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Arrich J, Schütz N, Oppenauer J, Vendt J, Holzer M, Havel C, Herkner H. Hypothermia for neuroprotection in adults after cardiac arrest. Cochrane Database Syst Rev 2023; 5:CD004128. [PMID: 37217440 PMCID: PMC10202224 DOI: 10.1002/14651858.cd004128.pub5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND Good neurological outcome after cardiac arrest is difficult to achieve. Interventions during the resuscitation phase and treatment within the first hours after the event are critical for a favourable prognosis. Experimental evidence suggests that therapeutic hypothermia is beneficial, and several clinical studies on this topic have been published. This review was originally published in 2009; updated versions were published in 2012 and 2016. OBJECTIVES To evaluate the benefits and harms of therapeutic hypothermia after cardiac arrest in adults compared to standard treatment. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 30 September 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs in adults comparing therapeutic hypothermia after cardiac arrest with standard treatment (control). We included studies with adults cooled by any method, applied within six hours of cardiac arrest, to target body temperatures of 32 °C to 34 °C. Good neurological outcome was defined as no or only minor brain damage allowing people to live an independent life. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcome was 1. neurological recovery. Our secondary outcomes were 2. survival to hospital discharge, 3. quality of life, 4. cost-effectiveness and 5. ADVERSE EVENTS We used GRADE to assess certainty. MAIN RESULTS We found 12 studies with 3956 participants reporting the effects of therapeutic hypothermia on neurological outcome or survival. There were some concerns about the quality of all the studies, and two studies had high risk of bias overall. When we compared conventional cooling methods versus any type of standard treatment (including a body temperature of 36 °C), we found that participants in the therapeutic hypothermia group were more likely to reach a favourable neurological outcome (risk ratio (RR) 1.41, 95% confidence interval (CI) 1.12 to 1.76; 11 studies, 3914 participants). The certainty of the evidence was low. When we compared therapeutic hypothermia with fever prevention or no cooling, we found that participants in the therapeutic hypothermia group were more likely to reach a favourable neurological outcome (RR 1.60, 95% CI 1.15 to 2.23; 8 studies, 2870 participants). The certainty of the evidence was low. When we compared therapeutic hypothermia methods with temperature management at 36 °C, there was no evidence of a difference between groups (RR 1.78, 95% CI 0.70 to 4.53; 3 studies; 1044 participants). The certainty of the evidence was low. Across all studies, the incidence of pneumonia, hypokalaemia and severe arrhythmia was increased amongst participants receiving therapeutic hypothermia (pneumonia: RR 1.09, 95% CI 1.00 to 1.18; 4 trials, 3634 participants; hypokalaemia: RR 1.38, 95% CI 1.03 to 1.84; 2 trials, 975 participants; severe arrhythmia: RR 1.40, 95% CI 1.19 to 1.64; 3 trials, 2163 participants). The certainty of the evidence was low (pneumonia, severe arrhythmia) to very low (hypokalaemia). There were no differences in other reported adverse events between groups. AUTHORS' CONCLUSIONS Current evidence suggests that conventional cooling methods to induce therapeutic hypothermia may improve neurological outcomes after cardiac arrest. We obtained available evidence from studies in which the target temperature was 32 °C to 34 °C.
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Affiliation(s)
- Jasmin Arrich
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Nikola Schütz
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Julia Oppenauer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Janne Vendt
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
| | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Christof Havel
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
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Yang BY, Bulger N, Chocron R, Counts CR, Drucker C, Yin L, Parayil M, Johnson NJ, Sotoodehenia N, Kudenchuk PJ, Sayre MR, Rea TD. Analysis of Epinephrine Dose, Targeted Temperature Management, and Neurologic and Survival Outcomes Among Adults With Out-of-Hospital Cardiac Arrest. JAMA Netw Open 2022; 5:e2226191. [PMID: 35951327 PMCID: PMC9372792 DOI: 10.1001/jamanetworkopen.2022.26191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
IMPORTANCE Epinephrine improves return of spontaneous circulation after out-of-hospital cardiac arrest (OHCA). These beneficial cardiac effects do not directly translate to better neurologic outcomes, possibly because of epinephrine-induced microvascular effects that produce critical brain ischemia. OBJECTIVE To examine whether targeted temperature management (TTM) modifies the adverse association between increasing prehospital epinephrine dose and neurologically favorable survival. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed 14 612 adults from Seattle and King County, Washington, with nontraumatic OHCA between January 1, 2008, and December 31, 2018, and included those who achieved return of spontaneous circulation and were unconscious at hospital admission. Data analysis was performed from April 2021 to May 2022. EXPOSURES Epinephrine dose and TTM during prehospital resuscitation. MAIN OUTCOMES AND MEASURES Favorable neurologic survival (Cerebral Performance Category [CPC] 1 or 2) and survival to hospital discharge. RESULTS Of the 14 612 assessed adults, 5253 (median age, 63 years; IQR, 51-74 years; 3460 [65.8%] male) were eligible for the study. The median epinephrine dose was 2.0 mg (IQR, 1.0-3.0 mg); 3052 patients (58.1%) received TTM. In all, 1889 patients (36.0%) survived with CPC 1 to 2, and 2177 (41.4%) survived to discharge. Increasing doses of epinephrine were associated with a decreasing likelihood of CPC 1 to 2 (odds ratio [OR], 0.46; 95% CI 0.42-0.50 for each additional milligram of epinephrine) and survival (OR, 0.47; 95% CI, 0.43-0.51). The dose-dependent epinephrine association was modified by TTM. After adjusting for Utstein covariates, TTM was associated with a relative stepwise improvement in odds of CPC 1 to 2 (interaction OR, 1.36; 95% CI, 1.22-1.51) and survival (interaction OR, 1.37; 95% CI, 1.24-1.51). A significant interaction was also observed when the analysis was stratified according to initial rhythm among shockable OHCA and nonshockable OHCA (shockable interaction OR, 1.20; 95% CI, 1.04-1.39; and nonshockable interaction OR, 1.24, 95% CI, 1.07-1.45). CONCLUSIONS AND RELEVANCE This cohort study found an interaction between TTM and epinephrine dose such that the beneficial association of TTM increased with increasing epinephrine dose, suggesting that TTM may attenuate the adverse effects of higher-dose epinephrine.
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Affiliation(s)
- Betty Y. Yang
- Department of Emergency Medicine, University of Washington, Seattle
| | - Natalie Bulger
- Department of Emergency Medicine, University of Washington, Seattle
| | - Richard Chocron
- Department of Emergency Medicine, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris Sudden Death Expertise Center, University of Paris, Paris, France
| | | | - Chris Drucker
- Emergency Medical Services, Division of Public Health–Seattle & King County, Seattle, Washington
| | - Lihua Yin
- Emergency Medical Services, Division of Public Health–Seattle & King County, Seattle, Washington
| | - Megin Parayil
- Emergency Medical Services, Division of Public Health–Seattle & King County, Seattle, Washington
| | - Nicholas J. Johnson
- Department of Emergency Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Nona Sotoodehenia
- Division of Cardiology, Department of Medicine, University of Washington, Seattle
| | - Peter J. Kudenchuk
- Division of Cardiology, Department of Medicine, University of Washington, Seattle
| | - Michael R. Sayre
- Department of Emergency Medicine, University of Washington, Seattle
| | - Thomas D. Rea
- Emergency Medical Services, Division of Public Health–Seattle & King County, Seattle, Washington
- Division of General Medicine, Department of Medicine, University of Washington, Seattle
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3
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Mishra SB, Patnaik R, Rath A, Samal S, Dash A, Nayak B. Targeted Temperature Management in Unconscious Survivors of Postcardiac Arrest: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2022; 26:506-513. [PMID: 35656059 PMCID: PMC9067499 DOI: 10.5005/jp-journals-10071-24173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Targeted temperature management (TTM) is a vital element of postresuscitation management after cardiac arrest. Though international guidelines recommend TTM, the supporting evidence is of low certainty. Aims and objectives To estimate the effect of TTM strategy on mortality and neurological outcomes in postcardiac arrest survivors. Materials and methods Randomized controlled trials (RCTs) published in English evaluating the use of TTM in adult comatose survivors of cardiac arrest were included. Studies were categorized into two groups, based on hypothermia vs normothermia. The main outcome was death due to any origin. The secondary outcome measures evaluated neurological outcome and complications associated with TTM. Outcomes were analyzed by calculating Odds Ratio (OR) of a worse outcome. ORs with 95% CIs in a forest plot were used to show the results of random-effects meta-analyses. Results On pooled analysis of 11 RCTs, no difference was observed in death due to any origin rates in the hypothermia compared to the normothermia group (OR; 0.88, 95% CI: 0.39–1.16). Overall, no difference in poor neurological outcome was observed between the two groups (OR; 0.86, 95% CI: 0.66–1.12). Trial sequencing analysis for mortality and poor neurological outcome showed that number to achieve power to predict futility has been achieved in both the parameters. Conclusions This meta-analysis showed that hypothermia compared to normothermia TTM strategies does not improve survival or neurologic outcomes. How to cite this article Mishra SB, Patnaik R, Rath A, Samal S, Dash A, Nayak B. Targeted Temperature Management in Unconscious Survivors of Postcardiac Arrest: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2022;26(4):506–513.
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Affiliation(s)
- Shakti Bedanta Mishra
- Department of Critical Care Medicine, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Rupali Patnaik
- Department of Critical Care Medicine, IMS and SUM Hospital, Bhubaneswar, Odisha, India
- Rupali Patnaik, Department of Critical Care Medicine, IMS and SUM Hospital, Bhubaneswar, Odisha, India, Phone: +91 8921354225, e-mail:
| | - Arun Rath
- Department of Critical Care Medicine, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Samir Samal
- Department of Critical Care Medicine, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Abhilash Dash
- Department of Critical Care Medicine, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Biswajit Nayak
- Department of Critical Care Medicine, IMS and SUM Hospital, Bhubaneswar, Odisha, India
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Schneck E, Janßen G, Vaillant V, Voelker T, Dechert O, Trocan L, Schmitz L, Rohde M, Sander M, Hauch H. Cardiopulmonary resuscitation in pediatric patients under palliative home care - A multicenter retrospective study. Front Pediatr 2022; 10:1105609. [PMID: 36704133 PMCID: PMC9872029 DOI: 10.3389/fped.2022.1105609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023] Open
Abstract
Introduction: Patients under palliative home care have special needs for their end-of-life support, which in general does not automatically include cardiopulmonary resuscitation. However, emergency medical services (EMS) respond to emergencies in children under palliative care that lead to cardiopulmonary resuscitation. To understand the underlying steps of decision-making, this retrospective, cross-sectional, multicenter study aimed to analyze pediatric patients under palliative home care who had been resuscitated. Methods: This study included patients from three spezialized pediatric palliative home care (SHPC) teams. The primary study parameters were the prevalence of cardiopulmonary resuscitation and the decision-making for carrying out pediatric advanced life support (PALS). Further analyses included the causes of cardiac arrest, the type of CPR (basic life support, advanced life support), the patient´s outcome, and involvement of the SHPC in the resuscitation. Descriptive statistical analysis was performed. Results: In total, 880 pediatric patients under palliative home care were included over 8.5 years, of which 17 patients were resuscitated once and two patients twice (overall, 19 events with CPR, 21.6 per 1,000 cases). In 10 of the 19 incidents (52.6%), cardiac arrest occurred suddenly without being predictable. The causes of cardiac arrest varied widely. PALS was performed in 78.9% of the cases by EMS teams. In 12 of 19 events (63.2%) resuscitation was performed on explicit wish of the parents. However, from a medical point of view, only four resuscitation attempts were reasonable. In total 7 of 17 (41.2%) patients survived cardiac arrest with a comparable quality of life. Discussion: Overall, resuscitation attempts were rare events in children under home palliative therapy, but if they occur, EMS are often the primary caregivers. Most resuscitation attempts occurred on explicit wish of the parents independently of the meaningfulness of the medical procedure. Despite the presence of a life-limiting disease, survival with a similar quality was achieved in one third of all resuscitated patients. This study indicates that EMS should be trained for advanced life support in children under home palliative therapy and SHPC should address the scenario of cardiac arrest also in early stages of palliative treatment. These results underline that advance care planning for these children is urgently needed.
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Affiliation(s)
- Emmanuel Schneck
- Department for Anaesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University, Giessen, Hesse, Germany
| | - Gisela Janßen
- Palliative Care Team for Children, Heinrich-Heine-University, Duesseldorf, North Rhine-Westphalia, Germany
| | - Vera Vaillant
- Palliative Care Team for Children, Justus Liebig University, Giessen, Hesse, Germany
| | - Thomas Voelker
- Palliative Care Team for Children, Kleine Riesen Kassel, Kassel, Hesse, Germany
| | - Oliver Dechert
- Palliative Care Team for Children, Heinrich-Heine-University, Duesseldorf, North Rhine-Westphalia, Germany
| | - Laura Trocan
- Palliative Care Team for Children, Heinrich-Heine-University, Duesseldorf, North Rhine-Westphalia, Germany
| | - Lioba Schmitz
- Palliative Care Team for Children, Heinrich-Heine-University, Duesseldorf, North Rhine-Westphalia, Germany
| | - Marius Rohde
- Department for Pediatric Oncology and Hematology, Justus Liebig University, Giessen, Hesse, Germany
| | - Michael Sander
- Department for Anaesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University, Giessen, Hesse, Germany
| | - Holger Hauch
- Palliative Care Team for Children, Justus Liebig University, Giessen, Hesse, Germany
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Nakaya H, Okamoto R, Ogihara Y, Sato T, Ito M, Dohi K. Giant deep vein thrombus complicating endovascular cooling therapy after cardiac arrest in a boy with hypertrophic cardiomyopathy. J Cardiol Cases 2021; 23:189-191. [PMID: 33841599 DOI: 10.1016/j.jccase.2021.02.001] [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: 10/31/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 11/24/2022] Open
Abstract
Mild hypothermia therapy (33-36 °C) is useful in preventing anoxic brain injury occurring after return of spontaneous circulation among survivors of cardiac arrest. Adverse events generally include bleeding, pneumonia, bradycardia, and deep vein thrombosis (DVT). However, one rare complication is huge DVT. We recently encountered a boy with ventricular fibrillation due to hypertrophic cardiomyopathy complicated by huge DVT from bilateral common femoral veins close to the hepatic vein during endovascular cooling therapy via his femoral vein. We successfully managed this case without any complications after infusion of unfractionated heparin to maintain a relatively high activated partial thromboplastin time. <Learning objective: We should be more careful in screening for deep vein thrombosis before and after endovascular cooling therapy.>.
