate in the context of understanding the significantly elevated risk of SUDEP in patients with SCN1A mutations.
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Affiliation(s)
- Maxine Dibué
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Jochem K H Spoor
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marjolein Dremmen
- Department of Radiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Philippe Ryvlin
- Department of Clinical Neurosciences, Centre Hospitalo-Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Marcel A Kamp
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
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244
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Takegawa R, Hayashida K, Rolston DM, Li T, Miyara SJ, Ohnishi M, Shiozaki T, Becker LB. Near-Infrared Spectroscopy Assessments of Regional Cerebral Oxygen Saturation for the Prediction of Clinical Outcomes in Patients With Cardiac Arrest: A Review of Clinical Impact, Evolution, and Future Directions. Front Med (Lausanne) 2020; 7:587930. [PMID: 33251235 PMCID: PMC7673454 DOI: 10.3389/fmed.2020.587930] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/02/2020] [Indexed: 12/24/2022] Open
Abstract
Despite three decades of advancements in cardiopulmonary resuscitation (CPR) methods and post-resuscitation care, neurological prognosis remains poor among survivors of out-of-hospital cardiac arrest, and there are no reliable methods for predicting neurological outcomes in patients with cardiac arrest (CA). Adopting more effective methods of neurological monitoring may aid in improving neurological outcomes and optimizing therapeutic interventions for each patient. In the present review, we summarize the development, evolution, and potential application of near-infrared spectroscopy (NIRS) in adults with CA, highlighting the clinical relevance of NIRS brain monitoring as a predictive tool in both pre-hospital and in-hospital settings. Several clinical studies have reported an association between various NIRS oximetry measurements and CA outcomes, suggesting that NIRS monitoring can be integrated into standardized CPR protocols, which may improve outcomes among patients with CA. However, no studies have established acceptable regional cerebral oxygen saturation cut-off values for differentiating patient groups based on return of spontaneous circulation status and neurological outcomes. Furthermore, the point at which resuscitation efforts can be considered futile remains to be determined. Further large-scale randomized controlled trials are required to evaluate the impact of NIRS monitoring on survival and neurological recovery following CA.
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Affiliation(s)
- Ryosuke Takegawa
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY, United States.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, United States.,Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kei Hayashida
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY, United States.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, United States
| | - Daniel M Rolston
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, United States.,Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States.,Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Timmy Li
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, United States.,Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Santiago J Miyara
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY, United States.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, United States.,Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States.,Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
| | - Mitsuo Ohnishi
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.,Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Tadahiko Shiozaki
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Lance B Becker
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY, United States.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, United States.,Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
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245
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Characterization of a novel model of global forebrain ischaemia-reperfusion injury in mice and comparison with focal ischaemic and haemorrhagic stroke. Sci Rep 2020; 10:18170. [PMID: 33097782 PMCID: PMC7585423 DOI: 10.1038/s41598-020-75034-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/27/2020] [Indexed: 12/31/2022] Open
Abstract
Stroke is caused by obstructed blood flow (ischaemia) or unrestricted bleeding in the brain (haemorrhage). Global brain ischaemia occurs after restricted cerebral blood flow e.g. during cardiac arrest. Following ischaemic injury, restoration of blood flow causes ischaemia-reperfusion (I/R) injury which worsens outcome. Secondary injury mechanisms after any stroke are similar, and encompass inflammation, endothelial dysfunction, blood-brain barrier (BBB) damage and apoptosis. We developed a new model of transient global forebrain I/R injury (dual carotid artery ligation; DCAL) and compared the manifestations of this injury with those in a conventional I/R injury model (middle-cerebral artery occlusion; MCAo) and with intracerebral haemorrhage (ICH; collagenase model). MRI revealed that DCAL produced smaller bilateral lesions predominantly localised to the striatum, whereas MCAo produced larger focal corticostriatal lesions. After global forebrain ischaemia mice had worse overall neurological scores, although quantitative locomotor assessment showed MCAo and ICH had significantly worsened mobility. BBB breakdown was highest in the DCAL model while apoptotic activity was highest after ICH. VCAM-1 upregulation was specific to ischaemic models only. Differential transcriptional upregulation of pro-inflammatory chemokines and cytokines and TLRs was seen in the three models. Our findings offer a unique insight into the similarities and differences in how biological processes are regulated after different types of stroke. They also establish a platform for analysis of therapies such as endothelial protective and anti-inflammatory agents that can be applied to all types of stroke.