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Affiliation(s)
- Hitoshi Nakaya
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Ryuji Okamoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.,Regional Medical Support Center, Mie University Hospital, Tsu, Japan
| | - Yoshito Ogihara
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Toru Sato
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
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Glibenclamide and Therapeutic Hypothermia Have Comparable Effect on Attenuating Global Cerebral Edema Following Experimental Cardiac Arrest. Neurocrit Care 2019; 29:119-127. [PMID: 29150777 DOI: 10.1007/s12028-017-0479-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cerebral edema is one of the major causes of mortality following cardiac arrest (CA) and cardiopulmonary resuscitation (CPR). A subunit of the sulfonylurea receptor 1-transient receptor potential M4 (Sur1-TRPM4) channel has been implicated in the pathogenesis of ischemia-evoked cerebral edema. In this study, we examined whether glibenclamide (GBC), a Sur1-TRPM4 channel inhibitor, attenuates cerebral edema following CA/CPR and further examined the efficacy of GBC combined with therapeutic hypothermia. METHODS Isoflurane-anesthetized adult male wild-type C57Bl/6 mice subjected to 7-min CA/CPR were randomized into five groups: sham operation, control with normothermia, GBC with normothermia, control with hypothermia, and GBC with hypothermia. The primary outcome was to evaluate regional brain water content; the secondary outcome was to measure blood glucose level, Sur1-TRPM4 expression, and pro-inflammatory factor expression. RESULTS Compared with normothermia, GBC treatment or hypothermia significantly attenuated brain water content in mice subjected to CA/CPR. GBC combined with hypothermia had no additional effects on attenuating cerebral edema. Pro-inflammatory factor messenger RNA expression (TNF-α and IL-6), NFκβ activation, and SUR1-TRPM4 levels were upregulated after CA/CPR. Compared with normothermia, hypothermia, but not GBC, partly suppressed these factors' expression. CONCLUSIONS GBC attenuated cerebral edema following CA/CPR by blocking Sur1-TRPM4 channels upregulated by CA insult. The effect of GBC was comparable with that of therapeutic hypothermia alone. These results suggest that GBC is an alternative approach for treating CA-evoked cerebral edema.
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Pluta R, Ułamek-Kozioł M, Czuczwar SJ. Neuroprotective and Neurological/Cognitive Enhancement Effects of Curcumin after Brain Ischemia Injury with Alzheimer's Disease Phenotype. Int J Mol Sci 2018; 19:E4002. [PMID: 30545070 PMCID: PMC6320958 DOI: 10.3390/ijms19124002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/04/2018] [Accepted: 12/10/2018] [Indexed: 12/11/2022] Open
Abstract
In recent years, ongoing interest in ischemic brain injury research has provided data showing that ischemic episodes are involved in the development of Alzheimer's disease-like neuropathology. Brain ischemia is the second naturally occurring neuropathology, such as Alzheimer's disease, which causes the death of neurons in the CA1 region of the hippocampus. In addition, brain ischemia was considered the most effective predictor of the development of full-blown dementia of Alzheimer's disease phenotype with a debilitating effect on the patient. Recent knowledge on the activation of Alzheimer's disease-related genes and proteins-e.g., amyloid protein precursor and tau protein-as well as brain ischemia and Alzheimer's disease neuropathology indicate that similar processes contribute to neuronal death and disintegration of brain tissue in both disorders. Although brain ischemia is one of the main causes of death in the world, there is no effective therapy to improve the structural and functional outcomes of this disorder. In this review, we consider the promising role of the protective action of curcumin after ischemic brain injury. Studies of the pharmacological properties of curcumin after brain ischemia have shown that curcumin has several therapeutic properties that include anti-excitotoxic, anti-oxidant, anti-apoptotic, anti-hyperhomocysteinemia and anti-inflammatory effects, mitochondrial protection, as well as increasing neuronal lifespan and promoting neurogenesis. In addition, curcumin also exerts anti-amyloidogenic effects and affects the brain's tau protein. These results suggest that curcumin may be able to serve as a potential preventive and therapeutic agent in neurodegenerative brain disorders.
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Affiliation(s)
- Ryszard Pluta
- Laboratory of Ischemic and Neurodegenerative Brain Research, Mossakowski Medical Research Centre, Polish Academy of Sciences, 02-106 Warsaw, Poland.
| | - Marzena Ułamek-Kozioł
- Laboratory of Ischemic and Neurodegenerative Brain Research, Mossakowski Medical Research Centre, Polish Academy of Sciences, 02-106 Warsaw, Poland.
- First Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland.
| | - Stanisław J Czuczwar
- Department of Pathophysiology, Medical University of Lublin, 20-090 Lublin, Poland.
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Dietz RM, Orfila JE, Rodgers KM, Patsos OP, Deng G, Chalmers N, Quillinan N, Traystman RJ, Herson PS. Juvenile cerebral ischemia reveals age-dependent BDNF-TrkB signaling changes: Novel mechanism of recovery and therapeutic intervention. J Cereb Blood Flow Metab 2018; 38:2223-2235. [PMID: 29611441 PMCID: PMC6282214 DOI: 10.1177/0271678x18766421] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Global ischemia in childhood often leads to poor neurologic outcomes, including learning and memory deficits. Using our novel model of childhood cardiac arrest/cardiopulmonary resuscitation (CA/CPR), we investigate the mechanism of ischemia-induced cognitive deficits and recovery. Memory is impaired seven days after juvenile CA/CPR and completely recovers by 30 days. Consistent with this remarkable recovery not observed in adults, hippocampal long-term potentiation (LTP) is impaired 7-14 days after CA/CPR, recovering by 30 days. This recovery is not due to the replacement of dead neurons (neurogenesis), but rather correlates with brain-derived neurotrophic factor (BDNF) expression, implicating BDNF as the molecular mechanism underlying impairment and recovery. Importantly, delayed activation of TrkB receptor signaling reverses CA/CPR-induced LTP deficits and memory impairments. These data provide two new insights (1) endogenous recovery of memory and LTP through development may contribute to improved neurological outcome in children compared to adults and (2) BDNF-enhancing drugs speed recovery from pediatric cardiac arrest during the critical school ages.
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Affiliation(s)
- Robert M Dietz
- 1 Department of Pediatrics, 129263 University of Colorado School of Medicine, Aurora, CO, USA.,2 Neuronal Injury Program, 129263 University of Colorado School of Medicine, Aurora, CO, USA
| | - James E Orfila
- 2 Neuronal Injury Program, 129263 University of Colorado School of Medicine, Aurora, CO, USA.,3 Department of Anesthesiology, 129263 University of Colorado School of Medicine, Aurora, CO, USA
| | - Krista M Rodgers
- 2 Neuronal Injury Program, 129263 University of Colorado School of Medicine, Aurora, CO, USA.,3 Department of Anesthesiology, 129263 University of Colorado School of Medicine, Aurora, CO, USA
| | - Olivia P Patsos
- 2 Neuronal Injury Program, 129263 University of Colorado School of Medicine, Aurora, CO, USA.,3 Department of Anesthesiology, 129263 University of Colorado School of Medicine, Aurora, CO, USA
| | - Guiying Deng
- 2 Neuronal Injury Program, 129263 University of Colorado School of Medicine, Aurora, CO, USA.,3 Department of Anesthesiology, 129263 University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicholas Chalmers
- 2 Neuronal Injury Program, 129263 University of Colorado School of Medicine, Aurora, CO, USA.,3 Department of Anesthesiology, 129263 University of Colorado School of Medicine, Aurora, CO, USA
| | - Nidia Quillinan
- 2 Neuronal Injury Program, 129263 University of Colorado School of Medicine, Aurora, CO, USA.,3 Department of Anesthesiology, 129263 University of Colorado School of Medicine, Aurora, CO, USA.,4 Department of Pharmacology, 129263 University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard J Traystman
- 2 Neuronal Injury Program, 129263 University of Colorado School of Medicine, Aurora, CO, USA.,3 Department of Anesthesiology, 129263 University of Colorado School of Medicine, Aurora, CO, USA.,4 Department of Pharmacology, 129263 University of Colorado School of Medicine, Aurora, CO, USA
| | - Paco S Herson
- 2 Neuronal Injury Program, 129263 University of Colorado School of Medicine, Aurora, CO, USA.,3 Department of Anesthesiology, 129263 University of Colorado School of Medicine, Aurora, CO, USA.,4 Department of Pharmacology, 129263 University of Colorado School of Medicine, Aurora, CO, USA
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9
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A Forgotten Approach After Cardiac Arrest Due to Acute Myocardial Infarction: Neuroprotective Therapeutic Hypothermia. JOURNAL OF SURGERY AND MEDICINE 2017. [DOI: 10.28982/josam.363746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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10
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Deng G, Orfila JE, Dietz RM, Moreno-Garcia M, Rodgers KM, Coultrap SJ, Quillinan N, Traystman RJ, Bayer KU, Herson PS. Autonomous CaMKII Activity as a Drug Target for Histological and Functional Neuroprotection after Resuscitation from Cardiac Arrest. Cell Rep 2017; 18:1109-1117. [PMID: 28147268 PMCID: PMC5540152 DOI: 10.1016/j.celrep.2017.01.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 12/22/2016] [Accepted: 01/07/2017] [Indexed: 11/21/2022] Open
Abstract
The Ca2+/calmodulin-dependent protein kinase II (CaMKII) is a major mediator of physiological glutamate signaling, but its role in pathological glutamate signaling (excitotoxicity) remains less clear, with indications for both neurotoxic and neuro-protective functions. Here, the role of CaMKII in ischemic injury is assessed utilizing our mouse model of cardiac arrest and cardiopulmonary resuscitation (CA/CPR). CaMKII inhibition (with tatCN21 or tatCN19o) at clinically relevant time points (30 min after resuscitation) greatly reduces neuronal injury. Importantly, CaMKII inhibition also works in combination with mild hypothermia, the current standard of care. The relevant drug target is specifically Ca2+-independent “autonomous” CaMKII activity generated by T286 autophosphorylation, as indicated by substantial reduction in injury in autonomy-incompetent T286A mutant mice. In addition to reducing cell death, tatCN19o also protects the surviving neurons from functional plasticity impairments and prevents behavioral learning deficits, even at extremely low doses (0.01 mg/kg), further highlighting the clinical potential of our findings.
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Affiliation(s)
- Guiying Deng
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, USA; Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - James E Orfila
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, USA; Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Robert M Dietz
- Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Myriam Moreno-Garcia
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, USA; Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Krista M Rodgers
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA; Department of Pharmacology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Steve J Coultrap
- Department of Pharmacology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Nidia Quillinan
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, USA; Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Richard J Traystman
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, USA; Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO 80045, USA; Department of Pharmacology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - K Ulrich Bayer
- Department of Pharmacology, University of Colorado School of Medicine, Aurora, CO 80045, USA.
| | - Paco S Herson
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, USA; Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO 80045, USA; Department of Pharmacology, University of Colorado School of Medicine, Aurora, CO 80045, USA.
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11
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Coderch C, Díaz de Cerio M, Zapico JM, Peláez R, Larrayoz IM, Ramos A, Martínez A, de Pascual-Teresa B. In silico identification and in vivo characterization of small molecule therapeutic hypothermia mimetics. Bioorg Med Chem 2017; 25:6597-6604. [PMID: 29137939 DOI: 10.1016/j.bmc.2017.10.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 10/20/2017] [Accepted: 10/29/2017] [Indexed: 01/05/2023]
Abstract
Hypothermia has been proved to have a beneficial effect on several pathologies. CIRBP is one of the so termed cold-shock proteins involved in this process. In this work, we have detected small molecules capable of modulating the activity of CIRBP in the absence of a cold stimulus, by High Throughput Virtual Screening (HTVS) of the Diversity Set IV of the NCI and 15 compounds of our in-house data base. Fifteen compounds were selected from the HTVS to carry out a second screening through a cell-based Western blot assay. This assay, together with molecular modeling studies allowed us to select compound zr17-2 for an in vivo experiment, which showed an interesting increase of CIRBP expression in several organs of experimental animals. Therefore, we have demonstrated that the effect of hypothermia can be mimicked by small molecules, which can be developed as first-in-class new drugs for the treatment of several diseases.
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Affiliation(s)
- Claire Coderch
- Department of Chemistry and Biochemistry, Facultad de Farmacia, Universidad San Pablo-CEU, Madrid, Spain
| | - María Díaz de Cerio
- Oncology Area, Center for Biomedical Research of La Rioja (CIBIR), Logroño, Spain
| | - Jose María Zapico
- Department of Chemistry and Biochemistry, Facultad de Farmacia, Universidad San Pablo-CEU, Madrid, Spain
| | - Rafael Peláez
- Oncology Area, Center for Biomedical Research of La Rioja (CIBIR), Logroño, Spain
| | - Ignacio M Larrayoz
- Oncology Area, Center for Biomedical Research of La Rioja (CIBIR), Logroño, Spain
| | - Ana Ramos
- Department of Chemistry and Biochemistry, Facultad de Farmacia, Universidad San Pablo-CEU, Madrid, Spain
| | - Alfredo Martínez
- Oncology Area, Center for Biomedical Research of La Rioja (CIBIR), Logroño, Spain
| | - Beatriz de Pascual-Teresa
- Department of Chemistry and Biochemistry, Facultad de Farmacia, Universidad San Pablo-CEU, Madrid, Spain.
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12
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Hypothermia Prevents Retinal Damage Generated by Optic Nerve Trauma in the Rat. Sci Rep 2017; 7:6966. [PMID: 28761115 PMCID: PMC5537267 DOI: 10.1038/s41598-017-07294-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 06/26/2017] [Indexed: 11/11/2022] Open
Abstract
Ocular and periocular traumatisms may result in loss of vision. Hypothermia provides a beneficial intervention for brain and heart conditions and, here, we study whether hypothermia can prevent retinal damage caused by traumatic neuropathy. Intraorbital optic nerve crush (IONC) or sham manipulation was applied to male rats. Some animals were subjected to hypothermia (8 °C) for 3 h following surgery. Thirty days later, animals were subjected to electroretinography and behavioral tests. IONC treatment resulted in amplitude reduction of the b-wave and oscillatory potentials of the electroretinogram, whereas the hypothermic treatment significantly (p < 0.05) reversed this process. Using a descending method of limits in a two-choice visual task apparatus, we demonstrated that hypothermia significantly (p < 0.001) preserved visual acuity. Furthermore, IONC-treated rats had a lower (p < 0.0001) number of retinal ganglion cells and a higher (p < 0.0001) number of TUNEL-positive cells than sham-operated controls. These numbers were significantly (p < 0.0001) corrected by hypothermic treatment. There was a significant (p < 0.001) increase of RNA-binding motif protein 3 (RBM3) and of BCL2 (p < 0.01) mRNA expression in the eyes exposed to hypothermia. In conclusion, hypothermia constitutes an efficacious treatment for traumatic vision-impairing conditions, and the cold-shock protein pathway may be involved in mediating the beneficial effects shown in the retina.
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13
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von Ulmenstein S, Storm C, Breuer TGK, Lask S, Attanasio P, Mügge A, Wutzler A. Hypothermia induced alteration of repolarization - impact on acute and long-term outcome: a prospective cohort study. Scand J Trauma Resusc Emerg Med 2017; 25:68. [PMID: 28693536 PMCID: PMC5504768 DOI: 10.1186/s13049-017-0417-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 07/05/2017] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The effects of target temperature management (TTM) on the heart aren't thoroughly studied yet. Several studies showed the prolongation of various ECG parameters including Tpeak-Tend-time under TTM. Our study's goal is to evaluate the acute and long-term outcome of these prolongations. METHODS In this study we included patients with successful resuscitation after cardiac arrest who were admitted to the Charité Virchow Klinikum Berlin or the Heart and Vascular Centre of the Ruhr University Bochum between February 2006 and July 2013 (Berlin) or May 2014 to November 2015 (Bochum). For analysis, one ECG during TTM was recorded after reaching the target temperature (33-34 °C) or in the first 6 h of TTM. If possible, another ECG was taken after TTM. The patients were being followed until February 2016. Primary endpoint was ventricular arrhythmia during TTM, secondary endpoints were death and hospitalization due to cardiovascular diseases during follow-up. RESULTS One hundred fifty-eight patients were successfully resuscitated in the study period of which 95 patients had usable data (e.g. ECGs without artifacts). During TTM significant changes for different parameters of ventricular de- and repolarization were noted: QRS (103.2 ± 23.7 vs. 95.3 ± 18.1; p = 0.003),QT (405.8 ± 76.4 vs. 373.8 ± 75.0; p = 0.01), QTc (474.9 ± 59.7 vs. 431.0 ± 56.8; p < 0.001), JT (302.8 ± 69.4 vs. 278.5 ± 75.2; p = 0.043), JTc (354.3 ± 60.2 vs. 318.7 ± 59.1; p = 0.001). 13.7% of the patients had ventricular arrhythmias during TTM, however these patients showed no difference regarding their ECG parameters in comparison to those were no ventricular arrhythmias occurred. We were able to follow 69 Patients over an average period of 35 ± 31 months. The 14 (21.5%) patients who died during the follow-up had significant prolongations of the TpTe-time in the ECGs without TTM (103.9 ± 47.2 vs. 75.8 ± 28.6; p = 0.023). CONCLUSION Our results show a significant prolongation of ventricular repolarization during TH. However, there was no significant difference between the ECG parameters of those who developed a ventricular arrhythmia and those who did not. The temporary prolongation of the repolarization during TTM seems to be less important for the prognosis of the patient. Whereas the prolongation of the repolarization in the basal ECG is associated with a higher mortality in our study.
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Affiliation(s)
- Sophie von Ulmenstein
- Department of Cardiology, Charité - Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine, Charité - Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Thomas G K Breuer
- Department of Internal Medicine of the Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Sebastian Lask
- Heart and Vascular Center of the Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Philipp Attanasio
- Department of Cardiology, Charité - Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Andreas Mügge
- Heart and Vascular Center of the Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Alexander Wutzler
- Department of Cardiology, Charité - Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.,Heart and Vascular Center of the Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
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14
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Abstract
Over the recent period, the use of induced hypothermia has gained an increasing interest for critically ill patients, in particular in brain-injured patients. The term “targeted temperature management” (TTM) has now emerged as the most appropriate when referring to interventions used to reach and maintain a specific level temperature for each individual. TTM may be used to prevent fever, to maintain normothermia, or to lower core temperature. This treatment is widely used in intensive care units, mostly as a primary neuroprotective method. Indications are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of TTM in adult and paediatric critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de Réanimation de Langue Française [SRLF]) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d’Anesthésie Réanimation [SFAR]) with the participation of the French Emergency Medicine Association (Société Française de Médecine d’Urgence [SFMU]), the French Group for Pediatric Intensive Care and Emergencies (Groupe Francophone de Réanimation et Urgences Pédiatriques [GFRUP]), the French National Association of Neuro-Anesthesiology and Critical Care (Association Nationale de Neuro-Anesthésie Réanimation Française [ANARLF]), and the French Neurovascular Society (Société Française Neurovasculaire [SFNV]). Fifteen experts and two coordinators agreed to consider questions concerning TTM and its practical implementation in five clinical situations: cardiac arrest, traumatic brain injury, stroke, other brain injuries, and shock. This resulted in 30 recommendations: 3 recommendations were strong (Grade 1), 13 were weak (Grade 2), and 14 were experts’ opinions. After two rounds of rating and various amendments, a strong agreement from voting participants was obtained for all 30 (100%) recommendations, which are exposed in the present article.
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15
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Nürnberger A, Herkner H, Sterz F, Olsen JA, Lozano M, van Grunsven PM, Lerner EB, Persse D, Malzer R, Brouwer MA, Westfall M, Souders CM, Travis DT, Herken UR, Wik L. Observed survival benefit of mild therapeutic hypothermia reanalysing the Circulation Improving Resuscitation Care trial. Eur J Clin Invest 2017; 47:439-446. [PMID: 28407232 PMCID: PMC5488218 DOI: 10.1111/eci.12759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 04/10/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Mild therapeutic hypothermia is argued being beneficial for outcome after cardiac arrest. MATERIALS AND METHODS Retrospective analysis of Circulation Improving Resuscitation Care (CIRC) trial data to assess if therapeutic cooling to 33 ± 1 °C core temperature had an association with survival. Of 4231 adult, out-of-hospital cardiac arrests of presumed cardiac origin initially enrolled, eligibility criteria for therapeutic hypothermia were met by 1812. Logistic regression was undertaken in a stepwise fashion to account for the impact on outcome of each significant difference and for the variable of interest between the groups. RESULTS Out-of- and in-hospital cooled were 263 (15%), only after admission cooled were 230 (13%) and not cooled were 357 (20%) patients. The group cooled out of- and in hospital had 98 (37%) survivors as compared to the groups cooled in hospital only [80 (35%)] and of those not cooled [68 (19%)]. After adjusting for known covariates (sex, age, witnessed cardiac arrest, no- and low-flow time, shockable initial rhythm, random allocation, bystander cardiopulmonary resuscitation and percutaneous coronary intervention), the odds ratio for survival comparing no cooling to out-of- plus in-hospital cooling was 0·53 [95% confidence interval (CI): 0·46-0·61, P < 0·001], and comparing to in-hospital cooling only was 0·67 (95% CI: 0·50-0·89, P = 0·006). CONCLUSION Mild therapeutic hypothermia initiated out of hospital and/or in hospital was associated with improved survival within this secondary analysis of the CIRC cohort compared to no therapeutic hypothermia.
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Affiliation(s)
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Wien, Austria
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Wien, Austria
| | - Jan-Aage Olsen
- Norwegian National Advisory Unit on Prehospital Emergency Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Michael Lozano
- Hillsborough County Fire Rescue, Hillsborough County Government, Tampa, FL, USA.,Department of Emergency Medicine, Lake Erie College, Bradenton, FL, USA
| | | | - E Brooke Lerner
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David Persse
- Houston Fire Department and the Baylor College of Medicine, Houston, TX, USA
| | - Reinhard Malzer
- Wiener Rettung, Municipal Ambulance Service of Vienna, Wien, Austria
| | - Marc A Brouwer
- Department of Cardiology, Heart Lung Center, GA Nijmegen, the Netherlands
| | - Mark Westfall
- Gold Cross Ambulance Service, Appleton Neenah-Menasha and Grand Chute Fire Departments, Grand Chute, WI, USA.,Theda Clark Regional Medical Center, Neenah, WI, USA
| | - Chris M Souders
- Houston Fire Department and the Baylor College of Medicine, Houston, TX, USA
| | - David T Travis
- Hillsborough County Fire Rescue, Hillsborough County Government, Tampa, FL, USA
| | | | - Lars Wik
- Norwegian National Advisory Unit on Prehospital Emergency Medicine, Oslo University Hospital, Oslo, Norway
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16
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Crombez T, Hachimi-Idrissi S. The influence of targeted temperature management on the pharmacokinetics of drugs administered during and after cardiac arrest: a systematic review. Acta Clin Belg 2017; 72:116-122. [PMID: 28220713 DOI: 10.1080/17843286.2017.1291782] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Pharmacokinetic parameters of drugs are widely investigated under normothermic conditions and normal hemodynamic parameters. The European Resuscitation Council recommends the use of targeted temperature management (TTM) with a target temperature of 34 °C in cardiac arrest (CA) patients. The aim of this literature review is to investigate the influence of CA combined with TTM on the pharmacokinetics of drugs. Results of preclinical and clinical studies are compared with each other. Only the most important drugs, administered during CA in emergency setting, were studied. METHODS A literature search was conducted within PubMed and Google Scholar. The search terms included 'therapeutic hypothermia', 'TTM', 'drug metabolism', 'pharmacokinetics during hypothermia', 'cardiac arrest/etiology'. In Pubmed, MeSH-terms were also included: 'myocardial infarction/therapy', 'heart arrest/complications' and 'hypothermia'. To search for preclinical studies: the search terms 'pigs' and 'swine' were used. After the primary shift of relevant findings, further articles were found through references of these (snowballing method), as well as through related articles as suggested by the databases. RESULTS Due to the reduced cardiac output during TTM, most of the distribution volume ([Formula: see text]) of drugs included in this literature study is decreased. Only the [Formula: see text] of chlorzoxazone in CA rats and midazolam in non-CA patients are significantly increased during respectively deep and mild hypothermia. The renal, hepatic and biliary clearance of drugs administered during CA/TTM/hypothermia are decreased. DISCUSSION The combination of a decreased [Formula: see text] and a decrease in the metabolization/excretion of drugs during CA/TTM result in higher plasma concentrations compared to the plasma concentrations during CA without TTM.
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Affiliation(s)
- Tessa Crombez
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Said Hachimi-Idrissi
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
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17
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The Chinese Expert Consensus on Evaluation of Coma after Cardiopulmonary Resuscitation. Chin Med J (Engl) 2017; 129:2123-7. [PMID: 27569242 PMCID: PMC5009599 DOI: 10.4103/0366-6999.189054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Carlin JL, Jain S, Gizewski E, Wan TC, Tosh DK, Xiao C, Auchampach JA, Jacobson KA, Gavrilova O, Reitman ML. Hypothermia in mouse is caused by adenosine A 1 and A 3 receptor agonists and AMP via three distinct mechanisms. Neuropharmacology 2017; 114:101-113. [PMID: 27914963 PMCID: PMC5183552 DOI: 10.1016/j.neuropharm.2016.11.026] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/02/2016] [Accepted: 11/28/2016] [Indexed: 10/20/2022]
Abstract
Small mammals have the ability to enter torpor, a hypothermic, hypometabolic state, allowing impressive energy conservation. Administration of adenosine or adenosine 5'-monophosphate (AMP) can trigger a hypothermic, torpor-like state. We investigated the mechanisms for hypothermia using telemetric monitoring of body temperature in wild type and receptor knock out (Adora1-/-, Adora3-/-) mice. Confirming prior data, stimulation of the A3 adenosine receptor (AR) induced hypothermia via peripheral mast cell degranulation, histamine release, and activation of central histamine H1 receptors. In contrast, A1AR agonists and AMP both acted centrally to cause hypothermia. Commonly used, selective A1AR agonists, including N6-cyclopentyladenosine (CPA), N6-cyclohexyladenosine (CHA), and MRS5474, caused hypothermia via both A1AR and A3AR when given intraperitoneally. Intracerebroventricular dosing, low peripheral doses of Cl-ENBA [(±)-5'-chloro-5'-deoxy-N6-endo-norbornyladenosine], or using Adora3-/- mice allowed selective stimulation of A1AR. AMP-stimulated hypothermia can occur independently of A1AR, A3AR, and mast cells. A1AR and A3AR agonists and AMP cause regulated hypothermia that was characterized by a drop in total energy expenditure, physical inactivity, and preference for cooler environmental temperatures, indicating a reduced body temperature set point. Neither A1AR nor A3AR was required for fasting-induced torpor. A1AR and A3AR agonists and AMP trigger regulated hypothermia via three distinct mechanisms.
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Affiliation(s)
- Jesse Lea Carlin
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA
| | - Shalini Jain
- Mouse Metabolism Core, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA
| | - Elizabeth Gizewski
- Department of Pharmacology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Tina C Wan
- Department of Pharmacology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Dilip K Tosh
- Molecular Recognition Section, Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA
| | - Cuiying Xiao
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA
| | - John A Auchampach
- Department of Pharmacology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Kenneth A Jacobson
- Molecular Recognition Section, Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA
| | - Oksana Gavrilova
- Mouse Metabolism Core, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA
| | - Marc L Reitman
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA.