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246
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Shoaib M, Becker LB. A walk through the progression of resuscitation medicine. Ann N Y Acad Sci 2020; 1507:23-36. [PMID: 33040363 DOI: 10.1111/nyas.14507] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 09/03/2020] [Accepted: 09/14/2020] [Indexed: 01/11/2023]
Abstract
Cardiac arrest (CA) is a sudden and devastating disease process resulting in more deaths in the United States than many cancers, metabolic diseases, and even car accidents. Despite such a heavy mortality burden, effective treatments have remained elusive. The past century has been productive in establishing the guidelines for resuscitation, known as cardiopulmonary resuscitation (CPR), as well as developing a scientific field whose aim is to elucidate the underlying mechanisms of CA and develop therapies to save lives. CPR has been successful in reinitiating the heart after arrest, enabling a survival rate of approximately 10% in out-of-hospital CA. Although current advanced resuscitation methods, including hypothermia and extracorporeal membrane oxygenation, have improved survival in some patients, they are unlikely to significantly improve the national survival rate any further without a paradigm shift. Such a change is possible with sustained efforts in the basic and clinical sciences of resuscitation and their implementation. This review seeks to discuss the current landscape in resuscitation medicine-how we got here and where we are going.
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Affiliation(s)
- Muhammad Shoaib
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,The Feinstein Institutes for Medical Research, Manhasset, New York
| | - Lance B Becker
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,The Feinstein Institutes for Medical Research, Manhasset, New York.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, New York
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247
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Successful Use of Electroconvulsive Therapy for Catatonia After Hypoxic-Ischemic Brain Injury. J Acad Consult Liaison Psychiatry 2020; 62:123-130. [PMID: 33023757 DOI: 10.1016/j.psym.2020.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/27/2020] [Accepted: 08/28/2020] [Indexed: 11/20/2022]
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248
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Fisher R, Bernett MJ, Paternoster R, Karabon P, Devlin W, Swor R. Utility of Abnormal Head Computed Tomography in Predicting Outcome in Out-of-Hospital Cardiac Arrest Victims. Ther Hypothermia Temp Manag 2020; 11:164-169. [PMID: 33021889 DOI: 10.1089/ther.2020.0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Head computed tomography (HCT) is often performed postcardiac arrest to assess for hypoxic-ischemic brain injury. Our primary objective was to assess whether cerebral edema (CE) on early HCT is associated with poor survival and neurologic outcome after out-of-hospital cardiac arrest (OHCA).We included subjects from a prospectively collected database of OHCA adults who received targeted temperature management at two hospitals from July 2009 to July 2018. We included cases if an emergency department (ED) HCT was performed. Patient demographics and cardiac arrest variables were collected. HCT results were abstracted from radiology reports. HCT findings were categorized as no acute disease, evidence of CE, or excluded (bleed, tumor, and stroke). Outcomes were survival to discharge or dichotomized discharge cerebral performance category (CPC) of 1-2 (good neurologic outcome) versus 3-5 (poor neurologic outcome). Univariate and multivariate analyses were performed. There were 425 OHCA, of which 315 had ED HCT with 277 cases included. Patients were predominately male (65.0%), average age of 60.9 years and average body mass index of 30.5. Of all cases, 44 (15.9%) showed CE on computed tomography. Univariate analysis demonstrated that CE was associated with 9.2-fold greater odds of poor outcome (odds ratio [OR]: 9.23; 95% confidence interval [CI] 1.73-49.2) and 9.1-fold greater odds of death (OR: 9.09, 95% CI 2.4-33.9). In adjusted analysis, CE was associated with a poor CPC outcome (adjusted odds ratios [AOR]: 14.9, 95% CI 2.49-88.4), and death (AOR: 13.7, 95% CI 3.26-57.4). Adjusted survival analysis demonstrated that patients with CE on HCT had 3.6-fold greater hazard of death than those without CE (hazard ratios 3.56, 95% CI 2.34-5.41). The results identify that CE on HCTs early in the postarrest period in OHCA patients is strongly associated with poor rates of survival and neurologic outcome. Prospective work is needed to further define the role of early HCT in postarrest neuroprognostication.