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19
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Storm C, Otto NM. Methods to safely implement hypothermia in the intensive care unit: a how-to guide. Rev Bras Ter Intensiva 2017; 28:1-4. [PMID: 27096668 PMCID: PMC4828083 DOI: 10.5935/0103-507x.20160007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/06/2015] [Indexed: 12/13/2022] Open
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20
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Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care. Neurocrit Care 2016; 24:90-6. [PMID: 26264064 DOI: 10.1007/s12028-015-0184-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Therapeutic hypothermia (TH) improves neurologic outcome in patients resuscitated from ventricular fibrillation. The purpose of this study was to evaluate TH effects on neurologic outcome in patients resuscitated from a non-shockable out-of-hospital cardiac arrest rhythm. DESIGN AND SETTING This is a retrospective cohort study of data reported to a registry in an emergency medical system in a large metropolitan region. Patients achieving field return of spontaneous circulation are transported to designated hospitals with TH protocols. PATIENTS Patients with an initial non-shockable rhythm were identified. Patients were excluded if awake in the Emergency Department or if TH was withheld due to preexisting coma or death prior to initiation. The decision to initiate TH was determined by the treating physician. MEASUREMENTS The primary outcome was survival with good neurologic outcome defined by a cerebral performance category of 1 or 2. MAIN RESULTS Of the 2772 patients treated for cardiac arrest during the study period, there were 1713 patients resuscitated from cardiac arrest with an initial non-shockable rhythm and 1432 patients met inclusion criteria. The median age was 69 years [IQR 59-82]; 802 (56%) male. TH was induced in 596 (42%) patients. Survival with good neurologic outcome was 14% in the group receiving TH, compared with 5% in those not treated with TH (risk difference = 8%, 95% CI 5-12%). The adjusted OR for a CPC 1 or 2 with TH was 2.9 (95% CI 1.9-4.4). CONCLUSION Analyzing the data collected from the registry of the standard practice in a large metropolitan region, TH is associated with improved neurologic outcome in patients resuscitated from initial non-shockable rhythms in a regionalized system for post-resuscitation care.
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21
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Shaefi S, Mittel AM, Hyam JA, Boone MD, Chen CC, Kasper EM. Hypothermia for severe traumatic brain injury in adults: Recent lessons from randomized controlled trials. Surg Neurol Int 2016; 7:103. [PMID: 28168089 PMCID: PMC5223395 DOI: 10.4103/2152-7806.194816] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 08/26/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a worldwide health concern associated with significant morbidity and mortality. In the United States, severe TBI is managed according to recommendations set forth in 2007 by the Brain Trauma Foundation (BTF), which were based on relatively low quality clinical trials. These guidelines prescribed the use of hypothermia for the management of TBI. Several randomized controlled trials (RCTs) of hypothermia for TBI have since been conducted. Despite this new literature, there is ongoing controversy surrounding the use of hypothermia for the management of severe TBI. METHODS We searched the PubMed database for all RCTs of hypothermia for TBI since 2007 with the intent to review the methodology outcomes of these trials. Furthermore, we aimed to develop evidence-based, expert opinions based on these recent studies. RESULTS We identified 8 RCTs of therapeutic hypothermia published since 2007 that focused on changes in neurologic outcomes or mortality in patients with severe TBI. The majority of these trials did not identify improvement with the use of hypothermia, though there were subgroups of patients that may have benefited from hypothermia. Differences in methodology prevented direct comparison between studies. CONCLUSIONS A growing body of literature disfavors the use of hypothermia for the management of severe TBI. In general, empiric hypothermia for severe TBI should be avoided. However, based on the results of recent trials, there may be some patients, such as those in Asian centers or with focal neurologic injury, who may benefit from hypothermia.
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Affiliation(s)
- Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Aaron M. Mittel
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jonathan A. Hyam
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - M. Dustin Boone
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Clark C. Chen
- Division of Neurosurgery, University of California, San Diego, California, USA
| | - Ekkehard M. Kasper
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Glover GW, Thomas RM, Vamvakas G, Al-Subaie N, Cranshaw J, Walden A, Wise MP, Ostermann M, Thomas-Jones E, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wetterslev J, Friberg H, Nielsen N. Intravascular versus surface cooling for targeted temperature management after out-of-hospital cardiac arrest - an analysis of the TTM trial data. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:381. [PMID: 27887653 PMCID: PMC5124238 DOI: 10.1186/s13054-016-1552-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 10/31/2016] [Indexed: 01/21/2023]
Abstract
Background Targeted temperature management is recommended after out-of-hospital cardiac arrest and may be achieved using a variety of cooling devices. This study was conducted to explore the performance and outcomes for intravascular versus surface devices for targeted temperature management after out-of-hospital cardiac arrest. Method A retrospective analysis of data from the Targeted Temperature Management trial. N = 934. A total of 240 patients (26%) managed with intravascular versus 694 (74%) with surface devices. Devices were assessed for speed and precision during the induction, maintenance and rewarming phases in addition to adverse events. All-cause mortality, as well as a composite of poor neurological function or death, as evaluated by the Cerebral Performance Category and modified Rankin scale were analysed. Results For patients managed at 33 °C there was no difference between intravascular and surface groups in the median time taken to achieve target temperature (210 [interquartile range (IQR) 180] minutes vs. 240 [IQR 180] minutes, p = 0.58), maximum rate of cooling (1.0 [0.7] vs. 1.0 [0.9] °C/hr, p = 0.44), the number of patients who reached target temperature (within 4 hours (65% vs. 60%, p = 0.30); or ever (100% vs. 97%, p = 0.47), or episodes of overcooling (8% vs. 34%, p = 0.15). In the maintenance phase, cumulative temperature deviation (median 3.2 [IQR 5.0] °C hr vs. 9.3 [IQR 8.0] °C hr, p = <0.001), number of patients ever out of range (57.0% vs. 91.5%, p = 0.006) and median time out of range (1 [IQR 4.0] hours vs. 8.0 [IQR 9.0] hours, p = <0.001) were all significantly greater in the surface group although there was no difference in the occurrence of pyrexia. Adverse events were not different between intravascular and surface groups. There was no statistically significant difference in mortality (intravascular 46.3% vs. surface 50.0%; p = 0.32), Cerebral Performance Category scale 3–5 (49.0% vs. 54.3%; p = 0.18) or modified Rankin scale 4–6 (49.0% vs. 53.0%; p = 0.48). Conclusions Intravascular and surface cooling was equally effective during induction of mild hypothermia. However, surface cooling was associated with less precision during the maintenance phase. There was no difference in adverse events, mortality or poor neurological outcomes between patients treated with intravascular and surface cooling devices. Trial registration TTM trial ClinicalTrials.gov number https://clinicaltrials.gov/ct2/show/NCT01020916NCT01020916; 25 November 2009
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Affiliation(s)
- Guy W Glover
- Department Intensive Care, Guy's and St Thomas' Hospital, King's College London, London, UK. .,Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Kings Health Partners, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Richard M Thomas
- Department of Intensive Care, University College Hospital, London, UK
| | - George Vamvakas
- Department of Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Nawaf Al-Subaie
- Department of Intensive Care, St George's Hospital, London, UK
| | - Jules Cranshaw
- Department of Intensive Care, Royal Bournemouth Hospital, Bournemouth, UK
| | - Andrew Walden
- Department of Intensive Care, Royal Berkshire Hospital, Reading, UK
| | - Matthew P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Marlies Ostermann
- Department Intensive Care, Guy's and St Thomas' Hospital, King's College London, London, UK
| | - Emma Thomas-Jones
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Tobias Cronberg
- Department of Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | - David Erlinge
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Yvan Gasche
- Department of Intensive Care, Geneva University Hospital, Geneva, Switzerland
| | - Christian Hassager
- The Heart Center, Copenhagen University Hospital, Righospitalet, Copenhagen, Denmark
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jesper Kjaergaard
- The Heart Center, Copenhagen University Hospital, Righospitalet, Copenhagen, Denmark
| | - Michael Kuiper
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Tommaso Pellis
- Department of Intensive Care, Santa Maria degli Ángeli, Pordenone, Italy
| | - Pascal Stammet
- Department of Anesthesiology and Intensive Care, Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg
| | - Michael Wanscher
- The Heart Center, Copenhagen University Hospital, Righospitalet, Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Center for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Hans Friberg
- Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Department of Anesthesiology and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
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Acute, unanticipated, and prolonged superior vena cava occlusion during pneumonectomy. J Clin Anesth 2016; 35:78-84. [PMID: 27871599 DOI: 10.1016/j.jclinane.2016.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/24/2016] [Accepted: 07/05/2016] [Indexed: 11/23/2022]
Abstract
Acute, unanticipated superior vena cava (SVC) occlusion during thoracic surgery can have profound hemodynamic consequences and lead to devastating neurologic injury. We describe the successful anesthetic management of a pneumonectomy complicated by prolonged intraoperative SVC occlusion lasting a total of 290 minutes. To our knowledge, this represents the longest reported SVC occlusion time with no subsequent neurologic sequelae. Based on our favorable outcome and a review of the relevant literature, we offer a discussion of strategies for anesthetic management.
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24
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Song L, Wei L, Zhang L, Lu Y, Wang K, Li Y. The Role of Targeted Temperature Management in Adult Patients Resuscitated from Nonshockable Cardiac Arrests: An Updated Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:2350974. [PMID: 27847808 PMCID: PMC5099489 DOI: 10.1155/2016/2350974] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/04/2016] [Accepted: 09/27/2016] [Indexed: 01/08/2023]
Abstract
Routine targeted temperature management is recommended for comatose adult patients with return of spontaneous circulation after cardiac arrest. However, the role of targeted temperature management in patients resuscitated from nonshockable cardiac arrests remains uncertain. We conducted an updated systematic review and meta-analysis to evaluate the effects of targeted temperature management in this population. Medline, EMBASE, and Cochrane databases were systematically reviewed for studies published between January 2005 and March 2016, in which targeted temperature management was compared with standard care or normothermia for adult patients resuscitated from nonshockable cardiac arrests. A total of 25 trials that included 5715 patients were identified from 10985 relevant papers. Pooled data showed that targeted temperature management not only associated with improved short-term survival (RR = 1.42, 95% CI: 1.28-1.57) and neurological function (RR = 1.63, 95% CI: 1.39-1.91) but also associated with improved long-term survival (RR = 1.64, 95% CI: 1.27-2.12) and neurological recovery (RR = 1.42, 95% CI: 1.07-1.90) in observational cohort studies. However, more frequent infectious complications were reported in hypothermia-treated patients (RR = 1.46, 95% CI: 1.26-1.70) and the quality of the evidence ranged from moderate to very low.
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Affiliation(s)
- Lijuan Song
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
| | - Liang Wei
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
| | - Lei Zhang
- Emergency Department, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Yubao Lu
- Emergency Department, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Kaifa Wang
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
| | - Yongqin Li
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
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25
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Villablanca PA, Makkiya M, Einsenberg E, Briceno DF, Panagiota C, Menegus M, Garcia M, Sims D, Ramakrishna H. Mild therapeutic hypothermia in patients resuscitated from out-of-hospital cardiac arrest: A meta-analysis of randomized controlled trials. Ann Card Anaesth 2016; 19:4-14. [PMID: 26750667 PMCID: PMC4900372 DOI: 10.4103/0971-9784.173013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
AIMS Guidelines recommend mild therapeutic hypothermia (MTH) for survivors of out-of-hospital cardiac arrest (OHCA). However, there is little literature demonstrating a survival benefit. We performed a meta-analysis of randomized controlled trials (RCTs) assessing the efficacy of MTH in patients successfully resuscitated from OHCA. MATERIALS AND METHODS Electronic databases were searched for RCT involving MTH in survivors of OHCA, and the results were put through a meta-analysis. The primary endpoint was all-cause mortality, and the secondary endpoint was favorable neurological function. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed using the Mantel-Haenszel method. A fixed-effect model was used and, if heterogeneity (I2 ) was >40, effects were analyzed using a random model. RESULTS Six RCT (n = 1400 patients) were included. Overall survival was 50.7%, and favorable neurological recovery was 45.5%. Pooled data demonstrated no significant all-cause mortality (OR, 0.81; 95% CI 0.55-1.21) or neurological recovery (OR, 0.77; 95% CI 0.47-1.24). No evidence of publication bias was observed. CONCLUSION This meta-analysis demonstrated that MTH did not confer benefit on overall survival rate and neurological recovery in patients resuscitated from OHCA.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Arizona, USA
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26
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Wang Y, Song J, Liu Y, Li Y, Liu Z. Mild Hypothermia Protects Pigs' Gastric Mucosa After Cardiopulmonary Resuscitation via Inhibiting Interleukin 6 (IL-6) Production. Med Sci Monit 2016; 22:3523-3528. [PMID: 27694796 PMCID: PMC5063424 DOI: 10.12659/msm.899688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background The purpose of this study was to determine the effect of mild hypothermia therapy on gastric mucosa after cardiopulmonary resuscitation (CPR) and the underlying mechanism. Material/Methods Ventricular fibrillation was induced in pigs. After CPR, the surviving pigs were divided into mild hypothermia-treated and control groups. The changes in vital signs and hemodynamic parameters were monitored before cardiac arrest and at intervals of 0.5, 1, 2, 4, 6, 12, and 24 h after restoration of spontaneous circulation. Serum IL-6 was determined at the same time, and gastroscopy was performed. The pathologic changes were noted, and the expression of IL-6 was determined by hematoxylin and eosin (HE) staining and immunohistochemistry under light. Results The heart rate, mean arterial blood pressure, and cardiac output in both groups did not differ significantly. The gastric mucosa ulcer index evaluated by gastroscopy 2 h and 24 h after restoration of spontaneous circulation (ROSC) in the mild hypothermic group was lower than that the control group (P<0.05). The inflammatory pathologic score of gastric mucosa in the mild hypothermic group 6–24 h after ROSC was lower than that in the control group (P<0.05). Serum and gastric mucosa IL-6 expression 0.5–4 h and 6, 12, and 24 h after ROSC was lower in the mild hypothermic group than in the control group (P<0.05). Conclusions Mild hypothermia treatment protects gastric mucosa after ROSC via inhibiting IL-6 production and relieving the inflammatory reaction.
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Affiliation(s)
- Yan Wang
- Department of Digestion, Beijing Chaoyang Hospital Affiliated to Capital Medical University, Beijing, China (mainland)
| | - Jian Song
- Department of Gastroenterology and Hepatology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, Ningbo, Zhejiang, China (mainland)
| | - Yuhong Liu
- Department of Digestion, Beijing Chaoyang Hospital Affiliated to Capital Medical University, Beijing, China (mainland)
| | - Yaqiang Li
- Department of Digestion, Beijing Lu He Hospital Affiliated to Capital Medical University, Beijing, China (mainland)
| | - Zhengxin Liu
- Department of Digestion, Beijing Chaoyang Hospital Affiliated to Capital Medical University, Beijing, China (mainland)
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27
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Bonaventura J, Alan D, Vejvoda J, Honek J, Veselka J. History and current use of mild therapeutic hypothermia after cardiac arrest. Arch Med Sci 2016; 12:1135-1141. [PMID: 27695505 PMCID: PMC5016592 DOI: 10.5114/aoms.2016.61917] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 08/05/2015] [Indexed: 11/17/2022] Open
Abstract
In spite of many years of development and implementation of pre-hospital advanced life support programmes, the survival rate of out-of-hospital cardiac arrest (OHCA) used to be very poor. Neurologic injury from cerebral hypoxia is the most common cause of death in patients with OHCA. In the past two decades, post-resuscitation care has developed many new concepts aimed at improving the neurological outcome and survival rate of patients after cardiac arrest. Systematic post-cardiac arrest care after the return of spontaneous circulation, including induced mild therapeutic hypothermia (TH) in selected patients, is aimed at significantly improving rates of long-term neurologically intact survival. This review summarises the history and current knowledge in the field of mild TH after OHCA.
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Affiliation(s)
- Jiří Bonaventura
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - David Alan
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Jiri Vejvoda
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Jakub Honek
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Josef Veselka
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
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Sutton RM, French B, Meaney PA, Topjian AA, Parshuram CS, Edelson DP, Schexnayder S, Abella BS, Merchant RM, Bembea M, Berg RA, Nadkarni VM. Physiologic monitoring of CPR quality during adult cardiac arrest: A propensity-matched cohort study. Resuscitation 2016; 106:76-82. [PMID: 27350369 PMCID: PMC4996723 DOI: 10.1016/j.resuscitation.2016.06.018] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 06/04/2016] [Accepted: 06/20/2016] [Indexed: 10/21/2022]
Abstract
AIM The American Heart Association (AHA) recommends monitoring cardiopulmonary resuscitation (CPR) quality using end tidal carbon dioxide (ETCO2) or invasive hemodynamic data. The objective of this study was to evaluate the association between clinician-reported physiologic monitoring of CPR quality and patient outcomes. METHODS Prospective observational study of index adult in-hospital CPR events using the AHA's Get With The Guidelines - Resuscitation Registry. Physiologic monitoring was defined using specific database questions regarding use of either ETCO2 or arterial diastolic blood pressure (DBP) to monitor CPR quality. Logistic regression was used to evaluate the association between physiologic monitoring and outcomes in a propensity score matched cohort. RESULTS In the matched cohort, (monitored n=3032; not monitored n=6064), physiologic monitoring of CPR quality was associated with a higher rate of return of spontaneous circulation (ROSC; OR 1.22, CI95 1.04-1.43, p=0.017) compared to no monitoring. Survival to hospital discharge (OR 1.04, CI95 0.91-1.18, p=0.57) and survival with favorable neurological outcome (OR 0.97, CI95 0.75-1.26, p=0.83) were not different between groups. Of index events with only ETCO2 monitoring indicated (n=803), an ETCO2 >10mmHg during CPR was reported in 520 (65%), and associated with improved survival to hospital discharge (OR 2.41, CI95 1.35-4.30, p=0.003), and survival with favorable neurological outcome (OR 2.31, CI95 1.31-4.09, p=0.004) compared to ETCO2 ≤10mmHg. CONCLUSION Clinician-reported use of either ETCO2 or DBP to monitor CPR quality was associated with improved ROSC. An ETCO2 >10mmHg during CPR was associated with a higher rate of survival compared to events with ETCO2 ≤10mmHg.
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Affiliation(s)
- Robert M Sutton
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Benjamin French
- University of Pennsylvania School of Medicine, Department of Biostatistics and Epidemiology, 423 Guardian Drive, Philadelphia, PA 19104, United States
| | - Peter A Meaney
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Alexis A Topjian
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Christopher S Parshuram
- Hospital for Sick Children, Department of Pediatrics 555 University Avenue, Toronto, Ontario, Canada
| | - Dana P Edelson
- University of Chicago, Department of Emergency Medicine, 5841 S. Maryland Avenue, Chicago, IL 60637, United States
| | - Stephen Schexnayder
- University of Arkansas College of Medicine/Arkansas Children's Hospital, Department of Pediatrics, One Children's Way, S-4415, Little Rock, AR 72202, United States
| | - Benjamin S Abella
- The Hospital of the University of Pennsylvania, Department of Emergency Medicine, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Raina M Merchant
- The Hospital of the University of Pennsylvania, Department of Emergency Medicine, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Melania Bembea
- Johns Hopkins Hospital/The Charlotte R. Bloomberg Children's Center, 1800 Orleans Street, Suite 6318B Baltimore, MD 21287, United States
| | - Robert A Berg
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Vinay M Nadkarni
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
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29
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Modisett KL, Walsh SJ, Heffner AC, Pearson DA, Kerns W. Outcomes in Cardiac Arrest Patients due to Toxic Exposure Treated with Therapeutic Hypothermia. J Med Toxicol 2016; 12:263-9. [PMID: 26856349 PMCID: PMC4996781 DOI: 10.1007/s13181-016-0536-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 01/12/2016] [Accepted: 01/26/2016] [Indexed: 01/10/2023] Open
Abstract
The incidence and outcome of patients who undergo therapeutic hypothermia (TH) after toxin-induced cardiac arrest (TICA) is not previously described. Our study aimed to describe the incidence, epidemiologic characteristics, and outcomes of patients who experience TICA in a dedicated clinical pathway for post-cardiac arrest care between November 2007 and February 2013. All patients were treated in an evidence-based clinical pathway that included TH. Database and medical records were independently reviewed by investigators to ascertain TICA. TICA was defined as cardiac arrest (CA) directly and immediately caused by a xenobiotic exposure. All patients were enrolled at Carolinas Medical Center, an urban 874-bed teaching hospital that serves as a regional cardiac resuscitation center. All patients were adult victims of cardiac arrest who had obtained return of spontaneous circulation and were enrolled in a clinical pathway for post-cardiac arrest care that included TH. Three hundred eighty-nine patients underwent treatment following CA during the study period and 48 (12 %) were deemed TICA. Patients who suffered TICA were slightly younger, less likely to have an initial shockable rhythm, and less likely to receive bystander CPR as compared to non-toxic cases. TICA accounted for a significant proportion of patients in this study. Additional, larger studies are needed to fully elucidate the optimal role for TH in TICA.
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Affiliation(s)
- Katharine L Modisett
- Department of Pulmonary and Critical Care Medicine, MedStar Washington Hospital Center, 110 Irving Street NW, 2A-68B, Washington, DC, 20010, USA.
| | - Steven J Walsh
- Division of Medical Toxicology, Department of Emergency Medicine, Einstein Medical Center, Korman Research Building, Suite B-9, 5501 Old York Road, Philadelphia, PA, 19141, USA
| | - Alan C Heffner
- Department of Emergency Medicine, Department of Internal Medicine, Division of Critical Care Medicine, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - David A Pearson
- Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - William Kerns
- Department of Emergency Medicine, Division of Medical Toxicology, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
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Larrayoz IM, Rey-Funes M, Contartese DS, Rolón F, Sarotto A, Dorfman VB, Loidl CF, Martínez A. Cold Shock Proteins Are Expressed in the Retina Following Exposure to Low Temperatures. PLoS One 2016; 11:e0161458. [PMID: 27556928 PMCID: PMC4996528 DOI: 10.1371/journal.pone.0161458] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 08/05/2016] [Indexed: 12/05/2022] Open
Abstract
Hypothermia has been proposed as a therapeutic intervention for some retinal conditions, including ischemic insults. Cold exposure elevates expression of cold-shock proteins (CSP), including RNA-binding motif protein 3 (RBM3) and cold inducible RNA-binding protein (CIRP), but their presence in mammalian retina is so far unknown. Here we show the effects of hypothermia on the expression of these CSPs in retina-derived cell lines and in the retina of newborn and adult rats. Two cell lines of retinal origin, R28 and mRPE, were exposed to 32°C for different time periods and CSP expression was measured by qRT-PCR and Western blotting. Neonatal and adult Sprague-Dawley rats were exposed to a cold environment (8°C) and expression of CSPs in their retinas was studied by Western blotting, multiple inmunofluorescence, and confocal microscopy. RBM3 expression was upregulated by cold in both R28 and mRPE cells in a time-dependent fashion. On the other hand, CIRP was upregulated in R28 cells but not in mRPE. In vivo, expression of CSPs was negligible in the retina of newborn and adult rats kept at room temperature (24°C). Exposure to a cold environment elicited a strong expression of both proteins, especially in retinal pigment epithelium cells, photoreceptors, bipolar, amacrine and horizontal cells, Müller cells, and ganglion cells. In conclusion, CSP expression rapidly rises in the mammalian retina following exposure to hypothermia in a cell type-specific pattern. This observation may be at the basis of the molecular mechanism by which hypothermia exerts its therapeutic effects in the retina.
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Affiliation(s)
- Ignacio M. Larrayoz
- Angiogenesis Study Group, Center for Biomedical Research of La Rioja (CIBIR), 26006, Logroño, Spain
- * E-mail:
| | - Manuel Rey-Funes
- Laboratorio de Neuropatología Experimental, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis” (IBCN), Facultad de Medicina, Universidad de Buenos Aires, CONICET, Paraguay 2155 (C1428ABG), Ciudad Autónoma de Buenos Aires, Argentina
| | - Daniela S. Contartese
- Laboratorio de Neuropatología Experimental, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis” (IBCN), Facultad de Medicina, Universidad de Buenos Aires, CONICET, Paraguay 2155 (C1428ABG), Ciudad Autónoma de Buenos Aires, Argentina
| | - Federico Rolón
- Laboratorio de Neuropatología Experimental, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis” (IBCN), Facultad de Medicina, Universidad de Buenos Aires, CONICET, Paraguay 2155 (C1428ABG), Ciudad Autónoma de Buenos Aires, Argentina
| | - Anibal Sarotto
- Laboratorio de Neuropatología Experimental, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis” (IBCN), Facultad de Medicina, Universidad de Buenos Aires, CONICET, Paraguay 2155 (C1428ABG), Ciudad Autónoma de Buenos Aires, Argentina
| | - Veronica B. Dorfman
- Centro de Estudios Biomédicos, Biotecnológicos, Ambientales y Diagnóstico (CEBBAD), Universidad Maimónides, Hidalgo 775 (C1405BCK), Ciudad Autónoma de Buenos Aires, Argentina
| | - Cesar F. Loidl
- Laboratorio de Neuropatología Experimental, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis” (IBCN), Facultad de Medicina, Universidad de Buenos Aires, CONICET, Paraguay 2155 (C1428ABG), Ciudad Autónoma de Buenos Aires, Argentina
- Laboratorio de Neurociencia, Facultad de Ciencias Médicas, Universidad Católica de Cuyo. San Juan, Argentina
| | - Alfredo Martínez
- Angiogenesis Study Group, Center for Biomedical Research of La Rioja (CIBIR), 26006, Logroño, Spain
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Nakajima Y. Controversies in the temperature management of critically ill patients. J Anesth 2016; 30:873-83. [PMID: 27351982 DOI: 10.1007/s00540-016-2200-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 06/04/2016] [Indexed: 11/30/2022]
Abstract
Although body temperature is a classic primary vital sign, its value has received little attention compared with the others (blood pressure, heart rate, and respiratory rate). This may result from the fact that unlike the other primary vital signs, aging and diseases rarely affect the thermoregulatory system. Despite this, when humans are exposed to various anesthetics and analgesics and acute etiologies of non-infectious and infectious diseases in perioperative and intensive care settings, abnormalities may occur that shift body temperature up and down. A recent upsurge in clinical evidence in the perioperative and critical care field resulted in many clinical trials in temperature management. The results of these clinical trials suggest that aggressive body temperature modifications in comatose survivors after resuscitation from shockable rhythm, and permissive fever in critically ill patients, are carried out in critical care settings to improve patient outcomes; however, its efficacy remains to be elucidated. A recent, large multicenter randomized controlled trial demonstrated contradictory results, which may disrupt the trends in clinical practice. Thus, updated information concerning thermoregulatory interventions is essential for anesthesiologists and intensivists. Here, recent controversies in therapeutic hypothermia and fever management are summarized, and their relevance to the physiology of human thermoregulation is discussed.
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Affiliation(s)
- Yasufumi Nakajima
- Department of Anesthesiology and Intensive Care, Kansai Medical University, Shinmachi 2-3-1, Hirakata, Osaka, 573-1191, Japan.
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Xiang Y, Zhao H, Wang J, Zhang L, Liu A, Chen Y. Inflammatory mechanisms involved in brain injury following cardiac arrest and cardiopulmonary resuscitation. Biomed Rep 2016; 5:11-17. [PMID: 27330748 DOI: 10.3892/br.2016.677] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 04/25/2016] [Indexed: 12/24/2022] Open
Abstract
Cardiac arrest (CA) is a leading cause of fatality and long-term disability worldwide. Recent advances in cardiopulmonary resuscitation (CPR) have improved survival rates; however, the survivors are prone to severe neurological injury subsequent to successful CPR following CA. Effective therapeutic options to protect the brain from CA remain limited, due to the complexities of the injury cascades caused by global cerebral ischemia/reperfusion (I/R). Although the precise mechanisms of neurological impairment following CA-initiated I/R injury require further clarification, evidence supports that one of the key cellular pathways of cerebral injury is inflammation. The inflammatory response is orchestrated by activated glial cells in response to I/R injury. Increased release of danger-associated molecular pattern molecules and cellular dysfunction in activated microglia and astrocytes contribute to ischemia-induced cytotoxic and pro-inflammatory cytokines generation, and ultimately to delayed death of neurons. Furthermore, cytokines and adhesion molecules generated within activated microglia, as well as astrocytes, are involved in the innate immune response; modulate influx of peripheral immune and inflammatory cells into the brain, resulting in neurological injury. The present review discusses the molecular aspects of immune and inflammatory mechanisms in global cerebral I/R injury following CA and CPR, and the potential therapeutic strategies that target neuroinflammation and the innate immune system.