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Affiliation(s)
- Rebecca Fisher
- Department of Emergency Medicine, Beaumont Health System, Royal Oak, Michigan, USA
| | | | - Ryan Paternoster
- Office of Research, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA
| | - Patrick Karabon
- Department of Emergency Medicine, Beaumont Health System, Royal Oak, Michigan, USA
| | - William Devlin
- Beaumont Hospital-Troy, Beaumont Health System, Royal Oak, Michigan, USA
| | - Robert Swor
- Department of Emergency Medicine, Beaumont Health System, Royal Oak, Michigan, USA
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249
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Li J, Wang J, Shen Y, Dai C, Chen B, Huang Y, Xu S, Wu Y, Li Y. Hyperoxygenation With Cardiopulmonary Resuscitation and Targeted Temperature Management Improves Post-Cardiac Arrest Outcomes in Rats. J Am Heart Assoc 2020; 9:e016730. [PMID: 32964774 PMCID: PMC7792384 DOI: 10.1161/jaha.120.016730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Oxygen plays a pivotal role in cardiopulmonary resuscitation (CPR) and postresuscitation intervention for cardiac arrest. However, the optimal method to reoxygenate patients has not been determined. This study investigated the effect of timing of hyperoxygenation on neurological outcomes in cardiac arrest/CPR rats treated with targeted temperature management. Methods and Results After induction of ventricular fibrillation, male Sprague-Dawley rats were randomized into 4 groups (n=16/group): (1) normoxic control; (2) O2_CPR, ventilated with 100% O2 during CPR; (3) O2_CPR+postresuscitation, ventilated with 100% O2 during CPR and the first 3 hours of postresuscitation; and (4) O2_postresuscitation, ventilated with 100% O2 during the first 3 hours of postresuscitation. Targeted temperature management was induced immediately after resuscitation and maintained for 3 hours in all animals. Postresuscitation hemodynamics, neurological recovery, and pathological analysis were assessed. Brain tissues of additional rats undergoing the same experimental procedure were harvested for ELISA-based quantification assays of oxidative stress-related biomarkers and compared with the sham-operated rats (n=6/group). We found that postresuscitation mean arterial pressure and quantitative electroencephalogram activity were significantly increased, whereas astroglial protein S100B, degenerated neurons, oxidative stress-related biomarkers, and neurologic deficit scores were significantly reduced in the O2_CPR+postresuscitation group compared with the normoxic control group. In addition, 96-hour survival rates were significantly improved in all of the hyperoxygenation groups. Conclusions In this cardiac arrest/CPR rat model, hyperoxygenation coupled with targeted temperature management attenuates ischemia/reperfusion-induced injuries and improves survival rates. The beneficial effects of high-concentration oxygen are timing and duration dependent. Hyperoxygenation commenced with CPR, which improves outcomes when administered during hypothermia.
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Affiliation(s)
- Jingru Li
- Department of Biomedical Engineering and Imaging Medicine Army Medical University Chongqing China
| | - Jianjie Wang
- Department of Biomedical Engineering and Imaging Medicine Army Medical University Chongqing China
| | - Yiming Shen
- Department of Emergency Chongqing Emergency Medical Center Chongqing China
| | - Chenxi Dai
- Department of Biomedical Engineering and Imaging Medicine Army Medical University Chongqing China
| | - Bihua Chen
- Department of Biomedical Engineering and Imaging Medicine Army Medical University Chongqing China
| | - Yuanyuan Huang
- Department of Neurology Southwest Hospital Army Medical University Chongqing China
| | - Senlin Xu
- Institute of Pathology and Southwest Cancer Center Southwest Hospital Army Medical University Chongqing China
| | - Yi Wu
- Department of Biomedical Engineering and Imaging Medicine Army Medical University Chongqing China
| | - Yongqin Li
- Department of Biomedical Engineering and Imaging Medicine Army Medical University Chongqing China
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250
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Carrera WM, Ng CC, Peng MY, Rosco MG, Johnson RN. Cardiopulmonary Resuscitation Retinopathy in an Adult. Ophthalmol Retina 2020; 5:388-390. [PMID: 32956859 DOI: 10.1016/j.oret.2020.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/06/2020] [Accepted: 09/15/2020] [Indexed: 11/29/2022]
Abstract
A man developed vision loss and bilateral subhyaloid, outer plexiform, and subretinal hemorrhages after 2 minutes of chest compressions. Several potential mechanisms, including venous transmission of pressure and elevated intracranial pressure (ICP), could explain these findings.
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Affiliation(s)
- William M Carrera
- California Pacific Medical Center, Department of Ophthalmology, San Francisco, California
| | - Caleb C Ng
- California Pacific Medical Center, Department of Ophthalmology, San Francisco, California; West Coast Retina, San Francisco, California
| | - Michelle Y Peng
- California Pacific Medical Center, Department of Ophthalmology, San Francisco, California; West Coast Retina, San Francisco, California
| | - Michael G Rosco
- California Pacific Medical Center, Department of Ophthalmology, San Francisco, California
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