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Affiliation(s)
- Yanxiao Xiang
- Department of Clinical Pharmacy, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China; Department of Emergency, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Hua Zhao
- Department of Orthopedics, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Jiali Wang
- Chest Pain Center, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China; Institute of Emergency and Critical Care Medicine, Shandong University, Jinan, Shandong 250012, P.R. China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Luetao Zhang
- Chest Pain Center, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China; Institute of Emergency and Critical Care Medicine, Shandong University, Jinan, Shandong 250012, P.R. China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Anchang Liu
- Department of Clinical Pharmacy, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Yuguo Chen
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China; Chest Pain Center, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China; Institute of Emergency and Critical Care Medicine, Shandong University, Jinan, Shandong 250012, P.R. China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
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Olai H, Thornéus G, Watson H, Macleod MR, Friberg H, Rhodes J, Nielsen N, Cronberg T, Deierborg T. Protocol for meta-analysis of temperature reduction in animal models of cardiac arrest. ACTA ACUST UNITED AC 2016; 3:e00014. [PMID: 27610239 PMCID: PMC4994256 DOI: 10.1002/ebm2.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 02/18/2016] [Accepted: 03/01/2016] [Indexed: 01/31/2023]
Abstract
Targeted temperature management (TTM) of 32–34 °C has been the standard treatment for out‐of‐hospital cardiac arrest since clinical trials in 2002 showed benefits to survival and neurological outcome. Recently, this treatment has been challenged by another clinical trial showing no difference in outcome between TTM of 33 °C and 36 °C. This protocol describes the methodology for a meta‐analysis detailing temperature‐reducing interventions to treat global ischaemia in animal models. By combining relevant data sets in the literature, we will explore the experimental evidence for TTM. Our aims are to explain possible translational gaps and provide methodological considerations for future experimental research and clinical trials.
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Affiliation(s)
- H Olai
- Department of Experimental Medical Science Experimental Neuroinflammation Laboratory Lund Sweden
| | - G Thornéus
- Department of Experimental Medical Science Experimental Neuroinflammation Laboratory Lund Sweden
| | - H Watson
- Department of Experimental Medical Science Experimental Neuroinflammation Laboratory Lund Sweden
| | - M R Macleod
- Centre for Clinical Brain Sciences University of Edinburgh Edinburgh UK
| | - H Friberg
- Department of Anesthesia and Intensive Care Skåne University Hospital Lund Sweden; Department of Clinical Sciences Lund University Lund Sweden
| | - J Rhodes
- Department of Critical Care, Anaesthesia and Pain Medicine University of Edinburgh Edinburgh UK; Intensive Care and Anaesthesia Western General Hospital Edinburgh UK
| | - N Nielsen
- Department of Clinical Sciences Lund University Lund Sweden; Department of Anaesthesia and Intensive Care Helsingborg Hospital Helsingborg Sweden
| | - T Cronberg
- Department of Clinical Sciences Lund University Lund Sweden; Department of Neurology Skåne University Hospital Lund Sweden
| | - T Deierborg
- Department of Experimental Medical Science Experimental Neuroinflammation Laboratory Lund Sweden
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Fukuda T. Targeted temperature management for adult out-of-hospital cardiac arrest: current concepts and clinical applications. J Intensive Care 2016; 4:30. [PMID: 27123306 PMCID: PMC4847228 DOI: 10.1186/s40560-016-0139-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 02/04/2016] [Indexed: 11/25/2022] Open
Abstract
Targeted temperature management (TTM) (primarily therapeutic hypothermia (TH)) after out-of-hospital cardiac arrest (OHCA) has been considered effective, especially for adult-witnessed OHCA with a shockable initial rhythm, based on pathophysiology and on several clinical studies (especially two randomized controlled trials (RCTs) published in 2002). However, a recently published large RCT comparing TTM at 33 °C (TH) and TTM at 36 °C (normothermia) showed no advantage of 33 °C over 36 °C. Thus, this RCT has complicated the decision to perform TH after cardiac arrest. The results of this RCT are sometimes interpreted fever control alone is sufficient to improve outcomes after cardiac arrest because fever control was not strictly performed in the control groups of the previous two RCTs that showed an advantage for TH. Although this may be possible, another interpretation that the optimal target temperature for TH is much lower than 33 °C may be also possible. Additionally, there are many points other than target temperature that are unknown, such as the optimal timing to initiate TTM, the period between OHCA and initiating TTM, the period between OHCA and achieving the target temperature, the duration of maintaining the target temperature, the TTM technique, the rewarming method, and the management protocol after rewarming. RCTs are currently underway to shed light on several of these underexplored issues. In the present review, we examine how best to perform TTM after cardiac arrest based on the available evidence.
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Affiliation(s)
- Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
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Dietz RM, Deng G, Orfila JE, Hui X, Traystman RJ, Herson PS. Therapeutic hypothermia protects against ischemia-induced impairment of synaptic plasticity following juvenile cardiac arrest in sex-dependent manner. Neuroscience 2016; 325:132-41. [PMID: 27033251 DOI: 10.1016/j.neuroscience.2016.03.052] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 03/18/2016] [Accepted: 03/22/2016] [Indexed: 10/22/2022]
Abstract
Pediatric cardiac arrest (CA) often leads to poor neurologic outcomes, including deficits in learning and memory. The only approved treatment for CA is therapeutic hypothermia, although its utility in the pediatric population remains unclear. This study analyzed the effect of mild therapeutic hypothermia after CA in juvenile mice on hippocampal neuronal injury and the cellular model of learning and memory, termed long-term potentiation (LTP). Juvenile mice were subjected to cardiac arrest and cardiopulmonary resuscitation (CA/CPR) followed by normothermia (37°C) and hypothermia (30°C, 32°C). Histological injury of hippocampal CA1 neurons was performed 3days after resuscitation using hematoxylin and eosin (H&E) staining. Field excitatory post-synaptic potentials (fEPSPs) were recorded from acute hippocampal slices 7days after CA/CPR to determine LTP. Synaptic function was impaired 7days after CA/CPR. Mice exposed to hypothermia showed equivalent neuroprotection, but exhibited sexually dimorphic protection against ischemia-induced impairment of LTP. Hypothermia (32°C) protects synaptic plasticity more effectively in females, with males requiring a deeper level of hypothermia (30°C) for equivalent protection. In conclusion, male and female juvenile mice exhibit equivalent neuronal injury following CA/CPR and hypothermia protects both males and females. We made the surprising finding that juvenile mice have a sexually dimorphic response to mild therapeutic hypothermia protection of synaptic function, where males may need a deeper level of hypothermia for equivalent synaptic protection.
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Affiliation(s)
- R M Dietz
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA; Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - G Deng
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - J E Orfila
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - X Hui
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - R J Traystman
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Pharmacology, University of Colorado School of Medicine, Aurora, CO, USA; Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - P S Herson
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Pharmacology, University of Colorado School of Medicine, Aurora, CO, USA; Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO, USA.
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Induced Hypothermia: Implications for Free Flap Survival. Arch Plast Surg 2016; 43:212-4. [PMID: 27019815 PMCID: PMC4807178 DOI: 10.5999/aps.2016.43.2.212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 12/14/2015] [Indexed: 11/20/2022] Open
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Giuliani E, Magnoni S, Fei M, Addis A, Zanasi R, Stocchetti N, Barbieri A. A Novel Cooling Device for Targeted Brain Temperature Control and Therapeutic Hypothermia: Feasibility Study in an Animal Model. Neurocrit Care 2016; 25:464-472. [PMID: 26927280 PMCID: PMC5138276 DOI: 10.1007/s12028-016-0257-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Therapeutic hypothermia (i.e., temperature management) is an effective option for improving survival and neurological outcome after cardiac arrest and is potentially useful for the care of the critically ill neurological patient. We analyzed the feasibility of a device to control the temperature of the brain by controlling the temperature of the blood flowing through the neck. Methods A lumped parameter dynamic model, with one-dimensional heat transfer, was used to predict cooling effects and to test experimental hypotheses. The cooling system consisted of a flexible collar and was tested on 4 adult sheep, in which brain and body temperatures were invasively monitored for the duration of the experiment. Results Model-based simulations predicted a lowering of the temperature of the brain and the body following the onset of cooling, with a rate of 0.4 °C/h for the brain and 0.2 °C/h for the body. The experimental findings showed comparable cooling rates in the two body compartments, with temperature reductions of 0.6 (0.2) °C/h for the brain and 0.6 (0.2) °C/h for the body. For a 70 kg adult human subject, we predict a temperature reduction of 0.64 °C/h for the brain and 0.43 °C/h for the body. Conclusions This work demonstrates the feasibility of using a non-invasive method to induce brain hypothermia using a portable collar. This device demonstrated an optimal safety profile and represents a potentially useful method for the administration of mild hypothermia and temperature control (i.e., treatment of hyperpyrexia) in cardiac arrest and critically ill neurologic patients. Electronic supplementary material The online version of this article (doi:10.1007/s12028-016-0257-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- E Giuliani
- Neuron Guard S.r.l., Via L. Castelvetro 15, 41124, Modena, Italy.
| | - S Magnoni
- Department of Anesthesiology and Intensive Care, Ospedale Fondazione IRCCS, Ca' Granda, Milan, Italy
| | - M Fei
- Neuron Guard S.r.l., Via L. Castelvetro 15, 41124, Modena, Italy
| | - A Addis
- CRABCC, Biotechnology Research Center for Cardiothoracic Applications, Rivolta d'Adda, CR, Italy
| | - R Zanasi
- Department of Engineering, University of Modena and Reggio Emilia, Modena, Italy
| | - N Stocchetti
- Department of Anesthesiology and Intensive Care, Ospedale Fondazione IRCCS, Ca' Granda, Milan, Italy.,Milan University, Milan, Italy
| | - A Barbieri
- Department of Anesthesiology and Intensive Care, University of Modena and Reggio Emilia, Modena, Italy
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Arrich J, Holzer M, Havel C, Müllner M, Herkner H. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database Syst Rev 2016; 2:CD004128. [PMID: 26878327 PMCID: PMC6516972 DOI: 10.1002/14651858.cd004128.pub4] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Good neurological outcome after cardiac arrest is difficult to achieve. Interventions during the resuscitation phase and treatment within the first hours after the event are critical. Experimental evidence suggests that therapeutic hypothermia is beneficial, and several clinical studies on this topic have been published. This review was originally published in 2009; updated versions were published in 2012 and 2016. OBJECTIVES We aimed to perform a systematic review and meta-analysis to assess the influence of therapeutic hypothermia after cardiac arrest on neurological outcome, survival and adverse events. SEARCH METHODS We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10); MEDLINE (1971 to May 2015); EMBASE (1987 to May 2015); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1988 to May 2015); and BIOSIS (1989 to May 2015). We contacted experts in the field to ask for information on ongoing, unpublished or published trials on this topic.The original search was performed in January 2007. SELECTION CRITERIA We included all randomized controlled trials (RCTs) conducted to assess the effectiveness of therapeutic hypothermia in participants after cardiac arrest, without language restrictions. We restricted studies to adult populations cooled by any cooling method, applied within six hours of cardiac arrest. DATA COLLECTION AND ANALYSIS We entered validity measures, interventions, outcomes and additional baseline variables into a database. Meta-analysis was performed only for a subset of comparable studies with negligible heterogeneity. We assessed the quality of the evidence by using standard methodological procedures as expected by Cochrane and incorporated the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. MAIN RESULTS We found six RCTs (1412 participants overall) conducted to evaluate the effects of therapeutic hypothermia - five on neurological outcome and survival, one on only neurological outcome. The quality of the included studies was generally moderate, and risk of bias was low in three out of six studies. When we compared conventional cooling methods versus no cooling (four trials; 437 participants), we found that participants in the conventional cooling group were more likely to reach a favourable neurological outcome (risk ratio (RR) 1.94, 95% confidence interval (CI) 1.18 to 3.21). The quality of the evidence was moderate.Across all studies that used conventional cooling methods rather than no cooling (three studies; 383 participants), we found a 30% survival benefit (RR 1.32, 95% CI 1.10 to 1.65). The quality of the evidence was moderate.Across all studies, the incidence of pneumonia (RR 1.15, 95% CI 1.02 to 1.30; two trials; 1205 participants) and hypokalaemia (RR 1.38, 95% CI 1.03 to 1.84; two trials; 975 participants) was slightly increased among participants receiving therapeutic hypothermia, and we observed no significant differences in reported adverse events between hypothermia and control groups. Overall the quality of the evidence was moderate (pneumonia) to low (hypokalaemia). AUTHORS' CONCLUSIONS Evidence of moderate quality suggests that conventional cooling methods provided to induce mild therapeutic hypothermia improve neurological outcome after cardiac arrest, specifically with better outcomes than occur with no temperature management. We obtained available evidence from studies in which the target temperature was 34°C or lower. This is consistent with current best medical practice as recommended by international resuscitation guidelines for hypothermia/targeted temperature management among survivors of cardiac arrest. We found insufficient evidence to show the effects of therapeutic hypothermia on participants with in-hospital cardiac arrest, asystole or non-cardiac causes of arrest.
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Affiliation(s)
- Jasmin Arrich
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20 / 6DViennaAustria1090
| | - Michael Holzer
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20 / 6DViennaAustria1090
| | - Christof Havel
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20 / 6DViennaAustria1090
| | - Marcus Müllner
- Internistisches Zentrum BrigittenauTreustrasse 43ViennaAustria1200
| | - Harald Herkner
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20 / 6DViennaAustria1090
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Carlin JL, Tosh DK, Xiao C, Piñol RA, Chen Z, Salvemini D, Gavrilova O, Jacobson KA, Reitman ML. Peripheral Adenosine A3 Receptor Activation Causes Regulated Hypothermia in Mice That Is Dependent on Central Histamine H1 Receptors. J Pharmacol Exp Ther 2016; 356:474-82. [PMID: 26606937 PMCID: PMC4746492 DOI: 10.1124/jpet.115.229872] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 11/23/2015] [Indexed: 11/22/2022] Open
Abstract
Adenosine can induce hypothermia, as previously demonstrated for adenosine A1 receptor (A1AR) agonists. Here we use the potent, specific A3AR agonists MRS5698, MRS5841, and MRS5980 to show that adenosine also induces hypothermia via the A3AR. The hypothermic effect of A3AR agonists is independent of A1AR activation, as the effect was fully intact in mice lacking A1AR but abolished in mice lacking A3AR. A3AR agonist-induced hypothermia was attenuated by mast cell granule depletion, demonstrating that the A3AR hypothermia is mediated, at least in part, via mast cells. Central agonist dosing had no clear hypothermic effect, whereas peripheral dosing of a non-brain-penetrant agonist caused hypothermia, suggesting that peripheral A3AR-expressing cells drive the hypothermia. Mast cells release histamine, and blocking central histamine H1 (but not H2 or H4) receptors prevented the hypothermia. The hypothermia was preceded by hypometabolism and mice with hypothermia preferred a cooler environmental temperature, demonstrating that the hypothermic state is a coordinated physiologic response with a reduced body temperature set point. Importantly, hypothermia is not required for the analgesic effects of A3AR agonists, which occur with lower agonist doses. These results support a mechanistic model for hypothermia in which A3AR agonists act on peripheral mast cells, causing histamine release, which stimulates central histamine H1 receptors to induce hypothermia. This mechanism suggests that A3AR agonists will probably not be useful for clinical induction of hypothermia.
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Affiliation(s)
- Jesse Lea Carlin
- Diabetes, Endocrinology, and Obesity Branch (J.L.C., C.X., R.A.P., M.L.R.), Molecular Recognition Section, Laboratory of Bioorganic Chemistry (D.K.T., K.A.J.), and Mouse Metabolism Core (O.G.), National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; and Department of Pharmacological and Physiological Science, Saint Louis University School of Medicine, St. Louis, Missouri (Z.C., D.S.)
| | - Dilip K Tosh
- Diabetes, Endocrinology, and Obesity Branch (J.L.C., C.X., R.A.P., M.L.R.), Molecular Recognition Section, Laboratory of Bioorganic Chemistry (D.K.T., K.A.J.), and Mouse Metabolism Core (O.G.), National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; and Department of Pharmacological and Physiological Science, Saint Louis University School of Medicine, St. Louis, Missouri (Z.C., D.S.)
| | - Cuiying Xiao
- Diabetes, Endocrinology, and Obesity Branch (J.L.C., C.X., R.A.P., M.L.R.), Molecular Recognition Section, Laboratory of Bioorganic Chemistry (D.K.T., K.A.J.), and Mouse Metabolism Core (O.G.), National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; and Department of Pharmacological and Physiological Science, Saint Louis University School of Medicine, St. Louis, Missouri (Z.C., D.S.)
| | - Ramón A Piñol
- Diabetes, Endocrinology, and Obesity Branch (J.L.C., C.X., R.A.P., M.L.R.), Molecular Recognition Section, Laboratory of Bioorganic Chemistry (D.K.T., K.A.J.), and Mouse Metabolism Core (O.G.), National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; and Department of Pharmacological and Physiological Science, Saint Louis University School of Medicine, St. Louis, Missouri (Z.C., D.S.)
| | - Zhoumou Chen
- Diabetes, Endocrinology, and Obesity Branch (J.L.C., C.X., R.A.P., M.L.R.), Molecular Recognition Section, Laboratory of Bioorganic Chemistry (D.K.T., K.A.J.), and Mouse Metabolism Core (O.G.), National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; and Department of Pharmacological and Physiological Science, Saint Louis University School of Medicine, St. Louis, Missouri (Z.C., D.S.)
| | - Daniela Salvemini
- Diabetes, Endocrinology, and Obesity Branch (J.L.C., C.X., R.A.P., M.L.R.), Molecular Recognition Section, Laboratory of Bioorganic Chemistry (D.K.T., K.A.J.), and Mouse Metabolism Core (O.G.), National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; and Department of Pharmacological and Physiological Science, Saint Louis University School of Medicine, St. Louis, Missouri (Z.C., D.S.)
| | - Oksana Gavrilova
- Diabetes, Endocrinology, and Obesity Branch (J.L.C., C.X., R.A.P., M.L.R.), Molecular Recognition Section, Laboratory of Bioorganic Chemistry (D.K.T., K.A.J.), and Mouse Metabolism Core (O.G.), National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; and Department of Pharmacological and Physiological Science, Saint Louis University School of Medicine, St. Louis, Missouri (Z.C., D.S.)
| | - Kenneth A Jacobson
- Diabetes, Endocrinology, and Obesity Branch (J.L.C., C.X., R.A.P., M.L.R.), Molecular Recognition Section, Laboratory of Bioorganic Chemistry (D.K.T., K.A.J.), and Mouse Metabolism Core (O.G.), National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; and Department of Pharmacological and Physiological Science, Saint Louis University School of Medicine, St. Louis, Missouri (Z.C., D.S.)
| | - Marc L Reitman
- Diabetes, Endocrinology, and Obesity Branch (J.L.C., C.X., R.A.P., M.L.R.), Molecular Recognition Section, Laboratory of Bioorganic Chemistry (D.K.T., K.A.J.), and Mouse Metabolism Core (O.G.), National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; and Department of Pharmacological and Physiological Science, Saint Louis University School of Medicine, St. Louis, Missouri (Z.C., D.S.)
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Zhang XW, Xie JF, Chen JX, Huang YZ, Guo FM, Yang Y, Qiu HB. The effect of mild induced hypothermia on outcomes of patients after cardiac arrest: a systematic review and meta-analysis of randomised controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:417. [PMID: 26619835 PMCID: PMC4665688 DOI: 10.1186/s13054-015-1133-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 11/06/2015] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Mild induced hypothermia (MIH) is believed to reduce mortality and neurological impairment after out-of-hospital cardiac arrest. However, a recently published trial demonstrated that hypothermia at 33 °C did not confer a benefit compared with that of 36 °C. Thus, a systematic review and meta-analysis of randomised controlled trials (RCTs) was made to investigate the impact of MIH compared to controls on the outcomes of adult patients after cardiac arrest. METHODS We searched the following electronic databases: PubMed/MEDLINE, the Cochrane Library, Embase, the Web of Science, and Elsevier Science (inception to December 2014). RCTs that compared MIH with controls with temperature >34 °C in adult patients after cardiac arrest were retrieved. Two investigators independently selected RCTs and completed an assessment of the quality of the studies. Data were analysed by the methods recommended by the Cochrane Collaboration. Random errors were evaluated with trial sequential analysis. RESULTS Six RCTs, including one abstract, were included. The meta-analysis of included trials revealed that MIH did not significantly decrease the mortality at hospital discharge (risk ratio (RR) = 0.92; 95 % confidence interval (CI), 0.82-1.04; p = 0.17) or at 6 months or 180 days (RR = 0.94; 95 % CI, 0.73-1.21; p = 0.64), but it did reduce the mortality of patients with shockable rhythms at hospital discharge (RR = 0.74; 95 % CI, 0.59-0.92; p = 0.008) and at 6 months or 180 days. However, MIH can improve the outcome of neurological function at hospital discharge (RR = 0.80; 95 % CI, 0.64-0.98; p = 0.04) especially in those patients with shockable rhythm but not at 6 months or 180 days. Moreover, the incidence of complications in the MIH group was significantly higher than that in the control group. Finally, trial sequential analysis indicated lack of firm evidence for a beneficial effect. CONCLUSION The available RCTs suggest that MIH does not appear to improve the mortality of patients with cardiac arrest while it may have a beneficial effect for patients with shockable rhythms. Although MIH may result in some adverse events, it helped lead to better outcomes regarding neurological function at hospital discharge. Large-scale ongoing trials may provide data better applicable to clinical practice.
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Affiliation(s)
- Xi Wen Zhang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine Southeast University, No.87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, China.
| | - Jian Feng Xie
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine Southeast University, No.87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, China.
| | - Jian Xiao Chen
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine Southeast University, No.87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, China.
| | - Ying Zi Huang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine Southeast University, No.87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, China.
| | - Feng Mei Guo
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine Southeast University, No.87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, China.
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine Southeast University, No.87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, China.
| | - Hai Bo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine Southeast University, No.87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, China.
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Kudenchuk PJ, Sandroni C, Drinhaus HR, Böttiger BW, Cariou A, Sunde K, Dworschak M, Taccone FS, Deye N, Friberg H, Laureys S, Ledoux D, Oddo M, Legriel S, Hantson P, Diehl JL, Laterre PF. Breakthrough in cardiac arrest: reports from the 4th Paris International Conference. Ann Intensive Care 2015; 5:22. [PMID: 26380990 PMCID: PMC4573754 DOI: 10.1186/s13613-015-0064-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 08/18/2015] [Indexed: 02/08/2023] Open
Abstract
Jean-Luc Diehl The French Intensive Care Society organized on 5th and 6th June 2014 its 4th "Paris International Conference in Intensive Care", whose principle is to bring together the best international experts on a hot topic in critical care medicine. The 2014 theme was "Breakthrough in cardiac arrest", with many high-quality updates on epidemiology, public health data, pre-hospital and in-ICU cares. The present review includes short summaries of the major presentations, classified into six main chapters: Epidemiology of CA Pre-hospital management Post-resuscitation management: targeted temperature management Post-resuscitation management: optimizing organ perfusion and metabolic parameters Neurological assessment of brain damages Public healthcare.
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Affiliation(s)
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy.
| | - Hendrik R Drinhaus
- Department of Anaesthesiology and Intensive Care Medicine, University of Koeln, Cologne, Germany.
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University of Koeln, Cologne, Germany.
| | - Alain Cariou
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris, France.
- Paris Descartes University and Sorbonne Paris Cité-Medical School and INSERM U970 (Team 4), Cardiovascular Research Center, European Georges Pompidou Hospital, Paris, France.
| | - Kjetil Sunde
- Division of Emergencies and Critical Care, Department of Anaesthesiology, Surgical Intensive Care Unit Ullevål, Oslo University Hospital, Oslo, Norway.
| | - Martin Dworschak
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Vienna General Hospital, Medical University Vienna, Vienna, Austria.
| | - Fabio Silvio Taccone
- Department of Intensive Care, Laboratoire de Recherche Experimentale, Erasme Hospital, Brussels, Belgium.
| | - Nicolas Deye
- Medical Intensive Care Unit, AP-HP, Lariboisière University Hospital, Inserm U942, Paris, France.
| | - Hans Friberg
- Anaesthesiology and Intensive Care Medicine, Skåne University Hospital, Lund University, Lund, Sweden.
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Centre, University of Liège and Liège 2 Department of Neurology, University Hospital of Liège, Liège, Belgium.
| | - Didier Ledoux
- Coma Science Group, Cyclotron Research Centre, University of Liège and Department of Intensive Care Medicine, University Hospital of Liège, Liège, Belgium.
| | - Mauro Oddo
- Department of Intensive Care Medicine, Faculty of Biology and Medicine, CHUV-University Hospital, Lausanne, Switzerland.
| | - Stéphane Legriel
- Intensive Care Unit, Centre Hospitalier de Versailles, Le Chesnay, France.
| | - Philippe Hantson
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
| | - Jean-Luc Diehl
- Medical Intensive Care Unit, AP-HP, European Georges Pompidou Hospital, Paris Descartes University and Sorbonne Paris Cité-Medical School, Paris, France.
| | - Pierre-Francois Laterre
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain Brussels, Brussels, Belgium.
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Chandrasekaran PN, Dezfulian C, Polderman KH. What is the right temperature to cool post-cardiac arrest patients? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:406. [PMID: 26577919 PMCID: PMC4650897 DOI: 10.1186/s13054-015-1134-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Citation Niklas Nielsen, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Åneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Køber L, Langørgen J, Lilja G, Møller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H. Targeted temperature management at 33 °C versus 36 °C after cardiac arrest. N Engl J Med. 2013;369:2197–206. doi:10.1056/NEJMoa1310519. Epub 2013 Nov 17. Pub Med PMID: 20089970. Background Brain ischemia and reperfusion injury leading to tissue degeneration and loss of neurological function following return of spontaneous circulation after cardiac arrest (CA) is a well-known entity. Two landmark trials in 2002 showed improved survival and neurological outcome of comatose survivors of out-of-hospital cardiac arrest (OHCA) of presumed cardiac origin when the patients were subjected to therapeutic hypothermia of 32 to 34 °C for 12 to 24 hours. However, the optimal target temperature for these cohorts is yet to be established and also it is not clear whether strict fever management and maintaining near normal body temperature are alone sufficient to improve the outcome. Methods Objective: The objective is to determine whether a hypothermic goal of a near-normal body temperature of 36 °C reduces all-cause mortality compared with a moderate hypothermia of 33 °C for the unconscious survivors of OHCA of presumed cardiac origin when subjected randomly to these different targeted temperatures. Design: A multicenter, international, open label, randomized controlled trial. Setting: Thirty-six ICUs in Europe and Australia participated in this study. Participants: Unconscious adults (older than 18 years of age) who survived (Glasgow coma scale less than 8) OHCA due to presumed cardiac origin with subsequent persistent return of spontaneous circulation (more than 20 minutes without chest compressions). Intervention: The above participant cohorts were randomized to targeted body temperature of either 33 °C or 36 °C for 36 hours after the CA with gradual rewarming of both groups to 37 °C (hourly increments of 0.5 °C) after the initial 28 hours. Body temperatures in both the groups were then maintained below 37.5 °C for 72 hours after the initial 36 hours. Outcomes: Primary outcome measure of all-cause mortality in both the groups at the end of the trial with the secondary outcome measure of all-cause mortality, composite neurological function as evaluated by cerebral performance category scale and modified ranking scale at the end of 180 days were studied. Results Out of the 939 participants, all-cause mortality at the end of the trial was 50 % in the 33 °C group (225 of 466 patients) compared with 48 % in the 36 °C group (235 of 473 patients); the hazard ratio with a temperature of 33 °C was 1.06 (95 % confidence interval (CI) 0.89 to 1.28, P = 0.51). At the end of 180 days, 54 % of patients in the 33 °C group versus 52 % in the 36 °C group had died or had poor neurological outcome according to cerebral performance category (risk ratio 1.02, 95 % CI 0.88 to 1.16, P = 0.78) but the modified ranking scale at the end of 180 days was unchanged (52 %) in both groups (risk ratio 1.01, 95 % CI 0.89 to 1.14, P = 0.87). Conclusions Maintaining targeted lower normothermia of 36 °C had similar outcomes compared with induced moderate hypothermia of 33 °C for unconscious survivors of OHCA of presumed cardiac cause.
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Affiliation(s)
| | - Cameron Dezfulian
- Department of Critical Care Medicine, University of Pittsburgh, Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Kees H Polderman
- Department of Critical Care Medicine, University of Pittsburgh, Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
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Vincent JL, Taccone FS. Difficulty interpreting the results of some trials: the case of therapeutic hypothermia after pediatric cardiac arrest. Crit Care 2015; 19:391. [PMID: 26549388 PMCID: PMC4638110 DOI: 10.1186/s13054-015-1121-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, 1070, Belgium.
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, 1070, Belgium
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Saigal S, Sharma JP, Dhurwe R, Kumar S, Gurjar M. Targeted temperature management: Current evidence and practices in critical care. Indian J Crit Care Med 2015; 19:537-46. [PMID: 26430341 PMCID: PMC4578199 DOI: 10.4103/0972-5229.164806] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Targeted temperature management (TTM) in today's modern era, especially in intensive care units represents a promising multifaceted therapy for a variety of conditions. Though hypothermia is being used since Hippocratic era, the renewed interest of late has been since early 21st century. There have been multiple advancements in this field and varieties of cooling devices are available at present. TTM requires careful titration of its depth, duration and rewarming as it is associated with side-effects. The purpose of this review is to find out the best evidence-based clinical practice criteria of therapeutic hypothermia in critical care settings. TTM is an unique therapeutic modality for salvaging neurological tissue viability in critically ill patients viz. Post-cardiac arrest, traumatic brain injury (TBI), meningitis, acute liver failure and stroke. TTM is standard of care in post-cardiac arrest situations; there has been a lot of controversy of late regarding temperature ranges to be used for the same. In patients with TBI, it reduces intracranial pressure, but has not shown any favorable neurologic outcome. Hypothermia is generally accepted treatment for hypoxic ischemic encephalopathy in newborns. The current available technology to induce and maintain hypothermia allows for precise temperature control. Future studies should focus on optimizing hypothermic treatment to full benefit of our patients and its application in other clinical scenarios.
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Affiliation(s)
- Saurabh Saigal
- Department of Trauma and Emergency Medicine, AIIMS, Bhopal, India
| | | | | | | | - Mohan Gurjar
- Department of Critical Care Medicine, SGPGIMS, Lucknow, India
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Pan J, Zhu JY, Kee HS, Zhang Q, Lu YQ. A review of compression, ventilation, defibrillation, drug treatment, and targeted temperature management in cardiopulmonary resuscitation. Chin Med J (Engl) 2015; 128:550-4. [PMID: 25673462 PMCID: PMC4836263 DOI: 10.4103/0366-6999.151115] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: Important studies of cardiopulmonary resuscitation (CPR) techniques influence the development of new guidelines. We systematically reviewed the efficacy of some important studies of CPR. Data Sources: The data analyzed in this review are mainly from articles included in PubMed and EMBASE, published from 1964 to 2014. Study Selection: Original articles and critical reviews about CPR techniques were selected for review. Results: The survival rate after out-of-hospital cardiac arrest (OHCA) is improving. This improvement is associated with the performance of uninterrupted chest compressions and simple airway management procedures during bystander CPR. Real-time feedback devices can be used to improve the quality of CPR. The recommended dose, timing, and indications for adrenaline (epinephrine) use may change. The appropriate target temperature for targeted temperature management is still unclear. Conclusions: New studies over the past 5 years have evaluated various aspects of CPR in OHCA. Some of these studies were high-quality randomized controlled trials, which may help to improve the scientific understanding of resuscitation techniques and result in changes to CPR guidelines.
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Affiliation(s)
| | | | | | | | - Yuan-Qiang Lu
- Department of Emergency Medicine, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, China
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Rawal G, Yadav S, Garg N. Therapeutic Hypothermia after Prolonged Cardiac Arrest: Case Report with Review of Literature. J Clin Diagn Res 2015; 9:OD01-2. [PMID: 26500937 DOI: 10.7860/jcdr/2015/14918.6491] [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: 05/16/2015] [Accepted: 08/03/2015] [Indexed: 11/24/2022]
Abstract
Patients who survive cardiac arrest often develop severe neurological dysfunction due to the hypoxic brain injury and reperfusion induced cell death. Therapeutic hypothermia (TH) has become a standard therapy of cerebral protection following the successful return of spontaneous circulation in patients of out-of-hospital cardiac arrest, according to American heart association guidelines. This is a case report of a 30-year-old patient who developed in-hospital cardiac arrest and was revived after prolonged cardiopulmonary resuscitation (CPR) and also required primary angioplasty. TH was then established with local measures for 24 hours for cerebral protection. The patient was gradually and successfully weaned off from ventilator with no neurological impairment. There is an increasing evidence of TH and its protective mechanisms in patients with non-shockable arrest rhythms with particular emphasis on neurological outcomes. This article emphasizes the role of TH in every successful CPR irrespective of the cardiac rhythm.
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Affiliation(s)
- Gautam Rawal
- Attending Consultant-Critical Care, Rockland Hospital, Qutab Institutional Area , New Delhi, India
| | - Sankalp Yadav
- General Duty Medical Officer-II, Chest Clinic , Moti Nagar, New Delhi, India
| | - Nitin Garg
- Senior Consultant and Head-Critical Care, Rockland Hospital , Qutab Institutional Area, New Delhi, India
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Gajarski RJ, Smitko K, Despres R, Meden J, Hutton DW. Cost-effectiveness analysis of alternative cooling strategies following cardiac arrest. SPRINGERPLUS 2015; 4:427. [PMID: 26306289 PMCID: PMC4540719 DOI: 10.1186/s40064-015-1199-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 07/29/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Using survival and neurologic outcome as endpoints , this study explored the incremental cost effectiveness of three mutually exclusive cooling strategies employed after resuscitated out-of-hospital cardiac arrests. DESIGN Economic analysis based on retrospective data collection and Markov modeling. SETTING Modeling based on patients housed in a tertiary ICU setting. PATIENTS Patients >18 years following resuscitation from out-of-hospital cardiac arrest. INTERVENTIONS Therapeutic cooling vs. conventional care. MEASUREMENTS AND MAIN RESULTS Using societal-based analytic decision modeling with a lifetime study horizon, incremental cost effectiveness ratios (ICERs) for blanket, peritoneal lavage, and V-V ECMO cooling strategies were compared with conventional care. Comprehensive cost data were obtained from available literature, national and local databases; health utility data were abstracted from previous publications and converted to quality-adjusted life years (QALYs)/person and stratified by neurologic outcome state. Future costs were discounted using a standard 3% discount rate. Cooling blankets produced better overall health outcomes at a lower cost than conventional care and V-V ECMO. Peritoneal lavage added an additional 0.67 QALYs at an ICER of $58,329/QALY. Monte-Carlo simulations incorporating uncertainty in all parameters showed that peritoneal lavage was 70% likely to be the preferred, cost-effective therapy if one were willing to pay (WTP) $100,000/QALY. CONCLUSIONS This analysis suggests that blankets are the most cost effective cooling strategy for post-ROSC therapeutic hypothermia, with peritoneal lavage as an acceptable alternative at higher WTP thresholds. Though uncertainty about the optimal therapy could be reduced with additional research, these results can inform policy-makers and healthcare providers about cost effectiveness of alternative cooling modalities designed to improve neurologic outcome for this expanding patient population. This may be particularly relevant as societal-based cost effectiveness analyses become more widely incorporated into studies evaluating treatment for frequently encountered diseases.
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Affiliation(s)
- Robert J Gajarski
- />University of Michigan Congenital Heart Center, C.S. Mott Children’s Hospital, 1540 E. Medical Center Dr. Floor 11, Rm 715Z, Ann Arbor, MI 48109 USA
- />Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, USA
| | - Kurtis Smitko
- />Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, USA
| | - Renee Despres
- />Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, USA
| | - Jeff Meden
- />Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, USA
| | - David W Hutton
- />Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, USA
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Mild hypothermia inhibits systemic and cerebral complement activation in a swine model of cardiac arrest. J Cereb Blood Flow Metab 2015; 35:1289-95. [PMID: 25757755 PMCID: PMC4528002 DOI: 10.1038/jcbfm.2015.41] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 02/16/2015] [Indexed: 01/13/2023]
Abstract
Complement activation has been implicated in ischemia/reperfusion injury. This study aimed to determine whether mild hypothermia (HT) inhibits systemic and cerebral complement activation after resuscitation from cardiac arrest. Sixteen minipigs resuscitated from 8 minutes of untreated ventricular fibrillation were randomized into two groups: HT group (n=8), treated with HT (33°C) for 12 hours; and normothermia group (n=8), treated similarly as HT group except for cooling. Blood samples were collected at baseline and 0.5, 6, 12, and 24 hours after return of spontaneous circulation (ROSC). The brain cortex was harvested 24 hours after ROSC. Complement and pro-inflammatory markers were detected using enzyme-linked immunosorbent assay. Neurologic deficit scores were evaluated 24 hours after ROSC. C1q, Bb, mannose-binding lectin (MBL), C3b, C3a, C5a, interleukin-6, and tumor necrosis factor-α levels were significantly increased under normothermia within 24 hours after ROSC. However, these increases were significantly reduced by HT. Hypothermia decreased brain C1q, MBL, C3b, and C5a contents 24 hours after ROSC. Hypothermic pigs had a better neurologic outcome than normothermic pigs. In conclusion, complement is activated through classic, alternative, and MBL pathways after ROSC. Hypothermia inhibits systemic and cerebral complement activation, which may provide an additional mechanism of cerebral protection.
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Kim YM, Youn CS, Kim SH, Lee BK, Cho IS, Cho GC, Jeung KW, Oh SH, Choi SP, Shin JH, Cha KC, Oh JS, Yim HW, Park KN. Adverse events associated with poor neurological outcome during targeted temperature management and advanced critical care after out-of-hospital cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015. [PMID: 26202789 PMCID: PMC4511983 DOI: 10.1186/s13054-015-0991-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Introduction The aim of this study was to investigate the association of adverse events (AEs) during targeted temperature management (TTM) and other AEs and concomitant treatments during the advanced critical care period with poor neurological outcome at hospital discharge in adult out-of-hospital cardiac arrest (OHCA) patients. Methods This was a retrospective study using Korean Hypothermia Network registry data of adult OHCA patients treated with TTM in 24 teaching hospitals throughout South Korea from 2007 to 2012. Demographic characteristics, resuscitation and post-resuscitation variables, AEs, and concomitant treatments during TTM and the advanced critical care were collected. The primary outcome was poor neurological outcome, defined as a cerebral performance category (CPC) score of 3–5 at hospital discharge. The AEs and concomitant treatments were individually entered into the best multivariable predictive model of poor neurological outcome to evaluate the associations between each variable and outcome. Results A total of 930 patients, including 704 for whom a complete dataset of AEs and covariates was available for multivariable modeling, were included in the analysis; 476 of these patients exhibited poor neurological outcome [CPC 3 = 50 (7.1 %), CPC 4 = 214 (30.4 %), and CPC 5 = 212 (30.1 %)]. Common AEs included hyperglycemia (45.6 %), hypokalemia (31.3 %), arrhythmia (21.3 %) and hypotension (29 %) during cooling, and hypotension (21.6 %) during rewarming. Bleeding (5 %) during TTM was a rare AE. Common AEs during the advanced critical care included pneumonia (39.6 %), myoclonus (21.9 %), seizures (21.7 %) and hypoglycemia within 72 hours (23 %). After adjusting for independent predictors of outcome, cooling- and rewarming-related AEs were not significantly associated with poor neurological outcome. However, sepsis, myoclonus, seizure, hypoglycemia within 72 hours and anticonvulsant use during the advanced critical care were associated with poor neurological outcome [adjusted odds ratios (95 % confidence intervals) of 3.12 (1.40–6.97), 3.72 (1.93–7.16), 4.02 (2.04–7.91), 2.03 (1.09–3.78), and 1.69 (1.03–2.77), respectively]. Alternatively, neuromuscular blocker use was inversely associated with poor neurological outcome (0.48 [0.28–0.84]). Conclusions Cooling- and rewarming-related AEs were not associated with poor neurological outcome at hospital discharge. Sepsis, myoclonus, seizure, hypoglycemia within 72 hours and anticonvulsant use during the advanced critical care period were associated with poor neurological outcome at hospital discharge in our study. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0991-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Young-Min Kim
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Chun Song Youn
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Soo Hyun Kim
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Byung Kook Lee
- Department of Emergency Medicine, College of Medicine, Chonnam National University, 160 Baekseo-ro, Dong-gu, Gwangju, 501-746, South Korea.
| | - In Soo Cho
- Department of Emergency Medicine, KEPCO Medical Center, 308 Uicheon-ro, Dobong-gu, Seoul, 132-703, South Korea.
| | - Gyu Chong Cho
- Department of Emergency Medicine, College of Medicine, Hallym University, Kangdong Sacread Heart Hospital 150 Seongan-ro, Gangdong-gu, Seoul, 134-701, South Korea.
| | - Kyung Woon Jeung
- Department of Emergency Medicine, College of Medicine, Chonnam National University, 160 Baekseo-ro, Dong-gu, Gwangju, 501-746, South Korea.
| | - Sang Hoon Oh
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Seung Pill Choi
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Jong Hwan Shin
- Department of Emergency Medicine, Boramae Medical Center, Seoul National University, 20 Boramae-ro, Dongjak-gu, Seoul, 156-707, South Korea.
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Wonju College of Medicine, Yonsei University, 20 Ilsan-ro, Wonju, Gangwon-do, 220-701, South Korea.
| | - Joo Suk Oh
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Hyeon Woo Yim
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Kyu Nam Park
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
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Bhatnagar UB, Bajwa A, Sharma A, Baweja P. Refractory ventricular fibrillation managed by coronary revascularisation performed during ongoing manual cardiac resuscitation lasting 1½ h. BMJ Case Rep 2015; 2015:bcr-2015-211126. [PMID: 26156842 DOI: 10.1136/bcr-2015-211126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Myocardial infarction is the most common cause of ventricular arrhythmias. Although there have been several improvements and refinements in coronary catheterisation with percutaneous intervention over the years, this intervention is still rarely considered during active ongoing resuscitation of patients, especially in cases of persistent ventricular arrhythmias. We present a case of refractory ventricular fibrillations due to in-stent thrombosis that was managed by emergent coronary angiogram and stent placement during ongoing cardiopulmonary resuscitation in a code that lasted about 1½ h. The patient subsequently made an excellent recovery and was discharged home 13 days later.
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Affiliation(s)
- Udit Bhaskar Bhatnagar
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Ata Bajwa
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Amit Sharma
- Department of Cardiology, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Paramdeep Baweja
- Department of Cardiology, Truman Medical Center, Kansas City, Missouri, USA
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